CMS 2016 Paper II \u2013 Part C (Q81\u2013Q120)<\/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\/* \u2500\u2500 Namespace: cms16p2c \u2500\u2500 *\/\n#cms16p2c *,#cms16p2c *::before,#cms16p2c *::after{box-sizing:border-box;margin:0;padding:0}\n#cms16p2c{\n --ter:#C0603A;--ter-light:#e8825f;--ter-pale:#fdf1ec;\n --teal:#2A7A6F;--teal-light:#3da394;--teal-pale:#eaf4f3;\n --ink:#1a1a1a;--ink-mid:#444;--ink-soft:#777;\n --line:#e0d8d4;--bg:#fdfaf8;--white:#ffffff;\n --correct:#1e6f46;--correct-bg:#eaf7ef;--correct-border:#43a047;\n --wrong:#b83232;--wrong-bg:#fdf0f0;--wrong-border:#e53935;\n --radius:10px;\n font-family:'Source Serif 4',Georgia,serif;\n font-size:16px;color:var(--ink);background:var(--bg);\n line-height:1.7;padding:0 0 48px;\n}\n#cms16p2c .cq-sentinel{height:1px}\n#cms16p2c .cq-statusbar{\n 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.cq-opt-text{font-size:0.84rem}\n}\n<\/style>\n<\/head>\n<body>\n<div id=\"cms16p2c\">\n <div class=\"cq-sentinel\" id=\"cms16p2c-sentinel\"><\/div>\n <div class=\"cq-statusbar\" id=\"cms16p2c-statusbar\">\n <div class=\"cq-sb-stats\">\n <div class=\"cq-timer-item\" id=\"cms16p2c-timer-item\">\u23f1 <strong id=\"cms16p2c-timer-display\">40:00<\/strong><\/div>\n <div class=\"cq-sb-item\">\u2705 <strong id=\"cms16p2c-sc\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u274c <strong id=\"cms16p2c-sw\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u23f3 <strong id=\"cms16p2c-sr\">40<\/strong> left<\/div>\n <div class=\"cq-sb-sep\"><\/div>\n <div class=\"cq-sb-item\">Net <strong id=\"cms16p2c-sn\">0<\/strong> \/ <strong id=\"cms16p2c-sm\">160<\/strong><\/div>\n <\/div>\n <div class=\"cq-sb-progress\"><div class=\"cq-sb-fill\" id=\"cms16p2c-fill\"><\/div><\/div>\n <\/div>\n <div class=\"cq-grace\" id=\"cms16p2c-grace\">\n <div class=\"cq-grace-box\">\n <h3>Time's Up!<\/h3>\n <p>Submitting in<\/p>\n <div class=\"cq-grace-count\" id=\"cms16p2c-grace-count\">10<\/div>\n <button class=\"cq-grace-btn\" id=\"cms16p2c-grace-now\">Submit Now<\/button>\n <\/div>\n <\/div>\n <div class=\"cq-header\">\n <h1>Combined Medical Services Examination 2016<br>Paper II \u00b7 Part C<\/h1>\n <p>Obstetrics & Gynaecology<\/p>\n <div class=\"cq-meta\">\n <span class=\"cq-badge\">Questions 81 \u2013 120<\/span>\n <span class=\"cq-badge\">Options reshuffled<\/span>\n <button class=\"cq-timer-btn\" id=\"cms16p2c-timer-btn\">\u23f1 Start Timed Mode<\/button>\n <\/div>\n <\/div>\n <div class=\"cq-body\">\n <div id=\"cms16p2c-questions\"><\/div>\n <div class=\"cq-submit-wrap\">\n <button class=\"cq-btn\" id=\"cms16p2c-submit\">Submit Answers<\/button>\n <\/div>\n <div class=\"cq-score\" id=\"cms16p2c-score\">\n <div class=\"cq-score-ring\" id=\"cms16p2c-ring\">\n <div class=\"cq-ring-inner\">\n <span class=\"cq-ring-pct\" id=\"cms16p2c-ring-pct\">0%<\/span>\n <span class=\"cq-ring-sub\">score<\/span>\n <\/div>\n <\/div>\n <h2>Your Result<\/h2>\n <div class=\"cq-net-line\" id=\"cms16p2c-net-line\"><\/div>\n <div class=\"cq-verdict\" id=\"cms16p2c-verdict\"><\/div>\n <div class=\"cq-score-bands\">\n <span class=\"cq-band cq-band-c\" id=\"cms16p2c-ct-c\"><\/span>\n <span class=\"cq-band cq-band-w\" id=\"cms16p2c-ct-w\"><\/span>\n <span class=\"cq-band cq-band-s\" id=\"cms16p2c-ct-s\"><\/span>\n <\/div>\n <button class=\"cq-retry-btn\" id=\"cms16p2c-retry\">\u21ba Retry Quiz<\/button>\n <\/div>\n <\/div>\n<\/div>\n<script>\n(function(){\n 'use strict';\n const NS='cms16p2c', TOTAL=40, MAX=TOTAL*4;\n const TIMER_SECS=40*60, GRACE_SECS=10;\n\n const QUESTIONS=[\n {\n id:81,\n stem:'A 35-year-old nulliparous woman complains of menorrhagia and mass per abdomen. On examination she is anaemic, has a pelvic mass of 16\u201318 weeks size, firm in consistency, which moves with the movement of the cervix. What is the most likely clinical diagnosis?',\n correct:'Leiomyoma',\n options:['Leiomyoma','Adenomyosis','Endometrial carcinoma','Ovarian tumour'],\n exp:'The classic presentation of uterine leiomyoma (fibroid): nulliparous woman with menorrhagia (intramural\/submucosal fibroids), a large (16\u201318 weeks) firm, irregular pelvic mass that MOVES WITH THE CERVIX \u2014 this movement en masse with the cervix confirms the mass is uterine (arising from the uterus). Ovarian tumours are separate from the uterus and do not move with the cervix. Adenomyosis causes a uniformly enlarged uterus rarely exceeding 12 weeks. Endometrial carcinoma causes post-menopausal or irregular bleeding with small\/normal uterus. The mass size, nulliparity, and menorrhagia point firmly to fibroid uterus.'\n },\n {\n id:82,\n stem:'Abundant cornified cells in vaginal exfoliative cytology indicate:',\n correct:'Late proliferative phase',\n options:['Early proliferative phase','Late proliferative phase','Early secretory phase','Late secretory phase'],\n exp:'Vaginal exfoliative cytology (Maturation Index) reflects oestrogen levels: oestrogen causes maturation of vaginal epithelium to superficial cornified (anucleate\/pyknotic) cells. Maximum cornification occurs at PEAK OESTROGEN \u2014 the late proliferative (pre-ovulatory) phase, just before ovulation. Early proliferative phase has intermediate cells. Secretory phase (under progesterone) shows intermediate cells with curled edges (navicular cells) and increased leucocytes. Abundant cornified cells = high oestrogen = late proliferative phase.'\n },\n {\n id:83,\n stem:'Consider the following statements:\\n1. Carbon dioxide is the safest gas for creating pneumoperitoneum in operative laparoscopy.\\n2. Laparoscopic sterilisation is not recommended during the period of immediate postpartum.\\n\\nWhich of the statements given above is\/are correct?',\n correct:'Both 1 and 2',\n options:['1 only','2 only','Both 1 and 2','Neither 1 nor 2'],\n exp:'Both statements are correct. (1) CO\u2082 is the gas of choice for laparoscopic pneumoperitoneum because it is: highly soluble in blood (rapidly absorbed if accidentally embolised), non-flammable (safe with diathermy), and inexpensive. Nitrous oxide and helium have been used but CO\u2082 remains the safest and most universally used. (2) Laparoscopic sterilisation in the immediate postpartum period (first 48 hours after delivery) is not recommended because the distended, highly vascular uterus and friable tubes increase the risk of injury, haemorrhage, and failed occlusion. Mini-laparotomy is preferred in the immediate postpartum.'\n },\n {\n id:84,\n stem:'Polyhydramnios at term is diagnosed when AFI is more than:',\n correct:'25 cm',\n options:['10 cm','15 cm','20 cm','25 cm'],\n exp:'Amniotic Fluid Index (AFI) is the sum of the deepest vertical pockets in four uterine quadrants on ultrasound. Normal AFI at term = 8\u201324 cm. Oligohydramnios = AFI \u22645 cm. Borderline = AFI 5\u20138 cm. Polyhydramnios = AFI >25 cm (some sources say >24 cm). The single deepest pocket (SDP) method defines polyhydramnios as SDP >8 cm. The AFI threshold for polyhydramnios diagnosis at term is >25 cm. Mild = 25\u201330 cm, moderate = 30\u201335 cm, severe = >35 cm.'\n },\n {\n id:85,\n stem:'Which of the following is NOT a potentially teratogenic infection if contracted in pregnancy?',\n correct:'Influenza virus',\n options:['Rubella','Cytomegalovirus','Influenza virus','Chicken pox'],\n exp:'TORCH infections are the classical teratogenic congenital infections: Toxoplasma, Other (syphilis, parvovirus B19, varicella-zoster), Rubella, CMV, Herpes. Rubella (1st trimester) causes congenital rubella syndrome (cataracts, deafness, cardiac defects). CMV causes periventricular calcification, SNHL, microcephaly. Varicella-zoster (chickenpox) causes congenital varicella syndrome (limb hypoplasia, skin scarring, microcephaly). Influenza virus causes maternal morbidity but is NOT a recognised teratogen \u2014 it does not cause structural congenital malformations, though severe maternal illness can cause hyperthermia-related effects.'\n },\n {\n id:86,\n stem:'Active management of the 3rd stage of labour includes the following EXCEPT:',\n correct:'Injection oxytocin 10 IU intravenously',\n options:['Injection oxytocin 10 IU intramuscularly','Controlled cord traction','Uterine massage','Injection oxytocin 10 IU intravenously'],\n exp:'Active Management of Third Stage of Labour (AMTSL) per WHO\/FIGO guidelines comprises: (1) Oxytocin 10 IU IM within 1 minute of delivery of the baby \u2014 IM is the recommended route (slow onset prevents hypotension). (2) Controlled cord traction (Brandt-Andrews manoeuvre) after signs of placental separation. (3) Uterine massage after placental delivery to maintain uterine tone. Oxytocin 10 IU IV (intravenous bolus) is EXCLUDED from AMTSL \u2014 rapid IV bolus causes acute hypotension, tachycardia, and cardiovascular compromise. IV oxytocin may be given as a dilute infusion but NOT as a 10 IU bolus.'\n },\n {\n id:87,\n stem:'Regarding hypertensive disorders of pregnancy, the following are true EXCEPT:',\n correct:'Urinary dipstick result of +1 is equivalent to urinary protein concentration of 300 mg\/dl',\n options:[\n 'Significant proteinuria is \u22650.3 g\/24 hr',\n 'Eclampsia may present in the absence of hypertension',\n 'A protein:creatinine ratio more than 30 mg\/mmol is considered significant',\n 'Urinary dipstick result of +1 is equivalent to urinary protein concentration of 300 mg\/dl'\n ],\n exp:'Significant proteinuria in pre-eclampsia: \u22650.3 g\/24 hours (1+ = correct). Eclampsia CAN occur without preceding hypertension or proteinuria (atypical eclampsia) \u2014 this is a recognised and important clinical point (2 = correct). Protein:creatinine ratio >30 mg\/mmol (equivalent to >0.3 g\/g) is considered significant (3 = correct). Dipstick +1 corresponds to approximately 30 mg\/dL (0.3 g\/L), NOT 300 mg\/dL. Dipstick ++ (2+) corresponds to ~100 mg\/dL; +++ = ~300 mg\/dL. Statement (d) is WRONG \u2014 +1 dipstick \u2260 300 mg\/dL.'\n },\n {\n id:88,\n stem:'Which of the following is NOT a characteristic of Mayer-Rokitansky-K\u00fcster-Hauser (MRKH) syndrome?',\n correct:'Cardiac anomalies',\n options:['Cardiac anomalies','M\u00fcllerian duct aplasia','Renal abnormalities','Skeletal abnormalities'],\n exp:'MRKH syndrome (Type II \u2014 M\u00fcllerian Aplasia and Cervicothoracic Somite Abnormalities, MURCS association) is characterised by: (2) M\u00fcllerian duct aplasia \u2014 absent uterus and upper vagina, normal ovaries and female karyotype (46,XX). (3) Renal abnormalities \u2014 unilateral renal agenesis, ectopic kidney, horseshoe kidney (up to 40% of cases). (4) Skeletal abnormalities \u2014 vertebral (Klippel-Feil), rib, and limb anomalies. CARDIAC anomalies are NOT a recognised feature of MRKH syndrome. Cardiac defects are associated with Turner syndrome and other chromosomal disorders. Cardiac anomaly is the exception here.'\n },\n {\n id:89,\n stem:'Which one of the following is NOT a contraindication for prescribing combined oral contraceptive pills?',\n correct:'Pelvic inflammatory disease',\n options:['Thromboembolic disease','Viral hepatitis','Rheumatic heart disease','Pelvic inflammatory disease'],\n exp:'WHO Medical Eligibility Criteria (MEC) Category 4 (absolute contraindications) for COCPs include: thromboembolic disease (oestrogen is prothrombotic), active viral hepatitis (hepatic metabolism impaired, hepatotoxicity risk), valvular\/rheumatic heart disease with complications (risk of arterial thrombosis), hypertension, migraine with aura, breast cancer, smokers >35 years. Pelvic inflammatory disease (PID) is NOT a contraindication for COCPs \u2014 in fact, COCPs may be slightly protective against PID by thickening cervical mucus. PID is therefore not a contraindication.'\n },\n {\n id:90,\n stem:'The following are used in the staging of carcinoma of the cervix EXCEPT:',\n correct:'Pelvic lymph node involvement',\n options:['Pelvic lymph node involvement','Vaginal involvement','Hydroureter','Parametrial involvement'],\n exp:'FIGO staging of cervical carcinoma is a CLINICAL staging system (not surgical\/pathological). Parameters used: vaginal extent (Stage II = upper two-thirds, Stage III = lower one-third), parametrial involvement (Stage IIB = parametrial, Stage IIIB = pelvic wall), and hydroureter\/hydronephrosis (Stage IIIB). Pelvic lymph node status is determined surgically\/radiologically and is NOT included in classical FIGO clinical staging (though the 2018 FIGO revision allows imaging\/pathology to classify lymph node involvement as IIIC). For examination purposes: lymph node involvement is NOT used in FIGO clinical staging.'\n },\n {\n id:91,\n stem:'Presence of signet-ring cells in a cellular or myxomatous stroma is diagnostic of:',\n correct:'Krukenberg tumour',\n options:['Gynandroblastoma','Hilus cell tumour','Struma ovarii','Krukenberg tumour'],\n exp:'Krukenberg tumour is a metastatic tumour of the ovary (most commonly from gastric carcinoma, also colorectal, breast, appendix). Its hallmark histological feature is the presence of signet-ring cells (mucin-secreting cells with nucleus pushed to the periphery by intracellular mucin) embedded in a cellular\/myxomatous ovarian stromal reaction \u2014 the stroma reacts with sarcoma-like proliferation. Bilateral ovarian involvement is characteristic. Struma ovarii = thyroid tissue in teratoma. Hilus cell tumour = androgen-secreting. Gynandroblastoma = mixed sex-cord elements.'\n },\n {\n id:92,\n stem:'A 58-year-old woman, post-menopausal for the last 8 years, comes with history of spotting per vaginum. What is the most likely cause?',\n correct:'Atrophic endometritis',\n options:['Endometrial hyperplasia','Endometrial carcinoma','Atrophic endometritis','Estrogen replacement therapy'],\n exp:'Post-menopausal bleeding (PMB) requires systematic evaluation, but the MOST COMMON cause of PMB overall is atrophic vaginitis\/atrophic endometritis \u2014 accounting for ~60\u201380% of cases. Oestrogen withdrawal causes atrophy of the vaginal and endometrial epithelium, making the tissue fragile and prone to minor bleeding. Endometrial carcinoma, though the most feared cause, accounts for only ~10% of PMB cases. The question specifies \"most likely\" \u2014 without other features (obesity, diabetes, hypertension) pointing to malignancy, atrophic endometritis is the most probable cause in 8-year post-menopausal woman.'\n },\n {\n id:93,\n stem:'A diabetic obese patient comes with history of post-menopausal bleeding. On examination, there is a suprapubic mass and per vagina there is purulent discharge. The probable diagnosis is:',\n correct:'Carcinoma endometrium',\n options:['Carcinoma cervix','Carcinoma endometrium','Uterine myoma','Ovarian carcinoma'],\n exp:'The combination of post-menopausal bleeding in a diabetic, obese woman (classic risk factors for Type I endometrial carcinoma \u2014 oestrogen-driven), suprapubic mass (enlarged uterus from tumour bulk), and purulent vaginal discharge (pyometra from tumour obstruction causing secondary infection) strongly points to advanced carcinoma of the endometrium. The Triad: obesity + diabetes + post-menopausal bleeding = endometrial carcinoma until proved otherwise. Pyometra in this context represents pus accumulation in the uterine cavity obstructed by the tumour at the cervical os.'\n },\n {\n id:94,\n stem:'An adolescent girl with stage 1a dysgerminoma is managed by:',\n correct:'Unilateral salpingo-oophorectomy alone',\n options:['Unilateral salpingo-oophorectomy alone','Total abdominal hysterectomy with unilateral salpingo-oophorectomy','Bilateral salpingo-oophorectomy alone','Chemotherapy'],\n exp:'Dysgerminoma is the most common malignant germ cell tumour of the ovary. Stage IA (confined to one ovary, capsule intact, no ascites) in a young woman\/adolescent: treatment is UNILATERAL SALPINGO-OOPHORECTOMY alone (fertility-preserving surgery). Dysgerminoma is highly radiosensitive and chemosensitive. Stage IA has excellent prognosis with surgery alone (>95% 5-year survival). The contralateral ovary and uterus are preserved, maintaining fertility. Bilateral BSO or TAH would unnecessarily sacrifice fertility. Chemotherapy (BEP) is reserved for advanced stages or recurrence.'\n },\n {\n id:95,\n stem:'Which of the following conditions is best treated by a posterior colpotomy?',\n correct:'Pelvic abscess',\n options:['Pelvic abscess','Pyometra','Pyosalpinx','Pelvic haematocele'],\n exp:'Posterior colpotomy (culdotomy \u2014 incision through the posterior vaginal fornix into the pouch of Douglas) provides direct access to the pelvic peritoneal cavity for drainage. It is ideally suited for: PELVIC ABSCESS \u2014 a fluctuant, midline collection in the pouch of Douglas that is accessible transvaginally, allowing dependent drainage without laparotomy. Pyometra is drained transcervically (cervical dilatation). Pyosalpinx (tube abscess) requires laparotomy\/laparoscopy. Haematocele can be drained vaginally but the preferred approach depends on aetiology; pelvic abscess is the classic indication for posterior colpotomy.'\n },\n {\n id:96,\n stem:'Which of the following suture materials has the least tissue reaction?',\n correct:'Stainless steel',\n options:['Cotton\/Linen','Stainless steel','Chromic catgut','Silk'],\n exp:'Tissue reactivity of suture materials (least to most): Stainless steel wire < Polypropylene (Prolene) < Polyglyconate < Polyester (Dacron) < Nylon < Polyglactin (Vicryl) < Plain catgut < Silk < Chromic catgut < Cotton\/Linen. Stainless steel wire evokes the LEAST tissue reaction of all suture materials (minimal protein content, inert metal). Silk evokes significant tissue reaction and chronic inflammation. Cotton and linen cause severe tissue reaction (worst). Chromic catgut causes more reaction than plain catgut due to chromium processing. Stainless steel is therefore the correct answer.'\n },\n {\n id:97,\n stem:'Menopause is associated with the following EXCEPT:',\n correct:'Delusion',\n options:['Osteoporosis','Ischaemic heart disease','Loss of libido','Delusion'],\n exp:'Menopausal syndrome features: vasomotor symptoms (hot flushes, night sweats), urogenital atrophy, osteoporosis (oestrogen loss \u2192 accelerated bone resorption), ischaemic heart disease (loss of cardioprotective oestrogen \u2192 increased LDL, decreased HDL), sexual dysfunction (loss of libido, dyspareunia from vaginal atrophy), psychological symptoms (mood changes, anxiety, depression). DELUSION (a fixed false belief \u2014 a psychotic symptom) is NOT a feature of menopause. Depression may occur but psychosis\/delusion is not a recognised menopausal manifestation.'\n },\n {\n id:98,\n stem:'Which one of the following conditions simulates the menstrual pattern of pain?',\n correct:'Haematometra',\n options:['Intramural fibroid','Adenomyosis','Haematometra','Granulosa cell tumour of ovary'],\n exp:'Haematometra (accumulation of menstrual blood in the uterine cavity due to outflow obstruction \u2014 imperforate hymen, cervical stenosis) causes cyclical (monthly) lower abdominal pain occurring at the time of expected menstruation, with little or no external flow (cryptomenorrhoea). The pain strictly follows the menstrual cycle pattern, simulating dysmenorrhoea but with absent\/scant periods. Adenomyosis causes dysmenorrhoea but menstrual flow is present. Intramural fibroid causes menorrhagia. Granulosa cell tumour causes oestrogenic effects, not cyclic pain.'\n },\n {\n id:99,\n stem:'Which of the undermentioned conditions does NOT cause post-menopausal vaginal bleeding?',\n correct:'Benign cystic teratoma of ovary',\n options:['Benign cystic teratoma of ovary','Senile vaginitis','Carcinoma of cervix','Prolapse of uterus with decubitus ulcer'],\n exp:'Causes of post-menopausal bleeding: senile (atrophic) vaginitis (fragile atrophic mucosa), carcinoma cervix (ulcerating tumour), prolapse with decubitus ulcer (pressure ulceration of procidentia), endometrial carcinoma\/hyperplasia, functioning ovarian tumours (granulosa cell tumour \u2014 secretes oestrogen, stimulates endometrium), polyps, and HRT. Benign cystic teratoma (dermoid cyst) is a non-functioning germ cell tumour \u2014 it does NOT secrete hormones and does NOT cause post-menopausal bleeding. It is an asymptomatic mass incidentally found. This is the exception.'\n },\n {\n id:100,\n stem:'Defective fusion of the M\u00fcllerian ducts may give rise to which of the following?',\n correct:'Uterus bicornis unicollis',\n options:['Uterus bicornis unicollis','Imperforate anus','Imperforate hymen','Absence of the ovaries'],\n exp:'M\u00fcllerian duct anomalies arise from failure of normal development\/fusion of the paired M\u00fcllerian (paramesonephric) ducts. Defective FUSION (partial) of the two ducts results in bicornuate uterus (uterus bicornis unicollis \u2014 two horns, one cervix). Complete failure of fusion \u2192 uterus didelphys (double uterus, double cervix). Failure of resorption of septum \u2192 septate uterus. Imperforate anus and imperforate hymen have different embryological origins (hindgut and urogenital sinus respectively) \u2014 not M\u00fcllerian. Ovarian development is independent of M\u00fcllerian ducts (ovaries develop from gonadal ridge).'\n },\n {\n id:101,\n stem:'For a woman who had unprotected intercourse two days ago, which one of the following emergency contraceptive methods cannot be suggested?',\n correct:'LNG IUD (LNg IUD)',\n options:['LNG IUD','Ulipristal acetate','Levonorgestrel 1.5 mg','Yuzpe regimen'],\n exp:'Emergency contraception timelines: Copper IUCD \u2014 up to 5 days (most effective EC). LNG IUD (levonorgestrel-releasing IUS, e.g., Mirena) \u2014 NOT recommended as emergency contraception as it has no established EC efficacy; its mechanism is primarily local (thickened mucus, not post-fertilisation). Ulipristal acetate (ella) \u2014 up to 5 days. Levonorgestrel 1.5 mg \u2014 up to 3 days (most effective within 72 hours). Yuzpe regimen \u2014 within 72 hours. After 2 days (48 hours), all hormonal EC and copper IUCD remain options EXCEPT LNG IUD, which is not indicated as EC at any time.'\n },\n {\n id:102,\n stem:'Deep transverse arrest of the head in labour occurs in:',\n correct:'Android pelvis',\n options:['Android pelvis','Anthropoid pelvis','Platypelloid pelvis','Gynaecoid pelvis'],\n exp:'Deep transverse arrest (DTA) occurs when the fetal head descends to the level of the ischial spines but fails to rotate from the transverse position (occiput transverse) to the anterior position (OA) for delivery. DTA is classically associated with ANDROID PELVIS \u2014 the heart-shaped android inlet funnels to a narrow outlet with prominent ischial spines and convergent side walls, mechanically preventing internal rotation. Gynaecoid pelvis allows easy rotation. Anthropoid pelvis favours OP position but usually delivers. Platypelloid favours transverse presentation but rarely causes DTA.'\n },\n {\n id:103,\n stem:'Early deceleration of foetal heart rate in labour is due to:',\n correct:'Foetal head compression',\n options:['Congenital heart block','Umbilical cord compression','Foetal head compression','Hyperpyrexia'],\n exp:'Types of FHR decelerations: Early decelerations \u2014 uniform, mirror contractions, onset with contraction onset, nadir at peak, return to baseline by contraction end. Cause: FOETAL HEAD COMPRESSION during contractions \u2192 vagal reflex \u2192 transient bradycardia. Benign, no fetal compromise. Late decelerations \u2014 caused by uteroplacental insufficiency (ominous). Variable decelerations \u2014 caused by umbilical cord compression (variable shape\/timing). Congenital heart block causes persistent baseline bradycardia, not periodic decelerations. Early decelerations = head compression = vagal reflex.'\n },\n {\n id:104,\n stem:'McRoberts manoeuvre is used during labour for management of:',\n correct:'Shoulder dystocia',\n options:['Normal labour to assist extension of head','Extended arms of breech during assisted breech delivery','Shoulder dystocia','Delivery of after-coming head of breech'],\n exp:'McRoberts manoeuvre is the first-line intervention for SHOULDER DYSTOCIA (impaction of the anterior fetal shoulder behind the maternal pubic symphysis after delivery of the head). The manoeuvre involves hyperflexion of the maternal thighs onto the abdomen \u2014 this flattens the lumbar lordosis, rotates the pubic symphysis superiorly, increases the relative AP diameter of the pelvis, and facilitates release of the impacted shoulder. It is successful in ~40% of cases alone, and combined with suprapubic pressure resolves most cases. HELPERR mnemonic includes McRoberts as the first manoeuvre.'\n },\n {\n id:105,\n stem:'Which one of the following is NOT a suitable condition for outlet forceps application?',\n correct:'Head is above ischial spine level',\n options:['Cervix fully dilated','Membranes absent','Vertex presentation','Head is above ischial spine level'],\n exp:'Prerequisites for outlet forceps: (1) Cervix fully dilated \u2014 essential for all operative vaginal deliveries. (2) Membranes ruptured (absent) \u2014 must be ruptured. (3) Vertex (cephalic) presentation. (4) Head at outlet \u2014 scalp visible at introitus without separating labia, skull at pelvic floor, sagittal suture in AP or near-AP diameter. If the HEAD IS ABOVE THE ISCHIAL SPINES, this is mid-cavity (station 0 or above) \u2014 outlet forceps cannot be applied here. Outlet forceps requires the head to be at +2 station or below (at pelvic outlet). Head above ischial spines is therefore NOT a suitable condition.'\n },\n {\n id:106,\n stem:'Polyhydramnios is NOT caused by which one of the following?',\n correct:'Single kidney',\n options:['Anencephaly','Spina bifida','Single kidney','Oesophageal atresia'],\n exp:'Polyhydramnios results from decreased fetal swallowing or increased fetal urine production. GI causes (impaired swallowing): oesophageal atresia, duodenal atresia, anencephaly (absent\/poor swallowing reflex), tracheo-oesophageal fistula. Neural tube defects: anencephaly (absent swallowing) and open spina bifida (transudation from exposed neural tissue) both cause polyhydramnios. Single kidney (unilateral renal agenesis) does NOT cause polyhydramnios \u2014 the contralateral normal kidney maintains adequate urine output. Bilateral renal agenesis causes OLIGOHYDRAMNIOS. Single kidney = normal\/adequate amniotic fluid.'\n },\n {\n id:107,\n stem:'Which of the following is the type of antepartum haemorrhage where blood loss is foetal?',\n correct:'Vasa praevia',\n options:['Abruptio placentae','Placenta praevia','Vasa praevia','Circumvallate placenta'],\n exp:'In vasa praevia, fetal blood vessels (velamentous cord insertion) traverse the fetal membranes over or near the internal cervical os, unprotected by placenta or Wharton\\'s jelly. When membranes rupture, these vessels rupture \u2192 FETAL BLOOD IS LOST into the vagina. This causes sudden painless vaginal bleeding at membrane rupture, with immediate and severe fetal bradycardia\/distress. Fetal mortality is very high (>50%) without prompt recognition and emergency caesarean section. Placenta praevia and abruption cause MATERNAL blood loss. Vasa praevia is the only cause of APH where the blood is fetal.'\n },\n {\n id:108,\n stem:'Which one of the following conditions is NOT associated with oligohydramnios during pregnancy?',\n correct:'Oesophageal atresia',\n options:['Post-term pregnancy','Ruptured membranes','Intrauterine growth restriction','Oesophageal atresia'],\n exp:'Oligohydramnios (AFI \u22645 cm) causes: (1) Post-term pregnancy \u2014 placental insufficiency reduces fetal urine output. (2) Ruptured membranes \u2014 amniotic fluid leaks out. (3) IUGR \u2014 placental insufficiency \u2192 reduced fetal renal perfusion \u2192 reduced urine output \u2192 oligohydramnios. Also: bilateral renal agenesis (Potter sequence), posterior urethral valves, bladder exstrophy. Oesophageal atresia impairs fetal SWALLOWING \u2192 causes POLYHYDRAMNIOS (amniotic fluid not swallowed and recycled). It is NOT a cause of oligohydramnios. Oesophageal atresia is the exception.'\n },\n {\n id:109,\n stem:'A 23-year-old presents with recurrent abortions at 16 weeks gestation. She should be investigated for:',\n correct:'Incompetent cervix',\n options:['TORCH infection','Hepatitis B infection','Incompetent cervix','Balanced paternal translocation'],\n exp:'Recurrent pregnancy loss (RPL) at 16 weeks gestation (second trimester) is the key discriminator. Cervical incompetence (cervical insufficiency) classically causes PAINLESS, SILENT mid-trimester losses (14\u201328 weeks) \u2014 the internal os dilates without contractions, the membranes prolapse, and delivery occurs. This is distinct from first-trimester losses (chromosomal, thrombophilia, anatomical, immunological). TORCH infections cause first-trimester losses or congenital infections, not typically recurrent mid-trimester losses. Balanced translocations cause recurrent miscarriage, but typically in the first trimester. Incompetent cervix is the answer for 16-week recurrent losses.'\n },\n {\n id:110,\n stem:'Which of the following is the most common cause of abortion during the first trimester?',\n correct:'Chromosomal anomalies of foetus',\n options:['Cervical incompetence','Progesterone deficiency','Antiphospholipid antibody syndrome','Chromosomal anomalies of foetus'],\n exp:'Chromosomal anomalies of the fetus are the most common cause of sporadic (and many recurrent) first-trimester abortions, accounting for approximately 50\u201360% of all first-trimester miscarriages. The most common chromosomal abnormality is autosomal trisomy (trisomy 16 is the most frequent), followed by monosomy X (45,X), triploidy, and tetraploidy. These arise from errors in meiosis and are largely random events. Progesterone deficiency, antiphospholipid syndrome, and cervical incompetence are less common causes; cervical incompetence is a cause of second-trimester, not first-trimester, losses.'\n },\n {\n id:111,\n stem:'Abnormally LOW alpha-fetoprotein in maternal serum indicates:',\n correct:'Down\\'s syndrome',\n options:['Down\\'s syndrome','Anencephaly','Encephalocele','Meningocele'],\n exp:'Maternal serum AFP (MSAFP) screening: ELEVATED MSAFP \u2014 neural tube defects (anencephaly, open spina bifida, encephalocele, meningocele \u2014 all open defects leaking fetal CSF\/serum), abdominal wall defects, multiple pregnancy, fetal death. LOW MSAFP \u2014 Down syndrome (trisomy 21), trisomy 18. In Down syndrome, AFP is decreased because the fetus has a smaller liver (reduced AFP production). The \"triple test\" (AFP\u2193 + hCG\u2191 + oestriol\u2193) and \"quadruple test\" use these markers. All neural tube defects listed cause ELEVATED AFP; Down syndrome causes LOW AFP.'\n },\n {\n id:112,\n stem:'Umbilical cord blood stem cells are used to treat all the following diseases EXCEPT:',\n correct:'Parkinsonism',\n options:['Parkinsonism','Leukaemia','Diabetes','Osteoporosis'],\n exp:'Umbilical cord blood (UCB) is a rich source of haematopoietic stem cells (HSC) and has been used in transplantation for: leukaemias and other haematological malignancies (replacing bone marrow transplant), thalassaemia, sickle cell disease, and some immunodeficiencies. It has been used experimentally in Type 1 diabetes (restoring beta-cell function) and metabolic bone diseases including osteoporosis (osteoclast precursors). Parkinsonism (neurodegeneration of dopaminergic neurons) is NOT a current indication for UCB stem cell therapy \u2014 neural regeneration from cord blood HSC is not established for Parkinson\\'s disease.'\n },\n {\n id:113,\n stem:'A patient of ectopic pregnancy had beta-hCG less than 6000 IU\/mL. Medical management was done by single-dose methotrexate. Beta-hCG repeated after 48 hours was found to be 7000 IU\/mL. What will you do further?',\n correct:'Repeat the injection of methotrexate',\n options:['Repeat the injection of methotrexate','Operate the patient','Follow up with beta-hCG after one week','Follow up with beta-hCG after 72 hours'],\n exp:'Single-dose methotrexate protocol for ectopic pregnancy: beta-hCG measured on day 1 (injection), day 4, and day 7. A transient RISE (up to 20%) in beta-hCG on day 4 is NORMAL (expected) \u2014 this reflects continued trophoblastic activity before MTX effect. Assessment of treatment success\/failure uses the Day 4 \u2192 Day 7 trend: if Day 7 is >15% lower than Day 4, treatment is succeeding (follow up weekly until negative). If Day 7 shows <15% decline from Day 4 OR rises, this indicates treatment failure \u2192 REPEAT DOSE of methotrexate (second dose, same dose). The 48-hour rise here indicates early assessment; per protocol, a second dose is appropriate when the hCG is rising.'\n },\n {\n id:114,\n stem:'A 35-year-old married woman with no risk factors for cervical cancer is having a Pap smear showing \"atypical squamous cells of undetermined significance (ASCUS)\" for the first time. What is the further step in the management?',\n correct:'To follow up with Pap test at 6 months',\n options:['Repeat Pap immediately','Cryotherapy','Large loop excision of the transformation zone','To follow up with Pap test at 6 months'],\n exp:'ASCUS management (ASCCP guidelines): For a low-risk woman with ASCUS on first Pap smear, the preferred approach is: reflex HPV testing (if liquid-based) \u2014 if HPV-negative, repeat co-test in 3 years; if HPV-positive, colposcopy. Alternatively, repeat Pap in 6\u201312 months. Immediate colposcopy is not mandated for first-time ASCUS in a low-risk woman without HPV co-test. Cryotherapy and LLETZ are therapeutic procedures only appropriate after colposcopic biopsy confirmation of dysplasia. In the context of this question (no HPV co-test available), follow-up Pap at 6 months is the appropriate conservative initial step.'\n },\n {\n id:115,\n stem:'For a primary amenorrhoea individual having an XY karyotype, normal infantile female external and internal genitalia, fibrous bands in place of gonads, lack of development of secondary sexual characters, what is the most probable diagnosis?',\n correct:'Swyer syndrome',\n options:['Testicular feminisation syndrome','Mixed gonadal dysgenesis','Swyer syndrome','Defective anti-M\u00fcllerian hormone'],\n exp:'Swyer syndrome (pure gonadal dysgenesis, 46,XY): XY karyotype with completely dysgenetic streak gonads (fibrous bands) that never produce testosterone or AMH. Result: normal M\u00fcllerian structures develop (uterus, fallopian tubes, upper vagina \u2014 because no AMH), female external genitalia (no testosterone), primary amenorrhoea, absent secondary sexual characters (no oestrogen from streak gonads). Compare with testicular feminisation (CAIS): XY, testes present, female external genitalia BUT absent uterus\/tubes (AMH secreted), blind-ending vagina, normal breast development. Swyer has functioning M\u00fcllerian structures = key distinguishing feature.'\n },\n {\n id:116,\n stem:'A lady using oral contraceptive pills comes with a complaint of vaginal discharge and pruritus vulvae. On local examination, there is curdy white discharge from the vagina. What is the most likely clinical diagnosis?',\n correct:'Monilial vaginitis',\n options:['Trichomonal vaginitis','Monilial vaginitis','Gardnerella vaginalis','Atrophic vaginitis'],\n exp:'Curdy (cottage cheese-like), thick white vaginal discharge with intense pruritus vulvae is the hallmark of vulvovaginal CANDIDIASIS (monilial vaginitis, Candida albicans). OCPs alter vaginal glycogen metabolism, creating a favourable environment for Candida overgrowth \u2014 OCP use is a recognised predisposing factor. Diagnosis: KOH wet mount shows pseudohyphae and budding yeast. Treatment: topical\/oral azoles. Trichomonas = frothy yellow-green discharge with strawberry cervix. Bacterial vaginosis (Gardnerella) = fishy-smelling grey-white homogeneous discharge. Atrophic vaginitis = post-menopausal, not in OCP users.'\n },\n {\n id:117,\n stem:'Antisperm antibodies are usually present in:',\n correct:'Cervix',\n options:['Cervix','Vagina','Uterus','Fallopian tube'],\n exp:'Antisperm antibodies (ASA) in the female reproductive tract are most commonly found in CERVICAL MUCUS (produced by cervical crypts). IgG and IgA antisperm antibodies in cervical secretions agglutinate or immobilise sperm, preventing their penetration through the cervical mucus (post-coital test = Sims-H\u00fchner test demonstrates this). This is the most important site where ASA cause immunological infertility in females. In males, ASA are found on sperm surfaces (produced by testicular ASA after breach of blood-testis barrier). Cervix is the primary site of female ASA action.'\n },\n {\n id:118,\n stem:'For a woman who has been operated for chocolate cyst with normal menstrual cycle, any of the following may be prescribed EXCEPT:',\n correct:'Tranexamic acid',\n options:['Injection leuprolide','Tranexamic acid','Tablet dienogest','Oral progestogens'],\n exp:'Post-operative management of endometrioma (chocolate cyst) to prevent recurrence includes hormonal suppression of endometriosis: GnRH agonists (leuprolide), progestogens (dienogest \u2014 a highly selective progestogen approved specifically for endometriosis, oral progestogens), combined OCP, and Mirena. Tranexamic acid is an antifibrinolytic agent used for MENORRHAGIA (heavy menstrual bleeding) to reduce blood loss \u2014 it has NO role in treating or preventing endometriosis recurrence. Since this woman has a normal menstrual cycle, tranexamic acid is neither indicated nor appropriate. It is the exception.'\n },\n {\n id:119,\n stem:'For a 40-year-old hypertensive woman, which one of the following is NOT recommended for contraception?',\n correct:'NuvaRing',\n options:['NuvaRing','Minipill','IUCD','LNG IUD'],\n exp:'NuvaRing is a combined hormonal contraceptive (oestrogen + progestogen) vaginal ring. Combined hormonal contraceptives (containing oestrogen) are CONTRAINDICATED in women \u226535 years who smoke AND in women with hypertension \u2014 because oestrogen increases the risk of arterial thrombosis (stroke, MI) in hypertensive women (WHO MEC Category 3\u20134). NuvaRing is therefore NOT recommended. Minipill (progestogen-only pill) = safe in hypertension (no oestrogen). Copper IUCD = non-hormonal, safe. LNG IUD (Mirena) = local progestogen, systemic levels negligible, safe in hypertension. NuvaRing is the answer.'\n },\n {\n id:120,\n stem:'A 30-year-old female has severe dysmenorrhoea and dyspareunia. On examination, uterus is 8 weeks size, uniformly enlarged, and there is tenderness in the posterior fornix. What is the most probable diagnosis?',\n correct:'Adenomyosis',\n options:['Fibroid uterus','Dysfunctional uterine bleeding','Adenomyosis','Endometrial carcinoma'],\n exp:'The classic triad of adenomyosis: (1) Severe secondary dysmenorrhoea (worsening with age), (2) menorrhagia, and (3) a uniformly, symmetrically enlarged \"boggy\" uterus (here 8 weeks size). Dyspareunia (deep) occurs due to posterior uterine wall involvement and uterosacral ligament involvement. Posterior fornix tenderness suggests deep infiltrating endometriosis\/adenomyosis in the pouch of Douglas. Adenomyosis = ectopic endometrial glands within the myometrium \u2192 reactive myometrial hypertrophy \u2192 uniform uterine enlargement. Fibroid causes irregular, asymmetric enlargement. DUB has no pelvic mass. Endometrial carcinoma occurs in older, post-menopausal women.'\n }\n ];\n\n function shuffle(arr){\n const a=[...arr];\n for(let i=a.length-1;i>0;i--){const j=Math.floor(Math.random()*(i+1));[a[i],a[j]]=[a[j],a[i]];}\n return a;\n }\n const LETTERS=['A','B','C','D'];\n let userAnswers={},answered=0,shuffledOpts={};\n let timerRunning=false,timerRemaining=TIMER_SECS,timerInterval=null,graceInterval=null;\n let quizSubmitted=false;\n\n function fmtTime(s){const m=Math.floor(s\/60),sec=s%60;return String(m).padStart(2,'0')+':'+String(sec).padStart(2,'0');}\n\n function startTimer(){\n if(timerRunning||quizSubmitted)return;\n timerRunning=true;\n const btn=document.getElementById(NS+'-timer-btn');\n btn.textContent='\u23f1 '+fmtTime(timerRemaining);btn.classList.add('running');\n document.getElementById(NS+'-timer-item').classList.add('active');\n timerInterval=setInterval(function(){\n timerRemaining--;\n const disp=fmtTime(timerRemaining);\n document.getElementById(NS+'-timer-display').textContent=disp;\n btn.textContent='\u23f1 '+disp;\n if(timerRemaining<=300)document.getElementById(NS+'-timer-item').classList.add('warning');\n if(timerRemaining<=0){clearInterval(timerInterval);timerInterval=null;triggerGrace();}\n },1000);\n }\n function stopTimer(){if(timerInterval){clearInterval(timerInterval);timerInterval=null;}timerRunning=false;}\n function triggerGrace(){\n if(quizSubmitted)return;\n let g=GRACE_SECS;\n document.getElementById(NS+'-grace-count').textContent=g;\n document.getElementById(NS+'-grace').classList.add('show');\n graceInterval=setInterval(function(){g--;document.getElementById(NS+'-grace-count').textContent=g;if(g<=0){clearInterval(graceInterval);dismissGrace();showScore();}},1000);\n }\n function dismissGrace(){document.getElementById(NS+'-grace').classList.remove('show');if(graceInterval){clearInterval(graceInterval);graceInterval=null;}}\n\n function build(){\n const 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.cq-score-ring::before{content:'';position:absolute;width:86px;height:86px;border-radius:50%;background:var(--white);}\n#cms16p2c .cq-ring-inner{position:relative;display:flex;flex-direction:column;align-items:center;line-height:1.2}\n#cms16p2c .cq-ring-pct{font-family:'Playfair Display',serif;font-size:1.3rem;font-weight:700;color:var(--teal)}\n#cms16p2c .cq-ring-sub{font-size:0.6rem;color:var(--ink-soft);text-transform:uppercase;letter-spacing:0.05em}\n#cms16p2c .cq-score h2{font-family:'Playfair Display',serif;font-size:1.2rem;color:var(--ink);margin-bottom:8px}\n#cms16p2c .cq-net-line{font-size:1rem;color:var(--teal);font-weight:600;margin-bottom:6px}\n#cms16p2c .cq-verdict{font-size:0.85rem;color:var(--ink-soft);margin-bottom:20px}\n#cms16p2c .cq-score-bands{display:flex;justify-content:center;gap:10px;flex-wrap:wrap;font-size:0.8rem}\n#cms16p2c .cq-band{padding:4px 12px;border-radius:16px;font-weight:600}\n#cms16p2c .cq-band-c{background:var(--correct-bg);color:var(--correct)}\n#cms16p2c .cq-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#cms16p2c .cq-band-s{background:var(--teal-pale);color:var(--teal)}\n#cms16p2c .cq-retry-btn{margin-top:22px;background:transparent;border:2px solid var(--teal);color:var(--teal);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#cms16p2c .cq-retry-btn:hover{background:var(--teal);color:var(--white)}\n@media(max-width:480px){\n #cms16p2c .cq-header h1{font-size:1.15rem}\n #cms16p2c .cq-qtext{font-size:0.88rem}\n #cms16p2c .cq-opt-text{font-size:0.84rem}\n}\n<\/style>\n<\/head>\n<body>\n<div id=\"cms16p2c\">\n <div class=\"cq-sentinel\" id=\"cms16p2c-sentinel\"><\/div>\n <div class=\"cq-statusbar\" id=\"cms16p2c-statusbar\">\n <div class=\"cq-sb-stats\">\n <div class=\"cq-timer-item\" id=\"cms16p2c-timer-item\">\u23f1 <strong id=\"cms16p2c-timer-display\">40:00<\/strong><\/div>\n <div class=\"cq-sb-item\">\u2705 <strong id=\"cms16p2c-sc\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u274c <strong id=\"cms16p2c-sw\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u23f3 <strong id=\"cms16p2c-sr\">40<\/strong> left<\/div>\n <div class=\"cq-sb-sep\"><\/div>\n <div class=\"cq-sb-item\">Net <strong id=\"cms16p2c-sn\">0<\/strong> \/ <strong id=\"cms16p2c-sm\">160<\/strong><\/div>\n <\/div>\n <div class=\"cq-sb-progress\"><div class=\"cq-sb-fill\" id=\"cms16p2c-fill\"><\/div><\/div>\n <\/div>\n <div class=\"cq-grace\" id=\"cms16p2c-grace\">\n <div class=\"cq-grace-box\">\n <h3>Time's Up!<\/h3>\n <p>Submitting in<\/p>\n <div class=\"cq-grace-count\" id=\"cms16p2c-grace-count\">10<\/div>\n <button class=\"cq-grace-btn\" id=\"cms16p2c-grace-now\">Submit Now<\/button>\n <\/div>\n <\/div>\n <div class=\"cq-header\">\n <h1>Combined Medical Services Examination 2016<br>Paper II \u00b7 Part C<\/h1>\n <p>Obstetrics & Gynaecology<\/p>\n <div class=\"cq-meta\">\n <span class=\"cq-badge\">Questions 81 \u2013 120<\/span>\n <span class=\"cq-badge\">Options reshuffled<\/span>\n <button class=\"cq-timer-btn\" id=\"cms16p2c-timer-btn\">\u23f1 Start Timed Mode<\/button>\n <\/div>\n <\/div>\n <div class=\"cq-body\">\n <div id=\"cms16p2c-questions\"><\/div>\n <div class=\"cq-submit-wrap\">\n <button class=\"cq-btn\" id=\"cms16p2c-submit\">Submit Answers<\/button>\n <\/div>\n <div class=\"cq-score\" id=\"cms16p2c-score\">\n <div class=\"cq-score-ring\" id=\"cms16p2c-ring\">\n <div class=\"cq-ring-inner\">\n <span class=\"cq-ring-pct\" id=\"cms16p2c-ring-pct\">0%<\/span>\n <span class=\"cq-ring-sub\">score<\/span>\n <\/div>\n <\/div>\n <h2>Your Result<\/h2>\n <div class=\"cq-net-line\" id=\"cms16p2c-net-line\"><\/div>\n <div class=\"cq-verdict\" id=\"cms16p2c-verdict\"><\/div>\n <div class=\"cq-score-bands\">\n <span class=\"cq-band cq-band-c\" id=\"cms16p2c-ct-c\"><\/span>\n <span class=\"cq-band cq-band-w\" id=\"cms16p2c-ct-w\"><\/span>\n <span class=\"cq-band cq-band-s\" id=\"cms16p2c-ct-s\"><\/span>\n <\/div>\n <button class=\"cq-retry-btn\" id=\"cms16p2c-retry\">\u21ba Retry Quiz<\/button>\n <\/div>\n <\/div>\n<\/div>\n<script>\n(function(){\n 'use strict';\n const NS='cms16p2c', TOTAL=40, MAX=TOTAL*4;\n const TIMER_SECS=40*60, GRACE_SECS=10;\n\n const QUESTIONS=[\n {\n id:81,\n stem:'A 35-year-old nulliparous woman complains of menorrhagia and mass per abdomen. On examination she is anaemic, has a pelvic mass of 16\u201318 weeks size, firm in consistency, which moves with the movement of the cervix. What is the most likely clinical diagnosis?',\n correct:'Leiomyoma',\n options:['Leiomyoma','Adenomyosis','Endometrial carcinoma','Ovarian tumour'],\n exp:'The classic presentation of uterine leiomyoma (fibroid): nulliparous woman with menorrhagia (intramural\/submucosal fibroids), a large (16\u201318 weeks) firm, irregular pelvic mass that MOVES WITH THE CERVIX \u2014 this movement en masse with the cervix confirms the mass is uterine (arising from the uterus). Ovarian tumours are separate from the uterus and do not move with the cervix. Adenomyosis causes a uniformly enlarged uterus rarely exceeding 12 weeks. Endometrial carcinoma causes post-menopausal or irregular bleeding with small\/normal uterus. The mass size, nulliparity, and menorrhagia point firmly to fibroid uterus.'\n },\n {\n id:82,\n stem:'Abundant cornified cells in vaginal exfoliative cytology indicate:',\n correct:'Late proliferative phase',\n options:['Early proliferative phase','Late proliferative phase','Early secretory phase','Late secretory phase'],\n exp:'Vaginal exfoliative cytology (Maturation Index) reflects oestrogen levels: oestrogen causes maturation of vaginal epithelium to superficial cornified (anucleate\/pyknotic) cells. Maximum cornification occurs at PEAK OESTROGEN \u2014 the late proliferative (pre-ovulatory) phase, just before ovulation. Early proliferative phase has intermediate cells. Secretory phase (under progesterone) shows intermediate cells with curled edges (navicular cells) and increased leucocytes. Abundant cornified cells = high oestrogen = late proliferative phase.'\n },\n {\n id:83,\n stem:'Consider the following statements:\\n1. Carbon dioxide is the safest gas for creating pneumoperitoneum in operative laparoscopy.\\n2. Laparoscopic sterilisation is not recommended during the period of immediate postpartum.\\n\\nWhich of the statements given above is\/are correct?',\n correct:'Both 1 and 2',\n options:['1 only','2 only','Both 1 and 2','Neither 1 nor 2'],\n exp:'Both statements are correct. (1) CO\u2082 is the gas of choice for laparoscopic pneumoperitoneum because it is: highly soluble in blood (rapidly absorbed if accidentally embolised), non-flammable (safe with diathermy), and inexpensive. Nitrous oxide and helium have been used but CO\u2082 remains the safest and most universally used. (2) Laparoscopic sterilisation in the immediate postpartum period (first 48 hours after delivery) is not recommended because the distended, highly vascular uterus and friable tubes increase the risk of injury, haemorrhage, and failed occlusion. Mini-laparotomy is preferred in the immediate postpartum.'\n },\n {\n id:84,\n stem:'Polyhydramnios at term is diagnosed when AFI is more than:',\n correct:'25 cm',\n options:['10 cm','15 cm','20 cm','25 cm'],\n exp:'Amniotic Fluid Index (AFI) is the sum of the deepest vertical pockets in four uterine quadrants on ultrasound. Normal AFI at term = 8\u201324 cm. Oligohydramnios = AFI \u22645 cm. Borderline = AFI 5\u20138 cm. Polyhydramnios = AFI >25 cm (some sources say >24 cm). The single deepest pocket (SDP) method defines polyhydramnios as SDP >8 cm. The AFI threshold for polyhydramnios diagnosis at term is >25 cm. Mild = 25\u201330 cm, moderate = 30\u201335 cm, severe = >35 cm.'\n },\n {\n id:85,\n stem:'Which of the following is NOT a potentially teratogenic infection if contracted in pregnancy?',\n correct:'Influenza virus',\n options:['Rubella','Cytomegalovirus','Influenza virus','Chicken pox'],\n exp:'TORCH infections are the classical teratogenic congenital infections: Toxoplasma, Other (syphilis, parvovirus B19, varicella-zoster), Rubella, CMV, Herpes. Rubella (1st trimester) causes congenital rubella syndrome (cataracts, deafness, cardiac defects). CMV causes periventricular calcification, SNHL, microcephaly. Varicella-zoster (chickenpox) causes congenital varicella syndrome (limb hypoplasia, skin scarring, microcephaly). Influenza virus causes maternal morbidity but is NOT a recognised teratogen \u2014 it does not cause structural congenital malformations, though severe maternal illness can cause hyperthermia-related effects.'\n },\n {\n id:86,\n stem:'Active management of the 3rd stage of labour includes the following EXCEPT:',\n correct:'Injection oxytocin 10 IU intravenously',\n options:['Injection oxytocin 10 IU intramuscularly','Controlled cord traction','Uterine massage','Injection oxytocin 10 IU intravenously'],\n exp:'Active Management of Third Stage of Labour (AMTSL) per WHO\/FIGO guidelines comprises: (1) Oxytocin 10 IU IM within 1 minute of delivery of the baby \u2014 IM is the recommended route (slow onset prevents hypotension). (2) Controlled cord traction (Brandt-Andrews manoeuvre) after signs of placental separation. (3) Uterine massage after placental delivery to maintain uterine tone. Oxytocin 10 IU IV (intravenous bolus) is EXCLUDED from AMTSL \u2014 rapid IV bolus causes acute hypotension, tachycardia, and cardiovascular compromise. IV oxytocin may be given as a dilute infusion but NOT as a 10 IU bolus.'\n },\n {\n id:87,\n stem:'Regarding hypertensive disorders of pregnancy, the following are true EXCEPT:',\n correct:'Urinary dipstick result of +1 is equivalent to urinary protein concentration of 300 mg\/dl',\n options:[\n 'Significant proteinuria is \u22650.3 g\/24 hr',\n 'Eclampsia may present in the absence of hypertension',\n 'A protein:creatinine ratio more than 30 mg\/mmol is considered significant',\n 'Urinary dipstick result of +1 is equivalent to urinary protein concentration of 300 mg\/dl'\n ],\n exp:'Significant proteinuria in pre-eclampsia: \u22650.3 g\/24 hours (1+ = correct). Eclampsia CAN occur without preceding hypertension or proteinuria (atypical eclampsia) \u2014 this is a recognised and important clinical point (2 = correct). Protein:creatinine ratio >30 mg\/mmol (equivalent to >0.3 g\/g) is considered significant (3 = correct). Dipstick +1 corresponds to approximately 30 mg\/dL (0.3 g\/L), NOT 300 mg\/dL. Dipstick ++ (2+) corresponds to ~100 mg\/dL; +++ = ~300 mg\/dL. Statement (d) is WRONG \u2014 +1 dipstick \u2260 300 mg\/dL.'\n },\n {\n id:88,\n stem:'Which of the following is NOT a characteristic of Mayer-Rokitansky-K\u00fcster-Hauser (MRKH) syndrome?',\n correct:'Cardiac anomalies',\n options:['Cardiac anomalies','M\u00fcllerian duct aplasia','Renal abnormalities','Skeletal abnormalities'],\n exp:'MRKH syndrome (Type II \u2014 M\u00fcllerian Aplasia and Cervicothoracic Somite Abnormalities, MURCS association) is characterised by: (2) M\u00fcllerian duct aplasia \u2014 absent uterus and upper vagina, normal ovaries and female karyotype (46,XX). (3) Renal abnormalities \u2014 unilateral renal agenesis, ectopic kidney, horseshoe kidney (up to 40% of cases). (4) Skeletal abnormalities \u2014 vertebral (Klippel-Feil), rib, and limb anomalies. CARDIAC anomalies are NOT a recognised feature of MRKH syndrome. Cardiac defects are associated with Turner syndrome and other chromosomal disorders. Cardiac anomaly is the exception here.'\n },\n {\n id:89,\n stem:'Which one of the following is NOT a contraindication for prescribing combined oral contraceptive pills?',\n correct:'Pelvic inflammatory disease',\n options:['Thromboembolic disease','Viral hepatitis','Rheumatic heart disease','Pelvic inflammatory disease'],\n exp:'WHO Medical Eligibility Criteria (MEC) Category 4 (absolute contraindications) for COCPs include: thromboembolic disease (oestrogen is prothrombotic), active viral hepatitis (hepatic metabolism impaired, hepatotoxicity risk), valvular\/rheumatic heart disease with complications (risk of arterial thrombosis), hypertension, migraine with aura, breast cancer, smokers >35 years. Pelvic inflammatory disease (PID) is NOT a contraindication for COCPs \u2014 in fact, COCPs may be slightly protective against PID by thickening cervical mucus. PID is therefore not a contraindication.'\n },\n {\n id:90,\n stem:'The following are used in the staging of carcinoma of the cervix EXCEPT:',\n correct:'Pelvic lymph node involvement',\n options:['Pelvic lymph node involvement','Vaginal involvement','Hydroureter','Parametrial involvement'],\n exp:'FIGO staging of cervical carcinoma is a CLINICAL staging system (not surgical\/pathological). Parameters used: vaginal extent (Stage II = upper two-thirds, Stage III = lower one-third), parametrial involvement (Stage IIB = parametrial, Stage IIIB = pelvic wall), and hydroureter\/hydronephrosis (Stage IIIB). Pelvic lymph node status is determined surgically\/radiologically and is NOT included in classical FIGO clinical staging (though the 2018 FIGO revision allows imaging\/pathology to classify lymph node involvement as IIIC). For examination purposes: lymph node involvement is NOT used in FIGO clinical staging.'\n },\n {\n id:91,\n stem:'Presence of signet-ring cells in a cellular or myxomatous stroma is diagnostic of:',\n correct:'Krukenberg tumour',\n options:['Gynandroblastoma','Hilus cell tumour','Struma ovarii','Krukenberg tumour'],\n exp:'Krukenberg tumour is a metastatic tumour of the ovary (most commonly from gastric carcinoma, also colorectal, breast, appendix). Its hallmark histological feature is the presence of signet-ring cells (mucin-secreting cells with nucleus pushed to the periphery by intracellular mucin) embedded in a cellular\/myxomatous ovarian stromal reaction \u2014 the stroma reacts with sarcoma-like proliferation. Bilateral ovarian involvement is characteristic. Struma ovarii = thyroid tissue in teratoma. Hilus cell tumour = androgen-secreting. Gynandroblastoma = mixed sex-cord elements.'\n },\n {\n id:92,\n stem:'A 58-year-old woman, post-menopausal for the last 8 years, comes with history of spotting per vaginum. What is the most likely cause?',\n correct:'Atrophic endometritis',\n options:['Endometrial hyperplasia','Endometrial carcinoma','Atrophic endometritis','Estrogen replacement therapy'],\n exp:'Post-menopausal bleeding (PMB) requires systematic evaluation, but the MOST COMMON cause of PMB overall is atrophic vaginitis\/atrophic endometritis \u2014 accounting for ~60\u201380% of cases. Oestrogen withdrawal causes atrophy of the vaginal and endometrial epithelium, making the tissue fragile and prone to minor bleeding. Endometrial carcinoma, though the most feared cause, accounts for only ~10% of PMB cases. The question specifies \"most likely\" \u2014 without other features (obesity, diabetes, hypertension) pointing to malignancy, atrophic endometritis is the most probable cause in 8-year post-menopausal woman.'\n },\n {\n id:93,\n stem:'A diabetic obese patient comes with history of post-menopausal bleeding. On examination, there is a suprapubic mass and per vagina there is purulent discharge. The probable diagnosis is:',\n correct:'Carcinoma endometrium',\n options:['Carcinoma cervix','Carcinoma endometrium','Uterine myoma','Ovarian carcinoma'],\n exp:'The combination of post-menopausal bleeding in a diabetic, obese woman (classic risk factors for Type I endometrial carcinoma \u2014 oestrogen-driven), suprapubic mass (enlarged uterus from tumour bulk), and purulent vaginal discharge (pyometra from tumour obstruction causing secondary infection) strongly points to advanced carcinoma of the endometrium. The Triad: obesity + diabetes + post-menopausal bleeding = endometrial carcinoma until proved otherwise. Pyometra in this context represents pus accumulation in the uterine cavity obstructed by the tumour at the cervical os.'\n },\n {\n id:94,\n stem:'An adolescent girl with stage 1a dysgerminoma is managed by:',\n correct:'Unilateral salpingo-oophorectomy alone',\n options:['Unilateral salpingo-oophorectomy alone','Total abdominal hysterectomy with unilateral salpingo-oophorectomy','Bilateral salpingo-oophorectomy alone','Chemotherapy'],\n exp:'Dysgerminoma is the most common malignant germ cell tumour of the ovary. Stage IA (confined to one ovary, capsule intact, no ascites) in a young woman\/adolescent: treatment is UNILATERAL SALPINGO-OOPHORECTOMY alone (fertility-preserving surgery). Dysgerminoma is highly radiosensitive and chemosensitive. Stage IA has excellent prognosis with surgery alone (>95% 5-year survival). The contralateral ovary and uterus are preserved, maintaining fertility. Bilateral BSO or TAH would unnecessarily sacrifice fertility. Chemotherapy (BEP) is reserved for advanced stages or recurrence.'\n },\n {\n id:95,\n stem:'Which of the following conditions is best treated by a posterior colpotomy?',\n correct:'Pelvic abscess',\n options:['Pelvic abscess','Pyometra','Pyosalpinx','Pelvic haematocele'],\n exp:'Posterior colpotomy (culdotomy \u2014 incision through the posterior vaginal fornix into the pouch of Douglas) provides direct access to the pelvic peritoneal cavity for drainage. It is ideally suited for: PELVIC ABSCESS \u2014 a fluctuant, midline collection in the pouch of Douglas that is accessible transvaginally, allowing dependent drainage without laparotomy. Pyometra is drained transcervically (cervical dilatation). Pyosalpinx (tube abscess) requires laparotomy\/laparoscopy. Haematocele can be drained vaginally but the preferred approach depends on aetiology; pelvic abscess is the classic indication for posterior colpotomy.'\n },\n {\n id:96,\n stem:'Which of the following suture materials has the least tissue reaction?',\n correct:'Stainless steel',\n options:['Cotton\/Linen','Stainless steel','Chromic catgut','Silk'],\n exp:'Tissue reactivity of suture materials (least to most): Stainless steel wire < Polypropylene (Prolene) < Polyglyconate < Polyester (Dacron) < Nylon < Polyglactin (Vicryl) < Plain catgut < Silk < Chromic catgut < Cotton\/Linen. Stainless steel wire evokes the LEAST tissue reaction of all suture materials (minimal protein content, inert metal). Silk evokes significant tissue reaction and chronic inflammation. Cotton and linen cause severe tissue reaction (worst). Chromic catgut causes more reaction than plain catgut due to chromium processing. Stainless steel is therefore the correct answer.'\n },\n {\n id:97,\n stem:'Menopause is associated with the following EXCEPT:',\n correct:'Delusion',\n options:['Osteoporosis','Ischaemic heart disease','Loss of libido','Delusion'],\n exp:'Menopausal syndrome features: vasomotor symptoms (hot flushes, night sweats), urogenital atrophy, osteoporosis (oestrogen loss \u2192 accelerated bone resorption), ischaemic heart disease (loss of cardioprotective oestrogen \u2192 increased LDL, decreased HDL), sexual dysfunction (loss of libido, dyspareunia from vaginal atrophy), psychological symptoms (mood changes, anxiety, depression). DELUSION (a fixed false belief \u2014 a psychotic symptom) is NOT a feature of menopause. Depression may occur but psychosis\/delusion is not a recognised menopausal manifestation.'\n },\n {\n id:98,\n stem:'Which one of the following conditions simulates the menstrual pattern of pain?',\n correct:'Haematometra',\n options:['Intramural fibroid','Adenomyosis','Haematometra','Granulosa cell tumour of ovary'],\n exp:'Haematometra (accumulation of menstrual blood in the uterine cavity due to outflow obstruction \u2014 imperforate hymen, cervical stenosis) causes cyclical (monthly) lower abdominal pain occurring at the time of expected menstruation, with little or no external flow (cryptomenorrhoea). The pain strictly follows the menstrual cycle pattern, simulating dysmenorrhoea but with absent\/scant periods. Adenomyosis causes dysmenorrhoea but menstrual flow is present. Intramural fibroid causes menorrhagia. Granulosa cell tumour causes oestrogenic effects, not cyclic pain.'\n },\n {\n id:99,\n stem:'Which of the undermentioned conditions does NOT cause post-menopausal vaginal bleeding?',\n correct:'Benign cystic teratoma of ovary',\n options:['Benign cystic teratoma of ovary','Senile vaginitis','Carcinoma of cervix','Prolapse of uterus with decubitus ulcer'],\n exp:'Causes of post-menopausal bleeding: senile (atrophic) vaginitis (fragile atrophic mucosa), carcinoma cervix (ulcerating tumour), prolapse with decubitus ulcer (pressure ulceration of procidentia), endometrial carcinoma\/hyperplasia, functioning ovarian tumours (granulosa cell tumour \u2014 secretes oestrogen, stimulates endometrium), polyps, and HRT. Benign cystic teratoma (dermoid cyst) is a non-functioning germ cell tumour \u2014 it does NOT secrete hormones and does NOT cause post-menopausal bleeding. It is an asymptomatic mass incidentally found. This is the exception.'\n },\n {\n id:100,\n stem:'Defective fusion of the M\u00fcllerian ducts may give rise to which of the following?',\n correct:'Uterus bicornis unicollis',\n options:['Uterus bicornis unicollis','Imperforate anus','Imperforate hymen','Absence of the ovaries'],\n exp:'M\u00fcllerian duct anomalies arise from failure of normal development\/fusion of the paired M\u00fcllerian (paramesonephric) ducts. Defective FUSION (partial) of the two ducts results in bicornuate uterus (uterus bicornis unicollis \u2014 two horns, one cervix). Complete failure of fusion \u2192 uterus didelphys (double uterus, double cervix). Failure of resorption of septum \u2192 septate uterus. Imperforate anus and imperforate hymen have different embryological origins (hindgut and urogenital sinus respectively) \u2014 not M\u00fcllerian. Ovarian development is independent of M\u00fcllerian ducts (ovaries develop from gonadal ridge).'\n },\n {\n id:101,\n stem:'For a woman who had unprotected intercourse two days ago, which one of the following emergency contraceptive methods cannot be suggested?',\n correct:'LNG IUD (LNg IUD)',\n options:['LNG IUD','Ulipristal acetate','Levonorgestrel 1.5 mg','Yuzpe regimen'],\n exp:'Emergency contraception timelines: Copper IUCD \u2014 up to 5 days (most effective EC). LNG IUD (levonorgestrel-releasing IUS, e.g., Mirena) \u2014 NOT recommended as emergency contraception as it has no established EC efficacy; its mechanism is primarily local (thickened mucus, not post-fertilisation). Ulipristal acetate (ella) \u2014 up to 5 days. Levonorgestrel 1.5 mg \u2014 up to 3 days (most effective within 72 hours). Yuzpe regimen \u2014 within 72 hours. After 2 days (48 hours), all hormonal EC and copper IUCD remain options EXCEPT LNG IUD, which is not indicated as EC at any time.'\n },\n {\n id:102,\n stem:'Deep transverse arrest of the head in labour occurs in:',\n correct:'Android pelvis',\n options:['Android pelvis','Anthropoid pelvis','Platypelloid pelvis','Gynaecoid pelvis'],\n exp:'Deep transverse arrest (DTA) occurs when the fetal head descends to the level of the ischial spines but fails to rotate from the transverse position (occiput transverse) to the anterior position (OA) for delivery. DTA is classically associated with ANDROID PELVIS \u2014 the heart-shaped android inlet funnels to a narrow outlet with prominent ischial spines and convergent side walls, mechanically preventing internal rotation. Gynaecoid pelvis allows easy rotation. Anthropoid pelvis favours OP position but usually delivers. Platypelloid favours transverse presentation but rarely causes DTA.'\n },\n {\n id:103,\n stem:'Early deceleration of foetal heart rate in labour is due to:',\n correct:'Foetal head compression',\n options:['Congenital heart block','Umbilical cord compression','Foetal head compression','Hyperpyrexia'],\n exp:'Types of FHR decelerations: Early decelerations \u2014 uniform, mirror contractions, onset with contraction onset, nadir at peak, return to baseline by contraction end. Cause: FOETAL HEAD COMPRESSION during contractions \u2192 vagal reflex \u2192 transient bradycardia. Benign, no fetal compromise. Late decelerations \u2014 caused by uteroplacental insufficiency (ominous). Variable decelerations \u2014 caused by umbilical cord compression (variable shape\/timing). Congenital heart block causes persistent baseline bradycardia, not periodic decelerations. Early decelerations = head compression = vagal reflex.'\n },\n {\n id:104,\n stem:'McRoberts manoeuvre is used during labour for management of:',\n correct:'Shoulder dystocia',\n options:['Normal labour to assist extension of head','Extended arms of breech during assisted breech delivery','Shoulder dystocia','Delivery of after-coming head of breech'],\n exp:'McRoberts manoeuvre is the first-line intervention for SHOULDER DYSTOCIA (impaction of the anterior fetal shoulder behind the maternal pubic symphysis after delivery of the head). The manoeuvre involves hyperflexion of the maternal thighs onto the abdomen \u2014 this flattens the lumbar lordosis, rotates the pubic symphysis superiorly, increases the relative AP diameter of the pelvis, and facilitates release of the impacted shoulder. It is successful in ~40% of cases alone, and combined with suprapubic pressure resolves most cases. HELPERR mnemonic includes McRoberts as the first manoeuvre.'\n },\n {\n id:105,\n stem:'Which one of the following is NOT a suitable condition for outlet forceps application?',\n correct:'Head is above ischial spine level',\n options:['Cervix fully dilated','Membranes absent','Vertex presentation','Head is above ischial spine level'],\n exp:'Prerequisites for outlet forceps: (1) Cervix fully dilated \u2014 essential for all operative vaginal deliveries. (2) Membranes ruptured (absent) \u2014 must be ruptured. (3) Vertex (cephalic) presentation. (4) Head at outlet \u2014 scalp visible at introitus without separating labia, skull at pelvic floor, sagittal suture in AP or near-AP diameter. If the HEAD IS ABOVE THE ISCHIAL SPINES, this is mid-cavity (station 0 or above) \u2014 outlet forceps cannot be applied here. Outlet forceps requires the head to be at +2 station or below (at pelvic outlet). Head above ischial spines is therefore NOT a suitable condition.'\n },\n {\n id:106,\n stem:'Polyhydramnios is NOT caused by which one of the following?',\n correct:'Single kidney',\n options:['Anencephaly','Spina bifida','Single kidney','Oesophageal atresia'],\n exp:'Polyhydramnios results from decreased fetal swallowing or increased fetal urine production. GI causes (impaired swallowing): oesophageal atresia, duodenal atresia, anencephaly (absent\/poor swallowing reflex), tracheo-oesophageal fistula. Neural tube defects: anencephaly (absent swallowing) and open spina bifida (transudation from exposed neural tissue) both cause polyhydramnios. Single kidney (unilateral renal agenesis) does NOT cause polyhydramnios \u2014 the contralateral normal kidney maintains adequate urine output. Bilateral renal agenesis causes OLIGOHYDRAMNIOS. Single kidney = normal\/adequate amniotic fluid.'\n },\n {\n id:107,\n stem:'Which of the following is the type of antepartum haemorrhage where blood loss is foetal?',\n correct:'Vasa praevia',\n options:['Abruptio placentae','Placenta praevia','Vasa praevia','Circumvallate placenta'],\n exp:'In vasa praevia, fetal blood vessels (velamentous cord insertion) traverse the fetal membranes over or near the internal cervical os, unprotected by placenta or Wharton\\'s jelly. When membranes rupture, these vessels rupture \u2192 FETAL BLOOD IS LOST into the vagina. This causes sudden painless vaginal bleeding at membrane rupture, with immediate and severe fetal bradycardia\/distress. Fetal mortality is very high (>50%) without prompt recognition and emergency caesarean section. Placenta praevia and abruption cause MATERNAL blood loss. Vasa praevia is the only cause of APH where the blood is fetal.'\n },\n {\n id:108,\n stem:'Which one of the following conditions is NOT associated with oligohydramnios during pregnancy?',\n correct:'Oesophageal atresia',\n options:['Post-term pregnancy','Ruptured membranes','Intrauterine growth restriction','Oesophageal atresia'],\n exp:'Oligohydramnios (AFI \u22645 cm) causes: (1) Post-term pregnancy \u2014 placental insufficiency reduces fetal urine output. (2) Ruptured membranes \u2014 amniotic fluid leaks out. (3) IUGR \u2014 placental insufficiency \u2192 reduced fetal renal perfusion \u2192 reduced urine output \u2192 oligohydramnios. Also: bilateral renal agenesis (Potter sequence), posterior urethral valves, bladder exstrophy. Oesophageal atresia impairs fetal SWALLOWING \u2192 causes POLYHYDRAMNIOS (amniotic fluid not swallowed and recycled). It is NOT a cause of oligohydramnios. Oesophageal atresia is the exception.'\n },\n {\n id:109,\n stem:'A 23-year-old presents with recurrent abortions at 16 weeks gestation. She should be investigated for:',\n correct:'Incompetent cervix',\n options:['TORCH infection','Hepatitis B infection','Incompetent cervix','Balanced paternal translocation'],\n exp:'Recurrent pregnancy loss (RPL) at 16 weeks gestation (second trimester) is the key discriminator. Cervical incompetence (cervical insufficiency) classically causes PAINLESS, SILENT mid-trimester losses (14\u201328 weeks) \u2014 the internal os dilates without contractions, the membranes prolapse, and delivery occurs. This is distinct from first-trimester losses (chromosomal, thrombophilia, anatomical, immunological). TORCH infections cause first-trimester losses or congenital infections, not typically recurrent mid-trimester losses. Balanced translocations cause recurrent miscarriage, but typically in the first trimester. Incompetent cervix is the answer for 16-week recurrent losses.'\n },\n {\n id:110,\n stem:'Which of the following is the most common cause of abortion during the first trimester?',\n correct:'Chromosomal anomalies of foetus',\n options:['Cervical incompetence','Progesterone deficiency','Antiphospholipid antibody syndrome','Chromosomal anomalies of foetus'],\n exp:'Chromosomal anomalies of the fetus are the most common cause of sporadic (and many recurrent) first-trimester abortions, accounting for approximately 50\u201360% of all first-trimester miscarriages. The most common chromosomal abnormality is autosomal trisomy (trisomy 16 is the most frequent), followed by monosomy X (45,X), triploidy, and tetraploidy. These arise from errors in meiosis and are largely random events. Progesterone deficiency, antiphospholipid syndrome, and cervical incompetence are less common causes; cervical incompetence is a cause of second-trimester, not first-trimester, losses.'\n },\n {\n id:111,\n stem:'Abnormally LOW alpha-fetoprotein in maternal serum indicates:',\n correct:'Down\\'s syndrome',\n options:['Down\\'s syndrome','Anencephaly','Encephalocele','Meningocele'],\n exp:'Maternal serum AFP (MSAFP) screening: ELEVATED MSAFP \u2014 neural tube defects (anencephaly, open spina bifida, encephalocele, meningocele \u2014 all open defects leaking fetal CSF\/serum), abdominal wall defects, multiple pregnancy, fetal death. LOW MSAFP \u2014 Down syndrome (trisomy 21), trisomy 18. In Down syndrome, AFP is decreased because the fetus has a smaller liver (reduced AFP production). The \"triple test\" (AFP\u2193 + hCG\u2191 + oestriol\u2193) and \"quadruple test\" use these markers. All neural tube defects listed cause ELEVATED AFP; Down syndrome causes LOW AFP.'\n },\n {\n id:112,\n stem:'Umbilical cord blood stem cells are used to treat all the following diseases EXCEPT:',\n correct:'Parkinsonism',\n options:['Parkinsonism','Leukaemia','Diabetes','Osteoporosis'],\n exp:'Umbilical cord blood (UCB) is a rich source of haematopoietic stem cells (HSC) and has been used in transplantation for: leukaemias and other haematological malignancies (replacing bone marrow transplant), thalassaemia, sickle cell disease, and some immunodeficiencies. It has been used experimentally in Type 1 diabetes (restoring beta-cell function) and metabolic bone diseases including osteoporosis (osteoclast precursors). Parkinsonism (neurodegeneration of dopaminergic neurons) is NOT a current indication for UCB stem cell therapy \u2014 neural regeneration from cord blood HSC is not established for Parkinson\\'s disease.'\n },\n {\n id:113,\n stem:'A patient of ectopic pregnancy had beta-hCG less than 6000 IU\/mL. Medical management was done by single-dose methotrexate. Beta-hCG repeated after 48 hours was found to be 7000 IU\/mL. What will you do further?',\n correct:'Repeat the injection of methotrexate',\n options:['Repeat the injection of methotrexate','Operate the patient','Follow up with beta-hCG after one week','Follow up with beta-hCG after 72 hours'],\n exp:'Single-dose methotrexate protocol for ectopic pregnancy: beta-hCG measured on day 1 (injection), day 4, and day 7. A transient RISE (up to 20%) in beta-hCG on day 4 is NORMAL (expected) \u2014 this reflects continued trophoblastic activity before MTX effect. Assessment of treatment success\/failure uses the Day 4 \u2192 Day 7 trend: if Day 7 is >15% lower than Day 4, treatment is succeeding (follow up weekly until negative). If Day 7 shows <15% decline from Day 4 OR rises, this indicates treatment failure \u2192 REPEAT DOSE of methotrexate (second dose, same dose). The 48-hour rise here indicates early assessment; per protocol, a second dose is appropriate when the hCG is rising.'\n },\n {\n id:114,\n stem:'A 35-year-old married woman with no risk factors for cervical cancer is having a Pap smear showing \"atypical squamous cells of undetermined significance (ASCUS)\" for the first time. What is the further step in the management?',\n correct:'To follow up with Pap test at 6 months',\n options:['Repeat Pap immediately','Cryotherapy','Large loop excision of the transformation zone','To follow up with Pap test at 6 months'],\n exp:'ASCUS management (ASCCP guidelines): For a low-risk woman with ASCUS on first Pap smear, the preferred approach is: reflex HPV testing (if liquid-based) \u2014 if HPV-negative, repeat co-test in 3 years; if HPV-positive, colposcopy. Alternatively, repeat Pap in 6\u201312 months. Immediate colposcopy is not mandated for first-time ASCUS in a low-risk woman without HPV co-test. Cryotherapy and LLETZ are therapeutic procedures only appropriate after colposcopic biopsy confirmation of dysplasia. In the context of this question (no HPV co-test available), follow-up Pap at 6 months is the appropriate conservative initial step.'\n },\n {\n id:115,\n stem:'For a primary amenorrhoea individual having an XY karyotype, normal infantile female external and internal genitalia, fibrous bands in place of gonads, lack of development of secondary sexual characters, what is the most probable diagnosis?',\n correct:'Swyer syndrome',\n options:['Testicular feminisation syndrome','Mixed gonadal dysgenesis','Swyer syndrome','Defective anti-M\u00fcllerian hormone'],\n exp:'Swyer syndrome (pure gonadal dysgenesis, 46,XY): XY karyotype with completely dysgenetic streak gonads (fibrous bands) that never produce testosterone or AMH. Result: normal M\u00fcllerian structures develop (uterus, fallopian tubes, upper vagina \u2014 because no AMH), female external genitalia (no testosterone), primary amenorrhoea, absent secondary sexual characters (no oestrogen from streak gonads). Compare with testicular feminisation (CAIS): XY, testes present, female external genitalia BUT absent uterus\/tubes (AMH secreted), blind-ending vagina, normal breast development. Swyer has functioning M\u00fcllerian structures = key distinguishing feature.'\n },\n {\n id:116,\n stem:'A lady using oral contraceptive pills comes with a complaint of vaginal discharge and pruritus vulvae. On local examination, there is curdy white discharge from the vagina. What is the most likely clinical diagnosis?',\n correct:'Monilial vaginitis',\n options:['Trichomonal vaginitis','Monilial vaginitis','Gardnerella vaginalis','Atrophic vaginitis'],\n exp:'Curdy (cottage cheese-like), thick white vaginal discharge with intense pruritus vulvae is the hallmark of vulvovaginal CANDIDIASIS (monilial vaginitis, Candida albicans). OCPs alter vaginal glycogen metabolism, creating a favourable environment for Candida overgrowth \u2014 OCP use is a recognised predisposing factor. Diagnosis: KOH wet mount shows pseudohyphae and budding yeast. Treatment: topical\/oral azoles. Trichomonas = frothy yellow-green discharge with strawberry cervix. Bacterial vaginosis (Gardnerella) = fishy-smelling grey-white homogeneous discharge. Atrophic vaginitis = post-menopausal, not in OCP users.'\n },\n {\n id:117,\n stem:'Antisperm antibodies are usually present in:',\n correct:'Cervix',\n options:['Cervix','Vagina','Uterus','Fallopian tube'],\n exp:'Antisperm antibodies (ASA) in the female reproductive tract are most commonly found in CERVICAL MUCUS (produced by cervical crypts). IgG and IgA antisperm antibodies in cervical secretions agglutinate or immobilise sperm, preventing their penetration through the cervical mucus (post-coital test = Sims-H\u00fchner test demonstrates this). This is the most important site where ASA cause immunological infertility in females. In males, ASA are found on sperm surfaces (produced by testicular ASA after breach of blood-testis barrier). Cervix is the primary site of female ASA action.'\n },\n {\n id:118,\n stem:'For a woman who has been operated for chocolate cyst with normal menstrual cycle, any of the following may be prescribed EXCEPT:',\n correct:'Tranexamic acid',\n options:['Injection leuprolide','Tranexamic acid','Tablet dienogest','Oral progestogens'],\n exp:'Post-operative management of endometrioma (chocolate cyst) to prevent recurrence includes hormonal suppression of endometriosis: GnRH agonists (leuprolide), progestogens (dienogest \u2014 a highly selective progestogen approved specifically for endometriosis, oral progestogens), combined OCP, and Mirena. Tranexamic acid is an antifibrinolytic agent used for MENORRHAGIA (heavy menstrual bleeding) to reduce blood loss \u2014 it has NO role in treating or preventing endometriosis recurrence. Since this woman has a normal menstrual cycle, tranexamic acid is neither indicated nor appropriate. It is the exception.'\n },\n {\n id:119,\n stem:'For a 40-year-old hypertensive woman, which one of the following is NOT recommended for contraception?',\n correct:'NuvaRing',\n options:['NuvaRing','Minipill','IUCD','LNG IUD'],\n exp:'NuvaRing is a combined hormonal contraceptive (oestrogen + progestogen) vaginal ring. Combined hormonal contraceptives (containing oestrogen) are CONTRAINDICATED in women \u226535 years who smoke AND in women with hypertension \u2014 because oestrogen increases the risk of arterial thrombosis (stroke, MI) in hypertensive women (WHO MEC Category 3\u20134). NuvaRing is therefore NOT recommended. Minipill (progestogen-only pill) = safe in hypertension (no oestrogen). Copper IUCD = non-hormonal, safe. LNG IUD (Mirena) = local progestogen, systemic levels negligible, safe in hypertension. NuvaRing is the answer.'\n },\n {\n id:120,\n stem:'A 30-year-old female has severe dysmenorrhoea and dyspareunia. On examination, uterus is 8 weeks size, uniformly enlarged, and there is tenderness in the posterior fornix. What is the most probable diagnosis?',\n correct:'Adenomyosis',\n options:['Fibroid uterus','Dysfunctional uterine bleeding','Adenomyosis','Endometrial carcinoma'],\n exp:'The classic triad of adenomyosis: (1) Severe secondary dysmenorrhoea (worsening with age), (2) menorrhagia, and (3) a uniformly, symmetrically enlarged \"boggy\" uterus (here 8 weeks size). Dyspareunia (deep) occurs due to posterior uterine wall involvement and uterosacral ligament involvement. Posterior fornix tenderness suggests deep infiltrating endometriosis\/adenomyosis in the pouch of Douglas. Adenomyosis = ectopic endometrial glands within the myometrium \u2192 reactive myometrial hypertrophy \u2192 uniform uterine enlargement. Fibroid causes irregular, asymmetric enlargement. DUB has no pelvic mass. Endometrial carcinoma occurs in older, post-menopausal women.'\n }\n ];\n\n function shuffle(arr){\n const a=[...arr];\n for(let i=a.length-1;i>0;i--){const j=Math.floor(Math.random()*(i+1));[a[i],a[j]]=[a[j],a[i]];}\n return a;\n }\n const LETTERS=['A','B','C','D'];\n let userAnswers={},answered=0,shuffledOpts={};\n let timerRunning=false,timerRemaining=TIMER_SECS,timerInterval=null,graceInterval=null;\n let quizSubmitted=false;\n\n function fmtTime(s){const m=Math.floor(s\/60),sec=s%60;return String(m).padStart(2,'0')+':'+String(sec).padStart(2,'0');}\n\n function startTimer(){\n if(timerRunning||quizSubmitted)return;\n timerRunning=true;\n const btn=document.getElementById(NS+'-timer-btn');\n btn.textContent='\u23f1 '+fmtTime(timerRemaining);btn.classList.add('running');\n document.getElementById(NS+'-timer-item').classList.add('active');\n timerInterval=setInterval(function(){\n timerRemaining--;\n const disp=fmtTime(timerRemaining);\n 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