Surgical Complications in Obstetrics — MCQs
Bleeding in rupture of the uterus associated with a large broad ligament hematoma is controlled most simply by :
A multigravida woman in labor room, after delivery and placenta removal, uncontrolled bleeding was seen. What is the most common cause of PPH in this woman?
A patient underwent LSCS for arrest of second stage of labour. A lateral extension of an angle of uterine incision occurred during delivery of head which was secured. Post operatively after 2 hours patient develops pallor, abdominal distension with tachycardia. Hb dropped from 10 gm% (pre op) to 6.5 gm%. Pelvic exam revealed mild PPH. Next step in management is?
What is the correct order of ligation for devascularization in the management of Postpartum Hemorrhage (PPH)?
Which of the following is NOT a suitable management option for accidental injury of the ureter during an abdominal operation?
Which of the following statements are correct regarding audit in Obstetrics and Gynaecology? I. It can replace the out of date clinical practices with better ones. II. It is an efficient educational tool. III. It should be based on scientific evidences with facts and figures. IV. It is not labour-intensive. Select the answer using the code given below :
Identify the maneuver shown in the image:
McDonald stitch is applied in the following conditions except:
Internal podalic version was done for transverse lie, which of these is a possible complication?
Shirodkar cerclage may be associated with all complications except:
Surgical Complications in Obstetrics Indian Medical PG Practice Questions and MCQs
Question 1: Bleeding in rupture of the uterus associated with a large broad ligament hematoma is controlled most simply by :
- A. Ligation of hypogastric artery
- B. Ligation of common iliac artery
- C. Suture of laceration
- D. Ligation of uterine artery (Correct Answer)
Explanation: ***Ligation of uterine artery*** - **Ligation of the uterine artery** is the **most simple and direct first-line approach** for controlling bleeding from uterine rupture with broad ligament hematoma. - The uterine artery provides the **primary blood supply** to the uterus and is easily accessible at the lower uterine segment, making it technically straightforward to ligate. - This method effectively controls bleeding by directly cutting off the major vascular supply to the area of rupture and the broad ligament hematoma. - Success rate is 80-90% for controlling hemorrhage, and it preserves blood flow to other pelvic structures. *Ligation of hypogastric artery* - **Ligation of the hypogastric artery** (internal iliac artery) is a **second-line procedure** requiring more extensive retroperitoneal dissection. - While effective, it is technically more difficult and time-consuming compared to uterine artery ligation, making it less "simple." - Reserved for cases where uterine artery ligation fails or when there is widespread pelvic bleeding from multiple sources. - It reduces blood flow to the entire pelvis, including bladder and rectum, not just the uterus. *Ligation of common iliac artery* - **Ligation of the common iliac artery** is an extreme measure with severe consequences, including compromised blood flow to the entire lower limb. - This is **not a standard procedure** for uterine rupture and carries unacceptable risks of leg ischemia and other complications. - Never considered a first-line approach for obstetric hemorrhage due to its extensive and potentially catastrophic effects. *Suture of laceration* - While **suturing the laceration** is essential for repairing the uterine defect, it does not provide adequate vascular control when a large broad ligament hematoma is present. - The hematoma indicates **significant vessel injury** within the broad ligament, requiring proximal vascular control first. - Suturing alone without controlling the bleeding source will not stop the hemorrhage and may lead to continued blood loss. - The correct approach is to first ligate the uterine artery for hemostasis, then repair the uterine tear.
Question 2: A multigravida woman in labor room, after delivery and placenta removal, uncontrolled bleeding was seen. What is the most common cause of PPH in this woman?
- A. Clotting factor deficiency
- B. Atony (Correct Answer)
- C. Traumatic PPH
- D. Retained tissues
Explanation: ***Atonic*** - **Uterine atony** is the most common cause of **postpartum hemorrhage (PPH)**, accounting for approximately 70-80% of cases. The uterus fails to contract adequately after placental delivery, leading to continuous bleeding from the placental bed. - Risk factors for uterine atony include multiparity, prolonged labor, rapid labor, polyhydramnios, and multiple gestations, which can lead to overdistension and fatigue of the uterine muscle. *Clotting factor deficiency* - While **coagulopathies** (clotting factor deficiencies) can cause PPH, they are a less common primary cause than uterine atony. - This cause would be suspected if there is a history of bleeding disorders, liver disease, or if PPH persists despite a well-contracted uterus. *Traumatic PPH* - **Traumatic PPH** results from lacerations of the cervix, vagina, or perineum, or from uterine rupture. These are less common than uterine atony. - This cause is typically suspected when the uterus feels firm but bleeding continues, or when visible trauma is present. *Retained tissues* - **Retained placental tissue** can prevent the uterus from contracting effectively, leading to PPH. However, it is less common than atony. - This cause is usually identified by the presence of placental fragments or membranes in the uterine cavity upon examination.
Question 3: A patient underwent LSCS for arrest of second stage of labour. A lateral extension of an angle of uterine incision occurred during delivery of head which was secured. Post operatively after 2 hours patient develops pallor, abdominal distension with tachycardia. Hb dropped from 10 gm% (pre op) to 6.5 gm%. Pelvic exam revealed mild PPH. Next step in management is?
- A. Blood transfusion and monitoring
- B. Intrauterine packing and blood transfusion
- C. Immediate exploration in OT (Correct Answer)
- D. Uterotonics for control of PPH and blood transfusion
Explanation: ***Immediate exploration in OT*** - The patient presents with signs of **hypovolemic shock** (pallor, tachycardia, significant drop in Hb) and **abdominal distension** after a lateral extension of the uterine incision, which strongly suggests **internal bleeding**. - Given the rapid deterioration and suspicion of internal hemorrhage, **immediate surgical exploration** is crucial to identify and repair the bleeding source. *Blood transfusion and monitoring* - While a **blood transfusion** is essential for stabilizing the patient, it is not sufficient as the sole intervention in the presence of ongoing, significant internal bleeding. - **Monitoring** alone can delay definitive treatment, leading to further deterioration and potentially life-threatening complications. *Intrauterine packing and blood transfusion* - **Intrauterine packing** is primarily used for **uterine atony** or **diffuse uterine bleeding** within the uterine cavity. - In this case, the bleeding is likely due to the **extension of the uterine incision** into surrounding tissues (e.g., broad ligament, uterine artery), which will not be controlled by intrauterine packing. *Uterotonics for control of PPH and blood transfusion* - **Uterotonics** are effective for **uterine atony**, which is a common cause of **postpartum hemorrhage (PPH)**, but less likely to control bleeding from a lacerated vessel due to an incisional extension. - While PPH is mentioned, the context of the uterine incision extension and rapid progression of shock points to a **surgical bleeding site** that requires direct intervention, which uterotonics cannot address.
Question 4: What is the correct order of ligation for devascularization in the management of Postpartum Hemorrhage (PPH)?
- A. Uterine artery, internal iliac, obturator artery
- B. Uterine artery, pudendal artery, vaginal artery
- C. Uterine artery, ovarian artery, vaginal artery
- D. Uterine artery, ovarian artery, internal iliac artery (Correct Answer)
Explanation: ***Uterine artery, ovarian artery, internal iliac artery*** - Ligation of the **uterine artery** is typically the first step due to its primary role in supplying the uterus. It often resolves PPH. - If PPH persists, the next step is typically bilateral ligation of the **ovarian arteries**, followed by the **internal iliac arteries (hypogastric arteries)**. This sequence progressively reduces blood flow to the uterus while preserving collateral circulation as much as possible. *Uterine artery, internal iliac, obturator artery* - While initial ligation of the **uterine artery** is correct, the **obturator artery** is not a primary target for devascularization in PPH management. - The obturator artery mainly supplies the thigh and pelvic floor, and its ligation would not significantly impact uterine blood flow in the context of PPH. *Uterine artery, pudendal artery, vaginal artery* - **Uterine artery** ligation is appropriate, but the **pudendal artery** is not typically ligated for PPH; it supplies the perineum and external genitalia. - While the **vaginal artery** supplies part of the lower uterus and vagina, it is usually addressed after or in conjunction with the hypogastric arteries if uterine and ovarian vessel ligation is insufficient, and not before ovarian arteries. *Uterine artery, ovarian artery, vaginal artery* - Ligation of the **uterine artery** and **ovarian artery** is correct in sequence, but the **vaginal artery** alone is usually insufficient. - The next major supply to be considered if bleeding persists after uterine and ovarian ligation would be the **internal iliac artery** to address collateral supply from other branches, not just the vaginal artery in isolation.
Question 5: Which of the following is NOT a suitable management option for accidental injury of the ureter during an abdominal operation?
- A. Colonic implantation
- B. End-to-end anastomosis through an ureteric catheter
- C. Ligation of the ureter (Correct Answer)
- D. Implantation into the bladder
Explanation: ***Ligation of the ureter*** - **Ligation** of the ureter is generally not a suitable management option as it typically leads to **kidney damage** due to obstruction and hydronephrosis, potentially necessitating **nephrectomy** if renal function is severely compromised. - This approach permanently blocks urine flow, causing **irreversible renal damage** unless the ureter is repaired or diverted very soon after injury. *End-to-end anastomosis through an ureteric catheter* - This is a common and appropriate technique for repairing a **transected ureter**, particularly when the injury is clean and there is minimal tissue loss. - An **ureteric catheter** acts as a stent, maintaining patency and facilitating healing while preventing stricture formation at the repair site. *Implantation into the bladder* - **Ureteroneocystostomy (implantation into the bladder)** is suitable for **distal ureteral injuries** where a sufficient length of ureter remains to reach the bladder without tension. - This procedure re-establishes continuity of the urinary tract directly into the bladder, bypassing the injured segment. *Colonic implantation* - **Colonic implantation** (ureterosigmoidostomy or ureterocolonic anastomosis) is a more complex procedure reserved for specific situations, such as extensive ureteral loss or bladder exstrophy, where direct bladder implantation is not feasible. - It involves diverting urine into the colon, allowing for reabsorption of water, but can lead to complications such as **hyperchloremic metabolic acidosis** and an increased risk of urinary tract infections.
Question 6: Which of the following statements are correct regarding audit in Obstetrics and Gynaecology? I. It can replace the out of date clinical practices with better ones. II. It is an efficient educational tool. III. It should be based on scientific evidences with facts and figures. IV. It is not labour-intensive. Select the answer using the code given below :
- A. I, II and IV
- B. I, II and III (Correct Answer)
- C. I, III and IV
- D. II, III and IV
Explanation: ***Correct: I, II and III*** - Statement I is correct: Clinical audit aims to improve **patient care** and **outcomes** by systematically reviewing care against explicit criteria, identifying areas for improvement, and implementing changes that **replace outdated practices** with evidence-based approaches. - Statement II is correct: Audit serves as a powerful **educational tool** by providing feedback to clinicians, highlighting best practices, and encouraging critical appraisal of current methods. - Statement III is correct: Effective audits must be based on **scientific evidence** with facts and figures to ensure validity, robustness, and clinical relevance. - Statement IV is **incorrect**: Clinical audit is **labour-intensive**, requiring significant time, resources, and coordination for data collection, analysis, meetings, implementation of changes, and follow-up assessments. *Incorrect: I, II and IV* - While statements I and II are correct, statement IV is incorrect because audit is generally **labour-intensive**, not the opposite. Effective audits involve substantial resource-demanding tasks. *Incorrect: I, III and IV* - While statements I and III are correct (audit replaces outdated practices with evidence-based approaches), statement IV is incorrect as thorough audits require **considerable effort and resources**. *Incorrect: II, III and IV* - While statements II and III are correct (audit as educational tool based on scientific evidence), statement IV is incorrect; audits often require **substantial time and effort** for all phases of the audit cycle.
Question 7: Identify the maneuver shown in the image:
- A. Burn Marshall
- B. Lovset
- C. Mauriceau-Smellie-Veit (Correct Answer)
- D. None of the options
Explanation: ***Mauriceau-Smellie-Veit*** - This maneuver is used for **head delivery in a breech presentation**, where the fetus's body is supported while pressure is applied to the maxilla or mandible to flex the head. - The image typically shows the operator's hand supporting the fetus's body and fingers placed on the fetal jaw to facilitate head flexion and delivery. *Burn Marshall* - The Burn Marshall maneuver involves **delivering the fetal head by applying suprapubic pressure** to the maternal abdomen while the fetal body is gently swept upwards over the maternal abdomen. - This maneuver is generally used for a **spontaneous breech delivery** if the head does not deliver easily after the body. *Lovset* - The Lovset maneuver is employed to **deliver the fetal shoulders** in a breech presentation by rotating the fetal trunk to bring the anterior shoulder under the pubic arch and then the posterior shoulder. - This maneuver aims to extract the shoulders sequentially, which might be necessary if they are impacted. *None of the options* - The visual representation aligns with the steps of the Mauriceau-Smellie-Veit maneuver, making this option incorrect. - This maneuver is clearly depicted by the hand placement and objective of aiding head delivery in breech.
Question 8: McDonald stitch is applied in the following conditions except:
- A. Placenta previa (Correct Answer)
- B. Incompetent os
- C. Previous history of preterm birth
- D. Bad obstetrical history
Explanation: ***Placenta previa*** - McDonald stitch (cervical cerclage) is a procedure to prevent **premature cervical dilation** and is not indicated for **placenta previa** - **Placenta previa** involves the placenta covering the cervical os, which can cause antepartum hemorrhage and usually necessitates a cesarean section - Cerclage is contraindicated as it does not address placental position and manipulation of the cervix could provoke bleeding *Incompetent os* - This is the **primary indication** for McDonald cerclage, as it directly addresses cervical insufficiency that leads to painless cervical dilation and second-trimester pregnancy loss - The cerclage reinforces the weak cervix, preventing **preterm birth** due to cervical incompetence - This can be diagnosed by history, physical examination, or ultrasound findings *Previous history of preterm birth* - A history of **recurrent second-trimester miscarriages** or **preterm deliveries** attributed to cervical insufficiency is a strong indication for prophylactic McDonald cerclage - This is termed **history-indicated cerclage**, performed electively between 12-14 weeks in subsequent pregnancies - Studies show cerclage reduces preterm birth rates in women with prior spontaneous preterm births due to cervical factors *Bad obstetrical history* - Bad obstetric history, particularly with **recurrent second-trimester losses** suggesting cervical insufficiency, is a classic indication for prophylactic cerclage - This overlaps with history-indicated cerclage and aims to prevent recurrence in high-risk patients - Thorough evaluation is needed to confirm cervical etiology rather than other causes of pregnancy loss
Question 9: Internal podalic version was done for transverse lie, which of these is a possible complication?
- A. Uterine rupture (Correct Answer)
- B. Cervical laceration
- C. Vaginal laceration
- D. Uterine inertia
Explanation: ***Uterine rupture*** - **Internal podalic version** involves manually inserting a hand into the uterus to grasp the fetal feet and turn the fetus from transverse to longitudinal lie, requiring significant uterine manipulation and stretching. - This is the **most serious and classically described complication**, particularly in multiparous women, those with previous uterine scars, or overdistended uterus. - The forceful manipulation and traction can cause **tearing of the uterine wall**, making this a life-threatening emergency. - Due to this high risk, internal podalic version has been largely **replaced by cesarean section** in modern obstetrics. *Cervical laceration* - While cervical lacerations can occur during internal version (especially if performed through an incompletely dilated cervix), this is **not the primary or most characteristic complication** of the procedure. - More commonly associated with rapid fetal descent or instrumental delivery in the second stage. *Vaginal laceration* - Vaginal tears are possible but are **less directly related** to the internal version itself and more associated with the subsequent vaginal delivery. - Not the most significant or characteristic complication of internal podalic version. *Uterine inertia* - **Uterine inertia** (inadequate uterine contractions) is not a direct mechanical complication of internal podalic version. - This refers to labor dysfunction rather than a procedural complication of the manipulation itself.
Question 10: Shirodkar cerclage may be associated with all complications except:
- A. Enterocele
- B. Ureteral injury
- C. Subacute intestinal obstructions
- D. Paresthesia over inner aspect (Correct Answer)
Explanation: ***Paresthesia over inner aspect*** - Paresthesia over the inner thigh is typically associated with injury to the **femoral nerve** or its branches, or the **obturator nerve**. - While surgery in the pelvic region always carries some nerve injury risk, a Shirodkar sling operation, which is a cervical cerclage, is **unlikely to directly cause paresthesia** in this specific distribution. *Enterocele* - An **enterocele** is a type of pelvic organ prolapse where the small bowel descends into the lower pelvic cavity, creating a bulge in the vagina. - The Shirodkar sling procedure involves placing a suture around the cervix, which can alter pelvic anatomy and potentially contribute to the development or worsening of an enterocele, by **changing pressure dynamics** or creating adhesion. *Ureteral injury* - The **ureters** pass close to the cervix as they course into the bladder, especially where the uterosacral ligaments attach. - During the placement of the Shirodkar cervical cerclage, there is a risk of **ligating or damaging the ureters** due to their proximity to the surgical field. *Subacute intestinal obstructions* - Any pelvic surgery, including a Shirodkar sling operation, carries a risk of **adhesion formation**. - These **post-surgical adhesions** can involve segments of the bowel, potentially leading to kinking or narrowing of the intestinal lumen, which can cause symptoms of subacute intestinal obstruction.
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