Operative Obstetrics Practice Questions

Q: What is the management of a 5 cm dermoid cyst that has undergone torsion at 10 weeks of pregnancy?

Immediate removal. **Explanation:** **1. Why Immediate Removal is Correct:** Adnexal torsion is a surgical emergency, regardless of the gestational age. When a dermoid cyst (mature cystic teratoma) undergoes torsion, the blood supply to the ovary is compromised, leading to ischemia, necrosis, and potential peritonitis. In pregnancy, the primary goal is to prevent maternal morbidity and secondary fetal loss due to systemic inflammation or infection. Therefore, **immediate surgical intervention** (preferably laparoscopic detorsion or cystectomy) is mandatory to save the adnexa and stabilize the patient. **2. Why Other Options are Incorrect:** * **A & D (Wait and watch/Serial USG):** These are contraindicated in torsion. Delaying surgery increases the risk of gangrene, rupture of the cyst (which can cause chemical peritonitis in dermoids), and maternal sepsis. * **B (Removal in the 2nd trimester):** While the 2nd trimester (14–16 weeks) is the "elective window" for removing asymptomatic large cysts to prevent future complications, it does not apply to **acute emergencies** like torsion. An acutely twisted cyst cannot wait for the second trimester. **Clinical Pearls for NEET-PG:** * **Most common benign ovarian tumor in pregnancy:** Dermoid cyst (Mature cystic teratoma). * **Most common complication of dermoid in pregnancy:** Torsion (most frequent during the 1st trimester when the uterus rises or postpartum when the uterus involutes). * **Surgical approach:** Laparoscopy is considered safe in the 1st and 2nd trimesters when performed by experts. * **Progesterone Support:** If the corpus luteum is removed during surgery before 10–12 weeks, exogenous progesterone (e.g., micronized progesterone or dydrogesterone) must be supplemented to maintain the pregnancy until placental shift occurs.

Q: All of the following drugs are used for the medical management of ectopic pregnancy except?

Misoprostol. **Explanation:** The medical management of ectopic pregnancy aims to halt the growth of trophoblastic tissue and induce its resorption without surgical intervention. **Why Misoprostol is the correct answer:** **Misoprostol** is a synthetic Prostaglandin E1 (PGE1) analogue primarily used for cervical ripening, induction of labor, and medical abortion (to expel intrauterine contents). In an ectopic pregnancy, the gestational sac is located outside the uterine cavity (most commonly the fallopian tube). Misoprostol causes uterine contractions, which are ineffective at expelling extrauterine tissue and do not address the trophoblastic growth. Therefore, it has no role in the management of ectopic pregnancy. **Analysis of other options:** * **Methotrexate (MTX):** The gold standard for medical management. It is a folic acid antagonist that inhibits DNA synthesis in rapidly dividing cells (trophoblasts), leading to the resolution of the ectopic mass. * **Potassium Chloride (KCl):** Used for **local** medical management. It is injected directly into the fetal heart under ultrasound guidance to induce fetal asystole, typically in cases of heterotopic or live cervical/cesarean scar pregnancies. * **Mifepristone:** An anti-progestogen that blocks progesterone receptors. While less commonly used than MTX, it can be used as an adjunct to Methotrexate to increase the success rate of medical management by sensitizing the trophoblast. **NEET-PG High-Yield Pearls:** 1. **Ideal Candidate for MTX:** Hemodynamically stable, hCG 15% decline in hCG levels between Day 4 and Day 7 after MTX administration.

Q: All of the following are true about vasa previa except?

Fetal mortality rate of 10% with undiagnosed cases. **Explanation:** **Vasa Previa** is a rare but life-threatening obstetric emergency where fetal vessels run through the membranes, unprotected by placental tissue or the umbilical cord, across the internal os. **Why Option B is the Correct Answer (The False Statement):** The fetal mortality rate in **undiagnosed** cases of vasa previa is significantly higher than 10%; it is estimated to be between **50% and 95%**. Because the bleeding is entirely fetal in origin (rupture of fetal vessels), even a small amount of blood loss can lead to rapid fetal exsanguination and death. Conversely, if diagnosed prenatally, the survival rate is excellent (>95%). **Analysis of Other Options:** * **Option A:** The incidence is approximately **1 in 2000 to 1 in 5000** deliveries, making it a rare but critical condition to identify. * **Option C:** It is strongly associated with **low-lying placentas**, placenta previa, velamentous cord insertion, and succenturiate placental lobes. * **Option D:** **Cesarean section** is mandatory. If diagnosed prenatally, an elective CS is typically performed at 34–36 weeks to avoid the risk of membrane rupture during labor. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Rupture of membranes (spontaneous or artificial) + Painless vaginal bleeding + Fetal bradycardia/distress. * **Diagnosis:** Antenatal diagnosis is made via **Transvaginal Ultrasound with Color Doppler** (showing flow over the internal os). * **Apt Test:** Used to differentiate fetal hemoglobin from maternal hemoglobin in vaginal blood (Fetal blood remains pink; maternal blood turns yellow-brown). * **Management:** Immediate emergency CS if bleeding occurs; steroids for lung maturity if diagnosed prenatally.

Q: Infants of diabetic pregnancies may have hypertrophic cardiomyopathy that occasionally progresses to congestive heart failure. Cardiomyopathy generally disappears by what age?

6 months of age. **Explanation:** **Hypertrophic Cardiomyopathy (HCM)** in infants of diabetic mothers (IDM) is primarily driven by fetal hyperinsulinemia. Insulin acts as an anabolic hormone that triggers the deposition of glycogen and fat into the myocardial cells, leading to disproportionate thickening of the interventricular septum. This can cause subaortic outflow tract obstruction and, in severe cases, congestive heart failure. **1. Why 6 months is correct:** The underlying pathophysiology is transient because the stimulus (maternal hyperglycemia and subsequent fetal hyperinsulinemia) is removed at birth. Once the infant is no longer exposed to high glucose levels, the excess myocardial glycogen is gradually metabolized. Clinical and echocardiographic resolution of the septal hypertrophy typically occurs within **6 months of age**. **2. Why other options are incorrect:** * **1 month & 3 months:** While symptoms may improve as the infant stabilizes, complete anatomical resolution of the thickened myocardium usually takes longer than the first trimester of life. * **12 months:** Most cases resolve well before the end of the first year. If cardiomyopathy persists beyond 6–9 months, clinicians should investigate other genetic or metabolic etiologies (e.g., Pompe disease or familial HCM). **Clinical Pearls for NEET-PG:** * **Management:** Unlike adult HCM, the primary treatment for symptomatic IDM with HCM is **Beta-blockers** (e.g., Propranolol) to slow the heart rate and improve diastolic filling. * **Contraindication:** **Digoxin and Inotropes** are generally contraindicated as they increase contractility, which can worsen the outflow tract obstruction. * **Incidence:** Asymmetric septal hypertrophy occurs in approximately 30% of IDMs, though only a small fraction (5-10%) develop clinical heart failure.

Q: What is the indication for internal podalic version?

Transverse lie of the second twin. **Explanation:** **Internal Podalic Version (IPV)** is an obstetric maneuver where the fetus is turned from a transverse or cephalic presentation into a breech presentation by reaching inside the uterus, grasping the feet, and pulling them down into the birth canal. **Why Option B is Correct:** The primary and most common indication for IPV in modern obstetrics is the **transverse lie of the second twin**. After the delivery of the first twin, if the second twin is in a transverse lie, IPV is performed to convert it into a footling breech, followed by immediate breech extraction. This is preferred because the cervix is already fully dilated and the uterus is spacious enough to allow internal manipulation. **Analysis of Incorrect Options:** * **A. Transverse lie (Singleton):** In a singleton pregnancy, a transverse lie is an absolute indication for a **Cesarean Section**. IPV is contraindicated here due to the high risk of uterine rupture and fetal trauma. * **C. Breech presentation:** Breech is managed via planned Cesarean or assisted vaginal breech delivery. IPV is used to *create* a breech, not to treat one. * **D. Polyhydramnios:** This is a risk factor for unstable lie but not an indication for IPV. In fact, sudden rupture of membranes in polyhydramnios can lead to cord prolapse. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisites for IPV:** Full cervical dilation, ruptured membranes, and a relaxed uterus (often under general anesthesia). * **Contraindications:** Ruptured membranes for a long duration (dry labor), thinned-out lower uterine segment, or a contracted uterus, as these significantly increase the risk of **uterine rupture**. * **External Cephalic Version (ECV)** is different; it is done at 36+ weeks for breech/transverse lie to convert them to cephalic, performed externally through the abdominal wall.

Question 1

What is the incidence of rupture in classical cesarean sections?

Accepted Answer

4-9%

Answer

0.5 - 1.5%

Answer

2-5%

Answer

>10%

Question 2

What is the management of a 5 cm dermoid cyst that has undergone torsion at 10 weeks of pregnancy?

Accepted Answer

Immediate removal

Answer

Wait and watch

Answer

Removal in the 2nd trimester

Answer

Serial ultrasonography monitoring

Question 3

A 26-year-old patient has had three consecutive spontaneous abortions early in her pregnancy. As part of an evaluation for this problem, which of the following tests would be least useful?

Accepted Answer

Testing for TORCH infections, Postcoital test

Answer

Hysterosalpingogram, Testing for TORCH infections, Postcoital test

Answer

Hysterosalpingogram, Testing for TORCH infections

Answer

Postcoital test only

Question 4

A woman at 32 weeks of gestation presents with labor pains. On examination, her cervix is 2 cm dilated and one uterine contraction is felt every 20-30 seconds. What is the appropriate management?

Accepted Answer

Isoxsuprine hydrochloride

Answer

Wait and watch

Answer

Augmentation of labor

Answer

Emergency lower segment cesarean section

Question 5

All of the following drugs are used for the medical management of ectopic pregnancy except?

Accepted Answer

Misoprostol

Answer

Potassium Chloride

Answer

Methotrexate

Answer

Mifepristone

Question 6

Prophylactic anti-D injection in non-immunized Rh-negative women should be given at which points?

Accepted Answer

28 weeks and within 72 hours after delivery

Answer

28 weeks, 32 weeks, and within 72 hours after delivery

Answer

28 weeks, 36 weeks, and within 72 hours after delivery

Answer

28 weeks, 34 weeks, and within 72 hours after delivery

Question 7

All of the following are true about vasa previa except?

Accepted Answer

Fetal mortality rate of 10% with undiagnosed cases

Answer

Incidence is 1:2000 deliveries

Answer

Associated with low-lying placenta

Answer

Cesarean section is indicated

Question 8

Which prostaglandin is used for ripening of the cervix during labor?

Accepted Answer

Dinoprostone (PGE2)

Answer

Misoprostol

Answer

Prostacyclin

Answer

Mifepristone

Question 9

Infants of diabetic pregnancies may have hypertrophic cardiomyopathy that occasionally progresses to congestive heart failure. Cardiomyopathy generally disappears by what age?

Accepted Answer

6 months of age

Answer

1 month of age

Answer

3 months of age

Answer

12 months of age

Question 10

What is the indication for internal podalic version?

Accepted Answer

Transverse lie of the second twin

Answer

Transverse lie

Answer

Breech presentation

Answer

Polyhydramnios

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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