Maternal-Fetal Medicine Practice Questions

Q: A 35-year-old woman at 36 weeks of gestation presents with a history of 5 convulsions at home. Her BP is 170/100 mmHg. The diagnosis made by the doctor is eclampsia. What is the next management?

MgSO4 + Labetalol. ***MgSO4 + Labetalol*** - The patient presents with **eclampsia**, characterized by convulsions and severe hypertension (BP 170/100 mmHg) during pregnancy. Magnesium sulfate (**MgSO4**) is the **first-line treatment for preventing and managing eclamptic seizures**. - **Labetalol** is an appropriate antihypertensive for **severe hypertension in pregnancy** (BP ≥160/110 mmHg) and must be used concurrently with MgSO4 to control the high blood pressure and prevent maternal complications like stroke or placental abruption. - Both medications are required for comprehensive management of eclampsia with severe hypertension. *Clonidine* - **Clonidine** is an alpha-2 adrenergic agonist used to treat hypertension but is **not the first-line antihypertensive choice in acute eclampsia** due to potential sedative effects and slower onset compared to other agents like Labetalol, Hydralazine, or Nifedipine. - While it can lower blood pressure, it **does not address the seizure risk** in eclampsia. *Only Labetalol* - While **Labetalol** is crucial for managing severe hypertension, treating eclampsia requires both seizure control and blood pressure management. Administering only Labetalol would **fail to prevent recurrent seizures**, which is the primary life-threatening concern. - It would adequately lower blood pressure but **does not address the underlying seizure pathology** of eclampsia. *Only MgSO4* - **MgSO4** is essential for seizure prophylaxis and treatment in eclampsia. However, in this patient with a blood pressure of **170/100 mmHg (severe hypertension)**, **MgSO4 alone would not adequately control the severe hypertension**, which poses risks of maternal complications like stroke, intracerebral hemorrhage, or placental abruption. - While it prevents seizures effectively, it **does not sufficiently manage severe maternal hypertension**, requiring an additional antihypertensive agent like Labetalol.

Q: A G4P2 lady presented with history of two abortions at 16 weeks and 20 weeks POG. Which of the following could be the most likely reason for these abortions?

Cervical incompetence. ***Cervical incompetence*** - **Recurrent second-trimester pregnancy losses** (16 and 20 weeks) with a history of two previous abortions are highly suggestive of cervical incompetence, where the cervix dilates prematurely. - This condition is characterized by painless, progressive cervical dilation leading to **fetal expulsion** without contractions, which aligns with the presentation of repeated mid-trimester abortions. *Thyroid abnormality* - While **untreated hypothyroidism** or **hyperthyroidism** can increase the risk of miscarriage, these typically lead to **earlier first-trimester losses** or other obstetric complications, not recurrent mid-trimester abortions. - Abortion due to thyroid dysfunction is often associated with other signs and symptoms of thyroid disease, which are not mentioned. *Chromosomal abnormality* - **Chromosomal abnormalities** are the most common cause of **first-trimester miscarriages**, accounting for about 50% of them. - While they can cause later losses, recurrent mid-trimester abortions are less commonly attributed solely to chromosomal issues, especially in the absence of other malformations. *Placenta previa* - **Placenta previa** is a condition where the placenta partially or totally covers the cervix, causing painless vaginal bleeding in the **late second or third trimester**. - It increases the risk of preterm birth but is not a direct cause of recurrent fetal loss at 16 and 20 weeks gestation in the manner described.

Q: Which of the following can be a cause of Oligohydramnios?

Renal agenesis. ***Renal agenesis*** - **Fetal urine production** is the primary source of **amniotic fluid** in the latter half of pregnancy, so **bilateral renal agenesis** prevents this production. - Oligohydramnios due to renal agenesis is often associated with **Potter sequence**, characterized by facial anomalies, limb deformities, and pulmonary hypoplasia due to prolonged severe oligohydramnios. *Macrosomia* - **Macrosomia** (large baby) is not a cause of oligohydramnios; a larger fetus does not directly reduce amniotic fluid volume. - In fact, conditions like **gestational diabetes** which can cause macrosomia, are often associated with **polyhydramnios** (excess amniotic fluid) due to increased fetal urination. *Multiparity* - **Multiparity** (having had multiple previous pregnancies) is not directly associated with oligohydramnios. - While it can be a risk factor for certain pregnancy complications, it does not physiologically lead to reduced amniotic fluid. *Twins* - A multifetal pregnancy, such as **twins**, can sometimes be associated with complications like **twin-to-twin transfusion syndrome**, where one twin might develop oligohydramnios and the other polyhydramnios. - However, the presence of twins itself does not intrinsically cause oligohydramnios; it is a potential complication of specific twin types or their pathologies rather than a direct cause.

Q: In a patient with ectopic tubal pregnancy which is the earliest to rupture?

Isthmus. ***Isthmus*** - The **isthmus** is the **narrowest part** of the fallopian tube with the **least distensibility** and thin muscular wall. - Due to its limited capacity to accommodate the growing pregnancy, ectopic pregnancies in the isthmus rupture **earliest**, typically between **6-8 weeks of gestation**. - Rupture is often severe due to the narrow lumen and limited ability to expand. *Ampulla* - The **ampulla** is the most common site for ectopic pregnancies (approximately **70%** of cases). - It is wider and more distensible than the isthmus, allowing the pregnancy to grow for a longer period. - Rupture typically occurs **later**, between **8-12 weeks of gestation**. *Interstitial* - The **interstitial** (or cornual) portion is located within the **uterine wall**, surrounded by myometrium and rich vascular supply. - This location allows significant distensibility, so rupture occurs **latest** among tubal sites, typically at **12-16 weeks of gestation**. - When rupture occurs, it is **most catastrophic** with severe hemorrhage and highest risk of **maternal morbidity and mortality** due to the vascular supply. *Infundibulum* - Ectopic pregnancies in the **infundibulum** or fimbrial end are very rare. - Due to the wide opening, these pregnancies typically present as **tubal abortion** through the fimbria rather than rupture. - The area is less muscular, making contained rupture uncommon.

Q: Which of the following is consistent with a decision to perform a cerclage?

Cervix dilated to 3 cm. ***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.

Q: What does the below diagram indicate?

Placenta percreta. ***Placenta percreta*** - Involves the **placenta invading through the uterine wall** and potentially into adjacent organs like the bladder or rectum. This can lead to severe complications. - The image likely depicts the placenta extending **beyond the serosa**, indicating full-thickness invasion. *Placenta accreta* - Characterized by **abnormal adherence of the placenta** to the myometrium without invading through it. - The placental villi are directly anchored to the myometrium, but do not penetrate its full thickness. *Placenta increta* - Occurs when the placental villi **invade into the myometrium** but do not penetrate through the serosal layer of the uterus. - This is an intermediate stage of invasion, deeper than accreta but not as extensive as percreta. *Abruptio placenta* - Involves the **premature detachment of the placenta** from the uterine wall before delivery of the fetus. - This condition presents with painful vaginal bleeding and uterine tenderness, which is a different pathological process from abnormal placental implantation.

Q: McDonald stitch is applied in the following conditions except:

Placenta previa. ***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

Q: Possibility of vertical transfer of HIV infection if no prophylaxis is given:

25%. ***25%*** - Without **antiretroviral prophylaxis**, the risk of vertical transmission of HIV from mother to child is approximately **15-45%**, with 25% being a commonly cited average. - This risk is significantly reduced to less than **1%** with effective **antiretroviral therapy (ART)** during pregnancy, labor, and delivery, and ART for the infant. *75%* - A 75% risk of vertical transmission is **too high** and not consistent with current understanding of HIV mother-to-child transmission rates without intervention. - The risk is influenced by many factors including **maternal viral load**, **mode of delivery**, and **breastfeeding practices**. *100%* - A 100% chance of vertical transmission without prophylaxis is **incorrect**; many HIV-positive mothers, even without intervention, do not transmit the virus to their infants. - While the risk is substantial, it is not guaranteed for every pregnancy. *50%* - A 50% risk is **higher than the average** reported rates for vertical HIV transmission in the absence of prophylaxis. - While some individual circumstances might lead to a higher risk, it is not the general range.

Question 1

A 26-week pregnant female presents with hypertension for the first time. There is no proteinuria. What is the most likely diagnosis?

Accepted Answer

Hypertension diagnosed after 20 weeks of gestation without proteinuria

Answer

Hypertension diagnosed before 20 weeks of gestation

Answer

Hypertension with proteinuria or end-organ damage

Answer

Hypertension with seizures

Question 2

A 35-year-old woman at 36 weeks of gestation presents with a history of 5 convulsions at home. Her BP is 170/100 mmHg. The diagnosis made by the doctor is eclampsia. What is the next management?

Accepted Answer

MgSO4 + Labetalol

Answer

Clonidine

Answer

Only Labetalol

Answer

Only MgSO4

Question 3

A G4P2 lady presented with history of two abortions at 16 weeks and 20 weeks POG. Which of the following could be the most likely reason for these abortions?

Accepted Answer

Cervical incompetence

Answer

Thyroid abnormality

Answer

Chromosomal abnormality

Answer

Placenta previa

Question 4

Which of the following can be a cause of Oligohydramnios?

Accepted Answer

Renal agenesis

Answer

Macrosomia

Answer

Multiparity

Answer

Twins

Question 5

In a patient with ectopic tubal pregnancy which is the earliest to rupture?

Accepted Answer

Isthmus

Answer

Infundibulum

Answer

Ampulla

Answer

Interstitial

Question 6

Which of the following is consistent with a decision to perform a cerclage?

Accepted Answer

Cervix dilated to 3 cm

Answer

Gestation of 26 weeks

Answer

Uterine bleeding

Answer

Uterine contractions

Question 7

What does the below diagram indicate?

Accepted Answer

Placenta percreta

Answer

Placenta accreta

Answer

Placenta increta

Answer

Abruptio placenta

Question 8

McDonald stitch is applied in the following conditions except:

Accepted Answer

Placenta previa

Answer

Incompetent os

Answer

Previous history of preterm birth

Answer

Bad obstetrical history

Question 9

Possibility of vertical transfer of HIV infection if no prophylaxis is given:

Accepted Answer

25%

Answer

75%

Answer

100%

Answer

50%

Question 10

Which of the following statements is true regarding cerclage?

Accepted Answer

Prolapsing membranes can be reduced with Trendelenburg positioning and bladder filling prior to cerclage placement.

Answer

Timing of surgery is between 12 → 14 weeks gestation.

Answer

No need of antibiotic prophylaxis as membranes not ruptured.

Answer

Shirodkar procedure is most often selected.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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