Operative Obstetrics — MCQs
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At which gestational age is the Shirodkar stitch typically performed during pregnancy?
All the following drugs are used in various regimens of medical termination of pregnancy except?
Following molar pregnancy evacuation, in which timeframe do post-treatment HCG levels typically normalize?
What is the name of the procedure used to resolve head entrapment?
What is the best method to prevent cardiac failure in a pregnant woman with severe mitral stenosis, who is likely to experience failure during the antenatal period?
Which of the following is the earliest warning sign of Magnesium Sulphate toxicity?
What is the term for the softening of the vaginal portion of the cervix?
Indications of amnioinfusion include all of the following, except?
Which of the following statements is true regarding ventouse (vacuum extractor) usage?
Antiphospholipid syndrome is associated with all of the following except:
Operative Obstetrics Indian Medical PG Practice Questions and MCQs
Question 1: At which gestational age is the Shirodkar stitch typically performed during pregnancy?
- A. 6 weeks
- B. 12 weeks
- C. 14-16 weeks (Correct Answer)
- D. 20-24 weeks
Explanation: ### Explanation The **Shirodkar stitch** is a type of cervical cerclage used to treat cervical insufficiency (incompetence). The primary goal is to provide mechanical support to the internal os to prevent premature cervical dilation and subsequent mid-trimester pregnancy loss. **Why 14–16 weeks is the correct answer:** * **Safety and Viability:** By 12–14 weeks, the risk of early spontaneous miscarriage due to chromosomal anomalies has passed. Performing the procedure after this window ensures that a cerclage is not placed in a non-viable pregnancy. * **Anatomical Feasibility:** At 14–16 weeks, the cervix is still long and firm enough to allow the surgical dissection required for the Shirodkar technique (which involves reflecting the bladder and rectum to place the suture as close to the internal os as possible). **Analysis of Incorrect Options:** * **A (6 weeks):** Too early. The risk of early miscarriage is high, and the cervix has not yet faced the mechanical stress of a growing fetus. * **B (12 weeks):** While some clinicians perform cerclage at the end of the first trimester, 14–16 weeks is the standard "elective" window to ensure the first-trimester screening (NT scan/dual marker) confirms fetal well-being first. * **D (20–24 weeks):** This is considered "emergency" or "rescue" cerclage territory. At this stage, the membranes may already be bulging, making the procedure technically difficult and increasing the risk of iatrogenic rupture of membranes. **High-Yield Clinical Pearls for NEET-PG:** * **Shirodkar vs. McDonald:** Shirodkar is a **submucosal** stitch (requires dissection), whereas McDonald is a simple **purse-string** suture (no dissection). * **Suture Material:** Usually a non-absorbable synthetic tape (e.g., Mersilene tape). * **Removal:** Shirodkar stitches are often left in situ if a Cesarean section is planned, whereas McDonald stitches are typically removed at **37 weeks** for vaginal delivery. * **Contraindications:** Chorioamnionitis, ruptured membranes, and active labor.
Question 2: All the following drugs are used in various regimens of medical termination of pregnancy except?
- A. Methotrexate
- B. Mifepristone
- C. Misoprostol
- D. Mefenamic acid (Correct Answer)
Explanation: In medical termination of pregnancy (MTP), the goal is to induce uterine contractions and cervical ripening to expel the products of conception. **Why Mefenamic Acid is the Correct Answer:** Mefenamic acid is a Non-Steroidal Anti-Inflammatory Drug (NSAID) that acts as a **prostaglandin synthetase inhibitor**. By inhibiting the enzyme cyclooxygenase (COX), it reduces the production of prostaglandins. Since prostaglandins are essential for uterine contractions, Mefenamic acid actually antagonizes the process of abortion. It is clinically used to *reduce* menstrual pain and heavy bleeding, not to induce MTP. **Explanation of Other Options:** * **Mifepristone (RU-486):** An anti-progesterone that sensitizes the myocardium to prostaglandins and causes decidual necrosis, leading to detachment of the embryo. It is the first step in the standard medical MTP regimen. * **Misoprostol:** A PGE1 analogue that causes cervical softening and potent uterine contractions. It is used following Mifepristone to expel the products of conception. * **Methotrexate:** A folate antagonist that inhibits dihydrofolate reductase. It is toxic to rapidly dividing trophoblastic cells and is used as an alternative regimen for MTP (especially in very early or ectopic pregnancies). **High-Yield Clinical Pearls for NEET-PG:** * **Standard Regimen (up to 9 weeks/63 days):** 200 mg Mifepristone orally followed by 800 mcg Misoprostol (vaginal/oral/sublingual) after 24–48 hours. * **MTP Act (India) Update:** Medical termination is now legal up to **24 weeks** for specific categories of women, though medical regimens (drugs) are most effective in the first trimester. * **Contraindication:** Medical MTP is contraindicated in suspected ectopic pregnancy (unless using specific Methotrexate protocols), chronic adrenal failure, and patients on long-term corticosteroid therapy.
Question 3: Following molar pregnancy evacuation, in which timeframe do post-treatment HCG levels typically normalize?
- A. 3 weeks
- B. 6 weeks
- C. 9 weeks (Correct Answer)
- D. 12 weeks
Explanation: **Explanation:** The normalization of Human Chorionic Gonadotropin (hCG) levels is the primary marker for monitoring the resolution of a hydatidiform mole and screening for Gestational Trophoblastic Neoplasia (GTN). **1. Why 9 weeks is correct:** Following the suction evacuation of a molar pregnancy, serum β-hCG levels undergo a progressive decline. According to standard obstetric literature (including Williams Obstetrics), the average time for hCG to reach undetectable levels (<5 mIU/mL) is approximately **9 weeks**. While a complete mole may take slightly longer than a partial mole, the mean duration across studies for surveillance to reach the baseline is 9 weeks. **2. Analysis of Incorrect Options:** * **A (3 weeks):** This is too early. While hCG levels drop sharply in the first 48 hours post-evacuation, the remaining trophoblastic tissue takes significantly longer to regress completely. * **B (6 weeks):** This is the typical timeframe for the involution of the uterus and normalization of physiological changes in a normal pregnancy, but it is generally insufficient for molar hCG clearance. * **D (12 weeks):** While some cases may take up to 12–14 weeks to normalize, it is not the "typical" or mean timeframe. If levels remain elevated or plateau by this stage, it often raises suspicion for persistent GTN. **3. High-Yield Clinical Pearls for NEET-PG:** * **Follow-up Protocol:** Check hCG levels every 1–2 weeks until three consecutive weekly samples are negative (<5 mIU/mL). * **Surveillance Duration:** Once negative, follow up monthly for 6 months (for complete moles). * **Contraception:** Reliable contraception (preferably OCPs) is mandatory during the follow-up period to ensure a new pregnancy does not mask the rise of GTN. * **GTN Diagnosis (FIGO Criteria):** Suspect malignancy if hCG levels plateau (4 values over 3 weeks) or rise (3 values over 2 weeks).
Question 4: What is the name of the procedure used to resolve head entrapment?
- A. Symphysiotomy
- B. Pinard maneuver
- C. Duhrssen's incisions (Correct Answer)
- D. Zavanelli maneuver
Explanation: **Explanation:** **Duhrssen’s Incisions** are surgical incisions made in the cervix at the 2, 6, and 10 o'clock positions to facilitate the delivery of the **entrapped aftercoming head** of a breech fetus or a trapped head in a cephalic presentation when the cervix is not fully dilated. This procedure is typically a last resort when the cervix is thin and effaced but not sufficiently dilated to allow the head to pass, posing an immediate risk of fetal asphyxia. **Analysis of Incorrect Options:** * **Symphysiotomy (Option A):** This involves the surgical division of the pubic symphysis to increase the pelvic diameters. It is used for obstructed labor or severe shoulder dystocia, not specifically for cervical entrapment of the head. * **Pinard Maneuver (Option B):** This is a maneuver used in breech extraction to bring down the fetal legs in a frank breech presentation by applying pressure to the popliteal fossa. * **Zavanelli Maneuver (Option C):** This involves cephalic replacement (pushing the fetal head back into the uterus) followed by an emergency Cesarean section. It is the definitive management for catastrophic **shoulder dystocia**, not head entrapment by the cervix. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Incisions are made at **2, 6, and 10 o'clock** to avoid the uterine arteries (located at 3 and 9 o'clock). * **Prerequisite:** The cervix must be fully effaced. * **Complication:** The most significant risk is maternal hemorrhage or extension of the incision into the lower uterine segment. * **Modern Practice:** Due to the availability of Cesarean sections, Duhrssen’s incisions are rarely performed today but remain a critical "rescue" procedure in resource-limited settings or sudden breech entrapment.
Question 5: What is the best method to prevent cardiac failure in a pregnant woman with severe mitral stenosis, who is likely to experience failure during the antenatal period?
- A. Furosemide throughout pregnancy
- B. Balloon mitral valvuloplasty in the second trimester (Correct Answer)
- C. Digoxin for all patients
- D. Admission at 30 weeks gestation
Explanation: **Explanation:** In patients with severe Mitral Stenosis (MS), the physiological increase in blood volume and heart rate during pregnancy leads to elevated left atrial pressure, significantly increasing the risk of pulmonary edema and heart failure. **Why Option B is Correct:** **Percutaneous Transvenous Mitral Commissurotomy (PTMC)**, also known as Balloon Mitral Valvuloplasty (BMV), is the treatment of choice for symptomatic severe MS during pregnancy. The **second trimester** (specifically between 20-28 weeks) is the ideal window because organogenesis is complete (reducing fetal risk) and the hemodynamic stress of pregnancy has not yet reached its peak (which occurs around 28-32 weeks). It mechanically relieves the obstruction, providing a definitive hemodynamic improvement that medical management cannot achieve. **Why Other Options are Incorrect:** * **A. Furosemide:** While diuretics are used to manage acute pulmonary congestion, they do not treat the underlying mechanical obstruction and can lead to decreased placental perfusion if used aggressively throughout pregnancy. * **C. Digoxin:** Digoxin is primarily used for rate control in atrial fibrillation. It has no role in the routine management of MS with normal sinus rhythm, as it does not improve the mechanical orifice size. * **D. Admission at 30 weeks:** While close monitoring is essential, simple admission does not prevent the physiological failure triggered by the peak hemodynamic load. Intervention (BMV) is superior to expectant management in severe cases. **Clinical Pearls for NEET-PG:** * **Most common heart disease in pregnancy:** Rheumatic Heart Disease (Mitral Stenosis is the most common lesion). * **Most common cause of maternal death in MS:** Heart failure/Pulmonary edema. * **High-risk periods:** 28–32 weeks gestation, during labor (second stage), and the immediate postpartum period (due to autotransfusion). * **Beta-blockers:** The drug of choice for heart rate control in MS to allow longer diastolic filling time.
Question 6: Which of the following is the earliest warning sign of Magnesium Sulphate toxicity?
- A. Respiratory rate < 12 breaths/minute
- B. Loss of deep tendon reflexes (Correct Answer)
- C. Altered sensorium
- D. Urine output < 25-30 cc/hour
Explanation: **Explanation:** Magnesium Sulphate ($MgSO_4$) is the drug of choice for seizure prophylaxis in pre-eclampsia and control in eclampsia. It acts as a CNS depressant and neuromuscular blocker. Because it is excreted almost entirely by the kidneys, it has a narrow therapeutic index, making monitoring of clinical signs essential. **Why "Loss of Deep Tendon Reflexes" is correct:** The **loss of patellar reflex (knee-jerk)** is the **earliest clinical sign** of toxicity. It occurs when serum magnesium levels reach **7–10 mEq/L**. Magnesium inhibits the release of acetylcholine at the neuromuscular junction; since the reflex arc involves fewer synapses than the respiratory center, it is affected first. This serves as a critical "safety warning" before more severe life-threatening complications occur. **Analysis of Incorrect Options:** * **Respiratory rate < 12 breaths/minute:** This is a late and dangerous sign of toxicity, occurring at levels of **11–15 mEq/L**. Respiratory paralysis follows the loss of reflexes. * **Urine output < 25-30 cc/hour:** This is not a *sign* of toxicity itself, but a **predisposing factor**. Since $MgSO_4$ is renally excreted, oliguria leads to drug accumulation, which then causes toxicity. * **Altered sensorium:** This occurs at very high/toxic levels (usually >15 mEq/L) and may progress to coma or cardiac arrest (>25 mEq/L). **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic Range:** 4–7 mEq/L. * **Monitoring Triad:** Before every dose, check: 1. Presence of Patellar reflex, 2. Respiratory rate (>12-14/min), 3. Urine output (>30 ml/hr or 100 ml/4hrs). * **Antidote:** 10 ml of **10% Calcium Gluconate** IV (administered slowly over 10 minutes).
Question 7: What is the term for the softening of the vaginal portion of the cervix?
- A. Goodell's sign (Correct Answer)
- B. Chadwick's sign
- C. Hegar's sign
- D. Piskacek's sign
Explanation: **Explanation:** The correct answer is **Goodell’s sign**. This clinical finding refers to the significant softening of the vaginal portion of the cervix, which typically occurs around the **6th week** of gestation. Under the influence of estrogen and progesterone, there is increased vascularity, edema, and hyperplasia of the cervical glands, transforming the cervix from a consistency similar to the "tip of the nose" to one resembling the "lips" or "earlobe." **Analysis of Incorrect Options:** * **Chadwick’s Sign:** This is the bluish discoloration of the cervix, vagina, and labia minora due to pelvic congestion and increased vascularity. It is usually visible by the **6th to 8th week**. * **Hegar’s Sign:** This refers to the softening of the **isthmus** (the lower uterine segment). On bimanual examination, the upper part of the uterus and the cervix feel like two separate entities because the intervening isthmus is so soft it cannot be felt. It is most prominent between **6–10 weeks**. * **Piskacek’s Sign:** This is the asymmetrical enlargement of the uterus occurring when implantation happens near one of the cornua (lateral implantation), making one side feel softer and more prominent than the other. **High-Yield Clinical Pearls for NEET-PG:** * **Osiander’s Sign:** Increased pulsation felt through the lateral vaginal fornices due to increased vascularity (8th week). * **Palmer’s Sign:** Rhythmic uterine contractions felt during a bimanual examination in early pregnancy (4th–8th week). * **Ladins Sign:** Softening of the anterior midline of the uterus at the junction of the cervix and body (6th week). * **Sequence of appearance:** Most of these signs appear between 6–10 weeks; however, Goodell’s and Chadwick’s are among the earliest presumptive signs of pregnancy.
Question 8: Indications of amnioinfusion include all of the following, except?
- A. Prolonged rupture of membranes with oligohydramnios
- B. Variable decelerations
- C. Treatment of late decelerations during labour (Correct Answer)
- D. Decreasing risk of meconium aspiration during labour in patients with thick meconium
Explanation: **Explanation:** Amnioinfusion is the transcervical or transabdominal instillation of isotonic fluid (usually Normal Saline or Ringer’s Lactate) into the amniotic cavity. **Why Option C is the Correct Answer (The Exception):** Late decelerations are caused by **uteroplacental insufficiency**, reflecting fetal hypoxia. Amnioinfusion does not improve placental perfusion or oxygen exchange across the placenta; therefore, it has no role in treating late decelerations. Management of late decelerations involves intrauterine resuscitation (maternal position change, oxygen, hydration) or urgent delivery. **Analysis of Incorrect Options:** * **Variable Decelerations (Option B):** This is the **most common indication**. Variable decelerations are caused by umbilical cord compression due to low liquor volume. Amnioinfusion cushions the cord, relieving compression and reducing the need for emergency Cesarean sections. * **Thick Meconium (Option D):** Amnioinfusion dilutes thick meconium, theoretically reducing the severity of Meconium Aspiration Syndrome (MAS), though its routine use for this is now debated in modern guidelines. * **Prolonged ROM with Oligohydramnios (Option A):** It is used prophylactically in cases of preterm premature rupture of membranes (PPROM) to prevent cord compression and potentially improve neonatal pulmonary outcomes. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Fluid:** Normal Saline or Ringer’s Lactate at room temperature (or warmed to 37°C). * **Infusion Rate:** Typically a bolus of 250–500 mL followed by a continuous infusion of 150–200 mL/hour. * **Contraindications:** Chorioamnionitis, placental abruption, fetal malpresentation, and non-reassuring fetal heart rate patterns requiring immediate delivery (e.g., prolonged bradycardia). * **Complication:** Iatrogenic polyhydramnios and uterine hypertonus.
Question 9: Which of the following statements is true regarding ventouse (vacuum extractor) usage?
- A. Minor scalp abrasions and subgaleal hematomas in newborns are more frequent with ventouse than with forceps. (Correct Answer)
- B. Ventouse can be applied when the fetal head is above the level of the ischial spines.
- C. Maternal trauma is more frequent with ventouse than with forceps.
- D. Ventouse cannot be used when the fetal head is not fully rotated.
Explanation: ### Explanation **1. Why Option A is Correct:** The vacuum extractor (ventouse) works by creating negative pressure on the fetal scalp, leading to the formation of a **chignon** (artificial caput succedaneum). Because the cup can slip or cause shearing forces on the scalp, **minor scalp abrasions, lacerations, and cephalhematomas** are more common than with forceps. Most importantly, **subgaleal hematoma**—a potentially life-threatening condition where blood accumulates between the epicranial aponeurosis and the periosteum—is a specific risk associated with vacuum traction that is rarely seen in forceps deliveries. **2. Why the Other Options are Incorrect:** * **Option B:** Ventouse is contraindicated if the fetal head is above the ischial spines. Like forceps, it should only be used for **low or outlet procedures** (station +2 or lower) to avoid high-risk "high-station" extractions. * **Option C:** One of the primary advantages of ventouse is that it occupies less space in the birth canal compared to forceps blades. Therefore, **maternal trauma** (vaginal/perineal lacerations and anal sphincter injuries) is significantly **less frequent** with ventouse. * **Option D:** Unlike forceps, which require precise cephalic application, the ventouse can be used in **non-rotated heads** (e.g., occipito-posterior or occipito-transverse positions). The vacuum facilitates "auto-rotation" as the head descends through the pelvic floor. **3. High-Yield Clinical Pearls for NEET-PG:** * **Prerequisites:** Cervix must be **fully dilated**, membranes ruptured, and the pelvis must be adequate. * **The "Flexion Point":** The cup should be placed over the flexion point (3 cm anterior to the posterior fontanelle) to promote flexion and minimize the diameter of the presenting part. * **The "Rule of 3":** Discontinue the procedure if there are **3 pop-offs**, **3 pulls** with no descent, or if the procedure exceeds **20-30 minutes**. * **Contraindications:** Prematurity (<34 weeks due to risk of intraventricular hemorrhage), fetal bleeding diathesis, and face presentation.
Question 10: Antiphospholipid syndrome is associated with all of the following except:
- A. Recurrent abortion
- B. Venous thrombosis
- C. Pancytopenia (Correct Answer)
- D. Antibody to lupus
Explanation: **Explanation:** Antiphospholipid Syndrome (APS) is an autoimmune multisystem disorder characterized by arterial or venous thrombosis and/or pregnancy complications, associated with persistent antiphospholipid antibodies (aPL). **Why Pancytopenia is the correct answer:** Pancytopenia is **not** a diagnostic feature or a common association of APS. While **thrombocytopenia** (low platelet count) is frequently observed in APS patients (occurring in about 20–40% of cases), the other cell lines (red blood cells and white blood cells) are typically unaffected. Therefore, pancytopenia suggests an alternative diagnosis like Systemic Lupus Erythematosus (SLE) or bone marrow failure. **Analysis of other options:** * **Recurrent abortion:** This is a hallmark clinical criterion. APS causes placental insufficiency and thrombosis of utero-placental vessels, leading to recurrent pregnancy loss (usually >10 weeks), premature births, or pre-eclampsia. * **Venous thrombosis:** This is the most common clinical manifestation. APS can cause thrombosis in any vascular bed, with Deep Vein Thrombosis (DVT) being the most frequent presentation. * **Antibody to lupus:** This refers to the **Lupus Anticoagulant (LA)**, which is one of the three primary diagnostic antibodies for APS (alongside Anti-cardiolipin and Anti-β2-glycoprotein I). **High-Yield Clinical Pearls for NEET-PG:** * **Sapporo Criteria:** Diagnosis requires at least one clinical (thrombosis or pregnancy loss) and one laboratory criterion (positive aPL on two occasions, 12 weeks apart). * **The "Anticoagulant Paradox":** In vitro, Lupus Anticoagulant prolongs aPTT (acting like an anticoagulant), but in vivo, it is highly pro-thrombotic. * **Treatment in Pregnancy:** Combined low-dose Aspirin (LDA) and Low Molecular Weight Heparin (LMWH) is the gold standard to improve live birth rates. Warfarin is contraindicated due to teratogenicity.
Practice by Chapter
Cesarean Section Techniques
Practice Questions
Vaginal Birth After Cesarean
Practice Questions
Instrumental Deliveries
Practice Questions
Breech Delivery
Practice Questions
Episiotomy and Repair
Practice Questions
Management of Multiple Gestation
Practice Questions
Cervical Cerclage
Practice Questions
Obstetric Hysterectomy
Practice Questions
Surgery During Pregnancy
Practice Questions
Surgical Complications in Obstetrics
Practice Questions
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