Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 1181: In the context of fetal hypoxia, which parameter of the Biophysical Profile (BPP) is typically affected last?

A. Fetal tone (Correct Answer)
B. Fetal breathing movements
C. Fetal movements
D. Non-stress test (NST)

Explanation: ***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.

Question 1182: Which of the following statements about cardiovascular changes during pregnancy is true?

A. Increase in left ventricular end diastolic diameter (Correct Answer)
B. None of the options are true
C. Cardiac output decreases during pregnancy
D. Pregnancy causes right axis deviation

Explanation: ***Increase in left ventricular end diastolic diameter*** - Pregnancy leads to a significant increase in **blood volume** (up to 50% by the third trimester), which directly increases **venous return** to the heart. - This increased preload stretches the left ventricle, causing an increase in its **end-diastolic dimension** and volume to accommodate the larger blood volume. *Cardiac output decreases during pregnancy* - **Cardiac output actually increases** significantly during pregnancy, by 30-50%, reaching its peak in the second trimester and remaining high until delivery. - This increase is necessary to meet the metabolic demands of the growing fetus and uteroplacental unit, and is primarily driven by an increase in **stroke volume** and **heart rate**. *Pregnancy causes right axis deviation* - Pregnancy typically causes a **leftward shift of the cardiac axis**, leading to **left axis deviation** (or a more horizontal axis) on an electrocardiogram. - This is due to the elevation of the diaphragm by the gravid uterus, which pushes the heart superiorly and to the left. *None of the options are true* - This statement is incorrect because the increase in **left ventricular end-diastolic diameter** during pregnancy is a well-established physiological change. - The other two options are false, but there is a correct statement among the choices.

Question 1183: Which of the following is a complication of pre-eclampsia?

A. Eclampsia (Correct Answer)
B. HELLP syndrome
C. Postdatism
D. Disseminated Intravascular Coagulation (DIC)

Explanation: ***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

Question 1184: At what weeks of gestation does the second wave of trophoblastic invasion occur?

A. 10-12 weeks
B. 16-20 weeks
C. 8-11 weeks
D. 12-15 weeks (Correct Answer)

Explanation: ***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)**.

Question 1185: Earliest sign after IUFD is ?

A. Hyperflexion of spine
B. Overlapping of skull bones
C. Overcrowding of ribs
D. Gas in great vessel (Correct Answer)

Explanation: ***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.

Question 1186: Most common organism grown in urine culture of a pregnant woman with asymptomatic bacteriuria?

A. E. coli (Correct Answer)
B. Staph aureus
C. Pseudomonas
D. Proteus

Explanation: ***E. coli*** - **_E. coli_** is the most prevalent uropathogen due to its ability to adhere to uroepithelial cells and its common presence in the perianal flora. - It accounts for approximately **80% of all community-acquired urinary tract infections (UTIs)**, including asymptomatic bacteriuria in pregnant women. *Staph aureus* - **_Staphylococcus aureus_** is an uncommon cause of UTIs and is typically associated with **hematogenous spread** in cases of bacteremia. - It is rarely isolated in asymptomatic bacteriuria and would raise suspicion for a systemic infection if found in urine. *Pseudomonas* - **_Pseudomonas aeruginosa_** is generally associated with **nosocomial infections**, catheter-associated UTIs, or patients with structural urinary tract abnormalities or prolonged antibiotic use. - It is not a common cause of asymptomatic bacteriuria in otherwise healthy pregnant women. *Proteus* - **_Proteus_ species**, particularly **_Proteus mirabilis_**, are known for their ability to produce **urease**, which can lead to alkaline urine and the formation of struvite stones. - While they can cause UTIs, they are less common than _E. coli_ in asymptomatic bacteriuria in pregnant women.

Question 1187: What is the earliest sign of fetal death?

A. Adipocere formation
B. Absence of fetal movements
C. Spalding sign
D. Absence of fetal heart sounds (Correct Answer)

Explanation: ***Absence of fetal heart sounds*** - **Absence of fetal heart sounds** detected by **Doppler ultrasound** or **real-time ultrasound** is the **earliest and most definitive sign** of fetal death. - Cardiac activity ceases **immediately at the moment of fetal demise**, making this the **primary diagnostic criterion** for intrauterine fetal death. - **Ultrasound showing absent cardiac activity** is the gold standard for confirming fetal death and can detect it within minutes to hours. *Absence of fetal movements* - Absence of fetal movements is often the **first maternal perception** of potential fetal demise, typically noticed within hours to days. - However, it is **subjective and non-specific**, as fetal movements can naturally decrease during sleep cycles or may be less perceptible in some pregnancies. - While important for prompting further evaluation, it is not as definitive as absent cardiac activity on ultrasound. *Spalding sign* - The **Spalding sign** (overlapping of fetal skull bones) is a **late radiological sign** of fetal death that appears **1-2 weeks post-mortem**. - It occurs due to **brain liquefaction and decomposition**, causing collapse of the cranial vault and overlapping of skull sutures. - This is a **confirmatory sign of prolonged fetal demise**, not an early indicator. *Adipocere formation* - **Adipocere formation** (saponification of soft tissues) is a **very late post-mortem change** occurring **weeks to months** after death. - It represents advanced decomposition in a moist environment and is rarely seen in modern obstetric practice due to early detection and intervention. - This is the latest sign among all the options listed.

Question 1188: According to limited observational studies, in cases where fetal movement has significantly decreased, approximately how long may elapse before fetal heart rate cessation occurs?

A. 1 hr
B. 2 hrs
C. 6 hrs
D. 12 hrs (Correct Answer)

Explanation: ***Correct: 12 hrs*** - Limited observational studies suggest that in cases of significantly decreased fetal movement, **fetal heart rate cessation** may occur approximately **12 hours** later. - This timeframe highlights the urgency of investigating decreased fetal movement to prevent **fetal demise**. - This observation forms the basis for clinical recommendations to evaluate decreased fetal movement **urgently within 12-24 hours**. *Incorrect: 1 hr* - This is generally too short a period; **fetal heart rate cessation** typically does not occur within 1 hour of decreased fetal movement. - While immediate evaluation is crucial for decreased fetal movement, **perinatal outcomes** are rarely impacted this quickly unless direct acute events occur (e.g., placental abruption, cord accident). *Incorrect: 2 hrs* - While **fetal compromise** can occur rapidly, 2 hours is often too short for complete **fetal heart rate cessation** after only decreased movement. - This timeframe still allows for potential **intervention** if the cause of decreased movement is identified quickly. *Incorrect: 6 hrs* - Although more plausible than 1 or 2 hours, 6 hours is still generally considered too short for **fetal cardiac arrest** after significantly decreased movement based on observational data. - Urgent evaluation is still recommended within this window to avoid **adverse fetal outcomes**.

Question 1189: What is the lower end of the estimated risk of recurrence of anencephaly in subsequent pregnancies?

A. 2% (Correct Answer)
B. 4%
C. 1%
D. 3%

Explanation: ***2%*** - The estimated risk of recurrence for anencephaly in subsequent pregnancies ranges from 2% to 5%. - This 2% represents the **lower end** of the typical recurrence risk for anencephaly, a severe **neural tube defect (NTD)**. *1%* - A 1% recurrence risk is generally considered too low for a previous NTD such as anencephaly. - While it's lower than the recurrence risk for the general population (0.1%), it's still below the consensus range for a subsequent pregnancy. *4%* - A 4% recurrence risk falls within the accepted range (2-5%) and represents a **higher end** estimate. - This value would be plausible for the recurrence risk, but the question specifically asks for the *lower end*. *3%* - A 3% recurrence risk falls within the accepted range (2-5%) but is not the **lower end** of that range. - While a clinically relevant risk, it is not the minimum value requested in the question.

Question 1190: Which of the following statements is false regarding the management of intrauterine fetal death?

A. In 50% of cases spontaneous expulsion occurs in 2 weeks
B. Fibrinogen levels should be checked weekly (Correct Answer)
C. Delivery by medical induction is preferred if spontaneous expulsion does not occur
D. Caesarian section has limited place in management of intrauterine fetal death

Explanation: ***Fibrinogen levels should be checked weekly*** - This statement is considered **false** or **questionable** in the context of routine IUFD management. - While coagulation monitoring is important, **routine weekly fibrinogen checks** are not universally recommended for all cases of IUFD. - The risk of **consumptive coagulopathy (DIC)** becomes significant only after **3-4 weeks** of retaining a dead fetus. - Most guidelines recommend coagulation screening at diagnosis and then **periodic monitoring** if conservative management extends beyond 2-3 weeks, rather than mandatory weekly checks from the outset. - The frequency depends on clinical circumstances, gestational age, and institutional protocols. *In 50% of cases spontaneous expulsion occurs in 2 weeks* - This statement is **true**. Approximately **50-80%** of women will spontaneously go into labor within **2-3 weeks** after IUFD. - Most women prefer to await spontaneous labor initially, but medical induction is offered if this does not occur within a reasonable timeframe. *Delivery by medical induction is preferred if spontaneous expulsion does not occur* - This statement is **true**. **Medical induction of labor** is the preferred management when spontaneous expulsion does not occur. - Common induction agents include **misoprostol**, **mifepristone + misoprostol**, or **prostaglandin E2**. - Early delivery (within 1-2 weeks) minimizes maternal psychological distress and reduces the risk of coagulopathy. *Caesarian section has limited place in management of intrauterine fetal death* - This statement is **true**. **Cesarean delivery** is generally **avoided** in IUFD management because it carries maternal surgical risks without fetal benefit. - Vaginal delivery is preferred whenever possible. - C-section is reserved only for specific **obstetric indications** such as **placenta previa**, **previous classical cesarean scar**, or other contraindications to labor that exist regardless of fetal status.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

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Intrauterine Growth Restriction

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Multiple Gestation

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Rh Isoimmunization and Other Blood Group Incompatibilities

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Intrauterine Fetal Therapy

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Prenatal Diagnosis and Genetic Counseling

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Placental Abnormalities

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Preterm Labor and Delivery

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Management of Medical Disorders in Pregnancy

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