Numan’s Book Series Gynaecology Scenarios Solution (10th Edition)

Gynaecology
(Table of Specifications)
No. of No. of
S No. Contents
MCQs SEQs

1. Anatomy and development of the genital tract 2 1

2. Disorders of menstruation. 4 1

3. Miscarriages including ectopic gestation 5 1

4. Infertility 4 1

5. Infections of genital 5 1

6. Benign tumors of genital tract 4 1

7. Malignancies of the genital tract 6 1

8. Displacements of the uterus and urinary problems 4 1

9. Contraception 3 1

10. Common gynecological procedures 3 1

Adenomyosis/Endometriosis/Menopause/
11. 2 1
HRT

12. Pre & Post-operative care and complications 3 1

Total Questions 45 MCQs 12 SEQs

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Scenarios Solution (10th Edition) Gynaecology Paper B Model Papers

GYNAECOLOGY (Paper-B)
Annual Paper 2021

Note: • Attempt any NINE (09) questions from this section.

 Use only Blue / Black ink other than diagrams.
 Answer briefly and to the point avoiding unnecessary details
 Identification mark of any type on answer sheet is strictly forbidden.
 Possession of mobile phone and other electronic accessories is strictly prohibited.
 Every question must be attempted with in one single page of two sides specified in the answer book.

Q1) A 40 year old nulliparous women present with 2 year history of menorrhagia. She is married for
4 years and want to conceive. Her pelvic ultrasound confirms the presence of fundal fibroid of 10×12
size.
a. What are the different treatment option for fibroid uterus?
b. What is the best surgical treatment of this patient’s complaint?
Q2) A 30 year old women married for 5 years came in sub fertility clinic:
a. What id sub fertility and its type?
b. What are the causes of female sub fertility?

Q3) A 35 year old P5+0 came into OPD with her histopathology report of Pap smear which shows C/N
lll:
a. What are the different of cervical intra-epithelial neoplasia?
b. What are the different treatment option of C/N lll?

Q4) A 24 year old G2P1 had her last menstrual period 9 weeks ago. She present with heavy bleeding
and passage of fetal tissues per vaginum. BP is 90/50mmHg, pulse is 120/min, and Respiratory rate is
22/minute. The patient collapsed. What will you do?
Q5) Mrs.ABC, P2, 28 years of age presented to Outpatient department with complaints of pain in
hypogastrium for the last 4 days. On examination, she is well oriented but running fever of 100*F and is
tachycardiac. On pr abdominal examination she is tender. On per speculum examination cervix looks
inflamed with mucopurulent discharge. The patient could not tolerate the examination. A high vaginal
swab, urethral swab and endocervial swab was taken. She had few partners in recent months and took
treatment for chlamydia with poor compliance few weeks back. She practice unprotected intercourse.
a. What is the diagnosis?
b. What investigations do you need?
c. What is the management?

Q6) A 16 year old young school girl was brought by her mother to Outpatient department. The girl had
never menstruated. She experienced thelarche at 12 years of age and adrenarche at 13 years age. She
also experienced a monthly cramping lower abdominal pain. On physical examination she has Tanner
stage 4 breast and public hair. On genital examination a bulging bluish membrane could be seen at level
of hymen.
a. What are your differential diagnosis?
b. What is the most likely diagnosis?
c. What investigations should be performed?
d. How will you treat her?

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Q7) 55 year old women is complaining of something coming out of vagina since 5 years associated
with discomfort and backache?
a. What are the different diagnosis of this case?
b. What are treatment options?

Q8) A 55 years old women with no significant past obstetric history and no co-morbidities, came in clinic
for hormone replacement therapy;
a. What are initial symptoms after start of HRT?
b. What are relative and absolute contraindications of HRT?
Q9) A 48 year old patient P5Ab0Al 5 with heavy menstrual bleeding admitted in ward for abdominal
hysterectomy on elective list?
a. What are the investigation to be done?
b. What are compactions related to hysterectomy?

Q10) A male partner came in family planning OPD and want to know about vasectomy?
a. What is vasectomy?
b. What are the different techniques of vasectomy?
c. What are the complications of vasectomy?

Q11) A 35 year primigravida presents at 39 weeks gestation with contracted pelvis. She is advised to
undergo on elective caesarean section?
a. How will you prepare her for c/section? (any four)
b. What are different types of abdominal wall incisions used for c/section?
c. What is the method of delivery of placenta during c/section?
Q12) A 51 years old nulliparous, obese, diabetic patient came in OPD with complaint of heavy cycle
bleeding;
a. What are differential diagnosis of heavy cyclical bleeding?
b. What are risk factor for endometrial carcinoma?

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Scenarios Solution (10th Edition) Gynaecology Paper B Model Papers

Supply Paper 2021 - Gynaecology Paper B

1. A 32-year-old P2 is seeking advice for contraception. After counselling with health professional she
has opted for combined oral contraceptive pills.
a. What is mechanism of action of COCP? 2
b. Name active ingredients of COCP. 1
c. Name 3 side effects of COCP. 2

2. A couple married for 3 years is attending Gynae clinic for treatment of their subfertility. Semen
analysis is normal. Woman has normal menstrual cycle and normal hormonal assays.
a. Name the tests used to check tubal patency.
b. What is gold standard to check for tubal patency?
c. What are side effects of hysterosalpingography? Name any 2

3. A 42-year-old lady P4 is attending you in Gynae OPD. Her chief complaints are irregular heavy
menstrual bleeding and pain abdomen. Her hemoglobin level is 7 gm%
a. What tests would you advise for her?
b. How will you manage her?

4. A 40 years old P5 has presented with pruritus vulvae and burning sensation in vagina. She is diabetic
on oral drugs. On examination, she has hyperemic vaginal walls and thick white curdy discharge.
a. What is the diagnosis? 1
b. Which organism is involved in this disease? 1
c. What investigations would you advice? 1
d. What are the treatment options? 2

5. A 35 years old lady, P3 presented to Gynae OPD with complaint of something coming out of vagina.
She also complains of increased urinary frequency and has a history of prolonged labour followed by
outlet forceps vaginal delivery in her last pregnancy.
a. What is the most likely diagnosis?
b. What are the risk factors for the above condition?
c. What are the management options?

6. A 45 years old Para 6, with a BMI of 32, presented with urinary leakage on coughing.
a. What is the most probable diagnosis?
b. What is the etiology of the above condition?
c. What are the management options for this condition?

7. A 25 years old G2P1, presented to ER with 6 weeks amenorrhea, and pain hypogastrium. Her USG
show Gestational sac of 2.5 cm in R adnexa and B hCG of 1800 IU.
a. What is the criteria for starting medical treatment in Ectopic pregnancy?
b. How is monitoring of Beta HCG done?
c. What are contra indications to medical Rx?

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Scenarios Solution (10th Edition) Gynaecology Paper B Model Papers

8. A 35-year-old G2P1 presents to ER with 12wks amenorrhea F/b irregular bleeding Pv. Ultrasound
shows snow storm appearance of H mole.
a. How will you manage her?
b. Name the various gestational trophoblastic diseases.

9. A patient with recurrent miscarriages presented to the gynecology clinic. After investigation she has
been diagnosed to have double uterine cervices.
a. What is the group of abnormalities called? 1
b. What other group of abnormalities would this alert you to? 1
c. Name two structures of which the paramesonephric ducts are precursors. 2
d. What does the lower third of vagina develops from? 1

10. A 26 years old obese lady presents in Gynae OPD with complaint of primary infertility for last 3 years,
along with excessive hair growth on face. On examination, her weight is 92 kg and hirsuitism is
present. Multiple peripherally arranged follicles are seen in ovaries on ultrasound.
a. Give 3 differential diagnosis.
b. On the basis of history and appearance of ovaries on ultrasound what is the most probable
diagnosis?
c. How will you treat this case?

11. A 37 year old lady presented to you with regular and heavy periods.
a. What investigations will you undertake on her? 2
b. Briefly outline the options of treatment. 3

12. A 66 years old patient had vaginal hysterectomy 3 days ago having post-operative pyrexia.
a. List 4 routine examination you would perform. 1
b. List 2 microbiological investigations you would advise. 2
c. Vaginal examination reveals marked tenderness of the vault. A TVS report shows a 7x8x10cm collection
of fluid behind the bladder. Neither ovary was seen. What is the likely diagnosis? 1
d. What is the usual outcome/treatment? 1

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 Scenarios Solution Gynaecology Chapter-1: Anatomy & Embryo of Female Genital Tract

Chapter-1: Anatomy & Embryo of Female Genital Tract

Topic: Hematocolpos/ Imperforate Hymen
Reference Page # 12 Arshad Chohan

SCENARIO-I:
A 16 year old young school girl was brought by her mother to Outpatient department. The girl had never
menstruated. She experienced thelarche at 12 years of age and adrenarche at 13 years age. She also
experienced a monthly cramping lower abdominal pain. On physical examination she has Tanner stage 4
breast and public hair. On genital examination a bulging bluish membrane could be seen at level of
hymen.
a. What are your differential diagnosis?
b. What is the most likely diagnosis?
c. What investigations should be performed?
d. How will you treat her?

SCENARIO-II:
A young girl 13 years old presented to you with primary amenorrhea, tender abdominal mass and bluish
membrane on pelvic examination
a. What is the diagnosis?
b. How will you manage?
c. What is the differential diagnosis of mass abdomen?
 Dx: Hematocolpos due to imperforate hymen

OVERALL KEY OF ABOVE SCVENARIOS ON HEMATOCOLPOS:

a) D/Ds:
 Hematocolpos
 Transverse Vaginal Septum/ Blind Vagina
 Fibroid
 Ovarian cyst
 Chronic PID
b) Dx: Hematocolpos due to imperforated hymen.
c) Ix:
Hematocolpos can be easily diagnosed on Ultrasound & Clinical examination
d. Rx:
 If thin imperforate membrane  Simple excision (cruciate incision)
 For thick transverse vaginal septum  Z-Plasty
 For blind vaginaPartial/Complete Vaginoplasty
 For haematosalpinxLaparotomy (removal and reconstruction of tube)

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 Scenarios Solution Gynaecology Chapter-1: Anatomy & Embryo of Female Genital Tract

Topic: Uterine Anomalies

SCENARIO-I:
A patient with recurrent miscarriages presented to the gynecology clinic. After investigation she has
been diagnosed to have double uterine cervices.
a. What is the group of abnormalities called? 1
b. What other group of abnormalities would this alert you to? 1
c. Name two structures of which the paramesonephric ducts are precursors. 2
d. What does the lower third of vagina develops from? 1
KEY:
a) Name of group of abnormalities:
Müllerian duct anomalies (MDAs)
b) Other group of abnormalities would this alert you:
Renal and Urinary tract Anomalies: Up to 40 %
c) Names of two structures of which the paramesonephric ducts are precursors:
 Fallopian tubes (Upper + Middle Parts)
 The Uterus and Upper 4/5 the of Vagina
d) Lower third of vagina develops from:
 Sinovaginal bulbs of the urogenital sinus fuse with the paramesonephric duct
 Muscles of vagina develops from surrounding mesoderm

SCENARIO-II:
A patient with recurrent miscarriages presented to the gynecology clinic. After investigations, she has
been diagnosed to have double uterine cervix.
a. What is this group of abnormalities called?
b. What other group of abnormalities would this alert you to?
c. Name 2 structures for which paramesonephric ducts are precursors?
KEY: Reference P# 11, Arshad Chohan Reprint 2010
a) Fusion Anomalies
b) Anomalies of lower genital tract and anomalies of urinary tract
c) Names of structures:
 Fallopian tubes
 Uterus, Cervix
 Upper 1/5th of Vagina

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 Numan’s Book Series Scenarios Solution (10th Edition)

Chapter 2- Amenorrhea
Chapter 3- Abnormal Uterine Bleeding
Topic: Abnormal Uterine Bleeding (Regular and Heavy)

SCENARIO-I:
A 37 year old lady presented to you with regular and heavy periods.
a. What investigations will you undertake on her? 2
b. Briefly outline the options of treatment. 3

SCENARIO-II:
A 37 years old para 4 lady presented to Gynae OPD with regular but heavy periods. Based on this
scenario.
a. What investigations will you undertake on her? Mention at least four.
b. Briefly outline the treatment options for her?
KEY:
a) Ix:
i) Baseline Ix:
Full Blood count, Blood grouping, Urine R/E, Blood sugar and HBsAg/ Anti HCV
ii) Transvaginal Ultrasound: Done for Endometrial thickness, Polyp, Fibroid
iii) Hysteroscopy + Biopsy
iv) Pipelle sampling on outpatient basis
v) Endometrial sampling
b) Rx Options:
I) Medical Rx:
 NSAIDs
 Anti-fibrinolytics
 GnRH Analogue
 Combined Oral Contraceptive pills
 Danazol
 Progesterone
II) Surgical Rx:
 Hysterectomy
 Endometrial ablation
 Fibroid  Myomectomy
 Poly  Polypectomy

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 Numan’s Book Series Scenarios Solution (10th Edition)

Topic: Abnormal Uterine Bleeding (Irregular and Heavy)

SCENARIO-I:
A 42-year-old lady P4 is attending you in Gynae OPD. Her chief complaints are irregular heavy
menstrual bleeding and pain abdomen. Her hemoglobin level is 7 gm%
a. What tests would you advise for her?
b. How will you manage her?
KEY:
a) Ix:
i) Baseline Ix:
Full Blood count, Blood grouping, Urine R/E, Blood sugar and HBsAg/ Anti HCV
ii) Transvaginal Ultrasound: Done for Endometrial thickness, Polyp, Fibroid
iii) Dilatation and Curettage (D&C)/ Hysteroscopy + Biopsy
iv) Pipelle sampling on outpatient basis
b) Management:
I) MEDICAL Rx:
 First Line Rx:
1) Non-Hormonal: i) Anti-Fibrinolytics (ii) NSAIDs
2) Hormonal: i) COCPs (ii) MIRENA/ Oral Progesterone
 Second Line Rx:
i) Danazol (ii) Gestrinone
 Third Line Rx:
i) GnRH Agonists (ii) Selective Progesterone Receptor Modulation “SPRM”
II) SURGICAL Rx:
i) Endometrial Ablation
ii) Hysterectomy

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 Numan’s Book Series Scenarios Solution (10th Edition)

Chapter 6-Miscarriages
TYPES OF MISCARRIAGES WITH THE RELEVANT
ULTRASOUND FINDINGS AND CLINICAL PRESENTATION
(Reference Ten Teachers)
TYPE OF ULTRASOUND FINDINGS CLINICAL PRESENTATION
MISCARRIAGE
Threatened Intrauterine pregnancy Per vaginal bleeding and pain
miscarriage Speculum: Cervical Os close
Inevitable Intrauterine pregnancy Per vaginal bleeding and pain
miscarriage Speculum: Cervical Os open
Incomplete Retained products of conception Per vaginal bleeding and pain
miscarriage Speculum: Cervical Os open,
products of conception located in
cervical Os
Complete No retained products of conception Pain and bleeding has resolved
miscarriage Speculum: Cervical Os closed
Missed Fetal pole present, but no fetal heartbeat
miscarriage identified
Gestational sac present (diameter With or without pain and bleeding
>20 mm) but no fetal pole identified

Topic: Incomplete Miscarriage

Reference P# 64 Arshad Chohan

SCENARIO-I:
A 24 year old G2P1 had her last menstrual period 9 weeks ago. She present with pain, heavy bleeding
and passage of fetal tissues per vaginum. BP is 90/50mmHg, pulse is 120/min, and Respiratory rate is
22/minute. The patient collapsed. What will you do?

SCENARIO-II:
A Gravida 5 P4 presented with 9 weeks’ pregnancy. She has heavy vaginal bleeding, pain hypogastrium
and fainting attack since 2 hours. On examination, she is pale, BP 90/60, thready pulse, vagina is full of
clots along with some chorionic tissue, Os is open, and uterus is soft and compatible with eight weeks’
gestation.
a. What is the likely diagnosis?
b. What investigations will you advise to this patient? (Any four)?
c. How will you manage this case?

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OVERALL KEY OF ABOVE SCENARIOS:

a) Dx: Incomplete Miscarriage
b) Steps of Management:
I) Detailed Hx:
II) Examination:
 Per speculum examination the Vagina is full of products of conception, which are seen coming
through the cervical Os.
 The products of conception in the vagina and those coming through Cervix should be removed
through this examination
 Digital removal of these products relieves pain
III) Investigations:
 Baseline Investigations i.e. Complete blood count, Blood grouping
 Ultrasonography: On U/S examination the retained products appear as an irregular hyperechoic
shadow distending the uterine cavity
IV) Treatment:
 Initial Stabilization of Women:
Call for Help
CBA Circulation, Breathing and Airway
Circulation:
 Pass two wide bore I/V cannulae
 Draw 20 ml of blood for cross match, FBC, Base line Investigations, Liver function tests (LFTs),
Renal function tests (RFTs) and clotting profile
 I/V Fluids: Crystalloids and Colloids till blood products are arranged
 Arrange 6 units of Whole Blood and 4 units of Fresh Frozen Plasma (FFPs)
 Inj Syntocinon 40 units in 1000 ml R/L @ 8 drops/Min
 Monitoring of Vitals i.e. BP, Pulse, Temperature and Respiratory rate
 Input output charting
 Evacuation of Retained Products of Conception (ERPC):
i) Manual Vacuum Aspiration (MVA)
ii) Evacuation and Curettage (E&C)
 Post Evacuation Care

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Topic: Threatened Miscarriage

SCENARIO-I: (Obstetric Paper)

A 30 year old nulliparous woman comes to you at 8 weeks gestation with per vaginal bleeding for 2
days. Ultrasound confirms the presence of a viable fetus. On pelvic examination cervical Os is closed with
mild bleeding.
a) What is the diagnosis?
b) What are the anatomic reasons for miscarriages?
c) What is the difference between missed miscarriage and threatened miscarriage?
KEY:
a) Dx: Threatened Miscarriage
b) Anatomic reasons for miscarriages:
 Uterine Abnormalities:
i) Septate (ii) Arcuate (iii) Bicornuate Uterus (Uterus with two horns)
 Cervical insufficiency
 Fibroid: Intramural or Submucosal
c) Difference between missed miscarriage and threatened miscarriage:

TYPE OF ULTRASOUND FINDINGS CLINICAL PRESENTATION

MISCARRIAGE
Threatened Alive Intrauterine pregnancy Per vaginal bleeding and pain
miscarriage Speculum: Cervical Os close
Missed Fetal pole present, but no fetal
miscarriage heartbeat identified With or without pain and
Gestational sac present (diameter bleeding
>25 mm) but no fetal pole identified

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Topic: Missed Miscarriage

SCENARIO-I:
A 28 years old lady comes to Gynae OPD with 12 weeks’ amenorrhea and slight P/V bleeding. She has
morning sickness in first two months but now the symptoms have subsided. Pregnancy test was positive
45 days before. On examination internal Os is closed and uterus is 8-week size.
a. What is the most probable diagnosis?
b. How will you reach the diagnosis?
c. What complications this woman may develop?
d. What are the treatment options?
KEY:
a. Dx: Missed Miscarriage
b. How to reach the diagnosis:
 History
 Abdominal examination: For fundal height, fetal palpation and fetal heart activity
 Pre-vaginal examination and per speculum examination
 Ix:
 U/S abdomen: If fetal cardiac activity is absent then diagnosis is confirmed
c. Cx:
 DIC
 Severe hemorrhage
d. Rx options:
 Suction curettage
 Induction of labor with Oxytocin and prostaglandins
 Hysterotomy

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Topic: Cervical Cerclage

SCENARIO-I:
A 32 years lady came to OPD at 8 weeks of pregnancy with history of two miscarriage at 18 weeks and
one preterm delivery at 34 weeks. She went to a local gynecologist who advised her some procedure,
which will help her to prolong her duration of pregnancy. She has been referred to you for further
management.
a. What is the name of surgical procedure, which was advised by the local gynecologist?
b. At which gestation this procedure should be done.
c. Write any four complications of this procedure.
KEY: Reference P#77 Arshad Chohan
a) Name of Surgical Procedure Advised:
Cervical Cerclage called McDonald Suture
b) Gestation:
This procedure should be done at 14 weeks Gestation. Recently cervical Cerclage has been used in
first trimester recurrent aborters with improved outcome
c) Cx:
 Cervical Dystocia
 Premature contractions
 PROM
 Cervical infection
 Bleeding
 Iatrogenic Rupture of membranes

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Chapter 7- Ectopic Pregnancy

Reference: Page#85, Fundamentals of Gynaecology by Arshad Chohan

SCENARIO-I:
A 25 years old G2P1, presented to ER with 6 weeks amenorrhea, and pain hypogastrium. Her USG
show Gestational sac of 2.5 cm in R adnexa and B hCG of 1800 IU.
a. What is the criteria for starting medical treatment in Ectopic pregnancy?
b. How is monitoring of Beta HCG done?
c. What are contra indications to medical Rx?
KEY:
a) Criteria for starting medical treatment in Ectopic pregnancy:
 Patient clinically stable
 Asymptomatic or minimal symptoms
 Unruptured tubal pregnancy with less than 3cm in diameter.
 Absent hemoperitoneum on transvaginal USG
 Sonographically non-viable pregnancy
 Beta HCG levels less than 3000 IU/L
 Follow up possible for several weeks with serial Beta HCG and ultrasound.
b) Monitoring of Beta hCG:
β-hCG titers should be performed every 48 hours e.g. at Day 4 & Day 7 should be more than 15%
decrease, until values return to normal
c) Contraindications to Medical Rx:
 Evidence of tubal rupture/ Patient hemodynamically unstable
 Absence of fetal cardiac activity on ultrasonographic findings
 Quantitative hCG level which exceeds 6,000–15,000 mIU/ml
 Gestational Sac> 5cm

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Chap 9- Uterovaginal Prolapse

Topic: Pelvic Organs Prolapse
Reference: Page#107, Fundamentals of Gynaecology by Arshad Chohan

Pelvic Organ Prolapse:

“The herniation of one of the Pelvic organs (Uterus, Vaginal Apex, Rectum or bladder) from its
normal anatomical position into or beyond vagina” OR
“Protrusion of Uterus or vagina beyond their Anatomical confines.”

SCENARIO-I:
55 year old women is complaining of something coming out of vagina since 5 years associated with
discomfort and backache?
a. What are the different diagnosis of this case?
b. What are treatment options?
Key:
a. D/Ds:
 Uterovaginal Prolapse
 Gartner’s cyst Urethral diverticulum
 Periurethral cyst
 Vulval tumors
 Polyp
b. Treatment Options:
Treatment depends on Age, Fertility desire, Causative factors, Degree of Pelvic organ prolapse,
Concomitant symptoms & extent of symptoms.
I. Conservative:
 Life style modification
 Pelvic floor exercises
 Personal hygiene
 Obese should lose weight
 Chronic cough and constipation should be avoided
 Avoid weight lifting
 Ulceration of prolapse is treated with Triple sulphate cream (Vaginal packing)
 Pessary insertion (Ring or Shelf)
II. Surgical Treatment:
 Uterine Prolapse:
 Anterior Compartment prolapse: Anterior Colporrhaphy
 Posterior Compartment prolapse:
 Rectocele: Colpo-perinorrhaphy
 Enterocele: Moschowitz procedure & Sacrohysteropexy
 UV Prolapse:
 Hysterectomy (Abdominal or Vaginal)
 Uterine preserving surgery

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Chap 10- Infertility

Topic: Subfertility
SCENARIO-I:
A 30 year old women married for 5 years came in sub fertility clinic:
a. What id sub fertility and its type?
b. What are the causes of female sub fertility?
Key:
a. Def: Subfertility
“Failure of a couple to achieve a clinical pregnancy after one year of Regular unprotected sexual
intercourse.”
TYPES
Primary subfertility: When they never achieved conception before.
Secondary subfertility: Who fails to achieve conception after having conceived once or more.
b. Causes of female sub fertility:
 Failure of ovulations
 Tubal factors (PID, endometriosis, tubal surgery)
 Cervical factors (reduced amount of cervical mucus)
 Uterine factors (multiple submucous fibroid)
SCENARIO-II:
A couple married for 3 years is attending Gynae clinic for treatment of their subfertility. Semen analysis
is normal. Woman has normal menstrual cycle and normal hormonal assays.
a. Name the tests used to check tubal patency.
b. What is gold standard to check for tubal patency?
c. What are side effects of hysterosalpingography? Name any 2
KEY:
a) Tests used to check tubal patency:
Diagnostic Laparoscopy, Hysterosalpingography, ultrasound, salpingoscopy and Falloposcopy
b) Gold standard to check for tubal patency:
Diagnostic Laparoscopy + Dye test
c) Side effects of hysterosalpingography:
 Sticky vaginal discharge as some of the fluid drains out of the uterus.
 Crampy pains
 Feeling dizzy, faint, or sick
 Slight vaginal bleeding

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SCENARIO-III:
A couple who are married for the last 12 months came to Gynae OPD to seek advice as they have no kids.
Both partners are living together and physically fit. The couple has been labeled as having sub
fertility.
a) Define sub fertility. 1
b) What important points will you ask in history from both partners to reach a diagnosis? 2
c) If you want to investigate this couple, what baseline investigations will you perform? 2
KEY:
a) Sub Fertility:
“Failure of a couple to achieve a clinical pregnancy after one year or more of regular unprotected
sexual intercourse”
b) Important points to be asked in Hx:
I. From Female:
i) Ask about regularity of menstrual cycle
ii) Weight gain & Hirsutism
iii) Galactorrhea and hot flushes
iv) Drug Hx i.e. OCPs
v) Previous Hx of Abdominopelvic surgery
II. Hx Questions from Male:
i) Job status i.e. Driving etc
ii) Any Hx of Previous surgery i.e. Orchidopexy, Vasectomy etc
iii) Trauma
iv) Hx of infection i.e. Mumps, Gonorrhea etc
v) Exposure to toxins/radiations
vi) Frequency of coitus
c) Baseline Ix:
In Female:
i) Hormonal assays (ii) Ovarian U/S (iii) Cervical mucus test (iv) Laparoscopy (v)
Hysterosalpingography
(vi) Salphinoscopy (vii) Post coital test
In Male:
(i) Semen analysis (ii) Testicular biopsy (iii) Antisperm antibodies

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Topic: Primary Infertility

SCENARIO-I:
A 25 years old lady presented in Gynae OPD. She is married since last two years. Couple is living together
and wants to conceive.
a. Enumerate the investigations of female partner
b. Enumerate the investigations of male partner.
c. What are tubal patency tests?
d. Enumerate the assisted reproduction techniques
Key:
a) Ix of Female partner:
 Ovulation Detection:
Hormonal Assay, Ultrasound Pelvis, Basal body temperature, endometrial sampling, cervical mucus
test.
 Tubal Test:
Diagnostic Laparoscopy, Hysterosalpingography, ultrasound, salpingoscopy and Falloposcopy,
Rubins Test.
 Cervical Factors:
Post Coital test (PCT)
b) Ix of Male Partner:
 Semen analysis
 Hormonal assay
 Chromosomal analysis
 Testicular biopsy
 Antisperm antibodies
 Semen Fructose
c) Tubal patency tests:
 Diagnostic Laparoscopy: It is the investigation of choice
 Hysterosalpingography
d) Assisted reproduction techniques:
 Intrauterine insemination (IUI)
 In-vitro Fertilization ( IVF)
 Gamete Intra fallopian transfer (GIFT)
 Zygote intra fallopian transfer ( ZIFT)
 Micro Inseminization technique:
 Intracytoplasmic sperm injection (ICSI)
 Subzonal insemination (SUZI)

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Topic: Secondary Infertility

SCENARIO-I:
During investigations of a 32 years old P 1 who is having secondary infertility for the last 8 years
a. What radiological options will you consider?
b. What non-radiological options are available?
c. Outline the complications of these procedures?
KEY:
a) Radiological options:
 Ovarian Ultrasound
 Hysterosalpingography
b) Non-radiological options:
 Laparoscopy
 Salphinoscopy
 Hormonal Assay
 Post Coital test
c) Cx of Radiological & Non-Radiological options:
 Ascending infections
 Hemorrhage
 Trauma (Cervical tear & Uterine perforation)
 Vasovagal shock
 Injury to Bowel and Bladder
 Incisional hernia

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Chap 11- Contraception

Topic: Vasectomy

SCENARIO-I:
A male partner came in family planning OPD and want to know about vasectomy?
a. What is vasectomy?
b. What are the different techniques of vasectomy?
c. What are the complications of vasectomy?
d. When is Vasectomy considered complete?
KEY:
a) Vasectomy :
“It is typical mean of division or occlusion of Vas deferens to prevent passage of sperms.”
The Couple will practice contraception 3 months after Vasectomy.
b) Different Techniques:
 VAS OCCLUSION:
 Excision
 Ligation
 Thermal or Electrocautery
 Mechanical
 Chemical occlusion methods
 With Irrigation
 With Fascial Interposition
c) Complications:
 Overt failure
 Hematoma (bruising )
 Bleeding
 Infection
 Sperm granuloma
 Congestive epididymitis (Post- vasectomy syndrome )
 Antisperm antibody formation
 Psychogenic Impotence
d) When Vasectomy considered Complete:
When sperms are absent from two consecutive samples (after 12 weeks of procedure), Vasectomy is
considered complete until then alternative methods of Contraception should be used.

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Chap 12- Infections of Genital tract

Topic: Vaginal Candidiasis
Reference: Page#163, Fundamentals of Gynaecology by Arshad Chohan

Diagnostic Points:
 White curdy vaginal discharge.
 Pruritus vulvae which are worse at night
 Diabetics having poor compliance with anti-diabetic medications.

SCENARIO-I:
A 40 years old P5 has presented with pruritus vulvae and burning sensation in vagina. She is diabetic on
oral drugs. On examination, she has hyperemic vaginal walls and thick white curdy discharge.
a. What is the diagnosis? 1
b. Which organism is involved in this disease? 1
c. What investigations would you advice? 1
d. What are the treatment options? 2
KEY:
a) Dx: Vaginal Candidiasis (Moniliasis)
b) Causative Organism:
 Candida Albicans (Majority of cases)
 Other Candida Species and Torulopsis glabrata (10% of cases)
c) Ix:
 Wet smear examination
 Gram staining for fungal spores
 High vaginal swab
d) Rx:
 Treatment of predisposing factor i.e. Strong glycemic control
 Vaginal application of antifungal cream
 Fluconazole 50 mg for 7 days followed by prophylactic treatment of 150 mg single dose
fortnightly or monthly intervals of 3-6 months. This treatment regimen will also eradicate
gastrointestinal reservoir
 Male partner is often prescribed antifungal creams for application to Genetalia as in 25% cases
asymptomatic male partner is responsible for reinfection

SCENARIO-II:
A 35 years old diabetic woman came to OPD with the complaints of white and non-offensive vaginal
discharge perineal itching. Her speculum examination showed white curdy vaginal discharge
a. What is your diagnosis?
b. What is the causative organism?
c. What three special tests will you do to confirm your diagnosis?
d. How will you treat her?

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OVERALL KEY OF ABOVE SCENARIOS ON VAGINAL CANDIDIASIS:

a) Dx: Vaginal Candidiasis (Moniliasis)
Issues in Hx:
 Recurrent vaginal discharge
 Curdy white discharge
 Severe itching
Predisposing factors:
 Pregnancy
 Premenstrual phase
 OCPs

b) Causative Organism:
 Candida Albicans (Majority of cases
 Other Candida Species and Torulopsis glabrata (10% of cases)
c) Confirmation of Dx:
 Wet smear examination
 Gram staining for fungal spores
 High vaginal swab
d) Rx:
 Treatment of predisposing factor i.e. Strong glycemic control
 Vaginal application of antifungal cream
 Fluconazole 50 mg for 7 days followed by prophylactic treatment of 150 mg single dose
fortnightly or monthly intervals of 3-6 months. This treatment regimen will also eradicate
gastrointestinal reservoir
 Male partner is often prescribed antifungal creams for application to genetilia as in 25% cases
asymptomatic male partner is responsible for reinfection

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Chapter 14- Hirsuitism & Virilism

Topic: Polycystic Ovarian Syndrome (PCO)
Reference: Page#217, Fundamentals of Gynaecology by Arshad Chohan

Diagnostic Points:
 Excessive hair growth on face
 Raised BMI
 Infertility
 Irregular Periods

SCENARIO-I:
A 26 years old obese lady presents in Gynae OPD with complaint of primary infertility for last 3 years,
along with excessive hair growth on face. On examination, her weight is 92 kg and hirsuitism is
present. Multiple peripherally arranged follicles are seen in ovaries on ultrasound.
a. Give 3 differential diagnosis. 1.5
b. On the basis of history and appearance of ovaries on ultrasound what is the most probable
diagnosis? 1.5
c. How will you treat this case? 2
KEY:
a) D/Ds:
 Polycystic Ovarian disease
 Cushing disease
 Idiopathic Hirsuitism
 Virilizing Ovarian tumors
b) Most Probable Dx:
Polycystic Ovarian disease
c) Rx:

 For Weight Loss:

 Life style modification: Decrease weight by Diet & exercise
 Insulin sensitizing agents like Metformin
 Anti obesity drugs
 Bariatic surgery
 For Infertility:
 Clomiphene citrate for ovulation induction
 Aromatase inhibition
 Gonadotrophins
 Insulin Sensitizing agents
 Hyperandrogenism & Hirsuitism:
 Cosmetic & medical therapies like waxing,threading, electrolysis, Laser
 Topical treatment for Hirsuitism
 CPA (Spironolactone, Finasteride, Flutamide)
 Topical Anti-acne, Topical retinoids+ Anti Androgens for Acne if not contraindicated
 For Severe Acne Oral Isotretanion if not contraindicated

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Chapter 16-Benign Disease of Uterus

Topic: Fibroid
Reference: Page#237, Fundamentals of Gynaecology by Arshad Chohan

SCENARIO-I:
A 40 year old nulliparous women present with 2 year history of menorrhagia. She is married for 4
years and want to conceive. Her pelvic ultrasound confirms the presence of fundal fibroid of 10×12
size.
a. What are the different treatment option for fibroid uterus?
b. What is the best surgical treatment of this patient’s complaint?
Key:
a) Different treatment options for fibroid uterus:
 Medical Treatment:
 Correction of Anemia
 Transamine
 GnRH Analogues
 Danazol
 Gestrinone
 NSAIDs for dysmenorrhea
 Surgical treatment: Main Rx is surgical i.e.
 Myomectomy
b) Best surgical treatment of this patient’s complaint:
Myomectomy

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Chapter: 18- Diseases of Cervix

Topic: Carcinoma Cervix
Reference: Page#269, Fundamentals of Gynaecology by Arshad Chohan

SCENARIO-I:
A 45 year old P5+0 came into OPD with her cytology report of Pap smear which shows CIN lll:
a. What are the different types of cervical intra-epithelial neoplasia?
b. What are the different treatment option of CIN lll?
Key: Reference P# 262, Arshad Chohan Gynae
a. Classification of cervical intra-epithelial neoplasia:

Pre-Invasive Disease Involvement of Epithelium Cytological Findings

CIN I Basal 1/3 only Mild Dyskaryosis (Low Grade)

CIN II Basal & Middle 1/3 Moderate Dyskaryosis (High Grade)

(2/3 of Epithelium)
CIN III Whole Epithelium Severe Dyskaryosis (High Grade)

b. Different treatment option of CIN lll:

 Ablative Methods:
i) Cryotherapy
ii) Electrocoagulation Diathermy
iii) Cold Coagulation
iv) Laser Vaporization
 Excisional Methods:
i) Cone Biopsy
ii) Large Loop Excision of Transformation zone (LLETZ)
iii) Hysterectomy

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Chapter-23
Common Gynecological Operations & Procedures
Topic: Laparoscopy
Reference: Page#351, Fundamentals of Gynaecology by Arshad Chohan

SCENARIO-I:
A 23 years old woman with primary subfertility is going for diagnostic laparoscopy and dye test for
tubal patency on your elective list tomorrow morning. The patient is anxious about the procedure.
a. How would you explain the procedure to the patient?
b. What are the possible complications of laparoscopy?
c. What are the benefits of minimally invasive procedures over open laparotomy?
KEY:
a) Explanation of procedure:
 After informed consent + Semen Analysis of male, we shall proceed to any invasive procedure in
female
 This procedure involves:
 Small incision below the umbilicus (Sub Umbilical incision)
 Veress needle is passed & CO2 gas instilled to form Pneumoperitoneum (to prevent damage to
organs & proper visualization)
 Laparoscopic camera is inserted to visualize the pelvic cavity
 Injection of dye (Methylene Blue) into cervix & spillage of dye into peritoneal cavity is observed
directly under laparoscopy. Along with establishment of tubal patency co-existing pelvic
pathology can be diagnosed
b) Possible Complications of Laparoscopy:
 Cannot show the site of tubal blockage
 Cannot show pathologies inside uterus like polyp
 Needs skilled surgeon
 Costly procedure
 Introduction of infection
 Peritonitis
c) Advantages of Minimally Invasive Procedure:
They are less invasive comparatively, so required
 Less hospital Stay & Less post-op morbidity
 Patient can get back to routine / work early

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Topic: Hysterectomy
Reference: Page#357, Fundamentals of Gynaecology by Arshad Chohan

SCENARIO-I:
A 48 year old patient P5Ab0Al 5 with heavy menstrual bleeding admitted in ward for abdominal
hysterectomy on elective list?
a. What are the investigations to be done?
b. What are complications related to hysterectomy?
Key:
a) Investigations:
 Hematological test: FBC, HB electrophoresis, Blood grouping, Cross matching & Clotting
profile
 Urine R/E
 Liver Function Tests (LFTs)
 Hepatitis B surface antigen & Anti HCV
Imaging and electrocardiography:
 Abdominopelvic U/S
 Chest x-ray
 ECG
b. Complications
Immediate:
• Anesthesia related
 Hemorrhage: Leads to re-operation
• Trauma to neighboring organs ureter, bowel, bladder
• Paralytic ileus
• Urinary retention
• Infection
• Thromboembolism
Delayed:
 Bladder bowel dysfunction
 Sexual dysfunction
 Menopausal functions
 Incisional hernia
 Vault prolapse
 Incontinence

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