Operative Obstetrics — MCQs

A lady with 38 weeks of pregnancy is admitted due to a first episode of painless bleeding yesterday. On examination, her hemoglobin level is 10.5 g%, blood pressure is 124/78 mmHg, the uterus is relaxed, the head is unengaged and floating, and the fetal heart sounds are regular. Ultrasound confirms placenta previa. The next line of management is:

Q297

A 20-year-old woman has been brought to the casualty with a blood pressure of 70/40 mmHg, a pulse rate of 120/min, and a positive urine pregnancy test. She should be managed by:

Q298

In which of the following conditions is the use of forceps contraindicated?

Q299

In the surgical management of ectopic pregnancy, when comparing salpingostomy versus salpingectomy, which method results in a higher subsequent fertility rate?

Q300

Which anatomical structure is most commonly the target of incisions during major gynecological surgical procedures?

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 291: Which structure is least likely to be injured during common gynecological procedures?

A. Ureter at pelvic brim
B. Renal pelvis (Correct Answer)
C. Urinary bladder
D. Ureter at infundibulopelvic ligament

Explanation: ***Renal pelvis*** - The **renal pelvis** is anatomically distant from the surgical fields of most common gynecological procedures, making injury unlikely. - Its protected position deep within the abdominal cavity, surrounded by fat and muscle, generally shields it from inadvertent trauma during pelvic surgery. *Ureter at pelvic brim* - The **ureter** crosses the **pelvic brim**, an area often involved in gynecological dissections, especially during procedures like **pelvic lymphadenectomy** or management of large masses. - It is susceptible to injury during instrumentation or clamping in this region due to its close proximity to pelvic vessels. *Urinary bladder* - The **urinary bladder** is frequently in the surgical field during gynecological procedures, particularly those involving the anterior vaginal wall, cervix, or uterus (e.g., **hysterectomy**, **cystocele repair**). - Its thin wall and close proximity make it vulnerable to perforation, laceration, or thermal injury. *Ureter at infundibulopelvic ligament* - The **ureter** passes perilously close to the **infundibulopelvic ligament** (suspensory ligament of the ovary) as it enters the pelvis. - This area is frequently ligated or clamped during **oophorectomy** or adnexal mass removal, placing the ureter at high risk of kinking, ligation, or transection.

Question 292: What is a definitive indication for performing a Lower Segment Cesarean Section (LSCS)?

A. Mento anterior presentation
B. Occipito posterior presentation
C. Vertex presentation
D. Contracted pelvis (Correct Answer)

Explanation: ***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.

Question 293: The prostaglandin most commonly used for the termination of a second-trimester pregnancy is:

A. PGI2
B. PGA2
C. 15-methyl prostaglandin F2 alpha
D. PGE1 (Correct Answer)

Explanation: ***PGE1 (misoprostol)*** - **PGE1 analogues**, such as **misoprostol**, are the **most commonly used prostaglandins** for second-trimester pregnancy termination globally. - **Key advantages**: Low cost, stable at room temperature, highly effective for cervical ripening and inducing uterine contractions, and excellent safety profile. - Administered orally, vaginally, sublingually, or buccally, offering flexibility in clinical settings. - **WHO-recommended regimen**: Mifepristone followed by misoprostol is the preferred protocol for second-trimester medical termination. *PGI2 (prostacyclin)* - **PGI2** is primarily a vasodilator and inhibitor of platelet aggregation, not used for inducing uterine contractions. - Clinical applications include **pulmonary hypertension** and peripheral vascular disease, but it has no role in pregnancy termination. *PGA2* - **PGA2** is a naturally occurring prostaglandin with minimal clinical use. - Not employed in obstetric practice for cervical ripening or pregnancy termination. *15-methyl prostaglandin F2 alpha (carboprost)* - **Carboprost** is a synthetic PGF2α analogue that can induce strong uterine contractions. - While it has been used for second-trimester termination, it is **not the most commonly used agent** due to significant side effects including severe GI symptoms (nausea, vomiting, diarrhea), bronchospasm, and higher cost. - Currently, its **primary indication** is management of **refractory postpartum hemorrhage** due to uterine atony. - **Misoprostol is preferred** over carboprost for second-trimester termination due to better tolerability, lower cost, and ease of administration.

Question 294: Which of the following statements about the management of uterine inversion is false?

A. Surgical management is hysterectomy (Correct Answer)
B. May require laparotomy
C. In case of delayed presentation repositioning to be attempted only after securing IV lines and adequate anesthesia
D. Repositioning of uterus should be attempted immediately if diagnosed at the time of inversion

Explanation: ***Surgical management is hysterectomy*** - While hysterectomy is a possible outcome in severe, intractable cases, it is *not* the primary or routine surgical management for uterine inversion. - The goal of surgical intervention, when manual repositioning fails, is typically to *reposition the uterus* through laparotomy, not to remove it. *May require laparotomy* - **Laparotomy** (abdominal incision) may be necessary if **manual repositioning** of the inverted uterus is unsuccessful or if there are other complications requiring direct surgical access. - This approach allows the surgeon to directly visualize and manipulate the uterus to correct the inversion. *In case of delayed presentation repositioning to be attempted only after securing IV lines and adequate anesthesia* - For **delayed presentation** of uterine inversion, it is crucial to ensure maternal stability before attempting repositioning, as the patient may be in shock or have significant blood loss. - **Securing IV lines** for fluid resuscitation and ensuring **adequate anesthesia** are critical preparatory steps to manage pain and facilitate uterine relaxation. *Repositioning of uterus should be attempted immediately if diagnosed at the time of inversion* - **Immediate manual repositioning** (Johnson maneuver) is the primary first-line treatment for acute uterine inversion diagnosed at the time of delivery. - Prompt action is essential to minimize **blood loss**, prevent **shock**, and increase the chances of successful uterine replacement.

Question 295: Which of the following procedures is not performed in a case of complete hydatidiform mole (CHM)?

A. Blood transfusion
B. Urine microscopy and culture sensitivity
C. Caesarean section (Correct Answer)
D. Abortion

Explanation: ***Caesarean section*** - Caesarean section is **NOT performed** for the management of complete hydatidiform mole (CHM). - The standard treatment for CHM is **suction evacuation (suction curettage)**, which is the procedure of choice for removing molar tissue from the uterus. - Caesarean section is a surgical procedure for **delivering a fetus**, not for evacuating gestational trophoblastic disease. - There is **no indication** for Caesarean section in CHM management, even in cases of large molar volume. *Abortion (Suction evacuation)* - **Suction evacuation/curettage** is the primary and definitive treatment for complete hydatidiform mole. - This procedure involves removing the abnormal trophoblastic tissue from the uterus under ultrasound guidance. - It is sometimes referred to as therapeutic abortion in the medical literature. - **Oxytocin infusion** is typically started after evacuation begins to minimize bleeding. *Blood transfusion* - CHM can present with **significant vaginal bleeding**, potentially leading to severe anemia. - **Blood transfusion** may be necessary to correct anemia and stabilize hemodynamic status. - Pre-operative **hemoglobin assessment** and blood grouping/cross-matching are routine in CHM management. *Urine microscopy and culture sensitivity* - While not a routine part of CHM management, this test **may be performed** if there are clinical signs of urinary tract infection. - Patients with CHM may have urinary symptoms due to uterine enlargement or other complications. - This is **not a standard procedure** for all CHM cases but may be indicated based on clinical presentation.

Question 296: A lady with 38 weeks of pregnancy is admitted due to a first episode of painless bleeding yesterday. On examination, her hemoglobin level is 10.5 g%, blood pressure is 124/78 mmHg, the uterus is relaxed, the head is unengaged and floating, and the fetal heart sounds are regular. Ultrasound confirms placenta previa. The next line of management is:

A. Caesarean section (Correct Answer)
B. Induction of labor
C. Wait and watch
D. Blood transfusion

Explanation: ***Caesarean section*** - The combination of **painless vaginal bleeding** and an **unengaged, floating fetal head** in a 38-week pregnancy strongly suggests **placenta previa**. - **Placenta previa** is an absolute contraindication to vaginal delivery, necessitating a **Cesarean section** to prevent catastrophic hemorrhage. *Induction of labor* - **Vaginal examination** and, consequently, **induction of labor** are contraindicated in suspected or confirmed placenta previa due to the risk of severe hemorrhage. - Applying pressure to the cervix or performing an artificial rupture of membranes could directly traumatize the placental blood vessels. *Wait and watch* - While initial bleeding might temporarily stop, the risk of a more severe and sudden hemorrhage remains high with **placenta previa**, especially as labor progresses. - At 38 weeks, the fetus is term, and waiting carries unnecessary risks for both mother and fetus without clear benefit. *Blood transfusion* - Although the patient's hemoglobin is slightly low at 10.5 g%, the primary issue is the potential for acute, severe hemorrhage, not chronic anemia requiring immediate transfusion as the definitive management. - A **blood transfusion** might be indicated as supportive care if significant blood loss occurs, but it is not the primary management for placenta previa.

Question 297: A 20-year-old woman has been brought to the casualty with a blood pressure of 70/40 mmHg, a pulse rate of 120/min, and a positive urine pregnancy test. She should be managed by:

A. Immediate laparotomy for ruptured ectopic pregnancy (Correct Answer)
B. Laparoscopy for diagnosis
C. Resuscitation without surgical intervention
D. Culdocentesis for fluid analysis

Explanation: ***Immediate laparotomy for ruptured ectopic pregnancy*** - The patient presents with classic signs of **hypovolemic shock (BP 70/40 mmHg, pulse 120/min)** in the setting of a positive pregnancy test, strongly indicating a **ruptured ectopic pregnancy**. - This is a **life-threatening emergency** requiring immediate surgical intervention to control bleeding and stabilize the patient. *Laparoscopy for diagnosis* - While laparoscopy can be used for diagnosis and treatment of ectopic pregnancy, it is **contraindicated in unstable patients** due to the increased risk associated with pneumoperitoneum and a longer operative time compared to laparotomy for an actively bleeding rupture. - In a hemodynamically unstable patient, the priority is rapid control of hemorrhage, which is often best achieved via **laparotomy**. *Resuscitation without surgical intervention* - Resuscitation is crucial, but it must be performed **concurrently with preparations for immediate surgical intervention**. - Resuscitation alone will not address the source of internal bleeding, which can lead to further deterioration and death. *Culdocentesis for fluid analysis* - **Culdocentesis** involves aspirating fluid from the pouch of Douglas to check for hemoperitoneum, but it is an **invasive procedure with limited diagnostic utility** in the age of ultrasound. - More importantly, it **delays definitive management** and offers no therapeutic benefit in an unstable patient with suspected ruptured ectopic pregnancy.

Question 298: In which of the following conditions is the use of forceps contraindicated?

A. Twin delivery
B. Post maturity
C. After coming head of breech
D. Hydrocephalus (enlarged head) (Correct Answer)

Explanation: ***Hydrocephalus (enlarged head)*** - The use of forceps in cases of **hydrocephalus** can result in severe trauma to both the fetal head and the maternal birth canal due to the disproportionately large fetal head. - The increased risk of **intracranial hemorrhage**, skull fractures, and severe maternal soft tissue injury makes forceps delivery highly contraindicated. *Twin delivery* - Forceps can be used in twin deliveries, especially for the second twin, to expedite delivery or manage presentations if there are no other contraindications. - The decision depends on various factors such as presentation, size, and fetal well-being, but twin delivery itself is not a contraindication. *Post maturity* - **Post-maturity** itself is not a contraindication for forceps delivery, although these fetuses may be larger or have less resilient skulls. - Forceps may be considered if there's a need to shorten the second stage of labor due to **fetal distress** or maternal exhaustion in a post-term pregnancy, provided there's adequate fetal head engagement and no significant cephalopelvic disproportion. *After coming head of breech* - Forceps, specifically **Piper forceps**, are often indicated and used in the delivery of the **aftercoming head of a breech presentation**. - This maneuver helps to control the rate of head delivery, preventing sudden decompression and providing stability, which reduces the risk of fetal head trauma and intracranial hemorrhage.

Question 299: In the surgical management of ectopic pregnancy, when comparing salpingostomy versus salpingectomy, which method results in a higher subsequent fertility rate?

A. Both have similar fertility rates (Correct Answer)
B. Cannot be determined
C. Laparoscopic salpingostomy
D. Laparotomy with salpingectomy

Explanation: ***Both have similar fertility rates*** - Multiple randomized controlled trials and meta-analyses have shown that **subsequent intrauterine pregnancy rates** are **comparable** between **salpingostomy** (tube-preserving surgery) and **salpingectomy** (tube-removing surgery). - A landmark RCT showed intrauterine pregnancy rates of approximately **60-65% for both procedures** when the contralateral tube is normal. - The decision between these procedures depends on factors like **tubal damage severity**, **patient's desire for future fertility**, **risk of persistent ectopic**, and **contralateral tube status**, rather than a significant difference in fertility outcomes. *Laparoscopic salpingostomy* - This option incorrectly suggests salpingostomy (tube-preserving) has superior fertility rates. - While preserving the tube seems intuitive for better fertility, the **damaged tube after ectopic pregnancy** may not function normally, and studies show **no significant fertility advantage** over salpingectomy when the contralateral tube is healthy. - Salpingostomy has a **5-20% risk of persistent ectopic pregnancy** requiring additional treatment. *Cannot be determined* - This is incorrect because **extensive clinical research** including RCTs and systematic reviews have directly compared fertility outcomes between these procedures. - Evidence clearly shows comparable rates, making this determinable. *Laparotomy with salpingectomy* - This option incorrectly suggests salpingectomy has superior fertility rates. - While removing a tube might seem to decrease fertility, when the **contralateral tube is healthy**, overall fertility rates remain similar to salpingostomy. - Salpingectomy may actually be preferred when the affected tube is severely damaged, as a diseased tube can reduce fertility through mechanisms like tubal factor infertility.

Question 300: Which anatomical structure is most commonly the target of incisions during major gynecological surgical procedures?

A. Ovary
B. Cervix
C. Fallopian tube
D. Uterus (Correct Answer)

Explanation: ***Uterus*** - The **uterus** is the primary anatomical target for many major gynecological procedures, such as **hysterectomy** (removal of the uterus) and **myomectomy** (removal of fibroids from the uterus). - These are among the most commonly performed major gynecological surgeries, making the uterus the most frequent target for incisions in gynecological practice. - In obstetric procedures, the uterus is also incised during **cesarean sections**, highlighting its central role in both obstetric and gynecologic surgery. *Ovary* - While ovaries are involved in gynecological surgery (e.g., **oophorectomy**, cystectomy), they are not as frequently the *primary* target for incisions as the uterus in the context of major procedures. - Ovarian surgeries are often performed for **cysts**, **tumors**, or in conjunction with hysterectomy, but are less common than uterine procedures. - Many ovarian procedures can be managed laparoscopically without major incisions. *Cervix* - The **cervix** is incised in procedures like **trachelectomy** for cervical cancer or during specific cervical cerclage procedures, but these are less frequent compared to surgeries involving the uterine body itself. - Many cervical procedures are considered minor (e.g., LEEP, cone biopsy) or are part of a larger uterine surgery. *Fallopian tube* - The **fallopian tubes** are primarily targeted for procedures like **salpingectomy** (removal of the tube, often for ectopic pregnancy or sterilization) or salpingostomy. - While significant, these procedures are generally less common than those involving the uterus and overall less frequently associated with major incisions compared to uterine procedures.

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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