Maternal-Fetal Medicine Practice Questions

Q: A pregnant woman presents with symptoms consistent with Zika virus infection, and ultrasound reveals fetal abnormalities. What is the most appropriate course of action?

Perform amniocentesis to test for Zika virus RNA. ***Perform amniocentesis to test for Zika virus RNA*** - Amniocentesis is recommended to confirm the presence of **Zika virus RNA in amniotic fluid** when fetal abnormalities are detected and Zika infection is suspected. - This diagnostic step provides definitive evidence of **fetal infection**, which is crucial for counseling and management. *Terminate the pregnancy* - **Termination of pregnancy** is a significant decision that requires confirmed diagnosis and thorough counseling, and it is not the immediate first step. - While it may be considered later depending on the severity of fetal abnormalities and parental wishes, diagnostic confirmation is paramount. *Initiate antiviral therapy immediately* - Currently, there is **no specific antiviral therapy** approved or proven effective for treating Zika virus infection in pregnant women or fetuses. - Management is primarily supportive, focusing on monitoring and symptom relief. *Wait for further development and re-evaluate* - Given the presence of **fetal abnormalities** and symptoms consistent with Zika, **waiting for further development** without diagnostic intervention is inappropriate. - Prompt diagnosis is essential to understand the full extent of the infection and prognosticate fetal outcomes.

Q: Identify the most common risk factor for ectopic pregnancy.

History of pelvic inflammatory disease. ***History of pelvic inflammatory disease*** - **Pelvic inflammatory disease (PID)** is the *most common risk factor* for ectopic pregnancy as it can cause *inflammation* and *scarring* of the fallopian tubes, impairing ovum transport. - The resulting tubal damage, such as *adhesions* and *strictures*, creates a hostile environment for the fertilized egg, making it more likely to implant outside the uterus. *Previous ectopic pregnancy* - While a *significant risk factor*, a history of **ectopic pregnancy** is not the most common risk factor overall, as its prevalence is lower than that of PID. - Women who have had one ectopic pregnancy have a *10-15% chance* of having another, but this is a *recurrent risk* rather than a primary cause in the general population. *Use of intrauterine devices* - **Intrauterine devices (IUDs)**, particularly *progestin-releasing IUDs*, do not cause ectopic pregnancies but instead prevent intrauterine pregnancies. - If a pregnancy does occur with an IUD in place, there is a *higher chance* that it will be ectopic due to the successful prevention of uterine implantation. *Advanced maternal age* - Although **advanced maternal age** (typically defined as over 35 years) is associated with an *increased risk of infertility* and other pregnancy complications, it is not the leading risk factor for ectopic pregnancy. - The association is often due to the *cumulative exposure to other risk factors* over time, such as PID, rather than age itself directly causing ectopic implantation.

Q: A 35-year-old woman with a history of preterm labor at 32 weeks presents at 24 weeks with signs of preterm labor. Which treatment is recommended to prevent recurrence?

Progesterone supplementation. ***Correct: Progesterone supplementation*** - **Progesterone** helps maintain uterine quiescence and prevents cervical shortening, which is beneficial for women with a history of spontaneous preterm birth. - For women with a history of **preterm labor**, progesterone supplementation (either vaginal or intramuscular 17-alpha-hydroxyprogesterone caproate) is recommended to reduce the risk of recurrence. - This is supported by **ACOG guidelines** and multiple randomized controlled trials showing reduced risk of recurrent preterm birth. *Incorrect: Corticosteroids* - **Corticosteroids** (e.g., betamethasone or dexamethasone) are administered to women at risk of imminent preterm delivery to accelerate fetal lung maturity. - They are **not used for preventing recurrence** of preterm labor but rather for mitigating complications if preterm birth is unavoidable. - Typically given between 24-34 weeks when delivery is anticipated within 7 days. *Incorrect: Magnesium sulfate* - **Magnesium sulfate** is primarily used as a **neuroprotective agent** for the fetus in cases of anticipated preterm birth before 32 weeks, and for tocolysis to temporarily delay delivery. - It is **not a treatment for preventing recurrent preterm labor** or for long-term maintenance of pregnancy. - Used acutely, not for prophylaxis. *Incorrect: Cerclage* - **Cervical cerclage** is a surgical procedure to reinforce the cervix, typically performed in women with **cervical insufficiency** (a weakened cervix that opens prematurely). - It is indicated if the patient has a history of second-trimester losses due to cervical incompetence or if significant cervical shortening (<25mm) is observed in the current pregnancy. - Not the primary treatment for preventing recurrent preterm labor in the absence of documented cervical insufficiency.

Q: A 28-year-old woman at 32 weeks of gestation presents with vaginal bleeding and no pain. Ultrasound shows placenta previa. What is the initial management?

Expectant management. ***Expectant management*** - In a stable patient with **placenta previa** at 32 weeks and no signs of fetal distress or severe hemorrhage, the correct management **strategy** is expectant management (watchful waiting) rather than immediate delivery. - This involves **hospitalization** with close monitoring including **maternal vital signs**, amount of bleeding, and fetal well-being (e.g., nonstress tests). - **Corticosteroids should be administered immediately** as part of expectant management to promote fetal lung maturity, given the risk of preterm delivery. - The goal is to reach 36-37 weeks gestation when elective cesarean delivery can be performed safely. *Immediate delivery* - **Immediate delivery** is only indicated in cases of **severe hemorrhage**, maternal hemodynamic instability, or fetal distress. - At 32 weeks, delivering without urgent indication significantly increases neonatal morbidity and mortality. *Magnesium sulfate* - **Magnesium sulfate** may be used for **tocolysis** if uterine contractions are present or for **neuroprotection** before anticipated preterm delivery (to reduce risk of cerebral palsy). - However, it is not the primary initial management strategy compared to expectant management with monitoring. *Corticosteroids* - **Corticosteroids** (betamethasone or dexamethasone) are indeed administered immediately to promote **fetal lung maturity**. - However, this option alone is incomplete as an answer because it doesn't encompass the **overall management approach** (expectant vs immediate delivery), which is the key decision point. - Corticosteroids are an essential **component** of expectant management, not a separate strategy.

Q: What is the most appropriate management for a fetus diagnosed with non-immune hydrops due to fetal anemia?

Intrauterine transfusion. ***Intrauterine transfusion*** - Non-immune hydrops due to **fetal anemia** requires **intrauterine transfusion** as the most effective treatment. - This procedure directly addresses the underlying cause by providing healthy red blood cells, which can reverse heart failure and hydrops. - Common causes of anemia-induced hydrops include **parvovirus B19 infection**, **α-thalassemia**, and **fetomaternal hemorrhage**. *Immediate delivery* - While delivery might be considered in some severe cases close to term, it is generally not the initial management for hydrops, especially in **preterm fetuses**, as it introduces risks associated with prematurity. - The focus is often on treating the underlying *fetal condition* in utero to improve outcomes before delivery. *Corticosteroid administration* - Corticosteroids are primarily used to **accelerate fetal lung maturity** in anticipation of preterm delivery. - They do not address the *underlying cause* of anemia-induced hydrops and therefore are not the primary, most appropriate management. *Observation and serial ultrasounds* - This approach is generally insufficient for anemia-induced hydrops, which indicates **fetal compromise** and has a high mortality rate if left untreated. - While monitoring is part of management, active intervention with **intrauterine transfusion** to treat the **underlying anemia** is crucial for improving fetal outcomes.

Q: A 28-year-old primigravida at 38 weeks of gestation presents with intense itching, particularly on the palms and soles, without a rash. Liver function tests reveal abnormalities. What is the most likely diagnosis?

Intrahepatic cholestasis of pregnancy. ***Intrahepatic cholestasis of pregnancy*** - This condition typically presents in the **late second or third trimester** with generalized pruritus, predominantly on the **palms and soles**, without a primary rash. - **Elevated liver function tests** (LFTs), particularly bile acids, are characteristic, confirming the diagnosis. *Pruritic urticarial papules and plaques of pregnancy (PUPPP)* - PUPPP presents with **urticarial papules and plaques** that start in the striae of the abdomen and spread, which is different from the rash-less itching on palms/soles in this case. - Liver function tests are typically **normal** in PUPPP, distinguishing it from conditions with hepatic involvement. *Pemphigoid gestationis* - This is an **autoimmune blistering disease** of pregnancy, characterized by intensely pruritic urticarial lesions and blisters, usually starting around the periumbilical region. - While it causes severe itching, the key feature of **blisters** is absent in the patient's presentation, and liver involvement is not a primary feature. *Acute fatty liver of pregnancy* - This is a severe, life-threatening condition presenting with nausea, vomiting, abdominal pain, jaundice, and often **hypoglycemia** and **hepatic encephalopathy**. - While LFTs are abnormal and jaundice may cause itching, the primary symptom is not isolated pruritus without a rash, and the overall clinical picture is much more severe.

Q: A 25-year-old woman presents with a history of recurrent miscarriages. Blood tests reveal elevated anticardiolipin antibodies. What is the best treatment approach to prevent further pregnancy complications?

Daily aspirin and low-molecular-weight heparin. ***Daily aspirin and low-molecular-weight heparin*** - **Anticardiolipin antibodies** are associated with **antiphospholipid syndrome (APS)**, which causes recurrent miscarriages due to thrombosis in the placental circulation. - The combination of **low-dose aspirin** and **low-molecular-weight heparin (LMWH)** is the standard of care for pregnant women with APS to prevent thrombotic events and improve live birth rates. *Methotrexate therapy* - **Methotrexate** is an immunosuppressant and anti-proliferative agent, primarily used in conditions like **rheumatoid arthritis** or certain cancers. - It is **contraindicated in pregnancy** due to its teratogenic effects and would not prevent miscarriages in APS; instead, it would cause fetal harm. *Intravenous immunoglobulin* - **Intravenous immunoglobulin (IVIG)** is a therapy used for certain autoimmune conditions or immunodeficiencies. - While it has been explored for recurrent pregnancy loss in some autoimmune contexts, it is **not the first-line or standard treatment** for APS-related recurrent miscarriages, which primarily benefit from antithrombotic therapy. *Steroid pulse therapy* - **Steroid pulse therapy** involves high doses of corticosteroids over a short period and is typically used for severe flares of autoimmune diseases. - There is **no evidence** to support its effectiveness as a primary treatment for preventing recurrent miscarriages in **antiphospholipid syndrome**, and it carries significant side effects.

Q: The image shows different types of placenta in relation to the internal cervical os. Identify the type of placenta previa shown in the highlighted/marked image.

Type II (marginal).. ***Type II (marginal)*** - In **marginal placenta previa**, the placenta reaches the **edge of the internal cervical os** but does not cover it. - This is classified as a minor placenta previa, as depicted in the provided image. *Type I (low-lying)* - A **low-lying placenta** is when the placental edge is within **2 cm of the internal cervical os** but does not reach it. - The image for low-lying placenta shows the edge 1-20 mm from the os, not directly at the edge as in marginal. *Type III (partial)* - **Partial placenta previa** occurs when the placenta **partially covers the internal cervical os**. - The image labeled "Partial placenta previa" illustrates the placenta covering only a portion of the os, which is a major previa. *Type IV (complete)* - **Complete placenta previa** involves the placenta **completely covering the internal cervical os**. - The image labeled "Complete placenta previa" clearly shows the placenta entirely obstructing the os, which is a major previa.

Q: Which drug regimen is given to a pregnant woman with HIV infection?

All of the options. ***All of the options*** - All listed regimens—**Tenofovir disoproxil fumarate (TDF) with emtricitabine (FTC)**, **TDF with lamivudine (3TC)**, and **Abacavir (ABC) with lamivudine (3TC)**—are commonly used and generally safe combinations of **nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)** in pregnant women with HIV. - The choice of regimen depends on factors such as individual patient characteristics, viral resistance patterns, and potential side effects, but all mentioned regimens are considered **first-line options** in various guidelines for preventing mother-to-child transmission (PMTCT). *Tenofovir disoproxil fumarate with emtricitabine* - This combination is a common and effective **NRTI backbone** for HIV treatment, including in pregnancy, offering good efficacy and a generally favorable safety profile. - It is frequently paired with a third agent (e.g., a **non-nucleoside reverse transcriptase inhibitor (NNRTI)** or an **integrase strand transfer inhibitor (INSTI)**) as part of a highly active antiretroviral therapy (HAART) regimen. *Tenofovir disoproxil fumarate with lamivudine* - This is another widely used and effective **NRTI combination** and is also a recommended backbone for pregnant women with HIV. - While similar to TDF/FTC, some guidelines might prefer one over the other based on specific regional recommendations or drug availability. *Abacavir with lamivudine* - **Abacavir/lamivudine** is a well-established NRTI combination that is safe and effective in pregnancy, provided the mother is **HLA-B*5701 negative** to avoid hypersensitivity reactions. - It is considered a suitable alternative to TDF-containing regimens, especially when there are contraindications or intolerances to TDF.

Question 1

A pregnant woman presents with symptoms consistent with Zika virus infection, and ultrasound reveals fetal abnormalities. What is the most appropriate course of action?

Accepted Answer

Perform amniocentesis to test for Zika virus RNA

Answer

Terminate the pregnancy

Answer

Initiate antiviral therapy immediately

Answer

Wait for further development and re-evaluate

Question 2

Identify the most common risk factor for ectopic pregnancy.

Accepted Answer

History of pelvic inflammatory disease

Answer

Previous ectopic pregnancy

Answer

Use of intrauterine devices

Answer

Advanced maternal age

Question 3

A 35-year-old woman with a history of preterm labor at 32 weeks presents at 24 weeks with signs of preterm labor. Which treatment is recommended to prevent recurrence?

Accepted Answer

Progesterone supplementation

Answer

Corticosteroids

Answer

Magnesium sulfate

Answer

Cerclage

Question 4

A 28-year-old woman at 32 weeks of gestation presents with vaginal bleeding and no pain. Ultrasound shows placenta previa. What is the initial management?

Accepted Answer

Expectant management

Answer

Immediate delivery

Answer

Magnesium sulfate

Answer

Corticosteroids

Question 5

What is the most appropriate management for a fetus diagnosed with non-immune hydrops due to fetal anemia?

Accepted Answer

Intrauterine transfusion

Answer

Immediate delivery

Answer

Corticosteroid administration

Answer

Observation and serial ultrasounds

Question 6

A 28-year-old primigravida at 38 weeks of gestation presents with intense itching, particularly on the palms and soles, without a rash. Liver function tests reveal abnormalities. What is the most likely diagnosis?

Accepted Answer

Intrahepatic cholestasis of pregnancy

Answer

Pruritic urticarial papules and plaques of pregnancy (PUPPP)

Answer

Pemphigoid gestationis

Answer

Acute fatty liver of pregnancy

Question 7

A 25-year-old woman presents with a history of recurrent miscarriages. Blood tests reveal elevated anticardiolipin antibodies. What is the best treatment approach to prevent further pregnancy complications?

Accepted Answer

Daily aspirin and low-molecular-weight heparin

Answer

Methotrexate therapy

Answer

Intravenous immunoglobulin

Answer

Steroid pulse therapy

Question 8

The image shows different types of placenta in relation to the internal cervical os. Identify the type of placenta previa shown in the highlighted/marked image.

Accepted Answer

Type II (marginal).

Answer

Type I (low-lying).

Answer

Type III (partial).

Answer

Type IV (complete).

Question 9

A 22-year-old primigravida visits ANC OPD with 20 weeks POG. On examination uterine height reveals a 16-week size. USG shows reduced liquor. What will be the diagnosis?

Accepted Answer

Intrauterine growth restriction (IUGR)

Answer

Premature rupture of membranes (PROM)

Answer

Congenital absence of one or both kidneys

Answer

Polycystic kidney disease

Question 10

Which drug regimen is given to a pregnant woman with HIV infection?

Accepted Answer

All of the options

Answer

Tenofovir disoproxil fumarate with emtricitabine

Answer

Tenofovir disoproxil fumarate with lamivudine

Answer

Abacavir with lamivudine

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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