Operative Obstetrics — MCQs

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 51: What is the incidence of rupture in classical cesarean sections?

A. 0.5 - 1.5%
B. 2-5%
C. 4-9% (Correct Answer)
D. >10%

Explanation: The correct answer is **4-9%**. ### **Explanation** The risk of uterine rupture is significantly higher in a **Classical Cesarean Section** compared to a Lower Segment Cesarean Section (LSCS). This is because the classical incision is made vertically in the **upper muscular segment** of the uterus. Unlike the lower segment, the upper segment is thick, highly vascular, and undergoes active contractions during labor. Furthermore, the wound healing in this region is often less efficient, leading to a weaker scar that can rupture even **before the onset of labor**. ### **Analysis of Options** * **A (0.5 - 1.5%):** This is the incidence of rupture for a **Lower Segment Cesarean Section (LSCS)** scar. The lower segment is passive and thin, making it more stable during subsequent pregnancies. * **B (2-5%):** This range is often associated with T-shaped or J-shaped incisions, which carry an intermediate risk but are lower than a true classical incision. * **C (4-9%):** **Correct.** Standard textbooks (like Williams Obstetrics) cite this range for classical scars. The risk is high enough that a repeat elective cesarean is mandatory at 36-37 weeks. * **D (>10%):** While the risk is high, it rarely exceeds 10% in a single subsequent pregnancy unless there are multiple prior classical incisions or associated complications like infection. ### **High-Yield Clinical Pearls for NEET-PG** 1. **Timing of Rupture:** Classical scars often rupture **pre-labor** (late 2nd or 3rd trimester), whereas LSCS scars typically rupture **during labor**. 2. **Management:** Patients with a history of classical CS must undergo a **Repeat Elective Cesarean Section (RECS)**. Trial of Labor After Cesarean (TOLAC) is strictly **contraindicated**. 3. **Incision Type:** A classical incision involves the upper segment, while a **De Lee incision** (LSCS) is transverse in the lower segment. 4. **Other High-Risk Scars:** Hysterotomy and full-thickness myomectomy scars carry a similar high risk of rupture as classical CS.

Question 52: What is the management of a 5 cm dermoid cyst that has undergone torsion at 10 weeks of pregnancy?

A. Wait and watch
B. Removal in the 2nd trimester
C. Immediate removal (Correct Answer)
D. Serial ultrasonography monitoring

Explanation: **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.

Question 53: 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?

A. Hysterosalpingogram, Testing for TORCH infections, Postcoital test
B. Hysterosalpingogram, Testing for TORCH infections
C. Testing for TORCH infections, Postcoital test (Correct Answer)
D. Postcoital test only

Explanation: **Explanation:** Recurrent Pregnancy Loss (RPL) is defined as two or more consecutive spontaneous abortions. The evaluation of RPL focuses on identifying anatomical, genetic, endocrine, and immunological causes. **Why Option C is correct:** * **TORCH Infections:** While infections like Toxoplasmosis, Rubella, CMV, and Herpes can cause *sporadic* pregnancy loss, they are **not** recognized causes of *recurrent* early pregnancy loss. This is because the mother typically develops immunity after the initial exposure, preventing subsequent losses from the same agent. * **Postcoital Test (PCT):** This test evaluates cervical mucus-sperm interaction to diagnose infertility. It has no clinical relevance in maintaining a pregnancy once conception has occurred and is therefore useless in the workup of RPL. **Analysis of other options:** * **Hysterosalpingogram (HSG):** This is a **useful** and essential test in RPL. It identifies uterine anomalies (e.g., septate uterus, bicornuate uterus) or acquired defects (e.g., Asherman syndrome, submucosal fibroids) which are major causes of mid-trimester or early losses. * **Options A and B:** These are incorrect because they include HSG, which is a standard and necessary part of the RPL evaluation. * **Option D:** While the PCT is useless, it is not the *only* useless test listed; TORCH testing is equally irrelevant in this context. **NEET-PG High-Yield Pearls:** 1. **Most common cause of sporadic abortion:** Chromosomal anomalies (Trisomy is most common; Trisomy 16 specifically). 2. **Most common cause of RPL:** Often idiopathic (50%), but among known causes, **Antiphospholipid Antibody Syndrome (APS)** and **Uterine Septum** are high-yield. 3. **Standard RPL Workup:** Includes Parental Karyotyping, HSG/Hysteroscopy, Lupus Anticoagulant/Anticardiolipin antibodies, and Thyroid Stimulating Hormone (TSH) levels. 4. **TORCH screening** is a common "distractor" in exams; remember it is for congenital malformations, not recurrent losses.

Question 54: 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?

A. Isoxsuprine hydrochloride (Correct Answer)
B. Wait and watch
C. Augmentation of labor
D. Emergency lower segment cesarean section

Explanation: ### Explanation **Correct Option: A. Isoxsuprine hydrochloride** The patient is presenting with **Preterm Labor (PTL)**, defined as the onset of labor pains with cervical changes before 37 completed weeks of gestation. At 32 weeks, the primary goal of management is to delay delivery to allow for the administration of corticosteroids (for fetal lung maturity) and to facilitate transfer to a tertiary care center with neonatal intensive care facilities. **Isoxsuprine hydrochloride** is a beta-2 adrenergic agonist used as a **tocolytic agent**. It works by relaxing the uterine smooth muscles (myometrium) to arrest preterm contractions. While newer agents like Nifedipine (Calcium Channel Blockers) or Atosiban are now preferred due to fewer side effects, Isoxsuprine remains a classic pharmacological option in many clinical scenarios and exams. **Why other options are incorrect:** * **B. Wait and watch:** This is inappropriate because active preterm labor (2 cm dilation + frequent contractions) requires intervention to prevent the birth of a premature infant with potential respiratory distress syndrome. * **C. Augmentation of labor:** This involves using Oxytocin to increase the frequency/intensity of contractions. It is contraindicated here as we want to stop, not accelerate, labor at 32 weeks. * **D. Emergency LSCS:** Cesarean section is indicated for fetal distress or obstetric complications (like placenta previa). It is not the first-line management for uncomplicated preterm labor. **High-Yield Clinical Pearls for NEET-PG:** * **First-line Tocolytic:** Currently, **Nifedipine** is the drug of choice for PTL due to its oral route and better safety profile. * **Steroid Protocol:** Dexamethasone (6mg IM, 4 doses, 12h apart) or Betamethasone (12mg IM, 2 doses, 24h apart) is crucial between 24–34 weeks to prevent RDS, IVH, and NEC. * **Magnesium Sulfate:** Administered for **neuroprotection** if delivery is imminent before 32 weeks. * **Contraindications to Tocolysis:** Chorioamnionitis, severe pre-eclampsia, fetal demise, or lethal fetal anomalies.

Question 55: All of the following drugs are used for the medical management of ectopic pregnancy except?

A. Potassium Chloride
B. Methotrexate
C. Misoprostol (Correct Answer)
D. Mifepristone

Explanation: **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 <5000 mIU/mL, no fetal heart activity, and mass size <3.5–4 cm. 2. **Dose of MTX:** 50 mg/m² (Single-dose protocol is most common). 3. **Contraindication:** Ruptured ectopic pregnancy is an absolute contraindication to medical management; immediate laparoscopy/laparotomy is required. 4. **Monitoring:** Success is defined by a >15% decline in hCG levels between Day 4 and Day 7 after MTX administration.

Question 56: Prophylactic anti-D injection in non-immunized Rh-negative women should be given at which points?

A. 28 weeks, 32 weeks, and within 72 hours after delivery
B. 28 weeks, 36 weeks, and within 72 hours after delivery
C. 28 weeks, 34 weeks, and within 72 hours after delivery
D. 28 weeks and within 72 hours after delivery (Correct Answer)

Explanation: **Explanation:** The primary goal of administering Anti-D immunoglobulin (RhIg) is to prevent **Rh isoimmunization** in a non-immunized Rh-negative mother carrying an Rh-positive fetus. This occurs by neutralizing fetal D-antigens that enter the maternal circulation before the mother’s immune system can recognize them and produce its own antibodies. **Why Option D is Correct:** Current clinical guidelines (RCOG and ACOG) recommend a two-pronged approach for routine prophylaxis: 1. **Antenatal Prophylaxis:** Administered at **28 weeks** of gestation. This is because the risk of spontaneous feto-maternal hemorrhage increases significantly in the third trimester, and the effect of a 300 mcg dose lasts approximately 12 weeks, covering the period until term. 2. **Postnatal Prophylaxis:** Administered **within 72 hours of delivery**, provided the neonate is confirmed to be Rh-positive. This targets the large volume of fetal cells that may enter maternal circulation during placental separation. **Why Other Options are Incorrect:** Options A, B, and C suggest additional doses at 32, 34, or 36 weeks. These are **unnecessary** for routine prophylaxis. While some older protocols used a two-dose antenatal regimen (at 28 and 34 weeks), the single-dose 28-week regimen is now the standard of care as it is equally effective and more cost-efficient. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Dose:** 300 mcg (1500 IU) is the standard dose, which can neutralize up to 30 ml of fetal whole blood (or 15 ml of packed RBCs). * **The 72-Hour Rule:** While 72 hours is ideal, if missed, Anti-D should still be given as soon as possible up to **13–28 days** postpartum. * **Kleihauer-Betke Test:** Used to quantify the volume of feto-maternal hemorrhage to determine if additional doses of Anti-D are required. * **Other Indications:** Anti-D must also be given after "sensitizing events" such as abortion, ectopic pregnancy, amniocentesis, or abdominal trauma.

Question 57: All of the following are true about vasa previa except?

A. Incidence is 1:2000 deliveries
B. Fetal mortality rate of 10% with undiagnosed cases (Correct Answer)
C. Associated with low-lying placenta
D. Cesarean section is indicated

Explanation: **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.

Question 58: Which prostaglandin is used for ripening of the cervix during labor?

A. Dinoprostone (PGE2) (Correct Answer)
B. Misoprostol
C. Prostacyclin
D. Mifepristone

Explanation: **Explanation:** Cervical ripening is the process of softening and thinning the cervix to facilitate dilation during labor induction. This is mediated by the breakdown of collagen fibers and an increase in water content within the cervical stroma. **1. Why Dinoprostone (PGE2) is the Correct Answer:** Dinoprostone is a naturally occurring Prostaglandin E2. It is considered the **gold standard** for cervical ripening. It acts by stimulating the enzyme collagenase, which breaks down cervical collagen, and by increasing intracellular calcium, which helps in myometrial contraction. It is available as intracervical gels or controlled-release vaginal inserts (Cervidil). **2. Analysis of Incorrect Options:** * **Misoprostol (PGE1):** While Misoprostol is highly effective for both ripening and induction, it is a synthetic PGE1 analogue. In many clinical guidelines (and standard textbook definitions for "ripening"), PGE2 remains the primary agent specifically indicated for ripening, whereas Misoprostol is often categorized under induction of labor or management of PPH. * **Prostacyclin (PGI2):** This is a potent vasodilator and inhibitor of platelet aggregation. It does not play a significant role in cervical ripening or labor induction. * **Mifepristone:** This is an anti-progestogen. While it can be used for induction of labor in cases of intrauterine fetal death (IUFD), it is primarily used for medical termination of pregnancy (MTP) and is not a prostaglandin. **High-Yield Clinical Pearls for NEET-PG:** * **Bishop Score:** A score of $\leq 6$ indicates an "unripe" cervix and necessitates the use of ripening agents like Dinoprostone. * **Contraindication:** Prostaglandins should be avoided in patients with a previous Cesarean section (scarred uterus) due to the increased risk of uterine rupture. * **Side Effect:** The most common side effect of PGE2 is uterine tachysystole (more than 5 contractions in 10 minutes). * **Storage:** Dinoprostone gel requires refrigeration ($2-8^\circ\text{C}$), whereas Misoprostol is stable at room temperature.

Question 59: Infants of diabetic pregnancies may have hypertrophic cardiomyopathy that occasionally progresses to congestive heart failure. Cardiomyopathy generally disappears by what age?

A. 1 month of age
B. 3 months of age
C. 6 months of age (Correct Answer)
D. 12 months of age

Explanation: **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.

Question 60: What is the indication for internal podalic version?

A. Transverse lie
B. Transverse lie of the second twin (Correct Answer)
C. Breech presentation
D. Polyhydramnios

Explanation: **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.

Practice by Chapter

Cesarean Section Techniques

Practice Questions

Vaginal Birth After Cesarean

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Instrumental Deliveries

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Breech Delivery

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Episiotomy and Repair

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Management of Multiple Gestation

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Cervical Cerclage

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Obstetric Hysterectomy

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Surgery During Pregnancy

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Surgical Complications in Obstetrics

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