Obstetric Emergencies — MCQs
Comprehensive emergency obstetric care does not include:
What is the maneuver performed by the obstetrician to sharply flex the legs towards the abdomen when suspecting shoulder dystocia after the delivery of the head during a delivery?
A pregnant lady with persistent variable decelerations with cervical dilatation of 6 cm is planned for emergency LSCS. Which of the following is NOT done in management while preparing patient for surgery
A 25-year-old pregnant woman at 28 weeks gestation presents with a headache. Her pregnancy has been managed by a nurse practitioner. Her temperature is 99.0°F (37.2°C), blood pressure is 164/104 mmHg, pulse is 100/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam is notable for a comfortable appearing woman with a gravid uterus. Laboratory tests are ordered as seen below. Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 6,700/mm^3 with normal differential Platelet count: 100,500/mm^3 Serum: Na+: 141 mEq/L Cl-: 101 mEq/L K+: 4.4 mEq/L HCO3-: 25 mEq/L BUN: 21 mg/dL Glucose: 99 mg/dL Creatinine: 1.0 mg/dL AST: 32 U/L ALT: 30 U/L Urine: Color: Amber Protein: Positive Blood: Negative Which of the following is the most likely diagnosis?
What is the recommended management for a patient with complete placenta previa at 38 weeks gestation without any vaginal bleeding?
Which antihypertensive is considered the first-line treatment with the most extensive safety data for chronic hypertension in pregnancy?
Most common cause of secondary PPH is :
A 28-year-old woman, G2 P1, with severe PPH unresponsive to oxytocin presents with hypotension and tachycardia. She has a soft uterus and ongoing bleeding. What is the next best step in management?
Converting frank breech presentation into footling breech presentation within the upper birth canal is called
Palmer sign is related to ?
Obstetric Emergencies Indian Medical PG Practice Questions and MCQs
Question 1: Comprehensive emergency obstetric care does not include:
- A. Manual removal of placenta
- B. Cesarean section
- C. Routine antenatal care (Correct Answer)
- D. Hysterectomy
Explanation: ***Routine antenatal care*** - Routine antenatal care is a **preventive and monitoring service** provided during pregnancy to detect and prevent complications. - Comprehensive Emergency Obstetric Care (CEmOC) specifically refers to **emergency interventions** provided during obstetric complications, not routine preventive services. - According to WHO definitions, CEmOC includes **7 signal functions**: parenteral antibiotics, parenteral oxytocics, parenteral anticonvulsants, manual removal of placenta, removal of retained products, assisted vaginal delivery, cesarean section, and blood transfusion. - Routine antenatal care is provided at basic health facilities and is **not an emergency intervention**. *Manual removal of placenta* - This is a **core signal function** of CEmOC (signal function #4). - Essential intervention for managing **retained placenta**, a common cause of postpartum hemorrhage. - Failure to remove retained placenta can lead to severe hemorrhage, infection, and maternal death. *Cesarean section* - This is a **defining signal function** of CEmOC (signal function #7). - Life-saving intervention for managing obstructed labor, fetal distress, placenta previa, and other complications. - The ability to perform cesarean section is the **key differentiator** between Basic EmOC and Comprehensive EmOC. *Hysterectomy* - While hysterectomy may be performed in facilities providing CEmOC for severe complications like intractable postpartum hemorrhage, it is **not one of the 7 signal functions** that define CEmOC. - It is a surgical capability that may be available but is not a required component for a facility to be designated as providing comprehensive emergency obstetric care.
Question 2: What is the maneuver performed by the obstetrician to sharply flex the legs towards the abdomen when suspecting shoulder dystocia after the delivery of the head during a delivery?
- A. Rubin's maneuver
- B. Wood Corkscrew maneuver
- C. Zavanelli's maneuver
- D. McRoberts maneuver (Correct Answer)
Explanation: ***McRoberts maneuver*** - This maneuver involves sharply flexing the maternal thighs against the abdomen, which **flattens the sacrum** and rotates the symphysis pubis anteriorly. - This **increases the functional diameter** of the pelvic outlet and often helps dislodge the anterior shoulder in cases of shoulder dystocia. *Rubin's maneuver* - This maneuver involves reaching into the vagina and **rotating the anterior shoulder** to an oblique position or pushing the posterior shoulder anteriorly. - It is used when the McRoberts maneuver fails and aims to **reduce the bisacromial diameter**. *Wood Corkscrew maneuver* - This maneuver involves reaching into the vagina and **rotating the posterior shoulder** 180 degrees in a corkscrew fashion. - It works by sequentially engaging and disengaging shoulders, effectively **"walking" the baby out**. *Zavanelli's maneuver* - This is a **last-resort maneuver** used when other attempts to resolve shoulder dystocia have failed and involves replacing the fetal head back into the birth canal. - It is performed to then proceed with an **emergency cesarean section**.
Question 3: A pregnant lady with persistent variable decelerations with cervical dilatation of 6 cm is planned for emergency LSCS. Which of the following is NOT done in management while preparing patient for surgery
- A. O2 inhalation
- B. I.V. fluid
- C. Foley catheterization
- D. Supine position (Correct Answer)
Explanation: ***Supine position*** - Maintaining a **supine position** in a pregnant woman can lead to **aortocaval compression**, reducing **venous return** and **cardiac output**, which compromises uterine blood flow and fetal oxygenation. - To prevent this, the patient should be placed in a **left lateral tilt** (wedge under the right hip) to displace the uterus off the great vessels. *O2 inhalation* - Administering **oxygen via face mask** increases the mother's partial pressure of oxygen (PaO2), which can improve **fetal oxygenation** and potentially alleviate fetal distress. - This is a standard and safe intervention to maximize oxygen delivery to the fetus, especially in cases of **fetal compromise** indicated by variable decelerations. *I.V. fluid* - Administering **intravenous fluids** helps maintain maternal hydration and **circulatory volume**, crucial for adequate uterine perfusion. - This can improve **placental blood flow**, potentially reducing the frequency or severity of variable decelerations by increasing amniotic fluid volume and relieving **cord compression**. *Foleys catheterisation* - **Foley catheterization** is essential before a Cesarean section to **decompress the bladder**, preventing injury during surgery and improving surgical exposure. - A full bladder can obstruct the surgical field and increases the risk of accidental incision, therefore, it is a routine pre-operative step.
Question 4: A 25-year-old pregnant woman at 28 weeks gestation presents with a headache. Her pregnancy has been managed by a nurse practitioner. Her temperature is 99.0°F (37.2°C), blood pressure is 164/104 mmHg, pulse is 100/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam is notable for a comfortable appearing woman with a gravid uterus. Laboratory tests are ordered as seen below. Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 6,700/mm^3 with normal differential Platelet count: 100,500/mm^3 Serum: Na+: 141 mEq/L Cl-: 101 mEq/L K+: 4.4 mEq/L HCO3-: 25 mEq/L BUN: 21 mg/dL Glucose: 99 mg/dL Creatinine: 1.0 mg/dL AST: 32 U/L ALT: 30 U/L Urine: Color: Amber Protein: Positive Blood: Negative Which of the following is the most likely diagnosis?
- A. HELLP syndrome
- B. Acute fatty liver disease of pregnancy
- C. Preeclampsia
- D. Severe preeclampsia (Correct Answer)
- E. Eclampsia
Explanation: ***Severe preeclampsia*** - The patient exhibits **hypertension** (BP 164/104 mmHg), **proteinuria** (positive urine protein), and **thrombocytopenia** (platelet count 100,500/mm^3). The elevated BUN and creatinine also suggest **renal dysfunction**. - The blood pressure reading 164/104 mmHg meets the criteria for **severe range blood pressure** (systolic ≥160 mmHg or diastolic ≥110 mmHg), classifying this as severe preeclampsia. Headaches are also a symptom of severe preeclampsia. *HELLP syndrome* - While **thrombocytopenia** is present, the **liver enzymes (AST/ALT)** are not elevated (AST 32 U/L, ALT 30 U/L), which would be a primary diagnostic criterion for HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets). - There is no evidence of **hemolysis**, such as elevated bilirubin or schistocytes on a peripheral smear, which is also required for HELLP diagnosis. *Acute fatty liver disease of pregnancy* - This condition presents with significantly elevated **liver enzymes**, **jaundice**, and often severe **hypoglycemia** and **coagulopathy**, none of which are evident in this patient's lab results. - While it can cause elevated BUN and creatinine, it typically involves **more prominent liver dysfunction** than seen here. *Preeclampsia* - This patient meets the criteria for preeclampsia (hypertension and proteinuria), but her **blood pressure** (164/104 mmHg), **thrombocytopenia** (platelet count 100,500/mm^3), and elevated **creatinine** (1.0 mg/dL) all point to features that classify it as *severe* preeclampsia. - Preeclampsia without severe features generally involves blood pressure values below 160/110 mmHg and no evidence of significant organ dysfunction or severe laboratory abnormalities. *Eclampsia* - Eclampsia is defined as the occurrence of new-onset **grand mal seizures** in a woman with preeclampsia. - The patient presents with a **headache** but is described as "comfortable appearing" and there is no mention of seizures.
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
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.
Question 6: Which antihypertensive is considered the first-line treatment with the most extensive safety data for chronic hypertension in pregnancy?
- A. Methyldopa (Correct Answer)
- B. Labetalol
- C. Hydralazine
- D. ACE inhibitors
Explanation: ***Methyldopa*** - **Methyldopa** has been used for decades to treat **chronic hypertension in pregnancy** and has the most extensive data demonstrating its safety for both the mother and the fetus. - It is a centrally acting **alpha-2 adrenergic agonist** that reduces sympathetic outflow, leading to vasodilation and decreased blood pressure. *Labetalol* - **Labetalol** is an **alpha and beta-blocker** also considered a first-line agent, but its long-term safety data in pregnancy is not as extensive as methyldopa. - It is often used as an alternative or in cases where methyldopa is not sufficiently effective, especially for more acute or severe hypertension. *Hydralazine* - **Hydralazine** is a **direct vasodilator** often used for **hypertensive emergencies** in pregnancy, especially for managing severe hypertension or preeclampsia. - It is not typically recommended as a first-line agent for **chronic hypertension** due to a higher incidence of side effects like reflex tachycardia and fluid retention when used long-term. *ACE inhibitors* - **ACE inhibitors** (and ARBs) are **contraindicated in pregnancy** due to their association with severe fetal adverse effects, including **renal malformations**, **oligohydramnios**, and **fetal death**. - Their use should be avoided throughout pregnancy, and women on these medications should switch to safer alternatives upon conception or when planning pregnancy.
Question 7: Most common cause of secondary PPH is :
- A. Retained placenta (Correct Answer)
- B. Cervical tear
- C. Uterine atony
- D. Vaginal laceration
Explanation: ***Retained placenta*** - Retained placental tissue prevents the uterus from contracting effectively, leading to continued bleeding after delivery. - While it's a common cause of primary PPH as well, it often presents as a secondary PPH when small fragments remain and later detach or become infected. *Uterine atony* - This is the **most common cause of primary PPH**, occurring within 24 hours of delivery due to the uterus failing to contract. - It is less likely to be the primary cause of secondary PPH unless there's a delayed presentation. *Vaginal laceration* - Lacerations of the vagina usually present as **primary PPH**, with bright red blood despite a well-contracted uterus. - While bleeding can persist, it's not the most common cause of delayed, secondary PPH. *Cervical tear* - Cervical tears also typically cause **primary PPH**, characterized by continuous bleeding immediately after delivery. - Similar to vaginal lacerations, while continuous bleeding can occur, it's not the most common etiology for secondary PPH.
Question 8: A 28-year-old woman, G2 P1, with severe PPH unresponsive to oxytocin presents with hypotension and tachycardia. She has a soft uterus and ongoing bleeding. What is the next best step in management?
- A. IM carboprost (Correct Answer)
- B. Immediate hysterectomy
- C. Expectant management
- D. IV tranexamic acid
Explanation: ***IM carboprost*** - The **soft uterus** with ongoing bleeding despite oxytocin indicates **uterine atony** as the cause of PPH - Carboprost (PGF2α) is the **standard second-line uterotonic agent** after oxytocin failure - Effectively stimulates strong **uterine contractions** to control hemorrhage from the placental bed - Given intramuscularly at **0.25 mg every 15-90 minutes** (maximum 8 doses) - Contraindicated in active cardiac, pulmonary, or hepatic disease *Immediate hysterectomy* - Peripartum hysterectomy is a **last-resort surgical intervention** for refractory PPH - Should only be performed after failure of medical management (all uterotonics) and conservative surgical options (uterine tamponade, uterine artery ligation, B-Lynch suture) - **Too aggressive** as the immediate next step when second-line uterotonics haven't been tried *Expectant management* - **Completely inappropriate** for severe PPH with hemodynamic instability (hypotension, tachycardia) - Ongoing bleeding from uterine atony requires **immediate aggressive intervention** - Delays increase risk of hypovolemic shock, DIC, maternal morbidity, and mortality *IV tranexamic acid* - **Antifibrinolytic agent** that inhibits plasminogen activation, promoting clot stability - WHO recommends administration **within 3 hours** of PPH onset as an adjunct therapy - While useful in PPH management, it does **not address uterine atony** (the primary cause indicated by soft uterus) - Should be given **in addition to uterotonics**, not as a substitute for definitive management of atony
Question 9: Converting frank breech presentation into footling breech presentation within the upper birth canal is called
- A. Displacement
- B. Relaxation
- C. Decomposition (Correct Answer)
- D. Conversion
Explanation: ***Decomposition*** - **Decomposition** is the correct obstetric term for the maneuver of converting a frank breech presentation into a footling breech presentation. - This involves bringing down one or both feet from the extended position, making them accessible for **assisted breech delivery**. - The term specifically refers to "breaking down" or altering the configuration of the breech presentation within the birth canal. - This maneuver is part of **breech extraction techniques** and may be performed during vaginal breech delivery. *Displacement* - **Displacement** in obstetrics typically refers to pushing the presenting part upward or to the side. - Commonly used in cases of **cord prolapse** where the presenting part is displaced to relieve cord compression. - It does not describe the conversion between different types of breech presentation. *Relaxation* - **Relaxation** is a general term referring to the absence of uterine contractions or muscular tension. - It does not describe any specific obstetric maneuver or presentation change. *Conversion* - **Conversion** is a broader term that can refer to changing one presentation to another (e.g., **external cephalic version** to convert breech to cephalic). - However, the specific technical term for converting frank breech to footling breech is **decomposition**, not conversion.
Question 10: Palmer sign is related to ?
- A. Increased pulsations in uterine arteries
- B. Bluish discoloration of cervix and vagina
- C. Softening of the cervix during pregnancy
- D. Uterine contractions palpable through rectum during labor (Correct Answer)
Explanation: ***Uterine contractions palpable through rectum during labor*** - **Palmer sign** refers to the palpation of **uterine contractions** through the rectum, particularly during the early stages of labor or even in simulated labor pains. - This sign is an indicator used to assess uterine activity, especially when vaginal examination might be less informative or desired. *Softening of the cervix during pregnancy* - This describes **Goodell's sign**, which is caused by increased vascularity and edema of the cervix during early pregnancy. - While an important sign of pregnancy, it is not referred to as Palmer sign. *Bluish discoloration of cervix and vagina* - This phenomenon is known as **Chadwick's sign**, resulting from increased blood flow to the reproductive organs during pregnancy. - It is an early indication of pregnancy but distinct from the uterine contraction palpation. *Increased pulsations in uterine arteries* - This is known as **Osiander’s sign** or **uterine souffle**, characterized by a soft blowing sound over the uterus due to increased blood flow through the uterine arteries. - It is a vascular sign of pregnancy and not related to uterine contractions felt rectally.
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