Surgery During Pregnancy — MCQs
Which of the following is consistent with a decision to perform a cerclage?
Anesthesia of choice for cesarean section in severe preeclampsia:-
What is the management of eclampsia at 34 weeks of pregnancy?
All are cardiovascular system changes in pregnancy except.
What is the recommended management for a patient with complete placenta previa at 38 weeks gestation without any vaginal bleeding?
A lady with 36-week pregnancy with previous C-section comes with low BP, tachycardia, and on USG fluid present in peritoneum. What is the diagnosis and next management?
Termination of pregnancy in placenta previa is indicated in: a) Active bleeding b) Active labour c) Gestational age > 34 weeks with live fetus d) Fetal malformation e) Unstable lie
A 29-year-old woman with a ruptured ectopic pregnancy is admitted to a hospital for culdocentesis. A long needle on the syringe is most efficiently inserted through which of the following structures?
What is the most appropriate management for a 28-year-old hemodynamically stable patient with mild abdominal pain and an unruptured tubal ectopic pregnancy measuring 2.5 x 3 cm, with β-hCG level of 8500 mIU/mL, visible fetal cardiac activity, and who desires future fertility?
Which of the following cannot be treated by laparoscopy?
Surgery During Pregnancy Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is consistent with a decision to perform a cerclage?
- A. Gestation of 26 weeks
- B. Uterine bleeding
- C. Uterine contractions
- D. Cervix dilated to 3 cm (Correct Answer)
Explanation: ***Cervix dilated to 3 cm*** - In the context of **mid-trimester cervical dilation** (before 24 weeks) without contractions or bleeding, this represents **cervical insufficiency** - a potential indication for **emergency (rescue) cerclage**. - While 3 cm dilation is at the **upper limit** and somewhat controversial, emergency cerclage may still be considered if membranes are intact, there are no contractions, and gestational age is <24 weeks. - This is the **only option** that represents a clinical scenario where cerclage might be performed, as the other three options are **absolute contraindications**. - Note: Most clinicians prefer cervical dilation **<2 cm** for rescue cerclage, but individual cases at 2-3 cm may be considered based on clinical judgment. *Gestation of 26 weeks* - Cerclage is typically placed between **12-14 weeks** (prophylactic) or up to **23-24 weeks** (emergency). - At **26 weeks**, cerclage is **contraindicated** - the risks (membrane rupture, infection, preterm labor) outweigh benefits at this advanced gestation. - This is an **absolute contraindication** regardless of cervical findings. *Uterine bleeding* - **Active uterine bleeding** is an **absolute contraindication** to cerclage placement. - Bleeding increases risks of **infection, membrane rupture, and preterm labor**. - Must rule out **placental abruption, placenta previa**, or other complications before considering any cervical intervention. *Uterine contractions* - **Active uterine contractions** are an **absolute contraindication** for cerclage. - Placing cerclage during contractions can precipitate **preterm labor and delivery**. - Contractions indicate the cervix may be responding to labor stimuli, making cerclage ineffective and potentially harmful.
Question 2: Anesthesia of choice for cesarean section in severe preeclampsia:-
- A. Spinal (Correct Answer)
- B. GA
- C. Epidural
- D. Combined spinal-epidural (CSE)
Explanation: ***Spinal*** - **Spinal anesthesia** is generally preferred in severe preeclampsia because it provides **rapid onset** of dense block, which can be critical for emergent cesarean sections. - It avoids the risks associated with general anesthesia in these patients, such as difficult intubation and exaggerated **hypertensive response** to laryngoscopy. *GA* - **General anesthesia (GA)** in severe preeclampsia carries increased risks due to **airway edema**, potential for difficult intubation, and significant **blood pressure fluctuations** during induction and intubation. - It can exacerbate the already compromised uteroplacental perfusion due to the sympathetic blockade and the potential for a **hypotensive episode**. *Epidural* - While generally safe in less severe preeclampsia, an **epidural** has a **slower onset** compared to spinal anesthesia, which may be a disadvantage in emergent situations. - The gradual sympathetic blockade with an epidural is often preferred to avoid sudden drops in blood pressure, but the delay in achieving a surgical block might not be acceptable in severe, unstable cases. *Combined spinal-epidural (CSE)* - **Combined spinal-epidural (CSE)** offers the rapid onset of a spinal block with the flexibility of an epidural catheter for prolonged anesthesia or postoperative pain control. - However, in cases of severe preeclampsia where **hemodynamic instability** is a major concern, the relatively larger dose of local anesthetic required for epidural component can lead to a more pronounced or rapid drop in blood pressure.
Question 3: What is the management of eclampsia at 34 weeks of pregnancy?
- A. Continue convulsions and wait for 37 weeks to complete.
- B. Wait for spontaneous labor.
- C. Continue blood pressure management.
- D. Administer antihypertensives, anticonvulsants, and consider termination of pregnancy. (Correct Answer)
Explanation: **Administer antihypertensives, anticonvulsants, and consider termination of pregnancy.** - In eclampsia, emergent management includes immediate administration of **magnesium sulfate** as an anticonvulsant and **antihypertensives** (e.g., labetalol, hydralazine, nifedipine) to control blood pressure. - Given the gestational age of 34 weeks and the occurrence of eclampsia, **delivery of the fetus** is often indicated to resolve the maternal condition, regardless of fetal lung maturity. *Continue convulsions and wait for 37 weeks to complete.* - Allowing **convulsions to continue** is extremely dangerous for both mother and fetus, increasing risks of aspiration, trauma, hypoxemia, and placental abruption. - Eclampsia is a severe complication of pregnancy that necessitates immediate intervention and **should not be passively observed** until full term. *Wait for spontaneous labor.* - **Delaying delivery** while waiting for spontaneous labor in eclampsia significantly prolongs the mother's exposure to the severe complications of the condition. - Eclampsia is an ** obstetric emergency** where prompt delivery, often via induction or C-section, is the definitive cure. *Continue blood pressure management.* - While **blood pressure management** is a crucial component of eclampsia treatment, it is insufficient on its own. - Eclampsia specifically involves **seizures**, which require anticonvulsant therapy (magnesium sulfate) in addition to antihypertensives, and the ultimate treatment is delivery.
Question 4: All are cardiovascular system changes in pregnancy except.
- A. Increase in blood volume
- B. Increase in heart rate
- C. Increase in peripheral resistance (Correct Answer)
- D. Increase in cardiac output
Explanation: ***Increase in peripheral resistance*** - During normal pregnancy, **peripheral vascular resistance actually decreases** due to the effects of hormones like progesterone and the presence of the low-resistance uteroplacental circulation. - This decrease in resistance helps accommodate the increased blood volume and cardiac output. *Increase in cardiac output* - **Cardiac output increases significantly** during pregnancy (by 30-50%) to meet the metabolic demands of the growing fetus and maternal tissues. - This is primarily achieved through an increase in both stroke volume and heart rate. *Increase in blood volume* - **Blood volume increases substantially** (by 30-50%) during pregnancy, with plasma volume increasing more than red blood cell mass. - This expansion supports the increased cardiac output and placental perfusion. *Increase in heart rate* - **Heart rate increases** during pregnancy, typically by 10-20 beats per minute, contributing to the overall increase in cardiac output. - This physiological adaptation helps maintain adequate circulation.
Question 5: What is the recommended management for a patient with complete placenta previa at 38 weeks gestation without any vaginal bleeding?
- A. Elective caesarean section (Correct Answer)
- B. Observation and monitoring until delivery
- C. Conservative management with bed rest
- D. Urgent caesarean section due to bleeding risk
Explanation: ***Elective caesarean section*** - For women with **complete placenta previa** at term (38 weeks), an **elective caesarean section** is the recommended mode of delivery to avoid significant hemorrhage. - Even in the absence of bleeding, the risk of massive hemorrhage during labor with a complete previa is high, necessitating planned surgical delivery. *Observation and monitoring until delivery* - This approach is not safe for complete placenta previa at term due to the high risk of **unpredictable, severe hemorrhage** once labor begins or the cervix dilates. - Active monitoring without planned intervention carries significant maternal and fetal risk. *Conservative management with bed rest* - While bed rest may be used in cases of **placenta previa with bleeding** earlier in gestation to prolong pregnancy, it does not address the fundamental risk of hemorrhage from a complete previa at 38 weeks. - It would not prevent the need for an eventual caesarean section and prolongs potential risks. *Urgent caesarean section due to bleeding risk* - While there is a bleeding risk, this scenario describes a patient at 38 weeks gestation **without any vaginal bleeding**, making it an elective, rather than urgent, situation. - An **urgent caesarean section** is typically reserved for cases where active bleeding or other obstetric emergencies are present.
Question 6: A lady with 36-week pregnancy with previous C-section comes with low BP, tachycardia, and on USG fluid present in peritoneum. What is the diagnosis and next management?
- A. Abruptio and C-section
- B. Ectopic pregnancy and abortion
- C. Impending dehiscence and Laparoscopy
- D. Uterine scar rupture with Laparotomy (Correct Answer)
Explanation: ***Uterine scar rupture with Laparotomy*** - The presentation of **low blood pressure**, **tachycardia**, and **free fluid in the peritoneum** in a 36-week pregnant woman with a **previous C-section** is highly indicative of uterine scar rupture given the signs of **hemorrhagic shock**. - **Laparotomy** (emergency abdominal surgery) is the immediate and definitive management to repair the ruptured uterus, control bleeding, and deliver the fetus. *Abruptio and C-section* - **Placental abruption** typically presents with painful vaginal bleeding, uterine tenderness, and fetal distress, which are not explicitly mentioned as the primary symptoms here. - While a **C-section** would be indicated for abruption, the presence of free fluid in the peritoneum and hemodynamic instability in a woman with a prior C-section points more towards rupture. *Ectopic pregnancy and abortion* - An **ectopic pregnancy** is ruled out by the 36-week gestational age; these occur much earlier in pregnancy. - An **abortion** refers to the termination of pregnancy and does not cause these specific signs and symptoms at 36 weeks. *Impending dehiscence and Laparoscopy* - **Impending dehiscence** (separation of the uterine scar without complete rupture) would likely cause localized pain but typically not the severe signs of **hypovolemic shock** and free peritoneal fluid seen here. - **Laparoscopy** is a minimally invasive procedure and would not be appropriate for the emergency management of a potentially life-threatening hemorrhage from uterine rupture.
Question 7: Termination of pregnancy in placenta previa is indicated in: a) Active bleeding b) Active labour c) Gestational age > 34 weeks with live fetus d) Fetal malformation e) Unstable lie
- A. acd
- B. ab (Correct Answer)
- C. e
- D. abd
- E. abc
Explanation: ***ab*** - **Active bleeding** in placenta previa is an absolute indication for immediate delivery (usually by cesarean section) due to the risk of life-threatening maternal and fetal hemorrhage. - **Active labour** with placenta previa is a critical indication for immediate cesarean delivery, as progressive cervical dilation causes placental separation leading to catastrophic hemorrhage. *acd* - While active bleeding is an indication, gestational age > 34 weeks alone does not mandate immediate delivery in stable placenta previa patients. Expectant management until 36-37 weeks is standard practice. *e* - Unstable lie is not an indication for termination of pregnancy in placenta previa. While it may necessitate cesarean section at term, it does not indicate immediate delivery. *abc* - Active bleeding and active labour are correct indications, but gestational age > 34 weeks with a live fetus is NOT an isolated indication for immediate delivery in stable patients without bleeding. *abd* - Active bleeding and active labour are correct indications, but fetal malformation is not a specific indication for termination in the context of placenta previa management. Fetal malformation decisions are made independently of placenta previa status.
Question 8: A 29-year-old woman with a ruptured ectopic pregnancy is admitted to a hospital for culdocentesis. A long needle on the syringe is most efficiently inserted through which of the following structures?
- A. Anterior wall of the rectum
- B. Posterior fornix of the vagina (Correct Answer)
- C. Anterior fornix of the vagina
- D. Posterior wall of the uterine body
Explanation: ***Posterior fornix of the vagina*** - Culdocentesis is a procedure where fluid is aspirated from the **cul-de-sac (rectouterine pouch)**. - The **posterior vaginal fornix** is the thinnest and most accessible anatomical landmark for safely accessing the rectouterine pouch. *Anterior wall of the rectum* - Puncturing the **anterior rectal wall** could lead to peritonitis and is not the intended approach for culdocentesis. - The rectum is located posterior to the rectouterine pouch, making it an inappropriate entry point. *Anterior fornix of the vagina* - The **anterior fornix** is anatomically adjacent to the vesicouterine pouch (between the bladder and uterus), not the rectouterine pouch. - Puncturing this area would not access the fluid collection from a ruptured ectopic pregnancy, which accumulates in the rectouterine pouch. *Posterior wall of the uterine body* - Puncturing the **posterior wall of the uterine body** would damage the uterus and is not a route to the cul-de-sac. - The procedure aims to access the space behind the uterus, not the uterine organ itself.
Question 9: What is the most appropriate management for a 28-year-old hemodynamically stable patient with mild abdominal pain and an unruptured tubal ectopic pregnancy measuring 2.5 x 3 cm, with β-hCG level of 8500 mIU/mL, visible fetal cardiac activity, and who desires future fertility?
- A. Methotrexate therapy
- B. Laparoscopic salpingostomy (Correct Answer)
- C. Laparoscopic salpingectomy
- D. Expectant management
Explanation: ***Laparoscopic salpingostomy*** - This patient desires future fertility, making **salpingostomy** (tube-preserving surgery) the most appropriate management. - Salpingostomy involves making an incision in the fallopian tube, removing the ectopic pregnancy, and leaving the tube intact to preserve fertility potential. - While the presence of **fetal cardiac activity** and **β-hCG of 8500 mIU/mL** contraindicate medical management, they do not contraindicate conservative surgical management in a hemodynamically stable patient. - The patient meets criteria for conservative surgery: hemodynamically stable, unruptured ectopic, and desires future fertility. *Methotrexate therapy* - This patient has **absolute contraindications for methotrexate**: β-hCG level >5000 mIU/mL (here 8500) and presence of **fetal cardiac activity**. - Methotrexate is only suitable for hemodynamically stable patients with ectopic mass <3.5-4 cm, β-hCG <5000 mIU/mL, no fetal cardiac activity, and normal liver/renal function. - The high β-hCG and cardiac activity indicate a viable ectopic pregnancy that is unlikely to respond to medical management. *Laparoscopic salpingectomy* - Salpingectomy involves **complete removal of the affected fallopian tube**, which significantly reduces future fertility if this is the only functional tube or if the contralateral tube is damaged. - This option is preferred when: the tube is severely damaged, there is uncontrolled bleeding, recurrent ectopic in the same tube, or the patient does not desire future fertility. - Since this patient **specifically desires future fertility** and is hemodynamically stable with an unruptured ectopic, salpingostomy (tube preservation) is preferred over salpingectomy. *Expectant management* - Expectant management requires **very low or declining β-hCG levels** (typically <1000-1500 mIU/mL), absence of fetal cardiac activity, and very small ectopic size (<2 cm). - This patient has β-hCG of 8500 mIU/mL with **visible fetal cardiac activity**, indicating a viable growing ectopic pregnancy with high rupture risk. - These findings make expectant management unsafe and inappropriate.
Question 10: Which of the following cannot be treated by laparoscopy?
- A. Non descent of uterus
- B. Ectopic pregnancy
- C. Sterilization
- D. Genital prolapse (Correct Answer)
Explanation: ***Genital prolapse*** - Among the options listed, **genital prolapse** is the condition LEAST suited for complete laparoscopic management, particularly in the context of this examination question. - While **laparoscopic sacrocolpopexy** and **sacral hysteropexy** exist for vault prolapse and uterine prolapse respectively, these procedures were less established at the time of this exam (2012) and require advanced laparoscopic skills. - Most cases of **genital prolapse**, especially complete pelvic organ prolapse, traditionally require **vaginal surgical approaches** or **open abdominal procedures** for comprehensive repair of multiple compartment defects. - The complex anatomical reconstruction needed for severe prolapse (anterior, posterior, and apical compartments) is more challenging via laparoscopy compared to the other listed conditions. *Non descent of uterus* - **Non-descent vaginal hysterectomy** can be performed with **laparoscopic assistance (LAVH/LDVH)** or as **total laparoscopic hysterectomy (TLH)**. - Laparoscopy facilitates dissection of uterine attachments, ligation of vessels, and removal of the uterus with minimal morbidity. *Ectopic pregnancy* - **Ectopic pregnancy** is a standard indication for laparoscopic surgery, performed routinely worldwide. - Procedures include **laparoscopic salpingectomy** (removal of affected tube) or **salpingostomy** (conservative surgery preserving the tube). - Offers advantages of minimal invasiveness, reduced recovery time, and excellent visualization. *Sterilization* - **Laparoscopic tubal sterilization** is one of the most common laparoscopic procedures performed. - Methods include application of **Filshie clips, Falope rings**, or **electrocautery** to occlude fallopian tubes. - Gold standard for permanent contraception with minimal morbidity.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free