Operative Obstetrics Practice Questions

Q: Following cesarean section under general anesthesia, after easy delivery of the baby and placenta, the uterus is noted to be boggy and atonic despite intravenous infusion of oxytocin. Which of the following agents is NOT appropriate to use next?

Terbutaline administered intravenously. **Explanation:** The clinical scenario describes **Postpartum Hemorrhage (PPH)** due to **uterine atony** following a Cesarean section. The goal of management is to use **uterotonics**—agents that stimulate uterine contractions to compress intramyometrial blood vessels. **Why Terbutaline is the Correct Answer:** Terbutaline is a **Beta-2 adrenergic agonist**. In obstetrics, it acts as a **tocolytic**, meaning it relaxes the uterine smooth muscle. Administering terbutaline in a case of uterine atony would worsen the bogginess and exacerbate life-threatening hemorrhage. Therefore, it is contraindicated and "not appropriate" in this setting. **Analysis of Other Options:** * **Methylergonovine (Methergine):** An ergot alkaloid that causes sustained tetanic uterine contractions. It is a second-line uterotonic (after Oxytocin) administered IM. (Note: Avoid in hypertensive patients). * **Prostaglandin F2α (Carboprost/Hemabate):** A potent uterotonic used for refractory atony. While usually given IM or intramyometrally, prostaglandin analogs are effective in increasing uterine tone. (Note: Avoid in asthmatics). * **Misoprostol (Prostaglandin E1):** A versatile uterotonic that can be administered sublingually, orally, or rectally (suppositories) to manage atony when other injectable agents are unavailable or contraindicated. **NEET-PG High-Yield Pearls:** 1. **First-line management of PPH:** Uterine massage + Oxytocin (10–40 units IV infusion). 2. **Uterotonic Contraindications:** * **Methylergonovine:** Hypertension/Preeclampsia. * **PGF2α (Carboprost):** Asthma. 3. **Tocolytics (Uterine Relaxants):** Used in preterm labor or uterine inversion. Examples include Terbutaline, Ritodrine, Nifedipine (Calcium channel blocker), and Atosiban (Oxytocin antagonist).

Q: In which of the following situations should forceps not be used for delivery?

Hydrocephalus. **Explanation:** The primary prerequisite for any instrumental vaginal delivery (Forceps or Ventouse) is a **favorable cephalopelvic relationship**. In **Hydrocephalus**, the fetal head is pathologically enlarged, leading to a significant cephalopelvic disproportion (CPD). Attempting a forceps delivery in this scenario is contraindicated because the blades cannot securely grasp the oversized head, and the forceful traction required would lead to severe maternal soft tissue trauma or uterine rupture. The management of choice for hydrocephalus is usually cephalocentesis or Cesarean section. **Analysis of Incorrect Options:** * **Twin Delivery:** Forceps are frequently used to expedite the delivery of the second twin if there is fetal distress or maternal exhaustion, provided the head is engaged. * **Postmaturity:** Post-term pregnancy itself is not a contraindication. Forceps may be indicated if postmaturity leads to a non-reassuring fetal heart rate or a prolonged second stage of labor. * **After-coming head in Breech:** This is a classic indication. **Piper’s Forceps** are specifically designed to deliver the after-coming head of a breech to maintain flexion and protect the fetal head from sudden decompression. **NEET-PG High-Yield Pearls:** * **Prerequisites for Forceps:** Remember the mnemonic **FORCEPS**: **F**etus alive, **O**penned cervix (fully dilated), **R**uptured membranes, **C**ephalic presentation (or after-coming head), **E**ngaged head, **P**elvis adequate (no CPD), and **S**hadow/Bladder empty. * **Contraindications:** Fetal bleeding disorders (e.g., hemophilia), fetal demineralizing bone diseases (e.g., Osteogenesis Imperfecta), unengaged head, and incomplete cervical dilation. * **Piper’s Forceps:** Unique because they have a long shank with a perineal curve to allow application to the after-coming head without compressing the trunk.

Q: In a patient undergoing craniotomy for an extradural hematoma in the posterior cranial fossa, which bone is most commonly perforated to gain access?

Occipital bone. ### Explanation **1. Why the Correct Answer is Right:** The **posterior cranial fossa** is the deepest and largest of the three cranial fossae. It is bounded anteriorly by the petrous part of the temporal bone and posteriorly by the **occipital bone**. Therefore, to access an extradural hematoma (EDH) located in this region, a craniotomy or burr hole must be performed through the occipital bone. While EDHs are most common in the temporal region (due to middle meningeal artery injury), posterior fossa EDHs are rare but life-threatening emergencies that require suboccipital decompression. **2. Why the Incorrect Options are Wrong:** * **Parietal bone:** This bone forms the bulk of the vault of the skull. A craniotomy here would access the middle cranial fossa or the superior convexities, not the posterior fossa. * **Palate bone:** This is a facial bone forming the roof of the mouth and floor of the nasal cavity. It has no structural role in the cranial vault or the posterior fossa. * **Frontal bone:** This bone forms the forehead and the roof of the orbits. Access through the frontal bone leads to the anterior cranial fossa. **3. NEET-PG High-Yield Pearls:** * **Anatomical Landmark:** The internal acoustic meatus, jugular foramen, and foramen magnum are all located within the posterior cranial fossa. * **Clinical Sign:** Posterior fossa hematomas can cause rapid brainstem compression and tonsillar herniation. * **Vascular Association:** While the middle meningeal artery is the usual culprit in temporal EDHs, posterior fossa EDHs are often associated with tears in the **dural venous sinuses** (transverse or sigmoid sinus) or occipital bone fractures. * **Surgical Approach:** The standard approach for this region is the **suboccipital craniectomy**.

Q: Which of the following sites are the rarest and most common for ectopic pregnancy, respectively?

Cervix and ampulla of fallopian tube. **Explanation:** Ectopic pregnancy occurs when a fertilized ovum implants outside the normal uterine cavity. Understanding the distribution of these sites is a high-yield topic for NEET-PG. **1. Why Option C is Correct:** * **Most Common Site:** The **Fallopian tube** accounts for approximately 95–97% of all ectopic pregnancies. Within the tube, the **Ampulla** is the most frequent site (approx. 70%) due to its wide lumen and mucosal folds where fertilization typically occurs. * **Rarest Site:** The **Cervix** is considered the rarest site of implantation, occurring in <1% of cases. It is clinically significant due to the high risk of massive hemorrhage during management. **2. Analysis of Incorrect Options:** * **Option A:** While the Ampulla is the most common, the Ovary (approx. 3%) is more common than the cervix. * **Option B:** The Isthmus is the second most common tubal site (approx. 12%), but not the most common overall. The Broad ligament (intraligamentary) is rare but usually occurs secondary to tubal rupture. * **Option D:** Abdominal pregnancies (approx. 1%) are rare but still occur more frequently than cervical pregnancies in most epidemiological studies. **3. NEET-PG Clinical Pearls:** * **Order of Frequency in Fallopian Tube:** Ampulla (70%) > Isthmus (12%) > Fimbria (11%) > Interstitial/Cornual (2–3%). * **Highest Risk of Rupture:** The **Isthmus** tends to rupture early (6–8 weeks) because it is narrow and non-distensible. * **Most Dangerous Site:** **Interstitial/Cornual** pregnancies are the most dangerous because they rupture late (12–14 weeks) and cause massive, life-threatening hemorrhage due to the proximity of the uterine artery. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases).

Q: All the following are criteria for outlet forceps application EXCEPT?

Station is between 0 and +2 cm. This question tests your knowledge of the **ACOG classification of forceps delivery**, a high-yield topic for NEET-PG. ### **Explanation of the Correct Answer** **Option C** is the correct answer because it describes **Low Forceps**, not Outlet Forceps. According to ACOG criteria, for an **Outlet Forceps** application, the fetal station must be **on the pelvic floor (+3 cm or lower)**. A station between 0 and +2 cm (but not on the pelvic floor) is classified as **Mid-forceps** (if the head is engaged but station is <+2 cm) or **Low Forceps** (if the station is ≥+2 cm but not on the pelvic floor). ### **Analysis of Incorrect Options** * **Option A:** For outlet forceps, the fetal skull must have reached the pelvic floor. This ensures the head is low enough for a safe, low-traction delivery. * **Option B:** The scalp must be visible at the introitus without the need to separate the labia. This indicates the head is crowning or near-crowning. * **Option C:** The sagittal suture must be in the anteroposterior diameter, or in the right or left occiput anterior/posterior positions. The rotation required to reach the midline must **not exceed 45 degrees**. ### **Clinical Pearls for NEET-PG** * **Prerequisites for Forceps (FORCEPS Mnemonic):** **F**etus alive, **O**pthalmic/Pelvis adequate, **R**uptured membranes, **C**ervix fully dilated, **E**ngaged head, **P**osition known, **S**tation known/Bladder empty. * **High Forceps:** Historically used when the head is not engaged. It is **contraindicated** in modern obstetrics. * **Most common indication:** Prolonged second stage of labor. * **Key Distinction:** If rotation is **>45 degrees** and station is **≥+2 cm**, it is classified as **Low Forceps with rotation**, not Outlet Forceps.

Q: A gravida 3 female with a history of 2 previous second-trimester abortions presents at 22 weeks of gestation with cervical funneling. What is the most appropriate management?

Apply McDonald suture. ### Explanation The clinical presentation of a patient with a history of recurrent second-trimester abortions and current cervical funneling (shortening and opening of the internal os) is diagnostic of **Cervical Insufficiency**. **1. Why Option D is Correct:** The management of cervical insufficiency is **Cervical Cerclage**. Since the patient is currently at 22 weeks and demonstrating ultrasound changes (funneling), this is classified as **Ultrasound-Indicated Cerclage** (also known as "Rescue" or "Emergency" cerclage if the cervix is dilated). The **McDonald suture** is the most commonly performed technique; it involves a non-absorbable purse-string suture placed at the cervicovaginal junction to provide mechanical support to the weak cervix, thereby preventing premature delivery. **2. Why Other Options are Incorrect:** * **Options A & B (Dinoprostone/Misoprostol):** These are prostaglandins used for cervical ripening and induction of labor or abortion. Administering them in this scenario would be contraindicated as they would further soften the cervix and lead to pregnancy loss. * **Option C (Fothergill Suture):** This is a component of the Manchester operation used for treating **pelvic organ prolapse** (uterine descent) in women who wish to retain their uterus. It is not used for cervical insufficiency in pregnancy. **3. NEET-PG High-Yield Pearls:** * **Timing:** Prophylactic (History-indicated) cerclage is typically performed at **12–14 weeks**. * **Diagnosis:** On Ultrasound, a cervical length **<25 mm** or significant **funneling** (T, Y, V, U shapes) before 24 weeks indicates insufficiency. * **Suture Material:** Usually Mersilene tape (non-absorbable). * **Removal:** The suture is electively removed at **36–37 weeks** or immediately if labor starts to prevent cervical laceration. * **Contraindications:** Chorioamnionitis, active bleeding, ruptured membranes, or fetal anomalies.

Q: A 35-year-old lady, G4 P3, presents with amenorrhea of 12 weeks, excessive vomiting, and bleeding per vaginam. On examination, her pulse is 90/min, BP is 150/110 mm Hg, and the uterus is of 20 weeks size on palpation. What is your most probable diagnosis?

Molar pregnancy. **Explanation:** The clinical presentation is classic for a **Molar Pregnancy (Hydatidiform Mole)**. The diagnosis is based on the following triad: 1. **Size-Date Discrepancy:** The uterus (20 weeks) is significantly larger than the period of amenorrhea (12 weeks). 2. **Early-onset Preeclampsia:** Hypertension (150/110 mm Hg) occurring before 20 weeks of gestation is a hallmark sign of a molar pregnancy. 3. **Hyperemesis:** Excessive vomiting occurs due to abnormally high levels of hCG. **Analysis of Options:** * **Gestational Hypertension:** By definition, this occurs *after* 20 weeks of gestation. Hypertension in the first trimester strongly suggests a molar pregnancy or pre-existing chronic hypertension. * **Polyhydramnios:** While it causes a "size > dates" discrepancy, it typically manifests in the second or third trimester and is not associated with early-onset hypertension or excessive bleeding at 12 weeks. * **Antepartum Hemorrhage (APH):** This refers to bleeding from the genital tract after 28 weeks of gestation. At 12 weeks, bleeding is classified as an abortion or molar pregnancy. **NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** Pelvic Ultrasound showing a **"Snowstorm appearance"** (due to hydropic villi). * **hCG Levels:** Extremely high (often >100,000 mIU/mL). * **Associated Findings:** Theca lutein cysts (bilateral ovarian enlargement) and hyperthyroidism (hCG mimics TSH). * **Treatment of Choice:** Suction and Evacuation (S&E), regardless of uterine size. * **Follow-up:** Weekly serum hCG monitoring until three consecutive negative results to rule out Gestational Trophoblastic Neoplasia (GTN).

Question 1

A 31-year-old G3P2 patient at 34 weeks gestation presents with home blood pressure readings of 100-110/60-70 mmHg. She complains of bilateral pedal edema and mild calf pain at night. Urine dipstick shows trace protein. On examination, there is pitting edema of both legs without calf tenderness. What is the best advice to this patient?

Accepted Answer

Reassure the patient that this is a normal finding of pregnancy.

Answer

Prescribe Lasix (Furosemide) to relieve the painful swelling.

Answer

Perform venous Doppler studies to rule out deep vein thrombosis.

Answer

Admit the patient and investigate to rule out pre-eclampsia.

Question 2

A 29-year-old pregnant female is undelivered at 43 weeks gestation and agrees to undergo induction. Which of the following is NOT an option for cervical ripening?

Accepted Answer

Pitocin (oxytocin)

Answer

Laminaria

Answer

Cervidil (prostaglandin E2 insert)

Answer

Misoprostol

Question 3

Following cesarean section under general anesthesia, after easy delivery of the baby and placenta, the uterus is noted to be boggy and atonic despite intravenous infusion of oxytocin. Which of the following agents is NOT appropriate to use next?

Accepted Answer

Terbutaline administered intravenously

Answer

Methylergonovine administered intramuscularly

Answer

Prostaglandin F2a suppositories

Answer

Misoprostol suppositories

Question 4

In which of the following situations should forceps not be used for delivery?

Accepted Answer

Hydrocephalus

Answer

Twin delivery

Answer

Postmaturity

Answer

After the head has delivered in a breech presentation

Question 5

In a patient undergoing craniotomy for an extradural hematoma in the posterior cranial fossa, which bone is most commonly perforated to gain access?

Accepted Answer

Occipital bone

Answer

Parietal bone

Answer

Palate bone

Answer

Frontal bone

Question 6

Which of the following sites are the rarest and most common for ectopic pregnancy, respectively?

Accepted Answer

Cervix and ampulla of fallopian tube

Answer

Ovary and ampulla of fallopian tube

Answer

Broad ligament and isthmus of fallopian tube

Answer

Abdomen and isthmus of fallopian tube

Question 7

During dilatation and curettage, if the uterine fundus is perforated, what is the most appropriate management?

Accepted Answer

Abdominal exploration

Answer

Observation

Answer

Hysterectomy

Answer

Uterine artery embolization

Question 8

All the following are criteria for outlet forceps application EXCEPT?

Accepted Answer

Station is between 0 and +2 cm

Answer

Fetal skull has reached the pelvic floor

Answer

Scalp is visible at the introitus without separating the labia

Answer

Rotation does not exceed 45 degrees

Question 9

A gravida 3 female with a history of 2 previous second-trimester abortions presents at 22 weeks of gestation with cervical funneling. What is the most appropriate management?

Accepted Answer

Apply McDonald suture

Answer

Administer dinoprostone and bed rest

Answer

Administer misoprostol and bed rest

Answer

Apply Fothergill suture

Question 10

A 35-year-old lady, G4 P3, presents with amenorrhea of 12 weeks, excessive vomiting, and bleeding per vaginam. On examination, her pulse is 90/min, BP is 150/110 mm Hg, and the uterus is of 20 weeks size on palpation. What is your most probable diagnosis?

Accepted Answer

Molar pregnancy

Answer

Gestational hypertension

Answer

Polyhydramnios

Answer

Antepartum hemorrhage

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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