Cervical Cerclage — MCQs
What is the expected rate of cervical dilatation per hour during active labor in a primigravida?
Which of the following is consistent with a decision to perform a cerclage?
Which of the following is NOT a recommended prevention strategy for vertical transmission of HIV?
A pregnant woman presents with an IUD in place, and the thread is clearly visible. She wishes to continue the pregnancy. What is the most appropriate next step?
After 3rd stage of labour and expulsion of placenta, the patient is bleeding heavily. Ideal management would include all except:
How do you manage placenta accreta?
Purandare's cervicopexy is done in :
A 29-year-old primigravida presents at 36 weeks of gestation with a transverse lie. What is the recommended management?
A primigravida is in labor. Her per-vaginal examination revealed a posterior cervix with 5 cm cervical length, 1 cm dilatation, soft consistency, and head at -1 station. Calculate the Bishop score.
All of the following operations are done for uterine prolapse except:
Cervical Cerclage Indian Medical PG Practice Questions and MCQs
Question 1: What is the expected rate of cervical dilatation per hour during active labor in a primigravida?
- A. 1.0 cm (Correct Answer)
- B. 1.5 cm
- C. 2 cm
- D. 1-7 cm per hour
Explanation: ***1.0 cm*** - Historically, the **minimum expected rate** of cervical dilatation during the active phase of labor for a primigravida has been accepted as **1.0 cm per hour**. - This rate is often used to define **protraction disorders** in labor, when dilatation falls below this threshold. *1.5 cm* - This rate is typically associated with the expected cervical dilatation in **multiparous women** during active labor, who often progress faster than primigravidae. - While some primigravidae may dilate at this rate, it is not the traditionally accepted **minimum expected rate** for the entire group. *1-7 cm per hour* - This range is too broad and does not represent a specific, expected minimum rate, but rather a **wide spectrum of possible dilatation speeds**. - While actual dilatation can vary significantly, the question asks for the **expected rate**, which implies a more defined minimum or average. *2 cm* - A dilatation rate of 2 cm per hour is considered **very rapid** and, while beneficial, is not the minimum expected or average rate for a primigravida in active labor. - Such a fast rate would indicate excellent labor progression, rather than the baseline expectation.
Question 2: 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)
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.
Question 3: Which of the following is NOT a recommended prevention strategy for vertical transmission of HIV?
- A. Elective cesarean at 40 weeks (Correct Answer)
- B. Avoidance of breastfeeding
- C. Intrapartum zidovudine
- D. Antiretroviral therapy during pregnancy
Explanation: ***Elective cesarean at 40 weeks*** - This is **NOT recommended** as stated because: - When elective cesarean section is indicated (viral load >1000 copies/mL), it should be performed at **38 weeks gestation**, NOT 40 weeks - At 40 weeks, there's increased risk of spontaneous labor and membrane rupture, which defeats the purpose of elective cesarean - With adequate viral suppression (<1000 copies/mL or undetectable), **vaginal delivery is safe** and cesarean is not routinely recommended - The decision for cesarean is based on **viral load**, not simply gestational age *Avoidance of breastfeeding* - **Breastfeeding** is a known route of vertical HIV transmission due to the presence of the virus in breast milk - In developed countries where safe alternatives are available, **formula feeding** is recommended to completely eliminate this risk - This IS a recommended prevention strategy *Intrapartum zidovudine* - **Intravenous zidovudine (AZT)** administered during labor effectively reduces HIV transmission from mother to child - This is a crucial component of the prevention protocol, especially for mothers with detectable viral loads or those who have not received full antiretroviral therapy - This IS a recommended prevention strategy *Antiretroviral therapy during pregnancy* - **Antiretroviral therapy (ART)** taken throughout pregnancy significantly lowers the maternal viral load, which is the most critical factor in preventing vertical transmission - Suppressing the viral load to **undetectable levels** before delivery is the primary goal and most effective strategy - This IS a recommended prevention strategy
Question 4: A pregnant woman presents with an IUD in place, and the thread is clearly visible. She wishes to continue the pregnancy. What is the most appropriate next step?
- A. Leave the IUD inside
- B. Remove gently (Correct Answer)
- C. MTP (Medical Termination of Pregnancy)
- D. Cesarean section
Explanation: ***Remove gently*** - When the **IUD thread is visible**, gentle removal is recommended if the woman wishes to **continue the pregnancy**, as this significantly reduces the risk of miscarriage and infection. - Leaving an **IUD in situ** during pregnancy increases risks of **septic miscarriage**, **preterm delivery**, and **chorioamnionitis**. *Leave the IUD inside* - Leaving an **IUD in place** during pregnancy increases the risks of **septic miscarriage**, **chorioamnionitis**, and **preterm labor**. - The presence of the IUD can also lead to **placental complications** and difficulties with fetal development. *MTP (Medical Termination of Pregnancy)* - MTP is an option for unintended pregnancies but is not the most appropriate first step when the patient explicitly **wishes to continue the pregnancy**. - MTP would be considered if the patient chose to terminate, but the question states she wants to continue. *Cesarean section* - **Cesarean section** is a mode of delivery and is not an appropriate initial intervention for an early pregnancy with an **IUD in situ**. - The removal of an IUD from an early pregnancy does not necessitate a cesarean section.
Question 5: After 3rd stage of labour and expulsion of placenta, the patient is bleeding heavily. Ideal management would include all except:
- A. Check for laceration of labia
- B. Uterine massage and I/V oxytocin
- C. APGAR scoring (Correct Answer)
- D. Check for placenta in uterus
Explanation: ***APGAR scoring*** - **APGAR scoring** assesses the newborn's health immediately after birth and is not a management step for **postpartum hemorrhage**. - This intervention would divert critical attention from the mother's life-threatening bleeding. *Check for placenta in uterus* - **Retained placental fragments** are a common cause of **postpartum hemorrhage**, obstructing uterine contraction. - Checking for and removing any retained placenta is a crucial and immediate management step to control bleeding. *Check for laceration of labia* - **Lacerations of the birth canal**, including the labia, vagina, or cervix, can cause significant bleeding after delivery, even with a well-contracted uterus. - Identifying and repairing these lacerations is an essential part of managing **postpartum hemorrhage not due to atony**. *Uterine massage and I/V oxytocin* - **Uterine atony** (failure of the uterus to contract) is the most common cause of **postpartum hemorrhage**. - **Uterine massage** helps stimulate contraction, and **intravenous oxytocin** is a uterotonic agent used to promote uterine contraction and reduce bleeding.
Question 6: How do you manage placenta accreta?
- A. Classical cesarean; hysterectomy (Correct Answer)
- B. Low vertical cesarean; hysterectomy
- C. Low transverse cesarean; hysterectomy
- D. Classical cesarean; myometrial resection
Explanation: ***Classical cesarean; hysterectomy*** - A **classical cesarean section** (vertical incision in the upper uterine segment) allows for delivery of the fetus without disturbing the **placenta accreta** in the lower uterine segment. - Subsequent **hysterectomy** is often necessary due to the high risk of severe hemorrhage from the morbidly adherent placenta, which cannot be safely separated. *Low vertical cesarean; hysterectomy* - A **low vertical incision** is made in the lower uterine segment, which could potentially incise through the placenta accreta if it extends to that region, leading to significant hemorrhage. - While hysterectomy is likely indicated, the initial uterine incision might complicate management. *Low transverse cesarean; hysterectomy* - A **low transverse incision** is the most common type for routine cesarean sections but is contra-indicated in placenta accreta as the placenta is frequently implanted in the lower uterine segment. - Incising through the **placenta** during a low transverse cut would cause immediate massive hemorrhage, making this approach unsuitable. *Classical cesarean; myometrial resection* - While a **classical cesarean** would be the appropriate initial step for fetal delivery, **myometrial resection** to remove only the affected area of the myometrium is generally insufficient and carries a high risk of residual placental tissue and severe hemorrhage, often necessitating a hysterectomy anyway. - This approach is typically not recommended as a primary definitive management strategy for established placenta accreta.
Question 7: Purandare's cervicopexy is done in :
- A. Missed IUD
- B. Incompetent cervix
- C. Elongated cervix (Correct Answer)
- D. Congenital prolapse of uterus
Explanation: ***Elongated cervix*** - **Purandare's cervicopexy** is a surgical procedure specifically designed to treat **elongated cervix** (cervical elongation) associated with uterine prolapse. - This technique involves fixing the elongated cervix to the anterior abdominal wall to provide support and correct the anatomical defect. - The procedure addresses cervical elongation by suspending the cervix, preventing its descent and associated prolapse symptoms. - It is particularly useful when cervical elongation is a significant component of uterine prolapse. *Congenital prolapse of uterus* - While **congenital prolapse of uterus** is a rare condition requiring surgical management, Purandare's cervicopexy is not the primary procedure specifically designed for this indication. - Congenital prolapse may require various surgical approaches depending on the severity and anatomical findings. *Missed IUD* - A **missed IUD** refers to a situation where an intrauterine device is no longer found in its expected position within the uterus. - Management typically involves retrieval of the IUD, often with instruments, and does not involve cervical suspension procedures. *Incompetent cervix* - An **incompetent cervix** is a condition where the cervix dilates painlessly in the second trimester, leading to preterm birth or pregnancy loss. - The standard treatment is **cervical cerclage**, a stitch placed around the cervix to keep it closed during pregnancy, not cervicopexy which is a suspension procedure for prolapse.
Question 8: A 29-year-old primigravida presents at 36 weeks of gestation with a transverse lie. What is the recommended management?
- A. Induce labor
- B. Perform amniotomy
- C. Schedule cesarean delivery (Correct Answer)
- D. Attempt external cephalic version
Explanation: ***Schedule cesarean delivery*** - A persistent **transverse lie** at 36 weeks makes vaginal delivery impossible and requires definitive management. - **Cesarean delivery** is the definitive and safest option for ensuring maternal and fetal well-being when the transverse lie persists. - While external cephalic version may be attempted first, if unsuccessful, contraindicated, or the lie remains transverse near term, cesarean section is mandatory. - Attempting vaginal delivery with transverse lie risks **cord prolapse**, **uterine rupture**, and **obstructed labor**. *Induce labor* - Inducing labor with a transverse lie is **absolutely contraindicated** due to impossibility of vaginal delivery. - The fetal shoulder or arm would present first, preventing engagement and causing **obstructed labor**. - High risk of **cord prolapse**, **uterine rupture**, and severe maternal-fetal complications. *Perform amniotomy* - **Amniotomy** (artificial rupture of membranes) with a transverse lie is extremely dangerous and contraindicated. - Significantly increases the risk of **cord prolapse** as membranes rupture without an engaged presenting part. - Would necessitate immediate cesarean delivery in emergency conditions, worsening outcomes. *Attempt external cephalic version* - While **external cephalic version (ECV)** can be attempted for transverse lie at 36-37 weeks, it has lower success rates (30-50%) compared to breech presentation. - However, the question asks for "recommended management" which refers to the **definitive management plan** - cesarean delivery remains the final recommendation when transverse lie persists. - ECV may be offered as an option to avoid cesarean, but has risks including **placental abruption**, **fetal distress**, and **failure** requiring cesarean anyway. - At 36 weeks with persistent transverse lie, planning for cesarean delivery is the safest definitive approach.
Question 9: A primigravida is in labor. Her per-vaginal examination revealed a posterior cervix with 5 cm cervical length, 1 cm dilatation, soft consistency, and head at -1 station. Calculate the Bishop score.
- A. 5 (Correct Answer)
- B. 0
- C. 8
- D. 3
Explanation: ***5*** - The Bishop score calculation: **cervical position** (posterior = 0), **cervical effacement** (5 cm length = 0), **dilation** (1 cm = 1), **consistency** (soft = 2), and **station** (-1 = 1). - According to standard **Dutta textbook** references, this totals to 5 points (0 + 0 + 1 + 2 + 1), with soft consistency correctly scoring 2 points. *3* - This score incorrectly assigns only **1 point for soft consistency** instead of the standard 2 points. - The miscalculation underestimates the **cervical readiness** for labor induction. *0* - A score of 0 would require all parameters to be at their **minimum values** (firm consistency, closed cervix, high station). - The given parameters show **1 cm dilation**, **soft consistency**, and **-1 station**, each contributing positive points. *8* - A high score of 8 indicates a **very favorable cervix** with significant effacement, anterior position, and greater dilation. - The current findings show **minimal effacement** (5 cm length), **posterior position**, and only **1 cm dilation**, inconsistent with such a high score.
Question 10: All of the following operations are done for uterine prolapse except:
- A. Abdominocervicopexy
- B. Shirodkar (Correct Answer)
- C. Khanna
- D. Manchester
Explanation: ***Shirodkar*** - The **Shirodkar procedure** is a type of **cervical cerclage** used to address **cervical insufficiency** during pregnancy, to prevent preterm birth. - It involves placing a stitch around the cervix to keep it closed and is **not used for uterine prolapse**. *Abdominocervicopexy* - This procedure involves attaching the **cervix** to the **abdominal wall** using a sling-like material. - It is a recognized surgical technique for correcting **uterine prolapse**, particularly in younger women who wish to retain their uterus. *Khanna* - The **Khanna sling operation** is a specific type of **vaginal sling technique** used to support the uterus or vaginal vault. - It aims to suspend the prolapsed organ to stabilize its position within the pelvis. *Manchester* - The **Manchester operation** (also known as Fothergill's operation) is a classic procedure for **uterine prolapse** when the cervix is elongated. - It involves **cervical amputation**, **repair of the cardinal ligaments**, **anterior colporrhaphy**, and **posterior colpoperineorrhaphy**.
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