Operative Obstetrics — MCQs

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 61: A 30-year-old primigravida presents with a blood pressure of 160/96 mm Hg. Her BUN is 14 mg/dL and creatinine is 1.0 mg/dL. Urinalysis shows no proteinuria. Complete blood count and liver function tests are within normal limits. What is the first best drug to be given to this patient?

A. Furosemide
B. Labetalol (Correct Answer)
C. Lisinopril
D. Losartan

Explanation: ### Explanation **Diagnosis:** The patient is a primigravida with a blood pressure of 160/96 mm Hg, normal renal/liver function, and no proteinuria. This presentation is consistent with **Gestational Hypertension** (if >20 weeks) or **Chronic Hypertension** (if <20 weeks). Regardless of the specific classification, the immediate clinical goal is the safe management of hypertension in pregnancy. **Why Labetalol is Correct:** Labetalol is a combined alpha- and beta-adrenergic blocker and is considered a **first-line antihypertensive agent** in pregnancy. It is preferred due to its rapid onset of action, excellent safety profile, and lack of significant teratogenic effects. It effectively lowers blood pressure without causing significant reflex tachycardia or compromising uteroplacental blood flow. **Analysis of Incorrect Options:** * **Furosemide (A):** Diuretics are generally avoided in pregnancy as they can cause volume depletion and potentially decrease placental perfusion. They are only used in specific cases like pulmonary edema. * **Lisinopril (C) & Losartan (D):** ACE inhibitors and ARBs are **absolutely contraindicated** in pregnancy (Category D/X). They are associated with fetal renal dysgenesis, oligohydramnios, skull hypoplasia, and intrauterine growth restriction (IUGR). **Clinical Pearls for NEET-PG:** * **First-line drugs for Hypertension in Pregnancy:** Oral Labetalol, Methyldopa (safest long-term), and Nifedipine (long-acting). * **Management of Hypertensive Crisis (BP ≥160/110):** IV Labetalol, IV Hydralazine, or Oral Nifedipine. * **Drugs to Avoid:** ACE inhibitors, ARBs, Sodium Nitroprusside (cyanide toxicity), and Spironolactone. * **Target BP:** Aim to maintain systolic between 140–150 mmHg and diastolic between 90–100 mmHg to prevent maternal cerebrovascular accidents without compromising fetal circulation.

Question 62: In a nulliparous woman, what is the treatment of choice for a ruptured ectopic pregnancy?

A. Salpingectomy and end-to-end anastomosis
B. Salpingo-oophorectomy
C. Expectant management (Wait and watch)
D. Linear salpingostomy (Correct Answer)

Explanation: **Explanation:** The primary goal in managing a ruptured ectopic pregnancy in a **nulliparous woman** (who typically desires future fertility) is to preserve the fallopian tube whenever possible. **Why Linear Salpingostomy is the Correct Choice:** Linear salpingostomy is a **fertility-preserving (conservative) surgery**. It involves making a longitudinal incision on the antimesenteric border of the fallopian tube over the site of the ectopic pregnancy, removing the products of conception, and allowing the incision to heal by secondary intention. In a nulliparous patient, this approach is preferred over radical surgery to maintain reproductive potential, provided the patient is hemodynamically stable and the tube is not extensively damaged. **Why Other Options are Incorrect:** * **Salpingectomy and end-to-end anastomosis:** This is not a standard primary treatment. Primary anastomosis in an acutely inflamed or ruptured tube carries a high risk of stricture and repeat ectopic pregnancy. * **Salpingo-oophorectomy:** This is an overly radical procedure involving the removal of the ovary along with the tube. It is unnecessary unless the ovary is also damaged or involved in a tubo-ovarian mass. * **Expectant management:** This is contraindicated in a **ruptured** ectopic pregnancy. Rupture is a surgical emergency due to the risk of life-threatening intraperitoneal hemorrhage. **NEET-PG High-Yield Pearls:** * **Gold Standard for Diagnosis:** Transvaginal Ultrasound (TVS) + Serum β-hCG. * **Surgical Approach:** Laparoscopy is the preferred route over laparotomy unless the patient is hemodynamically unstable. * **Salpingectomy vs. Salpingostomy:** Salpingectomy (removal of the tube) is indicated if the tube is severely damaged, there is uncontrolled bleeding, or if the patient has completed her family. * **Follow-up:** After salpingostomy, weekly **β-hCG monitoring** is mandatory until levels reach <5 mIU/mL to rule out persistent trophoblastic tissue.

Question 63: What is the name of the maneuver performed for delivering the aftercoming head of a breech presentation?

A. Lovset maneuver
B. Burns Marshall maneuver
C. Pinard's maneuver
D. Mauriceau-Smellie-Veit maneuver (Correct Answer)

Explanation: **Explanation:** The **Mauriceau-Smellie-Veit maneuver** is the gold standard manual method for delivering the **aftercoming head** in a vaginal breech delivery. The primary objective is to promote **flexion** of the fetal head, which ensures the smallest diameters (suboccipitobregmatic) engage the maternal pelvis. In this maneuver, the fetus lies on the physician's forearm; the index and middle fingers are placed on the fetal malar bones (malar flexion), while the other hand applies pressure on the occiput to maintain flexion. **Analysis of Incorrect Options:** * **Lovset Maneuver:** Used for the delivery of the **extended arms** in breech presentation. It involves rotating the fetus 180° while maintaining downward traction to bring the posterior arm under the pubic symphysis. * **Burns Marshall Maneuver:** An alternative method for the aftercoming head where the baby is allowed to hang by its own weight to encourage flexion, then swung upward toward the mother’s abdomen. However, it is less preferred than Mauriceau-Smellie-Veit due to the risk of overextending the neck. * **Pinard’s Maneuver:** Used in **frank breech** to bring down the legs. It involves applying pressure to the popliteal fossa to flex the knee and abduct the thigh. **Clinical Pearls for NEET-PG:** * **Piper’s Forceps:** The most preferred instrument for delivering the aftercoming head (reduces intracranial hemorrhage risk). * **Prerequisite:** The aftercoming head must be delivered within **8 minutes** of the umbilicus appearing at the vulva to prevent fetal hypoxia. * **Zavanelli Maneuver:** Cephalic replacement used in shoulder dystocia (not breech).

Question 64: Which of the following scenarios poses the least risk of neonatal varicella pneumonia in an infant born to a mother with varicella infection?

A. Mother develops rash 2 days before delivery.
B. Mother develops rash during the postnatal hospital stay.
C. Mother develops rash 10 days before delivery. (Correct Answer)
D. Mother develops rash just before delivery and was treated with acyclovir.

Explanation: The risk of neonatal varicella is determined by the timing of maternal infection relative to delivery, which dictates the presence or absence of protective **maternal IgG antibodies** in the fetus. ### 1. Why Option C is Correct When a mother develops a varicella rash **10 days before delivery**, her immune system has sufficient time (usually >7 days) to produce VZV-specific IgG antibodies. These antibodies cross the placenta and provide **passive immunity** to the fetus. Even if the infant is infected during birth, the presence of these antibodies significantly reduces the severity of the disease, making the risk of neonatal pneumonia the lowest in this scenario. ### 2. Why Other Options are Incorrect * **Option A & D:** If the rash appears within **5 days before to 2 days after delivery**, the mother is viremic, but there is insufficient time for antibody production and placental transfer. This results in "malignant" neonatal varicella with a high risk of pneumonia and mortality (up to 30%). Treatment with acyclovir (Option D) helps the mother but does not guarantee the prevention of severe neonatal disease. * **Option B:** Postnatal exposure (after 2 days) carries a risk of neonatal chickenpox, but it is generally less severe than the "congenital" varicella syndrome or the "perinatal" varicella seen in the 5-day window, as the infant's exposure is not transplacental. ### 3. Clinical Pearls for NEET-PG * **The "Danger Zone":** Maternal rash appearing **5 days before to 2 days after** delivery. * **Management:** Infants born in this window must receive **Varicella-Zoster Immunoglobulin (VZIG)** immediately after birth. * **Congenital Varicella Syndrome:** Occurs with maternal infection in the **first 20 weeks** of gestation (characterized by cicatricial skin scars, limb hypoplasia, and chorioretinitis). * **Drug of Choice:** Oral Acyclovir for the mother (if presenting within 24h of rash); IV Acyclovir for the neonate if symptoms develop.

Question 65: Fothergill's operation involves:

A. Conization of cervix
B. Amputation of cervix (Correct Answer)
C. Radical hysterectomy
D. Vaginal hysterectomy

Explanation: **Explanation:** **Fothergill’s Operation** (also known as the Manchester operation) is a conservative surgical procedure designed for the management of **uterine prolapse**, specifically in women who wish to preserve their uterus. **Why the correct answer is right:** The hallmark of Fothergill’s operation is the **amputation of the cervix**. The procedure involves: 1. Dilation and Curettage (D&C). 2. Amputation of the elongated vaginal portion of the cervix. 3. **Plication of the Mackenrodt’s (cardinal) ligaments** in front of the cervical stump. This shortens the ligaments, providing structural support to elevate the uterus back into the pelvic cavity. **Why the incorrect options are wrong:** * **A. Conization of cervix:** This is a diagnostic or therapeutic procedure for cervical intraepithelial neoplasia (CIN) involving the removal of a cone-shaped wedge of tissue; it does not address pelvic organ prolapse. * **C. Radical hysterectomy:** This is an extensive surgery for cervical cancer (Wertheim’s operation) involving removal of the uterus, parametrium, and pelvic lymph nodes. * **D. Vaginal hysterectomy:** While used for prolapse, this involves complete removal of the uterus. Fothergill’s is specifically "uterine-sparing." **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Candidate:** A woman with second-degree prolapse who desires to retain her uterus or is unfit for major abdominal surgery. * **Key Step:** Shortening of the Mackenrodt’s ligaments is the most crucial step for providing support. * **Contraindication:** It should not be performed if there is suspected cervical malignancy or if the patient desires future pregnancy (due to high risk of mid-trimester abortion and cervical stenosis). * **Associated Procedure:** Often combined with anterior colporrhaphy and posterior colpoperineorrhaphy.

Question 66: A 38-year-old woman, gravida 1, para 0, delivers an appropriate-for-gestational age infant by spontaneous vaginal delivery in the vertex position. The infant is noted to have edematous swelling of the soft tissue of the scalp that crosses the midline. What is the most likely diagnosis?

A. Cephalohematoma
B. Subcutaneous fat necrosis
C. Fracture of the skull
D. Caput succedaneum (Correct Answer)

Explanation: **Explanation:** The clinical presentation describes **Caput succedaneum**, a common neonatal scalp condition [1]. The key diagnostic feature provided is edematous swelling that **crosses the midline (sutures)** [1]. 1. **Why Caput succedaneum is correct:** It is caused by pressure from the cervix or vaginal walls on the fetal head during labor, leading to venous congestion and accumulation of serosanguinous fluid in the subcutaneous tissue (above the periosteum). Because this fluid is located in the superficial soft tissue, it is not restricted by bone boundaries and thus crosses suture lines [1]. It is typically present at birth and resolves spontaneously within a few days [1]. 2. **Why other options are incorrect:** * **Cephalohematoma:** This is a collection of blood between the skull bone and the **periosteum** [1],[2]. Because the periosteum is fixed to the suture lines, the swelling **never crosses the midline** [1]. It often appears hours after birth and takes weeks to resolve [1],[2]. * **Subcutaneous fat necrosis:** This presents as firm, erythematous nodules or plaques on the skin, usually appearing days to weeks after birth, often following birth trauma or therapeutic cooling. * **Fracture of the skull:** While linear fractures can occur during delivery, they do not typically present as diffuse soft tissue swelling crossing sutures; they are often asymptomatic or associated with localized depression (ping-pong fracture). **High-Yield Clinical Pearls for NEET-PG:** * **Caput succedaneum:** Present at birth, crosses sutures, involves subcutaneous tissue [1]. * **Cephalohematoma:** Delayed onset, does **not** cross sutures, subperiosteal [1]. Risk of jaundice due to RBC breakdown [2]. * **Subgaleal Hemorrhage:** Bleeding between the aponeurosis and periosteum. It is a **surgical emergency** as it can lead to massive blood loss and shock. It also crosses sutures but is fluctuant and rapidly expanding.

Question 67: All of the following are true regarding the management of diabetic patients during pregnancy, EXCEPT?

A. Insulin is the most preferred drug, if required, for glycemic control.
B. Targeted sonography should be performed between 18 and 20 weeks to rule out fetal anomalies.
C. Metformin and Glyburide are oral hypoglycemics, safe for use in pregnancy.
D. A Glucose Tolerance Test (GTT) must be performed in all patients with known diabetes at the first visit. (Correct Answer)

Explanation: **Explanation:** The correct answer is **D**. A Glucose Tolerance Test (GTT) is a diagnostic tool used to identify diabetes in asymptomatic or high-risk individuals. In patients with **known diabetes** (pre-gestational), the diagnosis is already established. Performing a GTT is redundant and potentially harmful, as the high glucose load can cause severe hyperglycemia. Instead, these patients require immediate assessment of glycemic control via HbA1c, baseline renal/retinal screening, and adjustment of their existing treatment regimen. **Analysis of other options:** * **Option A:** Insulin remains the **gold standard** and most preferred drug because it does not cross the placenta and allows for precise titration to achieve strict glycemic targets. * **Option B:** Diabetes is associated with a higher risk of congenital anomalies (e.g., sacral agenesis, cardiac defects). A **Targeted Imaging for Fetal Anomalies (TIFFA)** scan at 18–20 weeks is mandatory to screen for these structural issues. * **Option C:** While insulin is preferred, **Metformin and Glyburide** are considered safe alternatives in many clinical guidelines (like ACOG/DIPSI) if a patient is non-compliant with or cannot afford insulin, though they do cross the placenta. **Clinical Pearls for NEET-PG:** * **Most common fetal anomaly in IDM:** Ventricular Septal Defect (VSD). * **Most specific fetal anomaly in IDM:** Sacral Agenesis (Caudal Regression Syndrome). * **DIPSI Criteria:** A single-step 75g Oral Glucose Tolerance Test is used in India; a 2-hour value **≥140 mg/dL** diagnoses GDM. * **HbA1c Goal:** Ideally **<6.0%** periconceptionally to minimize the risk of congenital malformations.

Question 68: A primigravida with vertex presentation is having a fully dilated cervix. The head is well engaged and is at a station of +2. Fetal heart monitoring shows late decelerations. What is the most appropriate management in this situation?

A. Observation
B. Vacuum extraction
C. Forceps application (Correct Answer)
D. Immediate Caesarean section

Explanation: **Explanation:** The clinical scenario describes a primigravida in the **second stage of labor** (fully dilated cervix) with **fetal distress** (late decelerations) and an **engaged head at +2 station**. The priority is immediate delivery to prevent fetal hypoxia. **Why Forceps application is correct:** For instrumental delivery, certain criteria must be met: the cervix must be fully dilated, membranes ruptured, and the head must be engaged (at or below station 0). At **+2 station**, the head is low enough for an instrumental vaginal delivery. In cases of **acute fetal distress**, **Forceps** are preferred over Vacuum because they allow for a quicker delivery and do not require maternal pushing efforts, which may be compromised during fetal compromise. **Why other options are incorrect:** * **Observation:** Late decelerations are a sign of uteroplacental insufficiency and fetal hypoxia; waiting is contraindicated as it risks fetal demise. * **Vacuum extraction:** While possible, vacuum extraction takes longer to achieve delivery (requires building pressure and multiple pulls) and is generally avoided if there is severe fetal distress or if the mother cannot assist with pushing. * **Immediate Caesarean section:** While a valid way to deliver, a C-section would take significantly longer to perform (transfer to OR, anesthesia, surgical entry) compared to an outlet or low-forceps delivery when the head is already at +2 station. **Clinical Pearls for NEET-PG:** * **Prerequisites for Instrumental Delivery:** Remember the mnemonic **FORCEPS**: **F**etus alive, **O**penned cervix (full), **R**uptured membranes, **C**ontractions present, **E**ngaged head, **P**elvis adequate, **S**ladder empty. * **Station:** Station 0 is at the level of ischial spines. Station +2 is considered a "Low" station. * **Late Decelerations:** Always indicate **Uteroplacental Insufficiency**. * **Forceps vs. Vacuum:** Forceps have a higher success rate and are faster for fetal distress, but carry a higher risk of 3rd/4th-degree perineal tears.

Question 69: Which forceps is used for the aftercoming head in a breech delivery?

A. Piper forceps (Correct Answer)
B. Kielland's forceps
C. Wrigley's forceps
D. Kocher's forceps

Explanation: **Explanation:** The correct answer is **Piper forceps**. In breech presentations, the delivery of the aftercoming head is a critical stage. Piper forceps are specifically designed for this purpose, featuring a **long shank with a perineal curve** (downward curve). This unique design allows the blades to be applied to the fetal head while the body of the baby is positioned above the level of the handles, preventing excessive extension of the fetal neck and protecting the head from sudden decompression. **Analysis of Incorrect Options:** * **Kielland's forceps:** These are specialized "rotational forceps" characterized by a minimal pelvic curve and a sliding lock. They are used for correcting asynclitism or rotating a head from an occipito-transverse/posterior position, not for breech. * **Wrigley's forceps:** These are short, light "outlet forceps." They are used for low-cavity or outlet deliveries when the head is on the perineum, often during Cesarean sections, but they lack the length and curve required for the aftercoming head. * **Kocher's forceps:** This is a surgical instrument (hemostat/clamp) used for grasping tissues or clamping vessels; it is not an obstetric forceps used for delivery. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisite:** For Piper forceps application, the fetal body must be held up by an assistant (the "Prague maneuver" is sometimes used in conjunction). * **Alternative:** The **Burns-Marshall method** and **Mariceau-Smellie-Veit maneuver** are manual techniques for delivering the aftercoming head. * **Key Feature:** Piper forceps lack a pelvic curve but possess a perineal curve to accommodate the fetal trunk.

Question 70: A 34-week pregnant woman, G3P2L2, complains of decreased fetal movements for the past 24 hours. She has no other significant pregnancy-related conditions. What is the next best step?

A. Instruct the patient to go to the hospital for a contraction stress test.
B. Reassure the patient that one fetal movement per hour is within normal limits.
C. Admit the patient to the hospital for delivery.
D. Instruct the patient to go to the hospital for a nonstress test. (Correct Answer)

Explanation: ### Explanation **Correct Option: D. Instruct the patient to go to the hospital for a nonstress test.** The primary goal in managing a complaint of decreased fetal movements (DFM) is to assess fetal well-being and rule out fetal distress or intrauterine fetal demise. At 34 weeks (viable gestational age), the **Nonstress Test (NST)** is the preferred initial screening tool. It evaluates the fetal heart rate (FHR) response to fetal movement. A "reactive" NST indicates a functional fetal autonomic nervous system and correlates with a low risk of fetal death within the next week. **Why other options are incorrect:** * **Option A:** A **Contraction Stress Test (CST)** is more invasive (requires oxytocin or nipple stimulation) and is generally used as a follow-up if the NST or Biophysical Profile (BPP) is non-reassuring. It is not the first-line investigation for DFM. * **Option B:** Reassurance is inappropriate. While "10 movements in 2 hours" (Sadovsky’s method) is a common threshold, any subjective perception of decreased movement by the mother requires objective clinical evaluation. * **Option C:** Delivery at 34 weeks is premature. Admission for delivery is only indicated if fetal distress is confirmed (e.g., persistent late decelerations or a BPP score <4/10) and the benefits of delivery outweigh the risks of prematurity. **Clinical Pearls for NEET-PG:** * **Reactive NST:** Defined as $\geq$ 2 accelerations (at least 15 bpm above baseline lasting 15 seconds) within a 20-minute window. * **First step in DFM:** Maternal history and physical exam (including FHR auscultation), followed immediately by an NST. * **Next step if NST is non-reactive:** Perform a **Biophysical Profile (BPP)** or Modified BPP (NST + Amniotic Fluid Index). * **High-yield:** The most common cause of a non-reactive NST is a **fetal sleep cycle** (usually lasting 20–40 minutes).

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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