Surgery During Pregnancy Indian Medical PG Practice Questions and MCQs
Practice Indian Medical PG questions for Surgery During Pregnancy. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Surgery During Pregnancy Indian Medical PG Question 1: Which of the following is consistent with a decision to perform a cerclage?
- A. Gestation of 26 weeks
- B. Uterine bleeding
- C. Uterine contractions
- D. Cervix dilated to 3 cm (Correct Answer)
Surgery During Pregnancy Explanation: ***Cervix dilated to 3 cm***
- In the context of **mid-trimester cervical dilation** (before 24 weeks) without contractions or bleeding, this represents **cervical insufficiency** - a potential indication for **emergency (rescue) cerclage**.
- While 3 cm dilation is at the **upper limit** and somewhat controversial, emergency cerclage may still be considered if membranes are intact, there are no contractions, and gestational age is <24 weeks.
- This is the **only option** that represents a clinical scenario where cerclage might be performed, as the other three options are **absolute contraindications**.
- Note: Most clinicians prefer cervical dilation **<2 cm** for rescue cerclage, but individual cases at 2-3 cm may be considered based on clinical judgment.
*Gestation of 26 weeks*
- Cerclage is typically placed between **12-14 weeks** (prophylactic) or up to **23-24 weeks** (emergency).
- At **26 weeks**, cerclage is **contraindicated** - the risks (membrane rupture, infection, preterm labor) outweigh benefits at this advanced gestation.
- This is an **absolute contraindication** regardless of cervical findings.
*Uterine bleeding*
- **Active uterine bleeding** is an **absolute contraindication** to cerclage placement.
- Bleeding increases risks of **infection, membrane rupture, and preterm labor**.
- Must rule out **placental abruption, placenta previa**, or other complications before considering any cervical intervention.
*Uterine contractions*
- **Active uterine contractions** are an **absolute contraindication** for cerclage.
- Placing cerclage during contractions can precipitate **preterm labor and delivery**.
- Contractions indicate the cervix may be responding to labor stimuli, making cerclage ineffective and potentially harmful.
Surgery During Pregnancy Indian Medical PG Question 2: Anesthesia of choice for cesarean section in severe preeclampsia:-
- A. Spinal (Correct Answer)
- B. GA
- C. Epidural
- D. Combined spinal-epidural (CSE)
Surgery During Pregnancy Explanation: ***Spinal***
- **Spinal anesthesia** is generally preferred in severe preeclampsia because it provides **rapid onset** of dense block, which can be critical for emergent cesarean sections.
- It avoids the risks associated with general anesthesia in these patients, such as difficult intubation and exaggerated **hypertensive response** to laryngoscopy.
*GA*
- **General anesthesia (GA)** in severe preeclampsia carries increased risks due to **airway edema**, potential for difficult intubation, and significant **blood pressure fluctuations** during induction and intubation.
- It can exacerbate the already compromised uteroplacental perfusion due to the sympathetic blockade and the potential for a **hypotensive episode**.
*Epidural*
- While generally safe in less severe preeclampsia, an **epidural** has a **slower onset** compared to spinal anesthesia, which may be a disadvantage in emergent situations.
- The gradual sympathetic blockade with an epidural is often preferred to avoid sudden drops in blood pressure, but the delay in achieving a surgical block might not be acceptable in severe, unstable cases.
*Combined spinal-epidural (CSE)*
- **Combined spinal-epidural (CSE)** offers the rapid onset of a spinal block with the flexibility of an epidural catheter for prolonged anesthesia or postoperative pain control.
- However, in cases of severe preeclampsia where **hemodynamic instability** is a major concern, the relatively larger dose of local anesthetic required for epidural component can lead to a more pronounced or rapid drop in blood pressure.
Surgery During Pregnancy Indian Medical PG Question 3: What is the management of eclampsia at 34 weeks of pregnancy?
- A. Continue convulsions and wait for 37 weeks to complete.
- B. Wait for spontaneous labor.
- C. Continue blood pressure management.
- D. Administer antihypertensives, anticonvulsants, and consider termination of pregnancy. (Correct Answer)
Surgery During Pregnancy Explanation: **Administer antihypertensives, anticonvulsants, and consider termination of pregnancy.**
- In eclampsia, emergent management includes immediate administration of **magnesium sulfate** as an anticonvulsant and **antihypertensives** (e.g., labetalol, hydralazine, nifedipine) to control blood pressure.
- Given the gestational age of 34 weeks and the occurrence of eclampsia, **delivery of the fetus** is often indicated to resolve the maternal condition, regardless of fetal lung maturity.
*Continue convulsions and wait for 37 weeks to complete.*
- Allowing **convulsions to continue** is extremely dangerous for both mother and fetus, increasing risks of aspiration, trauma, hypoxemia, and placental abruption.
- Eclampsia is a severe complication of pregnancy that necessitates immediate intervention and **should not be passively observed** until full term.
*Wait for spontaneous labor.*
- **Delaying delivery** while waiting for spontaneous labor in eclampsia significantly prolongs the mother's exposure to the severe complications of the condition.
- Eclampsia is an ** obstetric emergency** where prompt delivery, often via induction or C-section, is the definitive cure.
*Continue blood pressure management.*
- While **blood pressure management** is a crucial component of eclampsia treatment, it is insufficient on its own.
- Eclampsia specifically involves **seizures**, which require anticonvulsant therapy (magnesium sulfate) in addition to antihypertensives, and the ultimate treatment is delivery.
Surgery During Pregnancy Indian Medical PG Question 4: All are cardiovascular system changes in pregnancy except.
- A. Increase in blood volume
- B. Increase in heart rate
- C. Increase in peripheral resistance (Correct Answer)
- D. Increase in cardiac output
Surgery During Pregnancy Explanation: ***Increase in peripheral resistance***
- During normal pregnancy, **peripheral vascular resistance actually decreases** due to the effects of hormones like progesterone and the presence of the low-resistance uteroplacental circulation.
- This decrease in resistance helps accommodate the increased blood volume and cardiac output.
*Increase in cardiac output*
- **Cardiac output increases significantly** during pregnancy (by 30-50%) to meet the metabolic demands of the growing fetus and maternal tissues.
- This is primarily achieved through an increase in both stroke volume and heart rate.
*Increase in blood volume*
- **Blood volume increases substantially** (by 30-50%) during pregnancy, with plasma volume increasing more than red blood cell mass.
- This expansion supports the increased cardiac output and placental perfusion.
*Increase in heart rate*
- **Heart rate increases** during pregnancy, typically by 10-20 beats per minute, contributing to the overall increase in cardiac output.
- This physiological adaptation helps maintain adequate circulation.
Surgery During Pregnancy Indian Medical PG Question 5: What is the recommended management for a patient with complete placenta previa at 38 weeks gestation without any vaginal bleeding?
- A. Elective caesarean section (Correct Answer)
- B. Observation and monitoring until delivery
- C. Conservative management with bed rest
- D. Urgent caesarean section due to bleeding risk
Surgery During Pregnancy Explanation: ***Elective caesarean section***
- For women with **complete placenta previa** at term (38 weeks), an **elective caesarean section** is the recommended mode of delivery to avoid significant hemorrhage.
- Even in the absence of bleeding, the risk of massive hemorrhage during labor with a complete previa is high, necessitating planned surgical delivery.
*Observation and monitoring until delivery*
- This approach is not safe for complete placenta previa at term due to the high risk of **unpredictable, severe hemorrhage** once labor begins or the cervix dilates.
- Active monitoring without planned intervention carries significant maternal and fetal risk.
*Conservative management with bed rest*
- While bed rest may be used in cases of **placenta previa with bleeding** earlier in gestation to prolong pregnancy, it does not address the fundamental risk of hemorrhage from a complete previa at 38 weeks.
- It would not prevent the need for an eventual caesarean section and prolongs potential risks.
*Urgent caesarean section due to bleeding risk*
- While there is a bleeding risk, this scenario describes a patient at 38 weeks gestation **without any vaginal bleeding**, making it an elective, rather than urgent, situation.
- An **urgent caesarean section** is typically reserved for cases where active bleeding or other obstetric emergencies are present.
Surgery During Pregnancy Indian Medical PG Question 6: A lady with 36-week pregnancy with previous C-section comes with low BP, tachycardia, and on USG fluid present in peritoneum. What is the diagnosis and next management?
- A. Abruptio and C-section
- B. Ectopic pregnancy and abortion
- C. Impending dehiscence and Laparoscopy
- D. Uterine scar rupture with Laparotomy (Correct Answer)
Surgery During Pregnancy Explanation: ***Uterine scar rupture with Laparotomy***
- The presentation of **low blood pressure**, **tachycardia**, and **free fluid in the peritoneum** in a 36-week pregnant woman with a **previous C-section** is highly indicative of uterine scar rupture given the signs of **hemorrhagic shock**.
- **Laparotomy** (emergency abdominal surgery) is the immediate and definitive management to repair the ruptured uterus, control bleeding, and deliver the fetus.
*Abruptio and C-section*
- **Placental abruption** typically presents with painful vaginal bleeding, uterine tenderness, and fetal distress, which are not explicitly mentioned as the primary symptoms here.
- While a **C-section** would be indicated for abruption, the presence of free fluid in the peritoneum and hemodynamic instability in a woman with a prior C-section points more towards rupture.
*Ectopic pregnancy and abortion*
- An **ectopic pregnancy** is ruled out by the 36-week gestational age; these occur much earlier in pregnancy.
- An **abortion** refers to the termination of pregnancy and does not cause these specific signs and symptoms at 36 weeks.
*Impending dehiscence and Laparoscopy*
- **Impending dehiscence** (separation of the uterine scar without complete rupture) would likely cause localized pain but typically not the severe signs of **hypovolemic shock** and free peritoneal fluid seen here.
- **Laparoscopy** is a minimally invasive procedure and would not be appropriate for the emergency management of a potentially life-threatening hemorrhage from uterine rupture.
Surgery During Pregnancy Indian Medical PG Question 7: Termination of pregnancy in placenta previa is indicated in:
a) Active bleeding
b) Active labour
c) Gestational age > 34 weeks with live fetus
d) Fetal malformation
e) Unstable lie
- A. acd
- B. ab (Correct Answer)
- C. e
- D. abd
- E. abc
Surgery During Pregnancy Explanation: ***ab***
- **Active bleeding** in placenta previa is an absolute indication for immediate delivery (usually by cesarean section) due to the risk of life-threatening maternal and fetal hemorrhage.
- **Active labour** with placenta previa is a critical indication for immediate cesarean delivery, as progressive cervical dilation causes placental separation leading to catastrophic hemorrhage.
*acd*
- While active bleeding is an indication, gestational age > 34 weeks alone does not mandate immediate delivery in stable placenta previa patients. Expectant management until 36-37 weeks is standard practice.
*e*
- Unstable lie is not an indication for termination of pregnancy in placenta previa. While it may necessitate cesarean section at term, it does not indicate immediate delivery.
*abc*
- Active bleeding and active labour are correct indications, but gestational age > 34 weeks with a live fetus is NOT an isolated indication for immediate delivery in stable patients without bleeding.
*abd*
- Active bleeding and active labour are correct indications, but fetal malformation is not a specific indication for termination in the context of placenta previa management. Fetal malformation decisions are made independently of placenta previa status.
Surgery During Pregnancy Indian Medical PG Question 8: A 29-year-old woman with a ruptured ectopic pregnancy is admitted to a hospital for culdocentesis. A long needle on the syringe is most efficiently inserted through which of the following structures?
- A. Anterior wall of the rectum
- B. Posterior fornix of the vagina (Correct Answer)
- C. Anterior fornix of the vagina
- D. Posterior wall of the uterine body
Surgery During Pregnancy Explanation: ***Posterior fornix of the vagina***
- Culdocentesis is a procedure where fluid is aspirated from the **cul-de-sac (rectouterine pouch)**.
- The **posterior vaginal fornix** is the thinnest and most accessible anatomical landmark for safely accessing the rectouterine pouch.
*Anterior wall of the rectum*
- Puncturing the **anterior rectal wall** could lead to peritonitis and is not the intended approach for culdocentesis.
- The rectum is located posterior to the rectouterine pouch, making it an inappropriate entry point.
*Anterior fornix of the vagina*
- The **anterior fornix** is anatomically adjacent to the vesicouterine pouch (between the bladder and uterus), not the rectouterine pouch.
- Puncturing this area would not access the fluid collection from a ruptured ectopic pregnancy, which accumulates in the rectouterine pouch.
*Posterior wall of the uterine body*
- Puncturing the **posterior wall of the uterine body** would damage the uterus and is not a route to the cul-de-sac.
- The procedure aims to access the space behind the uterus, not the uterine organ itself.
Surgery During Pregnancy Indian Medical PG Question 9: What is the most appropriate management for a 28-year-old hemodynamically stable patient with mild abdominal pain and an unruptured tubal ectopic pregnancy measuring 2.5 x 3 cm, with β-hCG level of 8500 mIU/mL, visible fetal cardiac activity, and who desires future fertility?
- A. Methotrexate therapy
- B. Laparoscopic salpingostomy (Correct Answer)
- C. Laparoscopic salpingectomy
- D. Expectant management
Surgery During Pregnancy Explanation: ***Laparoscopic salpingostomy***
- This patient desires future fertility, making **salpingostomy** (tube-preserving surgery) the most appropriate management.
- Salpingostomy involves making an incision in the fallopian tube, removing the ectopic pregnancy, and leaving the tube intact to preserve fertility potential.
- While the presence of **fetal cardiac activity** and **β-hCG of 8500 mIU/mL** contraindicate medical management, they do not contraindicate conservative surgical management in a hemodynamically stable patient.
- The patient meets criteria for conservative surgery: hemodynamically stable, unruptured ectopic, and desires future fertility.
*Methotrexate therapy*
- This patient has **absolute contraindications for methotrexate**: β-hCG level >5000 mIU/mL (here 8500) and presence of **fetal cardiac activity**.
- Methotrexate is only suitable for hemodynamically stable patients with ectopic mass <3.5-4 cm, β-hCG <5000 mIU/mL, no fetal cardiac activity, and normal liver/renal function.
- The high β-hCG and cardiac activity indicate a viable ectopic pregnancy that is unlikely to respond to medical management.
*Laparoscopic salpingectomy*
- Salpingectomy involves **complete removal of the affected fallopian tube**, which significantly reduces future fertility if this is the only functional tube or if the contralateral tube is damaged.
- This option is preferred when: the tube is severely damaged, there is uncontrolled bleeding, recurrent ectopic in the same tube, or the patient does not desire future fertility.
- Since this patient **specifically desires future fertility** and is hemodynamically stable with an unruptured ectopic, salpingostomy (tube preservation) is preferred over salpingectomy.
*Expectant management*
- Expectant management requires **very low or declining β-hCG levels** (typically <1000-1500 mIU/mL), absence of fetal cardiac activity, and very small ectopic size (<2 cm).
- This patient has β-hCG of 8500 mIU/mL with **visible fetal cardiac activity**, indicating a viable growing ectopic pregnancy with high rupture risk.
- These findings make expectant management unsafe and inappropriate.
Surgery During Pregnancy Indian Medical PG Question 10: Which of the following cannot be treated by laparoscopy?
- A. Non descent of uterus
- B. Ectopic pregnancy
- C. Sterilization
- D. Genital prolapse (Correct Answer)
Surgery During Pregnancy Explanation: ***Genital prolapse***
- Among the options listed, **genital prolapse** is the condition LEAST suited for complete laparoscopic management, particularly in the context of this examination question.
- While **laparoscopic sacrocolpopexy** and **sacral hysteropexy** exist for vault prolapse and uterine prolapse respectively, these procedures were less established at the time of this exam (2012) and require advanced laparoscopic skills.
- Most cases of **genital prolapse**, especially complete pelvic organ prolapse, traditionally require **vaginal surgical approaches** or **open abdominal procedures** for comprehensive repair of multiple compartment defects.
- The complex anatomical reconstruction needed for severe prolapse (anterior, posterior, and apical compartments) is more challenging via laparoscopy compared to the other listed conditions.
*Non descent of uterus*
- **Non-descent vaginal hysterectomy** can be performed with **laparoscopic assistance (LAVH/LDVH)** or as **total laparoscopic hysterectomy (TLH)**.
- Laparoscopy facilitates dissection of uterine attachments, ligation of vessels, and removal of the uterus with minimal morbidity.
*Ectopic pregnancy*
- **Ectopic pregnancy** is a standard indication for laparoscopic surgery, performed routinely worldwide.
- Procedures include **laparoscopic salpingectomy** (removal of affected tube) or **salpingostomy** (conservative surgery preserving the tube).
- Offers advantages of minimal invasiveness, reduced recovery time, and excellent visualization.
*Sterilization*
- **Laparoscopic tubal sterilization** is one of the most common laparoscopic procedures performed.
- Methods include application of **Filshie clips, Falope rings**, or **electrocautery** to occlude fallopian tubes.
- Gold standard for permanent contraception with minimal morbidity.
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