Operative Obstetrics — MCQs

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 41: An HIV-infected pregnant woman presents for her 36-week prenatal visit. Which of the following discussion points regarding delivery is true?

A. All HIV-infected women should have a cesarean delivery.
B. She may have a vaginal delivery only if her viral load is < 100 copies/mL.
C. If her viral load is > 1,000 copies/mL, she will be scheduled for a cesarean delivery at 38 weeks. (Correct Answer)
D. She can deliver vaginally regardless of viral load because she is on highly active antiretroviral therapy.

Explanation: ### Explanation The primary goal in managing HIV during 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). **Why Option C is Correct:** Current guidelines (ACOG and NACO) recommend a **Scheduled Prelabor Cesarean Section (PLCS) at 38 weeks** for women with an HIV RNA viral load **> 1,000 copies/mL** or unknown viral load. Performing the surgery at 38 weeks (rather than 39) aims to deliver the patient before the onset of spontaneous labor or rupture of membranes, both of which increase the risk of vertical transmission. **Analysis of Incorrect Options:** * **Option A:** Cesarean delivery is not universal. Women with a viral load **< 1,000 copies/mL** have a very low risk of transmission and are candidates for a planned vaginal delivery. * **Option B:** The threshold for vaginal delivery is < 1,000 copies/mL, not < 100 copies/mL. While lower is better, the clinical cutoff for safety in vaginal birth is 1,000. * **Option D:** Being on HAART reduces the risk, but it does not eliminate it if viral suppression is inadequate. A high viral load despite HAART still necessitates a C-section. **High-Yield NEET-PG Pearls:** * **Zidovudine (AZT) Infusion:** Should be started 3 hours before a scheduled C-section if the viral load is > 1,000 copies/mL. * **Vaginal Delivery Precautions:** Avoid Artificial Rupture of Membranes (ARM), fetal scalp electrodes, and instrumental delivery (forceps/vaccum) as they increase blood contact. * **Post-exposure Prophylaxis (PEP):** The newborn should receive Nevirapine or Zidovudine prophylaxis immediately after birth. * **Breastfeeding:** In resource-rich settings, formula feeding is preferred; however, in India (NACO guidelines), exclusive breastfeeding for 6 months is recommended if replacement feeding is not "Acceptable, Feasible, Affordable, Sustainable, and Safe" (AFASS).

Question 42: Which of the following statements concerning polyhydramnios is true?

A. Acute polyhydramnios always leads to labor at the usual time.
B. The incidence of associated malformations is approximately 3%.
C. Maternal edema of the vulva and lower limbs is rare.
D. Complications include placental abruption, uterine dysfunction, and postpartum hemorrhage. (Correct Answer)

Explanation: **Explanation:** Polyhydramnios is defined as an amniotic fluid index (AFI) >25 cm or a single deepest pocket (SDP) >8 cm. It leads to significant overdistension of the uterus, which is the primary driver of its associated complications. **Why Option D is Correct:** * **Placental Abruption:** The sudden loss of a large volume of amniotic fluid (e.g., during rupture of membranes) causes a rapid decrease in intrauterine pressure and uterine surface area, leading to the shearing off of the placenta. * **Uterine Dysfunction:** Overstretching of the myometrium interferes with effective contractions during labor (hypotonic inertia). * **Postpartum Hemorrhage (PPH):** The overdistended myometrium fails to contract effectively after delivery (uterine atony), which is a classic cause of PPH. **Why the Other Options are Incorrect:** * **Option A:** Acute polyhydramnios is rare and usually occurs before 24 weeks. It typically leads to **preterm labor** or severe maternal distress necessitating intervention, rather than labor at the "usual time." * **Option B:** The incidence of associated fetal malformations (e.g., anencephaly, esophageal atresia) is much higher, ranging from **18% to 40%**, depending on the severity of the polyhydramnios. * **Option C:** Maternal edema of the vulva and lower limbs is actually **common**. It occurs due to the heavy uterus compressing the pelvic veins and the inferior vena cava, obstructing venous return. **NEET-PG High-Yield Pearls:** * **Most common cause:** Idiopathic (approx. 50-60%), followed by Maternal Diabetes. * **Associated Fetal Anomalies:** Neural tube defects (impaired swallowing) and GI obstructions (esophageal/duodenal atresia). * **Management:** Therapeutic amniocentesis (slow decompression) is indicated if the mother has respiratory distress. * **Risk of Cord Prolapse:** High during spontaneous or artificial rupture of membranes due to the gush of fluid.

Question 43: In an HIV-infected pregnant woman, when is an elective Cesarean section indicated?

A. In all cases
B. In all primipara cases
C. If viral load is greater than 1000 copies/ml (Correct Answer)
D. Only in cases of premature rupture of membranes

Explanation: 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.

Question 44: 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?

A. Middle cerebral artery (MCA) Doppler ultrasound (Correct Answer)
B. Amniocentesis for bilirubin estimation
C. Exchange transfusion
D. Cordocentesis

Explanation: **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).

Question 45: Which method of Medical Termination of Pregnancy is not used in the first trimester of pregnancy?

A. Intrauterine instillation of hypertonic saline (Correct Answer)
B. Suction and evacuation
C. Mifepristone
D. Misoprostol

Explanation: **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).

Question 46: IUGR is defined when:

A. Birth weight is below the tenth percentile of the average for gestational age (Correct Answer)
B. Birth weight is below the 20th percentile of the average for gestational age
C. Birth weight is below the 30th percentile of the average for gestational age
D. Birth weight of the baby is less than 1000 gm

Explanation: **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: $[Weight (g) / Length (cm)^3] \times 100$.

Question 47: Suction evacuation as MTP is best done up to how many weeks of gestation?

A. 9 weeks
B. 12 weeks (Correct Answer)
C. 18 weeks
D. 24 weeks

Explanation: **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.

Question 48: Which ligament is pierced by the needle to reach the pudendal nerve during a pudendal nerve block?

A. Sacral ligament
B. Ischial ligament
C. Pudendal ligament
D. Sacrospinous ligament (Correct Answer)

Explanation: **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 49: 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?

A. Vaginal delivery by breech extraction
B. Vaginal delivery after external cephalic version
C. Cesarean section (Correct Answer)
D. Internal podalic version

Explanation: **Explanation:** The clinical scenario describes a **Footling Breech** presentation (fetal foot palpated) in a **Primigravida** at term (41 weeks). **1. Why Cesarean Section is the Correct Choice:** In modern obstetrics, the standard of care for a breech presentation in a primigravida is a **Planned Cesarean Section**. This is based on the *Term Breech Trial*, which demonstrated significantly lower perinatal mortality and neonatal morbidity with cesarean delivery compared to planned vaginal birth. Specifically, a footling breech is an absolute indication for surgery because the irregular shape of the feet does not provide an effective dilating wedge for the cervix, increasing the risk of **umbilical cord prolapse** and entrapment of the after-coming head. **2. Why the Other Options are Incorrect:** * **A. Vaginal delivery by breech extraction:** Breech extraction is reserved almost exclusively for the delivery of the **second twin**. In a singleton pregnancy, it carries a high risk of fetal injury and cervical spine trauma. * **B. External Cephalic Version (ECV):** ECV is contraindicated once **rupture of membranes (PROM)** has occurred, as adequate amniotic fluid is necessary to rotate the fetus safely. * **D. Internal Podalic Version:** This procedure is strictly used for the delivery of a **second twin** (transverse lie) and is never performed in a singleton term pregnancy due to the high risk of uterine rupture. **Clinical Pearls for NEET-PG:** * **Most common type of breech:** Frank breech (hips flexed, knees extended). * **Highest risk of cord prolapse:** Footling breech (15–18%) > Complete breech (4–6%) > Frank breech (0.5%). * **Prerequisites for Vaginal Breech:** Multigravida, Frank/Complete breech, fetal weight 2.5–3.5 kg, and flexed neck. * **Burn-Marshall Maneuver:** Used for delivery of the after-coming head (assisted by gravity). * **Mauriceau-Smellie-Veit Maneuver:** Most common manual method for delivery of the after-coming head.

Question 50: A patient with Stage 1A2 cervical cancer is detected at 26 weeks of gestation. What is the next appropriate management step?

A. Lower segment Cesarean section followed by extrafascial hysterectomy at 28 weeks gestation
B. Immediate concurrent chemoradiotherapy
C. Classical Cesarean section followed by Wertheim's hysterectomy at 30-32 weeks gestation (Correct Answer)
D. Medical termination of pregnancy

Explanation: **Explanation:** The management of cervical cancer in pregnancy depends on the **clinical stage** and **gestational age**. **1. Why Option C is correct:** Stage 1A2 cervical cancer is an invasive malignancy (microinvasive with depth >3mm to 5mm). At 26 weeks, the fetus is approaching viability. In such cases, the standard protocol is to allow the pregnancy to continue until fetal maturity (usually 30–32 weeks) while monitoring closely. * **Classical Cesarean Section:** This is mandatory to avoid cutting through the lower uterine segment, which may be involved by the tumor or have increased vascularity, potentially causing hemorrhage or tumor seeding. * **Wertheim’s Hysterectomy (Radical Hysterectomy):** This is the definitive treatment for Stage 1A2/1B1, involving the removal of the uterus, parametrium, and pelvic lymph nodes. Performing it immediately after the C-section is the preferred surgical approach. **2. Why other options are incorrect:** * **Option A:** Extrafascial (Type I) hysterectomy is insufficient for Stage 1A2; a radical hysterectomy is required. Also, 28 weeks is often too early if the maternal condition is stable. * **Option B:** Chemoradiotherapy is contraindicated in a viable pregnancy as it causes fetal death and significant morbidity. It is reserved for advanced stages where pregnancy is sacrificed. * **Option C:** MTP is generally considered only if the cancer is diagnosed in the first trimester or early second trimester (before 20–24 weeks) and the patient chooses to start treatment immediately. **Clinical Pearls for NEET-PG:** * **Stage 1A1:** Can often be managed with conization if margins are clear; pregnancy can proceed to term. * **Mode of Delivery:** Vaginal delivery is contraindicated in visible cervical lesions due to the risk of recurrence at the episiotomy site and massive hemorrhage. * **Classical C-Section** is the incision of choice for all invasive cervical cancers in pregnancy.

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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