Maternal-Fetal Medicine Practice Questions

Q: Which imaging modality is the most sensitive for detecting early ectopic pregnancy?

Transvaginal ultrasound. ***Transvaginal ultrasound*** - **Transvaginal ultrasound (TVUS)** provides higher resolution imaging of pelvic organs due to closer proximity to the uterus and adnexa. - This allows for earlier and more accurate detection of an **extrauterine gestational sac** or adnexal mass characteristic of an early ectopic pregnancy. *Transabdominal ultrasound* - **Transabdominal ultrasound (TAUS)** offers lower resolution compared to TVUS, especially in early pregnancy. - It may miss small ectopic pregnancies or fail to accurately characterize a subtle adnexal mass. *MRI* - **MRI** is not typically the first-line imaging modality for suspected ectopic pregnancy due to its higher cost, longer scan time, and limited accessibility in emergency settings. - While it can provide detailed anatomical information, its sensitivity for very early ectopic pregnancies is not superior to TVUS. *CT scan* - **CT scans** involve ionizing radiation, which is generally avoided in pregnancy unless absolutely necessary. - It is not as effective as ultrasound in visualizing the early gestational sac or adnexal structures for ectopic pregnancy diagnosis.

Q: A 31-year-old G2P1 at 28 weeks of gestation with a known low-lying placenta presents with painless, bright red vaginal bleeding. What is the most likely diagnosis?

Placenta previa. ***Placenta previa*** - The classic presentation of **placenta previa** is **painless, bright red vaginal bleeding** in the second or third trimester. - A **low-lying placenta** noted earlier in pregnancy is a risk factor, as it can migrate to cover the cervical os. *Placental abruption* - Characterized by **painful vaginal bleeding**, often associated with uterine tenderness and contractions. - The bleeding in abruption can be dark red and may be concealed, unlike the bright red blood seen here. *Uterine rupture* - Typically presents with **sudden, severe abdominal pain**, fetal distress, and a loss of uterine tone, often following a prior C-section scar. - Vaginal bleeding may be present but is usually not the primary or only symptom, and pain is a prominent feature. *Vasa previa* - Involves fetal blood vessels running unprotected over the cervical os, leading to **fetal bleeding** when the membranes rupture. - While it can cause painless vaginal bleeding, it is usually associated with **fetal compromise** (e.g., bradycardia) and often occurs at the time of membrane rupture.

Q: A 30-year-old woman at 38 weeks of gestation presents with a sudden onset of severe abdominal pain and a firm, tender uterus. What is the diagnosis?

Abruptio placentae. ***Abruptio placentae*** - **Severe abdominal pain** and a **firm, tender uterus** in a patient at 38 weeks of gestation are classic signs of **abruptio placentae**, where the placenta prematurely detaches from the uterine wall. - This condition often presents with **vaginal bleeding** (though sometimes concealed) and can lead to fetal distress due to placental insufficiency. *Placenta previa* - Characterized by **painless vaginal bleeding** in the second or third trimester, often without abdominal pain or uterine tenderness. - The placenta is abnormally implanted near or over the **cervical os**. *Uterine rupture* - Typically presents with **sudden, severe abdominal pain**, **cessation of uterine contractions**, and often **fetal distress** or loss of fetal heart tones. - A history of prior uterine surgery (e.g., C-section) is a significant risk factor, and the uterus would likely feel soft or boggy rather than firm. *Preterm labor* - Involves regular **uterine contractions** leading to cervical changes before 37 weeks of gestation, usually associated with dull backache, pelvic pressure, or menstrual-like cramps, not sudden severe abdominal pain and uterine tenderness directly. - This patient is at **38 weeks**, so preterm labor is not applicable.

Q: In an emergency cesarean section, a parturient with eclampsia develops sudden hypoxia and hypotension. What is the most likely diagnosis?

Amniotic fluid embolism. ***Amniotic fluid embolism*** - The sudden onset of **hypoxia** and **hypotension** during a cesarean section in a parturient, especially with **eclampsia**, is highly suggestive of an amniotic fluid embolism. - This catastrophic event occurs when **amniotic fluid** enters the maternal circulation, leading to systemic shock, acute respiratory distress, coagulopathy, and often cardiac arrest. *Pulmonary embolism* - While pulmonary embolism can cause sudden **hypoxia** and **hypotension**, it is less likely to present with the rapid and severe systemic collapse typically seen with amniotic fluid embolism in this context. - Risk factors for pulmonary embolism include hypercoagulability, which is enhanced in pregnancy, but the **peripartum setting** points more strongly to an amniotic fluid embolism. *Aspiration pneumonitis* - **Aspiration pneumonitis** would typically present predominantly with **respiratory distress** and coughing, potentially leading to hypoxia, but less commonly with such immediate and severe hypotension. - It results from the inhalation of gastric contents, which can occur during general anesthesia but doesn't fully explain the complete clinical picture of profound **cardiovascular collapse**. *Acute respiratory distress syndrome* - **ARDS** is a syndrome of diffuse lung injury leading to severe **hypoxia** and reduced lung compliance, but it usually develops over hours to days. - The sudden onset of symptoms during the procedure makes ARDS as the primary immediate event less likely, though it can be a **secondary complication** of amniotic fluid embolism.

Q: What is the effect of glucocorticoid administration in a pregnant woman with preterm labor?

Helps fetal lung maturity. ***Helps fetal lung maturity*** - Glucocorticoids, such as **betamethasone** or **dexamethasone**, accelerate fetal lung maturation by inducing the synthesis and release of **surfactant** in the fetal lungs. - This intervention significantly reduces the incidence and severity of **respiratory distress syndrome (RDS)** in preterm infants. *Increased chances of Intraventricular hemorrhage* - Glucocorticoid administration is associated with a **decreased risk** of **intraventricular hemorrhage (IVH)** in preterm infants, not an increased risk. - This protective effect is thought to be due to improved vascular stability and reduced systemic inflammation. *Increased incidence of neonatal mortality* - Antenatal glucocorticoids have been shown to **reduce neonatal mortality** in preterm infants, primarily by decreasing the rates of RDS, IVH, and **necrotizing enterocolitis (NEC)**. - The benefits of glucocorticoid administration far outweigh the potential risks in the setting of preterm labor. *Reduced Surfactant production* - Glucocorticoids **increase**, rather than reduce, **surfactant production** by stimulating type II pneumocytes in the fetal lungs. - This enhanced surfactant production is crucial for maintaining alveolar stability and preventing lung collapse after birth.

Q: A patient with a history of recurrent early miscarriages is diagnosed with antiphospholipid syndrome. What is the recommended management for her next pregnancy?

Aspirin and heparin. ***Aspirin and heparin*** - The combination of **low-dose aspirin** and **low molecular weight heparin (LMWH)** is the **gold standard** for managing pregnant patients with antiphospholipid syndrome (APS) to prevent recurrent miscarriages. - This therapy aims to **reduce thrombotic events** in the placenta and improve uteroplacental blood flow, which are crucial for a successful pregnancy in APS patients. *Corticosteroids* - While corticosteroids are used in some autoimmune conditions, they are **not recommended as primary treatment** for preventing pregnancy loss in antiphospholipid syndrome. - Their use is generally reserved for inflammatory conditions or specific autoimmune flares, and they carry potential risks in pregnancy. *No specific treatment* - **Untreated antiphospholipid syndrome** in pregnancy carries a **very high risk of recurrent miscarriage**, stillbirth, and other obstetric complications. - Therefore, active management is essential for improving pregnancy outcomes in these patients. *Antibiotic prophylaxis* - **Antibiotic prophylaxis** is typically used to prevent or treat infections and has **no direct role** in preventing recurrent miscarriages due to antiphospholipid syndrome. - The underlying mechanism in APS involves thrombotic tendencies, not infection.

Q: Which of the following is NOT a component of the biophysical profile?

Placental grading. ***Placental grading*** - **Placental grading** (e.g., Grannum classification) is an ultrasound assessment of placental maturity based on its appearance, but it is **NOT** one of the five standard components of the biophysical profile. - While useful for assessing placental health and maturity, it does not directly reflect **acute fetal well-being** in the same way as the BPP parameters. *Fetal tone* - This **is** one of the five components assessed in a **biophysical profile (BPP)**, specifically looking for at least one episode of active extension with return to flexion. - A normal score for fetal tone indicates **fetal neurological integrity** and adequate oxygenation. *Nonstress test (Fetal heart rate)* - The **nonstress test (NST)** evaluating fetal heart rate accelerations in response to fetal movement **is** one of the five components of the biophysical profile. - It assesses fetal heart rate reactivity as an indicator of **fetal well-being** and adequate oxygenation. *Fetal breathing movements* - **Fetal breathing movements** **are** a component of the biophysical profile, requiring at least one episode of 30 seconds of sustained fetal breathing over 30 minutes. - This parameter assesses neurological function and helps confirm the maturity of the **fetal respiratory system**.

Q: Which of the following surgical procedures is most appropriate for a hemodynamically stable patient with a ruptured ectopic pregnancy?

Salpingectomy. ***Salpinectomy*** - For a **hemodynamically stable** patient with a **ruptured ectopic pregnancy**, **salpingectomy** (removal of the affected fallopian tube) is often the most appropriate surgical intervention. This approach definitively addresses the rupture and prevents further hemorrhage. - While other options might be considered for unruptured ectopic pregnancies or specific patient conditions, a ruptured ectopic pregnancy, even in a stable patient, necessitates surgical removal of the compromised tube to ensure patient safety and prevent significant blood loss. *Methotrexate* - **Methotrexate** is a medical management option typically reserved for **unruptured, hemodynamically stable ectopic pregnancies** with specific criteria (e.g., small gestational sac, low hCG levels). - It is contraindicated in cases of **ruptured ectopic pregnancy** due to the immediate risk of hemorrhage, which requires surgical intervention. *Laparotomy* - **Laparotomy** (open abdominal surgery) is an appropriate surgical approach for a ruptured ectopic pregnancy, especially in **hemodynamically unstable patients** or when minimally invasive techniques are not feasible. - However, for a **hemodynamically stable patient**, a **laparoscopic salpingectomy** is generally preferred due to its less invasive nature, quicker recovery, and reduced morbidity compared to open laparotomy. *Expectant management* - **Expectant management** involves close observation without immediate intervention and is only considered for **unruptured ectopic pregnancies** that are spontaneously resolving, with very low and declining hCG levels, and where the patient is asymptomatic and hemodynamically stable. - It is **contraindicated** in cases of **ruptured ectopic pregnancy** as it carries a significant risk of severe hemorrhage, maternal morbidity, and mortality, necessitating active intervention.

Q: A 28-year-old woman in labor with a history of preeclampsia presents with severe hypertension. What is the appropriate treatment?

Labetalol. ***Labetalol*** - **Labetalol IV** is a **first-line agent** for acute treatment of **severe hypertension in preeclampsia** with rapid onset (5-10 minutes) and predictable dose-response. - It works by blocking both **alpha- and beta-adrenergic receptors**, reducing blood pressure without significantly compromising **uteroplacental blood flow**. - **Advantages**: IV route allows titration, widely available, favorable maternal-fetal safety profile. *Hydralazine* - **Hydralazine IV** is **also a first-line agent** (not second-line) for severe hypertension in preeclampsia, with equal efficacy to labetalol. - **Disadvantages**: Can cause **reflex tachycardia** and **maternal headache/palpitations**, making it harder to distinguish from worsening preeclampsia symptoms. - Onset of action can be **less predictable** with more frequent maternal side effects compared to labetalol. *Nifedipine* - **Nifedipine (immediate-release oral)** is **also a first-line agent** for severe hypertension in pregnancy, with efficacy comparable to IV agents. - **Disadvantages**: Oral route may be less ideal during active labor; can cause **maternal flushing and headache**. - Risk of **hypotension** if combined with magnesium sulfate (commonly used in preeclampsia). *Methyldopa* - **Methyldopa** is used for **chronic hypertension in pregnancy**, NOT for acute severe hypertension. - Its **slow onset of action** (4-6 hours) makes it completely unsuitable for emergency blood pressure control in labor.

Question 1

Which imaging modality is the most sensitive for detecting early ectopic pregnancy?

Accepted Answer

Transvaginal ultrasound

Answer

Transabdominal ultrasound

Answer

MRI

Answer

CT scan

Question 2

What is the recommended management strategy for a pregnant woman at 28 weeks of gestation diagnosed with asymptomatic placenta previa?

Accepted Answer

Scheduled cesarean delivery between 36-37 weeks if no bleeding occurs

Answer

Immediate cesarean delivery

Answer

Natural vaginal delivery

Answer

Induction of labor at 34 weeks

Question 3

A 31-year-old G2P1 at 28 weeks of gestation with a known low-lying placenta presents with painless, bright red vaginal bleeding. What is the most likely diagnosis?

Accepted Answer

Placenta previa

Answer

Placental abruption

Answer

Uterine rupture

Answer

Vasa previa

Question 4

A 30-year-old woman at 38 weeks of gestation presents with a sudden onset of severe abdominal pain and a firm, tender uterus. What is the diagnosis?

Accepted Answer

Abruptio placentae

Answer

Placenta previa

Answer

Uterine rupture

Answer

Preterm labor

Question 5

In an emergency cesarean section, a parturient with eclampsia develops sudden hypoxia and hypotension. What is the most likely diagnosis?

Accepted Answer

Amniotic fluid embolism

Answer

Pulmonary embolism

Answer

Aspiration pneumonitis

Answer

Acute respiratory distress syndrome

Question 6

What is the effect of glucocorticoid administration in a pregnant woman with preterm labor?

Accepted Answer

Helps fetal lung maturity

Answer

Increased chances of Intraventricular hemorrhage

Answer

Increased incidence of neonatal mortality

Answer

Reduced Surfactant production

Question 7

A patient with a history of recurrent early miscarriages is diagnosed with antiphospholipid syndrome. What is the recommended management for her next pregnancy?

Accepted Answer

Aspirin and heparin

Answer

Corticosteroids

Answer

No specific treatment

Answer

Antibiotic prophylaxis

Question 8

Which of the following is NOT a component of the biophysical profile?

Accepted Answer

Placental grading

Answer

Fetal tone

Answer

Fetal heart rate

Answer

Breathing movements

Question 9

Which of the following surgical procedures is most appropriate for a hemodynamically stable patient with a ruptured ectopic pregnancy?

Accepted Answer

Salpingectomy

Answer

Laparotomy

Answer

Expectant management

Answer

Methotrexate

Question 10

A 28-year-old woman in labor with a history of preeclampsia presents with severe hypertension. What is the appropriate treatment?

Accepted Answer

Labetalol

Answer

Methyldopa

Answer

Nifedipine

Answer

Hydralazine

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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