Maternal-Fetal Medicine Practice Questions

Q: Which of the following are contra-indications to external cephalic version in antenatal management of breech presentation? 1. Antepartum haemorrhage 2. Multiple pregnancy 3. Reactive Non Stress Test 4. Severe oligohydramnios

1, 2 and 4. ***1, 2 and 4*** * **Antepartum haemorrhage**, **multiple pregnancy**, and **severe oligohydramnios** are all contraindications to external cephalic version (ECV) due to increased risks of fetal distress, placental abruption, and uterine rupture. * These conditions either compromise fetal well-being directly or make the procedure significantly more dangerous for both mother and fetus. *2, 3 and 4* * This option incorrectly includes a **reactive non-stress test** as a contraindication, which actually indicates fetal well-being and is a prerequisite for ECV. * Excluding **antepartum haemorrhage** as a contraindication is also incorrect, as it poses a significant risk. *1, 2, 3 and 4* * This option is incorrect because a **reactive non-stress test** is a sign of fetal health and is a requirement *before* performing an ECV, not a contraindication. * Including it diminishes the specificity of contraindications for this procedure. *1, 2 and 3* * This option erroneously lists a **reactive non-stress test** as a contraindication, when in reality, it's a reassuring finding critical for proceeding with ECV. * It also omits **severe oligohydramnios** which is a significant contraindication due to the inability to safely manipulate the fetus.

Q: A 32 years old woman with two live children was brought to emergency with history of missed period for 15 days, spotting since 7 days and pain abdomen since 6 hours. Her pulse was 120 per minute, pallor + +, systolic B.P. 80 mm Hg. There was fullness and tenderness on per abdomen examination. Copper T thread was seen through external os on per speculum examination. On p/ v examination, cervical movements were tender, uterus was anteverted, bulky and soft. There was fullness in pouch of Douglas. Most likely, she is suffering from:

Ruptured ectopic pregnancy. ***Ruptured ectopic pregnancy*** - The patient presents with **classic signs of ruptured ectopic pregnancy**: missed period, vaginal spotting, acute abdominal pain, **hypovolemic shock** (tachycardia, hypotension, pallor), and signs of internal bleeding (abdominal fullness, tenderness, cervical motion tenderness, fullness in the pouch of Douglas). - The presence of a **Copper T IUD** further increases the risk of ectopic pregnancy if conception occurs, as IUDs are highly effective at preventing intrauterine pregnancies but less so at preventing ectopic ones. *Pelvic inflammatory disease* - While PID can cause abdominal pain and cervical motion tenderness, it is usually associated with **fever, purulent vaginal discharge**, and a history of sexually transmitted infections, which are not mentioned here. - The **acute hemodynamic instability** (shock) and history of missed period are not typical features of uncomplicated PID. *Missed abortion with infection* - A missed abortion involves a non-viable pregnancy with a closed cervix, and while infection can occur, it typically presents with **fever, foul-smelling discharge**, and abdominal pain that is less acute and severe than seen in this case. - The profound shock and localized fullness in the pouch of Douglas are more indicative of **hemoperitoneum** from a ruptured ectopic pregnancy rather than an infected missed abortion. *Threatened abortion* - Threatened abortion is characterized by vaginal bleeding with a **closed cervix** and a **viable intrauterine pregnancy**, usually without severe pain or signs of shock. - The patient's **hemodynamic instability**, severe abdominal pain, and findings suggestive of internal bleeding rule out a simple threatened abortion.

Q: HELLP syndrome includes the following except:

Leucocytosis. ***Leucocytosis*** - HELLP syndrome is characterized by **hemolysis**, **elevated liver enzymes**, and **low platelet count**. Leucocytosis (an elevated white blood cell count) is **not a defining feature** of HELLP syndrome. - While leucocytosis can occur in conditions associated with inflammation or stress, it is **not a diagnostic criterion** for HELLP syndrome and doesn't represent one of its core components. *Low platelet count* - **Thrombocytopenia** (platelet count below 100,000/microL) is a critical component of HELLP syndrome, representing the "LP" in the acronym. - It results from increased platelet consumption and destruction due to widespread endothelial dysfunction. *Hemolysis* - **Hemolysis** (breakdown of red blood cells) is the "H" in the HELLP acronym. - It is evidenced by findings such as **schistocytes** on peripheral blood smear, elevated **lactate dehydrogenase (LDH)**, and unconjugated **hyperbilirubinemia**. *Elevated liver enzymes* - **Elevated liver enzymes** (e.g., aspartate aminotransferase (AST) and alanine aminotransferase (ALT) being at least twice the upper limit of normal) are the "EL" in HELLP. - This elevation indicates **hepatic dysfunction** and hepatocellular damage, often associated with periportal hemorrhage and fibrin deposition.

Q: Which of the following is the most common cause of abortion during first trimester?

Chromosomal anomalies of foetus. ***Chromosomal anomalies of foetus*** - **Chromosomal anomalies** are the leading cause of **sporadic first-trimester abortions**, accounting for up to 50-70% of cases. - These anomalies, such as **aneuploidy (e.g., trisomy 16, monosomy X)**, often lead to developmental abnormalities incompatible with life. *Antiphospholipid antibody syndrome* - While a significant cause of **recurrent pregnancy loss**, particularly in the second and third trimesters, it is less common than chromosomal anomalies for **sporadic first-trimester abortions**. - It causes abortions through **thrombotic events** in the placental vasculature. *Progesterone deficiency* - **Inadequate progesterone levels** can contribute to early pregnancy loss by compromising endometrial support for the embryo. - However, it is a less frequent cause of first-trimester abortion compared to **chromosomal abnormalities**. *Cervical incompetence* - **Cervical incompetence** primarily causes **second-trimester losses** due to the inability of the cervix to retain the pregnancy under increasing pressure. - It is not a common cause of first-trimester abortion, which is typically due to issues with the early embryo or implantation.

Q: A 23 year old presents with recurrent abortions at 16 weeks gestation. She should be investigated for:

Incompetent cervix. ***Incompetent cervix*** - Recurrent abortions, particularly in the **second trimester** (around 16 weeks gestation), are highly suggestive of an incompetent cervix. - An incompetent cervix dilates painlessly and prematurely without contractions, leading to **fetal loss**. *TORCH infection* - TORCH infections (Toxoplasmosis, Other [syphilis, varicella-zoster, parvovirus B19], Rubella, Cytomegalovirus, and Herpes) typically cause **fetal anomalies** or **early pregnancy loss**, or affect the neonate. - While they can cause miscarriage, recurrent losses at 16 weeks without other symptoms are less characteristic of isolated TORCH infections. *Hepatitis B infection* - **Hepatitis B infection** can be transmitted to the fetus, but it is not a direct cause of recurrent second-trimester abortions. - The primary concern with Hepatitis B in pregnancy is **vertical transmission** to the neonate. *Balanced paternal translocation* - A **balanced translocation** in either parent can lead to recurrent miscarriages, but these typically occur earlier in pregnancy due to genetically unbalanced conceptions. - While possible, the specific timing of 16 weeks recurrent loss points more strongly towards an anatomical issue like an incompetent cervix.

Q: Which one of the following conditions is not associated with oligohydramnios during pregnancy?

Oesophageal atresia. ***Oesophageal atresia*** - **Oesophageal atresia** hinders the fetus from swallowing amniotic fluid, leading to an *increase* in amniotic fluid, a condition known as **polyhydramnios**, not oligohydramnios. - The inability of the fetus to properly absorb and excrete amniotic fluid through the gastrointestinal tract is the primary mechanism. *Post term pregnancy* - In **post-term pregnancies** (beyond 40 weeks), placental function can decline, reducing blood flow to the kidneys which can decrease fetal urine production. - Decreased fetal urine output is a major contributor to **oligohydramnios**. *Ruptured membrane* - A **ruptured membrane** (premature rupture of membranes) directly allows amniotic fluid to leak out of the uterus. - This leakage results in a reduction of the total amniotic fluid volume, causing **oligohydramnios**. *Intrauterine growth restriction* - In **intrauterine growth restriction (IUGR)**, the fetus experiences chronic stress and reduced perfusion due to placental insufficiency. - This often leads to **redistribution of fetal blood flow** away from non-essential organs like kidneys, decreasing urine production and contributing to oligohydramnios.

Q: Which of the following is the type of antepartum haemorrhage where blood loss is foetal?

Vasa previa. ***Vasa previa*** - In **vasa previa**, foetal blood vessels traverse the foetal membranes unprotected across the cervical os, making them vulnerable to rupture during labor or membrane rupture, leading to **foetal blood loss**. - This condition is often suspected when **foetal bradycardia** or sinusoidal heart rate patterns appear following membrane rupture, especially if accompanied by vaginal bleeding. *Circumvallate placenta* - This refers to a placental anomaly where the chorionic plate is smaller than the basal plate, causing the membranes to fold back and create an elevated ring around the umbilical cord insertion. - While it can be associated with higher rates of **antepartum hemorrhage**, preterm labor, or foetal growth restriction, the blood loss is typically maternal in origin, from marginal placental separation. *Placenta previa* - **Placenta previa** occurs when the placenta partially or completely covers the cervical os, leading to painless vaginal bleeding in the second or third trimester. - The hemorrhage in placenta previa is **maternal blood loss** due to the separation of the maternal decidua from the placental villi. *Abruptio placenta* - **Abruptio placenta** involves the premature separation of a normally implanted placenta from the uterine wall. - The bleeding in abruptio placenta is predominantly **maternal blood**, often accumulating between the placenta and uterine wall, and is typically associated with abdominal pain and uterine tenderness.

Q: Polyhydramnios is not caused by which one of the following?

Single kidney. ***Single kidney*** - A single kidney or other renal agenesis conditions typically lead to **oligohydramnios**, not polyhydramnios, because fetal urine production is reduced or absent. - The fetal urinary system is crucial for maintaining amniotic fluid volume, and its malfunction results in decreased fluid. *Spina bifida* - **Neural tube defects** such as spina bifida can contribute to polyhydramnios by affecting fetal swallowing mechanisms or increasing fluid secretion from exposed meninges. - While not the most common cause, severe forms can impair neural control over fetal fluid regulation. *Oesophageal atresia* - This condition prevents the fetus from **swallowing amniotic fluid**, leading to its accumulation in the amniotic sac. - Fetal swallowing is a primary mechanism for amniotic fluid reabsorption, and its mechanical obstruction results in polyhydramnios. *Anencephaly* - **Anencephaly** is a severe **neural tube defect** where the brain and skull fail to develop, often leading to impaired fetal swallowing and excessive urination. - The exposed meninges can also leak cerebrospinal fluid into the amniotic sac, further contributing to polyhydramnios.

Question 1

Which of the following are contra-indications to external cephalic version in antenatal management of breech presentation?

1. Antepartum haemorrhage
2. Multiple pregnancy
3. Reactive Non Stress Test
4. Severe oligohydramnios

Accepted Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 2, 3 and 4

Answer

1, 2 and 3

Question 2

A 32 years old woman with two live children was brought to emergency with history of missed period for 15 days, spotting since 7 days and pain abdomen since 6 hours. Her pulse was 120 per minute, pallor + +, systolic B.P. 80 mm Hg. There was fullness and tenderness on per abdomen examination. Copper T thread was seen through external os on per speculum examination. On p/ v examination, cervical movements were tender, uterus was anteverted, bulky and soft. There was fullness in pouch of Douglas. Most likely, she is suffering from:

Accepted Answer

Ruptured ectopic pregnancy

Answer

Pelvic inflammatory disease

Answer

Missed abortion with infection

Answer

Threatened abortion

Question 3

Consider the following:

1. Fetal pulmonary hypoplasia
2. Fetal chromosomal anomalies
3. Prostaglandin synthetase inhibitors
4. Amniotic fluid index of 15 cm

Which of the above are associated with oligohydramnios?

Accepted Answer

1, 2 and 3

Answer

2, 3 and 4

Answer

1, 2 and 4

Answer

1, 3 and 4

Question 4

HELLP syndrome includes the following except:

Accepted Answer

Leucocytosis

Answer

Low platelet count

Answer

Hemolysis

Answer

Elevated liver enzymes

Question 5

A patient of ectopic pregnancy had beta-hCG of 5800 IU/ml. Medical management was done by single dose methotrexate. Beta-hCG repeated after 48 hours was found 7000 IU/ml. What will you do further?

Accepted Answer

Repeat the injection of methotrexate

Answer

Operate the patient

Answer

Follow up with Beta-hCG after one week

Answer

Follow up with Beta-hCG after 72 hours

Question 6

Which of the following is the most common cause of abortion during first trimester?

Accepted Answer

Chromosomal anomalies of foetus

Answer

Antiphospholipid antibody syndrome

Answer

Progesterone deficiency

Answer

Cervical incompetence

Question 7

A 23 year old presents with recurrent abortions at 16 weeks gestation. She should be investigated for:

Accepted Answer

Incompetent cervix

Answer

TORCH infection

Answer

Hepatitis B infection

Answer

Balanced paternal translocation

Question 8

Which one of the following conditions is not associated with oligohydramnios during pregnancy?

Accepted Answer

Oesophageal atresia

Answer

Post term pregnancy

Answer

Ruptured membrane

Answer

Intrauterine growth restriction

Question 9

Which of the following is the type of antepartum haemorrhage where blood loss is foetal?

Accepted Answer

Vasa previa

Answer

Circumvallate placenta

Answer

Placenta previa

Answer

Abruptio placenta

Question 10

Polyhydramnios is not caused by which one of the following?

Accepted Answer

Single kidney

Answer

Spina bifida

Answer

Oesophageal atresia

Answer

Anencephaly

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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