Operative Obstetrics Practice Questions

Q: Hayman hemostatic suture is applied on which of the following?

Uterus in PPH. **Explanation:** The **Hayman suture** is a uterine compression suture used in the management of **Postpartum Hemorrhage (PPH)** due to uterine atony. It is a modification of the classic B-Lynch suture. **Why Option B is correct:** The primary goal of the Hayman suture is to mechanically compress the uterus to control bleeding when medical management (oxytocics) fails. Unlike the B-Lynch suture, the Hayman technique does not require the lower uterine segment to be opened (no hysterotomy). Two to four vertical mattress sutures are passed directly through the anterior and posterior uterine walls and tied at the fundus. This "sandwich" effect compresses the myometrial sinusoids, effectively stopping the hemorrhage. **Why other options are incorrect:** * **Option A:** Vaginal biopsy sites are usually managed with simple interrupted sutures or packing; compression sutures are unnecessary for such small surface areas. * **Option C:** Fallopian tube reanastomosis requires delicate, non-absorbable microsutures (like 6-0 or 7-0 Prolene) to maintain patency, not compression. * **Option D:** Ovarian cystectomy involves hemostasis of the ovarian bed using fine absorbable sutures (like Vicryl) or cautery; compression sutures would compromise ovarian blood supply. **High-Yield Clinical Pearls for NEET-PG:** * **B-Lynch Suture:** The original "brace" suture; requires opening the uterus (hysterotomy). * **Cho Suture:** Multiple square/box sutures applied to the uterus to appose the walls. * **Pereira Suture:** Multiple longitudinal and transverse (cerclage-like) sutures. * **Stepwise Devascularization:** If compression sutures fail, the next surgical steps include ligation of the Uterine artery, then Ovarian artery, and finally Internal Iliac artery (Hypogastric artery).

Q: In a patient with a head injury, which of the following bones is perforated during a craniotomy?

Occiput. **Explanation:** In modern obstetrics, destructive operations are rare but remain a life-saving necessity in specific scenarios, such as a dead fetus in an obstructed labor where a cesarean section poses a high maternal risk. **Craniotomy** is performed to reduce the size of the fetal head by evacuating the brain contents, facilitating vaginal delivery. **Why Occiput is the Correct Answer:** The primary objective of a craniotomy is to decompress the skull. In a **cephalic presentation**, the perforation is ideally made through the **occipital bone** (specifically near the posterior fontanelle). This site is chosen because it provides the most direct access to the midbrain and medulla oblongata. Destroying these vital centers ensures the immediate cessation of fetal movements and cardiac activity, while also allowing for the collapse of the cranial vault. **Analysis of Incorrect Options:** * **Parietal Bone:** While the parietal bones are large, they are not the primary site for perforation in a standard craniotomy for cephalic presentations, as they do not offer the most direct route to the vital centers compared to the occipital approach. * **Palate:** Perforation through the hard palate is the specific technique used in cases of an **after-coming head in breech presentation**. It is not the standard site for a primary cephalic presentation. * **Frontal Bone:** This is avoided as it is thicker and does not provide optimal access to the brainstem. **NEET-PG High-Yield Pearls:** * **Instruments used:** Oldham’s Perforator is the standard instrument for skull perforation; Braun’s Cranioclast is used for extraction. * **After-coming head (Breech):** The preferred sites for perforation are the **hard palate** or the **suboccipital area** (below the occipital protuberance). * **Prerequisite:** The cervix must be fully dilated, and the pelvis must not be so contracted that vaginal delivery is impossible even after decompression.

Q: A 19-year-old woman desires medical termination of pregnancy at 6 weeks of gestation. Which of the following is an appropriate procedure to perform this termination?

Suction and evacuation. **Explanation:** The patient is at **6 weeks of gestation**, which falls within the **first trimester** (up to 12 weeks). For surgical termination of pregnancy in the first trimester, **Suction and Evacuation (S&E)** is the gold standard and the procedure of choice. **1. Why Suction and Evacuation is Correct:** Suction and evacuation (also known as vacuum aspiration) is preferred because it is faster, safer, and associated with fewer complications (like uterine perforation or excessive blood loss) compared to traditional sharp curettage. At 6 weeks, the products of conception are small enough to be easily removed via a 5–6 mm Karman cannula or electric suction. **2. Why Other Options are Incorrect:** * **Dilation and Curettage (D&C):** This involves sharp curettage of the uterine walls. It is no longer recommended as a primary method for MTP due to higher risks of trauma, Asherman syndrome, and increased pain. * **Hypertonic extra-amniotic saline infusion:** This is a method used for **second-trimester** abortions (usually 16–20 weeks). It is rarely used today due to the risk of "water intoxication" and the availability of safer prostaglandins. * **15-methyl Beta-prostaglandin (Carboprost):** This is typically used for second-trimester inductions or for managing postpartum hemorrhage (PPH). It is not a primary standalone method for a 6-week MTP. **Clinical Pearls for NEET-PG:** * **MTP Act (India):** Medical termination is legal up to **24 weeks** under specific conditions. * **Medical MTP:** Up to **9 weeks (63 days)**, the regimen of choice is **Mifepristone (200mg oral) followed by Misoprostol (800mcg vaginal/oral)** 24–48 hours later. * **Surgical MTP:** Suction evacuation is the method of choice for **7–12 weeks**. * **Manual Vacuum Aspiration (MVA):** Can be performed up to 12 weeks and does not require electricity, making it ideal for low-resource settings.

Q: Formation of one of the following is essential for the success of this instrument?

Chignon. ***Chignon*** - **Chignon formation** is essential for successful **vacuum extraction** as it creates a secure seal between the vacuum cup and fetal scalp, allowing effective traction during delivery. - The **artificial caput** formed by chignon provides the necessary grip for the vacuum extractor to assist in guiding the fetal head through the birth canal. *Caput* - **Caput succedaneum** is a natural swelling of fetal scalp tissues that occurs during normal labor due to pressure against the cervix. - It is not essential for vacuum extraction success and may actually interfere with proper **cup placement** and seal formation. *Phlegmon* - **Phlegmon** refers to a spreading **bacterial infection** of soft tissues, which is a pathological condition unrelated to obstetric procedures. - It represents an **infectious complication** rather than a necessary component for any obstetric instrument function. *None of the above* - This option is incorrect as **chignon formation** is indeed essential for successful vacuum-assisted delivery. - The **artificial swelling** created by the vacuum cup is a prerequisite for maintaining adequate suction and safe fetal extraction.

Q: Regarding the corpus luteum of pregnancy, all of the following are true EXCEPT:

The main hormone secreted is estrogen. The **Corpus Luteum of Pregnancy** is a vital temporary endocrine structure essential for maintaining early gestation. ### **Explanation of the Correct Answer (D)** The primary function of the corpus luteum is the secretion of **progesterone**, not estrogen. While it does secrete small amounts of estrogen and relaxin, progesterone is the "hormone of pregnancy" required to maintain decidual integrity and prevent uterine contractions. After 7–10 weeks, the placenta takes over this role (the luteo-placental shift). Therefore, stating that estrogen is the main hormone is incorrect. ### **Analysis of Other Options** * **A. Stimulated by chorionic gonadotropin (hCG):** This is true. In a non-pregnant cycle, the corpus luteum degenerates due to falling LH levels. In pregnancy, **hCG** (secreted by the syncytiotrophoblast) mimics LH, "rescuing" the corpus luteum and maintaining its function. * **B. Persists until the fourth month:** This is true. It reaches its maximum size and activity at about 8–10 weeks. While its essential role ends by the end of the first trimester, it persists anatomically until the 4th month (approx. 16 weeks) before gradually regressing. * **C. Secretes progesterone:** This is true. It is the sole source of progesterone until the placenta becomes functionally autonomous. ### **High-Yield NEET-PG Pearls** * **Luteo-placental shift:** Occurs between **7–10 weeks**. If the corpus luteum is removed before 7 weeks without exogenous progesterone support, abortion will occur. * **Relaxin:** The corpus luteum is the primary source of relaxin, which helps in softening pelvic ligaments. * **Size:** It typically occupies about **1/3rd of the ovary** during early pregnancy. * **Hormonal trigger:** hCG is detectable in maternal serum 8–9 days after ovulation (around the time of implantation).

Q: The drug being given is:

Ethacrydine lactate (0.1%). ***Ethacrydine lactate (0.1%)*** - **Ethacrydine lactate** (Rivanol) is easily identifiable by its characteristic **yellow color** when used as an intra-amniotic injection. - It is a commonly used **abortifacient** for **mid-trimester pregnancy termination** via intra-amniotic instillation. *20% mannitol* - **Mannitol** is a **colorless solution** used as an osmotic diuretic, not for pregnancy termination. - It lacks the distinctive **yellow coloration** that would make it identifiable in this clinical context. *50% Urea* - **Urea** solutions are **colorless** and were historically used for intra-amniotic abortion but are less commonly used now. - Does not have the **characteristic yellow appearance** that helps identify the drug being administered. *Misoprostol* - **Misoprostol** is a **prostaglandin E1 analog** available as **oral or vaginal tablets**, not as an injectable solution. - It is **white/off-white in color** and would not present as a colored liquid for injection.

Q: The most suitable method for medical termination of pregnancy (MTP) in the third month of pregnancy is:

Suction and evacuation. **Explanation:** The "third month" of pregnancy corresponds to the **9–12 week** gestational period. For termination of pregnancy in the first trimester (up to 12 weeks), **Suction and Evacuation (S&E)** is the gold standard surgical method. **Why Suction and Evacuation is Correct:** S&E is preferred because it is faster, associated with less blood loss, and has a significantly lower risk of uterine perforation compared to traditional sharp curettage. According to WHO and MTP guidelines, it is the safest surgical method for pregnancies up to 12–15 weeks. **Analysis of Incorrect Options:** * **A. Dilatation and Curettage (D&C):** This involves sharp curettage, which carries a higher risk of uterine injury and Asherman syndrome. It has largely been replaced by S&E. * **B. Extra-amniotic Ethacrydine:** This is a method used for **second-trimester** abortions (usually 15–20 weeks). It acts by stimulating endogenous prostaglandins to induce labor, which is unnecessary and inefficient for a 12-week fetus. * **C. Hysterectomy:** This is a major surgery involving the removal of the uterus. It is never a primary method for MTP unless there is a concurrent life-threatening pathology (e.g., uterine cancer or uncontrollable hemorrhage). **NEET-PG High-Yield Pearls:** * **MTP Act (India):** Termination is legal up to 20 weeks (standard) and 24 weeks (for specific categories like rape survivors or fetal anomalies). * **Medical Method:** Mifepristone (200mg) followed by Misoprostol (400-800mcg) is the preferred medical regimen up to **9 weeks (63 days)**. * **Surgical Method:** Suction & Evacuation is the method of choice from **7 to 12 weeks**. * **Second Trimester:** Medical induction (Prostaglandins/Oxytocin) or Dilatation and Evacuation (D&E) are preferred.

Q: At what gestational age is the following procedure ideally performed?

10-13 weeks. ***10-13 weeks*** - **Chorionic Villus Sampling (CVS)** is ideally performed at 10-13 weeks gestation for early **genetic diagnosis** and **chromosomal abnormalities**. - This timing allows for **first-trimester screening** while avoiding **limb defects** associated with earlier procedures and ensuring adequate **chorionic villi** development. *13-15 weeks* - This timing is **too late** for optimal CVS as the **chorionic villi** begin to regress and become less accessible. - **Amniocentesis** is the preferred procedure during this period (15-20 weeks) rather than CVS. *20-24 weeks* - This gestational age is appropriate for **detailed anatomical ultrasound** and **amniocentesis** for genetic testing. - CVS performed this late would be **technically challenging** and **unnecessary** as amniocentesis provides better **amniotic fluid sampling**. *24 weeks onwards* - This timing is used for **cordocentesis (PUBS)** - **percutaneous umbilical blood sampling** for fetal blood analysis. - CVS at this stage is **not indicated** as the **placental architecture** has changed and other diagnostic methods are more appropriate.

Q: Which of these changes in fetal circulation happen immediately at birth?

Functional closure of ductus arteriosus. **Explanation:** The transition from fetal to neonatal circulation involves immediate physiological changes and gradual anatomical changes. **Why Option C is Correct:** The **functional closure of the ductus arteriosus** occurs almost **immediately (within 10–15 hours)** after birth. This is triggered by two main factors: 1. **Increased Oxygen Tension:** As the baby takes its first breath, systemic $PaO_2$ rises, causing contraction of the smooth muscles in the ductus wall. 2. **Fall in Prostaglandin ($PGE_2$) levels:** The removal of the placenta (the primary source of $PGE_2$) and increased metabolism in the lungs lead to ductal constriction. **Why Other Options are Incorrect:** * **A & D (Obliteration of Ductus Venosus and Distal Hypogastric Arteries):** While these vessels cease to function shortly after the cord is clamped, their **obliteration** (anatomical closure) is a gradual process taking several days to weeks. * **B (Formation of Ligamentum Teres):** This is the end-stage anatomical result of the obliterated left umbilical vein. Anatomical closure of fetal remnants typically takes **2–3 months** to complete. **High-Yield NEET-PG Pearls:** * **Functional vs. Anatomical:** Functional closure (physiological) happens in hours; Anatomical closure (fibrosis) takes weeks. * **Remnants Summary:** * **Ductus Arteriosus** $\rightarrow$ Ligamentum arteriosum * **Ductus Venosus** $\rightarrow$ Ligamentum venosum * **Left Umbilical Vein** $\rightarrow$ Ligamentum teres hepatis * **Umbilical Arteries** $\rightarrow$ Medial umbilical ligaments * **Foramen Ovale** $\rightarrow$ Fossa ovalis (Functional closure is immediate due to increased left atrial pressure). * **Pharmacology:** **Indomethacin** (NSAID) is used to close a Patent Ductus Arteriosus (PDA), while **Alprostadil** ($PGE_1$) is used to keep it open in cyanotic heart diseases.

Question 1

Hayman hemostatic suture is applied on which of the following?

Accepted Answer

Uterus in PPH

Answer

Vagina after biopsy

Answer

Fallopian tubes after reanastomosis

Answer

Ovaries after cystectomy

Question 2

In a patient with a head injury, which of the following bones is perforated during a craniotomy?

Accepted Answer

Occiput

Answer

Parietal

Answer

Palate

Answer

Frontal

Question 3

A 19-year-old woman desires medical termination of pregnancy at 6 weeks of gestation. Which of the following is an appropriate procedure to perform this termination?

Accepted Answer

Suction and evacuation

Answer

Dilation and curettage

Answer

Hypertonic extra-amniotic saline infusion

Answer

15-methyl Beta-prostaglandin injection

Question 4

Formation of one of the following is essential for the success of this instrument?

Accepted Answer

Chignon

Answer

Caput

Answer

Phlegmon

Answer

None of the above.

Question 5

Regarding the corpus luteum of pregnancy, all of the following are true EXCEPT:

Accepted Answer

The main hormone secreted is estrogen

Answer

Stimulated by chorionic gonadotropin hormone

Answer

Persists until the fourth month

Answer

Secretes progesterone

Question 6

The drug being given is:

Accepted Answer

Ethacrydine lactate (0.1%)

Answer

20% mannitol

Answer

50% Urea

Answer

Misoprostol

Question 7

The most suitable method for medical termination of pregnancy (MTP) in the third month of pregnancy is:

Accepted Answer

Suction and evacuation

Answer

Dilatation and curettage

Answer

Extra-amniotic ethacrydine

Answer

Hysterectomy

Question 8

Which of the following statements is TRUE regarding Gestational Trophoblastic Disease?

Accepted Answer

Liver metastasis carries a poor prognosis similar to brain metastasis.

Answer

The most common site of metastasis is the vagina.

Answer

The presence of lung metastasis classifies the disease as stage 4 GTN.

Answer

GTN following a term pregnancy has a better prognosis than that with a previous molar pregnancy.

Question 9

At what gestational age is the following procedure ideally performed?

Accepted Answer

10-13 weeks

Answer

13-15 weeks

Answer

20-24 weeks

Answer

24 weeks onwards

Question 10

Which of these changes in fetal circulation happen immediately at birth?

Accepted Answer

Functional closure of ductus arteriosus

Answer

Obliteration of ductus venosus

Answer

Formation of ligamentum teres

Answer

Obliteration of distal hypogastric arteries

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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