19. 200. 201. Answer is A (Immediate Cesarian section): Dutta 6"/257, 259 Antepartum haemorrhage (Vaginal bleeding), with acute pain abdomen and fetal distress suggests a diagnosis of abruptio placenta. Definitive treatment involves expediting the delivery to prevent maternal complications and give a chance of survival to the fetus. Presence of etal distress is an indication of Caesarian section and hence immediate caessarian section is the single best management option, here [dications OF Casarian Section ‘+ Fetal distress® ‘© Induction of Labour by amniotomy fails to control bleeding '* Associated complicating factors such as falling fibrinogen levels and oliguria Note: The flow chart outlining management of abruptioplacenta in a case of revealed bleeding (Dutta 6/261) is ‘misleading as it does not take ‘etal distress” as a complication into account. Answer is A (Hypertension): Dutta 6/411 Atonicity of uterus is the commonest cause of postpartum haemorrhage. Multiple pregnancy, Hydramnios and Macrosomia are all causes of atonic uterus and postpartum haemorrhage. Hyperiention has not been mentioned as a cause of postpartum haemorrhage. Important causes of postpartum haemorrhage Td. ‘Aionie uterus (80%6) ‘Trauma 0%) Blood coagulopathy (minimal) Grand Multipara” ‘Trauma to genital tract following ‘Blood dyscrasia or blood. Overdistention of uterus ‘operative or spontaneous delivery coagulation disorders are less ~ Multiple, pregnancy? ‘common causes of postpartum + Hydramnios haemorrhage. ~ Large baby (macrosomia) ° Sareea rr eeeraeereeraSETEETESS ‘+ Prolonged labour? ‘+ Malformation of uterus + Uterine fibroid® ‘+ Retention of Placenta? * Ansesthesia Multiple pregnancy, Hydramnios and Large baby (Macrosomia) cause + Antepartum haemorrhage overdistention of uterus. Imperfect retraction and a large placental site are « Consiriction ring responsible for excessive bleeding and postpartum haemorrhage . + Mismanaged third stage of ~ Dutta 6°/4 11 labour Answer is B or D (B > D): ‘Spontaneous Intrapartum Vesicouterine Fistula -- Kaaki etal wow greenjournal.org/egi/content/full/107/2/449'; www: medicalprotection.org/medical/united_kingdom/publications/e asebook/20_vbac.aspx;/www.pubmedcentral nih gov/articlerender fegi?artid=1115282; Dutta 6" Fetal distress and bleeding per vaginum have been mentioned as signs of uterine rupture in most standard textbooks. Passage of meconium is a characteristic sign of fetal distress. Uterine rupture is an important cause for fetal distress ‘and hence passage of meconium should be logical positive evidence associated with uterine rupture. Hematuria may also be seen in cases of uterine rupture but its presence indicates concomitant bladder injury. Hematuria is seen only in those cases of uterine rupture that are associated with concomitant bladder injury. Amongst the options provided therefore , hematuria seems to be the single best answer of exclusion to me. Nevertheless I must admit hat even an extensive search on cyberspace does not reveal a direct text quoting the ‘association of meconium passage in a case of uterine rupture and hence you are free to pick up the single best answer of choice as per your own judgement, Fetal Distress and Bleeding Per Vaginum in Uterine rupture Signs of uterine rupture as derived form Dutta’s Text : Abdominal pain Distended tender lower segment Fetal distress / Absent FHS Varying amount of Vaginal bleeding Features of dehydration and shock on general examination634 ‘© AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2006 Passage of Meconium and Uterine Rupture: ‘Assessment of mother and fetus in abou BM!.1999 March 27; 318(7187): 858-861 + Normal fetuses usually pass meconium only after they have been born. + Passage of meconium by the fetus during labour is a characteristic indicator of fetal distress. The stimulus for its passage is probably activation of massive sensory input, a part of the “fight flight, and fright” reaction (distress) Uterine rupture is an important cause for fetal distress and hence passage of meconium should be logical positive evidence associated with uterine rupture. However I must admit that even an extensive search on cyberspace does not reveal a direct text quoting the association of meconium passage in a case of werine rupture. Hacmaturia And Uterine Rupture: ‘Lis important to note that intrapartum gross hematuria is often indicative of uterine rupture'- ‘Spontaneous Intrapartum Vesicouterine Fistula -- Kaaki et al(2006) “Uterine rupture constitutes one of the important causes of bladder injury. In uterine rupture cases the most common clinical signs of concomitant bladder damage are hematuria and meconium-stained urine’. ‘Bladder injury associated with rupture of the uterus’. Obstet Gynecol. 1975 Nov; 46(5):573-6. Although haematuria has been mentioned to be seen in cases of uterine rupture its presence indicates concomitant Bladder injury. Presence of haematuria should certainly alert the doctor towards a possible uterine rupture but presence of haematuria er se is a sign of associated bladder injury and not uterine rupture. Haematuria is seen only in those cases of uterine ‘rupture that are associated with concomitant bladder injury. Thus while both haematuria and meconium passage might be seen in a case of uterine rupture, haematuria is the less likely option as it will be present in only those cases of uterine rupture that are associated with concomitant bladder injury. PAEDIATRICS 202. 203. Answer is D (Build a tower of 3-4 cubes): Ghai 8"/49; Nelson 18/45, 49 10 months old child will not be able to build a tower of 3-4 cubes. A child is able to build a tower of 4 cubes only after 16-24 months of age. ‘A child can make a tower of 2 cubes by 12-20 months and 5 cubes by 16-24 months'- Ghai 6"/46 Answer is A (Constitutional delay in growth): Ghai 8/37 Constitutional delay in growth is a common cause of short stature (decreased height) in mid childhood. It is characteristically associated with normal average growth velocity and ultimate height attained is normal. Their skeletal maturation is slightly less than that expected for the chronological age. ‘Causes short stature (decreased height) in mid childhood + Average growth velocity is normal (an ultimate height is normal) Short stature in] Growth of these children lags behind mid childhood | their peers during the prepubescent phase Pubertal growth spurt is delayed Provides extra years of prepubescent growth to make up for the short stature of earlier years (LUST normal Vo west is requis) ‘+ Bone age (skeletal age) is slightly less than chronological age. Ratio between upper and lower segment is normal or slightly immature,‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2006 > 635 204. Answer is C (Thick ear cartilage): Ghai 8/1 38-140 The ears in a premature neonate are soft and flat with ear cartilage being deficient and pliant (and not thick) ‘Features of prematurity in a Neonate: Ghai 6°7135 ‘Baby is small in size usually less than 47 cm long Head is relatively large, sutures are widely separated and fontanelle are large Face is small and buccal pad of fat is minimal ‘Skin is thin and pinkish and appears shiny due to generalized edema. ‘Skin is covered with abundant lanugo and there i lite vernix caseosa. ‘Subcutaneous fat is reduced ‘The breast nodule is less than 5 mm wide The ears are soft and flat with ear cartilage being deficient and pliant Testes are not descended into scrotal sac. (Empty scrotum) Scrotal sac is poorly pigmented and has less rugosities. In females labia majora appears widely separated, exposing the labia minora and the clitoris. Deep creases are not well developed inthe sole (There may be a single deep crease over the anterior one third of the sole) ‘+ Neonatal reflexes such as Moro, Suckling & Swallowing are sluggish. + _ There is hypotonia with a poor recoil of flexed forearm when extended, 205. Answer is C (Convection): Ghai 6154 “Convection warmed incubators are being routinely used for thermal regulation of the premature neonate’s ambient air”- Ghai 6°/154 206. Answer is A (Onset after 6 years of age): Ghai 8°/61 Onset of symptoms of autism is usually before 3 years of age- Ghai 6/65 Autistic disorders are characterized by the triad of impaired social interaction, communication and imagination. These are associated with rigid repetitive pattern of behaviour. ‘Autism: Ghai O65 ‘Onset of symptoms is uswally Before 3 years of age Inability to develop normal social skili (lack of eye contact gestures and facial expression) Understand lle or no language (Therefore fail to acquire speech) Intrusive sterotypes (Repetitive behaviour) together with inability to concentrate may prevent children from engaging {in meaningful activity or social interaction. Deficient comprehension and communicative use of speech and gesture Do not engage in pretended play (which starts before age of 2 in normal children) Mental retardation (about 75% of children with autism are mentally retarded) Epilepsy develops in one fifth to one third of autistic individuals EEG abnormalities are noted in half ofthe patients. 207. Answer is B (Undescended testis): Ghai 8°"/638, htp://www.kedsg.org/AboutDownSyndrome.php 1. Sixty to 80 percent of children with Down syndrome have hearing deficits. Forty to 45 per cent of children with Down syndrome have congenital heart disease. ASD and VSD are the most common forms of congenital hear diseases seen. 3. Intestinal abnormalities also oceur ata higher frequency in children with Dow syndrome. Esophageal atresia, duodenal atresia and anal abnormalities are not uncommon in infants with Down syndrome. 4. Children with Down syndrome often have more eye problems than other children who do not have this chromosome disorder. Eye problems such as strabismus, refractive errors and other eye conditions are frequently observed in children with Down syndrome. Brushfeld’'s spots are whitish pecking om iris seen in light skinned people. 5, Thyroid dysfunctions ae more common in children with Down syndrome than in normal children. Between 15 and 20 per cent of children with Down syndrome have hypothyroidism. It is important o identify individuals with Down syndrome ‘who have thyroid disorders since hypothyroidism may compromise normal central nervous system functioning. 6. Skeletal problems have also been noted at a higher fequency in children with Down syndrome, including: patellar subluxation (incomplete or partial dislocation), hip dislocation, and atlantoaxial instability. Approximately 15 per cent of people wth Down syndrome have atiantoaxal instability 7. Other important medical aspects in Down syndrome, including immunologic concerns, leukemia, Alzheimer disease, se disorders, sleep apnea and skin disorders.