Operative Obstetrics — MCQs

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 121: A patient presents at 8 weeks of pregnancy with complaints of excessive vomiting, nausea, inability to tolerate oral intake, and decreased frequency of urination. What is the most appropriate management?

A. Pyridoxine plus doxylamine with plenty of oral fluids
B. Admit, administer IV fluids, IV antiemetics, and monitor input/output (Correct Answer)
C. Administer intravenous hydrocortisone
D. Administer intravenous promethazine

Explanation: ### Explanation The patient is presenting with signs of **Hyperemesis Gravidarum (HG)**, a severe form of nausea and vomiting in pregnancy (NVP). The key clinical indicators here are the inability to tolerate oral intake and decreased frequency of urination (suggesting **dehydration** and potential electrolyte imbalance). **1. Why Option B is Correct:** The primary goal in managing HG with signs of dehydration is **rehydration and correction of electrolyte imbalances**. Admission is mandatory when oral intake is impossible. Management involves: * **IV Fluids:** Usually Crystalloids (Ringer’s Lactate or Normal Saline). *Note: Dextrose should be avoided until Thiamine is administered to prevent Wernicke’s Encephalopathy.* * **IV Antiemetics:** To control vomiting when the oral route is compromised. * **Monitoring:** Strict input/output charts and monitoring for ketonuria are essential to assess the severity and response to treatment. **2. Why Other Options are Incorrect:** * **Option A:** Pyridoxine (Vitamin B6) and Doxylamine are the **first-line drugs for mild-to-moderate NVP**. However, they are ineffective in a patient who cannot tolerate oral fluids and shows signs of dehydration. * **Option C:** IV Hydrocortisone (Corticosteroids) is reserved for **refractory cases** of HG that do not respond to standard IV fluid and antiemetic therapy. It is not the initial step. * **Option D:** While Promethazine is an antiemetic, administering it in isolation without addressing the patient's dehydration and fluid-electrolyte status is incomplete and unsafe management. **Clinical Pearls for NEET-PG:** * **Definition:** HG is characterized by persistent vomiting, weight loss (>5% of pre-pregnancy weight), and ketonuria. * **Wernicke’s Encephalopathy:** A rare but fatal complication of HG due to Vitamin B1 (Thiamine) deficiency. Always give Thiamine before Dextrose-containing fluids. * **Electrolyte Imbalance:** Most common finding is **Hypokalemic Hypochloremic Metabolic Alkalosis**. * **USG:** Always perform an ultrasound to rule out multiple gestations or a molar pregnancy, both of which are associated with higher hCG levels and severe vomiting.

Question 122: All of the following are indications of classical cesarean section except:

A. Small breech baby
B. Large baby with transverse lie
C. Leiomyoma in lower pole of uterus
D. Cancer of the endometrium (Correct Answer)

Explanation: **Explanation:** In a **Classical Cesarean Section**, a vertical incision is made in the upper segment of the uterus. This procedure is rarely performed today due to the high risk of uterine rupture in subsequent pregnancies (4–9%), but it remains indicated when the lower uterine segment (LUS) is inaccessible or should not be incised. **Why Option D is the Correct Answer:** **Cancer of the endometrium** is not an indication for a classical C-section. In fact, pregnancy and endometrial cancer rarely coexist because the high progesterone levels of pregnancy are protective. If a malignancy is present during pregnancy, it is usually **Cervical Cancer**, where a classical incision is preferred to avoid cutting through the cancerous tissue in the cervix/LUS and to facilitate a subsequent radical hysterectomy. **Analysis of Incorrect Options (Indications for Classical C-section):** * **Small breech baby:** In cases of extreme prematurity or a very small fetus in breech presentation, the LUS is poorly developed and narrow. A vertical incision provides the necessary space to prevent head entrapment. * **Large baby with transverse lie:** When a large fetus is in a transverse lie (especially back-down), a lower segment incision does not provide enough room for safe rotation and extraction; a classical incision is required. * **Leiomyoma in lower pole:** A large fibroid obstructing the LUS makes a standard transverse incision technically impossible or risks heavy hemorrhage. **NEET-PG High-Yield Pearls:** * **Most common indication:** Carcinoma of the cervix (to avoid the LUS). * **Other indications:** Post-mortem C-section, anterior placenta previa with engorged vessels (though less common now), and peripartum hysterectomy for placenta accreta. * **Key Risk:** Classical C-section carries the highest risk of **scar rupture** (often occurring before the onset of labor). * **Suture material:** Usually 1-0 or 0 chromic catgut or synthetic absorbable (Vicryl) in three layers.

Question 123: Which of the following is NOT a criterion for the diagnosis of HELLP syndrome?

A. Hemolysis
B. SGOT > 72 IU/L
C. Convulsions (Correct Answer)
D. Platelets < 100,000/mm3

Explanation: **Explanation:** The diagnosis of **HELLP Syndrome** is based on specific laboratory criteria rather than clinical symptoms like seizures. HELLP is an acronym representing **H**emolysis, **E**levated **L**iver enzymes, and **L**ow **P**latelets. * **Why Convulsions is the correct answer:** Convulsions (seizures) are the hallmark of **Eclampsia**, not HELLP syndrome. While HELLP syndrome often coexists with severe pre-eclampsia or eclampsia (in about 10–20% of cases), it is a distinct hematologic and hepatic complication. Seizures are not required for the diagnosis of HELLP. * **Why other options are incorrect (The Tennessee Criteria):** * **Hemolysis (Option A):** A core component. It is diagnosed by the presence of schistocytes on a peripheral smear, elevated bilirubin (>1.2 mg/dL), or low haptoglobin. * **SGOT > 72 IU/L (Option B):** Reflects "Elevated Liver enzymes." According to the Tennessee Criteria, AST (SGOT) must be ≥ 70 IU/L to qualify. * **Platelets < 100,000/mm³ (Option C):** Reflects "Low Platelets." This is the most sensitive indicator of the severity of HELLP syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Mississippi Classification:** Classifies HELLP based on platelet count (Class 1: <50k, Class 2: 50k–100k, Class 3: 100k–150k). * **Most common symptom:** Epigastric or right upper quadrant pain (due to Glisson’s capsule distension). * **Management:** The definitive treatment is delivery if the gestational age is >34 weeks or if there is maternal/fetal deterioration. * **Steroids:** While dexamethasone is used to increase platelet counts, it does not improve maternal or neonatal outcomes.

Question 124: Which of the following is NOT an indication for a classical cesarean section?

A. Densely adhered bladder
B. Leiomyoma in the lower uterine segment
C. Breech presentation (Correct Answer)
D. Back-down transverse fetal lie

Explanation: **Explanation:** A **Classical Cesarean Section** involves a vertical incision in the upper contractile segment of the uterus. It is generally avoided due to increased blood loss and a higher risk of uterine rupture (4–9%) in subsequent pregnancies. **1. Why Breech Presentation is the correct answer:** Breech presentation is **not** a routine indication for a classical incision. Most breech deliveries via cesarean section are safely performed using a standard **Lower Segment Cesarean Section (LSCS)** with a transverse (Kerr) incision. A vertical incision is only considered in breech if the lower segment is poorly formed (e.g., extreme prematurity) or if there is an entrapment of the after-coming head, but the presentation itself does not mandate a classical approach. **2. Analysis of Incorrect Options:** * **Densely adhered bladder (A):** If the bladder is firmly attached to the lower segment due to previous surgeries or endometriosis, attempting an LSCS carries a high risk of cystotomy. A classical incision bypasses the bladder entirely. * **Leiomyoma in the lower segment (B):** A large fibroid obstructing the lower uterine segment makes a transverse incision technically impossible or risks heavy hemorrhage. A classical incision is used to enter the uterus above the fibroid. * **Back-down transverse lie (D):** In a transverse lie where the back is inferior, it is difficult to grasp the fetal feet through a lower transverse incision. A classical incision provides the necessary space for internal podalic version and extraction. **High-Yield Clinical Pearls for NEET-PG:** * **Other Indications:** Placenta previa with anterior implantation (accreta), post-mortem C-section, and cervical carcinoma. * **Risk of Rupture:** Classical C-section scars are more likely to rupture **before** the onset of labor, whereas LSCS scars typically rupture **during** labor. * **Future Delivery:** A history of classical C-section is an absolute indication for repeat elective C-section at 36-37 weeks; VBAC is contraindicated.

Question 125: Which drug is used for mid-trimester abortion?

A. Mifepristone (Correct Answer)
B. Atosiban
C. Valethamate
D. Methotrexate

Explanation: **Explanation:** **Mifepristone (Option A)** is the correct answer. It is a potent anti-progestational agent that sensitizes the myometrium to prostaglandins by blocking progesterone receptors. In mid-trimester abortions (13–24 weeks), Mifepristone is used as a pre-treatment (200 mg orally) 24–48 hours before administering prostaglandins (like Misoprostol). This combination significantly shortens the induction-to-abortion interval and increases the success rate compared to using prostaglandins alone. **Analysis of Incorrect Options:** * **Atosiban (Option B):** A competitive antagonist of oxytocin and vasopressin receptors. It is used as a **tocolytic** to suppress preterm labor, not to induce abortion. * **Valethamate (Option C):** An anticholinergic drug previously used as a cervical dilator to "speed up" the first stage of labor. Its use has largely been discontinued due to lack of proven efficacy and side effects (tachycardia, dry mouth). * **Methotrexate (Option D):** A folate antagonist used primarily for the medical management of **unruptured ectopic pregnancy** or early first-trimester medical abortions (off-label). It is not the standard of care for mid-trimester induction. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Mid-trimester:** The combination of **Mifepristone + Misoprostol** is currently the most effective medical method. * **MTP Act (India):** Medical termination is legal up to **24 weeks** for specific categories of women (as per 2021 amendment). * **Surgical Alternative:** Dilatation and Evacuation (D&E) is the surgical method for the second trimester, though medical induction is often preferred for safety. * **Ethacridine Lactate:** Historically used for mid-trimester (extra-amniotic instillation), but now largely replaced by prostaglandins.

Question 126: Mini laparotomy is indicated in all the following conditions except?

A. Ectopic pregnancy (Correct Answer)
B. Internal sterilization
C. Uterine elevation
D. Tubectomy

Explanation: ### Explanation **Mini-laparotomy** is a surgical approach involving a small abdominal incision (usually 2–5 cm), typically performed for permanent sterilization or simple pelvic procedures. **1. Why Ectopic Pregnancy is the Correct Answer:** Ectopic pregnancy is generally considered a **contraindication** for mini-laparotomy. An ectopic pregnancy (especially if ruptured) is a surgical emergency that requires rapid access, excellent visualization, and space to manage potential hemorrhage. A mini-laparotomy incision is too restrictive for safe salpingectomy or salpingostomy in the presence of hemoperitoneum or pelvic adhesions. The preferred approaches are **Laparoscopy** (if hemodynamically stable) or a formal **Laparotomy** (if unstable). **2. Analysis of Incorrect Options:** * **Internal Sterilization & Tubectomy (Options B & D):** These are the primary indications for mini-laparotomy. The procedure (e.g., Pomeroy’s technique) is performed via a small suprapubic or subumbilical incision to ligate the fallopian tubes. It is a mainstay of female sterilization in resource-limited settings. * **Uterine Elevation (Option C):** This is a specific surgical step/technique used *during* a mini-laparotomy. A uterine elevator is inserted vaginally to push the fundus toward the small abdominal incision, making the fallopian tubes accessible for ligation. **Clinical Pearls for NEET-PG:** * **Ideal Time:** Mini-laparotomy for sterilization is best performed in the **immediate postpartum period** (within 48 hours) when the fundus is high, or as a "concurrent" procedure with MTP. * **Pomeroy’s Method:** The most common technique used during mini-laparotomy tubectomy. * **Contraindications to Mini-lap:** Morbid obesity, previous pelvic surgery (due to adhesions), and acute pelvic inflammatory disease (PID).

Question 127: A 14-week pregnant woman presents with abdominal pain. Ultrasound reveals the fetus is located in a rudimentary uterine horn. What is the most appropriate management in this situation?

A. Hysterectomy
B. Surgical removal of the pregnant rudimentary uterine horn (Correct Answer)
C. Induction of labor using prostaglandins
D. Conservative management with no active treatment

Explanation: **Explanation:** A **rudimentary horn pregnancy** is a rare but life-threatening form of ectopic pregnancy occurring in a non-communicating horn of a unicornuate uterus (Müllerian anomaly Class II). **1. Why the correct answer is right:** The myometrium of a rudimentary horn is typically underdeveloped and cannot accommodate a growing fetus. This leads to a high risk of **spontaneous rupture**, usually in the second trimester (10–20 weeks), resulting in massive hemoperitoneum. Once diagnosed, the standard of care is **surgical removal of the pregnant rudimentary horn (excision)** to prevent rupture and maternal mortality. The ipsilateral fallopian tube is also typically removed to prevent a future ectopic pregnancy in that remnant. **2. Why incorrect options are wrong:** * **Hysterectomy (A):** This is overly radical for a 14-week pregnancy in a young patient. The main unicornuate uterus is functional and should be preserved to allow for future pregnancies. * **Induction of labor (C):** Most rudimentary horns do not communicate with the cervix. Therefore, prostaglandins will cause uterine contractions against an obstructed outlet, inevitably leading to rupture rather than delivery. * **Conservative management (D):** This is contraindicated due to the near-certainty of rupture and life-threatening hemorrhage as the pregnancy advances. **Clinical Pearls for NEET-PG:** * **Classic Presentation:** Severe abdominal pain and collapse in the second trimester (unlike tubal ectopics which rupture in the first trimester). * **Baartman’s Sign:** A clinical finding where the pregnant horn is palpated as a mass separated from the uterus by a groove. * **Ultrasound Finding:** A "pseudo-asymmetrical" uterus with a gestational sac surrounded by myometrium, separate from the main uterine body. * **Risk:** 80-90% of these pregnancies end in rupture.

Question 128: What is the effective pressure that should be achieved in vacuum extraction?

A. 0.1 kg/cm2
B. 0.1 kg/cm2
C. 0.6 kg/cm2 (Correct Answer)
D. 1.2 kg/cm2

Explanation: **Explanation:** In vacuum extraction (Ventouse), the goal is to create a sufficient vacuum between the fetal scalp and the cup to allow for traction without causing unnecessary trauma. 1. **Why 0.6 kg/cm² is correct:** To achieve an effective "chignon" (artificial caput succedaneum) and ensure the cup does not slip during traction, a negative pressure of **0.6 to 0.8 kg/cm²** is required. This is considered the standard therapeutic pressure. In SI units, this corresponds to approximately **600 mmHg** or **-0.8 kg/cm²** (depending on the specific device guidelines, but 0.6 is the classic exam answer). 2. **Why the other options are incorrect:** * **0.1 kg/cm² (Options A & B):** This is the initial pressure used to "fix" the cup to the scalp. It is insufficient for traction and is only meant to hold the cup in place while checking for any trapped maternal soft tissue (vaginal or cervical) before increasing to full pressure. * **1.2 kg/cm² (Option D):** This pressure is excessively high. Pressures exceeding 0.8 kg/cm² significantly increase the risk of fetal scalp trauma, including subgaleal hemorrhage, cephalhematoma, and intracranial bleeding. **Clinical Pearls for NEET-PG:** * **The "Rule of 3s":** Vacuum extraction should be abandoned if there are **3 pulls** with no descent, **3 pop-offs** (cup detachments), or if the procedure exceeds **20-30 minutes**. * **Placement:** The cup should be centered over the **flexion point** (6 cm posterior to the anterior fontanelle, on the sagittal suture) to promote flexion and minimize the diameter of the presenting part. * **Contraindications:** Prematurity (<34 weeks), face presentation, and fetal bleeding diathesis. * **Traction:** Should be applied only during uterine contractions and maternal pushing efforts.

Question 129: What is true about instrumental vaginal delivery?

A. Full cervical dilatation is the only prerequisite.
B. Forceps are used in all cases of breech delivery. (Correct Answer)
C. Forceps may be used if ventouse fails.
D. Ventouse cannot be used in rotational occipito-transverse/posterior delivery.

Explanation: **Explanation:** **1. Why Option B is Correct:** In breech presentations, the **Piper’s Forceps** is specifically designed to deliver the after-coming head of the fetus. Unlike cephalic presentations where forceps are an alternative to ventouse, in breech delivery, **ventouse is strictly contraindicated** because it cannot be applied to the face or the after-coming head. Therefore, forceps are the instrumental choice for the controlled delivery of the head to prevent sudden decompression and intracranial hemorrhage. **2. Analysis of Incorrect Options:** * **Option A:** Full cervical dilatation is a mandatory prerequisite, but it is **not the only one**. Other criteria include ruptured membranes, empty bladder, engaged head (at least +2 station), known fetal position, and adequate maternal pelvis/analgesia. * **Option C:** If ventouse fails, the standard recommendation is to proceed to a **Cesarean Section**. Sequential use of instruments (forceps after failed ventouse) is generally discouraged due to a significantly higher risk of severe fetal trauma and maternal perineal injury. * **Option D:** Ventouse **can** be used for rotational deliveries. While Bird’s modification of the Malmstrom cup is often used, the ventouse facilitates rotation by promoting flexion and allowing the head to rotate on the pelvic floor. **Clinical Pearls for NEET-PG:** * **Prerequisites Mnemonic (FORCEPS):** **F**etus alive, **O**s fully dilated, **R**uptured membranes, **C**ephalic/Contracted pelvis absent, **E**ngaged head, **P**osition known, **S**tation +2 or lower. * **Contraindication for Ventouse:** Prematurity (<34 weeks), face/breech presentation, and fetal coagulopathies. * **Preferred Instrument:** Ventouse is associated with less maternal trauma; Forceps are associated with a higher success rate but more 3rd/4th-degree perineal tears.

Question 130: In an unruptured ectopic pregnancy patient who underwent a salpingostomy procedure, what is the typical management of the tubal incision?

A. The tubal incision is left open for secondary healing. (Correct Answer)
B. The tubal incision is closed with sutures.
C. Milking of the tube is performed.
D. Partial excision of the tube is done.

Explanation: ### Explanation In the surgical management of an unruptured ectopic pregnancy, **Salpingostomy** is the preferred fertility-preserving procedure. **1. Why Option A is Correct:** During a linear salpingostomy, a longitudinal incision is made on the antimesenteric border of the fallopian tube over the site of the ectopic gestation. After the products of conception are removed and hemostasis is achieved, the **incision is left open to heal by secondary intention**. Studies have shown that suturing the thin, delicate tubal wall (primary closure) does not improve future pregnancy rates and may actually increase the risk of tubal scarring, narrowing, and subsequent recurrent ectopic pregnancy. **2. Why Other Options are Incorrect:** * **Option B:** Closing the incision with sutures (Salpingotomy) is generally avoided as it increases operative time and the risk of tubal lumen stenosis without providing any clinical benefit over salpingostomy. * **Option C:** "Milking" or tubal expression involves pushing the pregnancy out through the fimbrial end. This is associated with a higher risk of persistent trophoblastic tissue and a higher recurrence rate compared to salpingostomy. * **Option D:** Partial excision (Salpingectomy) is the treatment of choice for a **ruptured** ectopic pregnancy or when the tube is severely damaged, but it is not the standard for a simple salpingostomy. ### High-Yield Clinical Pearls for NEET-PG: * **Gold Standard for Diagnosis:** Transvaginal Ultrasound (TVS) + Serum β-hCG. * **Surgical Approach:** Laparoscopy is the gold standard for hemodynamically stable patients. * **Persistent Trophoblast:** The most common complication of salpingostomy. Post-operative weekly β-hCG monitoring is mandatory until levels are <5 mIU/mL. * **Rh-Negative Mothers:** Always administer Anti-D immunoglobulin post-procedure to prevent isoimmunization.

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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