Viva · Specialty
Obstetric and Gynaecological Viva Questions
Oral-exam style questions and answers on obstetric and gynaecological for MD, DNB and super-specialty practical examinations. Each answer links back to the playbook or Library entry it was written from.
- What does the 'L' in PALM-COEIN represent, and how is it structured?
- L stands for leiomyoma, one of the structural PALM causes of abnormal uterine bleeding. It has three tiers: presence of a leiomyoma, then submucous versus other, then the numerical type 0 to 8 based on the lesion's relationship to the endometrium and the serosa.
- Why are types 3 to 8 grouped as 'other'?
- Because the classification was designed for abnormal uterine bleeding, and submucosal lesions are the ones most strongly associated with bleeding and amenable to hysteroscopic treatment. Everything without a submucosal component falls into the FIGO 'other' group, which anatomically comprises intramural types 3 and 4, subserosal types 5 to 7, and non-myometrial type 8.
- Define FIGO types 0, 1 and 2.
- All are submucous. Type 0 is pedunculated and entirely intracavitary with no myometrial component, type 1 has less than fifty per cent intramural extension, and type 2 has fifty per cent or more intramural extension.
- How do you distinguish type 3 from type 4?
- Both are entirely intramural. Type 3 abuts the endometrium without distorting the cavity, whereas type 4 contacts neither the endometrium nor the serosa.
- For which types must the outer free margin be documented, and why?
- Types 2, 3 and 4. The distance in millimetres from the lesion to the serosa determines the safety of hysteroscopic resection and the risk of perforation, and guides the choice of procedural approach.
- What is a hybrid leiomyoma and how is it written?
- A lesion contacting both the endometrium and the serosa. It is written as two numbers separated by a hyphen, for example 2-5, where by convention the first digit describes the endometrial relationship and the second the serosal relationship.
- What is the pitfall with a type 7 leiomyoma, and what does type 8 mean for an interventional radiologist?
- A pedunculated subserosal fibroid can be mistaken for a solid adnexal mass; the bridging vascular stalk on Doppler or MRI confirms uterine origin. Type 8 lesions such as cervical, broad-ligament or parasitic fibroids sit outside the myometrium and may derive supply from vessels other than the uterine arteries, which must be sought before embolisation.
- What does the FIGO leiomyoma system deliberately not capture?
- It is purely anatomical. It does not encode fibroid size, number, vascularity or degeneration, so the report must add three-dimensional measurements, lesion count, position and uterine volume for treatment planning.
- What is placenta accreta spectrum?
- Placenta accreta spectrum is abnormal placental attachment, with a spectrum from abnormally adherent placenta to invasion into the myometrium and extension through the uterine serosa or adjacent organs.
- Enumerate the seven established ultrasound signs of placenta accreta spectrum.
- They are loss of the retroplacental clear zone, myometrial thinning, bladder-wall interruption, placental bulge, uterovesical hypervascularity, placental lacunae and bridging vessels.
- How are placental lacunae described on ultrasound?
- They are irregular hypoechoic spaces within the placenta containing vascular flow. Multiple large lacunae with irregular margins and high-velocity or turbulent flow are more concerning in an at-risk pregnancy.
- What are bridging vessels, and what is their principal mimic?
- Bridging vessels arise from the placenta and traverse the myometrium beyond the uterine serosa on colour Doppler. Their principal mimic is non-placental bladder varicosity.
- Enumerate the seven SAR–ESUR-recommended MRI signs of placenta accreta spectrum.
- They are T2-dark intraplacental bands, placental or uterine bulge, loss of the retroplacental T2-hypointense line, myometrial thinning or disruption, bladder-wall interruption, focal exophytic placental mass and abnormal vascularisation of the placental bed.
- Which MRI descriptors were categorised as uncertain by the SAR–ESUR consensus?
- Placental heterogeneity, asymmetric placental shape or thickening, placental ischaemic infarction and abnormal intraplacental vascularity did not reach the consensus threshold for recommended signs.
- What is the role of MRI when placenta accreta spectrum is suspected?
- MRI is an adjunct to ultrasound rather than the primary screening test. It helps when ultrasound is equivocal or limited and maps the topography, depth and possible bladder or parametrial extension for multidisciplinary planning.
- Why should a single imaging descriptor not be used to grade placenta accreta spectrum?
- Individual signs have imperfect specificity and may occur with placenta praevia, uterine scars or advancing gestation. Imaging should integrate multiple concordant signs, clinical risk factors and operative or pathological findings rather than assign an unsupported grade.