Maternal-Fetal Medicine Practice Questions

Q: Which of the following statements about MgSO4 is false?

Not used as antihypertensive. ***Not used as antihypertensive*** - This statement is **false** because **Magnesium sulfate (MgSO4)** is indeed used for its **antihypertensive** properties, especially in obstetric emergencies like **preeclampsia** and **eclampsia**, where it helps lower blood pressure. - While its primary role in these conditions is seizure prevention, its **vasodilatory effects** contribute to blood pressure reduction. *Deep tendon reflexes are monitored for toxicity* - This statement is **true**. The primary sign of impending **Magnesium sulfate toxicity** is the **loss of deep tendon reflexes**, particularly the patellar reflex. - Monitoring reflexes is crucial for safe administration and to prevent serious complications like **respiratory depression**. *It acts as a membrane stabilizer and neuroprotector* - This statement is **true**. MgSO4 is thought to exert its **anticonvulsant** effect by acting as a **membrane stabilizer** and a **neuroprotector**. - It reduces neuronal excitability, blocks glutamate receptors, and antagonizes calcium influx, thereby protecting brain cells from damage. *Duration of therapy may differ between eclampsia and preeclampsia* - This statement is **true**. The **loading dose** (4-6g IV) and **maintenance dose** (1-2g/hr) of MgSO4 are typically the same for both conditions. - However, the **duration of therapy** differs based on clinical presentation: eclampsia treatment requires continuation for 24 hours after the last seizure, while preeclampsia may require shorter durations. - Eclampsia may also necessitate longer monitoring to prevent recurrent seizures.

Q: What is the most common cause of death in babies with vasa previa?

Fetal exsanguination. ***Fetal exsanguination*** - In vasa previa, unprotected fetal blood vessels course directly over the **internal cervical os**. When the membranes rupture, these vessels are at high risk of tearing, leading to **rapid fetal blood loss**. - This acute hemorrhage results in **fetal exsanguination**, causing severe **anemia**, **hypoxia**, and ultimately **death** if not immediately identified and managed. *Infection* - While infection can arise in obstetric complications, it is **not the primary or most common cause of death** specifically associated with vasa previa. - The immediate and life-threatening danger in vasa previa is **acute blood loss**, not microbial invasion. *Maternal exsanguination* - Vasa previa primarily involves **fetal blood vessels** in the membranes, not maternal uterine vessels. - Therefore, the blood loss that occurs is almost exclusively fetal, and **maternal exsanguination is not a direct complication** of vasa previa. *Both maternal and fetal exsanguination* - As explained, vasa previa specifically endangers the fetus due to the exposed **fetal blood vessels**. - While fetal exsanguination is the critical event, **maternal exsanguination does not occur** as a direct result of vasa previa.

Q: What is the most common condition associated with a single umbilical artery?

Congenital heart disease. ***Congenital heart disease*** - Among major structural anomalies associated with a single umbilical artery (SUA), **congenital heart disease** is one of the most significant, occurring in approximately **15-20% of cases**. - Common cardiac defects include **ventricular septal defects (VSD)**, **atrial septal defects (ASD)**, and **coarctation of the aorta**. - SUA detected on prenatal ultrasound warrants **detailed fetal echocardiography** to rule out cardiac anomalies. - **Clinical significance**: Isolated SUA (without other anomalies) generally has a good prognosis, but cardiac evaluation is essential. *Neural tube defects (NTD)* - Neural tube defects are **not commonly associated** with single umbilical artery. - NTDs (such as spina bifida and anencephaly) are primarily linked to **folate deficiency** and have different screening markers including **elevated AFP** and direct ultrasound visualization. - The pathophysiology of NTDs is distinct from the vascular anomaly of SUA. *Fetal hydrops* - **Fetal hydrops** is a severe condition characterized by abnormal fluid accumulation in ≥2 fetal compartments (ascites, pleural effusion, pericardial effusion, skin edema). - While severe cardiac defects can lead to hydrops, **hydrops is not directly associated with SUA** as a primary finding. - Hydrops has multiple causes including severe anemia, cardiac failure, infections (TORCH), and chromosomal abnormalities. *Intrauterine fetal demise* - **IUFD is an adverse outcome**, not a congenital condition associated with SUA. - Isolated SUA has a **good prognosis** with only slightly increased perinatal risks when no other anomalies are present. - Risk of IUFD is elevated when SUA occurs with **multiple congenital anomalies** or **chromosomal abnormalities**, but IUFD itself is not the "condition associated with" SUA.

Q: Risk period for maximum fetal damage due to congenital rubella infection?

First trimester of pregnancy. ***First trimester of pregnancy*** - The **organogenesis** phase occurs predominantly in the first trimester, making the developing fetus highly vulnerable to teratogens like the **rubella virus**. - Infection during this period (especially **weeks 1-12**) leads to the highest incidence and most severe forms of **congenital rubella syndrome (CRS)**, affecting major organs such as the heart, eyes, and brain. *Second trimester of pregnancy* - While fetal infection can still occur, the risk of severe congenital anomalies significantly decreases as most major organs have already formed. - Infections in the second trimester are more likely to result in **fetal growth restriction** or later-onset defects rather than the classic CRS triad. *Third trimester of pregnancy* - Infection during the third trimester typically carries a very low risk of congenital malformations. - The primary concern during this period is **perinatal transmission** leading to neonatal infection rather than structural birth defects. *Risk is same throughout the pregnancy* - This statement is incorrect because the vulnerability of the fetus to rubella virus varies greatly depending on the stage of development, with the **first trimester** being the most critical period. - The developing organs in early pregnancy are far more susceptible to damage from viral replication and inflammation.

Q: A patient with juvenile myoclonic epilepsy on valproate comes to you at 5 months of pregnancy with a normal level II scan. What will you advise?

Continue the drug in the same dose. ***Continue the drug in the same dose*** - As the patient is already at **5 months of pregnancy** with a **normal level II scan**, the risk of major congenital malformations has largely passed. - **Maintaining seizure control** is crucial during pregnancy, as uncontrolled seizures pose significant risks to both the mother and fetus. *Change the drug* - Changing an antiepileptic drug during pregnancy, especially in the second trimester, can lead to a **loss of seizure control** and potentially expose the fetus to a new drug with unknown risks. - The period of highest risk for **major congenital malformations** from valproate exposure is during the first trimester. *Decrease the dose of the drug* - Decreasing the dose of valproate could lead to **breakthrough seizures**, which are dangerous for both the mother and the fetus. - **Plasma drug levels** often decrease in pregnancy due to increased volume of distribution and metabolism, potentially requiring a stable or even increased dose to maintain therapeutic levels. *Increase the dose of the drug* - Increasing the dose without clear clinical indication (e.g., breakthrough seizures or subtherapeutic levels) could increase the risk of **dose-dependent side effects** for both mother and fetus. - While therapeutic drug monitoring for valproate is often done in pregnancy, a **normal level II scan** does not automatically warrant a dose increase.

Q: A woman presents to you at 36 weeks of gestation with complaints of breathlessness and excessive abdominal distension. Fetal movements are normal. On examination, fetal parts are not easily felt and fetal heartbeat is heard but it is muffled. Her symphysis fundal height is 41 cm. Her abdomen is tense but not tender. What is the most likely diagnosis?

Polyhydramnios. ***Polyhydramnios*** - The patient's symptoms of **breathlessness**, **excessive abdominal distension**, a **symphysis fundal height of 41 cm at 36 weeks** (indicating a significantly larger than expected uterus), and **muffled fetal heart tones** are classic signs of polyhydramnios. - **Difficulty feeling fetal parts** is also consistent with excess amniotic fluid, which cushions the fetus and makes palpation harder. *Abruptio placenta* - This condition typically presents with sudden onset of **painful vaginal bleeding**, uterine tenderness, and fetal distress, none of which are described here. - While the abdomen might be tense due to uterine contractions or concealed bleeding, the lack of pain and bleeding makes this diagnosis unlikely. *Hydrocephalus of fetus* - Fetal hydrocephalus would primarily manifest as an **abnormally large fetal head** upon ultrasound, potentially leading to a higher fundal height. - However, it wouldn't directly explain the generalized excessive abdominal distension or the difficulty in feeling fetal parts due to fluid, though it could be a cause of polyhydramnios itself, it is not the most likely primary diagnosis from the given options directly addressing the symptoms. *Oligohydramnios* - This condition is characterized by **too little amniotic fluid**, which would result in a **smaller than expected symphysis fundal height** and an easily palpable fetus. - The patient's symptoms, particularly the excessive distension and high fundal height, directly contradict the features of oligohydramnios.

Q: A female presents with 6 weeks of amenorrhea, experiencing vaginal bleeding and slight abdominal pain. A urine pregnancy test is positive, and her hCG level is 2800 IU/L. A mass measuring 3 x 2.5 cm is observed on the left adnexa. She is hemodynamically stable. What is the most appropriate management for this patient?

Single-dose methotrexate injection. ***Single-dose methotrexate injection*** - The patient presents with a **hemodynamically stable ectopic pregnancy**, as suggested by the positive pregnancy test, amenorrhea, vaginal bleeding, abdominal pain, an hCG level of 2800 IU/L, and an adnexal mass. - A single-dose methotrexate injection is the **first-line medical management** for ectopic pregnancies in stable patients, particularly when hCG levels are typically below 5000 IU/L and the mass size is less than 4 cm (or 3.5 cm in some guidelines). *Oral methotrexate* - **Oral methotrexate** is not typically used for the treatment of ectopic pregnancy due to unpredictable absorption and less reliable therapeutic efficacy compared to intramuscular administration. - The **intramuscular route** is preferred to ensure consistent systemic exposure and effectiveness in dissolving the ectopic gestation. *Serial methotrexate + leucovorin rescue* - **Leucovorin rescue** is used to mitigate the adverse effects of high-dose methotrexate, typically in cancer chemotherapy, and is not indicated for the standard treatment of ectopic pregnancy. - Serial doses of methotrexate without leucovorin may be given if the initial single dose fails, but **leucovorin is not part of the standard initial treatment protocol** for ectopic pregnancy. *Salpingectomy* - **Salpingectomy (surgical removal of the fallopian tube)** is indicated for ectopic pregnancies that are **hemodynamically unstable**, ruptured, too large for medical management (e.g., >4 cm), or in cases where medical management with methotrexate fails or is contraindicated. - Since this patient is **hemodynamically stable** and meets the criteria for medical management, surgery is not the most appropriate initial management.

Q: A female patient presents to you with six weeks of amenorrhea, associated with abdominal pain and vaginal bleeding with normal blood pressure. Investigations revealed beta-hCG to be 1400 mIU/mL. An ultrasound scan was done which showed a trilaminar endometrium with normal adnexa. What is the next best step in the management of this patient?

Repeat beta – hCG after 48 hours. ***Repeat beta – hCG after 48 hours*** - With a beta-hCG of 1400 mIU/mL and no intrauterine pregnancy visible on ultrasound, repeating **beta-hCG after 48 hours** is crucial to assess its doubling time, which helps differentiate between a normal intrauterine pregnancy, ectopic pregnancy, or miscarriage. - An hCG level of 1400 mIU/mL is below the discriminatory zone (typically 1500-2000 mIU/mL) where an intrauterine gestational sac should be visible, making serial measurements essential. *Repeat ultrasound after 5 days* - While a repeat ultrasound may eventually be necessary, waiting 5 days without an interim hCG measurement could delay diagnosis and management, especially if the hCG levels are rising rapidly or are in a concerning range. - The current beta-hCG level is below the **discriminatory zone**, meaning a gestational sac would likely still not be visible even after 5 days, making hCG follow-up a more immediate and informative step. *Measurement of serum progesterone* - **Serum progesterone** levels can indicate overall pregnancy viability, but they do not specifically localize the pregnancy or differentiate between an intrauterine pregnancy and an ectopic pregnancy as effectively as serial hCG levels. - A single low progesterone level could indicate a non-viable pregnancy (either intrauterine or ectopic), but it does not guide immediate management for distinguishing between locations. *Laparoscopy* - **Laparoscopy** is an invasive surgical procedure and is not the first diagnostic step unless there are signs of ruptured ectopic pregnancy or hemodynamic instability, which are not present in this patient (normal blood pressure, mild symptoms). - It would be premature to proceed with laparoscopy without further biochemical or sonographic evidence of an ectopic pregnancy or clear signs of clinical deterioration.

Q: A 40 year old G2P1 woman with 18 weeks of amenorrhea comes with a dilated cervix. The cervical length is 15 mm. In spite of explaining the risks, she insisted on cerclage. Which of the following is a contraindication for cervical cerclage?

Ruptured membranes. ***Ruptured membranes*** - **Ruptured membranes** are an **absolute contraindication** to cervical cerclage because the protective barrier against infection is lost. - Placing a cerclage after membrane rupture would trap bacteria within the uterus, leading to serious complications such as **chorioamnionitis** and **sepsis**. - Once membranes rupture, the focus shifts to prevention of infection and preparation for delivery rather than cervical reinforcement. *Prolapse of membranes into the vagina* - This represents a **relative contraindication** rather than an absolute one; cerclage can still be attempted in selected cases with appropriate technique. - While bulging or prolapsed membranes make the procedure more technically challenging and increase risks of membrane rupture, the membranes can sometimes be reduced back before cerclage placement. - This scenario requires careful patient counseling about increased risks, but is not an absolute contraindication if the patient insists and understands the complications. *Advanced maternal age* - **Advanced maternal age** (40 years in this case) is **not a contraindication** for cerclage at all. - The decision for cerclage is based on cervical findings and obstetric history showing cervical insufficiency, not on maternal age. - Age may be a risk factor for other pregnancy complications, but does not preclude cerclage if indicated. *Fetal fibronectin positive* - A **positive fetal fibronectin** test indicates increased risk of preterm labor but is **not a contraindication** to cerclage. - It may prompt closer monitoring or influence timing of intervention, but doesn't rule out cerclage if there's a strong indication based on cervical insufficiency. - Prophylactic or rescue cerclage can still be performed despite positive fetal fibronectin if clinically indicated.

Q: Vertical transmission of HIV is highest with-

High viral RNA load. ***High viral RNA load*** - A **high maternal viral load** (HIV RNA copies per milliliter of blood) is the most significant risk factor for **mother-to-child transmission (MTCT)** of HIV. The higher the viral load, the greater the likelihood of the virus being transmitted to the infant. - This is because a higher viral load indicates more circulating virus that can cross the **placenta** during gestation, be exchanged during labor and delivery, or be transmitted through breast milk. *Elective caesarean section* - An **elective caesarean section (C-section)** is a method used to *reduce* the risk of vertical transmission of HIV, especially when the maternal viral load is high. It *does not increase* the risk. - By avoiding passage through the birth canal, C-section minimizes the infant's exposure to maternal blood and genital secretions. *Breast feeding* - **Breastfeeding** is a known route of vertical HIV transmission and significantly increases the risk compared to formula feeding in HIV-positive mothers who are not on antiretroviral therapy (ART). - However, the overall *highest risk* factor *before* deciding on infant feeding is the *maternal viral load*, which dictates the likelihood of transmission via any route (intrauterine, intrapartum, or postpartum). *Term delivery* - **Term delivery** (vaginal delivery at term) carries a higher risk of vertical HIV transmission compared to an elective C-section, especially in mothers with high viral loads. - However, the *primary determinant* of this risk, even during vaginal delivery, is the **maternal viral load**. A mother with a well-controlled, low viral load at term has a significantly reduced risk of transmission even during vaginal delivery.

Question 1

Which of the following statements about MgSO4 is false?

Accepted Answer

Not used as antihypertensive

Answer

It acts as a membrane stabilizer and neuroprotector

Answer

Deep tendon reflexes are monitored for toxicity

Answer

Duration of therapy may differ between eclampsia and preeclampsia

Question 2

What is the most common cause of death in babies with vasa previa?

Accepted Answer

Fetal exsanguination

Answer

Infection

Answer

Maternal exsanguination

Answer

Both maternal and fetal exsanguination

Question 3

What is the most common condition associated with a single umbilical artery?

Accepted Answer

Congenital heart disease

Answer

Neural tube defects (NTD)

Answer

Fetal hydrops

Answer

Intrauterine fetal demise

Question 4

Risk period for maximum fetal damage due to congenital rubella infection?

Accepted Answer

First trimester of pregnancy

Answer

Second trimester of pregnancy

Answer

Third trimester of pregnancy

Answer

Risk is same throughout the pregnancy

Question 5

A patient with juvenile myoclonic epilepsy on valproate comes to you at 5 months of pregnancy with a normal level II scan. What will you advise?

Accepted Answer

Continue the drug in the same dose

Answer

Increase the dose of the drug

Answer

Change the drug

Answer

Decrease the dose of the drug

Question 6

A woman presents to you at 36 weeks of gestation with complaints of breathlessness and excessive abdominal distension. Fetal movements are normal. On examination, fetal parts are not easily felt and fetal heartbeat is heard but it is muffled. Her symphysis fundal height is 41 cm. Her abdomen is tense but not tender. What is the most likely diagnosis?

Accepted Answer

Polyhydramnios

Answer

Abruptio placenta

Answer

Hydrocephalus of fetus

Answer

Oligohydramnios

Question 7

A female presents with 6 weeks of amenorrhea, experiencing vaginal bleeding and slight abdominal pain. A urine pregnancy test is positive, and her hCG level is 2800 IU/L. A mass measuring 3 x 2.5 cm is observed on the left adnexa. She is hemodynamically stable. What is the most appropriate management for this patient?

Accepted Answer

Single-dose methotrexate injection

Answer

Oral methotrexate

Answer

Serial methotrexate + leucovorin rescue

Answer

Salpingectomy

Question 8

A female patient presents to you with six weeks of amenorrhea, associated with abdominal pain and vaginal bleeding with normal blood pressure. Investigations revealed beta-hCG to be 1400 mIU/mL. An ultrasound scan was done which showed a trilaminar endometrium with normal adnexa. What is the next best step in the management of this patient?

Accepted Answer

Repeat beta – hCG after 48 hours

Answer

Laparoscopy

Answer

Repeat ultrasound after 5 days

Answer

Measurement of serum progesterone

Question 9

A 40 year old G2P1 woman with 18 weeks of amenorrhea comes with a dilated cervix. The    cervical length is 15 mm. In spite of explaining the risks, she insisted on cerclage. Which of the    following is a contraindication for cervical cerclage?

Accepted Answer

Ruptured membranes

Answer

Advanced maternal age

Answer

Fetal fibronectin positive

Answer

Prolapse of membranes into the vagina

Question 10

Vertical transmission of HIV is highest with-

Accepted Answer

High viral RNA load

Answer

Elective caesarean section

Answer

Breast feeding

Answer

Term delivery

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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