Maternal-Fetal Medicine — MCQs

A 28-year-old primigravida at 32 weeks of gestation presents for a routine prenatal visit. She has no significant past medical history. During the ultrasound examination, various parameters are assessed to evaluate fetal growth and well-being. Which of the following is NOT a criterion used to diagnose Intrauterine Growth Restriction (IUGR)?

Q1118

A 32-year-old female at 36 weeks of pregnancy presents with BP 170/100 mmHg, visual disturbances, headache, urine protein 3+. What will be the next step?

Q1119

What is the correct dosing regimen of Dexamethasone for promoting fetal lung maturity in preterm infants?

Q1120

A 35-year-old pregnant woman at 36 weeks of gestation presents with pruritus and jaundice. What is the most appropriate investigation?

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 1111: Which of the following is a criterion for infant at risk?

A. Preeclampsia in pregnancy (Correct Answer)
B. Has not taken 100 days folic acid
C. Malpresentation during birth
D. Working mothers

Explanation: ***Preeclampsia in pregnancy*** - **Preeclampsia** is a serious pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. - Infants born to mothers with preeclampsia are at **significantly higher risk** for complications including **preterm birth**, **intrauterine growth restriction (IUGR)**, low birth weight, respiratory distress syndrome, and perinatal mortality. - This is a **universally recognized criterion** for identifying high-risk infants in maternal-child health programs and NICU protocols. - Such infants require close monitoring and specialized care from birth. *Has not taken 100 days folic acid* - Periconceptional **folic acid supplementation** (ideally starting 3 months before conception and continuing through early pregnancy) reduces the risk of **neural tube defects** in the fetus. - While lack of folic acid supplementation increases the risk of congenital anomalies during pregnancy, this historical factor alone does not classify the infant as "at risk" after birth unless an actual neural tube defect or other complication is present. - This is primarily a **pregnancy risk factor** rather than a postnatal infant risk criterion. *Malpresentation during birth* - **Malpresentation** (e.g., breech, transverse lie, face presentation) increases the risk of birth complications such as **birth asphyxia**, **birth trauma**, cord prolapse, and difficult delivery. - While malpresentation is recognized as a risk factor during delivery and such infants may require closer initial monitoring, **preeclampsia** represents a more comprehensive and persistent risk affecting multiple organ systems and long-term outcomes. - In the context of identifying high-risk infants for follow-up programs, maternal preeclampsia is a more significant criterion than malpresentation alone (assuming no birth complications occurred). *Working mothers* - A mother's employment status does not inherently classify an infant as "at risk" from a medical or developmental standpoint. - While **socioeconomic factors** and access to care can impact infant health, simply being a working mother is not a direct medical criterion for defining an infant as high-risk.

Question 1112: A G1 P0 woman at 36 weeks presents with newly diagnosed gestational diabetes. What is the most appropriate initial management?

A. Induction of labor
B. Oral hypoglycemics
C. Diet control (Correct Answer)
D. Insulin

Explanation: ***Diet control (Medical Nutrition Therapy)*** - For newly diagnosed gestational diabetes, **lifestyle modifications**, primarily **dietary changes**, are the **first-line treatment** per ACOG and ADA guidelines - Medical nutrition therapy (MNT) aims to control blood glucose levels through proper nutrition and should be attempted for **1-2 weeks** before considering pharmacologic interventions - Target goals: Fasting glucose <95 mg/dL, 1-hour postprandial <140 mg/dL, 2-hour postprandial <120 mg/dL *Induction of labor* - **Induction of labor** is typically considered for gestational diabetes if there are concerns about **fetal macrosomia** (EFW >4000-4500g), **poor glycemic control despite treatment**, or other maternal-fetal complications - Generally considered at **39-40 weeks** in well-controlled GDM or earlier with complications - Not the initial management for a new diagnosis at 36 weeks without additional concerning features *Oral hypoglycemics* - **Metformin** or **glyburide** may be used as second-line agents when **dietary management fails** to achieve adequate glycemic control after 1-2 weeks - Metformin is increasingly preferred as it does not cross the placenta as readily as glyburide - They are **not the initial step** in management *Insulin* - **Insulin therapy** is indicated when **dietary modifications alone** are insufficient in maintaining target blood glucose levels - Also preferred if oral agents are contraindicated or fail to achieve glycemic targets - Represents a **secondary intervention** when primary non-pharmacological methods are inadequate

Question 1113: In a case of preterm labor, which steroid is used to enhance fetal lung maturity?

A. Dexamethasone (Correct Answer)
B. Prednisolone
C. Methylprednisolone
D. Hydrocortisone

Explanation: ***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.

Question 1114: Which is the most common complication of molar pregnancy?

A. Placenta previa
B. Ovarian torsion
C. Choriocarcinoma
D. Invasive mole (Correct Answer)

Explanation: **Invasive mole** - An **invasive mole** is the most common complication of molar pregnancy, occurring in about 10-15% of complete hydatidiform moles and 1-5% of partial moles. - It involves the trophoblastic tissue invading the myometrium, which can lead to continued **human chorionic gonadotropin (hCG) elevation** and persistent vaginal bleeding. *Placenta previa* - **Placenta previa** is a condition where the placenta partially or totally covers the cervix, which is unrelated to the abnormal trophoblastic proliferation seen in molar pregnancies. - Its primary risk factors differ from those for molar pregnancy complications and include prior C-sections or uterine surgery. *Ovarian torsion* - **Ovarian torsion** is the twisting of the ovary and/or fallopian tube, cutting off blood supply, and although it can occur in pregnancy, it is not a direct complication of molar pregnancy. - It is often associated with ovarian cysts or masses, and while **theca lutein cysts** can be seen with molar pregnancy, torsion of these cysts is less common than invasive mole. *Choriocarcinoma* - While a serious neoplastic complication of molar pregnancy, **choriocarcinoma** is much rarer than an invasive mole, occurring in only 2-3% of complete hydatidiform moles. - It represents a **malignant transformation** of trophoblastic tissue with metastatic potential, distinguishing it from the localized invasion of an invasive mole.

Question 1115: A pregnant woman presents with intrahepatic cholestasis. What is the first-line treatment?

A. Ursodeoxycholic acid (Correct Answer)
B. Silymarin
C. Methotrexate
D. Prednisolone

Explanation: ***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.

Question 1116: Which ultrasound finding is associated with trisomy 21 in a fetus?

A. Choroid plexus cysts
B. Echogenic foci in heart
C. Hyperechogenic bowel
D. Nuchal edema (Correct Answer)

Explanation: ***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 1117: A 28-year-old primigravida at 32 weeks of gestation presents for a routine prenatal visit. She has no significant past medical history. During the ultrasound examination, various parameters are assessed to evaluate fetal growth and well-being. Which of the following is NOT a criterion used to diagnose Intrauterine Growth Restriction (IUGR)?

A. Fetal weight less than the 3rd percentile
B. Abdominal circumference (AC) less than the 3rd percentile
C. Uterine artery Pulsatility Index (PI) > 95th percentile (Correct Answer)
D. Estimated fetal weight (EFW) below the 10th percentile for gestational age

Explanation: ***Uterine artery Pulsatility Index (PI) > 95th percentile*** - A **high uterine artery Pulsatility Index (PI)**, especially above the 95th percentile, is indicative of **increased vascular resistance** in the uteroplacental circulation. - While it suggests an **increased risk of IUGR** and other adverse pregnancy outcomes due to impaired placentation, it is a **risk predictor or screening tool, not a diagnostic criterion** for IUGR itself. - It helps identify high-risk pregnancies that require closer monitoring but does not diagnose IUGR. *Fetal weight less than the 3rd percentile* - This is a **direct diagnostic criterion** for severe IUGR, indicating significant growth restriction. - It signifies that the fetus is substantially smaller than expected for gestational age, reflecting a failure to meet its growth potential. *Abdominal circumference (AC) less than the 3rd percentile* - An **Abdominal Circumference (AC) below the 3rd percentile** is a **direct diagnostic criterion** for severe asymmetric IUGR. - The AC is a critical parameter as it reflects the fetal liver size and glycogen stores, which are reduced in growth restriction. - AC is often the first biometric parameter to show growth restriction in placental insufficiency. *Estimated fetal weight (EFW) below the 10th percentile for gestational age* - **EFW < 10th percentile** is the **most commonly used diagnostic criterion** for IUGR in clinical practice. - This threshold is widely accepted in international guidelines (ACOG, RCOG, ISUOG) for diagnosing IUGR. - Some centers use < 5th percentile or < 3rd percentile for severe IUGR, but the 10th percentile is the standard diagnostic cutoff.

Question 1118: A 32-year-old female at 36 weeks of pregnancy presents with BP 170/100 mmHg, visual disturbances, headache, urine protein 3+. What will be the next step?

A. IV labetalol and delivery at 37 weeks
B. IV labetalol, dexamethasone, and immediate termination of pregnancy
C. IV labetalol, dexamethasone, and conservative management
D. IV labetalol, magnesium sulfate (MgSO4), expedite delivery (Correct Answer)

Explanation: ***IV labetalol, magnesium sulfate (MgSO4), expedite delivery*** - The patient presents with **severe preeclampsia** (BP > 160/110 mmHg, visual disturbances, headache, proteinuria) at 36 weeks, requiring **antihypertensive therapy** (labetalol) and seizure prophylaxis (**magnesium sulfate**). - Given the severe features and gestational age, **expedited delivery** is indicated to prevent maternal and fetal complications, as expectant management beyond severe preeclampsia at this stage offers minimal benefit and increased risk. *IV labetalol and delivery at 37 weeks* - While IV labetalol is appropriate for **blood pressure control**, delaying delivery to 37 weeks might not be optimal given the **severe features of preeclampsia** at 36 weeks, increasing risks for both mother and fetus. - The plan is incomplete without mentioning **seizure prophylaxis** with magnesium sulfate, which is crucial for severe preeclampsia. *IV labetalol, dexamethasone, and immediate termination of pregnancy* - **Dexamethasone** is used for **fetal lung maturity** in preterm deliveries and is not indicated for immediate termination unless the fetus is preterm and lung maturity is a concern. At 36 weeks, lung maturity is usually established. - While immediate termination might be considered, the phrase "immediate termination" implies C-section without considering vaginal delivery and overlooks the need for **seizure prophylaxis**. *IV labetalol, dexamethasone, and conservative management* - **Dexamethasone** is not a primary treatment for severe preeclampsia itself but rather for **fetal lung maturation** in preterm deliveries, which is less critical at 36 weeks. - **Conservative management** is generally inappropriate for **severe preeclampsia** at 36 weeks, as it increases maternal and fetal risk; delivery is the definitive treatment.

Question 1119: What is the correct dosing regimen of Dexamethasone for promoting fetal lung maturity in preterm infants?

A. Dexamethasone 6 mg - 2 doses every 12 hrly
B. Betamethasone 12 mg - 2 doses every 24 hrly
C. Betamethasone 6 mg - 4 doses every 12 hrly
D. Dexamethasone 6 mg - 4 doses every 12 hrly (Correct Answer)

Explanation: **Dexamethasone 6 mg - 4 doses every 12 hrly** - The standard recommended dosing for **Dexamethasone** to promote fetal lung maturity is **6 mg intramuscularly every 12 hours for a total of four doses.** - This regimen ensures adequate **antenatal corticosteroid** exposure to enhance surfactant production and reduce the incidence and severity of **respiratory distress syndrome** in preterm infants. *Dexamethasone 6 mg - 2 doses every 12 hrly* - This regimen administers only **half the recommended total dose** of Dexamethasone. - It is **insufficient** to achieve the full benefits of antenatal corticosteroids for fetal lung maturity. *Betamethasone 12 mg - 2 doses every 24 hrly* - This is the correct dosing regimen for **Betamethasone**, not Dexamethasone. - While both are antenatal corticosteroids, their dosages and administration schedules differ. *Betamethasone 6 mg - 4 doses every 12 hrly* - This option uses an **incorrect total dose and frequency** for **Betamethasone**. - The standard Betamethasone regimen is 12 mg every 24 hours for two doses.

Question 1120: A 35-year-old pregnant woman at 36 weeks of gestation presents with pruritus and jaundice. What is the most appropriate investigation?

A. Liver function tests
B. Bile acids measurement (Correct Answer)
C. Ultrasound of liver
D. Serum bilirubin

Explanation: ***Bile acids measurement*** - Elevated **serum bile acids** are the hallmark of **intrahepatic cholestasis of pregnancy (ICP)**, which is strongly suggested by the patient's symptoms of pruritus and jaundice in late pregnancy. - This test directly measures the substance pathologically elevated in ICP, guiding diagnosis and management due to the associated risks to the fetus. *Liver function tests* - While **liver function tests (LFTs)** like **ALT** and **AST** are often abnormal in ICP (elevated), they are not as specific as bile acid levels for diagnosing ICP and can be elevated in various other liver conditions. - LFTs alone might not confirm the diagnosis of ICP, especially in cases where **pruritus** is the main symptom, and other liver enzymes are only mildly deranged. *Ultrasound of liver* - A **liver ultrasound** is useful for ruling out **extrahepatic cholestasis** (e.g., gallstones obstructing the bile duct) but will typically be normal in **intrahepatic cholestasis of pregnancy** itself. - It does not directly assess the biochemical markers indicative of ICP, which is primarily a functional disorder of bile acid transport. *Serum bilirubin* - While **elevated serum bilirubin** contributes to the **jaundice** observed in this patient, it is a non-specific finding that indicates impaired bile flow or liver dysfunction from various causes. - **Bilirubin** levels do not provide the specific diagnostic confirmation for **intrahepatic cholestasis of pregnancy** that **bile acid levels** do, nor do they reflect the severity or guide treatment for ICP as effectively.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

Practice Questions

Multiple Gestation

Practice Questions

Rh Isoimmunization and Other Blood Group Incompatibilities

Practice Questions

Intrauterine Fetal Therapy

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Prenatal Diagnosis and Genetic Counseling

Practice Questions

Placental Abnormalities

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Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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