NRE Step 1 Obstetrics and Gynaecology MCQs

Answer: Resuscitate and go to theatre. Suspected ruptured ectopic with shock: major haemorrhage protocol and emergency surgery.

• Discharge with review: Fatal error.
• Methotrexate: Only for stable unruptured ectopic.
• Wait for an ultrasound: Unstable: treat as ruptured ectopic.
• Serial hCG: Not in shock.

Answer: Twin-to-twin transfusion syndrome. TTTS occurs in monochorionic twins due to unbalanced vascular anastomoses in the shared placenta: the recipient becomes polyuric with polyhydramnios and heart failure; the donor becomes oliguric with oligohydramnios ("stuck twin"). Monochorionic twins need fortnightly scans from 16 weeks. Treatment: fetoscopic laser ablation of anastomoses (16–26 weeks). Dichorionic twins don’t get TTTS.

• Selective growth restriction: Doesn’t explain the fluid discrepancy.
• TRAP sequence: TRAP sequence involves an acardiac twin perfused by the other, not poly/oligohydramnios.
• Twin anaemia–polycythaemia sequence: Hb discordance without fluid discordance.

Answer: Obstructed labour — CS. Obstructed labour: failure of descent despite good contractions due to cephalopelvic disproportion, malpresentation (brow, shoulder) or pelvic masses. Signs: prolonged labour, maternal exhaustion, dehydration, ketosis, fever, tachycardia; tender lower segment, Bandl’s pathological retraction ring (thick upper segment, thinning lower segment — sign of impending rupture), severe moulding and caput, oedematous cervix/vulva, blood-stained urine (bladder compression), fetal distress or death. Complications: uterine rupture, PPH, sepsis, obstetric fistula (vesicovaginal/rectovaginal from pressure necrosis), nerve damage, fetal death. Management: resuscitate, antibiotics, catheterise (and keep catheter long-term to prevent fistula), never oxytocin, delivery by caesarean section; if fetus is dead and expertise available, destructive operation (craniotomy) may be safer. Prevention: partograph use, skilled birth attendance, timely referral.

• Augment with oxytocin: Oxytocin in obstructed labour risks uterine rupture.
• Prolonged latent phase: This is advanced obstruction, not a prolonged latent phase.
• Fundal pressure: Fundal pressure risks uterine rupture.

Answer: Oestrogen with a progestogen. Menopausal hormone therapy is the most effective treatment for vasomotor symptoms. Women with a uterus need progestogen (cyclical or continuous, or LNG-IUD) with oestrogen to prevent endometrial hyperplasia; women without a uterus take oestrogen alone. Transdermal oestrogen carries lower VTE risk. Contraindications: breast or endometrial cancer, undiagnosed vaginal bleeding, active VTE, active liver disease. Benefits: symptoms, bone protection; risks: breast cancer (combined), VTE (oral), stroke.

• Unopposed oestrogen: Unopposed oestrogen causes endometrial hyperplasia and cancer.
• Testosterone alone: Testosterone alone does not treat vasomotor symptoms.
• Tibolone with oestrogen: Tibolone is not combined with oestrogen.

Answer: Immediate manual replacement. Acute uterine inversion causes neurogenic and haemorrhagic shock. Call for help, resuscitate, and immediately attempt manual replacement (Johnson manoeuvre — push the fundus up through the cervix), leaving the placenta attached if still present. Tocolytics or anaesthesia may relax the uterus; if failed, hydrostatic (O’Sullivan) or surgical correction. Give oxytocin only after replacement. Prevention: avoid cord traction without uterine contraction and counter-traction.

• Give oxytocin first: Oxytocin first makes replacement impossible.
• Remove the placenta first: Removing the placenta first increases bleeding.
• Wait for spontaneous reduction: Waiting lets shock worsen.

Answer: IV thiamine. Hyperemesis gravidarum (weight loss > 5%, dehydration, ketosis, electrolyte imbalance) can cause Wernicke encephalopathy from thiamine deficiency — confusion, ataxia, ophthalmoplegia. Give IV thiamine (before dextrose), correct fluids with 0.9% saline + KCl, antiemetics, VTE prophylaxis. Exclude molar pregnancy and multiple pregnancy on ultrasound; check TFTs (gestational transient thyrotoxicosis).

• IV dextrose first: Dextrose first can precipitate Wernicke encephalopathy.
• Oral ondansetron only: Ondansetron does not treat the neurology.
• Oral iron: Iron is irrelevant here.

Answer: Full dilatation, head ≤ 1/5. Prerequisites for operative vaginal delivery (FORCEPS mnemonic): Fully dilated cervix, membranes ruptured, head engaged (≤ 1/5 palpable abdominally; station at/below spines), known position, adequate analgesia, empty bladder, consent, skilled operator with backup (theatre if trial), contractions. Ventouse avoided < 34 weeks (cephalhaematoma, intracranial haemorrhage); forceps for face presentation, preterm.

• Fetal head 3/5 palpable: With 3/5 palpable the head is not engaged.
• Unknown fetal position: The position must be known.
• Gestation of 30 weeks: Ventouse is avoided below 34 weeks.

Answer: Girls 9–14 years. HPV vaccination prevents cervical cancer (HPV 16/18 cause ~70%). WHO recommends vaccinating girls aged 9–14 (primary target) before sexual debut; a single-dose schedule is now acceptable. Pakistan introduced HPV vaccine via a campaign in 2025 for girls 9–14 years, followed by routine immunisation. Screening remains necessary as vaccines don’t cover all oncogenic types.

• Women over 50: Women over 50 were not the target.
• Boys 9–14 only: Girls were targeted.
• Pregnant women: HPV vaccine is not recommended in pregnancy.

Answer: Tamoxifen use. Endometrial cancer (type 1, endometrioid): unopposed oestrogen — obesity, nulliparity, early menarche/late menopause, PCOS, unopposed oestrogen HRT, tamoxifen (partial agonist on endometrium), diabetes, Lynch syndrome, oestrogen-secreting granulosa cell tumours. Protective: COCP, progestogens, multiparity, smoking. Presents with postmenopausal bleeding — transvaginal US (ET > 4 mm) → biopsy. Treatment: total hysterectomy + BSO ± staging.

• Combined oral contraceptive use: The combined pill is protective.
• Multiparity: Multiparity is protective.
• Smoking: Smoking is not a risk factor for endometrial cancer.

Answer: Metronidazole for both partners. Trichomonas vaginalis (flagellated protozoan, STI): frothy yellow-green discharge, itching, dysuria, strawberry cervix, pH > 4.5; motile trichomonads on wet mount, NAAT. Treat with metronidazole (7 days preferred for women, or 2 g single dose) and treat partners; avoid alcohol. Bacterial vaginosis: thin grey fishy discharge, clue cells, pH > 4.5, no inflammation. Candida: thick white, itchy, pH < 4.5.

• Clotrimazole pessary for her: Clotrimazole treats candida.
• Doxycycline for both partners: Doxycycline treats chlamydia.
• Single-dose fluconazole for her: Fluconazole treats candida.

Answer: Amniotomy, then oxytocin. Active first stage (WHO 2018: from 5 cm): progress slower than 1 cm/h is not alone an indication for intervention, but delay with inadequate contractions (< 3–4 in 10 min) — amniotomy then oxytocin augmentation, reassess in 2 hours. The partograph (alert/action lines) helps detect delay. Rule out obstruction (moulding, caput, CPD) before oxytocin. Instrumental delivery only when fully dilated.

• Immediate caesarean: Caesarean is not yet indicated.
• Ventouse-assisted delivery: The cervix is not fully dilated.
• Reassure — normal progress: This is slow progress.

Answer: No test needed. Menopause is a clinical diagnosis in women > 45: 12 months of amenorrhoea (or vasomotor symptoms in perimenopause). FSH testing is used for women < 45 with symptoms, or 40–45, and to diagnose premature ovarian insufficiency (< 40: two raised FSH 4–6 weeks apart). Management: lifestyle, HRT (oestrogen + progestogen if uterus present) for vasomotor symptoms; vaginal oestrogen for GSM.

• FSH on two occasions: FSH testing is only needed under 45.
• AMH level: AMH is not used for diagnosis.
• Pelvic ultrasound: Ultrasound is not needed.