Operative Obstetrics Practice Questions

Q: What is the surgery of choice for a 42-year-old woman with diffuse endometriosis?

Hysterectomy with BSO and resection of endometrial implants. ***Hysterectomy with BSO and resection of endometrial implants*** - This option offers the most **definitive treatment** for widespread or diffuse endometriosis in a woman who has completed childbearing. - **Hysterectomy** removes the uterus, **bilateral salpingo-oophorectomy (BSO)** removes the ovaries and fallopian tubes (eliminating the source of estrogen that fuels endometriosis), and **resection of implants** addresses existing endometriotic lesions throughout the pelvis. *Ovarian cystectomy & adhesiolysis* - This approach is too **conservative** for diffuse endometriosis and primarily addresses endometriomas and pelvic adhesions. - It would likely lead to **recurrence** of diffuse disease as the underlying hormonal stimulation and other implants remain. *Hysterectomy* - While removing the uterus would address uterine involvement like adenomyosis, it **does not remove the ovaries**, which are the primary source of estrogen responsible for the growth and persistence of endometrial implants. - This option leaves the patient susceptible to continued growth of endometrial implants and associated pain if the ovaries are retained. *Ovarian cystectomy & adhesiolysis & resection of implants* - This option addresses existing lesions but **does not remove the uterus or ovaries**, leaving the underlying hormonal environment conducive to further disease progression. - It's a more targeted approach but **less comprehensive** for diffuse disease and carries a higher risk of recurrence compared to definitive surgery.

Q: A patient delivered at home with a complete perineal tear came to the hospital after 2 weeks. What is the most appropriate management option?

Repair after 3 months. ***Repair after 3 months*** - Delayed repair of a **complete perineal tear** (third or fourth degree) is ideally performed after **3-6 months** postpartum to allow for complete resolution of **edema**, **inflammation**, and establishment of mature, non-friable tissue. - This timing ensures optimal healing conditions with reduced tissue friability, minimal infection risk, and better anatomical outcomes. - Operating during this window provides the best balance between allowing adequate tissue healing while avoiding excessive scar contracture. *Repair after 6-8 weeks* - At 6-8 weeks postpartum, tissues are still undergoing active healing and remodeling, making them suboptimal for surgical repair. - While some edema may have resolved, the **tissue integrity** is not yet mature enough for successful delayed reconstruction. - This timing is too early for the standard delayed repair protocol recommended for complete perineal tears. *Immediate surgical intervention* - Immediate repair (within 12-24 hours of delivery) is the **gold standard** for acute complete perineal tears diagnosed at the time of delivery. - Since the patient presents **2 weeks postpartum**, the optimal window for primary repair has passed, and attempting repair now would face significant challenges from **tissue edema** and early **wound healing processes**. *Repair after 2 weeks* - At 2 weeks postpartum, tissues are still markedly **edematous** and in the active inflammatory phase of healing. - Surgical intervention at this stage carries high risk of wound breakdown, infection, and poor anatomical results due to **tissue friability** and suboptimal healing conditions. - This timing is far too early for delayed repair of complete perineal tears.

Q: Which distension medium is used for hysteroscopy with bipolar cautery?

NS. ***NS*** - **Normal Saline (NS)** is an **electrolyte-containing solution** (0.9% NaCl) and is thus safe to use with **bipolar electrosurgery** because it does not conduct current across the tissue but only between the two poles of the instrument. - Its isotonicity minimizes fluid shifts and its clear nature allows for good visualization. *Glycine* - **Glycine** is a **non-electrolyte solution** that is used with **monopolar electrosurgery**, as it does not conduct electrical current to the patient but only through the active electrode. - Using it with bipolar devices is unnecessary and can lead to complications such as **dilutional hyponatremia** and **hyperammonemia** if significant intravascular absorption occurs. *Carbon Dioxide* - **Carbon dioxide** is used as a distension medium for **diagnostic hysteroscopy** because of its lack of risk for fluid overload and clear visualization. - It is **contraindicated with electrosurgery** because of the risk of **gas embolism** and its potential for impaired visualization with significant bleeding. *Dextran 70* - **Dextran 70** is a **high-viscosity, non-electrolyte solution** primarily used for diagnostic hysteroscopy when blood or mucus obscures the view. - It is **contraindicated for electrosurgery** due to its non-conductive nature and the risk of **anaphylactic reactions** and **pulmonary edema** from volume expansion.

Q: A pregnant patient, with a history of classical cesarean section in view of fetal growth retardation in the previous pregnancy, presents to you. She is currently at 35 weeks of gestation with breech presentation. What is the next step in management?

Cesarean section at 37 weeks. ***Cesarean section at 37 weeks*** - A history of **classical cesarean section** is an absolute contraindication to vaginal birth due to the high risk of **uterine rupture**. - Performing the cesarean section at 37 weeks, rather than waiting longer, minimizes the risk of spontaneous labor and rupture while ensuring fetal maturity. *Advice USG and visit after 2 weeks* - This option does not address the critical risk of **uterine rupture** due to the previous classical cesarean section. - Delaying definitive management by two weeks could increase the risk of spontaneous labor and associated complications. *Internal podalic version followed by vaginal delivery* - An **internal podalic version** is a procedure used to change fetal lie during labor, typically for the second twin, and it is **contraindicated** with a previous classical cesarean due to rupture risk. - Given the previous classical incision, a **vaginal delivery is unsafe** and should not be attempted. *External cephalic version at 36 weeks* - **External cephalic version (ECV)** is generally contraindicated in patients with a history of a **classical cesarean section** due to the increased risk of uterine rupture. - Even if successful, the patient would still require a cesarean section for delivery given the previous uterine scar.

Q: Which of the following methods is known as a fimbriectomy procedure?

Kroener procedure. ***Kroener procedure*** - The **Kroener procedure** is a method of **tubal ligation** particularly known as a **fimbriectomy**, where the fimbriated end of the fallopian tube is removed. - This sterilization technique primarily involves excising the **fimbriae**, preventing **ovum capture** and subsequent fertilization. *Uchida procedure* - The **Uchida procedure** involves **injecting a sclerosing solution** under the serosa of the fallopian tube, then excising a small segment and ligating the ends. - This method aims to **bury the fimbriated end** within the broad ligament, but it is not a fimbriectomy. *Irving procedure* - The **Irving procedure** involves **tying and transecting the fallopian tube**, then burying the severed medial end into the posterior wall of the uterus. - This technique is designed to prevent **fistula formation** and recanalization but does not involve fimbriectomy. *Madlener procedure* - The **Madlener procedure** involves **crushing a section** of the fallopian tube, usually a knuckle, and then ligating it. - This method is simpler but has a **higher failure rate** compared to other sterilization techniques and does not involve removal of the fimbriae.

Q: Which type of suture is primarily used for the repair of a complete perineal tear?

Vicryl. ***Correct Answer: Vicryl (Polyglactin 910)*** - **Vicryl is the gold standard suture material** for repair of complete perineal tears (third and fourth-degree) - It is a **synthetic absorbable braided suture** with excellent tensile strength that maintains tissue support during critical healing phase - **Absorption profile**: Loses 50% tensile strength by 2 weeks, completely absorbed in 56-70 days, ideal for perineal tissue healing - **Minimal tissue reaction** and low infection risk compared to natural sutures - **Recommended by RCOG and ACOG guidelines** for layer-by-layer repair of perineal tears involving anal sphincter *Incorrect: Monocryl* - Monocryl (Poliglecaprone 25) is a fast-absorbing monofilament suture primarily used for **subcuticular skin closure** - Not the first choice for deep tissue repair of complete perineal tears - Has faster absorption (90-120 days) which may not provide adequate support for sphincter repair *Incorrect: Catgut* - Catgut is a natural absorbable suture that was **historically used but is now largely obsolete** - **Higher tissue reaction**, increased infection risk, and unpredictable absorption make it unsuitable - Modern synthetic sutures like Vicryl have replaced catgut in current obstetric practice *Incorrect: Silk* - Silk is a **non-absorbable suture** that is inappropriate for perineal repair - Would require removal and carries risk of chronic foreign body reaction - Never used for internal structures in perineal reconstruction

Q: Uterine rupture is most common in -

Classical cesarean section. ***Classical cesarean section*** - A **classical cesarean section** involves a vertical incision in the uterine fundus, which heals less strongly and is more prone to rupture in subsequent pregnancies or labor due to the higher muscle content and poorer healing. - The **thinness and weaker scar tissue** in the fundus compared to the lower segment contribute significantly to the increased rupture risk. *Anterior lower segment C.S* - A **lower segment transverse incision** is the most common type of cesarean section today and has a significantly lower risk of uterine rupture (around 0.2-0.5%) compared to classical incisions. - This is because the lower uterine segment is thinner and contains less muscle, leading to a **stronger and more robust scar**. *Placenta previa* - While **placenta previa** is a serious obstetric complication that can cause massive hemorrhage, it is not directly associated with uterine rupture. - It involves the placenta covering the cervical os, leading to bleeding, but does not inherently weaken the uterine wall to cause rupture. *Normal labor* - Uterine rupture in an unscarred uterus during normal labor is extremely rare, often associated with factors like **grand multiparity**, improper use of oxytocin, or obstructed labor. - The intact uterine wall is generally resilient enough to withstand the forces of labor without rupturing spontaneously.

Q: In which of the following scenarios is the risk of uterine rupture the least?

Lower segment incision. ***Lower segment incision*** - A **low transverse uterine incision** (often called a lower segment incision) is made in the thinnest, most contractile part of the lower uterine segment, which heals with a **stronger scar**. - This type of scar is less likely to rupture in subsequent pregnancies compared to other incision types. *Classic cesarean section* - A **classic cesarean section** involves a **vertical incision in the upper, contractile part of the uterus**, which heals less strongly due to its higher muscle content and greater stretching during subsequent pregnancies. - This incision carries the **highest risk of uterine rupture** in future pregnancies, often necessitating repeat cesarean deliveries. *Inverted T incision* - An **inverted T incision** is a variation of a classic cesarean, occurring when a low transverse incision tears vertically, or is intentionally extended vertically, leading to a **T-shaped scar**. - This type of incision creates a **compromised and weaker scar** that is at a higher risk of rupture in future pregnancies, similar to a classic cesarean. *Low vertical incision* - A **low vertical incision** is made in the lower uterine segment but is oriented vertically instead of transversally. - While it is generally less risky than a classic cesarean, it still carries a **higher risk of rupture** compared to a low transverse incision, as vertical scars are inherently weaker than transverse ones.

Q: What is a definitive indication for performing a Lower Segment Cesarean Section (LSCS)?

Contracted pelvis. ***Contracted pelvis*** - A **contracted pelvis** means the maternal pelvic dimensions are too small to allow for the safe passage of the fetus, making a vaginal birth impossible or highly risky. - This **fetopelvic disproportion** (cephalopelvic disproportion) necessitates a C-section to prevent obstructed labor, fetal distress, and potential harm to both mother and baby. - A contracted pelvis is a **definitive indication** for LSCS as vaginal delivery is contraindicated. *Mento anterior presentation* - In a **mento anterior presentation**, the fetal chin (mentum) is anterior, which is a **favorable position** for vaginal delivery as it allows for proper neck extension and engagement. - This presentation does not typically require a C-section unless there are other complicating factors. *Occipito posterior presentation* - While an **occipito posterior presentation** can sometimes lead to prolonged labor or the need for instrumental delivery, it is **not an absolute indication** for C-section. - Many cases can still deliver vaginally, either spontaneously or with rotation, and surgical intervention is usually reserved for failure to progress or fetal distress. *Vertex presentation* - A **vertex presentation** means the fetal head is flexed and presenting first, which is the **most common and ideal presentation** for a vaginal birth. - This presentation is a sign of a normal, potentially uncomplicated delivery and is the opposite of an indication for C-section.

Q: The optimal timing for external cephalic version (ECV) is

36 weeks. ***36 weeks*** - At **36 weeks gestation**, there is still enough **amniotic fluid** and fetal size is not too large, which allows for successful manipulation. - This timing is particularly optimal for **multiparous women** according to **RCOG guidelines** (36-37 weeks). - This timing also minimizes the risk of **spontaneous reversion** back to a breech presentation before labor begins. - Balances adequate fetal maturity with sufficient uterine space for successful version. *34 weeks* - Performing an external cephalic version (ECV) at 34 weeks has a lower success rate and a higher chance of **spontaneous reversion** due to the smaller fetal size and relatively more amniotic fluid. - The chance of **spontaneous cephalic version** (natural turning) is still significant at this stage, making an earlier intervention potentially unnecessary. - Too early for routine ECV as many breech presentations spontaneously convert to cephalic before 36 weeks. *38 weeks* - By 38 weeks, the fetus is larger and there is proportionally less **amniotic fluid**, which makes successful external version more difficult and painful for the mother. - While **ACOG recommends 37-38 weeks**, the success rate decreases with advancing gestation due to reduced uterine space. - The risk of **uterine contractions** and iatrogenic induction of labor is higher at this gestation. *40 weeks* - At 40 weeks, the fetus is at term and much larger, occupying most of the uterine cavity, significantly reducing the chances of a successful external version. - The risk of complications such as **placental abruption**, **cord compression**, and premature labor is increased. - Success rates are markedly lower, making routine ECV at this stage generally not recommended.

Question 1

What is the surgery of choice for a 42-year-old woman with diffuse endometriosis?

Accepted Answer

Hysterectomy with BSO and resection of endometrial implants

Answer

Ovarian cystectomy & adhesiolysis

Answer

Hysterectomy

Answer

Ovarian cystectomy & adhesiolysis & resection of implants

Question 2

A patient delivered at home with a complete perineal tear came to the hospital after 2 weeks. What is the most appropriate management option?

Accepted Answer

Repair after 3 months

Answer

Repair after 2 weeks

Answer

Immediate surgical intervention

Answer

Repair after 6-8 weeks

Question 3

Which distension medium is used for hysteroscopy with bipolar cautery?

Accepted Answer

NS

Answer

Glycine

Answer

Carbon Dioxide

Answer

Dextran 70

Question 4

A pregnant patient, with a history of classical cesarean section in view of fetal growth retardation in the previous pregnancy, presents to you. She is currently at 35 weeks of gestation with breech presentation. What is the next step in management?

Accepted Answer

Cesarean section at 37 weeks

Answer

Advice USG and visit after 2 weeks

Answer

Internal podalic version followed by vaginal delivery

Answer

External cephalic version at 36 weeks

Question 5

Which of the following methods is known as a fimbriectomy procedure?

Accepted Answer

Kroener procedure

Answer

Uchida procedure

Answer

Irving procedure

Answer

Madlener procedure

Question 6

Which type of suture is primarily used for the repair of a complete perineal tear?

Accepted Answer

Vicryl

Answer

Monocryl

Answer

Catgut

Answer

Silk

Question 7

Uterine rupture is most common in -

Accepted Answer

Classical cesarean section

Answer

Anterior lower segment C.S

Answer

Placenta previa

Answer

Normal labor

Question 8

In which of the following scenarios is the risk of uterine rupture the least?

Accepted Answer

Lower segment incision

Answer

Classic cesarean section

Answer

Inverted T incision

Answer

Low vertical incision

Question 9

What is a definitive indication for performing a Lower Segment Cesarean Section (LSCS)?

Accepted Answer

Contracted pelvis

Answer

Mento anterior presentation

Answer

Occipito posterior presentation

Answer

Vertex presentation

Question 10

The optimal timing for external cephalic version (ECV) is

Accepted Answer

36 weeks

Answer

34 weeks

Answer

38 weeks

Answer

40 weeks

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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