Maternal-Fetal Medicine Practice Questions

Q: A 24-year-old woman with bacterial vaginosis is admitted to the hospital in preterm labor at 30 weeks. What is the most appropriate antibiotic regimen?

Metronidazole 500mg orally twice daily for 7 days. ***Metronidazole 500mg orally twice daily for 7 days*** - This regimen is an appropriate and effective treatment for **bacterial vaginosis**, with **oral metronidazole** being a first-line therapy. - Treating **bacterial vaginosis** in a pregnant woman with **preterm labor** is crucial as untreated BV is a known risk factor for preterm birth and other obstetric complications. *Metronidazole 2g orally single dose* - While a **single-dose 2g metronidazole** regimen is an alternative for non-pregnant patients, it is generally **less effective** and not typically recommended for pregnant women, especially those in preterm labor, where complete eradication is critical. - **Higher recurrence rates** have been reported with single-dose regimens compared to multi-day treatments. *Clindamycin 300mg orally twice daily for 7 days* - **Oral clindamycin** is an alternative treatment for bacterial vaginosis, but **metronidazole** is often preferred as a first-line option due to its efficacy and safety profile in pregnancy. - The patient's condition of **preterm labor** would generally favor the most established and safest first-line treatment. *Clindamycin 5g vaginal cream for 7 days* - **Vaginal clindamycin cream** is an effective treatment for bacterial vaginosis, but in a patient with **preterm labor**, an **oral systemic antibiotic** is often preferred to ensure adequate tissue penetration and reduce the risk of ascending infection affecting the uterus. - Vaginal creams might be less effective in preventing obstetric complications associated with BV compared to oral therapy in high-risk pregnancies.

Q: A pregnant woman at 34 weeks is diagnosed with trichomoniasis. What is the most appropriate treatment?

Metronidazole 500mg orally twice daily for 7 days. ***Metronidazole 500mg orally twice daily for 7 days*** - For pregnant women with trichomoniasis, **metronidazole** is the treatment of choice and is safe in all trimesters. - Both the **7-day course (500mg BID)** and **single 2g dose** are considered **equally effective first-line treatments** per CDC and ACOG guidelines. - The 7-day regimen may be preferred in cases of **treatment failure**, **recurrent infection**, or when **better tissue penetration** is desired. - It ensures adequate eradication and provides sustained therapeutic levels throughout the treatment period. *Clindamycin cream vaginally for 7 days* - **Clindamycin** is effective for bacterial vaginosis but **not effective against Trichomonas vaginalis**, which is a protozoan parasite. - Topical treatments do not achieve sufficient systemic levels to adequately treat trichomoniasis. *Defer treatment until after delivery* - Untreated trichomoniasis in pregnancy is associated with significant risks including **preterm birth**, **premature rupture of membranes**, **low birth weight**, and **increased HIV transmission risk**. - Treatment during pregnancy is strongly recommended to mitigate these complications. - Metronidazole is safe in all trimesters of pregnancy. *Metronidazole 2g orally as single dose* - The **single 2g dose** is an equally effective first-line treatment option and is often preferred for **better patient compliance**. - Both this regimen and the 7-day course have **equivalent cure rates** (approximately 90-95%). - In this question context, while both are acceptable, the 7-day regimen is considered the correct answer.

Q: A pregnant female at 37 weeks of gestation with a history of prosthetic heart valves is currently taking warfarin. She comes for a routine antenatal check-up. What is the appropriate management advice?

Switch to low molecular weight heparin. ***Switch to low molecular weight heparin*** - **Warfarin** is **teratogenic** and carries a significant risk of **fetal bleeding** and **malformations**, especially close to term. Switching to **low molecular weight heparin (LMWH)** is crucial at 37 weeks. - **LMWH** does not cross the placenta, making it a safer alternative for anticoagulation in late pregnancy for women with prosthetic heart valves. *Immediate induction of labor* - While delivery is approaching, immediate induction of labor without addressing the **warfarin** use directly puts the fetus at high risk of **bleeding complications** during delivery. - This option does not specify concurrent management of the anticoagulation, which is the primary concern. *Perform LSCS (Lower Segment Cesarean Section)* - Similar to induction of labor, performing a C-section while the mother is on **warfarin** significantly increases the risk of **maternal and fetal hemorrhage**. - A C-section is an invasive procedure, and the immediate priority is to switch the anticoagulant rather than select the mode of delivery without addressing the current medication. *Continue the same medication* - Continuing **warfarin** at 37 weeks is highly dangerous due to the increased risk of **fetal intracranial hemorrhage** during labor and delivery. - This approach disregards the well-established **teratogenic effects** and **bleeding risks** associated with warfarin in late pregnancy.

Q: A patient with eclampsia is being treated with magnesium sulfate. Which of the following is an indication to stop the drug?

Urine output less than 100 ml in 4 hours. ***Urine output less than 100 ml in 4 hours*** - A **decreased urine output of less than 100 mL in 4 hours (< 25-30 mL/hour)** suggests **renal impairment**, which can lead to magnesium accumulation and toxicity. - **Magnesium is primarily excreted by the kidneys**, so reduced renal function necessitates discontinuation to prevent toxicity. - This is one of the **critical monitoring parameters** before each dose of magnesium sulfate. *Respiratory rate more than 18 per minute* - A **respiratory rate of 18 breaths per minute or more** is considered normal and does not indicate magnesium toxicity. - **Respiratory depression**, characterized by a rate of **less than 12 breaths per minute**, is a sign of toxicity and an indication to stop magnesium sulfate. *Exaggerated deep tendon reflexes* - **Exaggerated deep tendon reflexes** are typically associated with conditions like **pre-eclampsia**, not magnesium toxicity. - **Loss or absence of deep tendon reflexes** is a key indicator of magnesium toxicity due to its neuromuscular blocking effects and is an indication to stop the drug. *Presence of visual disturbances* - **Visual disturbances** such as blurred vision, scotomas, or flashing lights are common symptoms of **severe pre-eclampsia and eclampsia** itself. - These visual changes are part of the disease process, not a direct sign of magnesium toxicity or an indication to stop the infusion.

Q: A woman at 30 weeks of gestation is diagnosed with deep vein thrombosis (DVT). Which of the following is the most appropriate treatment for this patient?

Low Molecular Weight Heparin (LMWH). ***Low Molecular Weight Heparin (LMWH)*** - **LMWH** is the preferred anticoagulant for DVT during pregnancy because it does **not cross the placenta**, making it safe for the fetus. - It also has a **predictable anticoagulant response** and a lower risk of **heparin-induced thrombocytopenia (HIT)** compared to unfractionated heparin. *Warfarin* - **Warfarin is teratogenic**, especially during the first trimester, and can cause **fetal warfarin syndrome**, which includes skeletal and central nervous system abnormalities. - It can also lead to **fetal bleeding** and miscarriage at any stage of pregnancy. *Apixaban* - **Apixaban** is a **direct oral anticoagulant (DOAC)**, and its safety in pregnancy has not been established. - There is insufficient data regarding its **placental transfer** and potential fetal effects, making its use generally contraindicated in pregnant women. *Fondaparinux* - While **fondaparinux** is an indirect Factor Xa inhibitor and might be considered in cases of heparin allergy or intolerance, its **safety profile in pregnancy is not as well-established** as LMWH. - It is generally reserved for situations where LMWH cannot be used, and its use requires careful consideration due to limited data.

Q: A G2P1L1 woman with a history of previous cesarean section presents with complications related to the placenta. The image below shows the gross appearance of the uterus with abnormal placental attachment to the uterine wall. What is the most likely diagnosis?

Placenta accreta. ***Placenta accreta*** - This diagnosis is strongly suggested by the image showing the **placenta adhered directly to the myometrium**, without invading through the uterine muscular wall. - The history of a **previous cesarean section** is a significant risk factor for placenta accreta, as prior uterine surgery can alter endometrial integrity. *Placenta abruption* - This condition involves the **premature separation of the placenta** from the uterine wall after 20 weeks of gestation but before birth. - It is characterized by symptoms such as **abdominal pain**, **vaginal bleeding**, and **uterine tenderness**, which are not directly depicted by abnormal placental attachment in the image. *Placenta percreta* - This represents the most severe form of abnormal placental adherence, where the **chorionic villi invade through the entire uterine wall** and into adjacent organs like the bladder. - While it shares risk factors with accreta, the image showing attachment "to the uterine wall" rather than invasion *through* it makes percreta less likely. *Placenta previa* - In this condition, the **placenta implants over or near the internal cervical os**, potentially blocking the birth canal. - The image describes abnormal placental attachment *to the uterine wall*, not its position relative to the cervix, differentiating it from placenta previa.

Q: A woman presents with a history of recurrent abortions at 8,11 , and 22 weeks, with normal fetal cardiac activity in all three pregnancies. She also has a history of preeclampsia in her last pregnancy. What is the most probable cause?

Antiphospholipid Antibody Syndrome (APLA). ***Antiphospholipid Antibody Syndrome (APLA)*** - The presentation of **recurrent abortions** (especially with normal fetal cardiac activity) and a history of **preeclampsia** is highly characteristic of Antiphospholipid Antibody Syndrome (APLA). - In APLA, antibodies cause **thrombosis** in the placental vasculature, leading to placental insufficiency, fetal loss, and complications like preeclampsia. *Syphilis* - While syphilis can cause fetal loss, it typically presents with **hydrops fetalis**, hepatosplenomegaly, and bone abnormalities, rather than recurrent losses with normal cardiac activity in the early stages. - Untreated syphilis usually leads to congenital syphilis or stillbirths later in pregnancy, not necessarily early recurrent abortions with good fetal heart tones. *Gestational Diabetes Mellitus (GDM)* - GDM is associated with complications like **macrosomia**, polyhydramnios, and an increased risk of shoulder dystocia, but it is not a direct cause of recurrent early and mid-trimester abortions with normal fetal cardiac activity. - While poorly controlled diabetes can affect fetal development and pregnancy outcomes, it does not typically manifest as recurrent unexplained fetal demise with this specific presentation. *TORCH infections* - TORCH infections (Toxoplasmosis, Other [syphilis, varicella-zoster, parvovirus B19], Rubella, Cytomegalovirus, and Herpes simplex virus) can cause congenital anomalies and fetal death. - However, they would usually present with specific fetal abnormalities, signs of infection, or hydrops, and not typically with recurrent, apparently healthy fetal losses followed by preeclampsia, as often seen in APLA.

Q: A woman with eclampsia is started on magnesium sulfate. What is the first sign of magnesium sulfate toxicity?

Loss of knee jerk. ***Loss of knee jerk*** - **Diminished or absent deep tendon reflexes**, particularly the knee jerk, is the **earliest clinical sign** of magnesium sulfate toxicity. - This occurs at serum magnesium levels between **7-10 mEq/L** (8.5-12 mg/dL) due to magnesium's depressant effect on the nervous system and neuromuscular transmission. *Respiratory depression* - **Respiratory depression** is a more severe and later sign of magnesium toxicity, occurring at higher serum levels (typically >12 mEq/L). - It indicates significant central nervous system depression and potential for respiratory arrest, usually after reflexes are already lost. *Hypotension* - While magnesium sulfate can cause **vasodilation** and a subsequent drop in blood pressure, it is generally **not the first sign of toxicity** and often occurs concurrently with other mild to moderate signs. - Hypotension may be part of the therapeutic effect to reduce blood pressure in eclampsia, rather than an initial indicator of toxicity. *Reduced muscle tone* - **Reduced muscle tone** or **flaccidity** is also a consequence of magnesium's neuromuscular blocking effect but typically manifests **after the loss of deep tendon reflexes**. - It signifies more profound neuromuscular impairment, closer to the progression towards respiratory depression.

Question 1

Which of the following is TRUE regarding herpes simplex virus (HSV) in pregnancy?

Accepted Answer

Transmission risk is highest with first-episode primary infection near delivery

Answer

Neonatal transmission risk is similar for HSV-1 and HSV-2

Answer

Cesarean delivery is recommended for all HSV-positive women

Answer

Suppressive therapy is contraindicated during pregnancy

Question 2

A 24-year-old woman with bacterial vaginosis is admitted to the hospital in preterm labor at 30 weeks. What is the most appropriate antibiotic regimen?

Accepted Answer

Metronidazole 500mg orally twice daily for 7 days

Answer

Metronidazole 2g orally single dose

Answer

Clindamycin 300mg orally twice daily for 7 days

Answer

Clindamycin 5g vaginal cream for 7 days

Question 3

A pregnant woman at 34 weeks is diagnosed with trichomoniasis. What is the most appropriate treatment?

Accepted Answer

Metronidazole 500mg orally twice daily for 7 days

Answer

Clindamycin cream vaginally for 7 days

Answer

Defer treatment until after delivery

Answer

Metronidazole 2g orally as single dose

Question 4

A 28-year-old woman in her first trimester of pregnancy is diagnosed with syphilis (VDRL 1:32, TPHA positive). She reports penicillin allergy with previous anaphylaxis. What is the most appropriate management?

Accepted Answer

Penicillin desensitization followed by benzathine penicillin

Answer

Doxycycline for 14 days

Answer

Erythromycin for 14 days

Answer

Azithromycin single dose

Question 5

A pregnant female at 37 weeks of gestation with a history of prosthetic heart valves is currently taking warfarin. She comes for a routine antenatal check-up. What is the appropriate management advice?

Accepted Answer

Switch to low molecular weight heparin

Answer

Immediate induction of labor

Answer

Perform LSCS (Lower Segment Cesarean Section)

Answer

Continue the same medication

Question 6

A patient with eclampsia is being treated with magnesium sulfate. Which of the following is an indication to stop the drug?

Accepted Answer

Urine output less than 100 ml in 4 hours

Answer

Respiratory rate more than 18 per minute

Answer

Exaggerated deep tendon reflexes

Answer

Presence of visual disturbances

Question 7

A woman at 30 weeks of gestation is diagnosed with deep vein thrombosis (DVT). Which of the following is the most appropriate treatment for this patient?

Accepted Answer

Low Molecular Weight Heparin (LMWH)

Answer

Warfarin

Answer

Apixaban

Answer

Fondaparinux

Question 8

A G2P1L1 woman with a history of previous cesarean section presents with complications related to the placenta. The image below shows the gross appearance of the uterus with abnormal placental attachment to the uterine wall. What is the most likely diagnosis?

Accepted Answer

Placenta accreta

Answer

Placenta abruption

Answer

Placenta percreta

Answer

Placenta previa

Question 9

A woman presents with a history of recurrent abortions at 8,11 , and 22 weeks, with normal fetal cardiac activity in all three pregnancies. She also has a history of preeclampsia in her last pregnancy. What is the most probable cause?

Accepted Answer

Antiphospholipid Antibody Syndrome (APLA)

Answer

Syphilis

Answer

Gestational Diabetes Mellitus (GDM)

Answer

TORCH infections

Question 10

A woman with eclampsia is started on magnesium sulfate. What is the first sign of magnesium sulfate toxicity?

Accepted Answer

Loss of knee jerk

Answer

Respiratory depression

Answer

Hypotension

Answer

Reduced muscle tone

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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