Operative Obstetrics — MCQs

A 32-year-old second gravida, who had a lower segment caesarean section (LSCS) in her first pregnancy, is admitted in labor. The fetus is in cephalic presentation, the head is engaged, and the estimated fetal weight is 3 kg. Uterine contractions are 2 per 10 minutes, and the fetal heart rate is 140 bpm. The cervical dilation is 5 cm. The vertex is felt 1 cm above the ischial spines, and the posterior fontanelle is palpable. The pelvis is adequate, and the membranes are intact. What is the best management option?

Q27Easy

What are the contraindications for the medical method (mifepristone and misoprostol) of first-trimester medical termination of pregnancy?

Q28Medium

Which of the following is associated with an increased risk of thromboembolism in a normal pregnancy?

Q29Medium

Which of the following is NOT used for first-trimester abortion?

Q30Medium

In which surgical approach is the tube opened to remove the gestational products, then left unsutured?

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 21: Which of the following procedures can be performed for all of the following conditions except?

A. An approach for tubal sterilization
B. Removal of fibroids or myxoma
C. Removal of displaced copper-T (Correct Answer)
D. Drainage of pelvic abscess

Explanation: The question refers to procedures performed via **Posterior Colpotomy** (entering the Pouch of Douglas through the posterior vaginal fornix). ### **Explanation** **Why "Removal of displaced Copper-T" is the correct answer:** When a Copper-T (IUCD) is "displaced," it has often perforated the uterus and migrated into the peritoneal cavity. While a simple pelvic Copper-T could theoretically be reached via colpotomy, it is **not the standard of care**. A displaced IUCD can migrate anywhere in the abdomen (omentum, paracolic gutters, or near the bowel). Therefore, **Laparoscopy** is the gold standard for locating and removing a displaced IUCD, as it provides a superior field of view compared to the restricted access of a colpotomy. ### **Analysis of Other Options:** * **A. Tubal Sterilization:** Posterior colpotomy was historically a common route for tubal ligation (vaginal tubectomy). Though largely replaced by laparoscopy, it remains a valid surgical approach. * **B. Removal of Fibroids/Myxoma:** Small, pedunculated subserous fibroids or prolapsed pedunculated submucous fibroids (sometimes referred to as "myxomas" in older texts) located in the Pouch of Douglas can be removed via this route. * **D. Drainage of Pelvic Abscess:** This is the **classic indication** for posterior colpotomy (Colpotomy Drainage). If a pelvic abscess is pointing into the posterior fornix, it is drained here to ensure dependent drainage. ### **NEET-PG High-Yield Pearls:** * **Culdocentesis:** A diagnostic procedure using a needle to aspirate fluid from the Pouch of Douglas (used for suspected ruptured ectopic pregnancy or pelvic inflammatory disease). * **Colpotomy vs. Culdotomy:** Often used interchangeably; it involves an incision into the vaginal wall to reach the peritoneal cavity. * **Contraindication:** Colpotomy should never be performed if the Pouch of Douglas is obliterated (e.g., severe endometriosis or dense adhesions).

Question 22: From what cervical dilatation (in cm) is a partogram plotted at regular intervals?

A. 4 cm (Correct Answer)
B. 5 cm
C. 6 cm
D. 8 cm

Explanation: ### Explanation **1. Why 4 cm is the Correct Answer:** The partogram is a graphical representation of labor progress. According to the **World Health Organization (WHO)** and standard obstetric guidelines, the partogram is initiated at the onset of the **Active Phase** of the first stage of labor. Traditionally, the active phase is defined as starting when cervical dilatation reaches **4 cm** in the presence of regular uterine contractions. Plotting at this stage allows for the early identification of labor dystocia (prolonged labor) by monitoring the rate of dilatation against the "Alert" and "Action" lines. **2. Analysis of Incorrect Options:** * **B (5 cm) & C (6 cm):** While recent guidelines (like the WHO Labor Care Guide 2020 and Zhang’s criteria) suggest that the active phase may actually accelerate closer to 5 or 6 cm, the **standard textbook definition** for exam purposes (and the traditional WHO partogram) remains 4 cm. * **D (8 cm):** This represents advanced labor. Plotting this late would defeat the purpose of the partogram, which is to provide an early warning system for deviations from normal labor progress. **3. High-Yield Clinical Pearls for NEET-PG:** * **Components of Partogram:** It monitors three areas: Fetal condition (FHR, membranes, liquor), Labor progress (Dilatation, descent, contractions), and Maternal condition (Pulse, BP, temperature, urine). * **Alert Line:** A diagonal line starting at 4 cm dilatation representing a rate of 1 cm/hour. * **Action Line:** Parallel to the alert line and usually **4 hours** to its right. Crossing this line indicates the need for intervention (e.g., augmentation or C-section). * **Latent Phase:** Defined as 0–3 cm dilatation; it is usually not plotted on the standard WHO partogram to avoid unnecessary early interventions. * **Frequency of PV Examination:** In the active phase, cervical dilatation is typically assessed every **4 hours** unless indicated otherwise.

Question 23: All of the following drugs have been used for medical abortion except?

A. Mifepristone
B. Misoprostol
C. Methotrexate
D. Atosiban (Correct Answer)

Explanation: **Explanation:** The correct answer is **Atosiban** because it is a **tocolytic agent**, not an abortifacient. **1. Why Atosiban is the correct answer:** Atosiban is a competitive **Oxytocin receptor antagonist**. Its primary clinical use is to inhibit uterine contractions to delay preterm labor (tocolysis). By blocking oxytocin receptors in the myometrium, it causes uterine relaxation. Since medical abortion requires uterine contraction and cervical ripening to expel the products of conception, a drug that relaxes the uterus is contraindicated for this purpose. **2. Analysis of Incorrect Options (Drugs used for Medical Abortion):** * **Mifepristone (RU-486):** An anti-progestogen that blocks progesterone receptors, leading to decidual breakdown, cervical softening, and increased uterine sensitivity to prostaglandins. It is the first step in the standard medical abortion regimen. * **Misoprostol:** A PGE1 analogue that causes cervical ripening and potent uterine contractions. It is used in combination with Mifepristone to expel the gestational sac. * **Methotrexate:** A folate antagonist that inhibits dihydrofolate reductase. It targets rapidly dividing trophoblastic cells. While less common now due to the high efficacy of Mifepristone, it is still a recognized medical option, especially in ectopic pregnancies or when Mifepristone is unavailable. **Clinical Pearls for NEET-PG:** * **Standard Regimen (up to 9 weeks/63 days):** 200 mg Mifepristone (Oral) followed by 800 mcg Misoprostol (Vaginal/Buccal/Sublingual) after 24–48 hours. * **MTP Act Amendment (2021):** Upper limit for abortion is increased to 24 weeks for specific categories of women; however, medical abortion is most effective in the first trimester. * **Atosiban Side Effects:** Generally well-tolerated; most common are nausea, headache, and injection site reactions. Unlike Beta-mimetics (Ritodrine), it has minimal cardiovascular side effects.

Question 24: Normally, what is the upper limit for Nuchal Translucency measurement?

A. More than 10 mm
B. Less than 6 mm
C. Less than 3 mm (Correct Answer)
D. More than 5 mm

Explanation: **Explanation:** **Nuchal Translucency (NT)** is the sonographic appearance of a collection of fluid under the skin behind the fetal neck in the first trimester. It is a critical screening marker for chromosomal abnormalities and structural defects. **1. Why "Less than 3 mm" is correct:** In clinical practice and standardized screening protocols (Fetal Medicine Foundation), the 95th percentile for NT thickness is approximately 2.5 mm, while the **99th percentile is 3.5 mm**. For the purpose of competitive exams like NEET-PG, **3 mm** is generally accepted as the upper limit of normal. A measurement **< 3 mm** is considered a low-risk finding, whereas a measurement ≥ 3 mm (or > 3.5 mm) is considered increased and warrants further diagnostic testing (CVS or Amniocentesis). **2. Why other options are incorrect:** * **Options A & D (> 10 mm and > 5 mm):** These values are significantly pathological. An NT > 3.5 mm is associated with a high risk of Trisomy 21 (Down Syndrome), Trisomy 18, Trisomy 13, and Turner Syndrome. * **Option B (< 6 mm):** This threshold is too high. Using 6 mm as a cutoff would result in a dangerously high false-negative rate, missing the majority of chromosomal anomalies. **3. High-Yield Clinical Pearls for NEET-PG:** * **Timing:** NT must be measured between **11 weeks and 13 weeks 6 days** of gestation. * **CRL Criteria:** The Fetal Crown-Rump Length (CRL) must be between **45 mm and 84 mm**. * **Associated Conditions:** Increased NT is not only seen in aneuploidies but is also a strong marker for **Congenital Heart Disease** (most common), diaphragmatic hernia, and skeletal dysplasias. * **Combined Test:** NT is used along with maternal age and biochemical markers (**PAPP-A and β-hCG**) to calculate the risk for Down Syndrome.

Question 25: Abortion at 11 weeks of pregnancy can be done by:

A. Suction evacuation (Correct Answer)
B. Hypertonic saline
C. Ethacrynine lactate
D. Oxytocin

Explanation: **Explanation:** The management of abortion is categorized based on the gestational age. For the **first trimester (up to 12 weeks)**, surgical evacuation via **Suction Evacuation (Suction Curettage)** is the gold standard. At 11 weeks, the products of conception are small enough to be safely aspirated using a Karman’s cannula or a rigid suction tip under negative pressure. This method is preferred due to its high efficacy, speed, and lower risk of complications compared to medical induction at this specific stage. **Analysis of Incorrect Options:** * **B. Hypertonic Saline & C. Ethacridine Lactate:** These are methods used for **second-trimester** induction (typically 15–20 weeks). They act as abortifacients by causing fetal demise and stimulating uterine contractions (intra-amniotic or extra-amniotic instillation). They are not used in the first trimester as the amniotic sac is too small for safe instillation. * **D. Oxytocin:** While oxytocin causes uterine contractions, the first-trimester uterus has a **low density of oxytocin receptors**. Therefore, high-dose oxytocin is ineffective for inducing abortion at 11 weeks and carries a risk of water intoxication. **High-Yield Clinical Pearls for NEET-PG:** * **MVA (Manual Vacuum Aspiration):** Can be done up to 12 weeks (ideally <10 weeks) using a handheld syringe. * **EVA (Electric Vacuum Aspiration):** Preferred for 10–12 weeks due to consistent pressure. * **Medical Method (Mifepristone + Misoprostol):** Recommended up to 9 weeks (63 days) as per WHO/RCOG, though some protocols extend this to 12 weeks. * **Dilatation and Evacuation (D&E):** The preferred surgical method for the second trimester (13–24 weeks).

Question 26: A 32-year-old second gravida, who had a lower segment caesarean section (LSCS) in her first pregnancy, is admitted in labor. The fetus is in cephalic presentation, the head is engaged, and the estimated fetal weight is 3 kg. Uterine contractions are 2 per 10 minutes, and the fetal heart rate is 140 bpm. The cervical dilation is 5 cm. The vertex is felt 1 cm above the ischial spines, and the posterior fontanelle is palpable. The pelvis is adequate, and the membranes are intact. What is the best management option?

A. Perform an amniotomy and allow labor to progress (Correct Answer)
B. Perform an amniotomy and commence an infusion of oxytocin
C. Perform a caesarean section
D. Perform a ventouse delivery in the second stage

Explanation: ### Explanation **Correct Option: A. Perform an amniotomy and allow labor to progress** The patient is a candidate for **Trial of Labor After Cesarean (TOLAC)**. She meets the favorable criteria: a single previous LSCS, cephalic presentation, adequate pelvis, and an estimated fetal weight <4 kg. She is already in the active phase of labor (5 cm dilation). In a patient with a scarred uterus, the preferred management is to allow spontaneous labor to progress under close monitoring. **Amniotomy (Artificial Rupture of Membranes)** is a safe intervention to augment labor naturally by increasing endogenous prostaglandin release and improving contact between the presenting part and the cervix. **Why other options are incorrect:** * **B. Oxytocin infusion:** While oxytocin can be used in TOLAC, it must be used with extreme caution due to the risk of **uterine rupture**. Since the patient is already progressing and has 2 contractions per 10 minutes, amniotomy should be the first step. Oxytocin is reserved for secondary arrest or inadequate contractions. * **C. Caesarean section:** There is no immediate indication for a repeat LSCS (ERCS). The fetal heart rate is stable, the pelvis is adequate, and labor is progressing. * **D. Ventouse delivery:** This is premature. Ventouse (vacuum) is an instrumental delivery method used in the **second stage** of labor. The patient is currently only 5 cm dilated (first stage). **Clinical Pearls for NEET-PG:** * **Success rate of VBAC:** Approximately 70–75% in selected cases. * **Contraindications for TOLAC:** Previous classical/T-shaped incision, previous uterine rupture, or more than two prior LSCS (relative). * **Monitoring:** The most reliable early sign of uterine rupture during TOLAC is **fetal heart rate abnormalities** (typically prolonged bradycardia), not abdominal pain. * **Bishop Score:** A score >6 is a favorable predictor for a successful VBAC.

Question 27: What are the contraindications for the medical method (mifepristone and misoprostol) of first-trimester medical termination of pregnancy?

A. Patient with a hemoglobin of 7 gm%
B. Suspected ectopic pregnancy
C. Glaucoma
D. All of the above (Correct Answer)

Explanation: The medical method of termination of pregnancy (MTP) using the combination of **Mifepristone** (Progesterone antagonist) and **Misoprostol** (Prostaglandin E1 analogue) is highly effective but requires careful patient selection. **Explanation of Options:** * **A. Hemoglobin of 7 gm% (Severe Anemia):** Medical MTP is associated with more blood loss compared to surgical methods. In a patient with severe anemia (Hb < 8 gm%), the physiological stress of bleeding can lead to cardiovascular instability or the need for emergency transfusion. * **B. Suspected Ectopic Pregnancy:** Mifepristone and Misoprostol act on the intrauterine decidua and myometrium. They are **ineffective** for tubal pregnancies. Administering them in a suspected ectopic case is dangerous as it delays definitive surgical or methotrexate treatment, risking tubal rupture. * **C. Glaucoma:** Prostaglandins (Misoprostol) can theoretically increase intraocular pressure or cause vasodilation that exacerbates certain types of glaucoma. While more relevant to specific prostaglandin types, it remains a standard contraindication in most clinical protocols. **High-Yield Clinical Pearls for NEET-PG:** 1. **Absolute Contraindications:** Confirmed/suspected ectopic pregnancy, chronic adrenal failure, long-term corticosteroid therapy, inherited porphyria, and known allergy to drugs. 2. **Relative Contraindications:** Severe anemia, uncontrolled hypertension, mitral stenosis, and presence of an IUCD (must be removed before the procedure). 3. **The Regimen:** According to the WHO and MTP Act, the standard regimen for up to 9 weeks (63 days) is **200 mg Mifepristone orally**, followed 24–48 hours later by **800 mcg Misoprostol** (vaginal, buccal, or sublingual). 4. **Failure Rate:** Medical MTP has a failure rate of approximately 1–5%; if it fails, surgical evacuation is mandatory due to the teratogenic potential of Misoprostol (e.g., Moebius syndrome).

Question 28: Which of the following is associated with an increased risk of thromboembolism in a normal pregnancy?

A. Increased progesterone level
B. Increased production of clotting factors by the liver (Correct Answer)
C. Change in blood viscosity
D. Decreased antithrombin III

Explanation: ### Explanation Pregnancy is a **hypercoagulable state**, an evolutionary adaptation designed to minimize blood loss during delivery. This state is primarily driven by Virchow’s Triad: venous stasis, endothelial injury, and hypercoagulability. **Why Option B is Correct:** The most significant contributor to hypercoagulability in pregnancy is the **increased hepatic synthesis of clotting factors** (driven by estrogen). There is a marked increase in **Factors I (Fibrinogen), VII, VIII, IX, X, and XII**. Fibrinogen levels rise by nearly 50%, reaching 400–600 mg/dL. This shift in the balance toward pro-coagulants significantly increases the risk of Thromboembolism (VTE). **Analysis of Incorrect Options:** * **Option A:** While progesterone causes smooth muscle relaxation leading to venous stasis (contributing to VTE), the **primary** biochemical change leading to a pro-thrombotic state is the estrogen-mediated increase in clotting factors. * **Option C:** Blood viscosity actually **decreases** in a normal pregnancy. This is because the plasma volume increases (approx. 45%) disproportionately to the red cell mass (approx. 20–30%), leading to physiological hemodilution. * **Option D:** In a normal pregnancy, levels of **Antithrombin III and Protein C remain relatively constant**. The natural anticoagulants that do decrease are **Protein S** (total and free levels) and an increase in Plasminogen Activator Inhibitor (PAI-1 and PAI-2), which inhibits fibrinolysis. **High-Yield NEET-PG Pearls:** 1. **Risk Factor:** The risk of VTE is increased 5–10 fold during pregnancy and is highest in the **postpartum period** (especially the first 6 weeks). 2. **Clotting Factors:** All factors increase EXCEPT **Factors XI and XIII**, which actually decrease. 3. **Left vs. Right:** DVT in pregnancy occurs more commonly in the **left leg** (80% of cases) due to the compression of the left common iliac vein by the right common iliac artery (May-Thurner phenomenon).

Question 29: Which of the following is NOT used for first-trimester abortion?

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

Explanation: **Explanation:** The first trimester of pregnancy is defined as the period up to 12 weeks of gestation. Methods for abortion during this period are categorized into medical and surgical techniques. **Why Option B is Correct:** **Extra-amniotic ethacrydine lactate (Emcredil)** is a method used exclusively for **second-trimester** abortions (13–20 weeks). It acts as a mechanical and chemical irritant, stimulating endogenous prostaglandin release to induce uterine contractions. It is not used in the first trimester because the extra-amniotic space is not sufficiently developed to facilitate the procedure effectively, and simpler, safer alternatives exist for early gestations. **Analysis of Incorrect Options:** * **Mifepristone (Option A):** An anti-progestogen used in medical management. Combined with Misoprostol, it is the gold standard for medical abortion up to 9–10 weeks (70 days) of gestation. * **Suction Evacuation (Option D):** This is the surgical method of choice for the first trimester (up to 12 weeks). It involves aspirating the products of conception using a Karman cannula or electric suction. * **Dilatation and Evacuation (Option C):** While more commonly associated with the early second trimester (13–15 weeks), it is frequently used in the late first trimester (10–12 weeks) when the products of conception are too large for simple suction alone. **High-Yield Clinical Pearls for NEET-PG:** 1. **MVA (Manual Vacuum Aspiration):** Can be used up to 12 weeks; it is highly effective and does not require electricity. 2. **Medical Method Regimen:** 200 mg Mifepristone (oral) followed by 800 mcg Misoprostol (vaginal/sublingual) after 24–48 hours. 3. **Ethacrydine Lactate Caution:** It is contraindicated in patients with a history of previous uterine scars (e.g., C-section) due to the risk of uterine rupture. 4. **Most common complication** of first-trimester suction evacuation is **incomplete abortion**.

Question 30: In which surgical approach is the tube opened to remove the gestational products, then left unsutured?

A. Salpingotomy
B. Salpingostomy (Correct Answer)
C. Salpingectomy
D. Salpingorrhaphy

Explanation: **Explanation:** The correct answer is **Salpingostomy**. This surgical procedure is a conservative management technique for ectopic pregnancy, typically performed when the patient desires future fertility and the contralateral tube is damaged. 1. **Why Salpingostomy is correct:** In a salpingostomy, a longitudinal incision is made on the antimesenteric border of the fallopian tube over the site of the ectopic pregnancy. The products of conception are removed (often via suction or irrigation), and the incision is **left open to heal by secondary intention**. This minimizes scarring and potential tubal occlusion that might occur with suturing. 2. **Why other options are incorrect:** * **Salpingotomy:** This involves making an incision to remove the products of conception, but the incision is **primarily closed with sutures**. * **Salpingectomy:** This is the total or partial **removal of the fallopian tube**. It is the treatment of choice if the tube is ruptured, there is uncontrollable bleeding, or the patient has completed her family. * **Salpingorrhaphy:** This refers to the **suturing/repair** of a fallopian tube, usually following a traumatic injury or rupture. **High-Yield Clinical Pearls for NEET-PG:** * **Indication:** Conservative surgery (Salpingostomy/otomy) is preferred if the ectopic mass is <4 cm, unruptured, and the patient is hemodynamically stable. * **Monitoring:** After conservative surgery, serial **β-hCG levels** must be monitored weekly until they reach <5 mIU/mL to rule out **Persistent Trophoblastic Tissue** (occurs in ~5-10% of cases). * **Site:** The most common site for ectopic pregnancy is the **Ampulla** (also the most common site for salpingostomy). * **Risk:** There is a slightly higher risk of recurrent ectopic pregnancy in the same tube following salpingostomy compared to salpingectomy.

Practice by Chapter

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Vaginal Birth After Cesarean

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Instrumental Deliveries

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Breech Delivery

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Episiotomy and Repair

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Management of Multiple Gestation

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Cervical Cerclage

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Obstetric Hysterectomy

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Surgery During Pregnancy

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Surgical Complications in Obstetrics

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