Operative Obstetrics Practice Questions

Q: A 35-week multigravida presents with epigastric pain, headache, visual symptoms, and proteinuria of 3+. What is the next step in management?

Start magnesium sulfate therapy. ### Explanation **Correct Answer: D. Start magnesium sulfate therapy** The patient presents with **Severe Preeclampsia** (35 weeks gestation, proteinuria, and "imminent symptoms" like epigastric pain, headache, and visual disturbances). These symptoms indicate cerebral and hepatic involvement, signaling an extremely high risk of progressing to **Eclampsia** (seizures). In any case of severe preeclampsia or eclampsia, the **immediate priority is stabilization**. Magnesium sulfate ($MgSO_4$) is the drug of choice for seizure prophylaxis and treatment. According to standard protocols (Pritchard or Zuspan), stabilization with $MgSO_4$ and blood pressure control must occur *before* proceeding to delivery, regardless of the planned mode of birth. **Why other options are incorrect:** * **A & C:** While delivery is the definitive treatment for preeclampsia, it should only be initiated *after* the mother is stabilized with $MgSO_4$. The mode of delivery (C-section vs. Induction) depends on obstetric indications (e.g., Bishop’s score, fetal distress); severe preeclampsia itself is not an absolute indication for a Cesarean section. * **B:** While steroids are indicated for fetal lung maturity before 34 weeks, this patient is at **35 weeks**. Furthermore, in the presence of "imminent symptoms," stabilization and delivery take precedence over waiting 48 hours for steroid efficacy. **Clinical Pearls for NEET-PG:** * **Drug of Choice for Seizures:** Magnesium sulfate (Superior to Diazepam/Phenytoin). * **Therapeutic Range:** 4–7 mEq/L. * **First Sign of Toxicity:** Loss of Patellar Reflex (Knee jerk) at 7–10 mEq/L. * **Antidote:** 10 ml of 10% Calcium Gluconate (administered IV over 10 mins). * **Management Goal:** In severe preeclampsia >34 weeks, stabilize and deliver. If <34 weeks and stable, conservative management can be considered.

Q: All of the following methods are used for MTP in the 2nd trimester except?

Menstrual regulation. **Explanation:** The correct answer is **Menstrual Regulation (D)**. This is because Menstrual Regulation (MR) is a method used for very early pregnancy termination, typically performed within **14 days of a missed period** (up to 6 weeks of gestation). It involves the aspiration of the endometrial lining using a Karman cannula and a syringe. Since the second trimester begins at 13 weeks, MR is technically and clinically inapplicable. **Analysis of other options:** * **Intra-amniotic saline (A):** This is a classical method for second-trimester MTP (15–20 weeks). Hypertonic saline (20%) is injected into the amniotic sac, causing fetal demise and stimulating uterine contractions. However, it is now largely replaced by prostaglandins due to risks like hypernatremia and DIC. * **Prostaglandins (B):** These are the **gold standard** for second-trimester induction. Drugs like Misoprostol (PGE1) or Carboprost (PGF2α) are used to ripen the cervix and induce labor. * **Hysterotomy (C):** This is a surgical method (similar to a mini-cesarean) used for second-trimester MTP when medical induction fails or when there is a contraindication to vaginal delivery (e.g., central placenta previa). **High-Yield NEET-PG Pearls:** * **MTP Act (India):** Termination is legal up to **24 weeks** for specific categories of women (as per 2021 amendment). * **Best Method (2nd Trimester):** Medical induction with Prostaglandins (Misoprostol) +/- Mifepristone. * **Most Common Complication (2nd Trimester MTP):** Incomplete evacuation and hemorrhage. * **Ethacridine Lactate (Extra-amniotic):** Another historical second-trimester method (Revici's method) that acts by releasing endogenous prostaglandins.

Q: A patient with rheumatic heart disease has postpartum hemorrhage (PPH). Which of the following drugs is contraindicated?

Methylergometrine. **Explanation:** The management of Postpartum Hemorrhage (PPH) in patients with cardiac disease requires careful selection of uterotonics to avoid hemodynamic instability. **Why Methylergometrine is Contraindicated:** Methylergometrine (Methergine) is an ergot alkaloid that causes generalized vasoconstriction and a sudden increase in peripheral vascular resistance. In patients with **Rheumatic Heart Disease (RHD)**, particularly those with valvular lesions like Mitral Stenosis, this sudden increase in afterload and venous return can lead to acute pulmonary edema, heart failure, or a hypertensive crisis. Therefore, it is strictly contraindicated in patients with heart disease and hypertension. **Analysis of Other Options:** * **Oxytocin:** This is the drug of choice for PPH in cardiac patients. While it can cause transient hypotension if given as a rapid bolus, it is safe when administered as a slow intravenous infusion. * **Carboprost (PGF2α):** While Carboprost is contraindicated in patients with **Asthma** (due to bronchoconstriction), it is not absolutely contraindicated in heart disease. However, it should be used with caution as it can increase pulmonary artery pressure. * **Mifepristone:** This is a progesterone antagonist used primarily for medical abortion or cervical ripening; it is not a standard treatment for active PPH and has no significant cardiovascular contraindications in this context. **NEET-PG High-Yield Pearls:** * **Drug of Choice for PPH in Cardiac Patients:** Oxytocin (Slow IV infusion). * **Methergine Contraindications:** Heart disease, Preeclampsia/Hypertension, and Raynaud's phenomenon. * **Carboprost (15-methyl PGF2α) Contraindications:** Active Asthma, hepatic, or renal disease. * **Misoprostol (PGE1):** Safe in asthma and generally safe in cardiac patients, though less effective than injectable uterotonics for active PPH.

Q: Which of the following is NOT considered a strong support of the uterus?

Round ligament of uterus. The supports of the uterus are divided into **Mechanical (Primary)** and **Muscular (Secondary)** supports. Understanding this classification is crucial for NEET-PG. ### Why Option B is the Correct Answer The **Round Ligament** is not a true support. Its primary function is to maintain the uterus in an **anteverted and anteflexed (AVAF)** position. It is a remnant of the gubernaculum and contains smooth muscle; however, it is lax and stretches easily. During pregnancy, it undergoes hypertrophy but does not prevent uterine prolapse. ### Explanation of Incorrect Options (Primary Supports) The primary supports are divided into the **Pelvic Diaphragm** (muscular) and the **Endopelvic Fascia/Ligaments** (visceral). * **Mackenrodt’s Ligament (Option C):** Also known as the **Transverse Cervical Ligament (Option D)** or Cardinal ligament. It is the **strongest support** of the uterus. It attaches the cervix and vaginal vault to the lateral pelvic walls. * **Uterosacral Ligament (Option A):** These ligaments attach the cervix to the sacrum (S2, S3). They pull the cervix backwards, helping to maintain the anteverted position and preventing downward displacement. ### Clinical Pearls for NEET-PG * **Strongest Support:** Mackenrodt’s (Cardinal) ligament. * **Main Muscle Support:** Levator ani (specifically the Pubococcygeus part). * **Level 1 Support (DeLancey):** Includes the Cardinal and Uterosacral ligaments. Damage here leads to **Vault or Uterine Prolapse**. * **Level 2 Support:** Includes the Pubocervical fascia and Rectovaginal fascia. Damage leads to **Cystocele or Rectocele**. * **Surgical Note:** During a Hysterectomy, the clamping of the Mackenrodt’s ligament is a critical step to mobilize the uterus.

Q: What procedure is the instrument shown below typically used for?

Papanicolaou smear. ***Papanicolaou smear*** - The **Ayre's spatula** and **cervical cytobrush** are specifically designed to collect **exfoliated cervical cells** from the transformation zone for cytological examination. - This procedure is the gold standard for **cervical cancer screening** and detecting **precancerous lesions** (dysplasia). *Visual inspection with acetic acid* - Uses **3-5% acetic acid** applied directly to the cervix, causing abnormal areas to appear **acetowhite**. - Does not require specialized collection instruments like spatulas or brushes, only **visual examination**. *Visual inspection with Lugol's iodine* - Involves applying **Lugol's iodine solution** to the cervix, where normal tissue stains **mahogany brown** while abnormal areas remain **unstained**. - This is a **naked-eye examination** technique that doesn't involve cell collection instruments. *Colposcopy* - Utilizes a **colposcope** (binocular microscope) to magnify the cervix **6-40 times** for detailed visualization. - While **biopsy forceps** may be used during colposcopy for tissue sampling, the primary instrument is the colposcope, not collection spatulas.

Q: A G2P1L1 patient presents with active labor. Her cervix is 8 cm dilated; fetal head is at +2 station, with Meconium Stained Liquor (MSL+). A Type 2 deceleration is seen on the Non-Stress Test (NST). What is the next step in management?

Low Cesarean Section. ### Explanation The patient is in the **active phase of labor** with signs of **fetal distress**, indicated by Meconium Stained Liquor (MSL+) and **Type 2 decelerations** (late decelerations). Late decelerations are a hallmark of uteroplacental insufficiency and signify fetal hypoxia. **1. Why Low Cesarean Section (LSCS) is the correct answer:** The definitive management for fetal distress in the first stage of labor is immediate delivery. Although the fetal head is at +2 station, the **cervix is only 8 cm dilated**. For any instrumental vaginal delivery (Forceps or Vacuum) to be performed, the **cervix must be fully dilated (10 cm)**. Since the first stage of labor is not yet complete, an emergency LSCS is the fastest and safest way to deliver the fetus and prevent birth asphyxia. **2. Why other options are incorrect:** * **A & B (Vacuum/Forceps):** These are contraindicated because the cervix is not fully dilated. Attempting instrumental delivery through an undilated cervix can lead to cervical tears, maternal hemorrhage, and fetal trauma. * **D (Continue monitoring):** In the presence of Type 2 decelerations and MSL, "watchful waiting" is inappropriate as it risks permanent fetal neurological damage or stillbirth. **Clinical Pearls for NEET-PG:** * **Prerequisites for Instrumental Delivery (FORCEPS mnemonic):** **F**etus alive, **O**ptiput position known, **R**uptured membranes, **C**ervix fully dilated, **E**ngaged head, **P**elvis adequate, **S**ubstantial anesthesia/Bladder empty. * **Type 2 Decelerations:** Associated with fetal hypoxia; the nadir of the deceleration occurs *after* the peak of the contraction. * **Station +2:** Indicates the leading bony part of the fetal head is 2 cm below the ischial spines. While the head is engaged, the incomplete cervical dilatation remains the deciding factor for LSCS here.

Question 1

A 35-week multigravida presents with epigastric pain, headache, visual symptoms, and proteinuria of 3+. What is the next step in management?

Accepted Answer

Start magnesium sulfate therapy

Answer

Immediate cesarean section

Answer

Betamethasone for fetal lung maturity

Answer

Induction of labor for vaginal delivery

Question 2

Forceps are applied in all the following obstetric presentations except:

Accepted Answer

Brow presentation

Answer

Breech presentation

Answer

Face presentation

Answer

Occipitoposterior position

Question 3

All of the following methods are used for MTP in the 2nd trimester except?

Accepted Answer

Menstrual regulation

Answer

Intra-amniotic saline

Answer

Prostaglandins

Answer

Hysterotomy

Question 4

A patient with rheumatic heart disease has postpartum hemorrhage (PPH). Which of the following drugs is contraindicated?

Accepted Answer

Methylergometrine

Answer

Mifepristone

Answer

Oxytocin

Answer

Carboprost

Question 5

Which of the following is NOT considered a strong support of the uterus?

Accepted Answer

Round ligament of uterus

Answer

Uterosacral ligament

Answer

Mackenrodt's ligament

Answer

Transcervical ligament

Question 6

Cesarean delivery is mandatory in which of the following types of placenta previa?

Accepted Answer

Type 3

Answer

Type 1

Answer

Type 2

Answer

All of the above

Question 7

Vacuum extraction is contraindicated in which of the following conditions?

Accepted Answer

Premature babies

Answer

Heart disease

Answer

Microcephaly

Answer

Polyhydramnios

Question 8

Which of the following is NOT a contraindication to external cephalic version?

Accepted Answer

Hydramnios

Answer

Contracted pelvis

Answer

Antepartum hemorrhage

Answer

Multiple pregnancy

Question 9

What procedure is the instrument shown below typically used for?

Accepted Answer

Papanicolaou smear

Answer

Visual inspection with acetic acid

Answer

Visual inspection with Lugol's iodine

Answer

Colposcopy

Question 10

A G2P1L1 patient presents with active labor. Her cervix is 8 cm dilated; fetal head is at +2 station, with Meconium Stained Liquor (MSL+). A Type 2 deceleration is seen on the Non-Stress Test (NST). What is the next step in management?

Accepted Answer

Low Cesarean Section

Answer

Vacuum-assisted delivery

Answer

Forceps-assisted delivery

Answer

Continue monitoring and await spontaneous delivery

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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