Maternal-Fetal Medicine Practice Questions

Q: The given image depicts:

Both succenturiate lobe and velamentous insertion. ***Both succenturiate lobe and velamentous insertion*** - The image clearly depicts two distinct placental lobes (**succenturiate lobes**), with a smaller accessory lobe separate from the main placental body. - The **umbilical vessels** are also seen running through the fetal membranes before reaching the placental tissue, which is characteristic of **velamentous insertion**. *Normal placenta* - A normal placenta consists of a **single, unified organ** directly attached to the decidua, with the umbilical cord inserting centrally or eccentrically into this main mass. - The **umbilical cord** in a normal placenta would insert directly into the placental tissue, not into the membranes. *Succenturiate lobe* - A succenturiate lobe (or accessory lobe) refers to one or more small lobes of the placenta located at a distance from the main placental body. - While a succenturiate lobe is present, the image also shows the umbilical vessels traversing the membranes, indicating an additional anomaly known as **velamentous insertion**, making this option incomplete. *Velamentous insertion of the cord* - Velamentous insertion is characterized by the **umbilical blood vessels** separating before reaching the placental disc, traveling through the fetal membranes. - While velamentous insertion is evident, the presence of a **separate accessory lobe** makes this option incomplete as it doesn't account for both depicted abnormalities.

Q: A 30-year-old pregnant female diagnosed with fibroid presented with fever, mild leukocytosis, and pain at 28 weeks. What is the likely cause?

Red degeneration of fibroid. ***Red degeneration of fibroid*** - **Red degeneration** (also known as carneous degeneration) is common in pregnancy due to rapid fibroid growth outstripping its blood supply, leading to **ischemic necrosis** and causing pain, fever, and leukocytosis. - This complication typically occurs during the **second and third trimesters** due to hormonal changes and increased vascularity, consistent with the 28-week presentation. *Fibroid infection* - While possible, **fibroid infection** is a rarer complication, often secondary to other procedures or prolonged degeneration. - It would likely present with more pronounced signs of infection, such as higher fever, significant leukocytosis, and possibly discharge or septic symptoms, which are not explicitly stated as severe here. *Fibroid torsion* - **Torsion** usually occurs with pedunculated fibroids when the stalk twists, leading to acute, severe pain and potentially necrosis. - This presentation does not specifically mention a pedunculated fibroid or the sudden, sharp, localized pain typically associated with torsion of an appendage. *Labor pain* - At 28 weeks, **labor pain** would indicate preterm labor, which would typically involve regular, escalating uterine contractions and cervical changes. - The symptoms of fever and leukocytosis are not characteristic of uncomplicated labor pain, suggesting an underlying inflammatory or degenerative process with the fibroid.

Q: Least chance of perinatal transmission?

Hepatitis A. ***Hepatitis A*** - Perinatal transmission of **hepatitis A virus (HAV)** is rare because it's primarily transmitted via the **fecal-oral route**. - While HAV can be present in blood during the viremic phase, the risk of maternal-fetal transmission is negligible due to the short duration of viremia and antibodies usually present in immune mothers. *HSV* - **Herpes simplex virus (HSV)** has a significant risk of perinatal transmission, especially during **vaginal delivery** if the mother has active genital lesions. - Neonatal herpes can lead to severe disseminated disease, central nervous system involvement, or skin, eye, and mouth disease. *Rubella* - **Rubella virus** can cause congenital rubella syndrome (CRS) if the mother is infected during pregnancy, leading to severe birth defects. - This highly teratogenic virus readily crosses the **placenta**, particularly in the first trimester. *CMV* - **Cytomegalovirus (CMV)** is the most common cause of congenital viral infection, with often asymptomatic mothers transmitting the virus to the fetus. - Perinatal transmission can occur *in utero*, during **delivery**, or through **breastfeeding**.

Q: All are the causes of non-immune hydrops except?

ABO incompatibility. ***ABO incompatibility*** - **ABO incompatibility** is a common cause of **immune hydrops fetalis** due to antibody-mediated hemolytic anemia. - Immune hydrops involves red blood cell destruction caused by maternal antibodies crossing the placenta, which is not characteristic of non-immune hydrops. *Thalassemia* - **Alpha-thalassemia major (Hb Barts hydrops fetalis)** is a severe form of thalassemia frequently leading to **non-immune hydrops** due to profound anemia. - The severe chronic anemia leads to **high-output cardiac failure**, diffuse edema, and ascites. *Cardiovascular causes* - **Structural heart defects** and **arrhythmias** can impair fetal circulation and cardiac function, leading to **non-immune hydrops**. - Conditions like **hypoplastic left heart syndrome** or **supraventricular tachycardia** can cause fluid overload and edema. *Parvovirus* - **Parvovirus B19 infection** in the fetus can cause severe **anemia** by targeting erythroid progenitor cells, resulting in bone marrow suppression. - This severe fetal anemia frequently leads to **non-immune hydrops** as a consequence of heart failure.

Q: A primigravida in her 10th week of gestation presents with spotting. On examination, the uterus corresponds to 12 weeks. Transvaginal ultrasound was done and it is given below. What is your diagnosis?

Hydatidiform mole. ***Hydatidiform mole*** - The ultrasound image shows a **"snowstorm" appearance**, characterized by multiple echogenic vesicles or cystic spaces within the uterine cavity, which is pathognomonic for a hydatidiform mole. - The clinical presentation of **vaginal spotting**, a uterus size **larger than expected for gestational age** (12 weeks uterus size at 10 weeks gestation), and possibly elevated hCG levels (though not given here) are all highly suggestive of a molar pregnancy. *Blighted ovum* - A blighted ovum, also known as an anembryonic pregnancy, involves a **gestational sac without an embryo**. - The ultrasound typically shows an empty gestational sac and does not feature the characteristic "snowstorm" pattern of a hydatidiform mole. *Ectopic pregnancy* - An ectopic pregnancy occurs when the **fertilized egg implants outside the uterus**, most commonly in the fallopian tube. - The ultrasound would typically show an **empty uterus** and a gestation outside the uterine cavity, usually with a mass in the adnexa, which is not seen here. *Missed abortion* - A missed abortion is characterized by the **death of the embryo or fetus but retention** within the uterus. - Ultrasound would show a **fetus without cardiac activity** or a gestational sac that is smaller than expected, without the typical vesicular pattern of a mole.

Q: A pregnant woman at 36 weeks gestation is found to have high blood pressure recording and a urine protein of 3+. Concomitant presence of which of the following symptoms would make you suspect imminent eclampsia? 1. Headache 2. Blurred vision 3. Persistent pedal oedema 4. Epigastric pain

1 and 2 only. ***1 and 2 only*** - **Headache** (severe, persistent, frontal or occipital) and **blurred vision** (scotomas, photophobia, or visual field defects) are the classic **neurological symptoms** indicating cerebral irritation and vasospasm that directly precede eclamptic seizures. - These symptoms reflect **imminent CNS involvement** and are the strongest predictors of impending seizure, requiring urgent intervention (magnesium sulfate prophylaxis, delivery planning). - While other symptoms indicate severe pre-eclampsia, these neurological signs specifically herald **imminent eclampsia**. *2 and 4 only* - **Blurred vision** is indeed a key warning sign, and **epigastric pain** (right upper quadrant pain) is an important symptom of severe pre-eclampsia indicating hepatic capsule distension or subcapsular hematoma. - However, this option misses **headache**, which is one of the most critical neurological warning signs of imminent seizure. Epigastric pain indicates hepatic involvement (severe disease) but is not as directly predictive of immediate seizure onset as the combination of headache and visual disturbances. *1,2,3,4* - While headache, blurred vision, and epigastric pain are all features of severe pre-eclampsia, **persistent pedal edema** is extremely common in normal pregnancy and pre-eclampsia (present in >80% of cases) and is **not a specific indicator of imminent eclampsia**. - Generalized edema alone does not indicate imminent seizure risk and is too non-specific to be grouped with the acute neurological warning signs. *1,2,3* - **Headache** and **blurred vision** are the correct neurological indicators of imminent eclampsia. - However, **persistent pedal edema** is very common in pre-eclampsia and not specific for imminent eclamptic seizure risk. It does not have the same predictive value as severe headache or acute visual disturbances for identifying patients at immediate risk of convulsion.

Q: A 29-year-old woman tests positive for HIV during pregnancy screening. She is concerned about transmission to her baby. Which of the following interventions most significantly reduces the risk of vertical transmission?

Antiretroviral therapy during pregnancy and labor. ***Antiretroviral therapy during pregnancy and labor*** - **Antiretroviral therapy (ART)** significantly reduces the **viral load** in the mother, thereby minimizing the risk of HIV transmission to the fetus during pregnancy and childbirth. - When combined with other strategies like **cesarean section** and **avoidance of breastfeeding** in developed countries, ART can reduce vertical transmission rates to less than 1%. *Avoiding breastfeeding only* - While **avoiding breastfeeding** is a crucial intervention, especially in settings where safe alternatives are available, it addresses only one mode of transmission (postnatal). - It does not prevent **in-utero** or **intrapartum transmission**, which are primary routes of vertical transmission if the viral load is high. *Cesarean delivery only* - **Cesarean delivery** can reduce the risk of transmission by avoiding exposure to maternal blood and secretions during vaginal delivery. - However, it is most effective when the maternal **viral load is high** and is often combined with ART for maximum efficacy; it's less effective without ART. *Maternal immunization* - **Maternal immunization** involves administering vaccines to the mother to protect against specific infections, primarily bacterial or viral diseases like influenza or tetanus. - It has **no direct impact** on the risk of HIV transmission, as there is currently no vaccine available for HIV.

Q: Which of the following is NOT a recommended prevention strategy for vertical transmission of HIV?

Elective cesarean at 40 weeks. ***Elective cesarean at 40 weeks*** - This is **NOT recommended** as stated because: - When elective cesarean section is indicated (viral load >1000 copies/mL), it should be performed at **38 weeks gestation**, NOT 40 weeks - At 40 weeks, there's increased risk of spontaneous labor and membrane rupture, which defeats the purpose of elective cesarean - With adequate viral suppression (<1000 copies/mL or undetectable), **vaginal delivery is safe** and cesarean is not routinely recommended - The decision for cesarean is based on **viral load**, not simply gestational age *Avoidance of breastfeeding* - **Breastfeeding** is a known route of vertical HIV transmission due to the presence of the virus in breast milk - In developed countries where safe alternatives are available, **formula feeding** is recommended to completely eliminate this risk - This IS a recommended prevention strategy *Intrapartum zidovudine* - **Intravenous zidovudine (AZT)** administered during labor effectively reduces HIV transmission from mother to child - This is a crucial component of the prevention protocol, especially for mothers with detectable viral loads or those who have not received full antiretroviral therapy - This IS a recommended prevention strategy *Antiretroviral therapy during pregnancy* - **Antiretroviral therapy (ART)** taken throughout pregnancy significantly lowers the maternal viral load, which is the most critical factor in preventing vertical transmission - Suppressing the viral load to **undetectable levels** before delivery is the primary goal and most effective strategy - This IS a recommended prevention strategy

Question 1

The given image depicts:

Accepted Answer

Both succenturiate lobe and velamentous insertion

Answer

Normal placenta

Answer

Succenturiate lobe

Answer

Velamentous insertion of the cord

Question 2

Which of the following is not true about lupus nephritis in pregnancy?

Accepted Answer

Ecosprin, methotrexate, cyclophosphamide, corticosteroids, azathioprine are safe in pregnancy

Answer

Pregnancy to be planned once the disease has been quiescent for at least 6 months and there is no evidence of renal dysfunction

Answer

High dose corticosteroids for lupus flare in pregnancy is safe

Answer

Immunosuppression can be continued during pregnancy

Question 3

A 30-year-old pregnant female diagnosed with fibroid presented with fever, mild leukocytosis, and pain at 28 weeks. What is the likely cause?

Accepted Answer

Red degeneration of fibroid

Answer

Fibroid infection

Answer

Fibroid torsion

Answer

Labor pain

Question 4

Least chance of perinatal transmission?

Accepted Answer

Hepatitis A

Answer

HSV

Answer

Rubella

Answer

CMV

Question 5

All are the causes of non-immune hydrops except?

Accepted Answer

ABO incompatibility

Answer

Thalassemia

Answer

Cardiovascular causes

Answer

Parvovirus

Question 6

A primigravida in her 10th week of gestation presents with spotting. On examination, the uterus corresponds to 12 weeks. Transvaginal ultrasound was done and it is given below. What is your diagnosis?

Accepted Answer

Hydatidiform mole

Answer

Blighted ovum

Answer

Ectopic pregnancy

Answer

Missed abortion

Question 7

A pregnant woman at 36 weeks gestation is found to have high blood pressure recording and a urine protein of 3+. Concomitant presence of which of the following symptoms would make you suspect imminent eclampsia?

1. Headache
2. Blurred vision
3. Persistent pedal oedema
4. Epigastric pain

Accepted Answer

1 and 2 only

Answer

1,2,3,4

Answer

2 and 4 only

Answer

1,2,3

Question 8

A 29-year-old woman tests positive for HIV during pregnancy screening. She is concerned about transmission to her baby. Which of the following interventions most significantly reduces the risk of vertical transmission?

Accepted Answer

Antiretroviral therapy during pregnancy and labor

Answer

Avoiding breastfeeding only

Answer

Cesarean delivery only

Answer

Maternal immunization

Question 9

Which of the following is NOT a recommended prevention strategy for vertical transmission of HIV?

Accepted Answer

Elective cesarean at 40 weeks

Answer

Avoidance of breastfeeding

Answer

Intrapartum zidovudine

Answer

Antiretroviral therapy during pregnancy

Question 10

A 32 year old pregnant woman presents with 36 week pregnancy with complaints of pain abdomen and decreased fetal movements. Upon examination PR= 96/min, BP = 156/100 mm Hg, FHR = 128 bpm. On per-vaginum examination there is altered blood seen and cervix is soft 1 cm dilated. What is the preferred management?

Accepted Answer

Perform cesarean section

Answer

Observation and monitoring

Answer

Initiate labor induction

Answer

Administer medications to delay labor

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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