NEETPG Predictor Series | OBGY by Dr. Deepti Bahl

0:58Hi everyone. So uh very very good

1:00afternoon to all the dear dear students.

1:03So did we all attempt the paper? Yes. So

1:08everyone have we attempted the paper and

1:11uh yes there were 200 questions sorry 20

1:14questions. And now tell me how many were

1:16you able to got get right in the exam?

1:19What was your score out of these 20

1:21questions? So if you realize out of

1:24these 20 MCQs, yes, I have tried to tell

1:28you which topics are important and we

1:31will cover important other aspects

1:33around it which can also come as

1:34separate MCQs. That is the first thing.

1:36The second important thing if you

1:38realize that the topics are not uncommon

1:41but yes it is the options. Yes. Did you

1:44find the options

1:46confusing? Yes. Okay. So we will

1:49definitely approach uh the questions uh

1:52as we expect them and we'll try and

1:54cover uh more around uh what we feel can

1:58be asked in the exam. Okay. So okay uh

2:02fair fair. So somebody so you know

2:05you're saying you did it in a hurry but

2:07it's okay. Okay. 15 is a fair score but

2:10we need to figure out what are the

2:11mistakes and why did we do the mistakes.

2:13So everyone ready? Okay. So let's look

2:17at the first question. Yes. Which of the

2:20following? And those who haven't

2:21attempted the test paper so far, attempt

2:23it now with me, try and mark your

2:26answers and see why did you do it wrong.

2:28Was your approach wrong? Was it a recall

2:30error? Was it a contentbased error?

2:33Okay. So let's look at the first one. So

2:35the first question is which of the

2:37following substances does not cross

2:40placenta. Right? So what is the key word

2:42here? Ji sata. The key word is not

2:45cross. So does glucose cross? It

2:48definitely crosses. What about IGG? We

2:51all know it crosses. That is why we've

2:53been talking about, you know, Rh

2:56incompatibility as well. So it crosses.

2:58What about the last two options? Do you

3:01realize it is the last two options? It's

3:03always the two options which are

3:04confusing. So what about propile

3:06thiouracil and heperin? Right? So those

3:09are the ones that we can get confused

3:11in. So what is the answer here? So the

3:13answer is going to be heperin right. So

3:16please remember heperin does not cross

3:20placenta and in fact this is why the low

3:23molecular weight heperin is the drug of

3:27choice for what? For DVT in pregnancy.

3:31So whenever we come across thrombosis in

3:33pregnancy and we all know that uh you

3:36know um pregnancy is a hypercoagulable

3:40state h and that is why you should know

3:43the drug of choice is going to be low

3:45molecular weight heperin is that

3:48understandable what about warerin we all

3:50know warerin does cross and we all know

3:53that it is

3:54terattogenic h and that is why it is

3:57category x or we say it is

3:59contraindicated Right. Can you tell me

4:01what is the only condition for which

4:03warerin is allowed in

4:05pregnancy? So warerin is only allowed to

4:09be prescribed for what? Mechanical heart

4:12valves. Right? So this is the only

4:14condition for which we do say that we

4:17can give orpherin in pregnancy otherwise

4:20the drug of choice for DVT will remain

4:22as heperin. Okay. What about PTU? Does

4:25it cross? So yes, please remember PTU

4:28also crosses but among other drugs it is

4:33the safest and that is why it is the

4:36drug of choice for

4:38hyperthyroidism in pregnancy. Okay. And

4:43that too when we talk about typically in

4:45the first trimester. Yes. What is the

4:48drug of choice in the second and third

4:51trimester? It is going to be methole.

4:55Right. Right. So it is going to be

4:56methole. Now some of the other things

4:58which I know NatePG is fond of asking

5:00and you should try and answer. Can you

5:02tell about which hormones okay which

5:05maternal hormones do not cross placenta?

5:09Can you tell me this one? Now important

5:11whatever I'm going to discuss today is

5:13important for nepg. Yes. So which

5:16hormones do not cross placenta. So

5:19please remember insulin. So maternal

5:22insulin does not cross placenta. What

5:25else? Very very important remember TSH

5:29again does not cross placenta. Also the

5:32protein hormones for example hCG, LH,

5:37FSH. Right? So they also do not cross

5:41placenta. Even growth hormone does not

5:44cross placenta. Right? So please

5:46remember these maternal hormones do not

5:49cross placenta. And that is why it is

5:51very essential. Whenever we have asked

5:53you about hormone responsible for fetal

5:57growth, we tell you it cannot be growth

6:00hormone. It doesn't cross. So it is not

6:02responsible for fetal growth. Primarily

6:05it is insulin like growth factors.

6:08Right? So IGF-1 is responsible for fetal

6:11growth. So remember these are the ones

6:13which do not cross placenta. Take care.

6:15Is it good? Okay. Perfect. Let's move on

6:18to the next question now. So can you

6:22tell me what is the most sensitive

6:24marker for fetal anemia on Doppler? So

6:28try out and let's see which are the two

6:30options that you can rule out and which

6:32are the ones that you're confused with.

6:34So this is actually the one question

6:36which should come to you reflexely. H so

6:40many

6:41come 50 to 60% of paper should come to

6:45you reflexely. Yes. So the key word here

6:48is fetal anemia. So when it is anemia,

6:51yes, you are all answering this one

6:53correct. It is going to be MCA Doppler.

6:57Very important for NEPG. Can you also

7:00tell me? We measure PSV which is peak

7:02systolic velocity. Who is going to tell

7:05me what is the cutff beyond which we say

7:08it is significant anemia? Can you tell

7:11me? So what is the cutff? The cutoff is

7:141.5 m o right multiples of median. So if

7:20it is more than or equal to 1.5 then

7:22there we say it is significant

7:26fetal anemia. Right? Okay. Now the next

7:30question I want to ask from you is what

7:33about SD ratio in the umblcol artery?

7:36What do we use it to measure jiha? So we

7:40use it in IUGR pregnancies. But what is

7:43it a marker of? It is a marker of

7:48uteroplacental insufficiency. So again

7:51every point that I say is a very very

7:54probable MCQ by itself. It's just not

7:56these 20 MCQs. Okay. Perfect. So now you

8:00are going to the tell me these two

8:02questions. My first question to you is

8:05if it is a normal pregnancy. Okay. If it

8:08is a normal pregnancy, what will happen

8:10to SD ratio as PG increases? Can you

8:16tell me what will happen to the SD ratio

8:19as PG increases? What is the answer? In

8:22a normal pregnancy, so I use the term

8:25normal pregnancy, the SD ratio should

8:29decrease, right? So in a normal

8:31pregnancy, it should decrease. Can you

8:33tell me therefore when you say there is

8:36uteroplacental

8:37insufficiency what will happen to the SD

8:40ratio? It will increase. Do you know the

8:43cutff beyond which we say it is UPI? So

8:47please remember if SD ratio is beyond

8:52three at and beyond 28 weeks then we say

8:56that it is uter placental insufficiency.

9:00Okay. Then we say it is UPI. Also I want

9:03to ask you another MCQ here. Can you

9:06tell me where else do we use it? So as I

9:10said we also use it to make a diagnosis

9:14of IUGR. Right. So can you tell me what

9:18do we use when we are making diagnosis

9:20of IUGR? When we sayal artery Doppler

9:24measure. So we measure

9:28pulsatitality index. Okay. Okay, it is

9:30called as PI. Similarly, uterine artery

9:34PI can also be used for diagnosis of

9:38IUGR. Very good. Now you have to tell me

9:41what is the cutff we use for

9:43pulsatitality index to say that it is

9:46IUGR. Can you tell me? Basically

9:48pulsatitality index is the best marker.

9:51So what is the cutff? If pi is more than

9:54the 95th

9:57percentile then yes we say it is IGR.

10:02Okay. Perfect. Okay. Can you tell me

10:05what is the most ominous finding in the

10:08umblcal artery doppler in a baby with

10:11IUGR? So can you tell me what is the

10:14most ominous finding in umblcal artery

10:19doppler if you are dealing with a

10:22pregnancy with IUGRi say so the worst

10:26finding or the most ominous finding is

10:28what it

10:29is

10:31ef okay so e df reversal of n diastolic

10:37flow it is the bad or the worst finding

10:39and therefore can you tell me the Cutoff

10:43we use to consider termination of

10:45pregnancy. So the single best answer

10:48will be 32 weeks. So iff is seen at and

10:54beyond 32 weeks we are going to do a

10:56termination. Excellent. Very good. And

10:59therefore can you also tell me AEF may

11:02what is the cutff absent and diastolic

11:05flow. So then we say at and beyond 34

11:09weeks we will consider termination. What

11:12will you do before 32 in RF? You're

11:15going to continue the management or

11:17monitoring of the baby. Right? Similarly

11:20in ADF we will continue the monitoring

11:23of the baby. Right? So we will do daily

11:25monitoring. We are going to give

11:26steroids cover and then we will try and

11:30take the pregnancy close to 32 inf and

11:3334 in AEF. Very good. Excellent. I think

11:37everyone has answered it correctly. So

11:40you should know this. And my last extra

11:43MCQ from this part is can you tell me

11:46uterine artery Doppler? Yes. So now

11:50again I'm talking about uterine artery

11:53Doppler. Where else do you use it? So we

11:57use it for prediction of

12:00preeacclampsia, right? So we use it for

12:03prediction of

12:04preeacclampsia. Especially if you do

12:07this doppler between 11 to 13 weeks,

12:11right? 11 to 13 weeks, then you are

12:15doing a prediction for early onset

12:20preeacclampsia. Okay? So then you say we

12:23are doing a prediction for early onset

12:25preeacclampsia. So when do you say

12:26preeacclampsia is early onset and late

12:28onset? What is the cutff? 34 weeks. So

12:32if the preeacclampsia develops before 34

12:36weeks, it is early onset. It is less

12:39common. Which type of preeacclampsia is

12:41most common? Late onset. So beyond 34

12:45weeks. Perfect. Very good. Are you ready

12:47for the next

12:48question? Okay. The next question on

12:51your screen is this. So your patient is

12:5432 years old and she is 34 weeks

12:57pregnant and she has come with pre-term

13:00labor. She is contracting regularly.

13:03Cervix is 1 cm dilated. Which is the

13:07most appropriate drug for toolsis? So I

13:10have highlighted the keywords for you.

13:12Can you tell me which is the drug for

13:14toolysis here? Okay. Can you rule out

13:18some of the drugs? So let's try the

13:20guessit technique. Did you all attend

13:22the transform session where we talked

13:23about guessit? So methen can be ruled

13:28out. Okay, methogen is never used

13:31antiatally. It is actually used for pph.

13:34It is used for prevention of pph as well

13:38as for management of pph. What about

13:42carboroprost? Again it is not a drug

13:45which we are going to use antiatally.

13:48It is also used for postpartum

13:51hemorrhage. Now I want to know from you

13:54if we talk about carborrost and PPH do

13:57we use it in

13:59AMTSL that is prevention or profile

14:03access? No. So carborrost is not used in

14:07AMTSL. Where do we use it? We use it in

14:10the management of postpartum hemorrhage.

14:13So now we are left with two options. One

14:16is

14:19endometidine. Are they both toolytics?

14:21Yes, they are both toolytics. But what

14:25is the answer to this

14:28question? Since the Pog is 34 weeks, we

14:32cannot give endomthin. You remember this

14:36endomethasin cannot be given beyond 32

14:40weeks. Can you tell me the why we have

14:42taught you? So which means the answer to

14:45this question is nifi. Very good. So why

14:48don't we give it beyond 32? Because it

14:51will cause

14:53premature closure of ductus arteriosis.

14:58Right now can you tell me some other

15:01important MCQs that I feel could come in

15:03the exam as well. So can you tell me if

15:07you are talking about toolsis in a

15:10diabetic

15:12pregnancy which drug will you avoid but

15:16which drug should not be given for

15:19tooltitis in a diabetic pregnancy? What

15:22is the answer? The answer is yes. Beta

15:26agonist because

15:28betaagonist they will cause

15:31hyperglycemia and remember they also

15:33cause

15:34hypocalemia h. So beta agonist cause

15:39hyperglycemia and

15:43hypocalemia. Okay. All right. Now can

15:46you tell me therefore even in a diabetic

15:49pregnancy the answer will remain as

15:52nifidene. So drug of choice will remain

15:54as nifyine. Okay. Now tell me if you

15:58want to give toolsis to a heart disease

16:01patient. Then can you tell

16:04me which drug will you give? Do you want

16:07to still answer it as nidipene? No, it

16:10is not the best answer now. So what is

16:13going to be the answer here? So in at uh

16:16in heart disease patients our answer

16:18will change

16:20to

16:22atoscyban. Okay. It is at bandan. Can

16:25you tell me what is it? Yes it is a

16:28oxytocin receptor

16:31antag. Okay. It is a oxytocin receptor

16:35antag. Okay. Now can you tell me which

16:39toolytic do we use before external

16:42syphalic version? Which toolytic do we

16:46use before external syphalic version? So

16:49before ECV we only have to give one

16:52dose. So which one are we going to use?

16:55We are going to use

16:58turbutilene. Right? So when it is about

17:00relaxation of the uterus and we want to

17:03give only one dose. All right. Then it

17:06is going to be

17:08tbutilene. Multiple doses. Turbutilene

17:12is not safe. So we use sniffy dipping.

17:15Okay, is that clear? All right. Now very

17:18very important when I'm talking about

17:20this I want you to tell me where

17:23toolytics will be

17:25contraindicated. So what would be the

17:28contraindication for toolytics? Because

17:31these are very gross things. Can I give

17:34toolytics in abruption? No. So please

17:38remember in general the overall

17:40management of abruption is delivery. So

17:43you are not going to stop the

17:45contractions. Second do not give

17:48toolytics to patients of impending

17:52eclampsia and eclampsia because here

17:55again we want the woman to deliver. We

17:58don't want to stop the process. Okay.

18:01Then very very essential when we talk

18:04about contraindications do not give it

18:06in a patient of

18:10coronamitis. So when there is an

18:12intrauterine infection you want her to

18:16deliver right and in all these

18:19conditions what else is special whether

18:21it is abruption impending eclamsia

18:24eclamsia or

18:26choreomnonitis in all these conditions

18:29can you tell me what is the mode of

18:31delivery the preferred mode of delivery

18:34is vaginal. So when the preferred mode

18:37is vaginal and the answer is deliver

18:40then we will not give toolytics. Okay

18:44then please do not give toolytics if the

18:47baby is already dead. If it's an IUD and

18:50the woman has gone into labor don't give

18:53toolytics right let her deliver. So

18:57these are very important concepts and

18:59therefore if you know them there are

19:02multiple ways how these needp people can

19:04ask confusing questions between options.

19:07So remember ja preferred mode vaginal

19:11delivery here va and the management

19:14itself is delivery then we will not give

19:17toolytics. Is this clear to everyone?

19:20Yes. Okay. Are you ready for the next

19:22question? Ch. Let's go on to the next

19:25question and let's see whether you have

19:28approached it in a correct way or not.

19:30So let me look at the next question. So

19:33this is a 15year-old girl. She has come

19:36with short stature. There is a webbed

19:38neck. There is no breast development.

19:42Okay. And obviously she has come with

19:45primary aminora. Okay. Then we have

19:48given you more details. Shield chest.

19:51Yes. Yes. Yes. All PDFs of predictor

19:54series are given in the DAMS Delhi

19:56official telegram channel. S predictor

19:59tests are free for everyone. The PDFs

20:02are shared in the telegram channel of

20:04dams and even this will come. Okay. Ch.

20:07So widely spaced nipples, high arched

20:10pallet and FSH is marketkedly elevated.

20:15This is a super important MCQ. Can you

20:18tell me why? Yes. I have given so many

20:21details in this MCQ. But what was the

20:24purpose of giving you these details

20:26because all these are individual exam

20:31hints that need PG and Inet has been

20:34giving. Either they will ask you about

20:37these findings or they will give these

20:40findings. So all these findings which I

20:43have highlighted for you are very

20:45important. You have to know these

20:48points. Is that clear to everyone? Yes.

20:51Now, next important thing that we need

20:54to know is once we know it is Turners,

20:57let's approach the options. Okay, we

21:00have to say which of the following is

21:03most likely present. Okay, let's look at

21:06option A and let's see if we can rule

21:09out 17 hydroxy progesterone is elevated.

21:13Is it true? No. Can you tell me why or

21:17where is 17 hydroxy progesterone

21:21elevated? It is a what? Screening test

21:24for something which is very important.

21:27What is it a screening test for? It is a

21:29screening test for congenital adrenal

21:33hyperlasia. So it is not elevated here.

21:36Okay. What is about option B? Do we have

21:39streak gonads? Yes, this part is true.

21:42There are streak gonads. Did you mark

21:44some of you? Did you mark option B? The

21:47option B is only half correct. Streak

21:50gonads but absent uterus is incorrect.

21:55So definitely there are streak gonads

21:59but uterus is present. It's not absent.

22:03What is the important thing about the

22:05uterus that you have to know? It may be

22:06smaller in size. Right? So uterus can be

22:11hypoplastic but it is not absent. It is

22:15present. Okay. Okay. Let's look at

22:18option C. Bicaspid iotic valve on

22:22ecoardiography. Is this true? Yes. Very

22:26very important because it is an MCQ by

22:28itself. Bicuspid iotic valve on echoc

22:32cardiography is the most common

22:36cardiovascular finding in women with

22:39Turner syndrome. Please remember the

22:42answer is not coactation. Yes,

22:44coactation of iota is common but it is

22:47not the most common finding.

22:50Okay. Normal

22:53carotype normal carotype with mosaicism

22:56in somatic cells is not what is the uh

23:00Turner syndrome which is classical

23:02Turner syndrome. So we all understand

23:04what is the carotype. The carotype is

23:0945XO. This is what is in turn. Can

23:13Turners be mosaic? Yes, they can be

23:16mosaics but it is uncommon. You don't

23:19think of mosaicism at the first go.

23:22Okay. Now if it is a turner mosaic right

23:26can you tell me what would be the

23:28carotype? So there will have two cell

23:30lines. One will be 45xo. What is the

23:34other cell line? That's where you need

23:36to understand. So the other one will be

23:3946 xx and not xy. Okay. XY is a

23:45completely diff you know different

23:47entity. So even if it is a mosaic most

23:51mosaics will be 45 XO and 46 XX not XY.

23:57This is the most common mosaic pattern

23:59you will see if at all it is a mosaic.

24:02Okay. Now the other important points

24:05that you definitely need to know. Now

24:08when we talk about Turner syndrome, can

24:10you tell me what is the finding in the

24:12hands? Hand make finding there are two

24:16important things one has already come in

24:20set. So one finding is short fourth

24:27metacarpel. Where do you find short

24:29fifth distal falank? That is down

24:33syndrome. Right? This is short fourth

24:35metacarper. Right? And this is a

24:38characteristic finding. What is the

24:39other finding? Cubitus valgus. Okay,

24:44cubit is vgus very very essential these

24:47exams whether it is nepg or any set they

24:50will ask you what about LHFSH findings

24:52so I have already given it to you please

24:55remember this internal syndrome which is

24:59actually the most common type of what

25:01gonadal

25:03disgenesis right so it is the most

25:05common type of gonadal disgenesis please

25:08remember this that the LH and FSH levels

25:13are high and that is why what is the

25:16other name we give

25:18it? So there is gonadal disgenesis. So

25:21there is no negative feedback. So LH,

25:24FSH are high. Yes. The other name is

25:31hypertonadorropic

25:35hypotonadism.

25:37Okay. So please remember this that this

25:40is the most common type of gonadal

25:42disgenesis. Right? The other findings

25:45that we have mentioned, you should

25:46remember those findings. And I'm sure if

25:48I ask you a couple of others you will be

25:50able to tell me. So tell me what about

25:53IQ level in Turner syndrome? The IQ is

25:57absolutely normal. Yes. What about

26:00lifespan? Lifespan is slightly short.

26:05Yes. What about bar body? Bar body is

26:09classically absent. Yes. What about

26:13autoimmune conditions? Which autoimmune?

26:17The most important ones are diabetes and

26:21Hashimoto's. But yes, they can also have

26:24inflammatory bowel disease.

26:28Right? You will not come across SLE. The

26:32single best answer is that you will not

26:35come across

26:36SLE. But the single best answer is SLE.

26:40Okay. My last question or second last

26:43question to you here is do you do a

26:45gonadctomy in

26:47turn? No. Please remember this. No

26:52gonadctomy. And if we ask you what is

26:55the treatment that you're going to give?

26:57We are going to give them HRT hormone

27:01replacement therapy which is in the form

27:04of E + P. Okay. So Turners is a very

27:08important topic. you're very likely to

27:10get questions in need PG right and these

27:13are important things that have the

27:15highest probability of being asked okay

27:18let's move on to the next question and

27:20let's see if you did this right so your

27:23patient has come in the second stage of

27:26labor and there is fetal distress the

27:31station is plus two it is a vertex

27:33position what instrument will you use so

27:37my first question to you is how do you

27:40get to know that the woman is in second

27:42stage of labor. Okay. So when we say

27:45that it means cervix is fully

27:51dilated and therefore can we do

27:53instrumental deliveries? Yes we can do

27:56instrumental deliveries. Okay. Now you

28:00will see all options here are

28:02instruments only. Can you rule out some

28:05of the options? Can you rule out? So we

28:08are not going to use pipers. Why? Can

28:12you tell me how did we rule it out?

28:14Because pipers is specially used only in

28:17one condition. It is used for after

28:21coming head of

28:25breach. So we are not going to use it

28:27here. My second question which other

28:30option can you rule out? So we can also

28:33rule out key land for steps. Keyland is

28:37typically used for deep transverse

28:41arrest when pelvis is normal which means

28:45there is no CPD then yes we can use

28:50kands for rotation. Okay. So it is a

28:54rotational

28:56forceps. Okay. But remember it is only

28:59used if there is no CPD. The pelvis is

29:02normal. Yes. So that is when you will

29:04use keyand. So now we are left with two

29:07options. Uh are we going to answer this

29:10as vacuum or are we going to answer it

29:12as wriglies? What is the

29:14answer? So please remember both can be

29:17used. Both are

29:19correct PG or initiate. There are two

29:23options and yes both are correct but we

29:25have to go with one which is a better

29:28answer. Right now what is going to be

29:31the answer here? What is the key word

29:33that helps us decide? Fetal distress.

29:37Again in fetal distress we can use both.

29:40We can use wriglies also. We can use

29:42vacuum also. But which is preferred

29:46forps. So when it is petal distress

29:51please remember we can use both vacuum

29:54and forceps but for preferred over

30:00vacuum. Okay. So that is why D becomes a

30:04better answer. Is this clear? So this is

30:06how we have to approach when we feel two

30:09options are correct. Now I'm going to

30:11ask you some more questions. Very very

30:14important again because you're very

30:15likely to have these in the exams as

30:18well. So my first extra question for you

30:20is if it is Wrigley's forceps and you

30:24are using it as plus two how will you

30:28classify this foreps delivery? So you

30:31are using wriglies the station is plus2

30:34as in this question. So then can you

30:37tell me how will you classify this? So

30:40we will classify this as low forceps

30:46delivery. Okay. So this is low forps.

30:49When do you say it is outlet forceps? So

30:53you will do an outlet forps when the

30:56station is more than or equal to + three

31:00or we say the head is on perennium or we

31:05say scalp is

31:09visible. Okay. So then we will say it is

31:12a outlet forceps do know whether it is

31:17outlet or low the forceps we use is

31:20wriglies only the classification becomes

31:23different. Is that clear to everyone?

31:24Okay, my next question to you

31:27is if they ask you a very basic question

31:31is wrigglies a low forceps, outlet

31:35forceps, high forceps or a mid cavity

31:38forceps, what will you answer? What kind

31:41of forceps is wrigglies? So when you get

31:43a very basic question like this, you

31:45have to remember that you have to go

31:47back to basics. So when we talk about

31:50wriglies we actually say it is a outlet

31:54for steps. So it is classified as outlet

31:57but we also use it for low forep

32:01delivery. Do you understand the

32:02difference in the MCQs? Very good.

32:05Excellent. So I want to you know ensure

32:07these finer points you don't get

32:09confused and you do it right in the

32:11exam. Very well done. Okay. My next

32:15question to you is in which conditions

32:18for can be used but vacuum cannot be

32:23used?

32:25Cons you can use forceps but not vacuum.

32:30Can you tell me what is the answer? So

32:33the first answer is pre-term bacha.

32:37Right? So if it is pre-term especially

32:40if it is less than 34 weeks then

32:43absolutely we are not going to use

32:45vacuum but you can definitely use

32:47forceps okay second important thing

32:50whenever we talk of presentations like

32:53face

32:54presentation breach presentation right

32:58in these conditions we can definitely

33:01use forps but not vacuum if there is a

33:05caput right So remember there is a capad

33:09but there is no molding then yes I can

33:13use instrument and preferably we will

33:16use a forceps not a vacuum is that clear

33:19to everyone so you should know the

33:21comparisons between forceps and vacuum

33:23you're likely to get some of the other

33:25question maybe a direct one maybe a

33:28clinical one but yes these are important

33:30topics are you ready for the next

33:33one let's go on to the next okay on day

33:37Five. Post

33:38LSCs. A woman presents with fever, foul

33:42smelling loia, uterus is tender. What is

33:46the likely diagnosis? So I am sure you

33:49can rule out certain options. What

33:52options can you rule out? Yes, even in

33:55heart disease forceps is preferred but

33:58vacuum is also used. Vacuum is not

34:00contraindicated in heart disease. So now

34:03I see that some students were confused

34:05and I can see that in the options as

34:07well. Some of you are answering as

34:10perpial sepsis do confusion B D. So it

34:16is not pepsis it is

34:20endomitis. Please remember this. What is

34:23the difference between pepsis and

34:25endometriis? Pepsis is a general term.

34:30Okay. Here we talk about infection of

34:34genital tract in a postpartum patient.

34:38Right? So it will have systemic findings

34:41as well. Okay. And there will can be

34:45involvement of uterus, parimetrium,

34:49pelvic cellular tissue, right? It can go

34:52and affect the paratonium as well. So it

34:55is a generalized term. It is not a

34:58localized infection. But in this

35:01question look at all the keywords.

35:04Number one the first keyword given to

35:06you is post

35:08LSCS. LSCS is the most important what

35:13risk factor for what? It is the most

35:16important risk factor for

35:20endomitis. Second we are telling you

35:23there is a foul smelling discharge. So

35:26again it means it is coming from the

35:28uterus. Then they are also telling you

35:30localized uterus is tender. So D is a

35:35more specific answer. P sepsis doesn't

35:38specify the site of infection. Okay,

35:41it's a generalized term which we use for

35:44infection of the genital tract. So this

35:46is a specified localized infection and

35:49therefore the answer becomes

35:52endomitis. Right? Now please remember

35:55this. What are the other findings? The

35:57uterus will also show

36:01subinvolution. Okay. So the uterus will

36:03also show subinvolution apart from

36:05tenderness. Right? Now can you tell me

36:09when you talk about postpartum sepsis or

36:12when you talk about perpial pyrexia what

36:15is the uh class uh diagnos diagnostic

36:19requirement of the fever? Can you tell

36:21me? No. Fever does not mean sepsis

36:24always. It is a localized infection.

36:26Okay. So please remember this when we

36:29talk about fever

36:34mastitisps mastitis patient sepsis no

36:37fever is a response okay so please

36:40remember this so now very very important

36:43yes to make a diagnosis of pepsis as we

36:47said the patient should have

36:49fever fever more than

36:5538° Yes. Or we say 100.4. Then what do

36:58we say? It has to be present on two

37:01occasions. Okay. On two occasions. From

37:04what day to what day? So please remember

37:07from day two to day 10

37:12postpartum. So please remember day 1 is

37:16not included in the diagnostic criteria

37:19and it is not up till 12 weeks. It is

37:22from day 2 to day 10. First 24 hours is

37:26what? It is excluded. Okay. Is that

37:29clear to everyone? Okay. Now once we

37:32understand this, please remember the

37:34risk factors. You are likely to get

37:36questions on risk factors of

37:39endomritis. The most important one I

37:42said is LSCS. What else? Prolonged

37:45rupture of membranes. When do you say it

37:48is prolonged rupture? Beyond 18 hours.

37:52Right? Right? So if it goes beyond 18

37:54hours, it is prolonged rupture. Yes. So

37:58LSCs, prolonged rupture, these are two

38:01very very important risk factors. All

38:04right. Then yes, if there is an evidence

38:07of infection, it could be group B

38:09streptocoal infection. It could also be

38:12bacterial vaginosis. So all those

38:14infections can also actually cause

38:17endometritis.

38:18Now other important thing is it a single

38:21organism or polyicrobial. So please

38:24remember always when we talk about

38:27endometriitis you have to know that it

38:29is

38:31polyicrobial right. So it can be ecoli

38:34also. It could be strep also. It could

38:37include staff also. Okay. So it is and

38:40anorobes also. Okay. So it is a

38:44polyicrobial infection and therefore

38:46what you are going to give is

38:48broadspectctrum antibiotics to ampa

38:52clindomy h. So we are going to put the

38:55patient on

38:57broadspectctrum IV antibiotics. Okay I'm

39:01going to go one level further because I

39:02do feel needp can ask this. Suppose you

39:05have started broadspectctrum antibiotics

39:08and your patient is not responding 48

39:13hours and she is not responding what are

39:16you going to do or what are you going to

39:18think of? So please remember when she is

39:22not responding and 48 hours have passed

39:25then you should definitely think of

39:28septic pelvic

39:34thrombopitis. Okay. Then you have to

39:36think of an infection gone further

39:38somewhere in the pelvic cellular tissue.

39:41Right. So pel septic pelvic

39:44thromboplabitis. So you can do a PV exam

39:47and you will feel a what? Maybe maybe

39:50you will feel a cordlike structure which

39:53is the thrombosed ovarian vein. Right?

39:57So if you don't feel the cord-like

39:59structure, we could do a CT MRI as well.

40:02Now the last part is if now I am

40:04thinking it is uh you know septic pelvic

40:08thromboplabitis, what should I do now?

40:10I've already put her on antibiotics.

40:12What do I do? So I've taken care of the

40:14septic walla part but I have not taken

40:17care of the

40:18thromboloflabitis walla part. So what

40:20should I do for the thromboflabitis

40:22walla part? So if you are

40:25suspecting septic pelvic

40:27thromboplabitis continue the antibiotics

40:30and now you will add what low molecular

40:34weight heperin and the moment you add

40:37heperin you will see that the patient

40:39responds very well to it. Right? So

40:42continue antibiotics and add LMW. Okay,

40:46good to go everybody. Shalo. Let's go on

40:49to the next question. Okay, again I am

40:52sure some of you were confused in two

40:54options in this one as well. A woman

40:57fails to lactate after massive PP. She

41:01has now am a minora. TSH and cortisol

41:05levels are low. What is the diagnosis?

41:09So can you tell me what are the two

41:11options that you are no in the previous

41:14you know

41:15culture blood culture has no value

41:18because we're talking about a localized

41:20infection take

41:21beta right so please remember we can

41:25easily rule out PCOS we can also rule

41:28out adenoma the adenoma doesn't present

41:31like this adenoma will present with

41:33visual disturbances headache galactoria

41:37but not like this so now we left with

41:39two options A and B. So what is the

41:42answer? Is it empty cella or is it shan?

41:45They can have similar presentations but

41:47what is the answer here? The answer here

41:50is going to be shehan. Why? Because we

41:54gave you the hint when it is secondary

41:59to

42:03pphic term which is shean. Okay. So

42:07there is

42:09panhypopituerism right? So all hormones

42:12coming from anterior

42:16pituitary they will all be reduced right

42:21because there is a pituitary what

42:24infection. Yes. So the reason here is

42:27pituitary infection. Please remember it

42:30is usually the anterior pituitary which

42:34is affected. posterior is usually spared

42:37right what would be the finding on MRI I

42:40do agree that on the MRI you may see

42:43empty cellar but we don't call it as

42:46empty cellar syndrome empty cellar

42:50syndrome is very specific you know when

42:52you talk about what herniation yes so

42:55there is herniation of the subaraconoid

42:57space and there is compression of the

42:59pituitary gland okay so MRI finding may

43:03still be called as empty cellar but this

43:05is not the empty cellar syndrome. Okay.

43:09Okay. So sometimes your needp as I told

43:12you is very very fond of asking this.

43:15Quickly answer the following questions.

43:18What will happen to LH FSH levels in

43:21shehan syndrome. They will be highly

43:25suppressed. So FSH levels will usually

43:28be less than uh you know four or we can

43:31say less than or equal to three. there

43:33will be very very suppressed levels.

43:35Okay. Second, can you tell me which is

43:38the first hormone to be

43:40affected? The first hormone to be

43:43affected here is growth hormone. But if

43:46we ask you the most common presentation

43:50of shehans, what would be the answer? So

43:52most common presentation is failure to

43:57lactate. So this woman has just given

43:59birth but she's not able to lactate. So

44:01that is the most common presentation.

44:03The second most common presentation is

44:08amoria. Okay, it is aminora. So the

44:12woman will need replacement of the other

44:15you know as I said uh all hormones from

44:17anterior pituitary. Now please remember

44:20when we say aminora your exams will

44:22confuse you primary or secondary. So

44:24this is going to present as secondary

44:28aminora not as primary. Right? And

44:31because it is secondary aminoria uh you

44:34know um please remember this that this

44:38is one of the basic differentiation when

44:40you are narrowing your options. Okay. So

44:43this is an important topic and they keep

44:45asking this question again and again.

44:48Are we ready for the next one? Let's go

44:50on to the next one. So a woman with

44:53chronic pelvic pain under goes a

44:56transvaginal

44:57ultrasound. There is an ovarian cyst

45:00which is showing ground glass

45:03ecoenicity. What is the likely

45:07diagnosis? So we have given you a

45:09characteristic ultrasound finding. What

45:12is the answer?

45:14So this is a term which is ground glass

45:20ecogenicity which we use yes only for

45:24endomtrioma as far as gyne is concerned.

45:28So we say you will see a cyst with

45:32homogeneous internal eos and that is why

45:36we say it is ground glass right. Can you

45:40tell me what is the characteristic

45:43appearance of hemorrhagic cyst? So this

45:46is called as fishnet or a reticular

45:51pattern. Right? So it is a fishnet

45:54pattern or a reticular pattern. Okay.

45:57What about dermmoid? Dermmoid is a cyst

46:01but it will show what? It will show

46:05calcification. Remember the

46:07calcification is not seen uh uniformly.

46:10It is only seen at one corner of the

46:14cyst. So there will be a calcification

46:17inside. Okay. Cirrus cyst adinoma. Now

46:21cirrus cyst adinoma usually presents as

46:25a cyst but yes uh it does the cyst per

46:29se tends to be unilocular. Right? So um

46:33this is adinoma not

46:36adenocarcenoma. It becomes very

46:38different when you say that. Okay. Is

46:40that clear? Can you tell me? Yes. Now

46:43coming to some more important questions.

46:45What is the classic ultrasound finding

46:48in dermmoid? What terms do we give? So

46:51one yes rocky tansky protuberance which

46:55is the area of calcification and the tip

46:59of iceberg sign. There is another very

47:02important sign that needp is fond of

47:04asking. What is that dot dash sign? So

47:09these are all on ultrasound and they are

47:11signs for dermmoid. They're very very

47:13important. Right. Okay. Can you tell me

47:16how will you see a tubo ovarian absis if

47:20it's an absis? So it will have some

47:23cystic areas but what is most important

47:26is there will be

47:29heterogeneous internal ecos. They are

47:33never homogeneous. It is pus. So it will

47:35settle down. Right? So it is a

47:37heterogeneous internal ecos and there

47:40will be increased flow on

47:44Doppler. Right? Right? If it's an absis,

47:46there is an inflammation, you will see

47:48increased flow on the Doppler studies.

47:51Is that clear to everyone? Okay. If it

47:54is a hydro

47:57salpistic term the ultrasound appearance

48:00is called as. So we say it is

48:06retortshaped. Also sometimes they will

48:08say sausage shaped right. So

48:12retortshaped, sausage shaped. These are

48:15terms that we use for hydro salps. It is

48:18a marker of what jeli? Yes, it is a

48:21marker of pid. So what are the other

48:25findings that you can see? Yes. So one

48:27is called as the cog wheel sign. So yes,

48:32hydroalpinks and pioinks can also show

48:36you the cog wheel sign. Right?

48:39Important. Apart from this the other are

48:42waste sign

48:44and beads on string sign. So these are

48:48all findings again as I said in

48:50ultrasound very characteristic and

48:53therefore they could be asked in the

48:55exams. Are we all good to go? Yes. Okay.

48:59Let's go on to the next question. So the

49:02next question says she is a 14year-old

49:04girl. She's come with primary aminora

49:08and clouro megali. Carot type is xx

49:12testosterone is high. What is the enzyme

49:17deficiency? Okay. What is the answer

49:19here? So pely cheese please remember the

49:23answer cannot be 17 hydroxyilles. Okay.

49:28Why? When we talk about 17 hydroxyilles

49:32deficiency, they cause ambiguous

49:36genitalia in only which ones? In

49:4146xy carotype, not in XX. So it is ruled

49:45out. It is also not aromatase

49:48deficiency. It is very uncommon and a

49:51rare thing. So we don't go with rare

49:53things. Now we are left with two

49:55answers. Both are you know dealing with

49:59congenital adrenal

50:02hyperoplasia right? Why? Because the

50:05testosterone levels are high. There is

50:07aminoria there is clytoromegali. So we

50:11do see

50:13virilization. Okay. And at birth we will

50:16as we said this is what we see. So we

50:19call them often as ambiguous genitalia.

50:21So now you have to tell me is it 21 or

50:24is it 17? the information is not

50:28complete. What are we going to go with?

50:30So I told you this trick also when MCQs

50:33have incomplete information then what

50:35are we going to do? We are going to go

50:38with what is most common. So which is

50:41the most common enzyme deficiency in CH?

50:44It is 21

50:48hydroxyles and therefore this becomes

50:51the answer over 11 hydroxyles. In case

50:55we had to give you some differentiation,

50:58how will you differentiate 21 from 11?

51:0121 hydroxilase is associated with

51:06hypotension and salt wasting.

51:08Aldoststerone levels are low. Right?

51:12Whereas when we talk about uh 11

51:15hydroxilase then this is associated with

51:19hypertension. Yes. Please

51:22remember congenital adrenal

51:26hyperplasia. Okay, congenital adrenal

51:29hypoplasia is responsible for what?

51:32Female pseudo

51:35harm. It is actually the most common

51:39cause of female pseudo

51:43hermafrodite.

51:44Deficiency. It is one of a very very

51:47rare things to happen. Right. So when we

51:49go for MCQ exams, we don't answer rare

51:52things as answers unless it is very very

51:55specific to that condition. Okay. So

51:59they cause female

52:01pseudohmaprodite. Remember the carotype

52:03will be

52:0546x in a female

52:08pseudohmaphrodite. Can you tell me what

52:11about male pseudohmaphrodite? What is

52:13the most common cause? So if we talk

52:16about male

52:18pseudohmaphrodite the most common cause

52:21here is a s androgen insensitivity

52:26syndrome. The carotype is xy here right

52:30it is xy here and

52:33remember there are other causes as well

52:36but the most common for male

52:38pseudoaphraditis ais okay androgen

52:42insensitivity syndrome. I have already

52:44taught you in the last question when we

52:47talk about CH what is the screening test

52:50but the screening test is 17 hydroxy

52:54progesterone levels 17 OP levels which

52:58will be raised and then what test will

53:01you do what is confirmatory

53:04ACC stimulation test confirmatory test

53:10consulation

53:13rest. Okay,

53:15perfect. Now we are going to go on to

53:18the next question. Are we all ready? So,

53:21let's see if you do this one right or

53:23wrong. This was an easy one. I hope

53:26everyone has done it right. Twin twin

53:28transfusion syndrome is a complication

53:32of which type of twin pregnancy? So now

53:35can you tell me do you see it in MC

53:38twins or dicorionic twins? So they are

53:41it is a characteristic complication of

53:44MC twins right? So monocorionic twins

53:48which means all options with dicorionic

53:52are going to be incorrect. Okay but what

53:55is the other part? Do we see it in

53:58monoorionic damnotic or monoamniotic? So

54:02it is much more common in MC DA. So

54:08therefore the answer is B. Mono

54:11chorionic monomniotic may uncommon here

54:15and conjoin twins are also a type of MA

54:18twins. So it is uncommon. Okay. Now

54:21quickly tell me when you say MCDA twins

54:24and twin twin transfusion syndrome. Can

54:27you tell me which kind of anasttomosis

54:31is responsible for this

54:33syndrome? So it has to be deep artery of

54:36the baby connected to the deep vein of

54:39the other twin. So deep artery and deep

54:42vein. What is the problem in MA twins?

54:45MA twins have plenty of

54:50superficial artery artery

54:55anastmosis and this is why twin twin

54:58transfusion syndrome is uncommon in

55:01them. It is more common in DA twins.

55:04Okay. Now can you tell me very very

55:07important MCQs your needp in set all are

55:10asking something or the other about

55:12twin. So very very important. Let's

55:13cover certain important ones here. Can

55:16you tell me what is the characteristic

55:18complication of MA twins?

55:22Monoamniotic a complication answer. What

55:25is that? It will be chord

55:29entanglement. Similarly, if I have to

55:32answer for monoorionic, we will answer

55:34it as twin twin transfusion syndrome.

55:37Okay. My next question to you is when we

55:40talk about twin twin transfusion, how do

55:42we make a diagnosis? Twin twin

55:45transfusion syndrome

55:48diagnosis what are to be included in the

55:52criteria? So, diagnosis is made on

55:56ultrasound. I have to ask you is the

55:58diagnostic criteria anemia and

56:02polyythemeia? No, that is not the

56:05diagnostic criteria. Diagnostic criteria

56:08is

56:10polyhydroamnos in one twin and oolig

56:15hydroamnos in the other twin. So it has

56:19to be simultaneous presence of poly in

56:23one and oligo in the other. My next

56:26question to you is there is no poly or

56:30oligo but there is anemia and

56:35polyythemeia. So one baby has anemia,

56:38one has polyythemeia but there is no

56:41polyanoligo. What is the diagnosis?

56:44Excellent. I see someone has already

56:46answer it. Shab deep. Excellent. So if

56:49there is no amniotic fluid discrepancy

56:52then the answer will become taps. Very

56:55good. Which is what is the full form?

56:58Twin anemia and polyythemeia sequence.

57:04Okay. All right. Now my next question to

57:07you is uh two more MCQs I will ask here.

57:10When it is twin twin transfusion

57:12syndrome

57:13TTTS, can you tell me what is the

57:16treatment of choice? What is the

57:18treatment of choice? So this is laser

57:21ablation of the

57:26anasttomosis. So it is a intrauterine

57:29surgery. You have to destroy the

57:31anastmosis. So it is laser ablation of

57:34the

57:35anastmosis. Right? We can usually do it

57:38uh up till 26 weeks and beyond that we

57:41will simply have to reduce the amniotic

57:43fluid. Okay. Next question. Listen to

57:46me. I'm going to draw it for you and

57:48then you're going to tell me how will

57:50you deliver the twins. So this is the

57:53drawing that I'm going to make.

57:59Okay. All right. So can you tell me how

58:02will you deliver these twins? So can you

58:06understand this is the first twin and

58:10this is the second twin. So how will you

58:14deliver this

58:15but the first twin is

58:18sephilic right? So how will you deliver?

58:21Okay I am already seeing the answers and

58:24majority of you are going to give me the

58:27answer I know as vaginal delivery but it

58:32is

58:33incorrect. You did not see the image

58:36clearly. No doubt the first twin is

58:39sephilic. But is there inter twin

58:42membrane present or no? There is no

58:46inter twin membrane. Which means what

58:50types of twins are these? They are ma

58:53twins.

58:55Monoamniotic. Monoamniotic twins are

58:58always delivered by cesarian. So be very

59:03careful. Please see whether dividing

59:06membrane is present or not. Is that

59:09clear to everybody? Cello. Should we go

59:11to the next question? Okay, let's go

59:14ahead now. The next question says, your

59:17patient is 35 years old. She has

59:21increased nucal

59:24translucency. Okay. There is low PAP A

59:28at 12 weeks. What is the next best step?

59:32So now when I ask you this uh what are

59:36you going to rule or what are the key

59:38words please see the keywords the

59:40question is asking you best okay it is

59:43the follow-up test but you have to

59:45select the best follow-up test right now

59:49if there is increased NT and there is

59:53low pap A what are we dealing with we

59:56are dealing with increased risk of down

1:00:01syndrome

1:00:02room. What happens to hCG levels? HCG

1:00:05levels are going to be high. So when you

1:00:08do this, this is what is called as a

1:00:12combined test. Combined test is a test

1:00:15of first trimester 11 to 13 weeks. Yes.

1:00:20And when you do

1:00:22only s pap or hcg combine, what is it?

1:00:27It is called as the dual test. When you

1:00:30include NT in it, it becomes the

1:00:33combined test. So they are all tests of

1:00:35first

1:00:36trimester. What is the cutff we take for

1:00:38NT? More than or equal to 3 mm is

1:00:42considered as increased entity. Now can

1:00:45you tell me what is the answer? So

1:00:47definitely we will not do the quad test.

1:00:50Why? Because it is done in the second

1:00:53trimester. Similarly, we will not do

1:00:57amnneoentesis because this is also done

1:01:00in the second trimester. So now we are

1:01:03left with two options. Yes, one is nip,

1:01:06one is CVS, corionic willless sampling.

1:01:09What is the answer? The answer will be

1:01:12corionic vless sampling. Why? Because

1:01:16this is a confirmatory test. Please

1:01:18remember

1:01:20NIP is only a screening test. We use it

1:01:25as a secondary screening test. It is not

1:01:29diagnostic. So already you have done one

1:01:32screening and that is high risk and

1:01:35therefore best is to go ahead with a

1:01:38confirmatory test. Is that clear? Okay.

1:01:42NIP can be done around 9 to 10 weeks.

1:01:46Single best answer is beyond 10 weeks.

1:01:49You can do it but it is only a screening

1:01:52test. What is the other name for NIP? It

1:01:55is called as cell free fetal DNA test.

1:02:01Yes. Whose sample are you going to take?

1:02:03It is maternal blood sample. Right. So

1:02:07it is actually a noninvasive test. Among

1:02:11the screening test

1:02:13please probability among all screening

1:02:17test this is the best. Okay. So this is

1:02:20actually the best screening test. It has

1:02:24highest what sensitivity as well as

1:02:28specificity. So your

1:02:30best

1:02:32confirmatory. So the better answer is

1:02:34corionic vless sampling. See corionic

1:02:38willless sampling can be done any time

1:02:42beyond 10 weeks but most commonly we do

1:02:46it between 11 to 13. What about amnneo?

1:02:50Amnneo can be done anytime beyond 15

1:02:53weeks but most commonly it is done

1:02:56between 16 to 18 weeks. They are both

1:03:01confirmatory first trimester or a second

1:03:05trimester. Is that clear?

1:03:07Yes. Yes. NIP is costly so not everybody

1:03:11can afford it. Okay. Is that clear to

1:03:13everybody? Ch. Are we ready for the next

1:03:15one? Quad test. Quad test. But quad test

1:03:20is done between 15 to 22 weeks. Okay.

1:03:25Anywhere between 15 to 22 weeks is quad

1:03:29test. Okay. And quad may I hope you

1:03:32remember the component. So it is hcg

1:03:36alpha phto protein u3 and inhibin a it

1:03:42is not inhibin b. Yes please remember

1:03:45hcg and inhibin a are higher while alpha

1:03:49ftop protein and uee3 are lower. Yes the

1:03:53range is 15 to 22 weeks but the earlier

1:03:57you do the better it is going to be. So

1:04:00generally we will do it between 16 to 18

1:04:04weeks.

1:04:07Why screening? Okay. Ch. Ready for the

1:04:11next one? Okay. Your next question is a

1:04:14sexually active woman presents with

1:04:17bilateral adexal tenderness. There is

1:04:20fever and there is cervical motion

1:04:24tenderness. What is the best next step?

1:04:28So now can you tell me what are you

1:04:30dealing with here? We are dealing with

1:04:34PID right? A sexually active woman lower

1:04:38abdominal pain and yes and if she has

1:04:42any of the

1:04:44following which is cervical motion

1:04:48tenderness, adexal tenderness or uterine

1:04:52tenderness then we say yes it is PID. So

1:04:57now once we know this is P, what are you

1:04:59going to do? Did you get confused about

1:05:02taking a culture, sending a swab? No,

1:05:06please remember P is a clinical

1:05:11diagnosis. Once you meet the diagnostic

1:05:14criteria, you're not going to get

1:05:16trapped. No overthinking, right? So then

1:05:19you are going to start her on empirical

1:05:23antibiotics. This is what we practice in

1:05:27India. These are Indian guidelines,

1:05:29nacko guidelines, right? We follow the

1:05:33syndromeic approach. We are not going to

1:05:36send any samples. We don't even do nat.

1:05:39Okay.

1:05:40US. So can you tell me which kit are you

1:05:44going to give? Yes, we are going to give

1:05:47kit six. What is the color? It is

1:05:50yellow. Who is going to tell me the

1:05:52contents of the kit?

1:05:54Say what are the contents? The contents

1:05:57are

1:05:59sephigzyme plus

1:06:02metronidazole plus

1:06:05doxycycine. Okay. Do you all know the

1:06:07update? What is the dose of

1:06:10sephzyme? It is 800 mg single dose.

1:06:15Metro is 400 mg twice a day for 14 days.

1:06:22What about doxycycan 100 mg twice a day

1:06:26for 14 days. Is that clear? So that is

1:06:30what we are going to give for u uh you

1:06:33know kitix or lower abdominal pain.

1:06:36Somebody is asking laparoscopy. Do you

1:06:38think we do laparoscopy for all patients

1:06:40of P? No, definitely laparoscopy is the

1:06:45best investigation but it is only done

1:06:48when you're not able to make a

1:06:50diagnosis. Okay. So please understand

1:06:53this lab is best

1:06:55investigation. We often say it is the

1:06:58investigation of choice for P. But it is

1:07:02never the initial investigation. If you

1:07:05have to do an investigation which one

1:07:07will you do? It will be trans vaginal

1:07:11ultrasound. So if you have to do then

1:07:14you will do a TVS not a laparoscopy but

1:07:17right. Okay. Can you tell me if now

1:07:21suddenly this patient of yours who is a

1:07:23case of pelvic inflammatory disease if

1:07:27today she presents

1:07:29with right upper quadrant pain what do

1:07:33you think has happened? So today I am

1:07:36and it is a very probable question for

1:07:38your nepg as well. So today she has

1:07:41right upper quadrant pain. What are you

1:07:45thinking of? So this is what is a

1:07:49complication called as

1:07:52perhapititis. What term do we give? Yes,

1:07:54we give it as fitz hug curtis syndrome.

1:08:00Remember on laparoscopy you will see

1:08:03violin string adhesions. Where do you

1:08:06see the adhesions? Not in the pelvis.

1:08:09These adhesions are between the capsule

1:08:12of liver and anterior abdominal wall.

1:08:15They are not in the pelvis but okay

1:08:18pelvis to P not here. Is that okay for

1:08:22everyone? Last thing if it is P or it is

1:08:26Fitz Hugh Curtis what organism are you

1:08:30going to mark? So whether it is P in the

1:08:33question or if it is Switz Curtis what

1:08:37organism are you going to mark? So

1:08:40always when it is P it is usually

1:08:43polyicrobial but if we have to mark one

1:08:47then the answer should be clamidia. If

1:08:51clamidia is not in the options you are

1:08:55going to mark gonoria. But please

1:08:58remember P is also a

1:09:01polyicrobial infection. Okay. And it is

1:09:04a ascending infection. So it is

1:09:08polyicrobial but usually you have to

1:09:10select one. Then we will go with

1:09:12clamidia followed by gonoria. Are you

1:09:16ready for the next one? Shall let's see

1:09:19if you could do this one right. This is

1:09:21again a place where needp keeps asking

1:09:23you tricky options and you get confused.

1:09:27So your patient is a 28-year-old woman

1:09:30and she is coming to you. What do you

1:09:34think is happening around 6 to 7 days

1:09:38post

1:09:40ovulation? Tell me what do you think is

1:09:42happening? So do you understand that as

1:09:45far as embryology is concerned post

1:09:49ovulation is same as postfertilization?

1:09:55Yes or no? Yes. Right. Because the day

1:09:58of ovulation is same as the day of

1:10:02fertilization. So what happens 6 to 7

1:10:05days

1:10:07postfertilization it is going to be

1:10:10implantation. Yes. So 6 to 7 days

1:10:15implantation

1:10:17begins. Right. Day eight

1:10:21implantation and by day 10 it is

1:10:24completed. Right? And please remember

1:10:27the options in this question are very

1:10:29important. The implantation happens in

1:10:32which phase? Yes, that is the other

1:10:35probable question.

1:10:37Blastoyst. Implantation happens in the

1:10:39blastoyst stage. Okay. All other options

1:10:44are also very important MCQs by

1:10:47themselves. Okay. What do you understand

1:10:50when they give you cleavage stage of

1:10:54zygote? Do you know this cleavage stage

1:10:58embryo or zygote is from day 1 to day

1:11:04three? What stage are we talking about?

1:11:06We are talking

1:11:08about morula, right? Morula. Day 1 to

1:11:12day three. Usually that those are

1:11:15cleavage stage. Okay. day. It's exactly

1:11:18like a 16 cell stage and it will enter

1:11:22the cavity on which day? On fourth

1:11:26day, right? Whereas when is blastoyst

1:11:30formed? So remember please blastocyst

1:11:33will be formed on day five. Right? There

1:11:37will be a cyst. Now

1:11:39blastocyst okay

1:11:42fertilization p it's a very basic

1:11:44question.

1:11:46fertilization site ampula right it is a

1:11:50true statement but it doesn't happen on

1:11:52day six okay the site is ampula remember

1:11:56ampula is also the most common site of

1:11:59ectopic pregnancy why because it is the

1:12:03site of fertilization and it has a lot

1:12:06of ple mucosal folds h so ampula has

1:12:12maximum ple what are ple They

1:12:16are mucosal folds. Shabash. Capacitation

1:12:21of

1:12:22sperm. What is the duration?

1:12:25Capacitation average duration 7 hours.

1:12:29The range is 6 to 8. What is the main

1:12:32site? The main site is fallopian tube.

1:12:36Yes, capacitation begins in the cervix

1:12:39but the main site is fallopian tube.

1:12:42Okay. Now I'm sure you'll be able to

1:12:44give me the other answer. Can you tell

1:12:46me when I ask you

1:12:49polyspermy

1:12:51prevention? What would be the single

1:12:53best answer for poly prevention?

1:12:56Pau the single best answer will be zona

1:13:01reaction. What happens in the zona

1:13:03reaction? Hardening of the zona

1:13:06pelucida. Right? So there is hardening

1:13:08of the zona pelucida. That is the single

1:13:11best answer. The second best answer is

1:13:15cortical reaction. Okay. The second best

1:13:18answer is cortical reaction. My last

1:13:21question for this one is when is zona

1:13:24pelucida lost? When is zona pelucida

1:13:28lost? So answer again will be day five.

1:13:32Okay, it is lost on day five. Shabash.

1:13:34Excellent. Are you ready for the next

1:13:36one? Okay, let's look at this one. Let

1:13:39me see if you answered this one correct

1:13:41or not. Your patient has one child. She

1:13:45wants a long-term contraception. She is

1:13:49asking for an intrauterine device. She

1:13:52has heavy menstrual bleeding. Which is

1:13:56the most appropriate IUD for her? Now

1:14:00tell me which two options can you rule

1:14:03out? Con say rule out. So now we have to

1:14:07understand all copper containing

1:14:12iods are going to increase menstrual

1:14:16blood

1:14:18loss and therefore if a woman has heavy

1:14:22bleeding right or minori it becomes a

1:14:25relative contraindication for copper

1:14:27tea. Okay, now we are left with two

1:14:30options. Yes, C and D both are

1:14:33progesterone containing devices. Which

1:14:36one is going to be the answer? Is it C

1:14:38or is it

1:14:39D? Okay, I see so many of you answering

1:14:42D as well. Absolutely no. Okay, the

1:14:46answer is C. Why not D? Do you know

1:14:51Proestaert is a very old IUD?

1:14:55It had a lifespan of only one year and

1:14:59it was causing a very high number of

1:15:03ectopic pregnancies and therefore it was

1:15:07withdrawn from the market. Projestaert

1:15:09is no longer available in the market. It

1:15:12is only available in the options for

1:15:14you. Right? We don't use progestera. The

1:15:17risk of ectopic is very very high. So it

1:15:20was withdrawn. So you are going to give

1:15:23her what? You are going to give her my

1:15:26right. So the answer is going to be C.

1:15:30The most appropriate one is going to be

1:15:33C. Okay? Is that clear also? Now please

1:15:37understand this means we already know

1:15:40now IUD is a LAR. What is Lark? Lark is

1:15:46long acting reversible contraception.

1:15:50Can you tell me what else is included in

1:15:53Lark? Yes, LG IUD is the other name for

1:15:59my because it contains LNG. Okay, Lark,

1:16:03long acting reversible contraceptives.

1:16:07What else is included here? So, IODS are

1:16:11included, implants are included,

1:16:15and yes, what else? Injectables are

1:16:19included. Please remember we will not

1:16:22include tubal liation. Why not? It is

1:16:27not a reversible method. Tubal liation

1:16:30is a permanent method. Some of you have

1:16:34doubts. I see

1:16:36here. Please remember myina is an

1:16:39intrauterine device but it is

1:16:42continuously giving progesterone. So

1:16:44what does it do? Myina will cause

1:16:48endometrial

1:16:50thinning. Okay. And it reduces the

1:16:54menstrual blood loss and therefore it is

1:16:57given to women who have heavy bleeding.

1:16:59We can even use it for fibroids,

1:17:02adenomiiosis, right? So it causes

1:17:04thinning and it reduces the blood loss.

1:17:08Can you tell me whenever we say IUDs by

1:17:11which method do they not act? So can you

1:17:14tell me they do not act by which method?

1:17:19So remember IOD's don't act by

1:17:22inhibition of

1:17:25ovulation. Whether it is myina or copper

1:17:28tea, their main action is not inhibition

1:17:31of ovulation. How do they act? They act

1:17:34by inhibition of

1:17:37fertilization. Okay, that's the best

1:17:40answer. Followed by inhibition of

1:17:42implantation. Okay, some oneliners I I

1:17:46definitely want to ask. Can you tell me

1:17:48what is the lifespan of copper T

1:17:5138A which is also called as paragard?

1:17:55The lifespan is 10

1:17:58years. Multi-load copper 375 the

1:18:02lifespan

1:18:04is 3 years. Okay, the lifespan here is

1:18:09generally around 3 years. Okay then tell

1:18:13me what about

1:18:15myina?

1:18:18Myina will have a lifespan of around 8

1:18:23years. Yes sorry 3 years n 5 years for

1:18:26multi load it is around 5 years. Okay 5

1:18:29years for around multiload. So some

1:18:32places do say 3 five but generally we

1:18:35take it as a lifespan of 5 years is

1:18:38acceptable for it. Okay, it's almost

1:18:41similar but yes for property it is 10

1:18:44years. Okay, what

1:18:46about is now approved for 8 years? Mina

1:18:515 years was the older thing. It is now

1:18:53approved for a span of 8 years. Okay.

1:18:57Haha five is a better answer. Most

1:19:01places give it as five only. Some places

1:19:03say multi load is usually for three but

1:19:06it is effective up to five. So we will

1:19:09take it as 5 years as the upper limit.

1:19:12Okay. Similarly for myina we will take

1:19:14the upper limit as 8 years. Okay. Clear

1:19:18to everyone? Okay.

1:19:20Ch. Next. Next. Some tricky ones coming

1:19:24your way. So first one. Your patient is

1:19:2755 year old post menopausal. Okay. Now

1:19:31tell me she presents with abdominal

1:19:34bloating and a pelvic mass. Imaging is

1:19:37success. uh showing a solid cystic mass

1:19:41with acitis which tumor marker is

1:19:44appropriate can you tell me what is the

1:19:46answer so look at the key words a 55

1:19:51year old so post

1:19:53menopausal then solid cystic mass with

1:19:56asitis which usually means advanced

1:20:01stage so which cancers do you see in

1:20:04postmenopausal which are all also

1:20:06usually advanced stage at the time of

1:20:09diagnosis. What is the answer? It is

1:20:12yes. It is serrus cancers which is a

1:20:16type of

1:20:18epithelial ovarian cancers. So in the

1:20:21post menopausal women it is usually

1:20:24epithelial ovarian cancers which are

1:20:26also epithelial I hope you know are most

1:20:30common ovarian cancers. 90% will be

1:20:34epithelial in origin and therefore what

1:20:37is the tumor marker? Yes, it is going to

1:20:40be CA1 125. Now tell me

1:20:45LDH tumor marker here. So this is the

1:20:48best answer for

1:20:51disgeroma. What about alpha protein?

1:20:55This is the best marker for what? Yoke

1:20:58sac tumor also called as

1:21:02endodermal sinus tumor. What about uh

1:21:07okay SCG? ECG is simple. ECG is the

1:21:10tumor marker for

1:21:13corocarcenoma. Yes. So these are

1:21:15important. What is the tumor marker for

1:21:17mucinus? So mucinus k it is going to be

1:21:22ca. That is the single best answer.

1:21:24Carcino embriionic antigen. But it can

1:21:27also be CA

1:21:29199. Yes. What about

1:21:32granulos? Okay. So yes, very nice. It is

1:21:36going to be inhabin. Typically inhibin B

1:21:39will be a better answer than inhibin A.

1:21:42Right. So granulosa cell it is inhabin.

1:21:46Perfect. Very very nice. Can you tell me

1:21:48which ovarian tumor is associated

1:21:52with sudo mixoma

1:21:56peroni? Which ovarian tumor is

1:21:58associated with pseudomigoma peroni? It

1:22:02is

1:22:04mucinus. Which ovarian tumor is

1:22:07associated with mig syndrome? So mig

1:22:11syndrome please remember is a triad of a

1:22:13benign tumor. It has to be a benign

1:22:16tumor plus ascitis plus eusion plural

1:22:21eusion. What is the single best answer

1:22:23for MIG? It is going to be fibram. The

1:22:28single best answer is fibramma. But it

1:22:30can also be what else? It can be

1:22:33granulosa cell, thea cell or theoma. It

1:22:38could also be bros. Right? Okay. Which

1:22:42tumor is associated

1:22:45with crookenbergs? So if it is a

1:22:48crookinberg tumor of the ovary, which

1:22:51cancer your patient is likely to have?

1:22:54But so she is likely to have stomach

1:22:58cancer. The best answer is stomach

1:23:00cancer, but it can also be colon and

1:23:03breast. So these are some of the

1:23:05important areas that we do tend to ask.

1:23:07You should be thorough with them. They

1:23:10are uh very very commonly asked

1:23:13pseudomiga if it is any other tumor

1:23:16apart from these four it should not be

1:23:19fibram it should not be granulosa

1:23:22briners and theoma if it is any other

1:23:24tumor then we say it is pseudomig

1:23:28okay last few questions and let's see if

1:23:31you did them right all the following

1:23:34improve the success rate of ECV except

1:23:38now This is a question where we are not

1:23:41asking you contraindications. We are

1:23:43asking you where the ACV would be more

1:23:47successful. So now tell me do you give

1:23:51toolytics to improve success? Yes, this

1:23:54is a true

1:23:56statement. Adequate amniotic fluid. This

1:24:00is also true because only if there is

1:24:02fluid will you be able to rotate.

1:24:05Multiparity. This is also true because

1:24:08they have lax abdominal wall. So it is

1:24:12easier to rotate. So by exclusion what

1:24:16is the answer? Engaged head because this

1:24:19means the head has gone inside the

1:24:21pelvis. Now it is very difficult to uh

1:24:24sorry engaged presenting part which here

1:24:27is breach. So which means the buttocks

1:24:30have gone deep into the pelvis and it's

1:24:33very difficult now to first push them up

1:24:36and then do the rotation. So the success

1:24:39rate will be less. Your exams are also

1:24:43please remember fond of asking

1:24:48uh timing of ECV. So please remember the

1:24:52best time to do external syphalic

1:24:55version is 37 weeks but yes ECV can be

1:25:00done anytime beyond 36 weeks. You will

1:25:04do ECV for which two conditions? We do

1:25:07it for a breach baby and we also do it

1:25:10for transverse lie. Okay. Now as I said

1:25:14your exams are also very fond of asking

1:25:18contraindications of ECV and some

1:25:22important ones you should never forget.

1:25:24For example, ruptured

1:25:27membranes. For example, twin

1:25:32pregnancy. For

1:25:34example, if there is

1:25:38nonreassuring fetal heart rate. For

1:25:41example, if there is conditions like

1:25:44placenta privia or contracted pelvis,

1:25:49then if the woman is in active labor.

1:25:54Apart from these, yes, malarian or uh

1:25:57fetal anomalies. So, anomalies can be in

1:26:00the baby, anomalies can be in the

1:26:04uterus. So, gross anomalies of uterus

1:26:06and gross anomalies of the baby. But

1:26:09very important will be the ones that I

1:26:11put at point number eight because neat

1:26:15PG. So 8 pay we will put the ones which

1:26:18are relative contraindications but yes

1:26:20they are

1:26:21contraindications. For

1:26:24example previous

1:26:26cesarian IUGR with oligo. Okay

1:26:32preclampsia macrosomia.

1:26:35Right your nep is fond of asking these

1:26:38conditions. So previous cesarian

1:26:42uh preeacclampsia macrosomia they are

1:26:45also going to be important

1:26:47contraindications classical vaginal

1:26:50delivery. So why would you do an ECV?

1:26:53Okay, classical cesarian may please

1:26:56remember we are not going to do a

1:26:59vaginal delivery then why would you do a

1:27:01cesar you know

1:27:03version be out of question here take ch

1:27:07let's go on to the next question which

1:27:10of the following is absolute

1:27:12contraindication to induction of labor

1:27:16so gestational diabetes at 40 is not a

1:27:20contraindication it is rather a

1:27:24indication. Can you tell me what is the

1:27:26best time to do induction? The best time

1:27:29is 39 weeks.

1:27:33Okay. IUGR again is not a

1:27:36contraindication. It is a

1:27:39indication. Previous lower segment

1:27:41cesarian section is not a

1:27:43contraindication. What is a

1:27:45contraindication? Classical cesarian.

1:27:48Okay, this is a contraindication. So the

1:27:51answer is yes. Transverse lie. So no

1:27:55vaginal delivery. So no induction.

1:27:59Remember other important

1:28:00contraindications. So other

1:28:02contraindications con. So again placenta

1:28:05pbia and contracted pelvis. What else?

1:28:10Cord

1:28:12prolapse. Vaza pia.

1:28:17Placenta acreta

1:28:20spectrum category 3 fetal heart rate

1:28:24these are all very important

1:28:26contraindications cancer cervix and

1:28:29active lesions of genital herpes. So

1:28:34these are the ones that I would

1:28:36definitely want you to remember. Please

1:28:39remember also your NEPG is very fond of

1:28:41asking when we talk about induction of

1:28:44labor. There are two drugs that you keep

1:28:46getting confused on. So one is

1:28:49dorost and the other is

1:28:52dorroone. Can you tell me which one will

1:28:55we use and which one we will not use? So

1:28:58do prost not used. Dorroone is used.

1:29:03Protone here PG

1:29:06E2 dinost here P GG F2 alpha okay so be

1:29:13very clear there are different different

1:29:14drugs caroprost is PGF2 alpha right so

1:29:19this is also

1:29:22caroprost so we do not use it for

1:29:25induction very good la last few

1:29:29questions three

1:29:30questions which of the following is the

1:29:32surgery of choice for a 35 year old lady

1:29:36uh with uterine prolapse and she wants

1:29:39to preserve

1:29:41fertility. Now tell me which ones can

1:29:45you rule out? Let's approach it that

1:29:47way. We obviously cannot do a

1:29:50hyerectomy. She wants to preserve

1:29:52fertility. Now then we can't even do

1:29:56culpolesis because this is a partial

1:30:00vaginal closure.

1:30:03Now we are left with two options for the

1:30:06gills and

1:30:09sacroyopex. Answer here is it A or is it

1:30:12D? What is the answer? It is D. It is

1:30:17not for the gills. Please remember for

1:30:20the gills will be done when family is

1:30:25complete. Okay. And it is typically done

1:30:27when there is cervical

1:30:32elongation. So answer is

1:30:35sacrohyopexy. It is a type of a sling

1:30:38surgery. But can you tell me what do we

1:30:40use here? We use a mesh. It is very

1:30:44similar to

1:30:46sacroopexi. The mesh here is put between

1:30:50sacral promonry and uterus. So it gives

1:30:55very good results but it is more

1:30:57extensive surgery. It's more difficult

1:31:00surgery. Can you tell me among sling

1:31:04surgeries overall which is the treatment

1:31:07of choice or the preferred

1:31:09sling? The preferred one usually is

1:31:13shir's abdominal sling. It is relatively

1:31:17easier with less complications. Okay. Is

1:31:20that clear to everyone? Okay. Let's move

1:31:23on to question number 19. So your

1:31:27patient has irregular bleeding. She has

1:31:30a foul

1:31:32discharge. There is a friable ulcerative

1:31:35growth which bleeds on touch. Now biopsy

1:31:40has al already con uh you know confirmed

1:31:44squammer cell cancer. Now this is what

1:31:46happens in your exams all the time.

1:31:48You're thinking of making a diagnosis

1:31:50and wasting your time. Last line is very

1:31:54important. Question is saying which of

1:31:57the following investigations is used for

1:31:59staging of cervical

1:32:02cancer. So remember the staging is

1:32:05definitely

1:32:06clinical but can we use investigations?

1:32:11Yes. Now tell me what is going to be the

1:32:14answer. It is not papsmear and it is not

1:32:17culposcopy because they are used for

1:32:21screening. Yes. So they are used for

1:32:24screening and making a diagnosis. So

1:32:27culpo biopsy is used for diagnosis while

1:32:31papsmear

1:32:33is used for screening. They are not for

1:32:36staging. Now we are left with two

1:32:38options. Is it MRI or is it chest X-ray?

1:32:42So always whenever we talk about

1:32:45cervical cancer is it first going to go

1:32:47to the lungs or is it first going to

1:32:50spread in the surrounding area. So you

1:32:52have to use some common sense if you

1:32:54don't know it exactly. Cancer cervix

1:32:57most common root of spread is local

1:33:01spread. So first it will spread to the

1:33:04surrounding area which is connective

1:33:06tissue. What is the best investigation

1:33:08for soft tissue? it is MRI. So there is

1:33:12no doubt I can use chest X-ray also but

1:33:15chest X-ray is does not help us in early

1:33:18stages. Okay. So please remember MRI

1:33:23will be the best investigation for

1:33:26parametrial

1:33:29spread. Can you tell me what is the best

1:33:31investigation for lymph node spread? So

1:33:35best for lymph node spread is CT pet.

1:33:40Okay, the combination. But yes, if CT

1:33:43pet is not available, can I do a CT

1:33:45guided biopsy and hystopathological

1:33:48confirmation? Yes, you can use that as

1:33:51well. But the best is CT PET. Is that

1:33:55clear to everyone? Okay. Why would we do

1:33:58a cystoscopy? Cystoscopy will be done to

1:34:01see spread to bladder.

1:34:05But very very important and tell me if

1:34:08on systocopy you see bullis edema of the

1:34:13bladder mucosa then is it stage 4 or

1:34:17not? No. So please remember bullis edema

1:34:22stage

1:34:234 because it means it is lymphatic

1:34:28blockade not literally spread. So just

1:34:31on this finding we don't make it stage

1:34:33four. Now quickly tell me what is 2B?

1:34:38Anybody say

1:34:402B? 2B is paramtrium is

1:34:45invaded. What is 3B? 3B is spread to

1:34:51lateral pelvic wall as well as spread to

1:34:56urtors. So hydro ura or

1:35:00hydronphosis. What is 3C? Lymph node are

1:35:04now

1:35:05positive. What is 4 A? Spread to bladder

1:35:10and rectum. What is 4B? Distant spread.

1:35:16Okay, please remember inguinal lymph

1:35:19nodes are considered as distant spread

1:35:23not 3C they will be 4B. Right? So this

1:35:26is very very important. 1 B3 is very

1:35:30important. It is bigger than 4 cm.

1:35:35Right? It is bigger than 4 cm. So please

1:35:39remember all stages beyond or equal to

1:35:431b3 we will do a cheo radiation. Okay.

1:35:48We will do a chemo radiation. Okay. That

1:35:52brings us to the last question for the

1:35:53day and then you will tell me how was

1:35:55the paper. Okay. Which of the following

1:35:58genetic mutations is most strongly

1:36:02associated with highgrade serrus cancer

1:36:06of the ovary? Now tell me what is the

1:36:09answer? So K RAS path K RAS generally

1:36:16does not cause highrade tumors. Okay. It

1:36:19causes lower grade tumors.

1:36:22Also this is not something we have ever

1:36:25taught you in ovarian cancers. Now we

1:36:28are left with two P10 and barka. What is

1:36:31sorry uh what is the answer here? So

1:36:33here the answer is going to be barka

1:36:37mutations. P10 is generally associated

1:36:41again with lower risk cancers and it is

1:36:44more important for

1:36:47endometrial cancer. Which

1:36:50hisystologology?

1:36:53Endomroidid. Okay, it is

1:36:56endomroid. K Rass mutations are

1:36:59generally seen with mucinous ovarian

1:37:02tumors, right? Burka one mutations.

1:37:05Which ovarian tumor which will your

1:37:07patient have? She will develop cirrus

1:37:10ovarian tumors. Right? So burka 1 will

1:37:14usually cause serrus tumors. All right.

1:37:17Can you tell me

1:37:20P53 important? So with

1:37:26CAVIX in terms of CAVIX, which viral

1:37:31gene will knock out P-53? It is E6. So

1:37:35E6 is

1:37:37P-53 and E7 is RB gene. Okay. In terms

1:37:43of CA ovary

1:37:46p-53 high grade always high grade it

1:37:49will be cirrus cyst adenoc

1:37:53carcinoma. In fact please remember in

1:37:56cirrus cyst adenocarcinomaomas or in

1:37:59ovarian cancers in general the most

1:38:03common mutation

1:38:05is

1:38:07p53 not barka 1. Barka 1 is responsible

1:38:11for only 10% of cancers. The remaining

1:38:16are because of

1:38:17p-53. What about endometrial

1:38:21CAS? So if we talk about endometrial

1:38:24cancer then tell me then p-53 is

1:38:28associated with type 2 cancers which are

1:38:32now called as aggressive cancers. Right?

1:38:37Please remember

1:38:39endomroid

1:38:41adenocarcinomaomas were earlier called

1:38:43as type one and they are now called as

1:38:47nonaggressive. They are associated with

1:38:50P10 mutations. Okay. But the aggressive

1:38:54ones are associated with P-53 or type 2.

1:38:59Is that clear to everyone? Somebody's

1:39:01asking ma'am out of burka 1 and two

1:39:03which is more important burka one pelle

1:39:06arena so higher risk of ovarian is with

1:39:09burka 1. So with this we finally come to

1:39:12an end with the MCQ discussion. These

1:39:16were 20 very very high yielding topics.

1:39:19Uh you are likely to get something or

1:39:21the other from these discussions. We've

1:39:23tried to made it to the best of our

1:39:25ability to help you use this time for

1:39:29your revisions and also to help you know

1:39:32that these are very very probable

1:39:34things. Right? So, how many of you got

1:39:38uh I would say 18, 19 or 20? How many of

1:39:43you got 18, 19 or 20? All of you who

1:39:46have got either 18 or 19 or 20 will give

1:39:51the fire emoji in the chat box. Let's

1:39:54see how many of you were on fire today.

1:39:57Yes. Tell me, tell me, tell me. So, very

1:40:01good. So, excellent. So, you know, every

1:40:03step you take, every MCQ that you

1:40:06improve is going to take you to the next

1:40:10level. Okay? So, please remember this.

1:40:12No matter where you are, every little

1:40:15improvement, even if it is one question,

1:40:18will make a lot of difference. And

1:40:20therefore, it is essential that we take

1:40:23every question as a possibility to do

1:40:26better and better. Okay. Okay. So, now

1:40:30let's see how many of you got 15, 16,

1:40:34and 17 out of 20. I am going to give you

1:40:38a heart. Okay. Very well done, and I am

1:40:41proud of you. And I am sure that you

1:40:44will put your heart and soul into your

1:40:46preparation and you will come out with

1:40:48flying colors. Okay. Anybody who has got

1:40:51less than 15 as well, please don't

1:40:54worry. You have done well. I am going to

1:40:58still clap for you now in anticipation

1:41:01that I will get an opportunity to clap

1:41:04for you even after the exam. I would

1:41:07love to do that. Okay. So, all the best

1:41:10everybody. You're all work in progress.

1:41:13You are going to do well. You're going

1:41:16to tell yourself, I'm going to try my

1:41:18best. Yes, I am work in progress and I'm

1:41:21improving and I'm getting better every

1:41:24single day. Okay, so take care everyone.

1:41:27All the best and stay focused. Keep

1:41:31studying and I'm sure that you will do

1:41:33exceedingly well. Good wishes and thank

1:41:36you so much for making me a part of your

1:41:38journey. Lots of love and lots of

1:41:40blessings to everyone. Take care

1:41:42everybody.