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GYN-Problem-Based Questions

Sep 02, 20259 min read

Table of Contents

Problem-Based Questions

R1-Boys

CD 1: Third Trimester Bleeding

Problem:

A 31-week pregnant woman, P3+0, with a history of 3 previous C/S, presents with painless vaginal bleeding. Her vitals are stable, there’s no ongoing bleeding, and ultrasound confirms placenta previa.

Guiding Questions:

  1. What is your initial approach to a patient with third-trimester bleeding?

    • ABCs stabilization: Assess airway, breathing, circulation; establish IV access (two large-bore cannulas).
    • Vital signs & resuscitation: Monitor BP, HR, O₂ saturation; administer O₂ if hypoxic; fluid resuscitation if unstable.
    • Fetal assessment: Immediate continuous CTG to evaluate fetal well-being and uterine activity.
    • History & exam: Detailed history (onset, volume, pain, trauma); avoid digital vaginal exam until placenta previa is ruled out.
    • Investigations: Complete blood count, coagulation profile, blood group/crossmatch (4 units); urgent ultrasound to identify placental location. - Catheter? z
    • Admission: Hospitalize for monitoring even if bleeding stops, due to risk of recurrence.

  2. Based on the history and examination, what are the likely causes of her bleeding?

    • Placenta previa (most likely): Confirmed by ultrasound; painless bleeding in a patient with prior uterine scars (3 C/S → high risk for previa). - increased heart rate of placenta + fetal heart sound

    • Vasa previa: Possible given prior C/S (abnormal placental cord insertion), but less common.

    • Unlikely causes:

      • Abruptio placentae (typically painful bleeding, uterine tenderness).
      • Uterine rupture (severe pain, instability; rare without labor).
      • Cervical/vaginal lesions (e.g., polyps, trauma; usually minor bleeding).

  3. How would you differentiate placenta previa from abruptio placenta clinically?

FeaturePlacenta PreviaAbruptio Placentae
PainPainless vaginal bleeding.Severe abdominal or back pain, often sudden.
BleedingBright‑red, sudden and intermittent.Dark red/maroon; may be concealed (≈25 % of cases).
UterusSoft, non‑tender, relaxed.Firm, tender with a characteristic “woody” hardness.
Fetal presentationFrequently malpresented (e.g., breech).Usually a normal presentation.
FHR changesLate decelerations only if severe blood loss occurs.Early decelerations, reflecting hypoxia.
UltrasoundShows placenta overlying or adjacent to the internal os.May reveal a retro‑placental clot (often absent).

  1. What are the maternal and fetal complications of placenta previa?

    • Maternal:
      • Hemorrhage → shock, disseminated intravascular coagulation (DIC).
      • Emergency cesarean delivery (risk of intraoperative hemorrhage, hysterectomy).
      • Infection (from prolonged hospitalization/procedures).
      • Increased risk of placenta accreta (given 3 prior C/S → up to 40% risk).
    • Fetal:
      • Preterm delivery → respiratory distress syndrome, NICU admission.
      • Fetal hypoxia/anemia from acute blood loss.
      • Intrauterine growth restriction (IUGR) from placental dysfunction.
      • Stillbirth (if severe undiagnosed hemorrhage).

  2. Outline your management plan for this patient.

    • Immediate:
      • Admit to antepartum unit; strict bed rest.
      • Continuous fetal monitoring (CTG) and maternal vitals q15min until stable, then q1-2h.
      • Type and crossmatch 4-6 units PRBCs; initiate IV fluids.
      • Administer corticosteroids (e.g., betamethasone) for fetal lung maturity (31 weeks).
    • Monitoring:
      • Serial Hb/Hct (q6-12h initially); ultrasound to reassess placental location (if bleeding recurs).
      • Rule out placenta accreta (MRI if suspicion high due to prior C/S).
    • Delivery planning:
      • Expectant management until 36–37 weeks if stable.
      • Cesarean delivery scheduled at 36–37 weeks (earlier if active bleeding, distress, or accreta suspected).
      • Multidisciplinary team (OB, anesthesia, NICU, blood bank); consider cell salvage if accreta risk.
      • Avoid labor induction (placenta covers internal OS).

  3. When is blood transfusion indicated, and what are its possible complications?

    • Indications:
      • Hemodynamic instability (tachycardia, hypotension) despite fluid resuscitation.
      • Symptomatic anemia (e.g., dyspnea, tachycardia at rest).
      • Hb <7 g/dL (or <8 g/dL if active bleeding, cardiac disease, or ongoing loss).
      • Note: Transfuse before Hb reaches critical levels in pregnancy due to physiological anemia.
    • Possible complications:
      • Acute: Febrile non-hemolytic reaction, allergic reaction, TRALI (transfusion-related acute lung injury), TACO (transfusion-associated circulatory overload).
      • Delayed: Hemolytic reaction (if ABO mismatch), iron overload (with massive transfusion), infections (e.g., hepatitis, HIV; rare with modern screening).
      • Special in obstetrics: Alloimmunization (risk in future pregnancies), hypocalcemia (from citrate in massive transfusion).

CD 2: Intrauterine Fetal Demise (IUFD)

Problem:

A 39-week pregnant patient, P2+5, with diabetes, presents with absent fetal movements for 1 week. There’s no fluid loss or bleeding, and ultrasound confirms absent fetal heart.

Guiding Questions:

  1. What are the etiologies and risk factors for IUFD in this patient?
  2. Which clinical features raise suspicion of IUFD?
  3. How do you confirm the diagnosis of IUFD?
  4. What are the management options once IUFD is confirmed?
  5. How would you address the psychosocial aspects of care in IUFD?

CD 3: Surgical Conditions during Pregnancy

Problem:

A 25-year-old woman at 20 weeks of gestation presents with acute left lower quadrant pain, tachycardia, and localized tenderness. Ultrasound suggests ovarian torsion.

Guiding Questions:

  1. How do you conduct a focused history and examination for acute abdomen in pregnancy?
  2. What are the differential diagnoses of acute abdomen during pregnancy?
  3. Which investigations would you order, and how do you interpret them?
  4. What is your management plan for ovarian torsion in this case?
  5. What are the potential complications of surgical intervention during pregnancy?

CD 4: Premenstrual Syndrome (PMS)

Problem:

A 34-year-old woman reports symptoms of hot flushes, mastalgia, irritability, and depression 5 days before menses, resolving after menstruation begins.

Guiding Questions:

  1. How would you define PMS?
  2. What history and examination are essential in evaluating PMS?
  3. What are the possible causes and pathophysiology of PMS?
  4. What are the diagnostic criteria for PMS?
  5. What is your management plan for PMS?

CD 5: Pelvic Inflammatory Disease (PID)

Problem:

A 20-year-old woman presents with 3 days of worsening lower abdominal pain, fever (39°C), and cervical motion tenderness. Swab is positive for chlamydia.

Guiding Questions:

  1. What is the pathophysiology of PID?
  2. What are the key history, examination, and investigations for PID?
  3. What are the diagnostic criteria for PID?
  4. What is your initial management approach?
  5. What are the long-term complications of PID?

CD 6: Ectopic Pregnancy

Problem:

A 27-year-old woman, 6 weeks post-LMP, presents with abdominal pain, vaginal bleeding, and an adnexal mass on ultrasound.

Guiding Questions:

  1. How do you define ectopic pregnancy?
  2. What risk factors predispose to ectopic pregnancy?
  3. What is your differential diagnosis for first-trimester bleeding and pain?
  4. Which investigations confirm the diagnosis of ectopic pregnancy?
  5. What are the management options (medical vs. surgical)?

CD 7: Abortion

Problem:

A 9-week pregnant woman presents with vaginal bleeding, clots, and cervical dilatation with tissue passage.

Guiding Questions:

  • What is your differential diagnosis for first-trimester bleeding?

    1. Threatened abortion (viable fetus)Z
    2. Inevitable abortion (bleeding + dilated cervix)
    3. Incomplete abortion (tissue passage + residual material)
    4. Complete abortion (all tissue passed)
    5. Missed abortion (retained non-viable fetus)
    6. Septic abortion (infection superimposed)
    7. Ectopic pregnancyZ
    8. Molar pregnancyZ
    9. Cervical/vaginal pathology (e.g., polyps, trauma)

  • How do you differentiate the types of abortion clinically (missed, threatened, incomplete, etc.)?

TypeBleedingCervical OSPainUltrasound Findings
ThreatenedMild-modClosedMildViable IUP
InevitableMod-sevOpenMod-severeIUP, no cardiac activity
IncompleteMod-sevOpenSevereRetained products
MissedScantClosedAbsent/mildNon-viable fetus (>7 weeks)
CompleteScantClosedResolvedEmpty uterus

  • What are the possible etiologies of spontaneous abortion?

    • Chromosomal (50%, e.g., trisomies)
    • Maternal factors: Endocrinopathies (DM, thyroid), infections (listeria, toxoplasma), structural (uterine anomalies, fibroids)
    • Immunological: Antiphospholipid syndrome
    • Environmental: Teratogens (alcohol, radiation)
    • Luteal phase defect (low progesterone)

  • What are the complications of spontaneous abortion? 1. Hemorrhagic shock 2. Infection → endometritis, sepsis 3. Disseminated intravascular coagulation (DIC) 4. Asherman’s syndrome (uterine synechiae) 5. Psychological trauma

  • How would you manage each type of abortion?

  • What are the methods of termination (surgical and non-surgical)? Non-Surgical

    • Medical: Mifepristone (anti-progesterone) + misoprostol (PGE1) ≤10 weeks
      Surgical
    • Vacuum aspiration (≤12-14 weeks)
    • D&C (≤12 weeks)
    • D&E (2nd trimester)

  • What are the complications of induced abortion? Immediate:

  • hemmorhage,

  • uterine hemorrhage

  • resulting in shock

  • cerrvical injury

  • antethesial?

  • septic miscarriage

  • PE

CC

Early (<48h)Late (>48h)
Perforation/hemorrhageInfection
Cervical lacerationRetained POC
Anesthetic complicationsAsherman’s syndrome; uterine adhesions
Uterine atonyRhesus sensitization
Incomplete abortion (~2%)Future preterm birth/subfertility

Key Practice Point:

  • Quantitative hCG + transvaginal US is diagnostic gold standard.
  • RhoGAM for all Rh(−) women regardless of abortion type to prevent isoimmunization.
  • Avoid curettage in desired pregnancies unless mandatory (e.g., hemorrhage).

CD 8: Pelvic Prolapse

Problem:

A 48-year-old multipara with 8 vaginal deliveries presents with pelvic heaviness and uterus protrusion. Examination confirms complete uterine prolapse.

Guiding Questions:

  1. What are the types of pelvic organ prolapse?
  2. What are the anatomic changes associated with prolapse?
  3. What history and examination are important for pelvic prolapse?
  4. How do you classify pelvic organ prolapse?
  5. What are the confirmatory investigations?
  6. What are the medical and surgical management options?

CD 9: Polycystic Ovarian Syndrome (PCOS)

Problem:

A 28-year-old obese woman with irregular menses and hirsutism for 2 years. Ultrasound shows >10 follicles/ovary.

Guiding Questions:

  1. What are the Rotterdam criteria for PCOS diagnosis?
    Diagnosis requires ≥2 of 3 criteria:

    • Oligo-/anovulation (e.g., irregular/absent menses).
    • Clinical and/or biochemical hyperandrogenism (e.g., hirsutism, acne, elevated serum androgens).
    • Polycystic ovaries on ultrasound (≥20 follicles per ovary or ovarian volume >10 mL). Note: The case states “>10 follicles/ovary,” but Rotterdam specifies ≥20 follicles (2–9 mm diameter) or volume >10 mL.

  2. What are the etiologies and risk factors for PCOS?

    • Etiologies: Multifactorial; insulin resistance (leading to hyperinsulinemia) and hyperandrogenism are central. Genetic predisposition (e.g., DENND1A, THADA variants) and ovarian dysfunction amplify androgen production.
    • Risk factors:
      • Obesity (exacerbates insulin resistance).
      • Family history of PCOS, diabetes, or cardiovascular disease.
      • Sedentary lifestyle, high-glycemic diet.

  3. What are the clinical features and physical findings?

    • Reproductive: Irregular/absent menses (oligoamenorrhea), infertility, recurrent miscarriage.
    • Dermatological: Hirsutism (face, chest, abdomen), acne, alopecia, acanthosis nigricans (insulin resistance sign).
    • Metabolic: Weight gain/obesity (50–80% of cases), increased risk of type 2 diabetes, dyslipidemia.
    • This patient exhibits irregular menses, hirsutism, and obesity—classic features.

  4. Which investigations are appropriate for PCOS?

    • First-line:
      • Hormonal: Total/free testosterone, SHBG, LH:FSH ratio (often elevated LH), TSH, prolactin (to exclude mimics).
      • Metabolic: Fasting glucose, HbA1c, lipid panel.
      • Ultrasound: Transvaginal (confirms polycystic morphology; must meet Rotterdam’s ≥20 follicles/ovary).
    • Exclusion tests: 17-OH progesterone (rule out CAH), DHEA-S (if adrenal hyperandrogenism suspected).
    • Avoid: AMH (not diagnostic but often elevated; useful for research).

  5. What is your management plan for PCOS?

    • Lifestyle modification (FIRST-LINE):
      • Weight loss (5–10% reduction): Calorie-restricted diet + aerobic exercise (improves insulin sensitivity, restores ovulation).
    • Symptom-specific treatment:
      • Hyperandrogenism/hirsutism: Combined oral contraceptive pills (COCPs; e.g., ethinyl estradiol + anti-androgen like drospirenone) or spironolactone (if COCP contraindicated).
      • Anovulation/infertility: Letrozole (first-line ovulation induction); metformin (if insulin resistance persists despite weight loss).
    • Metabolic monitoring: Annual screening for diabetes (HbA1c), lipids, BP.
    • For this patient: Prioritize weight loss + COCPs to regulate cycles and reduce hirsutism. Add metformin if prediabetes present.

Key Clarification: The case states “>10 follicles/ovary,” but Rotterdam criteria require ≥20 follicles per ovary. This discrepancy may indicate outdated imaging criteria; confirm follicle count meets current standards.

CD 10: Menopause

Problem:

A 55-year-old woman presents with severe hot flushes and night sweats. FSH and LH are elevated, and her last menses was 6 months ago.

Guiding Questions:

  1. How do you define menopause?
  2. What are the physiological changes in the hypothalamic-pituitary-ovarian axis?
  3. What are the common symptoms and exam findings of menopause?
  4. What are the management options for peri-menopausal symptoms?
  5. How would you counsel a patient regarding menopause?
  6. What are the long-term complications associated with menopause?

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