Maternal-Fetal Medicine Practice Questions

Q: Which of the following drugs used for management of preterm labor also has neuroprotective role in fetus:

MgSO4. ***MgSO4*** - **Magnesium sulfate (MgSO4)** is a commonly used tocolytic for preterm labor that also offers significant **neuroprotective benefits** for the fetus. - It reduces the risk and severity of **cerebral palsy** and other neurological morbidities in preterm infants. *Ritodrine* - **Ritodrine** is a **beta-2 adrenergic agonist** that relaxes uterine smooth muscle, thereby inhibiting contractions. - It has no known neuroprotective effects on the fetus; its primary role is solely to **delay preterm labor**. *Nifedipine* - **Nifedipine** is a **calcium channel blocker** that inhibits the entry of calcium into uterine smooth muscle cells, reducing contractions. - While effective as a tocolytic, it does not confer specific neuroprotective benefits to the fetus. *Isoxsuprine* - **Isoxsuprine** is a **beta-adrenergic agonist** that, similar to ritodrine, acts by relaxing uterine musculature. - It is used for tocolysis but lacks any documented neuroprotective properties for the developing fetus.

Q: Loading dose of MgSO4 (IV) for severe preeclampsia/eclampsia should be prepared as:

8 ml 50% w/v plus 12 ml NS. **Correct: 8 ml 50% w/v plus 12 ml NS** - A common regimen for a magnesium sulfate loading dose for severe preeclampsia/eclampsia is **4-6 grams IV over 15-20 minutes**. - To achieve **4 grams** with a 50% w/v MgSO4 solution (meaning **50 grams per 100 mL** or **500 mg per mL**), you would need **8 mL** (4000 mg / 500 mg/mL = 8 mL), which is then diluted with **12 mL of normal saline** to create a 20 mL solution that can be infused. - This is the **standard loading dose** recommended by WHO and most international guidelines. *Incorrect: 12 ml 50% w/v plus 8 ml NS* - This combination would deliver **6 grams of MgSO4** (12 mL x 500 mg/mL). While 6 grams can be used as a loading dose in some protocols, the most common and widely taught initial recommendation for severe preeclampsia is **4 grams**. - A higher dose without specific clinical indication could increase the risk of **magnesium toxicity**. *Incorrect: 4 ml 50% w/v plus 16 ml NS* - This combination would deliver only **2 grams of MgSO4** (4 mL x 500 mg/mL). - A 2-gram loading dose is generally **insufficient** for preventing or treating eclamptic seizures in severe preeclampsia, as it may not achieve therapeutic magnesium levels quickly enough. *Incorrect: 16 ml 50% w/v plus 4 ml NS* - This combination would deliver **8 grams of MgSO4** (16 mL x 500 mg/mL). - An 8-gram loading dose is **excessively high** and carries a significant risk of **magnesium toxicity**, including respiratory depression and cardiac arrest.

Q: A 36 week primigravida was admitted in view of a single seizure episode. On examination her BP is 170/100, PR is 90/min, fetal heart rate is present. Immediate next step in management is?

Inj. MgSO4. ***Inj. MgSO4*** - The patient presents with **seizure** and **hypertension** (BP 170/100) at 36 weeks gestation, which are classic signs of **eclampsia**. - **Magnesium sulfate** is the drug of choice for the prevention and treatment of eclamptic seizures due to its potent anticonvulsant and neuroprotective effects. *MRI brain* - While an **MRI brain** can be useful in evaluating neurological symptoms, it is not the immediate first step in the presence of an acute eclamptic seizure. - The priority is to control life-threatening seizures and hypertension, not to perform diagnostic imaging. *Inj. Calcium gluconate* - **Calcium gluconate** is primarily used as an antidote for **magnesium sulfate toxicity**. - It does not have anticonvulsant properties and would not be given as an initial treatment for eclamptic seizures. *Inj Phenytoin* - **Phenytoin** is an anticonvulsant used for various seizure disorders, but it is **less effective and has more side effects** compared to magnesium sulfate for eclamptic seizures. - While it can be considered in cases where magnesium sulfate is contraindicated or ineffective, it is not the first-line immediate management.

Q: Placenta grade 3, 35+3 weeks pregnancy, and absent end diastolic flow Doppler; next management is:

Dexamethasone and terminate after 48 hours. ***Dexamethasone and terminate after 48 hours*** - Absent end diastolic flow (AEDF) at 35+3 weeks indicates **severe uteroplacental insufficiency** and significant fetal compromise, requiring intervention. - Administering **dexamethasone** (corticosteroids) for 48 hours helps to accelerate **fetal lung maturity** before delivery, reducing the risk of respiratory distress syndrome. *Monitor* - Simply monitoring is an inappropriate and potentially harmful management strategy given the presence of **absent end diastolic flow**, which reflects **critical fetal hypoxia**. - Delaying intervention in cases of AEDF significantly increases the risk of **fetal demise** and severe morbidity. *Terminate after 37 weeks* - Waiting until 37 weeks is too long. **Absent end diastolic flow** at 35+3 weeks significantly increases the risk of **fetal compromise** and death if delivery is delayed. - The goal is to balance the risks of prematurity with the risks of continued intrauterine compromise. *Consult pediatrician and plan immediate delivery* - While immediate delivery might be considered in some scenarios of fetal distress, delivering without prior **corticosteroid administration** (dexamethasone) at 35+3 weeks would increase the risk of **neonatal respiratory distress syndrome**. - The 48-hour window allows for **fetal lung maturation** while still addressing the urgent need for delivery due to AEDF.

Q: A 30-year-old female with 8 weeks of amenorrhea presents with sudden onset lower abdominal pain and vaginal bleeding. She is hypotensive with a positive pregnancy test. Ultrasound shows no intrauterine pregnancy. What is the most likely diagnosis?

Ectopic pregnancy. ***Correct: Ectopic pregnancy*** - The combination of **amenorrhea**, **positive pregnancy test**, **abdominal pain**, **vaginal bleeding**, and **hypotension** with no intrauterine pregnancy on ultrasound is highly indicative of a **ruptured ectopic pregnancy**. - **Hypotension** suggests significant blood loss into the abdominal cavity (hemoperitoneum), a common and dangerous complication of a ruptured ectopic pregnancy. - This is a medical emergency requiring immediate surgical intervention. *Incorrect: Threatened abortion* - This is characterized by vaginal bleeding with a **closed cervix** and an **intrauterine pregnancy** seen on ultrasound, which is not the case here. - While bleeding is present, the **hypotension** and **empty uterus** on ultrasound rule out threatened abortion. *Incorrect: Molar pregnancy* - A molar pregnancy would present with a positive pregnancy test and vaginal bleeding, but typically features an **abnormally large uterus** for gestational age and characteristic **"snowstorm" appearance** on ultrasound, not an empty uterus. - **Hypotension** in this context is not a typical initial presentation of molar pregnancy; rather, it's suggestive of acute blood loss, more consistent with rupture. *Incorrect: Ovarian torsion* - Ovarian torsion causes **sudden, severe unilateral pelvic pain** and may be associated with nausea and vomiting but typically does not involve **vaginal bleeding** or a **positive pregnancy test**. - While pain can be severe, **hypotension** due to acute blood loss is not characteristic of ovarian torsion itself, differentiating it from a ruptured ectopic pregnancy.

Q: In a case of preterm labor, which steroid is used to enhance fetal lung maturity?

Dexamethasone. ***Dexamethasone*** - **Dexamethasone** is one of the two corticosteroids recommended for enhancing **fetal lung maturity** in preterm labor (the other being betamethasone). - It effectively crosses the placenta to stimulate **surfactant production** and lung structural maturation in the fetus. - Standard regimen: **6 mg IM every 12 hours for 4 doses** between 24-34 weeks of gestation. - Among the options provided, this is the **correct choice** for antenatal corticosteroid therapy. *Prednisolone* - **Prednisolone** is NOT used for fetal lung maturity as it is largely **inactivated by placental 11β-hydroxysteroid dehydrogenase**, limiting its transfer to the fetus. - Its efficacy in stimulating **fetal lung development** is significantly lower compared to dexamethasone or betamethasone. *Methylprednisolone* - Similar to prednisolone, **methylprednisolone** is also significantly **metabolized by the placenta**, reducing its availability to the fetus. - It is **not recommended** for **fetal lung maturity enhancement** in preterm labor. *Hydrocortisone* - **Hydrocortisone** has a shorter half-life and weaker potency compared to dexamethasone, making it ineffective for enhancing **fetal lung maturity**. - It does not achieve optimal fetal concentrations for the desired therapeutic effect in preterm labor.

Q: A pregnant woman presents with intrahepatic cholestasis. What is the first-line treatment?

Ursodeoxycholic acid. ***Ursodeoxycholic acid*** - **Ursodeoxycholic acid (UDCA)** is the **first-line treatment** for intrahepatic cholestasis of pregnancy (ICP) as it improves pruritus, liver function tests, and may reduce adverse fetal outcomes. - UDCA works by increasing the hydrophilicity of the bile acid pool, reducing serum bile acid levels, and protecting hepatocytes from toxic bile acids. *Silymarin* - **Silymarin** is a herbal derivative that has been studied for liver support, but it is **not considered first-line therapy** for ICP due to insufficient evidence of efficacy and safety in this condition. - It may have some hepatoprotective effects, but its role in managing the symptoms and potential fetal risks of ICP is not established. *Methotrexate* - **Methotrexate** is an **immunosuppressant** and antifolate agent primarily used in conditions like rheumatoid arthritis, psoriasis, and certain cancers. - It is **absolutely contraindicated in pregnancy** due to its severe teratogenic effects and is not used to treat liver conditions like ICP. *Prednisolone* - **Prednisolone** is a corticosteroid used to reduce inflammation and suppress the immune system, but it is **not a first-line treatment for ICP**. - While it has been investigated as an adjunctive therapy, its efficacy is inferior to UDCA, and it carries risks for both mother and fetus, especially with long-term use.

Q: Which ultrasound finding is associated with trisomy 21 in a fetus?

Nuchal edema. ***Nuchal edema*** - Increased nuchal translucency, or nuchal edema, is a classic and **strong marker for Trisomy 21** during the first-trimester ultrasound screening. - This finding reflects fetal lymphatic dysfunction and is a key indicator for further diagnostic testing. *Choroid plexus cysts* - While sometimes seen in Trisomy 18 (Edwards Syndrome), choroid plexus cysts are generally considered a **soft marker for aneuploidy** and are **rarely isolated findings** in Trisomy 21. - Many fetuses with choroid plexus cysts are chromosomally normal, especially if there are no other associated anomalies. *Echogenic foci in heart* - Intracardiac echogenic foci, often called a "golf ball sign," are a **minor or soft marker for aneuploidy**, including Trisomy 21, but their isolated finding has a **low predictive value**. - They represent mineralization within a papillary muscle and are often benign, especially in the absence of other risk factors or anomalies. *Hyperechogenic bowel* - Hyperechogenic bowel is a **non-specific finding** that can be associated with various conditions, including cystic fibrosis, intrauterine infection, or fetal growth restriction, as well as aneuploidy. - While it can be a soft marker for Trisomy 21, its presence alone is not a strong indicator without other associated anomalies.

Question 1

A pregnant woman at 28 weeks gestation is diagnosed with late latent syphilis. Which of the following is the most appropriate treatment?

Accepted Answer

Benzathine penicillin G 2.4 million units IM weekly for 3 weeks

Answer

Azithromycin 2g single dose

Answer

Doxycycline 100mg BD for 28 days

Answer

Erythromycin 500mg QID for 14 days

Question 2

A pregnant woman is diagnosed with syphilis at 20 weeks gestation. Which of the following constitutes adequate treatment for prevention of congenital syphilis?

Accepted Answer

Appropriately staged penicillin regimen

Answer

Single-dose benzathine penicillin

Answer

Delaying treatment until the third trimester

Answer

Azithromycin monotherapy

Question 3

Which of the following drugs used for management of preterm labor also has neuroprotective role in fetus:

Accepted Answer

MgSO4

Answer

Ritodrine

Answer

Nifedipine

Answer

Isoxsuprine

Question 4

Loading dose of MgSO4 (IV) for severe preeclampsia/eclampsia should be prepared as:

Accepted Answer

8 ml 50% w/v plus 12 ml NS

Answer

12 ml 50% w/v plus 8 ml NS

Answer

4 ml 50% w/v plus 16 ml NS

Answer

16 ml 50% w/v plus 4 ml NS

Question 5

A 36 week primigravida was admitted in view of a single seizure episode. On examination her BP is 170/100, PR is 90/min, fetal heart rate is present. Immediate next step in management is?

Accepted Answer

Inj. MgSO4

Answer

MRI brain

Answer

Inj. Calcium gluconate

Answer

Inj Phenytoin

Question 6

Placenta grade 3, 35+3 weeks pregnancy, and absent end diastolic flow Doppler; next management is:

Accepted Answer

Dexamethasone and terminate after 48 hours

Answer

Monitor

Answer

Terminate after 37 weeks

Answer

Consult pediatrician and plan immediate delivery

Question 7

A 30-year-old female with 8 weeks of amenorrhea presents with sudden onset lower abdominal pain and vaginal bleeding. She is hypotensive with a positive pregnancy test. Ultrasound shows no intrauterine pregnancy. What is the most likely diagnosis?

Accepted Answer

Ectopic pregnancy

Answer

Threatened abortion

Answer

Molar pregnancy

Answer

Ovarian torsion

Question 8

In a case of preterm labor, which steroid is used to enhance fetal lung maturity?

Accepted Answer

Dexamethasone

Answer

Prednisolone

Answer

Methylprednisolone

Answer

Hydrocortisone

Question 9

A pregnant woman presents with intrahepatic cholestasis. What is the first-line treatment?

Accepted Answer

Ursodeoxycholic acid

Answer

Silymarin

Answer

Methotrexate

Answer

Prednisolone

Question 10

Which ultrasound finding is associated with trisomy 21 in a fetus?

Accepted Answer

Nuchal edema

Answer

Choroid plexus cysts

Answer

Echogenic foci in heart

Answer

Hyperechogenic bowel

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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