Maternal-Fetal Medicine Practice Questions

Q: A 30-year-old woman is 14 weeks pregnant and has a history of two painless deliveries at 16 weeks. What is the next line of management?

Cervical length assessment. ***Cervical length assessment*** - With a history of **two painless preterm deliveries at 16 weeks**, the patient is at high risk for **cervical insufficiency** (incompetent cervix). - While this history may warrant **history-indicated cerclage**, many current protocols recommend **cervical length assessment** via transvaginal ultrasound as the next step to objectively evaluate cervical status and guide management decisions. - An **ultrasound-indicated approach** allows for selective cerclage placement if cervical shortening is documented, avoiding unnecessary procedures in some cases. - Cervical length <25 mm before 24 weeks indicates need for intervention. *Cervical encerclage* - **Prophylactic cerclage** (history-indicated) is an evidence-based option for women with ≥2 prior spontaneous second-trimester losses, and can be placed at 12-14 weeks. - However, the **ultrasound-indicated approach** (assess first, then place cerclage if indicated) is also widely accepted and may prevent unnecessary cerclage in patients with adequate cervical length. - Both approaches are supported by evidence; the question favors assessment first. *Evaluation for diabetes mellitus and thyroid disorders* - While **diabetes mellitus** and **thyroid disorders** can contribute to pregnancy complications, they are not the primary cause of recurrent **painless mid-trimester losses**. - The clinical presentation strongly suggests **cervical insufficiency**, which requires specific cervical evaluation and management. - Medical screening is not the most immediate priority in this scenario. *Tocolytics* - **Tocolytics** are used to suppress **preterm labor contractions**. - This patient's history of **painless deliveries** indicates cervical insufficiency rather than preterm labor with contractions, making tocolytics inappropriate for prevention.

Q: At what weeks of gestation does the second wave of trophoblastic invasion occur?

12-15 weeks. ***12-15 weeks*** - The **second wave of trophoblastic invasion** is a crucial event for proper placental development, occurring between **12 and 15 weeks of gestation**. - During this phase, **cytotrophoblast cells** invade the **spiral arteries** in the decidua and inner myometrium, replacing the smooth muscle and elastic tissue with fibrinoid material. *8-11 weeks* - This period primarily encompasses the **first wave of trophoblastic invasion**, where **cytotrophoblast cells** invade the decidual segments of the spiral arteries. - Inadequate first-wave invasion is associated with early pregnancy complications, but the full second wave has not yet occurred. *10-12 weeks* - While this period overlaps with the later part of the first wave and the very beginning of the second, it is not the primary window for the **complete second wave of trophoblastic invasion**. - The most significant remodelling of the deeper spiral arteries occurs slightly later in gestation. *16-20 weeks* - By this gestational stage, the **second wave of trophoblastic invasion** should have largely been completed, and the placental circulation is well-established. - Inadequate remodelling of the spiral arteries by this point is strongly associated with later pregnancy complications like **preeclampsia** and **intrauterine growth restriction (IUGR)**.

Q: Which of the following is NOT an indication for the administration of Betamethasone to preterm patients?

Prevent postpartum hemorrhage (PPH). ***Prevent postpartum hemorrhage (PPH)*** - **Betamethasone** is a **corticosteroid** primarily used in preterm labor to accelerate fetal lung development and reduce the risk of neonatal complications, not to prevent **postpartum hemorrhage**. - **Postpartum hemorrhage (PPH)** is typically managed with uterine massage, oxytocics (e.g., oxytocin, methylergonovine), or other interventions aimed at uterine contraction and hemostasis. *Fetal lung maturity* - **Betamethasone** is widely administered to pregnant individuals at risk of preterm delivery to promote **fetal lung maturation** by stimulating surfactant production. - This reduces the incidence and severity of **respiratory distress syndrome (RDS)** in premature infants. *Prevents periventricular leukomalacia* - **Antenatal corticosteroids** like **betamethasone** have been shown to reduce the risk of **periventricular leukomalacia (PVL)**, a form of brain injury in preterm infants. - This protective effect is thought to be mediated by improving fetal cerebral vascular stability and reducing inflammation. *Decrease intraventricular hemorrhage* - Administration of **betamethasone** significantly reduces the risk and severity of **intraventricular hemorrhage (IVH)** in preterm neonates. - This benefit is primarily due to the stabilization of cerebral vasculature and reduced fluctuations in cerebral blood flow.

Q: Which of the following is a complication of pre-eclampsia?

Eclampsia. ***Eclampsia*** - **Eclampsia** is defined as the occurrence of **generalized tonic-clonic seizures** in a woman with pre-eclampsia that cannot be attributed to other causes - It represents the **direct neurological progression** of pre-eclampsia and is the **most characteristic complication** - Eclampsia occurs in approximately **1-2%** of women with pre-eclampsia and is a **life-threatening emergency** - The seizures result from cerebral vasospasm, edema, and ischemia associated with the hypertensive disorder *HELLP syndrome* - **HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets)** is indeed a **recognized complication** of pre-eclampsia, occurring in **10-20% of severe cases** - However, HELLP represents a **specific multiorgan manifestation** involving hepatic dysfunction and hematological abnormalities, rather than the classic progression pathway - While both are serious complications, **eclampsia** is considered the **prototypical complication** that defines disease progression from pre-eclampsia - HELLP can occur with or without the full clinical picture of severe pre-eclampsia *Postdatism* - **Postdatism** (post-term pregnancy) refers to pregnancy extending beyond **42 weeks of gestation** - This is **completely unrelated** to pre-eclampsia, which is a hypertensive disorder of pregnancy - Pre-eclampsia typically occurs in the **third trimester** and is actually an indication for **delivery**, not prolonged pregnancy *Disseminated Intravascular Coagulation (DIC)* - **DIC** is a severe coagulopathy involving widespread activation of clotting cascades - While DIC can complicate severe pre-eclampsia, it is **not a primary or direct complication** - DIC more commonly develops as a consequence of **eclampsia, HELLP syndrome, placental abruption**, or other severe obstetric emergencies - It represents a **secondary complication** rather than a direct progression of pre-eclampsia itself

Q: Which of the following procedures is associated with the least risk of feto-maternal hemorrhage?

Amniocentesis. ***Amniocentesis*** - This procedure involves sampling **amniotic fluid**, which is primarily fetal urine and cells, not directly blood. - The needle typically avoids the placenta and fetal vessels, making **feto-maternal hemorrhage less likely** compared to procedures directly accessing fetal blood or placental tissue. - Risk of FMH is approximately **1-2%**, the lowest among invasive prenatal procedures. *Cordocentesis* - This procedure involves direct **percutaneous umbilical blood sampling** from the umbilical cord. - Due to direct needle puncture of fetal blood vessels, the potential for **feto-maternal hemorrhage is 40-50%**. - Highest risk among diagnostic procedures listed. *Chorionic villus sampling* - This procedure involves taking a sample of the **placenta** (chorionic villi), which contains fetal cells and is rich in blood vessels. - Disrupting the placental-uterine interface can lead to **feto-maternal hemorrhage in 10-15%** of cases. - Higher risk than amniocentesis due to placental manipulation. *External cephalic version* - This procedure involves **manual manipulation** of the fetus through the maternal abdomen to convert breech to cephalic presentation. - The mechanical pressure and manipulation can cause **placental separation or disruption**, leading to FMH in approximately **2-6%** of cases. - Risk is higher than amniocentesis due to physical manipulation of the gravid uterus.

Q: Which of the following conditions is NOT contraindicated in pregnancy?

WPW syndrome. **WPW syndrome** - **Wolff-Parkinson-White (WPW) syndrome** is a condition involving an extra electrical pathway in the heart, leading to episodes of rapid heart rate. - While it can cause arrhythmias, severe complications in pregnancy are rare, and it is generally *not* considered an absolute contraindication for pregnancy. *Primary Pulmonary Hypertension* - **Primary Pulmonary Hypertension (PPH)** carries a very high maternal mortality rate (25-50%) due to the physiological changes of pregnancy on the cardiovascular system. - The increased blood volume and cardiac output in pregnancy can lead to severe decompensation and right heart failure in women with PPH. *Eisenmenger's syndrome* - **Eisenmenger's syndrome** is a severe form of pulmonary hypertension with a right-to-left shunt, associated with an extremely high maternal mortality rate (30-50%). - Pregnancy significantly increases the risk of **pulmonary hypertensive crisis**, right heart failure, and thromboembolic events, making it highly contraindicated. *Marfan's with aortic root dilation* - **Marfan's syndrome** with **aortic root dilation** is a significant contraindication due to the high risk of **aortic dissection** and rupture. - The hemodynamic stress of pregnancy, including increased blood volume and cardiac output, places immense strain on the dilated aorta, increasing the risk of life-threatening events.

Q: Earliest sign after IUFD is ?

Gas in great vessel. ***Gas in great vessel*** - The presence of **intravascular gas** (often in the heart or great vessels) is considered the **earliest reliable sonographic sign of fetal death**, appearing within 1-2 hours after demise. - This gas is thought to result from post-mortem **autolysis** and bacterial activity. *Overlapping of skull bones* - Known as **Spalding's sign**, this indicates skull bone collapse due to liquefaction of brain tissue and typically appears **several days (3-7 days)** after fetal demise. - It reflects a more advanced stage of fetal decomposition rather than an immediate post-mortem change. *Hyperflexion of spine* - This sign, along with abnormal fetal posture, can be seen with fetal demise but is generally evident **later than intravascular gas**, as fetal muscle tone diminishes. - It is a less specific and later indicator compared to intravascular gas. *Overcrowding of ribs* - This is an inconsistent and non-specific finding that may be observed in IUFD but does not serve as an **early diagnostic marker**. - It generally reflects changes in fetal soft tissue and skeletal structures due to maceration, occurring much later.

Q: In the context of fetal hypoxia, which parameter of the Biophysical Profile (BPP) is typically affected last?

Fetal tone. ***Fetal tone*** - **Fetal tone** is the last biophysical parameter to be affected by worsening fetal hypoxia as it is controlled by the **lower brainstem and spinal cord**, which are the most primitive centers and spared until late decompensation. - This parameter requires significant and prolonged oxygen deprivation to be compromised, indicating severe fetal compromise. *Fetal breathing movements* - **Fetal breathing movements** are affected relatively early in fetal hypoxia, as they are controlled by the **upper brainstem (pons)** and thus more sensitive to oxygen deprivation. - Absence or decreased frequency of these movements can be an early sign of impending hypoxia. *Fetal movements* - **Gross fetal body movements** are also affected early by oxygen deprivation, as they are controlled by the fetal **cerebral cortex** and subcortical centers. - A reduction in fetal movements often signifies the fetus is conserving energy due to oxygen scarcity. *Non-stress test (NST)* - The **non-stress test (NST)**, which assesses **fetal heart rate accelerations** in response to movement, is typically the *first* parameter to be affected by hypoxia. - Loss of fetal heart rate accelerations occurs early because the **autonomic nervous system and cortical centers**, which control these responses, are highly sensitive to reduced oxygen levels.

Q: With reference to fetal heart rate, a nonstress test is considered reactive when?

Two fetal heart rate accelerations are noted in 20 minutes. **Two fetal heart rate accelerations are noted in 20 minutes** - A **nonstress test (NST)** is considered reactive when there are at least two accelerations of the fetal heart rate within a 20-minute period. - An **acceleration** is defined as an increase in fetal heart rate of at least 15 beats per minute above baseline, lasting for at least 15 seconds (for gestations ≥32 weeks). - This is the **standard definition** of a reactive NST and indicates adequate fetal well-being. *One fetal heart rate acceleration is noted in 20 minutes* - While an acceleration is a positive sign, a **reactive NST** specifically requires at least two accelerations within the 20-minute timeframe. - A single acceleration within 20 minutes would render the NST **non-reactive**, requiring further evaluation or extended monitoring up to 40 minutes. *Two fetal heart rate accelerations are noted in 10 minutes* - While two accelerations occurring in 10 minutes is clinically reassuring and technically occurs within 20 minutes, the **standard definition** for reporting NST reactivity specifically states "two or more accelerations **in** 20 minutes." - The 20-minute observation period is the established timeframe for NST assessment, not 10 minutes. - This option tests knowledge of the precise standard criteria rather than clinical interpretation. *Three fetal heart rate accelerations are noted in 30 minutes* - The standard definition for a **reactive NST** requires assessment within a **20-minute window**, not 30 minutes. - While three accelerations indicate fetal well-being, this exceeds the standard observation period and does not meet the formal definition of a reactive NST within the specified timeframe. - An NST is typically extended to 40 minutes if non-reactive at 20 minutes, but the definition of reactivity remains based on the 20-minute criterion.

Question 1

A 30-year-old woman is 14 weeks pregnant and has a history of two painless deliveries at 16 weeks. What is the next line of management?

Accepted Answer

Cervical length assessment

Answer

Cervical encerclage

Answer

Evaluation for diabetes mellitus and thyroid disorders

Answer

Tocolytics

Question 2

At what weeks of gestation does the second wave of trophoblastic invasion occur?

Accepted Answer

12-15 weeks

Answer

10-12 weeks

Answer

16-20 weeks

Answer

8-11 weeks

Question 3

Which of the following is NOT an indication for the administration of Betamethasone to preterm patients?

Accepted Answer

Prevent postpartum hemorrhage (PPH)

Answer

Prevents periventricular leukomalacia

Answer

Fetal lung maturity

Answer

Decrease intraventricular hemorrhage

Question 4

Which of the following is a complication of pre-eclampsia?

Accepted Answer

Eclampsia

Answer

HELLP syndrome

Answer

Postdatism

Answer

Disseminated Intravascular Coagulation (DIC)

Question 5

Which of the following procedures is associated with the least risk of feto-maternal hemorrhage?

Accepted Answer

Amniocentesis

Answer

Chorionic villus sampling

Answer

External cephalic version

Answer

Cordocentesis

Question 6

Which of the following conditions is NOT contraindicated in pregnancy?

Accepted Answer

WPW syndrome

Answer

Marfan's with aortic root dilation

Answer

Primary Pulmonary Hypertension

Answer

Eisenmenger's syndrome

Question 7

Earliest sign after IUFD is ?

Accepted Answer

Gas in great vessel

Answer

Hyperflexion of spine

Answer

Overlapping of skull bones

Answer

Overcrowding of ribs

Question 8

In the context of fetal hypoxia, which parameter of the Biophysical Profile (BPP) is typically affected last?

Accepted Answer

Fetal tone

Answer

Fetal breathing movements

Answer

Fetal movements

Answer

Non-stress test (NST)

Question 9

Which of the following is the BEST management principle regarding abdominal pregnancy?

Accepted Answer

The placenta can be left in situ at the time of surgery.

Answer

Fetal survival rate approaches 80% with modern care.

Answer

The placenta should always be removed to prevent infection.

Answer

Gastrointestinal symptoms are typically mild and resolve spontaneously.

Question 10

With reference to fetal heart rate, a nonstress test is considered reactive when?

Accepted Answer

Two fetal heart rate accelerations are noted in 20 minutes

Answer

One fetal heart rate acceleration is noted in 20 minutes

Answer

Two fetal heart rate accelerations are noted in 10 minutes

Answer

Three fetal heart rate accelerations are noted in 30 minutes

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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