Maternal-Fetal Medicine Practice Questions

Q: Which condition is characterized by high levels of human chorionic gonadotropin (hCG) and a 'snowstorm' pattern on ultrasound?

Complete hydatidiform mole. ***Complete hydatidiform mole*** - This condition is characterized by **abnormally high levels of human chorionic gonadotropin (hCG)** due to the proliferation of trophoblastic tissue. - The classic ultrasound finding is a uterine cavity filled with numerous small cysts, creating a distinctive **"snowstorm" or "grape-like cluster" appearance** without a fetal pole or amniotic sac. *Partial hydatidiform mole* - While it also involves elevated hCG and abnormal placental tissue, the hCG levels are typically **lower than in a complete mole** and often fall within the range of a normal pregnancy. - Ultrasound may show a **fetal pole (often malformed)** and amniotic sac, along with focal hydropic villi, which does not present as a classic "snowstorm" pattern. *Ectopic pregnancy* - In an ectopic pregnancy, hCG levels are usually **elevated but often lower than expected for gestational age** and may plateau or rise slowly, not reaching the extremely high levels seen in a complete mole. - Ultrasound characteristically shows an **empty uterus** and often an **adnexal mass** (gestational sac or complex mass in the fallopian tube), not a "snowstorm" appearance within the uterine cavity. *Missed abortion* - In a missed abortion, hCG levels typically **decline or plateau** after initial elevation as the pregnancy is no longer viable. - Ultrasound findings include a **gestational sac with no fetal heart activity** or a fetal pole that is smaller than expected for gestational age, without the proliferative molar tissue or "snowstorm" pattern.

Q: Which medication is considered the first-line treatment for managing hypertension during pregnancy?

Methyldopa. ***Methyldopa*** - **Methyldopa** is considered a **first-line treatment for chronic hypertension during pregnancy** and has the **longest safety record** with extensive data on maternal and fetal outcomes. - It works as a central alpha-2 adrenergic agonist, reducing sympathetic outflow and thereby **lowering blood pressure** without compromising uteroplacental blood flow. - While **labetalol** and **nifedipine** are also considered first-line agents, **methyldopa** is often preferred when a **long-term oral agent** is needed, particularly in resource-limited settings, and is specifically recommended by WHO guidelines. *ACE inhibitors* - **ACE inhibitors** are **absolutely contraindicated** during pregnancy, especially in the second and third trimesters, due to their association with **fetal renal abnormalities**, oligohydramnios, and **renal dysgenesis**. - Their use can lead to **fetal growth restriction**, **pulmonary hypoplasia**, **skull hypoplasia**, and **fetal/neonatal death**. *Beta-blockers* - **Labetalol** (a selective beta-blocker) is also considered a **first-line agent** for hypertension in pregnancy alongside methyldopa and is often preferred for acute management or when rapid control is needed. - However, in the context of chronic hypertension requiring long-term oral therapy, **methyldopa** has the most extensive safety data spanning decades. - Atenolol should be avoided due to associations with **fetal growth restriction**. *Calcium channel blockers* - **Nifedipine** (long-acting) is another **first-line option** for hypertension in pregnancy, particularly useful for **acute severe hypertension** and as an alternative when methyldopa is not tolerated. - While equally effective, it may be considered an **alternative first-line agent** rather than the primary choice for chronic management in some guidelines.

Q: A 24-year-old woman, G1P0, at 32 weeks of gestation presents with a sudden onset of severe, localized abdominal pain and vaginal spotting. Examination reveals a tender, rigid abdomen. What is the most likely diagnosis?

Placental abruption. ***Placental abruption*** - The sudden onset of **severe, localized abdominal pain**, **vaginal spotting**, and a **tender, rigid abdomen** in a pregnant woman at 32 weeks gestation are classic signs of placental abruption. - This condition involves the **premature separation of the placenta** from the uterine wall, leading to bleeding and uterine hypertonus. *Uterine rupture* - While it also presents with sudden severe pain, a **uterus rupture** often leads to signs of maternal shock and fetal distress, and the abdomen might be soft or have palpable fetal parts, which is not described. - It usually occurs in women with a history of **previous uterine surgery or trauma**, and there is no such history given. *Labor onset* - **Labor onset** typically involves rhythmic contractions and progressive cervical changes, which are usually not associated with a continuously rigid and tender abdomen between contractions. - Vaginal bleeding in labor is usually minimal and different from the spotting associated with abruption. *Urinary tract infection* - A **urinary tract infection (UTI)** would present with symptoms such as dysuria, urgency, frequency, and suprapubic discomfort; it would not cause severe, localized abdominal pain with a rigid abdomen. - A UTI is usually confirmed by urinalysis and culture, which would not explain the described acute abdominal findings.

Q: Which condition is not typically associated with polyhydramnios?

Renal agenesis. ***Renal agenesis*** - **Renal agenesis** leads to **oligohydramnios** (too little amniotic fluid) because fetal kidneys are crucial for producing amniotic fluid through urine. - The absence of kidneys means the fetus cannot contribute fluid, resulting in insufficient amniotic fluid volume. *Diabetes mellitus* - Maternal **diabetes mellitus** can cause **fetal hyperglycemia**, leading to an increase in fetal urination and thus **polyhydramnios**. - High glucose levels in the fetal blood are filtered by the kidneys, increasing osmotic diuresis and urine output. *Twin-twin transfusion syndrome* - In **twin-twin transfusion syndrome (TTTS)**, the recipient twin often develops **polyhydramnios** due to increased blood volume and subsequent diuresis. - The donor twin, conversely, typically experiences **oligohydramnios**. *Anencephaly* - **Anencephaly** is a neural tube defect where the fetus lacks a developed brain, leading to impaired swallowing reflexes. - Impaired swallowing prevents the fetus from adequately reabsorbing amniotic fluid, contributing to **polyhydramnios**.

Q: What is essential for confirming the diagnosis of placental abruption?

Initial clinical assessment (history and examination). ***Initial clinical assessment (history and examination)*** - The diagnosis of **placental abruption** is primarily clinical, based on sudden onset of **vaginal bleeding**, **abdominal pain**, and often a **tender, rigid uterus** on examination. - The **characteristic clinical presentation** (history and physical findings) is the cornerstone for confirming the diagnosis and guiding immediate management. - Clinical assessment has the highest diagnostic utility in acute settings and should be performed immediately. *Ultrasound* - **Ultrasound** has limited sensitivity (25-50%) for detecting acute placental abruption, as fresh blood clots can be isoechoic to the placenta. - It is more useful in **ruling out placenta previa** and assessing fetal well-being, rather than confirming abruption itself. - A negative ultrasound does **not exclude** placental abruption. *MRI (Magnetic Resonance Imaging)* - **MRI** is highly sensitive for detecting placental abruption, but it is not used for **acute diagnosis** due to its cost, time commitment, and limited availability in emergency settings. - Its role is mostly reserved for cases with **diagnostic uncertainty** or for research purposes. *Laboratory investigations (e.g., blood tests)* - **Laboratory tests** such as complete blood count (CBC), coagulation profile, and fibrinogen levels help assess the **maternal hemodynamic status** and screen for disseminated intravascular coagulation (DIC). - These tests are crucial for guiding treatment and managing complications, but they do not **confirm the diagnosis** of placental abruption itself.

Q: A 27-year-old woman at 10 weeks of gestation presents with painless vaginal bleeding. An ultrasound reveals an intrauterine gestational sac without a fetal pole, and her β-hCG levels are decreasing. What is the most appropriate management option?

Expectant management. ***Expectant management*** - With **decreasing β-hCG levels** and an **empty gestational sac**, a **missed abortion** is likely, and expectant management allows the body to pass the tissue naturally, avoiding invasive procedures. - This approach is appropriate for hemodynamically stable patients without signs of infection, and most will spontaneously complete the abortion within a few weeks. *Dilation and curettage* - This is an **invasive surgical procedure** generally reserved for cases of incomplete abortion with heavy bleeding, infection, or patient preference for a quicker resolution. - Performing D&C prematurely in a stable patient with decreasing hCG and no immediate complications might be an **overly aggressive initial management**. *Methotrexate therapy* - **Methotrexate** is primarily used for **ectopic pregnancies** or **gestational trophoblastic disease**. - It is **not indicated** for an intrauterine pregnancy arrest (missed abortion) when expectant management or surgical evacuation are safer and more appropriate options. *Progesterone supplementation* - **Progesterone** is sometimes used in cases of threatened abortion with documented **low progesterone levels** in the hope of maintaining the pregnancy. - However, in this scenario, the presence of an **empty gestational sac** and **decreasing β-hCG levels** indicates that the pregnancy is no longer viable, making progesterone supplementation ineffective.

Q: A 30-year-old G1P0 woman at 36 weeks of gestation presents with painless vaginal bleeding. Ultrasound shows the placenta covering the cervical os. What is the diagnosis?

Placenta previa. ***Placenta previa*** - This condition is characterized by the **placenta implantation** over or near the **cervical os**, leading to **painless vaginal bleeding** in the late second or third trimester. - The ultrasound finding of the **placenta covering the cervical os** directly confirms this diagnosis. *Abruptio placentae* - This involves the **premature separation** of the placenta from the uterine wall, typically causing **painful vaginal bleeding** and uterine tenderness. - The patient's bleeding is described as painless, and there is no mention of uterine pain or contractions. *Vasa previa* - Involves **fetal blood vessels** running within the membranes over the cervical os, susceptible to rupture, which leads to **fetal bleeding** and distress. - While it presents as painless vaginal bleeding, the ultrasound specifically shows the **placenta covering the os**, not isolated fetal vessels. *Uterine rupture* - This is a rare, life-threatening event often associated with a **previous C-section scar** or uterine trauma, presenting with sudden, severe abdominal pain, vaginal bleeding, and fetal distress. - The patient's symptoms are painless bleeding, and there is no mention of severe abdominal pain or a history suggestive of increased risk for uterine rupture.

Q: A patient at 28 weeks of gestation presents with a classical cesarean scar and complains of painless spotting. What is the first step in management?

Detailed ultrasound. ***Detailed ultrasound*** - A classical cesarean scar with painless spotting raises concern for **placenta accreta spectrum (PAS) disorders**, where the placenta abnormally adheres to the uterine wall, potentially invading the scar. - A **high-resolution ultrasound** is the initial and most crucial diagnostic step to evaluate placental location, depth of invasion, and proximity to the scar. *Immediate cesarean delivery* - This is an **invasive procedure** and should not be performed without a definitive diagnosis and proper planning, especially given the patient's gestational age of 28 weeks. - An immediate delivery would be indicated for **life-threatening hemorrhage** or **fetal distress**, neither of which is described as the primary complaint in this scenario. *MRI of the pelvis* - While **MRI can provide additional information** for PAS disorders, it is typically used as a **secondary imaging modality** after an inconclusive ultrasound or for surgical planning, not as the first step. - Ultrasound is **more accessible** and often sufficient for initial diagnosis and risk stratification. *Administration of tocolytics* - **Tocolytics are used to suppress uterine contractions** in preterm labor. - This patient is presenting with painless spotting and a concern for PAS, not preterm labor, so tocolytics would be **inappropriate** and potentially **mask critical signs** or delay necessary intervention for the bleeding cause.

Question 1

Which condition is characterized by high levels of human chorionic gonadotropin (hCG) and a 'snowstorm' pattern on ultrasound?

Accepted Answer

Complete hydatidiform mole

Answer

Partial hydatidiform mole

Answer

Ectopic pregnancy

Answer

Missed abortion

Question 2

Which medication is considered the first-line treatment for managing hypertension during pregnancy?

Accepted Answer

Methyldopa

Answer

ACE inhibitors

Answer

Beta-blockers

Answer

Calcium channel blockers

Question 3

A 24-year-old woman, G1P0, at 32 weeks of gestation presents with a sudden onset of severe, localized abdominal pain and vaginal spotting. Examination reveals a tender, rigid abdomen. What is the most likely diagnosis?

Accepted Answer

Placental abruption

Answer

Uterine rupture

Answer

Labor onset

Answer

Urinary tract infection

Question 4

What is the most recommended preventive measure for a pregnant woman at high risk of preterm birth due to a short cervix?

Accepted Answer

Progesterone therapy

Answer

Strict bed rest

Answer

Regular prenatal check-ups

Answer

Cerclage (cervical stitch)

Question 5

Which condition is not typically associated with polyhydramnios?

Accepted Answer

Renal agenesis

Answer

Twin-twin transfusion syndrome

Answer

Anencephaly

Answer

Diabetes mellitus

Question 6

What is essential for confirming the diagnosis of placental abruption?

Accepted Answer

Initial clinical assessment (history and examination)

Answer

MRI (Magnetic Resonance Imaging)

Answer

Ultrasound

Answer

Laboratory investigations (e.g., blood tests)

Question 7

A 27-year-old woman at 10 weeks of gestation presents with painless vaginal bleeding. An ultrasound reveals an intrauterine gestational sac without a fetal pole, and her β-hCG levels are decreasing. What is the most appropriate management option?

Accepted Answer

Expectant management

Answer

Dilation and curettage

Answer

Methotrexate therapy

Answer

Progesterone supplementation

Question 8

A 30-year-old G1P0 woman at 36 weeks of gestation presents with painless vaginal bleeding. Ultrasound shows the placenta covering the cervical os. What is the diagnosis?

Accepted Answer

Placenta previa

Answer

Abruptio placentae

Answer

Vasa previa

Answer

Uterine rupture

Question 9

Which of the following ultrasound findings is characteristic of a molar pregnancy?

Accepted Answer

Snowstorm appearance of the uterine contents

Answer

Increased nuchal translucency

Answer

Echogenic bowel

Answer

Choroid plexus cyst

Question 10

A patient at 28 weeks of gestation presents with a classical cesarean scar and complains of painless spotting. What is the first step in management?

Accepted Answer

Detailed ultrasound

Answer

Immediate cesarean delivery

Answer

MRI of the pelvis

Answer

Administration of tocolytics

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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