Operative Obstetrics — MCQs

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 131: Hayman hemostatic suture is applied on which of the following?

A. Vagina after biopsy
B. Uterus in PPH (Correct Answer)
C. Fallopian tubes after reanastomosis
D. Ovaries after cystectomy

Explanation: **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).

Question 132: In a patient with a head injury, which of the following bones is perforated during a craniotomy?

A. Occiput (Correct Answer)
B. Parietal
C. Palate
D. Frontal

Explanation: **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.

Question 133: 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?

A. Dilation and curettage
B. Hypertonic extra-amniotic saline infusion
C. Suction and evacuation (Correct Answer)
D. 15-methyl Beta-prostaglandin injection

Explanation: **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.

Question 134: Formation of one of the following is essential for the success of this instrument?

A. Caput
B. Chignon (Correct Answer)
C. Phlegmon
D. None of the above.

Explanation: ***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.

Question 135: Regarding the corpus luteum of pregnancy, all of the following are true EXCEPT:

A. Stimulated by chorionic gonadotropin hormone
B. Persists until the fourth month
C. Secretes progesterone
D. The main hormone secreted is estrogen (Correct Answer)

Explanation: 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).

Question 136: The drug being given is:

A. Ethacrydine lactate (0.1%) (Correct Answer)
B. 20% mannitol
C. 50% Urea
D. Misoprostol

Explanation: ***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.

Question 137: The most suitable method for medical termination of pregnancy (MTP) in the third month of pregnancy is:

A. Dilatation and curettage
B. Extra-amniotic ethacrydine
C. Hysterectomy
D. Suction and evacuation (Correct Answer)

Explanation: **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.

Question 138: Which of the following statements is TRUE regarding Gestational Trophoblastic Disease?

A. The most common site of metastasis is the vagina.
B. The presence of lung metastasis classifies the disease as stage 4 GTN.
C. Liver metastasis carries a poor prognosis similar to brain metastasis. (Correct Answer)
D. GTN following a term pregnancy has a better prognosis than that with a previous molar pregnancy.

Explanation: ### Explanation **Correct Answer: C. Liver metastasis carries a poor prognosis similar to brain metastasis.** **1. Why Option C is Correct:** In Gestational Trophoblastic Neoplasia (GTN), the site of metastasis is a critical prognostic factor. According to the **FIGO/WHO Scoring System**, metastases to the **liver and brain** are assigned the highest score (4 points) because they are associated with a significantly higher risk of treatment resistance and mortality compared to lung or vaginal metastases. These sites often require multimodal therapy, including radiation or surgery, alongside intensive chemotherapy. **2. Why Other Options are Incorrect:** * **Option A:** The **most common site of metastasis is the lung (80%)**, followed by the vagina (30%). * **Option B:** Lung metastasis classifies the disease as **Stage III**. Stage IV is defined by distant metastases to the liver and/or brain. * **Option C (Reiteration):** Correct. * **Option D:** GTN following a **term pregnancy** actually has a **worse prognosis** than GTN following a molar pregnancy. This is because post-term GTN is almost always a choriocarcinoma, which is more aggressive and often diagnosed at a later stage. **3. Clinical Pearls for NEET-PG:** * **FIGO Staging:** * Stage I: Confined to the uterus. * Stage II: Extends to adnexa/vagina/broad ligament. * Stage III: Lung involvement (with or without genital tract involvement). * Stage IV: All other distant sites (Brain/Liver). * **WHO Scoring:** A score of **≥7** is classified as **High-Risk GTN**, requiring multi-agent chemotherapy (EMA-CO regimen). * **Snowstorm appearance** on USG is characteristic of a Hydatidiform mole. * **hCG** is the most sensitive tumor marker for monitoring response to treatment and recurrence.

Question 139: At what gestational age is the following procedure ideally performed?

A. 10-13 weeks (Correct Answer)
B. 13-15 weeks
C. 20-24 weeks
D. 24 weeks onwards

Explanation: ***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.

Question 140: Which of these changes in fetal circulation happen immediately at birth?

A. Obliteration of ductus venosus
B. Formation of ligamentum teres
C. Functional closure of ductus arteriosus (Correct Answer)
D. Obliteration of distal hypogastric arteries

Explanation: **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.

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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