Operative Obstetrics Practice Questions

Q: The triple P procedure for placenta percreta involves all except:

Peripartum hysterectomy. ***Peripartum hysterectomy*** - The **triple P procedure** (or "Pelvic Perfusion and Placenta Praevia Percreta") is a conservative approach aimed at **avoiding hysterectomy** in cases of placenta percreta. - Its goal is to allow for later placental removal, thereby preventing the need for an immediate **peripartum hysterectomy**, which is a high-risk procedure. *Pelvic devascularization* - This typically involves techniques like **internal iliac artery ligation** or **uterine artery embolization** to reduce blood flow to the uterus and placenta. - Reducing perfusion helps to minimize hemorrhage during surgery and **facilitate future placental involution** and separation. *Placental localization using USG* - **Accurate mapping** of the placenta's boundaries and extent of invasion is critical before surgical intervention. - **Ultrasound** (USG) and other imaging modalities like **MRI** are used pre-operatively to guide incisions and determine the optimal approach for placental management. *Myometrial excision for placental nonseparation* - In cases where the placenta has invaded the myometrium (**placenta percreta**), a portion of the **myometrium containing the abnormally implanted placenta** is excised. - This step is crucial for separating the adherent portion of the placenta while preserving the uterus and is a key component of the triple P procedure to **avoid complete hysterectomy**.

Q: All of these may be considered for a classical caesarean section, EXCEPT?

Posterior placenta. ***Posterior placenta*** - A **posterior placenta** is a normal variant and does not necessitate a classical (vertical uterine incision) caesarean section. - The standard approach for a safe delivery in cases of posterior placenta is a **lower uterine segment transverse incision (LSCS)**. *Massive maternal obesity precluding safe access to LUS* - In cases of **severe obesity**, a classical caesarean section may be considered to avoid deep and potentially contaminated subcutaneous fat layers and to achieve safe delivery through a more accessible uterine fundus. - The increased tissue depth can make visualizing and safely incising the **lower uterine segment (LUS)** challenging via a transverse approach. *Previous LSCS with dense bladder adhesions* - **Dense adhesions** from a prior LSCS, especially involving the bladder, can make a repeat transverse lower uterine segment incision technically difficult and increase the risk of bladder injury. - A **classical incision** may be chosen to avoid these adhesions and access an unaffected part of the uterus. *Large lower uterine segment fibroid* - A large fibroid located in the **lower uterine segment** can obstruct the birth canal and prevent a safe transverse incision. - In such situations, a **classical incision** might be necessary to bypass the fibroid and deliver the fetus.

Q: Treatment of choice in placenta accreta :

Hysterectomy. ***Hysterectomy*** - In cases of **placenta accreta**, the placenta abnormally invades the uterine wall, making separation difficult and risking severe hemorrhage. - **Hysterectomy** is the treatment choice to prevent life-threatening bleeding and remove the abnormally adherent placenta along with the uterus. *Manual removal* - **Manual removal** is contraindicated in placenta accreta as it can lead to massive hemorrhage due to the abnormal placental adherence. - This method is typically used for uncomplicated, retained placentas that are not abnormally invasive. *Hysterotomy* - **Hysterotomy** is an incision into the uterus and is not a definitive treatment for placenta accreta. - While it may be used to deliver the baby in certain obstetric scenarios, it does not address the underlying issue of placental adherence. *Wait and watch* - A **wait and watch** approach (expectant management) is associated with a high risk of life-threatening hemorrhage and infection in placenta accreta. - This strategy is not recommended for cases of confirmed placenta accreta due to the significant maternal morbidity and mortality.

Q: Kamla, a 48 years old lady underwent hysterectomy. On the seventh day, she developed fever, burning micturition and continuous urinary dribbling. She can also pass urine voluntarily. The diagnosis is :

Uretero-vaginal fistula. ***Uretero-vaginal fistula*** - **Post-hysterectomy** onset of continuous urinary dribbling, despite being able to void voluntarily, is highly suggestive of a uretero-vaginal fistula. - The ability to pass urine voluntarily indicates the bladder and urethra are intact, suggesting urine is leaking from a higher point in the urinary tract into the vagina. *Vesico-vaginal fistula* - In a vesico-vaginal fistula, urine would leak continuously from the bladder directly into the vagina, leading to complete and constant incontinence and typically **no ability to pass urine voluntarily** once the bladder is emptied. - This patient can still pass urine voluntarily, which makes a uretero-vaginal fistula more likely where one ureter is leaking but the bladder can still collect and empty urine from the other kidney. *Stress incontinence* - This involves involuntary urine leakage with activities that increase **intra-abdominal pressure** (e.g., coughing, sneezing, laughing). - It does not present as continuous dribbling unrelated to physical exertion and would not typically arise as a new symptom seven days post-hysterectomy in this manner. *Urge incontinence* - Characterized by a sudden, strong need to urinate followed by involuntary leakage, often due to **detrusor overactivity**. - It does not cause continuous urinary dribbling and the patient would not be able to pass significant amounts of urine voluntarily in addition to the continuous leakage.

Q: Least common complication in outlet forceps is:

Vulval hematoma. ***Vulval hematoma*** - While possible, a **vulval hematoma** is generally considered a less frequent and often less severe complication specific to outlet forceps compared to tears of the reproductive tract. - Its incidence is lower than that of perineal or cervical tears, which are more directly associated with the mechanics of forceps delivery. *Complete perineal tear* - **Complete perineal tears** (third or fourth-degree) involving the anal sphincter are a significant risk associated with forceps delivery due to the increased tension and pressure on the perineum during extraction. - The instrument and the force applied can overtly stretch or rupture the perineal tissues. *Extension of episiotomy* - An **episiotomy**, often performed during forceps delivery to facilitate delivery and prevent irregular tears, can frequently extend into a more severe laceration, especially under forceful extraction. - The pre-existing incision makes the tissue more vulnerable to further tearing under stress. *Cervical tear* - **Cervical tears** can occur if the cervix is not fully dilated prior to the application and traction of forceps, or if the force applied is excessive. - Undiagnosed or unchecked cervical lacerations can lead to significant hemorrhage.

Q: In breech presentation, the following forceps/methods are used for delivery of the after-coming head EXCEPT:

Wrigley's forceps. ***Wrigley's forceps*** - **Wrigley's forceps** are **outlet forceps** designed for a fully engaged head at the pelvic outlet, with the sagittal suture in the anteroposterior diameter and the fetal scalp visible. - They are used for **cephalic presentations** to assist with delivery of the fetal head when it is low in the pelvis, not for the after-coming head in breech presentation. *Mauriceau-Smellie-Veit technique* - This is a **manual maneuver** specifically used to deliver the after-coming head in a **breech presentation**. - It involves supporting the fetal body and applying pressure to the maxilla to promote head flexion and delivery. *Kielland's forceps* - **Kielland's forceps** are used for **rotational deliveries** and can be applied in **breech presentations** for the delivery of the after-coming head, particularly when some degree of rotation is required. - Their unique design allows for application even when the head is malpositioned or high in the pelvis. *Piper forceps* - **Piper forceps** are specifically designed for the **after-coming head** in **breech delivery**. - They have a perineal curve and downward-angled shanks allowing them to be applied from below the fetal body to engage the head in the pelvis, preventing head extension and facilitating controlled delivery.

Q: End point of D&C is?

Uterine cry. ***Uterine cry*** - A "uterine cry" refers to the characteristic **grating sound** or sensation felt by the surgeon as the curette scrapes the firm, fibrous uterine wall after the removal of softer contents. - This sensation indicates that the **endometrial cavity has been adequately curetted** and that no further tissue, such as retained products of conception, remains. *After 2 strokes* - The number of strokes is **not a reliable endpoint** for a D&C, as the amount and consistency of uterine contents can vary widely. - Relying solely on a fixed number of strokes could lead to **incomplete evacuation** or **unnecessary scraping**, increasing risks. *Presence of fresh bleeding* - While some **fresh bleeding** is expected during and after a D&C, it is **not an endpoint**; excessive or persistent bleeding may indicate retained tissue or complications. - The goal is to **remove uterine contents and minimize bleeding**, not to continue until bleeding stops, which could be misleading. *All of the options* - Only the **uterine cry** is a widely accepted and reliable endpoint indicating thorough evacuation of the uterine cavity during a D&C. - The other options do not accurately represent the completion of the procedure or could indicate a complication.

Q: Internal podalic version is done for:

Transverse lie in 2nd twins. ***Transverse lie in 2nd twins*** - **Internal podalic version** is a procedure used to convert a fetal **transverse lie** into a **breech presentation**, allowing for vaginal delivery, particularly useful for the second twin. - It is often performed when the second twin is in a transverse lie or oblique lie after the first twin has been delivered, to expedite delivery and prevent complications. *Brow presentation* - **Brow presentation** is a cephalic presentation where the fetal head is incompletely flexed, presenting with the brow as the leading part through the birth canal. - Internal podalic version is not indicated for brow presentation; **cesarean section** is often necessary due to the large presenting diameter. *Breech presentation* - **Breech presentation** is when the fetus presents buttocks or feet first. - While external cephalic version (ECV) can be tried for breech presentation, internal podalic version is specifically used to *achieve* a breech presentation from a transverse lie, not to manage an existing breech. *None of the options* - This option is incorrect because internal podalic version has a specific, medically indicated use, as described with the correct option. - The procedure is a classic obstetric maneuver with clear indications in specific delivery scenarios.

Q: Most safe and effective evacuation in a patient with missed abortion at 14-16 weeks can be achieved with

Misoprostol. ***Misoprostol*** - **Misoprostol** is a **prostaglandin E1 analog** that ripens the cervix and stimulates uterine contractions, making it highly effective for inducing labor and expelling uterine contents in cases of missed abortion, especially in the second trimester (14-16 weeks). - Its oral or vaginal administration offers a **non-invasive**, safe, and cost-effective approach for uterine evacuation, minimizing the risks associated with surgical procedures. *Extra-amniotic ethacrydyl lactate* - Extra-amniotic ethacrydyl lactate is an older method that is **not commonly used** for cervical ripening and uterine evacuation due to better, safer, and more effective alternatives. - This method involves injecting a substance outside the amniotic sac, which can carry a **higher risk of infection** and potentially incomplete evacuation compared to modern approaches. *Carboprost* - **Carboprost** is a **prostaglandin F2 alpha analog** primarily used to manage **postpartum hemorrhage** and is less commonly the first-line agent for evacuating missed abortions at this gestation. - While it can induce contractions, its side-effect profile (e.g., **bronchospasm**, **gastrointestinal upset**) and specific indications make it less ideal for routine induction for missed abortion compared to misoprostol. *Oxytocin* - **Oxytocin** is effective in stimulating uterine contractions mainly when the cervix is already ripe or near term, but it is **less effective** for cervical ripening and prolonged induction in the second trimester for missed abortion. - In cases of missed abortion at 14-16 weeks, the uterus is less responsive to oxytocin alone, and large doses may be needed, which could carry increased risks.

Q: Which of the following cannot be treated by laparoscopy?

Genital prolapse. ***Genital prolapse*** - Among the options listed, **genital prolapse** is the condition LEAST suited for complete laparoscopic management, particularly in the context of this examination question. - While **laparoscopic sacrocolpopexy** and **sacral hysteropexy** exist for vault prolapse and uterine prolapse respectively, these procedures were less established at the time of this exam (2012) and require advanced laparoscopic skills. - Most cases of **genital prolapse**, especially complete pelvic organ prolapse, traditionally require **vaginal surgical approaches** or **open abdominal procedures** for comprehensive repair of multiple compartment defects. - The complex anatomical reconstruction needed for severe prolapse (anterior, posterior, and apical compartments) is more challenging via laparoscopy compared to the other listed conditions. *Non descent of uterus* - **Non-descent vaginal hysterectomy** can be performed with **laparoscopic assistance (LAVH/LDVH)** or as **total laparoscopic hysterectomy (TLH)**. - Laparoscopy facilitates dissection of uterine attachments, ligation of vessels, and removal of the uterus with minimal morbidity. *Ectopic pregnancy* - **Ectopic pregnancy** is a standard indication for laparoscopic surgery, performed routinely worldwide. - Procedures include **laparoscopic salpingectomy** (removal of affected tube) or **salpingostomy** (conservative surgery preserving the tube). - Offers advantages of minimal invasiveness, reduced recovery time, and excellent visualization. *Sterilization* - **Laparoscopic tubal sterilization** is one of the most common laparoscopic procedures performed. - Methods include application of **Filshie clips, Falope rings**, or **electrocautery** to occlude fallopian tubes. - Gold standard for permanent contraception with minimal morbidity.

Question 1

The triple P procedure for placenta percreta involves all except:

Accepted Answer

Peripartum hysterectomy

Answer

Pelvic devascularization

Answer

Placental localization using USG

Answer

Myometrial excision for placental nonseparation

Question 2

All of these may be considered for a classical caesarean section, EXCEPT?

Accepted Answer

Posterior placenta

Answer

Massive maternal obesity precluding safe access to LUS

Answer

Previous LSCS with dense bladder adhesions

Answer

Large lower uterine segment fibroid

Question 3

Treatment of choice in placenta accreta :

Accepted Answer

Hysterectomy

Answer

Manual removal

Answer

Hysterotomy

Answer

Wait and watch

Question 4

Kamla, a 48 years old lady underwent hysterectomy. On the seventh day, she developed fever, burning micturition and continuous urinary dribbling. She can also pass urine voluntarily. The diagnosis is :

Accepted Answer

Uretero-vaginal fistula

Answer

Vesico-vaginal fistula

Answer

Stress incontinence

Answer

Urge incontinence

Question 5

Least common complication in outlet forceps is:

Accepted Answer

Vulval hematoma

Answer

Complete perineal tear

Answer

Extension of episiotomy

Answer

Cervical tear

Question 6

In breech presentation, the following forceps/methods are used for delivery of the after-coming head EXCEPT:

Accepted Answer

Wrigley's forceps

Answer

Mauriceau-Smellie-Veit technique

Answer

Kielland's forceps

Answer

Piper forceps

Question 7

End point of D&C is?

Accepted Answer

Uterine cry

Answer

After 2 strokes

Answer

Presence of fresh bleeding

Answer

All of the options

Question 8

Internal podalic version is done for:

Accepted Answer

Transverse lie in 2nd twins

Answer

Brow presentation

Answer

Breech presentation

Answer

None of the options

Question 9

Most safe and effective evacuation in a patient with missed abortion at 14-16 weeks can be achieved with

Accepted Answer

Misoprostol

Answer

Extra-amniotic ethacrydyl lactate

Answer

Carboprost

Answer

Oxytocin

Question 10

Which of the following cannot be treated by laparoscopy?

Accepted Answer

Genital prolapse

Answer

Non descent of uterus

Answer

Ectopic pregnancy

Answer

Sterilization

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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