Operative Obstetrics Practice Questions

Q: In an HIV-infected pregnant woman, when is an elective Cesarean section indicated?

If viral load is greater than 1000 copies/ml. The primary goal of managing HIV in pregnancy is to minimize **Mother-to-Child Transmission (MTCT)**. The mode of delivery is determined by the maternal viral load near the time of delivery (usually measured at 34–36 weeks). ### **Explanation of the Correct Answer** **Option C is correct** because a viral load **>1,000 copies/ml** is associated with a significantly higher risk of vertical transmission during vaginal delivery due to contact with infected cervicovaginal secretions and blood. In such cases, an **Elective Cesarean Section (ELCS)** performed at **38 weeks** (before the onset of labor or ROM) reduces the risk of transmission by avoiding the birth canal and minimizing fetal exposure to maternal fluids. ### **Analysis of Incorrect Options** * **Option A & B:** ELCS is not mandatory for everyone. If a woman is on Effective Antiretroviral Therapy (ART) and has an **undetectable or low viral load (<50–1,000 copies/ml)**, the risk of transmission is <1%, and a **planned vaginal delivery** is recommended. Parity (Primipara vs. Multipara) does not dictate the mode of delivery in HIV. * **Option D:** If Rupture of Membranes (ROM) occurs or labor starts, the protective benefit of a Cesarean section is rapidly lost. ELCS is specifically "elective" to avoid these events. ### **NEET-PG High-Yield Pearls** * **Timing of ELCS:** Performed at **38 weeks 0 days** to prevent spontaneous labor (unlike the standard 39 weeks). * **Zidovudine (AZT) Infusion:** Should be started 4 hours before ELCS if the viral load is >1,000 copies/ml or unknown. * **Procedures to avoid:** Artificial Rupture of Membranes (ARM), fetal scalp electrodes, and instrumental delivery (forceps/vaccum) should be avoided as they increase transmission risk. * **Post-exposure Prophylaxis (PEP) for Neonate:** Usually started within 6–12 hours of birth.

Q: In a G2P1, Rh-negative mother with a previous history of hydrops fetalis, the indirect Coombs test (ICT) is positive at 20 weeks gestation. What is the next line of management?

Middle cerebral artery (MCA) Doppler ultrasound. **Explanation:** In a sensitized Rh-negative pregnancy (ICT positive), the primary goal is to monitor for **fetal anemia**. 1. **Why MCA Doppler is correct:** The Middle Cerebral Artery (MCA) Peak Systolic Velocity (PSV) is the non-invasive "Gold Standard" for detecting fetal anemia. In anemic fetuses, blood viscosity decreases and cardiac output increases, leading to a higher velocity of blood flow. A value **>1.5 MoM (Multiples of Median)** indicates severe anemia and the need for intervention. It has replaced invasive methods like amniocentesis due to its high sensitivity and non-invasive nature. 2. **Why other options are incorrect:** * **Amniocentesis (Liley’s Chart):** Previously used to measure bilirubin (ΔOD450), it is now obsolete for this purpose because it is invasive and less accurate than MCA Doppler, especially before 27 weeks. * **Cordocentesis:** This is the gold standard for *confirming* fetal hemoglobin levels, but it is an invasive procedure with a risk of feto-maternal hemorrhage. It is only performed if MCA Doppler indicates severe anemia (>1.5 MoM). * **Exchange Transfusion:** This is a neonatal procedure performed after birth to treat hyperbilirubinemia. The intrauterine equivalent is **Intrauterine Transfusion (IUT)**, which is only done after anemia is confirmed via cordocentesis. **Clinical Pearls for NEET-PG:** * **Critical Titer:** If ICT titer is **<1:16**, repeat every 2–4 weeks. If **≥1:16**, initiate MCA Doppler. * **First-line screening:** MCA Doppler is the first-line investigation for fetal anemia in sensitized mothers. * **Hydrops Fetalis:** Occurs when fetal hemoglobin falls below 7g/dL (or a 70% deficit).

Q: Which method of Medical Termination of Pregnancy is not used in the first trimester of pregnancy?

Intrauterine instillation of hypertonic saline. **Explanation:** The correct answer is **A. Intrauterine instillation of hypertonic saline.** Medical Termination of Pregnancy (MTP) methods are categorized based on the gestational age. The first trimester is defined as up to 12 weeks (though medical methods are often used up to 9–10 weeks). **Why Option A is correct:** Intrauterine instillation of hypertonic saline (or urea/prostaglandins) is a **second-trimester** method (usually 15–20 weeks). It involves injecting a 20% saline solution into the amniotic sac to induce fetal demise and uterine contractions. It is **never** used in the first trimester because the amniotic sac is too small to safely access via transabdominal amniocentesis, and the risk of systemic toxicity (hypernatremia) is high. **Why the other options are incorrect:** * **B. Suction and Evacuation:** This is the **gold standard surgical method** for first-trimester MTP (up to 12 weeks). It is quick, safe, and effective. * **C & D. Mifepristone and Misoprostol:** These are the primary drugs used in **Medical MTP**. According to current protocols, a combination of 200 mg Mifepristone (anti-progestogen) followed by 800 mcg Misoprostol (prostaglandin E1 analogue) is highly effective for terminating pregnancies up to 9–10 weeks. **High-Yield NEET-PG Pearls:** * **MTP Act (India) Update:** MTP can now be performed up to **24 weeks** for specific categories of women (e.g., survivors of sexual assault, minors, fetal anomalies). * **Best Surgical Method (<12 weeks):** Suction Evacuation. * **Best Surgical Method (12–15 weeks):** Dilatation and Evacuation (D&E). * **Most common complication of MTP:** Incomplete abortion. * **Hypertonic Saline Risk:** Can cause "Water Intoxication" or Consumption Coagulopathy (DIC).

Q: IUGR is defined when:

Birth weight is below the tenth percentile of the average for gestational age. **Explanation:** **Intrauterine Growth Restriction (IUGR)**, often used interchangeably with Small for Gestational Age (SGA) in clinical practice, is defined as a fetus whose estimated weight or birth weight is **below the 10th percentile** for its specific gestational age. This threshold is the globally accepted standard (ACOG/RCOG) to identify neonates at a higher risk for perinatal morbidity and mortality. * **Option A (Correct):** The 10th percentile is the statistical cutoff used to differentiate normal growth from restricted growth. It implies that 90% of babies at that same gestational age weigh more than the index baby. * **Options B & C (Incorrect):** The 20th and 30th percentiles are too high; using these would result in over-diagnosis, labeling many constitutionally small but healthy babies as growth-restricted. * **Option D (Incorrect):** A birth weight of less than 1000g defines an **Extremely Low Birth Weight (ELBW)** infant, regardless of gestational age. A baby can be 900g and be appropriate for gestational age (if very preterm) or IUGR (if term). **High-Yield NEET-PG Pearls:** * **SGA vs. IUGR:** SGA is a purely statistical definition (weight <10th percentile). IUGR refers to a fetus that has failed to reach its **biological growth potential** due to pathological factors (e.g., placental insufficiency). * **Symmetrical IUGR (Type I):** Occurs early in pregnancy; affects all organs equally (Head Circumference = Abdominal Circumference). Usually due to chromosomal anomalies or early infections (TORCH). * **Asymmetrical IUGR (Type II):** More common; occurs in the 3rd trimester. Shows "Head Sparing" (AC is reduced more than HC). Usually due to placental insufficiency or maternal hypertension. * **Ponderal Index:** Used to identify asymmetrical IUGR. Formula: $[Weight (g) / Length (cm)^3] \times 100$.

Q: Suction evacuation as MTP is best done up to how many weeks of gestation?

12 weeks. **Explanation:** **Suction Evacuation (Vacuum Aspiration)** is the gold standard surgical method for Medical Termination of Pregnancy (MTP) in the **first trimester**. * **Why 12 weeks is correct:** Up to 12 weeks of gestation, the products of conception are small enough to be safely aspirated through a Karman’s cannula or a rigid suction tip. Beyond 12 weeks, the fetal bones begin to ossify and the placenta becomes more vascular, significantly increasing the risk of incomplete evacuation, uterine perforation, and heavy hemorrhage if suction alone is used. * **Why other options are incorrect:** * **9 weeks:** While suction evacuation is safe at 9 weeks, it is not the *upper limit*. Medical methods (Mifepristone + Misoprostol) are often preferred up to 7–9 weeks, but suction remains effective until 12 weeks. * **18 and 24 weeks:** These fall into the second trimester. For these gestations, **Dilatation and Evacuation (D&E)** or medical induction (using Prostaglandins) are the methods of choice, as suction alone is insufficient to remove the larger fetal parts. **High-Yield Clinical Pearls for NEET-PG:** 1. **MVA vs. EVA:** Manual Vacuum Aspiration (MVA) is typically used up to **10 weeks** (using a 60ml syringe), while Electric Vacuum Aspiration (EVA) is preferred between **10–12 weeks** due to consistent pressure. 2. **Pressure:** The ideal pressure for EVA is **600 mmHg**. 3. **Cannula Size:** The size of the Karman’s cannula (in mm) should generally correspond to the weeks of gestation (e.g., 8mm for 8 weeks). 4. **MTP Act (India):** Recent amendments allow MTP up to **24 weeks** for specific categories of women, but the *surgical technique* of suction evacuation remains limited to the first trimester.

Q: Which ligament is pierced by the needle to reach the pudendal nerve during a pudendal nerve block?

Sacrospinous ligament. **Explanation:** The **pudendal nerve block** is a common procedure used in operative obstetrics to provide anesthesia for the perineum during the second stage of labor, forceps delivery, or extensive episiotomy repair. **1. Why Sacrospinous Ligament is Correct:** The pudendal nerve (S2, S3, S4) exits the pelvis through the greater sciatic foramen, crosses the **sacrospinous ligament** near its attachment to the **ischial spine**, and re-enters the pelvis through the lesser sciatic foramen. To perform a transvaginal block, the clinician palpates the ischial spine and directs the needle through the sacrospinous ligament. Depositing local anesthetic just posterior to this ligament ensures the nerve is bathed in the solution as it passes through Alcock’s canal. **2. Analysis of Incorrect Options:** * **Sacral and Ischial Ligaments:** These are anatomically vague terms. While the sacrum and ischium provide the bony landmarks, there are no specific "sacral" or "ischial" ligaments targeted in this procedure. * **Pudendal Ligament:** This is a distractor; no such ligament exists. The nerve travels within the pudendal (Alcock’s) canal, which is a sheath formed by the obturator internus fascia. **3. NEET-PG High-Yield Pearls:** * **Landmark:** The **ischial spine** is the most important bony landmark for the block. * **Nerve Root:** S2, S3, S4 ("S2, 3, 4 keeps the poop off the floor"). * **Area Anesthetized:** Perineum and lower 1/3rd of the vagina. It does **not** abolish uterine contraction pain (which is T10–L1). * **Complication:** Accidental injection into the **internal pudendal artery**, which runs immediately medial to the nerve. Always aspirate before injecting.

Question 1

An HIV-infected pregnant woman presents for her 36-week prenatal visit. Which of the following discussion points regarding delivery is true?

Accepted Answer

If her viral load is > 1,000 copies/mL, she will be scheduled for a cesarean delivery at 38 weeks.

Answer

All HIV-infected women should have a cesarean delivery.

Answer

She may have a vaginal delivery only if her viral load is < 100 copies/mL.

Answer

She can deliver vaginally regardless of viral load because she is on highly active antiretroviral therapy.

Question 2

Which of the following statements concerning polyhydramnios is true?

Accepted Answer

Complications include placental abruption, uterine dysfunction, and postpartum hemorrhage.

Answer

Acute polyhydramnios always leads to labor at the usual time.

Answer

The incidence of associated malformations is approximately 3%.

Answer

Maternal edema of the vulva and lower limbs is rare.

Question 3

In an HIV-infected pregnant woman, when is an elective Cesarean section indicated?

Accepted Answer

If viral load is greater than 1000 copies/ml

Answer

In all cases

Answer

In all primipara cases

Answer

Only in cases of premature rupture of membranes

Question 4

In a G2P1, Rh-negative mother with a previous history of hydrops fetalis, the indirect Coombs test (ICT) is positive at 20 weeks gestation. What is the next line of management?

Accepted Answer

Middle cerebral artery (MCA) Doppler ultrasound

Answer

Amniocentesis for bilirubin estimation

Answer

Exchange transfusion

Answer

Cordocentesis

Question 5

Which method of Medical Termination of Pregnancy is not used in the first trimester of pregnancy?

Accepted Answer

Intrauterine instillation of hypertonic saline

Answer

Suction and evacuation

Answer

Mifepristone

Answer

Misoprostol

Question 6

IUGR is defined when:

Accepted Answer

Birth weight is below the tenth percentile of the average for gestational age

Answer

Birth weight is below the 20th percentile of the average for gestational age

Answer

Birth weight is below the 30th percentile of the average for gestational age

Answer

Birth weight of the baby is less than 1000 gm

Question 7

Suction evacuation as MTP is best done up to how many weeks of gestation?

Accepted Answer

12 weeks

Answer

9 weeks

Answer

18 weeks

Answer

24 weeks

Question 8

Which ligament is pierced by the needle to reach the pudendal nerve during a pudendal nerve block?

Accepted Answer

Sacrospinous ligament

Answer

Sacral ligament

Answer

Ischial ligament

Answer

Pudendal ligament

Question 9

A primigravida presents at 41 weeks with premature rupture of membranes (PROM). On pelvic examination, the cervix is 3 cm dilated, and a fetal foot is palpated. The estimated fetal weight is 2.7 kg, and the fetal heart rate tracing is reactive. What is the recommended management for delivery?

Accepted Answer

Cesarean section

Answer

Vaginal delivery by breech extraction

Answer

Vaginal delivery after external cephalic version

Answer

Internal podalic version

Question 10

A patient with Stage 1A2 cervical cancer is detected at 26 weeks of gestation. What is the next appropriate management step?

Accepted Answer

Classical Cesarean section followed by Wertheim's hysterectomy at 30-32 weeks gestation

Answer

Lower segment Cesarean section followed by extrafascial hysterectomy at 28 weeks gestation

Answer

Immediate concurrent chemoradiotherapy

Answer

Medical termination of pregnancy

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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