Full transcript
0:02So hi everyone and I am back here for
0:06very very special test discussion.
0:08So you know
0:09this was one of the test that I sent a
0:11link to whoever wanted on Instagram to
0:15follow up with MCQ discussions so that
0:17you know you are on track and you are
0:19practicing MCQs every single day and I
0:21wanted to ensure that obs and gyne is
0:23part of your revision. So then you all
0:26said that madam please do a discussion
0:29as well for the test. So here it is and
0:31I hope it is going to be useful for
0:33everyone out there.
0:35If you haven't yet given the test
0:36connect to me on Instagram ask me for
0:39the link and I'm going to send you the
0:41link for the test. Okay.
0:43So this is the first question. Your
0:45patient is 38 weeks pregnant so she's in
0:48the third trimester and she is
0:50presenting to us with vaginal bleeding.
0:53Right? Now this is sudden onset and we
0:57have some key things. So this is APH.
1:00The uterus woody and hard and it is
1:03tender. There is also evidence of fetal
1:06distress. So now what is the likely
1:08diagnosis? So yes the answer here is
1:11abruption. So I've highlighted the
1:13keywords for you. So a tense tender
1:16uterus
1:18APH with the which is associated with
1:21pain. Right? These are characteristic
1:24things to differentiate abruption from
1:26placenta previa. So placenta previa we
1:29all know has to be painless and
1:31causeless. Right? Also
1:33fetal distress although can be present
1:35in both it is more common to come across
1:38fetal distress in abruption. Remember
1:41abruption is usually a sudden event or
1:44an acute event so there is no warning
1:47hemorrhages in abruption. Warning
1:49hemorrhages are usually a key feature of
1:52placenta previa.
1:54This is also not
1:56vasa previa. So vasa previa will not
1:59have a tense tender uterus. Also the key
2:02association of vasa previa will be a
2:04sudden rupture of membranes followed by
2:06severe bleeding followed by you know or
2:09associated with severe fetal distress.
2:12Right? And similarly in uterine rupture
2:14you will have some keywords. Like most
2:18importantly the patient would be a case
2:19of previous cesarean. Also in uterine
2:23rupture it is the reverse finding. The
2:25uterus is not hard and woody. You know
2:28the uterus will lose its contour. The
2:31contractions will stop and yes there
2:33will be fetal distress. Remember also
2:36vaginal bleeding in ruptured uterus is
2:38very small in amount. It is a major
2:40bleeding which you see in either
2:42placenta previa or in abruption.
2:45All right. Let's look at the next one.
2:48Which of the following is the most
2:49sensitive marker for detecting Down
2:51syndrome in the first trimester? So the
2:54moment we see that we already know that
2:57alpha fetoprotein and inhibin A are out.
3:00Because AFP and inhibin A are a part of
3:03quadruple test. Yes?
3:06Right? And quadruple test is a test of
3:08second trimester not of the first
3:11trimester. So it is alpha fetoprotein,
3:14it is hCG, it is inhibin and it is
3:17inhibin A not B and it is unconjugated
3:20estriol. Remember as I have taught that
3:23alpha fetoprotein levels will be low.
3:26UE3 will be low whereas hCG and inhibin
3:30A are raised. Now we are left with two
3:32options. So option B if you see is the
3:35dual test. And option C is the NT scan.
3:39Normally I know what you all know is
3:41that usually the most commonly done test
3:45for Down syndrome screening is a
3:46combined test.
3:49Right? So it is done in the first
3:50trimester and it includes both dual plus
3:54NT scan. But now what have we done? We
3:57have split the two for you. So now we
3:59are asking you individually which is
4:01more sensitive and it is definitely the
4:04NT scan. So NT NT scan individually in
4:07the first trimester is the most
4:09screening
4:11you know has the highest sensitivity
4:12amongst the options given. But what has
4:15higher sensitivity even more than NT
4:18scan or the combined test? Then the
4:20answer is NIPT or cell-free fetal DNA
4:24test. Please remember usually we do not
4:27do NT scan alone or dual markers alone.
4:31They are done together. Together they
4:33will have more sensitivity than NT alone
4:36or dual alone. Yes? And individually
4:39overall the highest sensitivity, the
4:41highest detection rate, the highest
4:43specificity among the screening test is
4:46cell-free fetal DNA test. Okay?
4:49Next.
4:50Your patient has come with
4:53>> [clears throat]
4:53>> primary infertility and cyclical pelvic
4:56pain. So we know we are talking about
4:58dysmenorrhea. And the second association
5:01we are talking about is infertility. So
5:06when you see this together you know
5:08always think of endometriosis. But other
5:10than that what else do we have? We have
5:13already a very characteristic finding.
5:15Laparoscopy shows a powder burnt lesion.
5:18Right? So powder burnt lesion are old
5:21lesions or chronic lesions seen in
5:23endometriosis.
5:25Right? And whenever we talk about first
5:29line medical management. Okay? Now
5:33please remember although when it comes
5:35to infertility medical management is not
5:38helpful. Right? So here we are not
5:41specifying whether we want it for
5:43infertility or for dysmenorrhea but we
5:46are specifying what is the first line
5:48among the medical management. Right? So
5:51then the answer is going to be combined
5:54oral contraceptive pills. They are the
5:57first line drugs that we give for
5:59endometriosis associated pain.
6:03Okay? We are currently not presuming
6:06that she has her main concern is
6:08fertility because as I said the medical
6:11management that you give will not help
6:13her conceive. Okay?
6:15So this is first line in endometriosis
6:18for dysmenorrhea or endometriosis
6:21related pain. A lot of times we will
6:24combine OCPs with NSAIDs. Okay? But
6:28whenever you have to mark single best
6:30answer you are going to mark it as OCPs.
6:33Which is the single best answer for mild
6:35to moderate pain in endometriosis.
6:38In case we see severe pain or a pain
6:42which the woman cannot bear then yes we
6:44can go ahead with GnRH agonist. And
6:48remember you have to give them in a
6:50continuous
6:52manner. Okay? So methotrexate we don't
6:56use for endometriosis. Hysterectomy is
6:58like the last resort and you will not do
7:00it in a 24 year old girl. Right?
7:03These are important things that you
7:05should know. Yes? Okay.
7:08Now moving on to the next question.
7:11So the next one says in a woman with
7:13PCOS who desires pregnancy which of the
7:16following is the current line or first
7:19line agent for ovulation induction? So
7:22we are very specifying a very clearly
7:24specifying ovulation induction. We are
7:26also specifying first line. So
7:29definitely the answer is not metformin.
7:33Okay? Metformin is primarily not given
7:35for ovulation induction. It is mainly
7:37given for insulin resistance in women.
7:42Or in women with PCOS.
7:44Okay? Spironolactone
7:46never answer this when we are talking
7:48about fertility or trying to conceive.
7:51Because spironolactone is anti-androgen.
7:55So you do not give it to someone who's
7:56trying to conceive. So now we are left
7:59with again two options clomiphene
8:00citrate and letrozole. So the answer is
8:04definitely letrozole. It is the current
8:07first line drug for ovulation induction
8:09in PCOS. It is aromatase inhibitor.
8:14Okay? The mechanism of action is
8:17increasing the FSH levels. It has become
8:20the first line because it causes mono
8:22follicular development. Okay? And it has
8:26better live birth rate than um uh
8:31clomiphene citrate and please remember
8:33it also have has a shorter half-life 48
8:37hours which makes it a safer option as
8:39well. So both clomiphene and letrozole
8:42are first line drugs. But letrozole is
8:46currently the drug of choice. Clomiphene
8:49again yes is a first line drug. It is a
8:52SERM. It also increases by increasing
8:56FSH and causes ovulation but it will
8:58cause multi follicular development. It
9:00has a much longer half-life and it is
9:03also an anti at the level of the
9:05endometrium and cervical mucus.
9:09Okay, let's go on to next one. Which of
9:11the following is the gold standard for
9:13prevention of eclamptic seizure
9:15seizures? Now this is prevention. So for
9:19eclampsia we all know we use mag sulf
9:21but do we use mag sulf even for
9:22prevention? The answer is yes. This is
9:25typically given in women with impending
9:27eclampsia or in women with severe
9:30preeclampsia.
9:32Right? So answer remains as mag sulf. We
9:35are using the Pritchard's regime and
9:39please remember that mag sulf is
9:42centrally acting. Okay? So it will act
9:46in the brain. It acts on the NMDA
9:48receptors. Right? And
9:51it is going to be used as the drug of
9:54choice. Remember when we talk about
9:55Pritchard's regime
9:57do not get confused about the loading
9:59dose. So, loading dose is a total of 14
10:02g, out of which 4 g is given IV and 10 g
10:07is given IM. Okay? And please remember,
10:10mag self is not an antihypertensive.
10:14So, you have to add an antihypertensive
10:17for severe preeclampsia, which is going
10:19to be the drug of choice is labetalol,
10:22which is an alpha plus beta blocker. So,
10:24this is what is the drug of choice for
10:26anti among the antihypertensives, while
10:29mag self is the drug of choice for
10:31prevention or treatment of eclampsia.
10:34Also remember, when we are giving the
10:35loading dose, we do not check the kidney
10:38functions. It has to be given
10:39irrespective of the kidney functions.
10:42Okay?
10:44All right. The next question says, "What
10:46is the definitive initial treatment for
10:48hydatidiform mole?" So, this means we
10:51are talking about complete mole, and the
10:54treatment of choice is very simple. It
10:56is suction and evacuation, and this is
11:00irrespective of the size of the uterus.
11:03Okay? Please do not get confused with
11:06systemic chemotherapy. Okay?
11:07Chemotherapy is what you give for GTN.
11:11Like choriocarcinoma is a very very
11:14chemo-sensitive tumor.
11:16When will you change the answer to
11:18hysterectomy? Suppose I say the patient
11:20is more than or equal to 40 years old,
11:23and she has a complete mole, and I am
11:26telling you that she has completed her
11:29family, then yes, these women, specially
11:32if they have very high hCG levels as
11:34well, they are high risk for conversion
11:37to GTN. So, only under these conditions
11:40for complete mole, we may go ahead and
11:42do a hysterectomy. Otherwise, the answer
11:44remains as suction and evacuation. Okay?
11:47Please remember, the surveillance period
11:49for complete mole will remain as 6
11:52months with OCPs as the contraception of
11:55choice.
11:57Okay.
11:59Your next question is a 30-year-old
12:01woman who has come with heavy menstrual
12:03bleeding, and we know the reason. It is
12:06intramural fibroid. Now, the question
12:09says she wants to avoid a major surgery.
12:12Okay? What are we going to do?
12:15Now, for an intramural fibroid, can we
12:19give
12:20Mirena for her heavy menstrual bleeding?
12:23Definitely, yes. But, read the question
12:26carefully. Question says, "What is the
12:28most appropriate radiological option?"
12:32Right? So, the most appropriate
12:34radiological option is going to be
12:36uterine artery embolization. Had we not
12:40specified radiological option, then yes,
12:42the answer would have been Mirena. Okay?
12:45They are the first-line OCPs or Mirena
12:49are the first-line agents that we will
12:50give for heavy menstrual bleeding. Okay?
12:54Myomectomy is typically done, uh you
12:56know, when the woman wants to conceive.
12:59Yes? That's when uh it becomes the
13:03first-line treatment. Hysterectomy, we
13:05all know, is the last resort. Please
13:07remember to be very careful. When we say
13:09uterine artery embolization, it comes
13:12between the medical management and
13:14surgical, which means medical management
13:17is what we give first. If the woman does
13:19not respond, and
13:21she does not want to go for surgical
13:23management, that's when we go for UAE.
13:26But, be very careful. Uterine artery
13:28embolization is usually done when the
13:31family is complete. Okay? So, that is a
13:35small nuance that you should know. So,
13:37it's not, you know, given to someone
13:39who's wanting to conceive. Okay?
13:42Also remember, one of the other
13:44radiological options that we have is
13:46called as MRgHIFU.
13:49Right? So, magnetic resonance-guided
13:51high-intensity focused ultrasound. So,
13:54this is again a relatively new
13:57technique, and it again comes between
13:59medical and surgical management. Right?
14:03But, for this, we need the number of
14:05fibroids to be less than five. We don't
14:07want them to be calcified. And again,
14:09preferably, we want the family to be
14:11complete.
14:13Okay. Now, a very important, but a very
14:16basic question repeatedly asked in NEET
14:18PG exams, "What is the most common cause
14:21of primary PPH?" So, primary PPH is
14:24something that happens within 24 hours,
14:27and secondary is something which happens
14:29beyond 24 hours and up to
14:3312 weeks. So, the most common cause of
14:36primary PPH is uterine atony, whereas
14:39for secondary, it is retained placental
14:43tissue.
14:44Okay? But, always remember the 4 Ts. The
14:48first T is the most common cause. It is
14:50tone. When we ask you the second most
14:53common cause of PPH, don't answer it as
14:57retained tissue. The second leading
14:59cause is trauma to the genital tract.
15:02The third is retained tissue, and the
15:05fourth is a defective thrombosis. Right?
15:08Which means maybe a coagulopathy. So,
15:11yes, these are the 4 Ts for postpartum
15:13hemorrhage that you must know.
15:15Also,
15:17please remember, it is a blood loss of
15:19more than or equal to 500 ml
15:22after vaginal delivery. Right? So, after
15:24vaginal delivery, a blood loss of more
15:26than 500 ml is taken as PPH. But, that
15:30is as per the new update.
15:33Even if the blood loss is more than or
15:35equal to 300 ml, and there are any signs
15:38of hemodynamic instability,
15:43okay?
15:44Then, yes.
15:47You should again consider it as PPH. And
15:51when we say hemodynamic instability, we
15:53want number one,
15:55either the heart rate to be 100 uh more
15:57than 100. Okay? Shock index to be more
16:00than one.
16:01Then, uh
16:03>> [clears throat]
16:03>> a systolic blood pressure which is less
16:06than 100 mm of mercury, and a diastolic
16:09blood pressure which is less than 60 mm
16:12of mercury. Any of these is If present,
16:15will be considered as hemodynamic
16:17instability.
16:19Okay, another simple one out there. So,
16:21Bishop score is primary
16:24primarily used to assess which of the
16:26following? So, we all know it is to
16:29assess the readiness of cervix for
16:31induction. So, it is basically a
16:33pre-induction
16:35score.
16:37And remember, when we say Bishop's,
16:41uh that the five parameters are very
16:42simple. So, the most important one is
16:45dilatation. Then we use effacement.
16:48Then it is station,
16:50and then it has to be cervical position
16:54and cervical consistency. Okay?
16:57The least important one is cervical
17:00position. Now, when you replace
17:02effacement with cervical length, that's
17:05when it becomes modified Bishop's. Okay?
17:09And what is simplified Bishop's? Do you
17:11know this? Simplified Bishop's uses only
17:14three parameters. They are cervical
17:18dilatation, effacement, and station. So,
17:22when you use only these three, it
17:24becomes
17:26um as I said, it becomes Yes. Simplified
17:30Bishop's. Remember, a Bishop score of
17:32more than or equal to six, if we ask
17:34what do you do next, you say you will
17:36put oxytocin.
17:38But, if it is less than or equal to
17:40five, then you should be doing a
17:43cervical priming. Most commonly, we use
17:47PGE2,
17:48which is dinoprostone for cervical
17:51priming. We can also use PGE1,
17:54but we never never never never use PGF2
17:57alpha for induction. Yes? Okay. That
18:01brings us to the last question, and in
18:02the end, I always give simpler questions
18:04to give my students a feeling of win.
18:07Yes? So, this is primary amenorrhea,
18:10and we have the keywords. Again,
18:12something that NEET PG is very fond of
18:13doing. Short stature and webbed neck, we
18:17are talking about Turner syndrome. So, I
18:20think everyone knows it's going to be 45
18:22X. So, please remember the other
18:25keywords apart from this is, you know, a
18:28shield chest.
18:30You should know that there are widely
18:32separated nipples. And what else? You
18:35should know there is a low posterior
18:38hairline. Then you should know there is
18:40short fourth metacarpal.
18:43And what else?
18:45We should know about cubitus valgus.
18:47Yes? Okay. And these patients have very
18:51commonly associated cardiovascular
18:54anomalies. They have,
18:56you know, renal horseshoe kidneys very
18:59very commonly. Then, you should know
19:02they have autoimmune diseases. Right?
19:06Like Hashimoto's and diabetes, but not
19:08RA and not SLE. They also have ocular
19:12complications.
19:14Uh so, please remember, we must screen
19:17for diabetes in them. We should look out
19:19for thyroid function tests, as I
19:20mentioned. Okay? And remember, no
19:23routine gonadectomy in Turner syndrome.
19:26And the treatment of choice, yes, is
19:28going to be HRT. So, an E plus P type of
19:33HRT is what is the treatment of choice
19:36for Turner syndrome. Okay? So, I hope
19:39the discussion is useful. Look out for
19:42the second Obs and Gynae test that I am
19:44going to give, uh you know,
19:46intermittently on my Instagram profile.
19:49I will share it,
19:51Uh you know, just to ensure that you
19:53stay on track and you keep practicing
19:55some Obs and Gynae mix back questions.
19:57All the best.