UPSC PAPER-2 1997

1.      Consider the following types of infective agents:

1.   Herpes simplex type I                                                             2.     Herpes simplex type II

3.   Human papilloma virus

         Among these, causative agents of carcinoma cervix would include:

A.   1 and 2                                                                                      B.    1 and 3

C.   2 and 3                                                                                      D.    1, 2 and 3

Ans. C  (Harrison 16th ed., p 557)

Virus infections by herpes virus type 2 and human papilloma virus (types 16, 18, 31, 33) have been implicated in causing dysplasia and carcinoma of cervix. HPV type 45, 51 and 53 are also implicated as causative agents of CA cervix.

Herpes simplex type 1 is not associated with CA cervix. It causes stomatitis in children. In adults it causes cold sores, keratitis and erythema multiforme.

2.      Which of the following pairs are correctly matched?

1.   Cancer of cervix                       –      Irregular bleeding

2.   Cancer of endometrium          –      Adenocarcinoma  

3.   Dysgerminoma                          –      Menopause

4.   Cancer vulva                             –      Pruritus

         Select the correct answer using the codes given below:

Codes:

A.   1 and 2                                                                                      B.    2, 3 and 4

C.   1, 2 and 4                                                                                  D.    1, 3 and 4

Ans. C  (Shaw 13th ed., p. 378, 387, 393)

l   Four main symptoms of CA cervix are:

–   Haemorrhage.

–   Discharge.

–   Cachexia.

–   Pain.

Typical haemorrhage is metrorrhagia, bleeding superimposed upon normal menstrual bleeding. In majority haemorrhage follows coitus.

l   CA of endometrium is adenocarcinoma histologically in 80-90% cases.

l   Most patients of CA vulva complain of pruritus, vulval swelling, lump or ulcer. Lesion bleeds or there may be offensive discharge.

l   Dysgerminoma arises in young women or in children, with an average age of incidence of 20 years. Dysgerminoma is not a tumour of menopause.

3.      A 40-year old primiparous woman suspected to be suffering from endometriosis is subjected to diagnostic laparoscopy for confirmation of diagnosis and also to see the extent of the spread of the disease. Laparoscopic findings indicate: Uterus normal; both the ovaries show presence of chocolate cysts; endometriotic deposits are seen on the round ligament right side, both the fallopian tubes and the pouch of Douglas; moderately dense adhesions are present between the fallopian tubes and the pouch of Douglas.

         The treatment of choice in this case is:

A.   Total hysterectomy with bilateral salpingo-oophorectomy

B.   Danazol therapy

C.   Progesterone therapy

D.   Fulguration of endometriotic deposits

Ans. D  (Essentials of Gynaecology 1st ed., p 186; DC Dutta Textbook of Gynaecology 3rd ed., p 289-292)

According to American Fertility Association (1985) classification the patient is suffering from severe endometriosis i.e., ovarian involvement with endomrtriomas exceeding 2 cm, dense peritubal and periovarian adhesions, involvement of uterosacral ligaments, bowel and urinary tract.

This classification based on laparoscopy helps in prognosis, to choose therapy, to evaluate treatment protocol and assessing the fertility rate in a woman effected by endometriosis.

In this case surgery is treatment of choice. It is indicated in:

1.  Endometriosis with severe symptoms unresponsive to hormone therapy.

2.  Severe endometriosis to correct the distortion of pelvic anatomy.

3.  Endometriomas of more than 1 cm.

Conservative surgey by laparotomy or laparoscopy is done. It includes any surgery short of removal of uterus and preserving at least one ovary. Fertility is restored even if one-tenth of an ovary could be preserved. Both the tubes may have to be removed to eradicate the lesions. Preservation of the uterus and the ovary will help IVF and ET in future. The surgery includes destruction of peritoneal implants by diathermy or laser vaporisation or resection of endometriomas or division of adhesions using laser. Laparoscopic uterosacral nerve ablation (LUNA) is done when pain is very severe.

Radical surgery is indicated in cases of severe endometriosis who have completed the family. Radical surgery means hysterectomy with bilateral salpingo-oophorectomy along with resection of endometrial tissues as complete as possible.

Hormonal treatment: The aim of the hormonal treatment is to induce atrophy of the endometriotic implants. It should be considered suppressive rather than curative because of high recurrence rate.

The mechanism of atrophy is either by producing ‘psudopregnancy’ or by ‘pseudomenopause’ or by ‘medical castration’. The hormonal use is gratifying in superficial peritoneal implants of endometriomas of less than 1 cm without firm adhesion.

The drugs used are combined oestrogen and progestogen (oral pill), progestogens, danazol and GnRH analogues. All the drugs are used continuously to produce amenorrhoea.

Combined oral pills result in anovulatory acyclic hormonal milieu and mimic pregnancy state. Indicated if other regimens can not be used or contraindicated.

Oral progestogens induce a hypoestrogenic acyclic hormonal environment. They suppress gonadotropins, inhibits ovulation and produces amenorrhoea. It has less side effects and avoids complications of oestrogen therapy.

Danazol has mild anabolic, antiestrogenic and antiprogestional action. It inhibits pituitary gonadotropins. Symptomatic relief occurs particularly in early stages of endometriosis. Endometriomas > 1 cm in diameter and advanced lesions poorly respond to danazol.

4.      All of the following statements concerning methods of limiting family size, are true, except:

A.   Women who do not breastfeed are much more likely to become pregnant than those who do

B.   Globally, the number of tubectomies far exceeds the number of vasectomies

C.   The barrier methods (condoms and diaphragms) are perhaps the most effective at limiting family size

D.   All anovulatory drugs are particularly likely to cause side effects in women over 35 years of age and women who smoke

Ans. C  (DC Dutta Textbook of Gynaecology 4th ed., p 439; DC Dutta Textbook of Obstetrics 6th ed., p 533-534)

The barrier methods (condoms and diaphragms) are not most effective at limiting family size. Sterilization methods are most effective in preventing further pregnancy. Vasectomy and tubectomy are used to prevent pregnancy in couples that have completed their family.

Barrier methods are only partially reliable.

Failure rate of Dutch cap is 4-6 per 100 women years while of condoms is 10-14 per 100 women years.

Even though vasectomy is minor surgical procedure as compared to tubectomy but still tubectomy as a sterilization procedure far exceeds the number of vasectomy all over the world.

Prolonged and sustained breast-feeding offers a natural protection from pregnancy. Risk of pregnancy is less than 2% in first 6 months in females who are fully breast-feeding and having amenorrhoea. Additional contraceptive support is given by condoms, IUCD or injectable steroid for complete contraception.

5.      The contraceptive “Today” contains which one of the following as the active ingredient?

A.   Nor-ethisterone                                                                        B.    Nonoxynol-9

C.   Prostaglandin E2                                                                                                          D.    Progestogen-estrogen

Ans. B  (DC Dutta Textbook of Obstetrics 6th ed., p 534)

Today is type of occlusive cap (diaphragm); a type of barrier contraceptive.

l   Mushroom shaped, 2 × 1 inch size, disposable polyurethane sponge with a loop for easy removal,

l   Contains 1 gm of nonoxynol-9, remains effective for 24 hours.

l   Should be kept high upon vagina and should not be removed for 6 hours after intercourse.

l   Failure rate is 9-30 per HWY.

l   Toxic shock syndrome is not common but allergic reactions and vaginal stenosis are known side effects.

l   Acts as a mechanical barrier and prevents entry of sperms into the cervical canal, absorbs semen and contain a spermicidal agent.

Remember the following important points commonly asked in examination:

l   Various spermicidal agents are:

–   Nonoxynol-9.

–   Octoxynol.

–   Menfegol.

–   Enzyme inhibiting agents e.g., ORF 13900.

ORF agglutinates sperms, inhibits sperm acrosin and alters mucus sperm interaction.

l   Other spermicidal agents are surfactants.

6.      Condom provides protection against AIDS because of:

A.   Spermicidal action                                                                  B.    Agglutination of spermatozoa

C.   Inhibition of sperm acrosin                                                   D.    None of the above

Ans. D  (DC Dutta Textbook of Gynaecology 4th ed., p 436; DC Dutta Textbook of Obstetrics 6th ed., p 533)

Condom is a barrier contraceptive and by preventing the mixing of vaginal secretion with seminal discharge condom gives added advantage of protection against sexually transmitted diseases likes AIDS (HIV), HPV, gonorrhoea, chlamydia etc.

Remember the following important points about condoms:

1.  Condoms are made of polyurethane or latex.

2.  Provides protection against STDs e.g., gonorrhoea, chlamydia, HIV, HPV etc.

3.  Provides protection against cervical cell abnormality.

4.  Method of contraception in patients of heart diseases where steroidal contraceptives are contraindicated.

5.  Use of condoms:

l   Elective contraception.

l   Interim contraception during:

–   Pill use.

–   Following vasectomy.

–   In cases of lost IUD before new IUD is inserted.

l   During treatment of trichomonas vaginalis of females.

l   Immunological infertility.

6.  Fem shield is female condom made of polyurethane, 15 cm in length with one polyurethane bag at each end.

7.      A patient with IUCD insertion a year back comes for follow-up reporting that she cannot feel the thread. Consider the following steps in the line of investigation:

1.   Exposing the cervix and looking for the thread                 2.     Laparoscopy

3.   Taking X-ray of pelvis after inserting another IUCD       4.     Laparotomy

         The correct sequence of these steps is:

A.   1, 3, 2, 4                                                                                     B.    1, 2, 3, 4

C.   1, 3, 4, 2                                                                                     D.    1, 2, 4, 3

Ans. A  (Shaw 13th ed., p 224)

Management of a case of misplaced IUCD:

l   Per vaginal examination looking for the thread.

l Plain X ray or pelvis USG to show IUCD is inside or outside uterine cavity.

    

Inside uterus                                                                                      Outside uterus

l  Uterine sound/another IUCD inserted in uterine cavity on X-ray     l    Laparotomy (copper-T causing

    will show proximity to misplaced IUCD and diagnose perforation.               adhesions to omentum or gut cannot be

l  Hysteroscopy:                                                                                easily retrieved by laparoscopy).

–  To locate IUCD.

–  To retrieve IUCD.

     Can also be removed with Shirodker’s hook or curette.

Causes of tail of IUCD not seen through os:

l   Uterus has enlarged through pregnancy.

l   Thread has curled inside.

l   Perforation has occurred.

l   Expelled IUCD.

8.      A 27-year old married lady has been on combined oral contraceptive pill. At first she had regular withdrawal bleeding. Four years after marriage, she had decided to have a baby and hence discontinued the pill. Unfortunately, spontaneous period did not occur. After nine months of amenorrhoea, she reported to a gynaecologist. The most likely diagnosis is:

A.   Hyperprolactinaemia                                                             B.    Polycystic ovarian disease

C.   Weight related amenorrhoea                                                 D.    Tuberculosis of endometrium

Ans. A  (Harrison 16th ed., p 2085)

The patient has most probably developed hyperprolactinemia due to estrogen component of OCP. According to table 328-8 of Harrison 15th ed., estrogen causes hyperprolactinaemia. It manifests in the form of amenorrhoea with or without galactorrhoea.

9.      Which one of the following sets of hormones is present in “Mala D”?

A.   D-norgestrel 0.30 mg and ethinyl oestradiol 0.03 mg

B.   Norethisterone acetate 1.0 mg and ethinyl oestradiol 0.03 mg

C.   L-norgestrel 0.50 mg and ethinyl oestradiol 0.03 mg

D.   Desogestrel 0.15 mg and ethinyl oestradiol 0.03 mg

Ans. A  (DC Dutta Textbook of Obstetrics 6th ed., p 543)

Table: Composition of oral contraceptives.

Mala D                                   Mala N                                   Loette                                    Femilon                                  Composition

D-norgestrel 0.30 mg         Norgestrel 0.30 mg             Levonorgestrel 0.1 mg       Desogestrel 0.15 mg           Progestins (mg)

Ethinyl oestradiol 30 µg     Ethinyl oestradiol 30 µg     Ethinyl oestradiol 20 µg     Ethinyl oestradiol 20 µg       Oestrogen (µg)

Mala-N is distributed through government channels free of cost.

10.    Consider the following statements:

         Depo-provera is:

1.   17 a-hydroxy progesterone caproate (Proluton depot)    2.     Depot medroxyprogesterone acetate

3.   Given intramuscularly 3-monthly                                        4.     Safe for lactating mothers

         Of  these statements:

A.   2 alone is correct                                                                      B.    1, 2 and 3 are correct

C.   1 and 3 are correct                                                                  D.    2, 3 and 4 are correct

Ans. D  (Ashok Kumar Essentials of Gynaecology 1st ed., p 31)

Depo-provera is DMPA. It is a long acting injectable contraceptive. It is aqueous suspension of micro crystals of 17 acetoxy 6 methyl progestin. 150 mg is given by IM route every 3 months. According to DC Dutta Textbook of Obstetrics it has very little effect on breast milk and can be safely used during lactation. It probably increases milk secretion without altering the composition.     

11.    Failure of which of the following contraceptive methods are associated with a high incidence of ectopic pregnancy?

1.   Tubal sterilisation                                                                    2.     IUCD

3.   Oral contraception

         Select the correct answer using the codes given below:

Codes:

A.   1 and 2                                                                                      B.    1 and 3

C.   2 and 3                                                                                      D.    1, 2 and 3

Ans. D  (DC Dutta Textbook of Obstetrics 6th ed., p 180)

In contraception failure though absolute number of ectopic pregnancy is very less because pregnancy occurs less often but in few selected contraception failure the incidence of ectopic pregnancy is increased.

1.  IUCD: Prevents uterine pregnancy effectively, tubal pregnancy to lesser extent and ovarian pregnancy not at all.

l   CuT-380 and levonorgestrol devices have got the lowest rate of ectopic pregnancy.

l   Progestasert has got the highest rate of ectopic pregnancy.

2.  Sterilization operation:

l   Following tubal sterilization 15-20% chances of ectopic pregnancy.

l   Risk is highest following laparoscopic fulguration without tubal ligation.

3. Oral pills of progestin only or post coital oestrogenic preparations may lead to ectopic pregnancy.

Even tubal surgeries, intrapelvic adhesions following pelvic surgery, ART (IVF-ET and GIFT) and ovulation induction increase chances of ectopic pregnancy.

12.    An unmarried girl presents with 16 weeks pregnancy. Which one of the following would be a safe method of terminating her pregnancy?

A.   Suction evacuation                                                                 B.    Intraamniotic instillation of hypertonic saline

C.   Extraamniotic instillation of mannitol                                D.    Extraamniotic instillation of ethacridine lactate

Ans. D  (DC Dutta Textbook of Obstetrics 6th ed., p 174-177)

Extraamniotic instillation of ethacridine lactate is a very safe method of termination of pregnancy. It is safer than hypertonic saline and suction evacuation. However in USA surgical termination of pregnancy is considered to be safer than medical methods of termination of pregnancy.

Methods of termination of pregnancy between 16-20 weeks:

A.  Intrauterine instillation of hypertonic solution.

l   Intraamniotic:

–   Hypertonic saline (20%) commonly employed among unmarried or mother of one child.

     Contraindicated in CVS lesion, renal lesion, severe anaemia.

–   Hyperosmolar urea (40%).

l   Extraamniotic:

–   Ethacridine lactate (0.1%).

B.  Prostaglandins:

–   Vaginal: PGE1 (Misoprostol), PGE2 (Dinoprostone).

–   Intramuscular: 15 methyl PGF2a (Carboprost), sulprostone (PGE2 analogue).

–   Extraamniotic: PGF2a, PGE2.

–   Intraamniotic: PGE2, PGF2a.

     Prostaglandins are contraindicated in asthmatics.

C.  Oxytocin intra/extra amniotically.

D.  Hysterotomy.

l   In non immunized women IM administration of 100 µg anti-D gamma globulin is given within 72 hours of abortion.

Method of termination of pregnancy in rest of cases of mid-trimester abortion i.e., between 14-15 weeks of gestation:

l   To allow pregnancy to continue & uterus to enlarge to 16 weeks size and intrauterine instillation of pharmacological agents mentioned above.

l   Prostaglandins.

l   Transcervical intraaminotic hypertonic saline 20% or extraamniotic i.e., ethacridine lactate 0.1%.

l   Hysterotomy: Concurrent sterilization is must.

13.    If anti-epileptic drugs are given during pregnancy, there will be an increased chance of which of the following foetal anomalies?

1.   Cleft lip and cleft palate                                                        2.     Cardiac abnormalities

3.   Open neural tube defects

         Select the correct answer using the codes given below:

Codes:

A.   1 and 2                                                                                      B.    1 and 3

C.   2 and 3                                                                                      D.    1, 2 and 3

Ans. D  (Harrison 16th ed., p 2371)

Cleft lip and cleft palate is a teratogenic effect of carbamazepine. Open neural tube defect (meningomyelocele, spina bifida) is a teratogenic effect of valproic acid. Phenytoin is responsible for pulmonary stenosis, aortic stenosis, coarctation of aorta, PDA etc.

14.    Which one of the following hypertensive drugs is absolutely contraindicated in pregnancy induced hypertension?

A.   a-methyl dopa                                                                         B.    Nifedipine

C.   Enalapril                                                                                    D.    Labetalol

Ans. C  (Harrison 16th ed., p 33)

Enalapril is contraindicated in treatment of PIH. ACE inhibitors can cause fetal and neonatal morbidity and mortality when administered to pregnant women during the second and third trimesters. Fetal exposure to ACE inhibitors during the second and third trimesters can cause hypotension, reversible or irreversible renal failure, anuria, neonatal skull hypoplasia, and death of the fetus or neonate. Maternal oligohydramnios, which may result from decreased fetal renal function, has been reported and associated with fetal limb contractures, craniofacial deformation, and hypoplastic lung development. Other adverse effects that have been reported are prematurity, intrauterine growth retardation, and patent ductus arteriosus, although how these effects are related to exposure to ACE inhibitors is not clear. Infants who have been exposed in utero to ACE inhibitors should be observed closely for hypotension, oliguria, and hyperkalemia.

15.    Which of the following pairs are correctly matched?

1.   Circumvellate placenta    –               Antepartum haemorrhage

2.   Succenturiate lobe             –               Retained placenta

3.   Deep transverse arrest       –               Shoulder presentation

4.   Single umbilical artery      –               Foetal congenital abnormalities

         Select the correct answer using the codes given below:

A.   2 and 4                                                                                      B.    1, 3 and 4

C.   1, 2 and 4                                                                                  D.    1, 2 and 3

Ans. C 

In deep transverse arrest the head is deep inside the pelvic cavity and there is no progress of head even after ½ to 1 hour after full dilatation of cervix in spite of good contractions. This is not possible in shoulder presentation. Shoulder presentation is seen in transverse lie. Rest of the choices are correctly matched.

16.    One week after an extended hysterectomy, the patient leaks urine per vaginum. In spite of the leakage, she has to pass urine from time to time. The most likely cause is:

A.   Vesico-vaginal fistula                                                             B.    Ureterovaginal fistula

C.   Stress incontinence                                                                  D.    Overflow incontinence

Ans. B  (Merck Manual of Geriatrics. Chapter 118 – Female Genital Disorder)

This patient has developed ureterovaginal fistula during extended hysterectomy. It is an uncommon complication of various gynaecology operations.

Probably only one ureter is damaged and the other one is intact. The injured ureter has made a fistula with vault of vagina and this leads to leakage of urine per vaginum. The other uninjured ureter is draining into bladder and hence she is passing urine from time to time.

Postvoiding incontinence is one of the main feature of this condition.

In VVF there is continuous leakage of urine per vaginum i.e., total incontinence.

17.    A multiparous woman with rupture of upper uterine segment is best treated by:

A.   Uterine packing                                                                        B.    Total abdominal hysterectomy

C.   Wertheim’s hysterectomy                                                      D.    Bilateral internal iliac ligation

Ans. B  (DC Dutta Textbook of Obstetrics 6th ed., p 431)

The two main features of treatment of rupture uterus are resuscitation and laparotomy. Depending upon the clinical condition either laparotomy has to be done after resuscitation or both have to be performed simultaneously.

Since it is a case of multipara there is no point of trying to save the uterus. Hysterectomy is the main treatment. Generally a quick subtotal hysterectomy is preferred but if the condition permits then total hysterectomy can be done.

18.    Consider the following statements:

         The term “disease control” describes ongoing operations aimed at reducing the:

1.   Incidence of disease

2.   Financial burden to the community

3.   Effect of infection including both physical and psychological complications

4.   Duration of disease and its transmission

         Of these statements:

A.   1, 2 and 3 are correct                                                              B.    1, 3 and 4 are correct

C.   1, 2 and 4 are correct                                                              D.    1, 2, 3 and 4 are correct

Ans. D  (Park 18th ed., p 35)

Disease control: Operation aimed at reducing:

1.  The incidence of disease.

2.  The duration of disease and consequently the risk of transmission.

3.  The effects of infection, including both the physical and psychological complications.

4.  The financial burden to the community.

Most of disease control programme combine both primary prevention or secondary prevention.

l   In disease control, disease ‘agent’ is permitted to persist in the community at a level where it ceases to be pubic health problem according to the tolerance of the local population.

Disease elimination is used to describe ‘interruption of transmission of disease’.

Disease eradication means tear out by roots. Eradication of disease implies termination of all transmission of infection by extermination of the infectious agent.

19.    In an outbreak of cholera in a village of 2000 population, 20 cases have occurred and 5 have died. Case fatality rate is:

A.   1%                                                                                              B.    0.25%

C.   5%                                                                                              D.    25%

Ans. D  (Park 18th ed., p 52)

Case fatality rate (CFR) =

=  = 25%.

Remember of the following important points about case fatality rate:

l   Represents the killing power of the disease.

l   Case fatality rate is a ratio.

l   Used for acute infectious diseases. Its use in chronic disease is limited.

l   CFR is closely related to virulence.

l   CFR for same disease may vary in different epidemics because of changes in the agent, host and environmental factors.

20.    Investigation of an epidemic in a community includes all of the following except:

A.   Verification of case                                                                 B.    Confirmation of the epidemic

C.   Isolation of cases                                                                    D.    Studying ecofactors

Ans. C  (Park 18th ed., p 109)

Investigation of an epidemic

In investigation of an epidemic, it is desired to have an orderly procedure or practical guidelines as outlined below which are applicable for almost any epidemic study.

1.  Verification of diagnosis.

2.  Confirmation of the existence of an epidemic.

3.  Defining the population at risk.

4.  Rapid search for all cases and their characteristics.

5.  Data analysis.

6.  Formulation of hypothesis.

7.  Testing of hypothesis.

8.  Evaluation of ecological factors.

9.  Further investigation of population at risk.

10. Writing the report.

21.    Which of the following are associated with randomized controlled trials?

1.   Randomization

2.   Selecting reference and experimental population

3.   Avoidance of manipulation (intervention)

4.   Assessment of the outcome of the trial in terms of positive and negative results

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 3                                                                                  B.    1, 2 and 4

C.   1 and 4                                                                                      D.    1, 2, 3 and 4

Ans. B  (Park 18th ed., p 75-77)

In randomized controlled trial (RCT) manipulation (intervention) is not avoided. Rather study and control groups are formed, the next step is to intervene/manipulate the study (experimental) group by the delibrate application or withdrawal or reduction of suspected causal factor.

Basic steps in conducting a RCT:

l   Drawing up a protocol.

l   Selecting reference and experimental populations.

l   Randomization.

l   Manipulation or intervention.

l   Follow-up.

l   Assessment of outcome.

22.    Consider the following indication:

1.   Good evidence of association between exposure and disease

2.   Exposure is rare but incidence of disease is high among the exposed

3.   Ample funds are available

4.   The disease is of epidemic proportion in the area

         Indications for cohort studies would include:

A.   1, 2 and 3                                                                                  B.    2, 3 and 4

C.   1, 2 and 4                                                                                  D.    1, 3 and 4

Ans. A  (Park 18th ed., p 69)

Indications of cohort study:

a.  When there is good evidence of an association between exposure and disease, as derived from clinical observation and supported by descriptive and case-control studies.

b.  When exposure is rare but the incidence of disease is high among exposed.

c.  When attrition of study population can be minimized e.g., follow up is easy, cohort is stable, co-operative and easily accessible.

d.  When ample funds are available.

23.    At the end of the year 1990, the population of a primary health centre was 30,000 and there were 120 cases of pulmonary tuberculosis. At the end of the year 1991, the population was 30,600 and 30 new cases were detected and 2 cases had died. Based on this data all of the following rates can be calculated except:

A.   Incidence                                                                                  B.    Prevalence

C.   Case fatality                                                                             D.    Proportional mortality

Ans. D  (Park 18th ed., p 52, 55-56)

Proportional mortality from a specific disease =

Total deaths from all cases in that year is required which has not been provided in the question so proportional mortality can not be calculated.

Data in question is:

Total population under PHC at the end of 1990 = 30,000.

Total population under PHC at the end of 1991 = 30,600.

Cases of TB = 150.

Death due to TB = 2.

Now cases detected in between 1990 to 1991 = 30

Case fatality rate (ratio) =

=  = 1.33.

Incidence rate =

=  = 0.98 per 1000.

Prevalence =

= = 0.49.

So, all other rates can be calculated by given data except proportional mortality.

24.    The relative risk of disease associated with exposure is obtained from the:

A.   Ratio of incidence among the exposed divided by incidence among the non-exposed

B.   Ratio of incidence among the non-exposed divided by incidence among the exposed

C.   Ratio of prevalence among the exposed divided by prevalence among the non-exposed

D.   Rate of incidence among the exposed minus the rate of incidence among the non-exposed.

Ans. A  (Park 18th ed., p 72)

Relative risk/risk ratio: Ratio between the incidence of disease among exposed persons and incidence among non-exposed.

Case-control study does not provide incidence rates from which relative risk can be calculated directly, because there is no appropriate denominator or population at risk, to calculate these rates. Relative risk can be exactly determined only from cohort study.

25.    To get an idea of the status of immunity against diphtheria among the primary school children, Schick test was done and throat swab was examined for Corynebacterium diphtheriae. The result were tabulated as follows:

1.   Schick positive                                                                         2.     Schick negative

3.   Swab positive                                                                           4.     Swab negative

         The carriers among the children would include those with:

A.   1 and 4                                                                                      B.    1 and 3

C.   2 and 3                                                                                      D.    2 and 4

Ans. C  (Park 18th ed., p 134)

Carrier is defined as an infected person or animal that harbours a specific infectious agent in the absence of discernible clinical disease and serves as a potential source of infection for others. They are less infectious than cases, but epidemiologically, they are more dangerous than cases because they escape recognition and continuing as they do to live a normal life among the population of community, they readily infect the susceptible individuals over a wider area and longer period of time, under favourable conditions.

l   Schick negative reaction means the person is immune to diphtheria and Schick positive reaction means that the person is susceptible to diphtheria.

l   Carriers of diphtheria can be detected only by cultural method and since they do not suffer from clinical disease they are immune.

So carriers will be Schick negative and swab positive.

26.    An 8-month old female baby is brought for fever, cough and failure to thrive. From birth she had received 1:1 cow’s milk up to six months. Since then ragi conjee and mashed idlis were added to her feed. One month back she had developed measles. Now she has fever, cough and is irritable and refuses to open her eyes. She is diagnosed to have marasmus, post-measles bronchopneumonia and corneal xerosis and keratomalacia. For the treatment of marasmus, the diet should include:

A.   100 cal/kg of her present weight                                           B.    110 cal/kg of her expected weight

C.   150 cal/kg of her present weight                                           D.    200 cal/kg of her present weight

Ans. A (Nelson 17th ed., p 173; OP Ghai 6th ed., p 109-110)

The initiation of the cure of the marasmic child is started in step wise fashion as vigorous feeds may lead to heart failure and death due to:

1.  Excessive dietary sodium.

2.  Activated sodium pump.

3.  Rapidly expanding ECF volume.

The route of feeding is oral and if it is not possible then a nasogastric tube may be used. Quantum of feeds is limited to three percent of present body weight with frequency up to 12 per day on first and second day to 6 to 8 per day on third to seventh day. Types of feeds are usually milk based diets containing sugar and oil to increase the calories.

All the calculations now are done based on present weight. The calorie intake should not exceed 100 Kcal/kg/day on first day. In a week’s time this may be gradually increased to 150 Kcal/kg/day. Total amount of fluids should be kept within 100-125 ml/kg/day.

Iron is added after a week of therapy. During these seven days marasmus child will gain little or no weight and kwashiorkor child will lose weight. Rehabilitative phase starts after seven days.

27.    Consider the following statements:

         Compared to cow’s milk, breast milk has:

1.   More casein                                                                              2.     Less fat

3.   Better antiinfective properties                                               4.     More sugar

         Of these statements:

A.   1 and 4 are correct                                                                  B.    2, 3 and 4 are correct

C.   1, 2 and 3 are correct                                                              D.    1, 2, 3 and 4 are correct

Ans. B  (Nelson 16th ed., Chapter 41)

Casein content of breast milk is less than that of human milk. According to Nelson casein content of breast milk is 3.7 g/l whereas it is 24.9 g/l in cow’s milk. According to Park the ratio of casein to albumin is nearly 1:1 in a human milk as compared to 15:1 in cow’s milk. Human milk is rich in cysteine.

According to Park the fat content of human milk is 3.40% whereas it is 4.1% in cow’s milk and 6.5% in buffalo milk. However according to Nelson the total fat content of breast milk is 71 g/l and it is 47 g/l in cow’s milk.

Breast milk has better anti-infective properties because it contains:

1.  Secretory IgA.

2.  Macrophages, lymphocytes.

3.  Anti-streptococcal factor.

4.  Lysozyme.

5.  Lactoferrin.

28.    Which of the following pairs are correctly matched?

1.   Growth monitoring                                  –    Growth chart

2.   Primary prevention                                 –    Immunization

3.   Nutritional surveillance                          –    Health education

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 3                                                                                  B.    1 and 3

C.   2 and 3                                                                                      D.    1 and 2

Ans. D  (Park 18th ed., p 36-37, 402)

Growth chart or road to health chart is designed primarily for the longitudinal follow up of physical growth and development (growth monitoring) of a child.

Primary prevention is action taken prior to the onset of disese, which removes the possibility that a disease will ever occur. It can be accomplished by measures designed to promote general health and well being and quality of life of people or by specific protective measures. Primary prevention strategies include health promotion and specific protection. Health promotion measures include health education, environmental modifications, nutritional interventions, lifestyle and behaviroual changes.

The specific protection measures include:

a.  Immunization.

b.  Use of specific nutrients.

c.  Chemoprophylaxis.

d.  Protection against occupational hazards.

e.  Protection against accidents.

f.   Protection from carcinogens.

g.  Avoidance of allergens.

h.  Control of specific hazards in the general environment e.g., air pollution, noise control.

i.   Control of consumer product quality and safety of foods, drugs, cosmetics etc.

Nutritional surveillance is defined as keeping watch over nutrition, in order to make decisions that will lead to improvement in nutrition in population. Three distinct objectives have been defined for surveillance systems:

a.  To aid long term planning in health and development.

b.  To provide input for programme management and evaluation.

c.  To give timely warning and intervention to prevent short term food consumption crises.

Health education is a process aimed at encouraging people to want to be healthy, to know how to stay healthy, to do what they can individually and collectively to maintain health and to seek help when needed.

29.    A 3-months old female infant weighs 4 kg and is suffering from loose motions. On examination, she is found to be suffering from some dehydration. The amount of ORS to be given to her in the four hours will be:

A.   100 ml                                                                                       B.    300 ml

C.   500 ml                                                                                       D.    600 ml

Ans. B  (OP Ghai 6th ed., p 274; Park 18th ed., p 180)

Table: Guidelines for oral rehydration therapy (for all ages) during first four hours.

Age                               Under 4 months       4-11 months      1-2 years        2-4 years         5-14 years        15 years or above

Weight (kg)                  Under 5                       5-7.9                    8-10.9              11-15.9             16-29.9              30 or over

ORS solution (ml)       200-400                      400-600              600-800          800-1200         1200-2200        2200-4000

l    Patient’s age should be used only if weight is not known.

l    Approximate amount of ORS required in ml may also be calculated by multiplying the patient’s weight (expressed in kg) by 75.

WHO has classified dehydration into three degrees i.e., nil, some and severe. The plan according to WHO guidelines for some dehydration has plan B. Plan B has two important phases, the deficit replacement phase and the maintenance fluid therapy phase.

The deficit replacement is done in first four hours where 75 ml/kg of ORS is given (hence 300 ml).

Once the signs of dehydration disappear then the maintenance fluid therapy with 10-20 ml per kg for each liquid stool is replaced as ongoing losses. Further it is important to recommend that plain water of 100-200 ml may be given to less than six months babies during the deficit replacement phase and thereafter frequent feeds.

30.    The “Baby Friendly Hospital” initiative advocates initiation of breast feeding within:

A.   One hour of birth                                                                     B.    Two hours of birth

C.   Four hours of birth                                                                  D.    Eight hours of birth

Ans. A  (Park 18th ed., p 411)

Global baby friendly has listed 10 steps which hospital must fulfil.

They are:

l   Initiate breast feeding within the first hour of birth in normal delivery and 4 hours following caesasan section.

l   Encourage breast feeding on demand.

l   Allow mothers and infants to remain together 24 hours a day except for medical reasons.

l   Give newborn infants no food or drink other than breast milk unless medically indicated.

l   Exclusive breast feeding till 4-6 months of age.

l   No advertisement, promotional material or free products for infants should be allowed in the facility.

BFHI is created and promoted by WHO and UNICEF.

31.    Which of the following index/indices can be used to assess the antenatal care provided at a primary health centre?

1.   Percentage of pregnant women registered                          2.     Percentage of women registering in the I, II and III trimesters

3.   Number of contacts with pregnant women

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 3                                                                                  B.    1 and 3

C.   2 alone                                                                                       D.    2 and 3

Ans. A  (Park 18th ed., p 387)

Antenatal care is the care of the woman during pregnancy. The primary aim is to achieve at the end of a pregnancy a healthy mother and a healthy baby. Ideally this care should begin soon after conception and continue throughout pregnancy.

All the three indices mentioned can be used to assess the antenatal care provided at a primary health centre.

32.    For the longitudinal follow-up (growth monitoring) of an under-5 child, ideally, the weight of the child is to be recorded and plotted on a graph:

A.   Once every month

B.   Once a month during infancy, once every two months during the second year and once every three months thereafter till the child is 5 years old

C.   Once every month during the first two years and once every two months thereafter till the child is 5 years old

D.   Once every month during infancy, once in two months during the second year, once in three months during the third year, once in four months during the fourth year and once in six months during the fifth year

Ans. B  (Park 18th ed., p 401)

Basic activity of under-fives clinic is growth monitoring. In growth monitoring, weight of child is measured monthly during infancy, every 2 months during 2nd year and every 3 months there after up to the age of 5 to 6 years.

33.    What is the elemental iron content in the iron and folic acid tablets supplied by the hospitals and health centres to the pregnant women under the CSSM programme?

A.   60 mg                                                                                         B.    66 mg

C.   100 mg                                                                                      D.    200 mg

Ans. C  (National Child Survival and Safe Motherhood Programme, Govt. of India Publication)

Under the CSSM programme to make up for the extra iron requirements during pregnancy, the diet of pregnant women must be supplemented with iron and folic acid (IFA) tablets.

l   All pregnant women must be given 1 tablet daily of IFA-large (containing 100 mg of elemental iron) for at least 100 days. IFA tablets should be continued till delivery.

l   Women with visible signs of anaemia must be given 2 tablets of IFA-large daily.

l   Those with haemoglobin levels below 11 gm% should also receive 2 tablets daily.

34.    The safest vaccine for post-exposure prophylaxis against rabies in humans is:

A.   Sheep brain vaccine                                                                B.    Inactivated duck embryo vaccine

C.   Human diploid cell vaccine                                                   D.    Inactivated chick embryo vaccine

Ans. C  (Park 18th ed., p 219)

Safest vaccine for both pre-and post exposure immunization is human diploid cell vaccine (HDC vaccine). But because of low cost and potency second generation tissue culture vaccine are being preferred.

Remember the following important points about rabies:

l   Rabies vaccine is unique because it is the only vaccine that is given after exposure to infection.

l   Rabies is caused by a bullet shaped neurotrophic RNA virus, Lyssavirus type I.

l   Fixed virus is obtained by serial brain to brain passage of the street virus in rabbit till its incubation period is progressively reduced and fixed (4-6 days).

–   It does not form Negri bodies.

–   It no longer multiplies in extraneural tissues.

l   Source of infection to man is the saliva of rabid animals.

l   Reservoir of infection are dogs, jackal, fox, hyena, vampire bat, etc.

l   All warm blooded animals including man are susceptible.

l   Rabies in man is a dead-end infection.

l   Modes of infection are – animal bites, licks, aerosols, person to person (rare), corneal and organ transplant.

l   Incubation period is highly variable and depends on site of bite, severity of bite, number of wounds, amount of virus injected, species of biting animal, protection provided by clothing and treatment undertaken.

l   Virus replicates in muscles and connective tissue cells at a near site of introduction before it attaches to nerve endings and enters peripheral nerves.

Clinical features:

l   Prodromal symptoms: Headache, malaise, sore throat and slight fever, followed by widespread excitation and stimulation of all parts of nervous system involving in order, the sensory system, motor system, sympathetic and mental system.

l   Intolerance to noise, bright light, cold draught of air.

l   Aerophagia: Fear of air.

l   Hydrophobia (fear of water) is characteristic pathognomonic symptom.

l Patient may die because of convulsions.

l   On examination there is increased reflexes, muscle spasms along with dilatation of pupils and increased perspiration, salivation and lacrimation.

l   Rabies can be confirmed by antigen detection using immunofluorescence of skin biopsy and by virus isolation from saliva and other secretions.

l   There is no specific treatment for rabies.

l   Observation period applies only to dogs and cats.

l   Recommended dose schedule of post exposure prophylaxis is 0, 3, 7, 14, 28 and a booster dose on day 90.

l   Injections are given IM in deltoid and must not be given in buttock. For pre-exposure prophylaxis 1 ml IM/0.1 ml intradermally given on 0, 7 and 28 days. Booster dose should be administered at intervals of 2 years.

35.    After  two doses of vaccination against plague, the immunity will last for:

A.   Six months                                                                                B.    One year

C.   Eighteen months                                                                      D.    Twenty-four months

Ans. A  (Park 18th ed., p 237)

For plague prevention two doses of formalin killed vaccine 0.5 and 1.0 ml at interval of 7 to 14 days are given. Immunity starts 5 to 7 days after inoculation and lasts for about 6 months.

l   Booster doses are recommended 6 monthly for person at continuing risk of infection.

Remember the following important points about plague:

1.  Plague is primarily and basically a zoonoses caused by Y. pestis a gram negative, non-motile, cocco-bacillus that exhibits bipolar staining with special stains.

2. In Northern India plague season starts from September until May.

3.  Commonest and most efficient vector of plague is rat flea, X. cheopis.

4.  In India, Tatera indica (wild rodent) has been incriminated as the main reservoir of plague not the domestic rat R. rattus.

5.  Disease in man occurs in 3 main clinical forms:

l Bubonic plague: 2-7 days.

l Pneumonic plague: 1-3 days.

l Septicemic plague: 2-7 days incubation period.

6.  DOC for chemoprophylaxis is doxycycline.

7.  Bubonic plague is the most common type.

8.  Plague is a notifiable disease.

9.  Absolute confirmation of plague infection in human beings, rodents or fleas require the isolation and identification of plague bacilli.

10. Most effective method to break the chain of transmission is destruction of flea by proper application of an effective insecticide.

36.    Which of the following are true of ‘Saheli’?

1.   It is commenced on the fifth day of the start of menstrual bleeding

2.   One tablet is taken twice a week in the first three months

3.   It is a non-hormonal contraceptive

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 3                                                                                  B.    1 and 2

C.   1 and 3                                                                                      D.    2 and 3

Ans. D  (Shaw 13th ed., p 232)

Saheli contains centchroman which is developed by CDRI Lucknow. Saheli is the trade name.

It is a synthetic non steroidal contraceptive which is taken as a 30 mg tablet, started on first day of menses and taken twice weekly for 3 months and then weekly thereafter.

Remember the following important points about centchroman:

1.  It prevents implantation by endometrial changes.

2.  It has strong antioestrogenic and weak estrogenic action at peripheral receptor level.

3.  The main side effect is prolonged cycles and oligomenorrhea.

4.  Pregnancy rate is 1.83 per 100 women years.

5.  Can be used as post coital pill.

37.    Which of the following pairs of contraceptives and the failure rate per 100 women years are correctly matched?

1.   Nirodh                                         –      5 to 15

2.   Oral pill                                       –      Less than one

3.   Tubectomy                                –      2

         Select the correct answer using the codes given below:

A.   2 and 3                                                                                      B.    1 and 3

C.   1 and 2                                                                                      D.    1, 2 and 3

Ans. C  (Shaw 13th ed., p 219, 226)

Failure rate per 100 woman years is 10-14 for condom and about 0.1% for OCP (lowest of all contraceptives). Failure rate of Pomeroy’s technique is only 0.4%.

Contraceptive method                                                                               Pregnancy rate/100 women years

None used                                                                                                                                   80

Rhythm method                                                                                                                          25

Coitus interruptus                                                                                                                       25

Diaphragm                                                                                                                                4 to 6

Femshield                                                                                                                                  5-15

Today                                                                                                                                          9-30           

Progestasert                                                                                                                               0-3

DMPA                                                                                                                                             1

Minipill                                                                                                                                         2-3

NET-EN                                                                                                                                        0.6

Centchroman                                                                                                                            1.83

Vasectomy                                                                                                                                 0.15

Laparoscopic sterilization                                                                                                        0.6

38.    A 50-year old male has been having cough for the past one month. In the past one week, he had also noticed some blood in his sputum. Under the National Tuberculosis Control Programme, he would now need:

A.   A chest X-ray at the district centre                                       B.    Sputum examination

C.   A course of antibiotics                                                            D.    Antituberculosis treatment

Ans. B  (Park 18th ed., p 335)

Under National Tuberculosis Programme case finding is done by primary health care workers by collecting, fixing the sputum of symptomatics on a slide during their routine visits to villages and send the slide to nearest health centre for microscopic examination.

39.    Which one of the following is more directly associated with coronary heart disease?

A.   HDL                       –    High density lipoproteins

B.   LDL                        –    Low density lipoproteins

C.   VLDL                     –    Very low density lipoproteins

D.   VHDL                    –    Very high density lipoproteins

Ans. B  (Park 18th ed., p 290)

The levels of low-density lipoprotein (LDL) cholesterol is most directly associated with CHD (coronary heart disease).

It should be less than 100 mg% in persons who are at risk of having CHD (for e.g., diabetic patient).

40.    Match List-I (Cancers) with List-II (Etiologically related organisms) and select the correct answer using the codes given below the Lists:

       List-I                                                                                                      List-II

a.   Cancer bladder                                                                              1.   Hepatitis B

b.   Burkitt’s lymphoma                                                                     2.   Epstein Barr virus

c.    Kaposi’s sarcoma                                                                         3.   Schistosoma haematobium

d.   Cancer liver                                                                                    4.   Cytomegalovirus

Codes:

A.   a     b     c      d              B.   a     b     c      d           C.   a      b       c      d              D.   a      b    c     d

       3     2     4     1                    2     3     4     1                  3      2       1      4                    2      3    1    4

Ans. A  (Robbins 6th ed., p 248, 312-313, 1007)

Schistosoma haemotobium infections in areas where these are endemic (Egypt, Sudan) are an established risk for urinary bladder neoplasia. Seventy percent of the cancers are squamous cell CA, the remainder being transitional cell CA.

There is a close association between hepatitis B virus infection and occurrence of liver cancer. Hepatitis C virus is also strongly linked to pathogenesis of hepatocellular carcinoma.

Epstein-Barr virus (EBV) a member of the herpes family has been implicated in pathogenesis of African form of Burkitt lymphoma; B cell lymphomas in immunosuppressed individuals, particularly in those with HIV infection and organ transplantation; some cases of Hodgkin disease and nasopharyngeal carcinoma.

Kaposi sarcoma associated herpesvirus (KSHV) is present in KS lesions. Types 8 human herpesvirus is associated with Kaposi sarcoma. The main correlation between cytomegalovirus and Kaposi’s sarcoma is that cytomegalovirus belongs to b herpesvirus group.

41.    The decibel level of sound above which auditory fatigue occurs is:

A.   60 db                                                                                          B.    70 db

C.   85 db                                                                                          D.    140 db

Ans. C  (Park 18th ed., p 551)

A daily exposure up to 85 dB is about the limit people can tolerate without substantial damage to their hearing.

Effect of noise exposure:

1.  Auditory effect:

l Auditory fatigue appears in 90 dB region and greatest at 4,000 Hz.

l Deafness:

–   Most serious pathological effect.

–   Most temporary hearing loss occurs in frequency range between 4,000-6,000 Hz.

–   Repeated or continuous exposure to nose around 100 decibels may result in a permanent hearing loss.

–   Exposure to noise above 160 dB may rupture the tympanic membrane and cause permanent loss of hearing.

2.  Non-auditory effect:

l Interference with speech.

l Annoyance.

l Decreased efficiency.

l Physiological changes:

–   Increased BP.

–   Increased ICT (intracranial tension).

–   Increased heart rate, breathing and increase in sweating.

l Economic losses.

42.    A coalmine worker, working since he was 15 years old is now at the age of 40 years and having chronic cough and breathlessness. The most likely diagnosis is:

A.   Bagassosis                                                                                B.    Asbestosis

C.   Anthracosis                                                                               D.    Byssinosis

Ans. C  (Park 18th ed., p 609; Kumar and Clark 4th ed., p 817)

There are two phases of anthracosis/coal miner’s pneumoconiosis:

1.  First phase labelled as simple pneumoconiosis is associated with little ventilatory impairment. This phase may require about 12 years of work exposure for its development.

2.  The second phase is characterised by progressive massive fibrosis (PMF). There are round fibrotic masses several centimeters in diameter, involving upper lobes, resulting in emphysema and airway damage. Lung function tests show a mixed restrictive and obstructive ventilatory defect with loss of lung volume, irreversible airflow limitation and reduced gas transfer.

The patient with PMF suffers considerable effort dyspnoea, usually with a cough. The disease can progress (or even develop) after exposure to coal dust has ceased. Eventually respiratory failure may supervene.

Coal miner’s pneumoconiosis has been declared a notifiable disease in the Indian Mines Act of 1952 and also compensatable in the Workmen’s Compensation (Amendment) Act of 1959.

Pneumoconiosis

1.  Inorganic dusts: Disease

–   Coal dust                                            Anthracosis

–   Silica                                                  Silicosis

–   Asbestos                                            Asbestosis, cancer lung

–   Iron                                                     Siderosis

2.  Organic (vegetable) dusts:

–   Cane fibre                                           Bagassosis

–   Cotton dust                                         Byssinosis

–   Tobacco                                             Tobaccosis

–   Hay/grain dust                                     Farmer’s lung

43.    Hardy-Weinberg law relates to:

A.   Societal bonds                                                                          B.    Demography

C.   Epidemiology                                                                           D.    Population genetics

Ans. D  (Park 18th ed., p 628)

Hardy-Weinberg law is about population genetics. This law assumes that human population is static but in reality, human population and consequently human gene pool is never static.

44.    Study of the behaviour of an individual in relation to his family, friends and other members of a society is known as:

A.   Medical sociology                                                                   B.    Social psychology

C.   Anthropology                                                                           D.    Human psychology

Ans. B  (Park 18th ed., p 493)

Sociology includes study of relationship between human beings. Sociology also concerns with study of human behaviour.

Medical sociology includes studies of medical profession, of the relationship of medicine to public and of the social factors, in the aetiology, prevalence, incidence and interpretation of disease.

Psychology is defined as the study of human behaviour – of how people behave and why they behave in just the way they do.

Social psychology deals with behaviour of individuals in relation to his family, friends and other members of the society.

45.    Mental disturbances are causes by the deficiency of:

A.   Fluoride                                                                                     B.    Iodine

C.   Zinc                                                                                            D.    Managanese

Ans. B  (Park 18th ed., p 633)

Environmental factors other than psychosocial ones capable of producing abnormal human behaviour are:

l Toxic substances: Carbon disulfide, tin, Hg, Mn, Pb compounds etc.

l   Psychotropic drugs: Barbiturates, alcohol, griseofulvin.

l   Nutritional factors: Deficiency of thiamine, pyridoxine.

l   Minerals: Deficiency of iodine.

l   Infective agents: Infectious diseases (e.g., measles, rubella) during the prenatal, perinatal and post-natal periods of life may have adverse effect on the brain’s development and integration of mental functions.

l   Traumatic: Roadside and occupational accidents.

l   Radiation.

46.    The most commonly abused drug causing addiction among Indians is:

A.   Amphetamine                                                                          B.    Cocaine

C.   Cannabis                                                                                   D.    LSD

Ans. C  (Park 18th ed., p 635)

The most widely used drug for drug abuse is cannabis. It is obtained from hemp plants – Cannabis sativa, C. indica and C. americana.

The resinous exudate from the flowering tops of the female plant contains most of the active ingredients called hashish or charas.

The dried leaves and flowering shoots are called bhang and the ganja. In USA, term marijuana is used to refer to any part of the plant which induces somatic and psychic changes in man.

It produces psychic dependence.

47.    In solving public health problems, long lasting solutions/results can be obtained from:

A.   Participatory approach                                                          B.    Regulatory approach

C.   Educational approach                                                            D.    Service approach

Ans. C  (Park 18th ed., p 657)

Many public health problems can be solved only through health education. It is believed that the people will be better off if they have autonomy over their own lives, including health affairs on which an informed person should be able to make decisions to protect their own health. These are the higher goals of health education. If necessary behaviour changes are to take place, people must be educated through planned learning experiences what to do, and be informed, educated and encouraged to make their own choice for a healthy life. The results are slow, but enduring. Since attitudes and behavioural patterns are formed early in life, health education must be started with young population.

48.    In a district, the immunization programme was evaluated by assessing the reduction in prevalence of disease in terms of the monetary expenditure involved. This process is called:

A.   Cost accounting                                                                       B.    Cost benefit analysis

C.   Cost effectiveness analysis                                                   D.    Programme evaluation and review

Ans. C  (Park 18th ed., p 669)

Cost-benefit analysis: Management technique in which economic benefit of any programme are compared with the cost of that programme. The benefits are expressed in monetary terms to determine whether a given programme is economically sound and to select the best out of several alternate programmes.

Cost-effective analysis is more promising tool than cost-benefit analysis. In it the benefit instead of being expressed in monetary terms is expressed in terms of results achieved e.g., number of lives saved or number of days free from disease.

Cost accounting provides basic data on cost structure of any programme. Financial records are kept in a manner permitting costs to be associated with the purpose for which they are incurred.

Programme evaluation and review technique is a management technique which makes possible more detailed planning and more comprehensive supervision. In it an arrow diagram is constructed which represents the logical sequence in which events must take place.

49.    In a primary health centre with an infant population of 900, the amount of DPT vaccine required for a year will be:

A.   2700 doses                                                                                B.    3600 doses

C.   4800 doses                                                                                D.    7200 doses

Ans. A  (Park 18th ed., p 346)

Three doses of DPT each of which is usually 0.5 ml should be considered optimal for primary immunization.

Total infant = 900

Dose per child = 3

Total doses required = 900 × 3 = 2,700.

Accordingly PHC with an infant population of 900 require 2700 doses with a dose of 3 vaccines per infant.

50.    The drug schedule used for radical treatment of falciparum malaria is:

A.   600 mg chloroquine

B.   600 mg chloroquine and 15 mg primaquine for four days

C.   600 mg chloroquine and 45 mg primaquine in one dose

D.   300 mg chloroquine once a week

Ans. C  (Park 18th ed., p 208)

1.  In low risk areas:

a.  Presumptive treatment: Tablet chloroquine 10 mg/kg body weight.

b.  Radical treatment after confirmation of species.

l   P. vivax: Tab. chloroquine 10 mg/kg body weight single dose and tab. primaquine 0.25 mg/kg body weight daily for 5 days.

l   P. falciparum: Tab. chloroquine 10 mg/kg body weight plus tablet primaquine 0.75 mg/kg body weight single dose.

2.  In high risk areas:

a.  Presumptive treatment of all suspected/clinical malaria cases:

l   Day 1: Tab. chloroquine 10 mg/kg body weight (600 mg adult dose). Tablet primaquine 0.75 mg/kg body weight (45 mg adult dose).

l   Day 2: Tab. chloroquine 10 mg/kg body weight (600 mg adult dose).

l   Day 3: Tab. chloroquine 5 mg/kg body weight (300 mg adult dose).

3.  Radical treatment after microscopic confirmation of species:

l P. falciparum: No further treatment required.

l P. vivax: Tab. primaquine 0.25 mg/kg body weight (15 mg adult dose) daily for 5 days.

51.    The multidrug regimen under the National Leprosy Eradication Programme for the treatment of all multibacillary leprosy would include:

A.   Clofazimine, thiacetazone and dapsone                            B.    Clofazimine, rifampicin and dapsone

C.   Ethionamide, rifampicin and dapsone                                D.    Propionamide, rifampicin and dapsone

Ans. B  (Park 18th ed., p 261; 17th ed., p 250)

Treatment of multibacillary leprosy case:

l Rifampicin : 600 mg once monthly given under supervision.

l   Dapsone: 100 mg daily, self administered.

l   Clofazimine: 300 mg once monthly supervised and 50 mg daily, self-administered.

Recommended duration for multibacillary leprosy is 12 months.

Treatment of paucibacillary leprosy:

l Rifampicin: 600 mg once a month for 6 months supervised.

l   Dapsone: 100 mg for 6 months self-administered.

Recommended duration of treatment is 6 months.

Single lesion paucibacillary leprosy: One single dose of a combination of rifampicin 600 mg, ofloxacin 400 mg and 100 mg of minocycline (ROM) is used.

52.    Human development index (UNDP) includes:

A.   Life expectancy, gross national product and per capita income

B.   Education, social status and life expectancy

C.   Per capital income, education and life expectancy

D.   Education, life expectancy and purchasing power

Ans. C  (Park 18th ed., p 16)

Human development index (HDI) represents 3 dimensions:

1.  Longevity (life expectancy at birth).

2.  Knowledge (adult literacy rate).

3.  Income (real GDP per capita in purchasing power).

l HDI for India is  = 0.545.

l   India comes in medium HDI category at no. 132.

53.    The following are the vital statistics of a town with mid-year population of 50,000:

CBR = 40

CDR = 15

IMR = 100

MMR = 5

         The total number of maternal deaths in this town is:

A.   40                                                                                               B.    30

C.   20                                                                                               D.    10

Ans. D  (Park 18th ed., p 412)

Total number of births in this town of 50,000 is calculated by:

Birth rate =

40 =

Number of live births during the year =  = 2000

Now maternal mortality rate is exressed as a rate per 1000 live births and is defined as:

5 =

Total no. of female deaths =  = 10

54.    The mid-year population of a village in 1994 was 3000. There were 120 births and 30 infant deaths during this year. The infant mortality rate for the village in the year 1994 was:

A.   10                                                                                               B.    100

C.   200                                                                                             D.    250

Ans. D  (Park 18th ed., p 417)

Infant mortality rate =

Applying data IMR =  = 250

55.    All of the following are methods of presentation of statistical data except:

A.   Bar charts                                                                                 B.    Pie diagram

C.   Normal curve                                                                           D.    Frequency polygon

Ans. C  (Park 18th ed., p 643-644)

Presentation of statistical data: Various methods are tables, charts, diagrams, graphs, pictures, special curves.

1.  Tables:

a.  Simple table.

b.  Frequency distribution tables.

2.  Charts and diagrams:

a.  Bar charts.

b.  Histogram/frequency polygon.

c.  Line diagram.

d.  Pie charts.

e.  Pictogram.

3.  Statistical maps.

Normal distribution or normal curve is an important concept of statistical theory. Normal curve has bilateral symmetry with peak in the middle. It has a bell shape.

56.    Which of the following are true of Anopheles mosquito?

1.   The adult sits on the wall making an angle with it

2.   The eggs are seen floating singly in water

3.   The larvae have two siphon tubes

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 3                                                                                  B.    1 and 2

C.   2 and 3                                                                                      D.    1 and 3

Ans. B  (Park 18th ed., p 576)

Table: Differentation between anopheline and culicine.

Tribe/Genus    Anophelini/Anopheles                                                       Culicini/Culex, Aedes, Mansonia

Eggs                 Laid singly                                                                           Laid in clusters of rafts, each raft containing

                                                                                                                        100-250 eggs (except aedes)

                          Eggs are boat shaped and provided                                Eggs are oval shaped and not provided with

                          with lateral floats                                                                 lateral floats

Larvae              Rest parallel to water surface                                             Suspended with head downwards at an angle

                                                                                                                        to water surface

                          No siphon tube                                                                    Siphon tube present

                          Palmate hairs present on abdominal segments               No palmate hairs

Pupae               Siphon tube is broad and short                                         Siphon tube is long and narrow

Adult                 When at rest, inclined at an angle to surface                   When at rest, the body exhibit a hunch back

                          Wings spotted                                                                     Wings unspotted

                          Palpi long in both sexes                                                    Palpi short in females

57.    In the context of human filarial infections, match List-I (Organism) with List-II (Vector) and select the correct answer using the codes given below the Lists:

       List-I                                                                                                      List-II

a.   Wuchereria bancrofti                                                                  1.   Simulum flies

b.   Burgia malayi                                                                               2.   Culex mosquitoes

c.    Onchocerca volvulus                                                                   3.   Mansonia mosquitoes

d.   Loa loa                                                                                           4.   Chrysops flies

Codes:

A.   a     b     c      d              B.   a     b     c      d           C.   a      b       c      d              D.   a      b    c     d               

       2     3     1     4                    2     3     4     1                  3      2       4      1                    3      2    1    4

Ans. A  (Park 18th ed., p 212)

Table: Human filarial infections.

Organisms                              Vectors                                                   Disease produced

Wuchereria bancrofti               Culex mosquito                                     Lymphatic filariasis

Brugia malayi                            Mansonia mosquito                              Lymphatic filariasis

Brugia timori                             Anopheles mosquito                            Lymphatic filariasis

                                                 Mansonia mosquito

Oncocerca volvulus                 Simulum flies                                          River blindness, subcutaneous nodules

Loa Loa                                    Chrysopes flies                                     Recurrent, transient subcutaneous swelling

T. perstans                               Culicoides                                              Rarely any clinical illness

T. striptocerca                          Culicoides                                              Rarely any clinical illness

Mansonella ozzardi                   Culicoides                                              Rarely any clinical illness

58.    Which of the following pairs are correctly matched?

1.   Horrock’s test                    –    Chlorine demand

2.   Rideal-Walker test            –    Bactericidal activity

3.   Chandler’s index               –    Ascariasis

4.   Casoni test                         –    Hydatid disease

         Select the correct answer using the codes given below:

Codes:

A.   1, 2, 3 and 4                                                                              B.    2 and 4

C.   1, 2 and 4                                                                                  D.    1 and 3

Ans. C  (Park 18th ed., p 195, 244, 540)

Chandler’s index is used in epidemiogical study of hookworm disease (infection caused by Ancylostoma duodenale or Necator americanus) and not for ascariasis.

Chandler’s index is average number of eggs per gram of stools.

l Below 200: Hookworm infection is not of much significance.

l   200-250: May be regarded as potential danger.

l   250-300: Mild public health problem.

l   Above 300: Important public health problem.

Casoni test is used for diagnosis of hydatid disease (E. granulosus), used intradermally and often lacks specificity.

Horrock’s apparatus is used to find out dose of bleaching powder required for disinfection of water.

Rideal Walker test is an index of bactericidal efficiency of disinfectant/sterilizing agent. The sterilizing capacity of phenol is compared to that of the germicide to be tested.

         The following 12 (twelve) items consist of two statements, one labelled the ‘Assertion A’ and the other labelled the ‘Reason R’. You are to examine these two statements carefully and decide if the Assertion A and the Reason R are individually true and if so, whether the Reason is a correct explanation of the Assertion. Select your answers to these items using the codes given below and mark your answer sheet accordingly:

Codes:

A.   Both A and R are true and R is the correct explanation of A

B.   Both A and R are true but R is not a correct explanation of A

C.   A is true but R is false

D.   A is false but R is true

59.    Assertion A         :   Neonatal mortality is greater among boys than among girls throughout the world.

         Reason R             :   Proportion of boys is more than that of girls in most populations.

Ans. C  (Park 18th ed., p 419)

Neonatal mortality is greater in boys thoughout the world, because newborn boys are biologically more fragile than girls.

60.    Assertion A         :   Copper T is a very effective contraceptive, its failure rate being 3 to 5 per 100 women year.

         Reason R             :   The copper ion released by it kill the sperms as they pass through the uterus on their way to the fallopian tubes.

Ans. D  (Ashok Kumar Essentials of Gynaecology 1st ed., p 22, 24)

The statement is partly false. CuT is highly effective but the failure rate is only 2 to 3/100 woman years after one year of use.

The mechanism of action of CuT is:

1.  Release of free copper ions that destroy the sperm and ova.

2.  Sterile inflammatory (foreign body) reaction in uterus prevents fertilization.

3.  Increased WBC, prostaglandin, lysosomal enzymes in the fluids of tubes and uterus interfere with sperm transportation and damage the ova and sperms.

61.    Assertion A         :   Hardness of water causes damage to pipes, boilers and cooking vessels.

         Reason R             :   Hardness of water is due to the presence of chloride and nitrates of calcium and magnesium in the water.

Ans. C  (Park 18th ed., p 538)

Hardness of water is defined as the soap destroying power of water. It is mainly caused by presence of any of the four dissolved compounds i.e., calcium bicarbonate, magnesium bicarbonate, calcium sulphate and magnesium sulphate. Chlorides and nitrates of calcium and magnesium can also cause hardness but they occur generally in small amounts.

a.  Temporary (carbonate): Due to presence of calcium and magnesium bicarbonate.

b.  Permanent (non carbonate): Due to calcium and magnesium sulphates, chlorides and nitrates.

Disadvantages of hardness:

1.  Hardness in water consumes more soap and detergents.

2.  When hard water is heated carbonates are precipitated and bring about furring or scaling of boilers. This leads to great fuel consumption, loss of efficiency and sometimes boiler explosions.

3.  Adversely affects cooking. Food cooked in soft water retains its natural colour and appearance.

4.  Decreases fabric life on washing.

5.  In many industrial processes hard water is unsuited and gives rise to economic losses.

6.  Shortens life of pipes and fixtures.

Classification of hardness (mEq/L):

l Soft water: Less than 1 (< 50 mg/L).

l   Moderately hard: 1-3 (50-150 mg/L).

l   Hard water: 3-6 (150-300 mg/L).

l   Very hard water: Over 6 (>300 mg/L).

Remember the following important points about hardness of water:

l Hardness of water is expressed in terms of milli-equivalents per litre (mEq/L). One mEq/L of hardness producing ion is equal to 50 mg CaCO3 (50 ppm) in one litre of water.

l   Drinking water should be moderately hard. Softening of water is recommended when the hardness exceeds 3 mEq/L.

l   Methods of removal of hardness:

a.  Temporary hardness: Boiling, addition of lime, addition of sodium bicarbonate, permutit or base exchange process.

b.  Permanent: Addition of sodium carbonate and permutit (base exchange) process.

62.    Assertion A         :   Quarantine is the process of preventing a person exposed to a communicable disease from mixing with the general public.

         Reason R             :   Quarantine prevents transmission of the disease.

Ans. A  (Park 18th ed., p 102)

Quarantine is defined as ‘the limitation of freedom of movement of such well persons/domestic animals exposed to communicable disease for a period of time not longer than the longest incubation period of the disease, in such a manner as to prevent effective contact with those not so exposed’.

Used to prevent the spread of disease, reservoirs of disease or vectors of disease.

63.    Assertion A         :   Bagassosis is an occupational lung disease causing cough and breathlessness.

         Reason R             :   Bagassosis is caused by a thermophilic actinomycete.

Ans. B  (Park 18th ed., p 609)

Bagassosis is caused by inhalation of bagasse or sugar-cane dust. Bagassosis is due to thermophilic actinomycetes, Thermoactinomyces sacchari.

Symptoms consists of breathlessness, cough, hemoptysis and slight fever. Initially there is diffuse bronchiolitis. If untreated fibrosis, emphysema and bronchiectasis may be seen.

Preventive measures:

l Dust control.

l   Personal protection.

l   Medical control.

l   Bagasse control: By keeping moisture content above 20% and spraying bagasse with 2% propionic acid.

64.    Assertion A         :   Mass media is not an effective means of health education.

         Reason R             :   Mass media allows only one-way communication.

Ans. D  (Park 18th ed., p 664)

l   Mass media is a one-way method of communnication.

l   Mass media alone are generally inadequate in changing human behaviour. For effective health communication they should be used in combination with other methods.

65.    Assertion A         :   Standardised rates are needed for comparing two populations.

         Reason R             :   They give ideal rates.

Ans. B  (Park 18th ed., p 53)

For comparing two populations with different age-composition, the crude rate is not the yard stick because rates are comparable if the population upon which they are based are comparable. It is cumbersome to use a series of age specific death rates. Age adjustment or age standardization removes the confounding effect of different age structures and yields a single standardized or adjusted rate, by which the mortality experience can be directly compared.

66.    Assertion A         :   Delivery in vertex position is easier in anterior position.

         Reason R             :   Head is well flexed in occipito-anterior position.

Ans. A 

Both the statement and the reason are true. In anterior position the head is well flexed and properly engaged that results in smooth labour. In posterior position the head is deflexed and it results in delayed engagement. The engaging diameter is either suboccipito-frontal or occipitofrontal. This results in difficult labour with a risk of deep transverse arrest.

67.    Assertion A         :   In atonic post-partum haemorrhage, a syntocinon drip is started by adding 20 units of syntocinon in a pint of 5% glucose.

         Reason R             :   Syntocinon concentration higher than this may cause rupture of the soft uterus.

Ans. C  (DC Dutta Textbook of Obstetrics 6th ed., p 416; www.show.scot.nhs.uk)

According to DC Dutta 10 units of syntocinon is started in 500 ml of NS (1 pint = 0.568 litre) for management of atonic PPH. However much higher dose is mentioned in several reputed journals. Maximum dose mentioned in literature is up to 50 units in 1000 ml of Hartmann’s solution. According to guideline of Royal College/Scottish obstetric guideline 30 units in 500 ml of Hartmann’s solution is given as infusion in management of atonic PPH.

Higher dose is associated with complications of syntocinon like water intoxication. We have not come across any side effect like rupture post partum uterus.

Oxytocin is an octapeptide. It is synthesized in the supraoptic and paraventricular nuclei of the hypothalamus. It is transported to the posterior pituitary from where it is eventually released.

It has a half life of 3-4 minutes and duration of action is approximately 20 minutes.

It binds to oestrogen dependent receptors on myometrial cell membranes. Bound intracellular calcium near the cell membrane is eventually mobilized from the sarcoplasmic reticulum to activate the contractile protein. The uterine contractions are similar to physiological pattern i.e., causing fundal contraction with relaxation of the cervix.

Synthetic oxytocin (syntocinon) is widely used. It has only got oxytocic effect without any vasopressor action.

For induction of labour if is started in low dose (4 mU/min) but escalated quickly if there is no response. In majority of cases, a dose of less than 16 mU per minute is enough to achieve the objective. However in unresponsive state, higher dose may be required.

In labour it is used in uterine inertia or for augmentation of labour. An initial dose of 2 mU/min may be stepped up to the usual maximum of 3-4 mU/min to achieve the objective.

Uterine rupture occurs in:

1.  Wrong selection of cases.

2.  Injudicious administration of the amount of oxytocin.

3.  Improper supervision.

4.  Hypersensitivity of the uterus to oxytocin.

68.    Assertion A         :   MTP is not allowed after 20 weeks of pregnancy.

         Reason R             :   Foetal parts become big after 20 weeks of pregnancy.

Ans. C  (DC Dutta Textbook of Obstetrics 6th ed., p 174)

According to MTP Act, MTP is permitted up to 20 weeks of pregnancy. Medical termination of pregnancy is deliberate termination of pregnancy before the period of viability i.e., 20 weeks (according to the international standard). It has got nothing to do with the size of the foetal parts.

69.    Assertion A         :   About 30% of newborn babies born in India are low birth weight babies.

         Reason R             :   The majority of the low birth weight babies are preterm babies.

Ans. C  (Park 18th ed., 396, 462)

Low birth weight babies i.e., infants with a birth weight less than 2.5 kg regardless of gestational age, represent about 26 percent of all live births in India. More than half of these are born at term and are due to fetal growth retardation. Maternal malnutrition and anaemia are significant risk factors in its occurrence. The goal of the National Health Policy is to reduce the incidence of LBW infants to about 10 percent by the year 2000.

70.    Assertion A         :   Rifampicin is a useful drug in preventing H. influenzae meningitis in children.

         Reason R             :   Rifampicin eradicates nasopharyngeal carrier in household contacts.

Ans. A  (Kenneth F, Swainman Pediatric Neurology – Principles and Practice 2nd ed., p 625; Nelson 17th ed., p 628)

Rifampicin is an important drug used for the chemoprophylaxis in children who are household contacts (living in residence/or in contact for more than four hours for seven days preceding the patient’s hospitalization). Family members should receive the drug immediately as secondary cases occur in first week in 50 percent of cases. The concept behind this chemoprophylaxis is that in some situations bacterial meningitis appears to be contagious. Spread presumably occurs by colonization of the nasopharynx with the virulent strains. The dose in H. influenzae prophylaxis is 20 mg/kg/day single dose for 4 days and for N. meningitides is 10 mg/kg/dose every 12 hours for 2 days.

71.    Which of the following conditions present with congestive cardiac failure at birth?

1.   Hypoplastic left heart syndrome                                          2.     Rh-isoimmunization

3.   Tetralogy of Fallot                                                                  4.     Coarctation of aorta

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 4                                                                                  B.    1 and 2

C.   2, 3 and 4                                                                                  D.    1 and 4

Ans. A  (OP Ghai 6th ed., p 369, 407; Nelson 17th ed., p 602, 1542; Mich Med 1971 March; 70(6):205-7)

Hypoplastic left and right heart syndrome may present with CHF at birth. However CHF occur commonly between 4 to 7 days of age. Mitral, aortic and pulmonary atresia usually presents with CHF at birth to 3 days. Coarctation of aorta present with CHF between 7 days to 30 days of age. However severe coarctation of aorta is associated with CHF in newborn. This condition (though not very common) is mentioned in several reputed journals. CHF is especially common if the ductus arteriosus closes early.

In severe Rh-isoimmunization (hydrops foetalis) there is severe haemolysis and tissue anoxemia. This effects the foetal heart and brain. Foetal death occurs sooner or later due to cardiac failure.

In TOF there is obstruction to right ventricle outlet along with RVH and VSD. Because of presence of VSD the right ventricle is decompressed by left ventricle and CCF never occurs. CCF can occur in TOF if there is coexisting severe anaemia, hypertension, infective endocarditis or myocarditis.

Table: Time of onset of CHF in congenital heart disease.

Age                              Cardiac lesion

Birth to 3 days            Mitral, aortic and pulmonary atresia.

4 days to 7 days        Transposition and malposition of great arteries, hypoplastic left and right heart syndromes.

7 days to 30 days      Coarctation of aorta, endocardial fibroelastosis, transposition and mal­position complexes.

1 to 2 months             VSD, PDA, endocardial cushion defects, transposition and malposition complexes, anomalous origin of left coronary artery from pulmonary artery, total anomalous pulmonary venous connection, transposition and mal­position complex.

2 to 6 months             PDA, AS, VSD, coarctation of aorta, transposition and malposition com­plexes, total anomalous pulmonary venous connection.

         The next two items (question) are based on the following case history. Study the same carefully and attempt the two items that follow it.

         A 4-year old girl is brought with severe respiratory distress and fever of 39°C. On examination, she has a II/VI precordial systolic murmur, 4 cm hepatomegaly and moderate pallor. There is diminished air entry on the right hemithorax and the percussion note is dull.

72.    Which one of the following is the most likely diagnosis?

A.   Status asthmaticus                                                                  B.    Empyema thoracis

C.   Congestive cardiac failure                                                     D.    Congenital lung cyst

Ans. B  (Nelson 17th ed., p 1463)

The child is most likely suffering from empyema thoracis. Empyema in children occur secondary to bacterial pneumonia – Streptococcus (developed countries), Staphylococcus (in developing countries) and posttraumatic cases. Except for those treated partially for pneumonia most patients are afebrile. Respiratory distress is moderate in infants but severe in older children. The finding of decreased air entry on right hemithorax and dull percussion note is highly suggestive of empyema in an ill child.

73.    Which one of the following measures should be undertaken as the first step to treat the child?

A.   Nebuliser therapy with salbutamol                                      B.    Intravenous furosemide

C.   Diagnostic pleurocentesis                                                       D.    Humidified oxygen

Ans. C  (Nelson 17th ed., p 1463)

The first step in this child should be diagnostic pleurocentesis. It should always be done when empyema is suspected and if pus is obtained, immediately closed tube drainage is instituted and continued for at least one week.

74.    A 6-month old male baby is admitted with a history of diarrhoea and vomiting of 2 days duration. On examination, he was drowsy, his pulse was rapid and thready; his eyes were sunken and skin turgor was markedly decreased. Chest was clear. Abdomen was soft. Which one of the following should be the immediate management?

A.   Oral rehydration solution                                                       B.    Antibiotic

C.   IV Ringer lactate                                                                     D.    IV 5% dextrose

Ans. C  (OP Ghai 6th ed., p 274)

For severe dehydration two of the following signs are required:

–   Lethargic or unconscious.

–   Sunken eye.

–   Not able to drink or drinking poorly.

–   Skin pinch goes back very slowly.

6 months old child with history of diarrhoea and vomiting who is:

l Drowsy, rapid and thready pulse,

l   Sunken eyes and

l   Markedly decreased skin turgor is a case of severe dehydration.

l Treatment for severe dehydration is IV fluids.

l   Ringer lactate is fluid of choice for treating dehydration. In absence of Ringer lactate, normal saline is used. Give 100 ml/kg Ringer lactate solution divided as given in the table below.

Age                                                              First give                                              Then give

                                                                     30 ml/kg body wt in                             70 ml/kg body wt in

< 12 months                                               1 hour                                                    5 hours

12 months to 5 year child                        30 minutes                                            2½ hours

l Reassess the child every 1-2 hours. If hydration status is not improving, give the IV drip rapidly.

l   As soon as child can drink (usually after 3-4 hours in infants and 1-2 hours in children) also give ORS about 5 ml/kg/hr.

75.    A male newborn has mouth breathing difficulty, cyanosis and respiratory distress on and off, cyanosis worsening on nursing. The most likely cause is:

A.   Pierre Robin syndrome                                                           B.    Foreign body in the nose

C.   Bilateral choanal atresia                                                        D.    Macroglossia

Ans. A  (Nelson 17th ed. p. 1209; OP Ghai 5th ed., p 155)

Male child with mouth breathing difficulty, cyanosis and respiratory distress on and off, cyanosis worsening on nursing is a case of Pierre Robin syndrome, in which there is cleft palate associated with micrognathia (retracted jaw) and large tongue with a tendency for glossoptosis.

Tongue should be stabiilzed early in life to maintain an adequate airway.

l In bilateral choanal atresia respiratory difficulty with cyanosis is present but mouth breathing is normal.

l   Although rare but foreign body in nose in newborn too is not associated mouth breathing difficulty.

l   In isolated macroglossia mouth breathing is not present in presence of normal respiratory passage.

76.    Consider the following features:

1.   Highly selective proteinuria                                                   2.     Gross haematuria

3.   Decreased C3 level                                                                   4.     Response to prednisone therapy

         The features found in minimal change nephrotic syndrome in children would include:

A.   1 and 4                                                                                      B.    1 and 2

C.   1, 2 and 3                                                                                  D.    2, 3 and 4

Ans. A  (Nelson 17th ed., p 1755; OP Ghai 6th ed.,p 451)

l   Minimal change nephrotic syndrome (MCNS) is most common cause of nephrotic syndrome in children (80-85%). Membranous glomerulonephritis is the commonest cause in adults.

l   Serum C3 level is normal in MCNS while IgG is low and IgM is elevated.

l   Protein selectivity is the ratio of the clearance of high molecular weight (e.g., transferrin, albumin) to low molecular weight proteins (e.g., IgG). Low ratio indicates highly selective proteinuria as in MCNS.

l   Haematuria is rare and blood pressure is normal. Gross haematuria or persistent microscopic haematuria suggests the likelihood of significant glomerular lesions. Similarly sustained elevated blood pressure suggests the possibility of significant glomerular lesion.

l   90-95% children with MCNS will respond to prednisolone with diuresis, loss of oedema and abolition of proteinuria within 28 days, in many by 10-14 days.

Remember the following important points about MCNS:

l Renal biopsy is not required to confirm the diagnosis of MCNS prior to starting treatment.

l   Proteins like transferrin, albumin etc are decreased due to excretion but fibrinogen level is elevated due to increased synthesis.

l   On light microscopy renal biopsy does not show significant abnormality.

l   Electron microscopy discloses obliteration of epithelial cell foot processes.

77.    An 11-year old girl is presented with recurrent frontal headache, diplopia and drooping of right eyelid for the past one year. On examination, the positive findings included ptosis of right eyelid with weakness of right superior rectus, right inferior oblique, right lateral rectus and right levator palpebrae superioris. Pupils on both sides were normal. Left eye was normal. Mantoux test, X-ray chest and CT scan of brain were normal. The tensilon test was negative. The
most likely diagnosis is:

A.   Subdural haematoma                                                            B.    Tuberculoma

C.   Myasthenia gravis                                                                   D.    None of the above

Ans. D  (Nelson 17th ed., p 2013; Kenneth F Swainman Pediatric Neurology – Principles Practice 2nd ed., p 868)

The history given is suggestive of ophthalmoplegic migraine. In ophthalmoplegic migraine headache is located behind the eye in frontal region in association with complete or incomplete third nerve palsy. The headache may last several hours, but ophthalmoplegia may persist for days or weeks. In some patients recurrent ophthalmoplegia on same side and permanent sequelae are observed.

Third nerve dysfunction is caused due to oedema of internal carotid artery within the cavernous sinus, or by oedema of the distal basilar artery, hence VI, VIII nerve may be involved. Acute treatment with steroids decreases the duration of ophthalmoplegia and reduces the pain.

The headache in subdural hematoma (subacute 3-21 days, or chronic more than 21 days) is due to increased intracranial tension and headache is posterior. Recurrent vomiting, enlarging head size, seizure are frequent with motor deficit including hypertonicity and jitteriness. The systemic signs like fever, vomiting and poor weight gain may be present.

78.    Consider the following statements associated with typical febrile convulsions in children:

1.   First attack is between 6 months and 3 years of age

2.   The cause of fever is extracranial in origin

3.   EEG tracing must be obtained after 2 weeks

         Of these statements:

A.   1, 2 and 3 are correct                                                              B.    1 and 2 are correct

C.   2 and 3 are correct                                                                  D.    1 and 3 are correct

Ans. B  (OP Ghai 6th ed., p 508-509; Nelson 17th ed. p. 1994)

EEG tracing is usually not required in a case of febrile seizure. It is required in a case of atypical seizure e.g., focal seizure, post ictal coma persisting for more than 15 mintues etc.

In febrile convulsion EEG is normal. The long term anticonvulsant therapy is controversial in febrile seizures. Status epilepticus is not common. Only 3-10% patients have recurrent seizures.

Febrile convulsion is the commonest cause of seizure in early childhood. It is seen between 6 months and 5 years of age. The convulsions are always gene­ralised and never focal. They are associated with fever and infections outside CNS and they are not related to degree of rise of temperature. CSF examination and CT head reveals no abnormality.

79.    A 10-year old girl is brought to the out-patient department by her parents who are worried that she is the shortest girl in her class. Her height is 100.5 cm and her weight is 26 kg. The rest of her physical examination shows nothing abnormal. Her father is 175 cm tall and her mother who attained menarche at the age of 16 years, is 165 cm tall. The patient’s wrist X-ray shows a bone age of eight years. The most likely diagnosis is:

A.   Growth hormone deficiency                                                  B.    Constitutional growth delay

C.   Genetic short stature                                                               D.    Chronic malnutrition

Ans. B  (OP Ghai 6th ed., p 50)

The child is suffering from constitutional growth delay. Constitutional growth delay is a significant (most common) cause of short stature in mid-childhood. Here ultimate height is normal and the birth weight/height ratio is normal. The growth of children lags behind their peers during the prepubescent phase and pubertal spurt is delayed. As a result extra years of prepubescent growth make up for short stature.

The bone age is less than expected for the age. History of one parent having short stature in childhood with delay in the onset of puberty is important.

In growth hormone deficiency even though short stature manifest after one year of age with normal mentation but bone age falls behind chronological age. There is definite infantile gonadal development with loss of secondary sexual characters, that being normal in this particular case.

In genetic short stature, the history of short parents is present with children short at birth. Here the bone age is corresponding to the chronological age.

80.    Which of the following is/are the feature(s) of Pendred syndrome in children?

1.   It is transmitted as autosomal recessive

2.   Deafness is present from birth

3.   Most affected patients are clinically euthyroid

4.   Deficiency of iodide peroxidase is usually present

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 3                                                                                  B.    1, 3 and 4

C.   2 and 4                                                                                      D.    1 and 3

Ans. A  (Nelson 17th ed., p 1873)

Pendred syndrome appears due to the defect in sulphate transport protein common to thyroid gland and cochlea. This results in thyroid peroxidase defect and not deficiency. As the iodine cannot be oxidized it accumulates in gland as free iodine.

The administration of anions such as perchlorate and thiocynate will cause discharge or release of unbound iodine. This has led to simple test to detect organification defect.

Radioactive iodine ® rapid uptake ® potassium perchlorate (0.5-1 g) orally ® rapid discharge of radioactive iodine.

This is autosomal recessive disorder associated with deafness, goitre and normal mentation. Though these patients are clinically euthyroid, in Bailey and Love the syndrome is classified under hypothyroidism.

81.    Antisera are given in the case of:

A.   Tuberculosis, diphtheria and tetanus                                   B.    Diphtheria and tetanus

C.   Cholera                                                                                      D.    None of the above

Ans. B  (Harrison 16th ed., p. 835, 841)

Antiserum is given in management of tetanus and diphtheria.

Tetanus antiserum is now replaced by tetanus immunoglobulin because of the risk of side effects (hypersensitivity, serum sickness) of horse tetanus antiserum. Antiserum neutralizes the circulating toxin and unbound toxin in the wound. The dose of human tetanus immune globulin is 3000-6000 units IM.

Equine diphtheria antitoxin is used for management of diphtheria. There is a risk for hypersensitivity and epinephrine should be kept ready. 20,000-40,000 units of antitoxin is required for disease £ 48 hours involving pharynx on larynx; 40,000-60,000 units for nasopharyngeal infections and 80,000-100,000 units for extensive diphtheria, which is present for > 3 days. Antitoxin is given IV in saline over 60 min. There is a 10% risk of serum sickness.

82.    Which of the following are true of normal growth of a child during infancy?

1.   The infant gains 10 g/day in the first three months of age

2.   The gain in height is 25 cm in the first year                       

3.   The head circumference increased by 10 cm in the first year

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 3                                                                                  B.    1 and 2

C.   2 and 3                                                                                      D.    1 and 3

Ans. C  (Nelson 17th ed. p. 31, 33; OP Ghai 6th ed., p 4)

Gain of weight in first three months is 25-30 g/day, thereafter 400 g every month till 1 year.

Length at birth is 50 cm, 60 cm at 3 months, 70 cm at 9 months and 75 cm at 1 year. Hence there is a gain of 25 cm.

Head circumference at birth is 35 cm, at 3 months is 40 cm and at 1 year is 45 cm. Hence there is a gain of 10 cm.

83.    If normally developing infant just acquires a pincer grasp, which of the following would be his recently acquired gross motor milestones?

1.   Ability to sit without support                                                 2.     Ability to pull to stand

3.   Ability to crawl on the floor

         Select the correct answer using the codes given below:

Codes:

A.   2 and 3                                                                                      B.    1 and 2

C.   1 and 3                                                                                      D.    1, 2 and 3

Ans. D  (OP Ghai 6th ed., p 44; Nelson 17th ed., p 36)

Pincer grasp is developed at 9 months of age. At this age the child can crawl, sits steadily without support and also pulls himself to stand.

Remember the following milestones of development:

l 2½ months:                                                                 l  11 months:

–    Develops social smile.                                              –      Creeps.

l 4 months:                                                                     –      Walks with support (both hand held).

–    Grasp a rattle by both hands.                                   –      One meaningful word speech.

–    Complete head control.                                            l  12 months:

l 6 months:                                                                     –      Casts objects, 2 to 3 meaningful words.

–    Transfers a rattle from one hand to other.            l  13-15 months:

–    Sits with support.                                                        –      Walks without support.

–    Rolls prone to supine.                                               –      Creeps upstairs.

l 7 months:                                                                     –      Feeds self.

–    Rolls supine to prone.                                               –      Scribbling.

–    Single hand approach.                                             –      Tower of cubes.

–    Bangs cubes, toys etc.                                              l  18 months:

–    Gives response to name.                                         –      Up and down stairs with support of railing.

l 8 months:                                                                     –      Jumping.

–    Sits momentarily without support:                          l  2 years:

–    Say da, ma.                                                                 –      Dry by day.

l 9 months:                                                                     –      Up and down stairs freely.

–    Crawls backward.                                                      –      Tower of six cubes.

–    Sits steadily.                                                                –      Parallel play.

–    Pulls to stand.                                                             –      Shying develops.    

–    Pincer grasp.                                                               –      2 to 3 words sentence.

l 10 months:

–    Crawls forward.

–    Releases object.

–    Waves bye-bye.

84.    Consider the following conditions:

1.   Phlyctenular conjunctivitis                                                    2.     Erythema nodosum

3.   Positive Mantoux test

         Allergy to Mycobacterium tuberculosis in children may manifest as:

A.   1, 2 and 3                                                                                  B.    1 and 2

C.   2 and 3                                                                                      D.    1 and 3

Ans. A  ( FJW Miller Tuberculosis in Children 1982 ed., p 152, 157)

All the three manifestations are due to allergy (hypersensitivity) to Mycobacterium tuberculosis. The eruption of erythema nodosum is not specific to tuberculosis but may occur as sensitivity response to number of infections and to chemical stimuli.

Phlyctenular conjunctivitis is painful and troublesome recurrent form of conjunctivitis and it is one of the sensitivity phenomenon of tuberculosis in children and sometime in adults.

Positive Mantoux test is considered to be helpful in diagnosis of tuberculosis. It is a delayed hypersensitivity to tubercular antigen. Induration (not erythema) is considered to be positive.

85.    Which one of the following is true of ‘transient tachypnoea of newborn’ (TTNB):

A.   It is the commonest respiratory disorder caused by absence of surfactant

B.   In premature babies, it is often fatal

C.   Onset of respiratory distress is immediately after birth and it rarely lasts beyond 48 hours

D.   It often leads to chronic lung disease

Ans. C  (Nelson 17th ed., p 583)

Respiratory distress syndrome type one or hyaline membrane disease is the commonest respiratory disorder due to absence of surfactant. Transient tachypnoea of newborn is a benign disease. Even though it may occur in premature baby it is not fatal as there is sudden recovery on day 3 with absence of a reticular pattern or air bronchogram in CXR.

This does not lead to chronic lung disease like meconium aspiration syndrome and hyaline membrane disease as the cause here is transient that is slow absorption of lung fluid resulting in decreased pulmonary compliance and tidal volume and increased dead space.

86.    Which of the following are associated with double volume exchange transfusion done for haemolytic disease of the newborn?

1.   It prevents kernicterus

2.   It removes circulating antibody coated red blood cells

3.   It causes cardiac failure due to circulatory overload

4.   It is not useful in spherocytosis

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 3                                                                                  B.    1 and 2

C.   3 and 4                                                                                      D.    1, 2, 3 and 4

Ans. D  (JP Cloharty Manual of Neonatal Care 5th ed., p 210-212; Merck Manual of Diagnosis and Therapy Section 19, Chapter 260)

The important indications of exchange transfusion are to prevent bilirubin to reach toxic levels, stop haemolysis by removing antibody and sequestered RBC, correct anaemia and improve heart failure in hydrops fetalis. It has no role in spherocytosis.

According to Merck Manual double volume exchange transfusion (volume of blood is double the amount of blood in newborn) is mainly used for severe rhesus isoimmunization. In congenital spherocytosis exhange transfusion is mentioned as a treatment option if there is severe hyperbilirubinemia.

We have not yet come across the role of double volume exchange transfusion in spherocytosis in any standard textbook or journal.

The complications of the procedure may be hypocalcaemia, hypoglycaemia, hypomagnesemia, acid base disorder, hypercalcaemia, cardiovascular compromise like perforation of vessels, embolization, infarctions, arrhythmia, volume overload, cardiac arrest etc. Bleeding, infections, necrotizing enterocolitis may occur.

87.    The recommended treatment of splenic trauma in patients below five years of age is:

A.   Laparotomy and splenectomy

B.   Non-operative treatment and observation in the hospital

C.   Laparotomy, suture of spleen or autotransplant

D.   Laparoscopy

Ans. B  (Nelson 17th ed., p 1676)

Small capsular tear of spleen should be treated by conservative methods. Careful observation of vitals, serial haemoglobin, available prompt surgery are of great importance. Any blood transfusion should be limited to less than 25 ml/kg/48 hr. These patients are hospitalised for 10 to 14 days and their activity is restricted for months.

A laparotomy with or without splenectomy is indicated for more severe abdominal bleeding, for clinical instability or deterioration, or when other organ damage is suspected. Partial splenectomy and splenic repairs should be substituted for total splenectomy whenever possible. The major long-term risk of splenectomy is sudden overwhelming infection (sepsis or meningitis) mainly by encapsulated bacteria. This risk is especially high in children younger than 5 years at the time of surgery. Encapsulated bacteria such as Streptococcus pneumoniae (> 60% of cases), Haemophilus influenzae, and Neisseria meningitides are the most common organisms associated with postsplenectomy sepsis.

88.    Match List-I with List-II and select the correct answer using the codes given below the Lists:

       List-I (Radiological appearance)                               List-II (Clinical condition)

a.   Snowman’s heart                                                    1.     Down’s syndrome

b.   Olegemic lung fields                                                2.     Total anomalous pulmonary venous drainage

c.    Double bubble appearance                                   3.     Transposition of great vessels

d.   Egg-shaped heart                                                     4.     Pulmonary stenosis

Codes:

A.   a     b     c      d              B.   a     b     c      d           C.   a      b       c      d              D.   a      b    c     d

       2     4     3     1                    2     4     1     3                  4      2       1      3                    4      2    3    1

Ans. B  (OP Ghai 6th ed., p 413-414, 421)

Roentgenogram in total anomalous pulmonary venous drainage is pathognomonic in older children if the anomalous pulmonary veins enter the innominate vein and persistent left superior vena cava. There is a large supracardiac shadow that together with the normal cardiac shadow forms a “snowman” appearance. This appearance is not helpful for diagnosis in early infancy because of the thymus.

In pulmonary stenosis blood flow to lungs will be less because of stenosis and the lung fields will be oligaemic.

Double bubble appearance is seen in Down’s syndrome because duodenal atresia is very common GI anomaly.

Egg on end appearance is seen in transposition of great arteries.

89.    In the case of CNS relapse in AML, chemotherapy would consist of intrathecal:

A.   Methotrexate                                                                           B.    Methotrexate + cytosine arabinoside

C.   Prednisolone                                                                             D.    Adriamycin

Ans. B  (Nelson 17th ed., p 1696; OP Ghai 5th ed., p 464)

In case of CNS relapse in AML intrathecal chemotherapy will consist of methotrexate and cytosine arabinoside.

Major site of relapse is bone marrow. Intensive chemotherapy has reduced CNS and testicular relapse to less than 5%.

Isolated testicular relapse is treated by bilateral testicular irradiation and systemic chemotherapy. CNS relapse is also treated with cranial irradiation and systemic therapy along with intrathecal therapy.

Worst are patients with bone marrow relapse. When on treatment they should be considered for allogenic bone marrow transplantation.

90.    A 2-year old healthy child is brought with history of accidental ingestion of some tablets. He is cyanosed but without any respiratory distress. The most likely diagnosis is:

A.   Polycythemia                                                                           B.    Methemoglobinemia

C.   Haemoglobinemia                                                                  D.    Congenital cyanotic heart disease

Ans. B  (Harrison 16th ed., p 598)

The child is suffering from methemoglobinemia. It results from exposure to chemicals that oxidize the ferrous (Fe2+) iron in hemoglobin to ferric (Fe3+) state. It cannot carry oxygen and shift oxygen dissociation curve to left.

Cyanosis with a gray-brown discolouration occurs when methemoglobin level exceeds 15% (1.5 g/dl of absolute methemoglobin). Usually the patients are asymptomatic until it is > 20 to 30%. Cyanosis without respiratory distress is the main clue in this question.

The various agents that cause methemoglobinemia are:

1.  Aniline.

2.  Aminophenol.

3.  Aminophenone.

4.  Chlorates.

5.  Dapsone.

6.  Benzocaine.

7.  Nitrites.

8.  Nitrates.

9.  Naphthalene.

10. Nitrobenzene.

11. Oxides of nitrogen.

12. Primaquine.

13. Sulfonamide.

91.    In infants, the cause of blindness arising out of oxygen toxicity is:

A.   Degeneration of crystalline lens

B.   Growth of blood vessels into vitreous followed by fibrosis

C.   Damage to cornea

D.   Enzymic defect in lens

Ans. B  (Nelson 17th ed., p 2113)

Oxygen toxicity leading to blindness is also called retinopathy of prematurity. High inspired oxygen concentration causes cellular damage, perhaps mediated by free radicals. Later peripheral hypoxia occurs and vascular endothelial growth factors are produced in non vascularized retina. These promote abnormal vasculogenesis and neovascularization may occur. This may lead to scarring and visual loss.

92.    A blood gas estimation in a child revealed, pH = 7.21, PaO2 = 68, PaCO2 = 36 and HCO3– = 20 with a base deficit of 18. The most likely diagnosis is:

A.   Metabolic acidosis                                                                  B.    Respiratory alkalosis

C.   Metabolic alkalosis                                                                 D.    Respiratory acidosis

Ans. A 

The normal pH is 7.35 to 7.45. Hence pH 7.21 indicates acidosis.

The normal PaCO2 is below 40 mmHg. The normal PaO2 is above 60 mmHg. Hence in this question there is no respiratory disturbance.

Normal HCO3 level is 22 to 25 mEq/l. In the question it is 20; hence there is metabolic acidosis. Base deficit of 18 reflects deficit of bicarbonate buffers. A primary defect of bicarbonate buffer and decrease of HCO3 level indicates metabolic disturbance.

93.    Which of the following mechanisms are involved in the regulation of amniotic fluid volume?

1.   Transudation from maternal blood                                     2.     Foetal swallowing

3.   Secretion by amniotic sac                                                      4.     Foetal micturition

         Select the correct answer using the codes given below:

Codes:

A.   1 and 2                                                                                      B.    1 and 4

C.   2, 3 and 4                                                                                  D.    1, 2, 3 and 4

Ans. D  (DC Dutta Textbook of Obstetrics 6th ed., p 37)

Precise origin of liquid amnii is unknown, probably of mixed maternal and fetal origin.

Liquor amnii is formed from the following:

l Transudate from maternal serum across the fetal membranes or from maternal circulation in placenta.

l   Transudate across umbilical cord or from fetal circulation in placenta or secretion from amniotic epithelium.

l   Contribution from fetal urine.

l   Secretion of:

–   Tracheobronchial tree.

–   Fetal skin before the skin becomes keratinized at 20th week.

Fetal swallowing although not given in textbook as a direct cause but it is related as the amount of liquor the fetus drinks (400 ml) the same is excreted in urine.

Remember the following important points about amniotic fluid:

l Amniotic fluid is replaced every 3 hours.

l   Amniotic fluid is faintly alkaline, with low specific gravity of 1.010 and becomes hypotonic to maternal serum at term pregnancy.

l   Osmolarity of 250 mOsmol/L is suggestive of fetal maturity.

94.    All of the following statements are true of the syncytium (syncytiotrophoblast) except:

A.   It is derived from cytotrophoblast                                       B.    It is a mitotic end stage

C.   It has abundant endoplasmic reticulum                             D.    It is composed of Hofbauer cells

Ans. D  (DC Dutta Textbook of Obstetrics 6th ed., p 31-32)

Syncytiotrophoblast is not made up of Hofbauer cells. The terminal villus is composed of the following from outside inwards:

1.  Outer syncytiotrophoblast.

2.  Cytotrophoblast.

3.  Basement membrane.

4.  Central stroma containing fetal capillaries, primitive mesenchymal cells, connective tissue and few Hofbauer cells.

Hofbauer cells are round cells, which are capable of phagocytosis and can trap maternal antibodies crossing through the placenta. These cells have IgG surface receptors and can express class II MHC molecules. Considering these facts it can be concluded that Hofbauer cells do not form syncytiotrophoblast rather they are present in central stoma of terminal villus.

95.    A primigravida with 16 weeks pregnancy develops convulsive seizures. The provisional diagnosis is:

A.   Eclampsia                                                                                 B.    Epileptic fits

C.   Severe anaemia                                                                       D.    Urinary tract infection

Ans. B  (DC Dutta Textbook of Obstetrics 6th ed., p 298)

The patient has developed epileptic fits. This diagnosis is by exclusion of the other causes as there is no direct evidence in this question.

Pre-eclampsia and eclampsia are diagnosed after 20 weeks of pregnancy in a previously normotensive and non proteinuric patient. However features of PIH may appear before 20 weeks in cases of H. mole and acute polyhydramnios.

Primigravida with 16 weeks pregnancy and convulsive seizures in absence of H. mole/acute polyhydramnios is a case of epilepsy in pregnancy.

UTI does not cause convulsion.

Severe anaemia may cause convulsion due to hypoxic encephalopathy. However for this there are no clues in the question and besides this severe anaemia is not likely to occur at 16 weeks of pregnancy.

Remember the following important points about epilepsy in pregnancy:

l Frequency of convulsion is unchanged in pregnancy in majority; increased in some.

l   Oestrogens activate seizure focus.

l   Increased plasma clearance of anti-convulsant drugs.

l   Third trimester bleeding and megaloblastic anaemia is related with anti-convulsant induced folic acid deficiency.

l   Drug of choice in pregnancy is phenobarbitone as per CMDT.

96.    In gestational diabetes, doing HbA1c is of value, if done:

A.   Before 16 weeks of pregnancy                                             B.    After 30 weeks of pregnancy

C.   At 36 weeks of pregnancy                                                     D.    At term

Ans. A (Harrison 15th ed., p 2129; DC Dutta Textbook of Obstetrics 6th ed., p 287)

Glycosylated haemoglobin A (HbA1c) before 14 weeks can predict fetus affection. If it is detected early in pregnancy there is a high risk of congenital anomalies and if it is detected late in pregnancy it indicates increased incidence of macrosomia and neontal morbidity and mortality.

HbA1c value £ 8.5% has got least chances of severe malformation of fetus. Chances of malformation are more if the values rise to 9.5% or more.

l In general target HbA1c should be < 7.0%

l   Increased plasma glucose leads to increase in nonenzymatic glycation of haemoglobin. This alteration i.e., glycosylated Hb reflects the glycemic history over the previous 2-3 months.

l   Depending on assay methodology for HbA1c haemoglobinopathies, haemoglytic anaemia and uremia may interfere with HbA1c.

l   HbA1c of 6% is 6.6 mmol/L i.e., 120 mg/dl of plasma glucose.

–   7% = 8.3 mmol/L i.e., 150 mg/dl.

–   8% = 10.8 mmol/L (180 mg/dl).

–   1% rise of HbA1c translates into a 1.7 mmol/L (30 mg/dl) rise in plasma glucose.

l   Fructosamine assay (using albumin) is an alternative method of glycemic control over 2 to 4 prior weeks.

97.    Magnesium sulphate potentiates the hypotensive action of:

A.   Methyl dopa                                                                             B.    Nifedipine

C.   Enalapril                                                                                    D.    Hydralazine

Ans. B  (Harrison 16th ed., p 2245)

Magnesium sulfate has hypotensive action though it is mainly used for management of convulsion in eclampsia. According to Williams Obstetrics magnesium sulfate acts by antigonizing calcium. Hypermagnesemia depreses PTH secretion and induces end organ resistance to PTH and cause hypocalcaemia. Hence it will potentiate the action of nifedipine which is a calcium channel blocker.

Remember: Severe hypermagnesemia is treated with calcium infusion.

98.    A 30-year old second gravida reports with history of 2 months amenorrhoea and bleeding per vaginum. Her general condition is good. The uterus is about 8 weeks size and there is no bleeding at present (at the time of examination). Ultrasound report is a gestational sac of 2.5 cm. No foetal node is seen. She should be advised:

A.   Rest and sedation                                                                    B.    Progesterone

C.   Chorionic gonadotrophin                                                       D.    Suction evacuation

Ans. D  (DC Dutta Textbook of Obstetrics 6th ed., p164-165; Callen Ultrasound in Obstetrics and Gynaecology 3rd ed., p 78-79)

30 years old G2 female with 2-month amenorrhoea and bleeding PV, uterus size of 8 weeks and gestation sac of 2.5 cm size with absent foetal node on sonography is a case of missed abortion.

The main clue in this question is “no foetal node is seen”. This means that gestation sac is present but there is no viable foetus.

In 25 mm gestational sac embryo should be visible and in 20 mm gestational sac yolk sac must be seen in ultrasound.

Since bleeding is not present it means missed abortion and this patient should be treated with suction and evacuation or by D & E.

99.   

         The sketch given above is a diagrammatic representation of an ultrasound examination done routinely at 20 weeks of pregnancy in a second gravida. Which one of the following statements is true in this regard?

A.   The placenta is likely to descend by term

B.   The placenta is likely to ascend by term

C.   Caesarean section will be necessary for delivery

D.   Pregnancy must be terminated at 32 weeks

Ans. B  (DC Dutta Textbook of Obstetrics 5th ed., p 29, 258)

In given diagram placenta reaches the internal os but does not cover it and it is called marginal/type II anterior placenta praevia. Pregnancy is continued up to 38 weeks and not terminated at 32 weeks. The placenta is likely to ascend by term.

Until the end of 16th weeks the placenta grows both in thickness and circumference subsequently there is little increase in thickness but it increases circumferentially till term.

Caesarean section is indicated for type II posterior, III and IV type of placenta praevia.

l Placenta ascends by the growth of uterus.

Type of placenta praevia:

l Type I (lateral): Major part is attached to upper segment only lower margin encroaches onto lower segment but not up to os.

l Type II (marginal): Placenta reaches the internal os but does not cover it.

l Type III (incomplete central): Covers the os when closed but does not entirely so when dilated fully.

l Type IV (central): Placenta completely covers the os even when fully dilated.

Anterior placenta is towards pubis and posterior placenta is towards sacrum.

100. Which of the following pairs are correctly matched?

1.   Contracted pelvis                                –      Ultrasonography

2.   Chronic foetal distress                        –      Foetal movement score

3.   Intra-uterine growth retardation       –      Placental insufficiency

4.   Pre-eclampsia                                       –      Oliguria

         Select the correct answer using the codes given below:

Codes:

A.   2, 3 and 4                                                                                  B.    3 and 4

C.   1 and 2                                                                                      D.    1, 2, 3 and 4

Ans. A  (DC Dutta Textbook of Obstetrics 5th ed., p 371, 496)

Contracted pelvis is diagnosed by:

l Clinical pelvimetry.

l   Radiopelvimetry.

l   CT pelvimetry.

In contracted pelvis X-ray pelvimetry is done. USG will not help in establishing a diagnosis.

Rest of the three are correctly matched. Decreased urine output is an ominous sign in pre-eclampsia.

Predisposing factors for pre-eclampsia:

l Elderly/young primigravida.

l   Family history of pre-eclampsia or eclampsia.

l   Poor or under privileged.

l   Pregnancy complications:

–   H. mole.

–   Multiple pregnancy.

–   Polyhydramnios.

–   Rh incompatibility.

l   Medical disorder:

–   Hypertension.

–   Nephritis.

–   DM.

l   New paternity.

l   Hereditary.

Chronic placental insufficiency due to blood flow to placental site causes IUGR and occurs in condition such as eclampsia, essential HT, chronic nephritis, organic heart disease, placental and cord abnormality.

101. “Chemical pregnancy” means:

A.   Negative beta HCG and absent gestational sac                B.    Positive beta HCG and present gestational sac

C.   Positive beta HCG and absent gestational sac                  D.    Negative beta HCG and crenated sac margin

Ans. C  (Ashok Kumar Essentials of Gynaecology 1st ed., p 197; www.obgyn.net)

Chemical pregnancy: hCG level is 5 mIU/ml almost immediately after nidation i.e., day 20 or 23 post menstrual. No gestational sac is visible. Chemical pregnancy is a very early pregnancy in which sophisticated tests for detection of b HCG are positive but there is no other evidence of pregnancy.

Biochemical pregnancy: hCG level is 25 mIU/ml i.e., day 27or 28 post menstrual. Detected by pregnancy kit in urine. No gestational sac is visible.

102. Incoordinate uterine contraction are associated with which of the following?

1.   Retention of urine                                                                   2.     Occipito-posterior vertex presentation

3.   Backache                                                                                  4.     Contracted pelvis

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 3                                                                                  B.    1 and 3

C.   2 and 4                                                                                      D.    1, 2, 3 and 4

Ans. D  (DC Dutta Textbook of Obstetrics 5th ed., p 382)

Abnormal uterine action: Any deviation of the normal pattern of uterine contractions affecting the course of labour.

Causes:

l Elderly pregnancy.

l   Prolonged pregnancy.

l   Over-distension of uterus due to twins and/or hydrannios.

l   Psychologic factors.

l   Contracted pelvis, malpresentation and deflexed head.

l   Full bladder and loaded rectum.

l   Injudicious administration of sedatives, analgesics and oxytocics.

l   Premature attempt at vaginal delivery or attempted vaginal delivery under light anaesthesia.

In lower spastic segment patient is in agony with unbearable pain referred to back.

103. Consider the following statements about Caput succedaneum:

1.   There is a accumulation of fluid in the subcutaneous tissue of the scalp

2.   In the left occipito posterior, the caput occurs on the right parietal bone

3.   With increasing flexion, the caput is situated more anteriorly

         Of these statements:

A.   1 and 2 are correct                                                                  B.    1 and 3 are correct

C.   2 and 3 are correct                                                                  D.    1, 2 and 3 are correct

Ans. A  (DC Dutta Textbook of Obstetrics 6th ed., p 87)

With increasing flexion, the caput is placed more posteriorly; not anteriorly.

Caput succedaneum is swelling due to stagnation of fluids in the layers of scalp beneath the girdle of contact.

l Swelling is diffuse, boggy and is not limited by suture line.

l Location of caput gives an idea about the position of head occupied in the pelvis and the degree of flexion achieved. In left position, the caput is placed on right parietal bone and in right position on left parietal bone.

104. Consider the following statements:

         Difficulty in the delivery of the after-coming head of the breech occurs due to:

1.   Cervix not being fully dilated                                                2.     Good uterine contractions

3.   Large size of the baby                                                            4.     Pressure from the perineum

         Of these statements:

A.   2, 3 and 4 are correct                                                              B.    1, 2 and 3 are correct

C.   1 and 4 are correct                                                                  D.    1, 3 and 4 are correct

Ans. C  (DC Dutta Textbook of Obstetrics 6th ed., p 386-388)

Good uterine contraction is not a cause of difficulty in delivery of after coming head. Large size of baby is a cause of delay in descent of breech. Only if the large baby has a big size of head it will cause difficulty in delivery of after coming head. We have not yet come across this information in a standard textbook.

Causes of arrest of after coming head:

1.  At the brim:

l   Deflexed head.

l   Contracted pelvis.

l   Hydrocephalus.

2.  In cavity:

l   Deflexed head.

l   Contracted pelvis.

3.  At the outlet:

l   Rigid perineum.

l   Deflexed head.

Methods employed for delivery of after coming head in breech:

l Burns-Marshall method.

l   Malar flexion and shoulder traction [Modified Mauriceu-Smellie-Veit method].

l   Forceps delivery.

Lovset’s maneuver is for delivery of extended arm in breech.

Pinard maneuver is for bringing down a leg.

105. Which one of the following immunoglobulins present in the breast milk affords protection to the newborn against enteric infection?

A.   IgA                                                                                             B.    IgE

C.   IgG                                                                                             D.    IgM

Ans. A  (DC Dutta Textbook of Obstetrics 6th ed., p 451)

Breast-feeding confers passive immunity to baby. Secretory IgA exerts its protective action by preventing bacterial contact to epithelial cell surfaces thus preventing gastro-intestinal infection.

Advantages of breast-feeding:

l Easily available and digestible, with low osmotic load.

l   Protection against infection.

l   Contains lactoferrin, which inhibits the growth of bacilli and thereby prevents gastroenteritis.

l   Confers passive immunity.

l   Acts as a natural contraceptive.

106. Which one of the following statements is true of deep vein thrombosis?

A.   Examination of lungs is the most accurate diagnostic method

B.   Ultrasonography of pelvic organs can detect deep vein thrombosis

C.   In 75% of the cases, embolus occurs without any warning

D.   Pulmonary embolus is the leading cause of maternal death in India

Ans. C  (DC Dutta Textbook of Obstetrics 6th ed., p 442)

About 80-90% of pulmonary embolism occur without any previous clinical manifestations of DVT. Ultrasonography of pelvic organs will not be able to detect DVT. Only doppler ultrasonography of pelvic and femoral veins can identify DVT.

Doppler ultrasound detects the changes in the velocity of blood flow in the femoral vein by noting the alteration of the characteristic ‘whoosh’ sound audible from femoral vein. Partial occlusion or presence of big collateral circulation may give false positive results.

1.  Doppler USG: To detect changes in velocity of blood flow in veins.

2.  Real time USG: Detect intramural thrombus and blood flow through the veins.

3.  Phlebography: Detect filling defect in venous lumen.

l   Examination of lung is normal in deep vein thrombosis. Only in pulmonary embolism, pulmonary angiography is diagnostic followed by ventilation perfusion scan.

l   Most cases of DVT are asymptomatic but not the patients with embolism which have symptoms according to site.

l   Most common cause of maternal death is haemorrhage and anaemia.

l   Calf tenderness and positive Homan’s test are seen in DVT.

Treatment of DVT:

1.  Bed rest with foot end raised above the heart level.

2.  Analgesics for pain.

3.  Anticoagulants: Heparin 15,000 units IV followed by 10,000 units 4 to 6 hourly for 4-6 injections. Heparin is continued for at least 7 days or even longer if thrombosis is severe. Warfarin is used with an overlap of at least three days with heparin.

l   Venous thrombectomy is rarely indicated.

107. A patient had full-term normal delivery 10 days back. She comes back with fever for last 3 days with rigors and foul smelling lochia. There is lower abdominal tenderness and rigidity. Uterus is mid-way between symphysis pubis and umbilicus. On per vaginal examination, vagina is found to be hot, the cervix admits one finger and placental bits are felt. Which of the following do these findings suggest?

1.   Puerperal sepsis                                                                        2.     Sub-involution of uterus

3.   Retained products                                                                   4.     TO masses

         Select the correct answer using the codes given below:

Codes:

A.   2, 3 and 4                                                                                  B.    1 and 3

C.   1, 2 and 3                                                                                  D.    1, 3 and 4

Ans. C  (DC Dutta Textbook of Obstetrics 6th ed., p 433-437)

The patient has retained products that have lead to puerperal sepsis with subinvolution of uterus.

Organisms responsible for puerperal sepsis:

1.  Aerobic: S. pyogenes, E. coli, Klebsiella, Psuedomonas, S. aureus.

2.  Anaerebic: Anaerobic streptococci, Bacteroides, Cl. welchii, Cl. tetani.

Mode of infection:

l Endogenous: Where organisms are present in genital tract before delivery and become pathogenic in above mentioned conditions.

l   Autogenous: The organisms are present elsewhere in body, migrate to the genital organs either through blood stream or by droplet infection or are conveyed at the site by the patient herself or her attendants.

l   Exogenous: Infection is contracted from some other source outside the patient.

108. In which one of the following cases can anti Rh(D) gammaglobulin injection prevent isoimmunization in a Rh negative woman?

A.   Soon after the delivery of a Rh positive infant by a primigravida

B.   Seen 10 days after the delivery of a Rh positive infant by a primigravida

C.   Soon after the delivery of a Rh negative infant by a primigravida

D.   After a few hours of delivery of a Rh positive infant by a woman whose second and third babies were affected by Rh incompatibility

Ans. A  (DC Dutta Textbook of Obstetrics 6th ed., p 334)

Rh anti-D immunoglobulin should be administered within 72 hours or preferably earlier following delivery or abortion.

It should be given provided the baby is Rh +ve and the direct Coombs’ test is negative.

109. Which one of the following is true regarding foetal circulation?

A.   The ductus venosus short-circuits the capillaries of the liver

B.   The umbilical arteries carry oxygenated blood

C.   The foramen ovale connects the ventricles of the heart

D.   The ductus arteriosus joins the aorta proximal to the aortic arch

Ans. A  (DC Dutta Textbook of Obstetrics 6th ed., p 43)

Ductus venosus short circuits the capillaries of the liver.

l Oxygenated (80% saturated) blood in fetus is carried by umbilical veins from the placenta.

l   Foramen ovale is the communication between two atria.

Remember the following important points commonly asked in examination:

l Mean cardiac output is comparatively high in fetus about 225 ml/kg/min.

l   Umbilical vein forms ligamentum teres and ductus venosus becomes ligamentum venosum.

l   Foramen ovale closes functionally immediately after birth, anatomical closure takes about 1 year.

110. A 17-year old girl who has not yet attained menarche is brought by her mother with complaints of acute retention of urine. On questioning, the girl gives history of monthly lower abdominal pain and backache for the past 2 years. Examination after catheterisation shows a suprapubic lump arising out of pelvis and extending up to two finger-breadths below the umbilicus. The lump is dull on percussion. The most likely diagnosis is:

A.   Cryptomenorrhoea                                                                 B.    Appendicular lump

C.   Tuberculous peritonitis                                                           D.    Ovarian tumour

Ans. A  (Shaw 13th ed., p 89)

The patient is suffering from cryptomenorrhoea.

Cryptomenorrhoea due to imperforate hymen causes hematocolpos.

Girls present with cyclic colicky pain. Menarche has not yet set in. Suprapubic/hypogastric pubic bulge is often seen.

–   Bluish bulging membrane is visible on separating labia.

–   On rectal examination bulge anteriorly in vagina is seen.

Surgical excision of hymen and drainage of hematocolpos by cruciate incision is treatment of choice.

l Tubercular peritonitis does not present with suprapubic mass.

l   Ovarian tumours are usually on either side of midline.

Age and monthly lower abdominal pain for 2 years are against the diagnosis of ovarian tumour.

Appendicular lump is situated in right iliac fossa. It is preceded by history of acute appendicitis.

111. A 30-year old female with secondary amenorrhoea, galactorrhoea and hyperprolactinaemia is most likely to have:

A.   Hypothalamic amenorrhoea                                                B.    Disorder of pituitary gland (adenoma)

C.   Ovarian disorder                                                                      D.    Lower genital tract disorder

Ans. B  (Shaw 13th ed., p 279)

The patient has developed prolactinoma.

l Pituitary gland adenoma causes secondary amenorrhoea.

l   Serum prolactin is increased and gonadotropin level declines.

Galactorrhoea and visual symptoms are due to compression of optic chiasma.

Pituitary causes of secondary amenorrhoea:

l Neoplasm:

–   Prolactinoma.

–   Craniopharyngioma.

l   Hypopituitary states:

–   Simmond’s disease.

–   Chiari Frommel syndrome.

–   Forbes-Albright syndrome.

112. Ovarian function after hysterectomy:

A.   Increase

B.   Decrease

C.   Remains the same

D.   May increase, decrease or remain the same depending on the prehistory of the patient

Ans. C  (Jeffcoate’s Principles of Gynaecology International ed., 2001, p 789; J Endocrinol 1992, Dec 135(3): 597-602)

According to Jeffcoate “….Contrary to an earlier belief that the ovaries ordinarily atrophy and cease to function as a result of hysterectomy, it is now established by hormone assays, vaginal smears, temperature charting and symptomatology that ovarian function continues normally in most women until the natural age of menopause. In some cases these may be explained by a naturally occurring premature menopause, others perhaps by interference with blood supply to the ovary following hysterectomy.…”

According to J Endocrinology ovarian function remains the same after hysterectomy. Since majority of hysterectomies are done near the age of menopause, erroneously it is believed that ovarian function declines whereas it is the natural decline of ovarian function at menopause.

113. Consider the following statements:

1.   Ovulation occurs usually 14 days prior to the onset of next menstruation

2.   ‘LH surge’ precedes ovulation

3.   Corpus luteum forms after ovulation

         Of these statements:

A.   1, 2 and 3 are correct                                                              B.    1 and 2 are correct

C.   2 and 3 are correct                                                                  D.    1 and 3 are correct

Ans. A  (Shaw 13th ed., p 29)

Ovulation occurs 14 days before the 1st day of succeeding cycle and this interval is more or less fixed. Follicular phase varies; luteal phase remains constant at 14 days.

Soon after ovulation, Graafian follicle cyst collapses and luteinization of theca and granulosa cells take place. LH surge occurs 24 hours before ovulation.

Unless fertilized, ovum does not survive for more than 24 hours.

l Corpus luteum is formed after ovulation and reaches maximum activity by the 22nd day of normal cycle.

If pregnancy fails to occur, by the eighth day corpus luteum starts degenerating.

114. Consider the following statements:

         Menorrhagia means:

1.   Frequent menstruation

2.   Prolonged menstruation for more than 7 days

3.   Infrequent menstruation which lasts for 10 to 12 days

4.   Heavy bleeding even with 28 days cycle, with a bleeding phase of 3 to 4 days

         Of these statements:

A.   2 and 4 are correct                                                                  B.    1, 2 and 4 are correct

C.   2, 3 and 4 are correct                                                              D.    1 and 3 are correct

Ans. B  (Shaw 13th ed., p 291)

Menorrhagia is cyclic regular bleeding, which is excessive in amount or duration.

Infrequent menstruation is not a feature of menorrhagia. Normal blood loss is 50-80 ml and does not exceed 100 ml. Menstrual cycle is unaltered but the duration and quantity of menstrual bleeding are increased.

115. A 51-year old nulliparous lady complains of heavy, prolonged, irregular bleeding for the past 6 months. On examination, she was obese, moderately hypertensive with a blood pressure of 160/100 mm of Hg. Her breasts were normal. Per
speculum examination revealed a healthy and nulliparous cervix. On bimanual examination, the uterus felt bulky, irregularly enlarged to 12 weeks size, anteverted and mobile and the ovaries were not palpable. The first line of management in this
case will be to:

A.   Give progestogens                                                                   B.    Do a fractional curettage and cervical biopsy

C.   Do hysteroscopy followed by fractional curettage           D.    Do hysterectomy straight away

Ans. C  (Shaw 13th ed., p 394)

The patient is suffering from endometrial cancer. The following clue are given in the question that suggest endometrial cancer:

1.  Nulliparous lady.

2.  Bleeding PV (prolonged, irregular).

3.  Obese.

4.  Hypertensive.

5.  Healthy cervix.

6.  Bulky, irregularly enlarged uterus.

At present times the patient should undergo diagnostic hysteroscopy followed by selective biopsy of suspicious area, a thorough fractional curettage and histologic examination of removed tissue. Fractional curettage comprises of separate sampling of uterine body and endocervix. This helps in staging the disease and plan the treatment.

116. Consider the following statements:

         A patient with uterovaginal prolapse is more likely to develop:

1.   Decubitus ulcer                                                                        2.     Cystitis and ascending infection of the urinary tract

3.   Carcinoma of the cervix

         Of these statements:

A.   1 and 2 are correct                                                                  B.    1 and 3 are correct

C.   2 and 3 are correct                                                                  D.    1, 2 and 3 are correct

Ans. A  (Shaw 13th ed., p 323)

Decubitus ulcer in prolapsed cervix occurs due to friction, congestion and circulatory changes in the dependent part of the prolapse. The main cause of ulcer is circulatory changes. It shows a clean edge and heals on reposition and vaginal packing. It does not show any malignant change on biopsy.

There is no increased incidence of CA cervix in prolapse.

Due to cystocele and kinking of distal ureters in procidentia there may be hydroureter and hydronephrosis. Urinary tract infection is not uncommon if residual urine remains in bladder in large cystocele. UTI must be treated prior to operation of prolapse.    

117. Which of the following pathogen(s) is/are responsible for pelvic inflammatory disease?

1.   Neisseria gonorrhoeae                                                          2.     Mycoplasma hominis

3.   Chlamydia trachomatis

         Select the correct answer using the codes given below:

Codes:

A.   1 and 2                                                                                      B.    2 and 3

C.   1 and 3                                                                                      D.    1 alone

Ans. C  (Ashok Kumar Essentials of Gynaecology 1st ed., p 166)

Neisseria and Chlamydia are important causes of STD and PID. Chlamydia is responsible for more than 50% cases of PID. Genital mycoplasma also causes PID. The other important pathogens are:

1.  Group B streptococci.

2.  Coagualse negative staphylococci.

3.  E. coli.

4.  Gardenerella vaginalis.

5.  H. influenzae.

6.  Peptostreptococci.

7.  Peptococci.

8.  Bacteroides bividus.

9.  Black pigmented bacteroides.

118. A young woman aged 24 years is admitted with history of infertility, irregular menstrual cycles, pain in abdomen and fever off and on. Pelvic examination shows unilateral, tender adnexal mass. The most likely diagnosis is:

A.   Pyosalpinx                                                                                B.    Ectopic pregnancy

C.   Twisted ovarian cyst                                                               D.    Tubercular TO mass

Ans. D  (Shaw 13th ed., p 148-149)

Infertility, irregular menstrual cycle, pain in abdomen, fever on and off and unilateral tender adnexal mass favors the diagnosis of TO mass of tubercular origin.

Twisted ovarian cyst usually presents with acute pain and can be fixed and immobilized but unlike the tubercular encysted lesion, menstrual history is usually normal.

In ectopic pregnancy amenorrhoea, pain and unilateral pelvic mass are the features. On and off fever is not seen in ectopic pregnancy.

Pyosalpinx has an acute presentation.

119. Consider the following statements:

         Infertility in a case of submucous fibromyoma uterus results from:

1.   Hypermotility in the tube                                                       2.     Tubal block

3.   Anovulation                                                                             4.     Unfavourable cervical mucus

         Of these statements:

A.   1, 2, 3 and 4 are correct                                                          B.    1 and 2 are correct

C.   2 and 3 are correct                                                                  D.    3 and 4 are correct

Ans. B  (Ashok Kumar Essentials of Gynaecology 1st ed., p 166)

The various causes of infertility in a case of fibroid uterus are:

1.  Occlusion of fallopian tubes.

2.  Alteration in tubal motility.

3.  Alteration of normal relationship between the cervix and vaginal pool of semen.

4.  Distortion of uterine cavity.

5.  Disruption of gamete and embryo transfer.

6.  Impairment of rhythmic uterine contraction required for sperm transport.

7.  Impaired implantation due to:

l    Atrophy and ulceration of the endometrium over submucous fibroid.

l    Congestion and venous dilatation in the endometrium.

After extensive review of literature we have not come across anovulation and unfavourable cervical mucus as the causes of infertility. Hence we have mentioned choice B as the answer.

120. Post-coital test showing non-motile sperms in the cervical smear and motile sperms from the posterior fornix suggests:

A.   Faulty coital practice                                                              B.    Immunological defect

C.   Hypospadias                                                                            D.    Azoospermia

Ans. B  (DC Dutta Textbook of Obstetrics 5th ed., p 202)

The presence of non-motile sperms in cervical smear in presence of normal sperms in posterior fornix suggest immunological deficit.