Operative Obstetrics — MCQs

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 151: Which gynecological surgery utilizes the instrument shown in the image?

A. Tubectomy
B. Cesarean section
C. Myomectomy (Correct Answer)
D. Hysterectomy

Explanation: ***Myomectomy*** - The instrument shown is a **myoma screw** (spiral/corkscrew forceps), specifically designed to grasp and manipulate **uterine fibroids** during their surgical removal. - This specialized instrument allows secure grip on the **fibroid tissue** while minimizing trauma to surrounding **myometrium** during enucleation. *Tubectomy* - Uses standard **laparoscopic instruments** like **electrocautery** or **clips** for fallopian tube occlusion or removal. - The myoma screw has no application in tubal procedures as it's designed for **solid tissue manipulation**, not tubular structures. *Cesarean section* - Employs **scalpels**, **forceps**, and **retractors** for uterine incision and fetal delivery. - The myoma screw is unnecessary as cesarean delivery focuses on **uterine incision** and **fetal extraction**, not fibroid manipulation. *Hysterectomy* - Uses **clamps**, **scissors**, and **electrocautery** for systematic removal of the entire uterus. - The myoma screw is not needed since the **entire uterus** is removed rather than selectively extracting specific masses.

Question 152: A 26-year-old primipara at term gestation with labour pains presents with cervical dilation 3 cm, 60% effacement, meconium-stained liquor, and decreased fetal heart rate. What is the most appropriate management?

A. Administer oxytocin drip to accelerate labour.
B. Administer IV drotaverine to improve cervical dilatation.
C. Attempt a vacuum delivery.
D. Provide oxygen and shift to the operating theatre for emergency lower segment caesarean section (LSCS). (Correct Answer)

Explanation: ### Explanation The correct management is **Option D: Provide oxygen and shift to the operating theatre for emergency LSCS.** **Why it is correct:** The patient presents with **fetal distress** (decreased fetal heart rate and meconium-stained liquor) in the **latent phase of labor** (cervical dilation <6 cm). In the presence of fetal compromise, the priority is immediate delivery. Since the cervix is only 3 cm dilated, vaginal delivery is not imminent. Therefore, an emergency Lower Segment Caesarean Section (LSCS) is the safest and fastest route to rescue the fetus. Oxygen administration serves as intrauterine resuscitation while preparing for surgery. **Why the other options are incorrect:** * **Option A:** Oxytocin is used for labor augmentation. In the presence of fetal distress, oxytocin is contraindicated as it increases uterine contraction frequency and intensity, further compromising placental blood flow and worsening fetal hypoxia. * **Option B:** Drotaverine is an antispasmodic used to hasten cervical dilation. It has no role in managing fetal distress and would cause a dangerous delay in definitive treatment. * **Option C:** Instrumental delivery (Vacuum/Forceps) requires specific prerequisites: the cervix must be **fully dilated (10 cm)**, the head must be engaged, and the membranes must be ruptured. At 3 cm dilation, vacuum extraction is contraindicated and physically impossible. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisites for Instrumental Delivery:** Remember the mnemonic **FORCEPS** (Fetus alive, Os fully dilated, Ruptured membranes, Cephalic presentation, Engaged head, Position known, Show/Bladder empty). * **Meconium-Stained Liquor (MSL):** While not always a sign of distress, when combined with FHR abnormalities (bradycardia or late decelerations), it indicates significant fetal hypoxia. * **Management Priority:** In fetal distress, if vaginal delivery is not possible within minutes, LSCS is the gold standard.

Question 153: Pregnancy resulting from contraceptive failure can be terminated as per which indication of the Medical Termination of Pregnancy (MTP) Act?

A. To save the life of the mother
B. Social indication (Correct Answer)
C. Eugenic indication
D. None of the above

Explanation: ### Explanation The Medical Termination of Pregnancy (MTP) Act of 1971 (amended in 2021) outlines specific legal grounds under which a pregnancy can be terminated. **1. Why "Social Indication" is correct:** Contraceptive failure is categorized under **Social Indications**. The law recognizes that a pregnancy resulting from the failure of a contraceptive device or method (used by a woman or her partner) can cause significant mental agony and social distress. This provision is unique as it acknowledges the psychological impact of an unplanned pregnancy on the woman’s mental health. **2. Analysis of Incorrect Options:** * **A. To save the life of the mother (Therapeutic Indication):** This refers to situations where the continuation of pregnancy poses a risk to the life of the pregnant woman or causes grave injury to her physical or mental health (e.g., severe cardiac disease). * **C. Eugenic Indication:** This applies when there is a substantial risk that if the child were born, it would suffer from serious physical or mental abnormalities (e.g., major structural anomalies or genetic disorders). * **Humanitarian Indication (Not listed):** This refers to pregnancies resulting from sexual assault or rape. **3. High-Yield Facts for NEET-PG:** * **Gestational Age Limit:** Under the 2021 Amendment, the upper limit for MTP is **24 weeks** for specific categories (rape survivors, minors, etc.). For contraceptive failure, it is generally up to **20 weeks**. * **Opinion Required:** One RMP (Registered Medical Practitioner) is needed for termination up to 20 weeks; two RMPs are required for 20–24 weeks. * **Anomalies:** There is **no upper gestation limit** for termination if a Medical Board confirms substantial fetal abnormalities. * **Confidentiality:** The name and particulars of the woman must not be revealed, punishable by up to one year in prison.

Question 154: Which of the following is NOT a benefit of surgical evacuation compared to medical regimens?

A. Invasive procedure (Correct Answer)
B. Lower failure rate
C. No need for follow-up
D. Predictable bleeding

Explanation: **Explanation:** The question asks to identify which option is **NOT** a benefit of surgical evacuation (Dilation and Curettage/Manual Vacuum Aspiration) when compared to medical management (e.g., Misoprostol) for early pregnancy loss or termination. **Why "Invasive procedure" is the correct answer:** An invasive procedure is a **disadvantage**, not a benefit. Surgical evacuation requires instrumentation of the uterus, often necessitates anesthesia, and carries specific risks such as uterine perforation, cervical trauma, and Asherman syndrome (intrauterine adhesions). In contrast, medical management is non-invasive. **Analysis of incorrect options (Benefits of Surgery):** * **B. Lower failure rate:** Surgical evacuation has a higher success rate (>95-98%) compared to medical regimens, which have a higher risk of incomplete evacuation requiring subsequent surgery. * **C. No need for follow-up:** Because the clinician can confirm the uterus is empty at the time of the procedure, routine follow-up to confirm completion is generally not required. Medical management requires follow-up (ultrasound or serial hCG) to ensure the products of conception have been fully expelled. * **D. Predictable bleeding:** In surgery, the bulk of the tissue is removed instantly, leading to immediate and predictable tapering of bleeding. Medical management involves prolonged, heavy, and sometimes unpredictable bleeding over several days. **NEET-PG High-Yield Pearls:** * **MVA (Manual Vacuum Aspiration):** Preferred over sharp curettage; uses a Karman cannula and a 60cc syringe creating a vacuum of **26 inches (660 mmHg)**. * **Medical Regimen:** For early loss, Misoprostol (800 mcg vaginally) is common. For induced abortion up to 9 weeks, the WHO recommends Mifepristone (200 mg) followed by Misoprostol (800 mcg). * **Choice of Method:** Patient preference is the most important factor if there are no contraindications (like hemorrhage or infection, which necessitate immediate surgery).

Question 155: Ward Mayo's operation is indicated in:

A. Carcinoma of the uterus
B. Prolapse in a nulliparous patient
C. Procidentia (Correct Answer)
D. Carcinoma of the cervix

Explanation: **Explanation:** **Ward Mayo’s Operation** is a surgical procedure involving a **Vaginal Hysterectomy with Pelvic Floor Repair**. It is the gold-standard treatment for **Procidentia** (third-degree or total uterine prolapse) in postmenopausal women or those who have completed their family. 1. **Why Procidentia is correct:** In cases of procidentia, the uterus is completely herniated outside the introitus. Ward Mayo’s operation addresses this by removing the uterus vaginally and performing an anterior colporrhaphy and posterior colpoperineorrhaphy to strengthen the weakened pelvic supports (cystocele and rectocele repair). 2. **Why other options are incorrect:** * **Carcinoma of the uterus/cervix:** Malignancies require radical surgeries (like Wertheim’s Hysterectomy) and lymph node dissection, usually performed via an abdominal or laparoscopic approach to ensure oncological clearance. Vaginal hysterectomy is generally contraindicated in invasive cancers. * **Prolapse in a nulliparous patient:** In young or nulliparous patients who wish to preserve fertility, "Uterine Sparing" surgeries are preferred. Examples include **Shirodkar’s or Khanna’s Fothergill operation** (Manchester repair) or **Sling operations** (e.g., Shirodkar’s abdominal sling). **High-Yield Clinical Pearls for NEET-PG:** * **Manchester Operation:** Indicated for uterine prolapse when the patient wants to preserve the uterus (involves cervical amputation and Fothergill’s stitch). * **Le Fort’s Colpocleisis:** Indicated for procidentia in **very elderly** patients who are not sexually active and are unfit for major surgery (involves partial closure of the vagina). * **Step of Ward Mayo’s:** The most crucial step to prevent future vault prolapse is the high ligation of the uterosacral ligaments.

Question 156: Which of the following statements is NOT related to symphysiotomy?

A. The operation is done only when obstruction is anticipated (Correct Answer)
B. Isolated outlet contraction is the ideal case
C. Fetal heart sounds must be present
D. Ventouse is preferable to forceps for extraction

Explanation: **Explanation:** Symphysiotomy is a surgical procedure where the fibers of the pubic symphysis are partially divided to increase the pelvic diameters (primarily the transverse and sagittal diameters) to facilitate vaginal delivery. **1. Why Option A is the Correct Answer (The "NOT" related statement):** Symphysiotomy is **never** performed prophylactically when obstruction is merely "anticipated." It is an emergency procedure performed only when **actual obstruction** is encountered during labor (e.g., mild to moderate cephalopelvic disproportion or trapped after-coming head of a breech). Performing it without confirmed obstruction is against clinical guidelines. **2. Analysis of Other Options:** * **Option B:** Isolated outlet contraction is indeed an ideal indication. Since symphysiotomy significantly increases the transverse diameter of the outlet, it effectively resolves outlet dystocia. * **Option C:** Fetal heart sounds must be present. Symphysiotomy is a morbid procedure for the mother (risk of gait instability, hemorrhage, and bladder injury); therefore, it is only justified if the fetus is alive and viable. If the fetus is dead, a destructive procedure (craniotomy) is preferred to avoid maternal surgical trauma. * **Option D:** Ventouse (Vacuum) is preferred over forceps. After the symphysis is divided, the pelvic space is unstable. Forceps require more space for application and can cause further trauma to the urethra and bladder, whereas the vacuum occupies less space and facilitates descent more safely. **Clinical Pearls for NEET-PG:** * **Maximum Separation:** The gap created should not exceed **2.5 cm** to prevent permanent damage to the sacroiliac joints. * **Local Anesthesia:** It is typically performed under local infiltration. * **Positioning:** The patient is placed in a modified lithotomy position; the legs must be held by two assistants to prevent abduction beyond 80 degrees, which protects the sacroiliac ligaments.

Question 157: During a cesarean section, how is the lower uterine segment physically identified?

A. Loose attachment of visceral peritoneum (Correct Answer)
B. Presence of dilated venous sinuses
C. Deflection of the uterine artery towards the upper segment
D. Thinness of its wall compared to the upper segment

Explanation: **Explanation:** The identification of the lower uterine segment (LUS) is a critical step in a cesarean section to ensure the correct placement of the hysterotomy. **Why Option A is Correct:** The most reliable anatomical landmark for the LUS is the **loose attachment of the visceral peritoneum** (the uterovesical fold). In the upper uterine segment, the peritoneum is firmly adherent to the underlying myometrium. However, as it descends toward the bladder, it becomes loosely attached. This laxity allows the surgeon to identify the "reflection" of the peritoneum, incise it, and push the bladder downward (bladder flap) to safely expose the thin, non-contractile lower segment. **Analysis of Incorrect Options:** * **Option B:** While venous sinuses are present, they are not a specific anatomical marker for the LUS and are often more prominent in the upper segment or in cases of placenta accreta. * **Option C:** The uterine artery reaches the uterus at the level of the internal os and then ascends. Its deflection is not a primary physical landmark used to identify the LUS during surgery. * **Option D:** Although the LUS is indeed thinner than the upper segment (especially in labored patients), "thinness" is a subjective finding and can be misleading in a non-labored or thick-walled uterus. The peritoneal attachment remains the objective surgical landmark. **High-Yield Clinical Pearls for NEET-PG:** * **Formation:** The LUS develops from the **isthmus** of the non-pregnant uterus. * **Timing:** It is fully formed only after **28 weeks** of gestation. * **Surgical Significance:** The LUS is the preferred site for incision (Munro-Kerr incision) because it is less vascular, has less muscle fibers (leading to better healing), and carries a lower risk of rupture in subsequent pregnancies compared to classical incisions. * **Bladder Relation:** The bladder is anatomically related to the LUS; hence, the loose peritoneum must be mobilized to avoid bladder injury.

Question 158: In which genetic condition is this most likely to be seen?

A. Trisomy 16
B. Monosomy X
C. Trisomy 21 (Correct Answer)
D. Trisomy 13

Explanation: ***Trisomy 21*** - The **double bubble sign** (duodenal atresia) on prenatal ultrasound has a strong association with **Down syndrome**, occurring in approximately **30%** of cases. - **Trisomy 21** is the most common viable autosomal trisomy and frequently presents with gastrointestinal anomalies including **duodenal atresia**. *Trisomy 16* - **Most common trisomy** in spontaneous miscarriages but is **not compatible with life** beyond early pregnancy. - Does not typically present with duodenal atresia as affected fetuses do not survive to term. *Monosomy X* - **Turner syndrome** classically presents with **cystic hygroma**, **coarctation of aorta**, and **webbed neck** on prenatal imaging. - Gastrointestinal anomalies like duodenal atresia are **not characteristic** features of this condition. *Trisomy 13* - **Patau syndrome** typically presents with **holoprosencephaly**, **polydactyly**, and severe central nervous system malformations. - While gastrointestinal anomalies can occur, **duodenal atresia** is not a classic association with this condition.

Question 159: What is the recommended pressure range employed during suction evacuation in MTP?

A. 200-400 mm Hg
B. 400-600 mm Hg (Correct Answer)
C. 600-800 mm Hg
D. 800-1000 mm Hg

Explanation: ### Explanation **Suction Evacuation (Vacuum Aspiration)** is the gold standard surgical method for Medical Termination of Pregnancy (MTP) in the first trimester (up to 12 weeks). **1. Why 400-600 mm Hg is Correct:** To effectively detach and aspirate the products of conception (decidua and chorionic tissue) from the uterine wall, a negative pressure of **400–600 mm Hg** (or 60–80 kPa) is required. This range provides sufficient suction to empty the uterus quickly while minimizing the risk of trauma to the myometrium. **2. Analysis of Incorrect Options:** * **A (200-400 mm Hg):** This pressure is generally **insufficient** to dislodge the gestational sac and placental tissue, leading to incomplete evacuation and increased procedure time. * **C & D (600-1000 mm Hg):** Pressures exceeding 600 mm Hg are **excessive**. High negative pressure increases the risk of uterine perforation, Asherman syndrome (due to over-denudation of the basal layer of the endometrium), and cervical injury. **3. Clinical Pearls for NEET-PG:** * **Cannula Size Rule:** The size of the Karman cannula (in mm) should correspond to the weeks of gestation (e.g., an 8 mm cannula for 8 weeks of pregnancy). * **Manual Vacuum Aspiration (MVA):** Uses a handheld syringe (60cc) that creates a constant vacuum of approximately **600 mm Hg**. * **Signs of Completion:** The procedure is complete when "gritty" sensations are felt against the cannula, bubbles appear in the tube, and the uterus contracts around the cannula. * **MTP Act Update:** Remember that under the MTP (Amendment) Act 2021, the upper gestation limit for termination has been increased to **24 weeks** for specific categories of women.

Question 160: A 38-year-old primigravida, pregnant following IVF, has a sonogram at 12 weeks 4 days gestation showing a nuchal translucency of 5 mm. Which of the following is the only true statement?

A. The embryo has a high risk of neural tube defect.
B. The embryo has a high risk of cardiac malformation. (Correct Answer)
C. The nuchal translucency will enlarge by 20 weeks.
D. If the embryo is aneuploid, the most likely diagnosis is Turner syndrome.

Explanation: **Explanation:** **1. Why Option B is Correct:** Nuchal Translucency (NT) is the sonographic appearance of a collection of fluid under the skin behind the fetal neck in the first trimester (11 to 13+6 weeks). A measurement of **≥3.5 mm** is considered significantly increased. While NT is primarily used to screen for aneuploidies (like Down syndrome), an increased NT in a **euploid (chromosomally normal) fetus** is strongly associated with **congenital heart defects (CHDs)**, such as Tetralogy of Fallot or Septal defects. This is likely due to transient heart failure or altered hemodynamics during development. **2. Why the Other Options are Incorrect:** * **Option A:** Neural tube defects (NTDs) are associated with abnormal maternal serum alpha-fetoprotein (MSAFP) and specific second-trimester ultrasound findings (e.g., lemon sign, banana sign), not increased NT. * **Option C:** Increased NT usually **resolves** or evolves into a cystic hygroma or nuchal edema by the second trimester; it does not typically "enlarge" as a standard progression. * **Option D:** While Turner syndrome (45,X) is associated with very high NT/cystic hygroma, the **most common** aneuploidy associated with increased NT is **Trisomy 21 (Down syndrome)**. **Clinical Pearls for NEET-PG:** * **Ideal Timing for NT:** 11 weeks to 13 weeks 6 days (CRL 45–84 mm). * **Combined Screening:** NT + PAPP-A + hCG (Detection rate for Down syndrome ~85-90%). * **Next Step:** If NT is increased, the patient should be offered invasive testing (CVS/Amniocentesis) for karyotyping and a **Fetal Echocardiogram** at 18–22 weeks. * **IVF Pregnancy:** IVF itself is an independent risk factor for cardiac malformations, further increasing the relevance of this finding.

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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