Obstetric Hysterectomy — MCQs
Bleeding in rupture of the uterus associated with a large broad ligament hematoma is controlled most simply by :
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?
Which surgical procedure has the highest incidence of ureteric injury?
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?
Which of the following statements is false regarding postpartum hemorrhage and pelvic hematomas?
Treatment of endometrial hyperplasia with atypia in a 45-year-old female:
Preferred treatment for menorrhagia in reproductive age group?
Identify the maneuver shown in the image:
McDonald stitch is applied in the following conditions except:
Obstetric Hysterectomy Indian Medical PG Practice Questions and MCQs
Question 1: Bleeding in rupture of the uterus associated with a large broad ligament hematoma is controlled most simply by :
- A. Ligation of hypogastric artery
- B. Ligation of common iliac artery
- C. Suture of laceration
- D. Ligation of uterine artery (Correct Answer)
Explanation: ***Ligation of uterine artery*** - **Ligation of the uterine artery** is the **most simple and direct first-line approach** for controlling bleeding from uterine rupture with broad ligament hematoma. - The uterine artery provides the **primary blood supply** to the uterus and is easily accessible at the lower uterine segment, making it technically straightforward to ligate. - This method effectively controls bleeding by directly cutting off the major vascular supply to the area of rupture and the broad ligament hematoma. - Success rate is 80-90% for controlling hemorrhage, and it preserves blood flow to other pelvic structures. *Ligation of hypogastric artery* - **Ligation of the hypogastric artery** (internal iliac artery) is a **second-line procedure** requiring more extensive retroperitoneal dissection. - While effective, it is technically more difficult and time-consuming compared to uterine artery ligation, making it less "simple." - Reserved for cases where uterine artery ligation fails or when there is widespread pelvic bleeding from multiple sources. - It reduces blood flow to the entire pelvis, including bladder and rectum, not just the uterus. *Ligation of common iliac artery* - **Ligation of the common iliac artery** is an extreme measure with severe consequences, including compromised blood flow to the entire lower limb. - This is **not a standard procedure** for uterine rupture and carries unacceptable risks of leg ischemia and other complications. - Never considered a first-line approach for obstetric hemorrhage due to its extensive and potentially catastrophic effects. *Suture of laceration* - While **suturing the laceration** is essential for repairing the uterine defect, it does not provide adequate vascular control when a large broad ligament hematoma is present. - The hematoma indicates **significant vessel injury** within the broad ligament, requiring proximal vascular control first. - Suturing alone without controlling the bleeding source will not stop the hemorrhage and may lead to continued blood loss. - The correct approach is to first ligate the uterine artery for hemostasis, then repair the uterine tear.
Question 2: 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 3: 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 4: Which surgical procedure has the highest incidence of ureteric injury?
- A. Vaginal hysterectomy
- B. Anterior colporraphy
- C. Abdominal hysterectomy
- D. Radical hysterectomy (Correct Answer)
Explanation: ***Radical hysterectomy*** - This procedure involves extensive dissection to remove the uterus, cervix, and surrounding parametrial tissue, which places the **ureters at high risk of injury** due to their close proximity to the surgical field. - The **ureter** runs directly through the **parametrium** (cardinal and uterosacral ligaments), which are ligated and excised during a radical hysterectomy, making it the procedure with the highest incidence of ureteral injury. *Vaginal hysterectomy* - While ureteric injury can occur, it is generally less common than in radical hysterectomy due to the less extensive dissection and different angle of approach. - The risk is present during clamping and ligating the **uterosacral and cardinal ligaments** but is typically lower than with a radical approach. *Anterior colporraphy* - This procedure primarily involves the anterior vaginal wall and bladder, usually without deep pelvic dissection that would place the ureters at significant risk. - The main risks are typically related to the bladder itself, rather than the ureters, as the dissection is superficial to the ureteral course. *Abdominal hysterectomy* - While there is a risk of ureteric injury, especially during the ligation of the **uterine arteries** and cardinal ligaments, the dissection is less extensive than in a radical hysterectomy. - Standard abdominal hysterectomy involves less parametrial dissection, thus exposing the ureters to a lower, though still present, risk of injury compared to radical procedures.
Question 5: 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 6: Which of the following statements is false regarding postpartum hemorrhage and pelvic hematomas?
- A. The vulva is the most common site for pelvic hematoma. (Correct Answer)
- B. Hematomas less than 5 cm can often be managed conservatively.
- C. Uterine atony is the most common cause of postpartum hemorrhage.
- D. The most common artery to form a vulvar hematoma is the pudendal artery.
Explanation: ***The vulva is the most common site for pelvic hematoma.*** - While vulvar hematomas are common, the **vagina is actually the most common site** for puerperal hematomas. - **Retroperitoneal hematomas** are the least common but most dangerous type, often associated with a higher mortality rate due to delayed diagnosis. *Hematomas less than 5 cm can often be managed conservatively.* - **Small, stable hematomas** (typically less than 2-5 cm) that are not expanding can often be managed with observation, pain control, and ice packs. - Close monitoring for continued bleeding, signs of infection, or hemodynamic instability is crucial even with conservative management. *Uterine atony is the most common cause of postpartum hemorrhage.* - **Uterine atony** (failure of the uterus to contract after birth) accounts for approximately 70-80% of all cases of postpartum hemorrhage. - This condition leads to excessive bleeding from the placental site due to the inability of uterine muscle fibers to compress blood vessels effectively. *The most common artery to form a vulvar hematoma is the pudendal artery.* - Vulvar hematomas primarily arise from injury to branches of the **pudendal artery**, particularly during lacerations or episiotomies. - Trauma to the **perineum** during childbirth can cause these arteries or their venous counterparts to bleed into the surrounding loose connective tissue.
Question 7: Treatment of endometrial hyperplasia with atypia in a 45-year-old female:
- A. Progestin
- B. Mirena
- C. Hysterectomy (Correct Answer)
- D. Endometrial ablation
Explanation: ***Hysterectomy*** - **Endometrial hyperplasia with atypia** carries a significant risk of progression to **endometrial cancer**, ranging from 20% to 50% over several years, making hysterectomy a definitive treatment option. - For a 45-year-old female, especially if she has completed childbearing or is nearing menopause, a **hysterectomy** eliminates the uterine pathology and prevents future recurrence or malignant transformation. *Progestin* - While progestin therapy can be used for endometrial hyperplasia without atypia or for atypical hyperplasia in women who desire to preserve fertility, its effectiveness for **simple atypical hyperplasia** is 70-80%. - The risk of residual or coexisting carcinoma, and the potential for recurrence if fertility is not a concern, makes progestin a less definitive treatment than hysterectomy in this age group. *Mirena* - The **Mirena IUD** (levonorgestrel-releasing intrauterine system) delivers local progestin, which is effective for **endometrial hyperplasia without atypia** and is sometimes used for atypical hyperplasia when fertility preservation is desired. - However, for **atypical hyperplasia**, which has a notable risk of malignancy, a more definitive treatment like hysterectomy is generally preferred, especially as Mirena's systemic effects are limited and regular follow-up biopsies are needed. *Endometrial ablation* - **Endometrial ablation** destroys the endometrial lining and is typically used for managing **heavy menstrual bleeding (menorrhagia)** when fertility is not desired. - It is **contraindicated in cases of endometrial hyperplasia with atypia** due to the risk of obscuring underlying or developing malignancy and making future surveillance difficult.
Question 8: Preferred treatment for menorrhagia in reproductive age group?
- A. Cu IUD
- B. Hysterectomy
- C. NOVA T
- D. OCPs (Correct Answer)
Explanation: ***OCPs*** - **Combined oral contraceptives (OCPs)** are a common and effective first-line treatment for menorrhagia in reproductive-aged women, particularly when contraception is also desired. - They work by stabilizing the **endometrial lining**, reducing menstrual blood loss and regulating cycles. *NOVA T* - NOVA T is a type of **copper IUD (intrauterine device)**, which is known to potentially *increase* menstrual bleeding and dysmenorrhea, making it unsuitable for menorrhagia. - Its primary function is contraception, not the management of heavy menstrual bleeding. *Cu IUD* - The **copper intrauterine device (Cu IUD)** is generally contraindicated in women with menorrhagia because it can exacerbate heavy menstrual bleeding. - While an effective contraceptive, it does not offer therapeutic benefits for managing heavy periods. *Hysterectomy* - **Hysterectomy** is a surgical procedure for removing the uterus and is considered a definitive treatment for menorrhagia. - However, it is an **invasive procedure** with irreversible loss of fertility, typically reserved for severe cases where conservative treatments have failed or when other uterine pathology is present.
Question 9: Identify the maneuver shown in the image:
- A. Burn Marshall
- B. Lovset
- C. Mauriceau-Smellie-Veit (Correct Answer)
- D. None of the options
Explanation: ***Mauriceau-Smellie-Veit*** - This maneuver is used for **head delivery in a breech presentation**, where the fetus's body is supported while pressure is applied to the maxilla or mandible to flex the head. - The image typically shows the operator's hand supporting the fetus's body and fingers placed on the fetal jaw to facilitate head flexion and delivery. *Burn Marshall* - The Burn Marshall maneuver involves **delivering the fetal head by applying suprapubic pressure** to the maternal abdomen while the fetal body is gently swept upwards over the maternal abdomen. - This maneuver is generally used for a **spontaneous breech delivery** if the head does not deliver easily after the body. *Lovset* - The Lovset maneuver is employed to **deliver the fetal shoulders** in a breech presentation by rotating the fetal trunk to bring the anterior shoulder under the pubic arch and then the posterior shoulder. - This maneuver aims to extract the shoulders sequentially, which might be necessary if they are impacted. *None of the options* - The visual representation aligns with the steps of the Mauriceau-Smellie-Veit maneuver, making this option incorrect. - This maneuver is clearly depicted by the hand placement and objective of aiding head delivery in breech.
Question 10: McDonald stitch is applied in the following conditions except:
- A. Placenta previa (Correct Answer)
- B. Incompetent os
- C. Previous history of preterm birth
- D. Bad obstetrical history
Explanation: ***Placenta previa*** - McDonald stitch (cervical cerclage) is a procedure to prevent **premature cervical dilation** and is not indicated for **placenta previa** - **Placenta previa** involves the placenta covering the cervical os, which can cause antepartum hemorrhage and usually necessitates a cesarean section - Cerclage is contraindicated as it does not address placental position and manipulation of the cervix could provoke bleeding *Incompetent os* - This is the **primary indication** for McDonald cerclage, as it directly addresses cervical insufficiency that leads to painless cervical dilation and second-trimester pregnancy loss - The cerclage reinforces the weak cervix, preventing **preterm birth** due to cervical incompetence - This can be diagnosed by history, physical examination, or ultrasound findings *Previous history of preterm birth* - A history of **recurrent second-trimester miscarriages** or **preterm deliveries** attributed to cervical insufficiency is a strong indication for prophylactic McDonald cerclage - This is termed **history-indicated cerclage**, performed electively between 12-14 weeks in subsequent pregnancies - Studies show cerclage reduces preterm birth rates in women with prior spontaneous preterm births due to cervical factors *Bad obstetrical history* - Bad obstetric history, particularly with **recurrent second-trimester losses** suggesting cervical insufficiency, is a classic indication for prophylactic cerclage - This overlaps with history-indicated cerclage and aims to prevent recurrence in high-risk patients - Thorough evaluation is needed to confirm cervical etiology rather than other causes of pregnancy loss
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