Risk of Down Syndrome–related to maternal age:
Maternal age Risk
35 1/385
40 1/100
42 1/60
45 1/30
4A. In which of the following scenarios is D and C not indi-cated?
a. Removal of retained products of conception b. Uncomplicated endometrial biopsy
c. Insufficient endometrial biopsy in patient with strong risk of endometrial cancer
d. Molar pregnancy
Ans. is (b) i.e. Uncomplicated endometrial biopsy (Ref: Read explanation below)
Dilatation and curettage is indicated for conditions such as retained products of conception, insufficient endometrial biopsy in patient with a strong risk of endometrial cancer, and molar pregnancy. D and C is not indicated in uncomplicated endometrial biopsy (choice b).
5. Ms. Seema a 33 year-old (G2 P0 A2) Woman with a previ-ous history of regular menses, presents with secondary amenorrhea and infertility. Her history is significant for two spontaneous abortions and D and C. Based on her history, what is the most likely diagnosis of this patient?
a. Intrauterine adhesions b. Hemorrhage
c. Uterine perforation d. Infection
Ans. is (a) i.e Intrauterine adhesions (Ref: William Gynae 2/e, p 444)
This patient is unable to conceive following a D and C, so most probably it has lead to formation of intrauterine adhesions i.e.
Ashermann Syndrome.
Ashermann Syndrome
In a series of 1856 women with ashermann syndrome, it was observed that 88% followed post abortal or postpartum uterine currettage. In ashermann syndrome the spectrum ranges from filmy adhesions, dense bands or complete obliteration of the uter-ine cavity.
6. What is the most common cause of abortion in the first trimester?
a. Syphilis
b. Chromosomal anomalies c. Elective abortions d. Cervical incompetence
Ans. is (b) i.e. Chromosomal anomalies
(Ref: Dutta Obs 7/e, p 159-160, COGD T 10/e, p 259, Williams Obs 23/e, p. 215)
Explanation: Abortion in the first trimester is most likely caused by chromosomal abnormalities. Up to 80% of all abortions occur before 12 week and among these 50-75% are caused by chromosomal abnormalities (choice b).
7. During her first pregnancy, Ms. Seema at 7 weeks gesta-tion came to your clinic complaining of vaginal bleeding and abdominal cramping. She denied passage of any tis-sue. On examination, her cervical os was open. What is the most likely diagnosis?
a. Complete abortion b. Inevitable abortion c. Missed abortion d. Threated abortion
Ans. is (b) i.e. Inevitable abortion
Explanation: An inevitable abortion (choice b) is the diagnosis in this case because the patient complains of vaginal bleeding accompanied by dilatation of the cervical os. Abdominal pain is present and bleeding is usually more severe than threatened abortions.
In all these types of questions—Remenber:
1. Abortions with internal OS closed
Abortions with internal OS open
8. Which of the following would most likely be seen upon histological examination of this patient’s endometrium before the therapeutic hysteroscopy was performed?
a. Avascular fibrous bands joining the uterine walls
b. A thin atrophic endometrium consisting only of the stratum basalis with sparse glands
c. Multiple large bundles of smooth muscle cells arranged in a whorled pattern
d. Thickened endometrium with crowded glands
Ans. is (a) i.e. Avascular fibrous bands joining the uterine walls
Explanation: Asherman’s syndrome is defined as secondary amenorrhea occurring in women with normal endocrine func-tion, and is caused by adhesions that form due to endometrial trauma most commonly from curettage for treatment of preg-nancy complications. In developing countries with a high preva-lence of tuberculosis, genital tuberculosis is also a relatively com-mon cause of Asherman’s syndrome.
Though histological examination of the endometrium is not used to diagnose asherman syndrome it most commonly is seen as avascular fibrous strands joining the uterine walls (Choice a).
(Choice b) This description best represents what is seen upon histological examination of the postmenopausal endometrium.
(Choice c) This best describes uterine leiomyomas (fibroids).
(Choice d) This best describes endometrial hyperplasia which most commonly presents with heavy uterine bleeding, not amenorrhea.
9. Which of the following is the embryologic cause of a sep-tated uterus?
a. Persistence of the mesonephric duct b. Regression of an entire mullerian duct c. In utero exposure to DES
d. Failed degeneration of septum created by mullerian duct fu-sion
Ans. is (d) i.e. Failed degeneration of septum created by mullerian duct fusion.
Explanation: Mullerian duct appears between 5-6 week. Earlier it is lateral to wolffianduct, then cross them and fusion begins at 7-8 weeks and is completed by 12 weeks. Cervix can be differentiated from corpus by 10 weeks and cervix is differentiated from vagina by 20 weeks. Septum disappears by 5th month of IUL.
If the fusion of the mulllerian ducts is incomplete uterus didelphys (horns may or may not share a common cervix) or a bicornuate uterus (two uterine horns with a single shared cervix) may arise.
A septate uterus forms when the fusion of the mullerian ducts occurs properly but the normally transient septa created by their apposition does not regress (Choice d). The amount of septum that persists determines whether the septum is partial or complete.
(Choice a) The mesonephric duct in males contributes to the:
epididymis, vas deferens, seminal vesicle, and ejaculatory duct.
In females only portions of the mesonephric duct persist as the appendix vesiculosa, duct of epoophoron, and gartner’s duct.
(Choice b1) Regression or failed elongation of an entire mullerian duct of me side results I unicornuate uterus.
(Choice c) In utero exposure to DES is linked to both cervicovaginal and uterine developmental abnormalities. Uterine abnormalities related to DES exposure in utero include: uterine hypoplasia, T-shaped uterine cavity, and an incompletely formed cervix.
10. If the patient’s secondary amenorrhea was due to anor-exia nervosa which of the following laboratory findings would most likely be present?
a. High FSH, High LH, Low estrogen
b. Normal FSH, Normal LH, Normal estrogen c. Low FSH, Low LH, Low estrogen
d. Low FSH, Low LH, High estrogen Ans. is (c) Low FSH, Low LH, Low estrogen
(Ref: Novak 15/e, p 1055)
Explanation: Excessive weight loss and decreased fat stores leads to diminished synthesis and release of gonadotropin-releasing hormone (GnRH). The decreased output of GnRH from the hypothalamus leads to low serum FSH and LH which in turn causes low estrogen (choice c). The end result is secondary amenorrhea due to a lack of endometrial stimulation from estrogen.
(Choice a) This hormone profile is that of a postmenopausal woman. As a woman’s store of primordial follicles decreases due to ovulation or degeneration the ability of the ovaries to produce estrogen diminishes as well. LH and FSH levels are high during menopause because there is a lack of estrogen to inhibit their production.
(Choice b) Asherman’s syndrome is characterized by normal hormone levels and secondary amenorrhea.
(Choice d) This hormone profile would be that of a pregnant female or a patient with a granulosa cell tumor.
11. What is the treatment of choice for women of reproduc-tive age with moderate intrauterine adhesions?
a. Laparoscopic hysterectomy b. D+C
c. Watchful waiting
d. Hysteroscopic adhesiolysis Ans. is (d) Hysteroscopic adhesiolysis
(Ref: Williams Gynae, 12/e, p. 444)
Explanation: Hysteroscopic adhesiolysis is the method of choice for managing Ashermann syndrome.
12. What follow up is needed after treatment of intrauterine adhesions?
a. None b. Sterile speculum exam
c. Laparoscopy d. Hysterosalpingography Ans. is (d) i.e. Hysterosalpingography
Explanation: Following adhesiolysis, and after allowing time for the patient to heal, physicians should perform a repeat HSG in order to verify that the adhesions are resolved and to evaluate tubal patency.
(Choice b) One of the initial exams used to rule out premature labor
(Choice c) Some indication for laparoscopy include endometriosis, tubal or ovarian surgery, and intraperitonal hemorrage.
13. What is the pregnancy rate following adhesiolysis for mod-erate intrauterine adhesions in a patient with three or more unsuccessful pregnancies?
a. 93% b. 75%
c. 64% d. 18%
Ans. is (b) i.e. 75%
(Ref: Williams gynae 2/e, p 444)
Explanation: Following adhesiolysis, while fertility is returned, the likelihood of getting pregnant is remains lower than a patient who had never had adhesions and is 75%, and of these 80%
achieve live birth rate.
Prior to surgery, patients must be counselled of the likely outcomes of surgery so that they are able to make an informed decision regarding their care.
CASE STUDY # 2