Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 1231: Which of the following is NOT a cause of oligohydramnios?

A. Renal agenesis
B. Amnion nodosum
C. Chorioangioma (Correct Answer)
D. IUGR

Explanation: ***Chorioangioma*** - A **chorioangioma** is a benign placental tumor that causes **polyhydramnios** (excess amniotic fluid), which is the **opposite** of oligohydramnios. - Large chorioangiomas lead to increased transudation from the tumor's vascular channels, fetal anemia, and high-output cardiac failure, resulting in increased fetal urine production. - This is clearly **NOT a cause** of oligohydramnios, making it the correct answer. *IUGR* - **Intrauterine growth restriction (IUGR)**, particularly with placental insufficiency, is a common cause of **oligohydramnios**. - Reduced placental perfusion leads to decreased **fetal renal blood flow** and diminished urine production. - Since fetal urine is the main source of amniotic fluid after 16 weeks, reduced output causes oligohydramnios. *Renal agenesis* - **Bilateral renal agenesis** (Potter syndrome) is a classic and severe cause of **oligohydramnios/anhydramnios**. - Complete absence of kidneys means **no fetal urine production**, eliminating the primary source of amniotic fluid in the second and third trimesters. - Results in severe oligohydramnios with associated pulmonary hypoplasia and Potter facies. *Amnion nodosum* - **Amnion nodosum** refers to small, grayish-yellow nodules on the fetal surface of the amnion, composed of aggregated fetal squamous epithelial cells and vernix. - These nodules are a **pathological finding** that occurs as a **consequence** of chronic oligohydramnios, not a cause. - They form due to prolonged contact between the fetal skin and amnion when amniotic fluid is severely reduced. - While technically "not a cause," it is strongly **associated with** oligohydramnios, whereas chorioangioma causes the opposite condition entirely.

Question 1232: Uterine height is greater than gestational age of the patient in a case of all except -

A. Fibroid uterus
B. Wrong dates
C. Polyhydramnios
D. IUGR (Correct Answer)

Explanation: ***IUGR*** - In **Intrauterine Growth Restriction (IUGR)**, the fetus is smaller than expected for gestational age, leading to a **fundal height** that measures less than the actual gestational age. - This condition is characterized by a **restricted growth rate** of the fetus, causing the uterine size to be disproportionately small. *Fibroid uterus* - The presence of **uterine fibroids** (leiomyomas) can increase the overall size of the uterus beyond what would be expected for a given gestational age. - These benign tumors add bulk to the uterine wall, leading to a **larger-than-expected uterine height**. *Wrong dates* - Incorrect estimation of the **Last Menstrual Period (LMP)** or date of conception can lead to a miscalculation of gestational age. - If the gestational age is **underestimated**, the actual uterine height will appear greater than the calculated gestational age. *Polyhydramnios* - **Polyhydramnios** is a condition characterized by an **excessive accumulation of amniotic fluid**, which distends the uterus. - Increased amniotic fluid volume leads to a significantly **larger uterine size** and a fundal height greater than the gestational age.

Question 1233: Which of the following is not associated with maternal age?

A. Preterm labour
B. Aneuploidy
C. Hydatidiform mole
D. Post maturity (Correct Answer)

Explanation: ***Post maturity*** - **Post-maturity** (post-term pregnancy, >42 weeks) does NOT have a consistent or strong association with maternal age in current obstetric literature. - While some older studies suggested associations, modern evidence shows **no significant independent effect of maternal age** on post-term pregnancy rates. - Post-term pregnancy is more related to factors like **first pregnancy**, **prior post-term delivery**, and **fetal sex** (males more common). *Preterm labour* - **Preterm birth is strongly associated with maternal age**, particularly at both extremes: - **Teenage mothers** (<20 years): Increased risk due to biological immaturity and socioeconomic factors - **Advanced maternal age** (≥35 years): Increased risk due to higher rates of maternal complications (hypertension, diabetes) and placental dysfunction - This is well-established in obstetric literature and clinical guidelines. *Aneuploidy* - The risk of **aneuploidy**, particularly **Down syndrome (Trisomy 21)**, **increases dramatically with advancing maternal age**. - At age 35: ~1/350 risk; at age 40: ~1/100 risk; at age 45: ~1/30 risk - Due to age-related decline in oocyte quality causing meiotic errors during egg formation. *Hydatidiform mole* - **Gestational trophoblastic disease** (hydatidiform mole) is strongly associated with **extremes of maternal age**: - **Women >40 years**: 5-10 fold increased risk - **Teenagers**: 1.5-2 fold increased risk - Related to abnormal fertilization events more common at age extremes.

Question 1234: Which of the following statements is true regarding placental site trophoblastic disease?

A. Has a highly malignant potential
B. It secretes human placental lactogen (Correct Answer)
C. Mainly contains syncytiotrophoblasts
D. The treatment of choice is hysterectomy followed by chemotherapy

Explanation: ***It secretes human placental lactogen*** - Placental site trophoblastic tumor (PSTT) characteristically consists of intermediate trophoblasts which secrete **human placental lactogen (hPL)**. - Unlike choriocarcinoma, PSTT secretes relatively low levels of **human chorionic gonadotropin (hCG)**. *Has a highly malignant potential* - PSTT generally has a **good prognosis** if the disease is confined to the uterus, with a survival rate of over 95%. - It has a low metastatic potential compared to choriocarcinoma, with metastases occurring in only about 15% of cases. *Mainly contains syncytiotrophoblasts* - PSTT is composed predominantly of **intermediate trophoblasts** that infiltrate the myometrium, rather than syncytiotrophoblasts or cytotrophoblasts. - The distinctive feature is the proliferation of these intermediate trophoblasts at the implantation site. *The treatment of choice is hysterectomy followed by chemotherapy* - **Hysterectomy** is generally the primary treatment for PSTT confined to the uterus, and it often cures the disease. - **Chemotherapy** is usually reserved for metastatic or recurrent disease, or in cases of extensive local invasion, and is not a routine follow-up after an uncomplicated hysterectomy.

Question 1235: Most common antigen involved in erythroblastosis fetalis is:

A. C antigen in Rh group
B. E antigen in Rh group
C. Duffy antigen
D. D antigen in Rh group (Correct Answer)

Explanation: ***D antigen in Rh group*** - The **D antigen** is the most immunogenic of the Rh antigens and is responsible for the vast majority of cases of **erythroblastosis fetalis** (hemolytic disease of the fetus and newborn). - When an **Rh-negative mother** is exposed to Rh-positive fetal blood (usually during previous pregnancies or transfusions), she can form antibodies against the D antigen, which can then cross the placenta in subsequent pregnancies and attack Rh-positive fetal red blood cells. *C antigen in Rh group* - While the **C antigen** is part of the Rh blood group system, antibodies to it are much less common and typically cause less severe hemolytic disease compared to anti-D antibodies. - The C antigen is less immunogenic than the D antigen, meaning it is less likely to provoke an immune response in an Rh-negative individual. *E antigen in Rh group* - Similar to the C antigen, the **E antigen** is another Rh antigen, but antibodies against it (anti-E) are also less frequently implicated in severe erythroblastosis fetalis than anti-D. - Antibodies to E can cause hemolytic disease, but their clinical significance is usually milder than that of anti-D. *Duffy antigen* - The **Duffy antigen system** is separate from the Rh system and is known for its role in resistance to certain malarial parasites (e.g., *Plasmodium vivax*). - Although antibodies to Duffy antigens (anti-Fya, anti-Fyb) can cause **hemolytic disease of the fetus/newborn**, they are a far less common cause of erythroblastosis fetalis than antibodies to the Rh D antigen.

Question 1236: A G2P1L1 female presents at 28 weeks of gestation with a 1:4 anti-D titre. What is the most appropriate management option?

A. MCA Doppler (Correct Answer)
B. Caesarean section
C. Induction of labour
D. Amniocentesis

Explanation: ***MCA Doppler*** - The presence of anti-D antibodies in a pregnant woman indicates **Rh isoimmunization**, which can lead to **hemolytic disease of the fetus and newborn (HDFN)**. - Even though a titre of **1:4 is below the critical threshold** (usually 1:16 or 1:32), any detectable anti-D titre at 28 weeks warrants **fetal surveillance** to detect early signs of fetal anemia. - **Middle cerebral artery (MCA) Doppler** is the **non-invasive gold standard** for detecting fetal anemia by measuring peak systolic velocity (PSV), which increases in anemic fetuses due to hyperdynamic circulation. - Serial MCA Doppler monitoring allows timely intervention if fetal anemia develops, avoiding unnecessary invasive procedures. *Caesarean section* - This is a mode of delivery and would only be considered if there were severe **fetal compromise** or other obstetric indications after proper monitoring and management. - At 28 weeks gestation with a low anti-D titre, immediate delivery is **not indicated** and would result in significant prematurity risks. *Induction of labour* - Induction of labour is a delivery method that would only be planned at term or for specific indications like severe fetal compromise unresponsive to other interventions. - At **28 weeks gestation**, the focus should be on **monitoring and prolonging pregnancy** while ensuring fetal wellbeing, not on delivery. *Amniocentesis* - Historically used to assess **bilirubin levels (ΔOD450)** in amniotic fluid as an indirect measure of fetal hemolysis, but it is an **invasive procedure** with risks (miscarriage ~1%, infection, worsening sensitization). - **MCA Doppler has largely replaced amniocentesis** for initial and serial assessment of fetal anemia due to its non-invasive nature, high sensitivity, and ability to be repeated safely.

Question 1237: All are true about uteroplacental circulation except:

A. The villi depend on the maternal blood for their nutrition
B. Blood in the intervillous space is completely replaced 3-4 times per minute
C. A mature placenta has 150 ml of blood in the villi system and 350 ml of blood in the intervillous space (Correct Answer)
D. Intervillous blood flow at term is 500-600 ml per minute

Explanation: ***A mature placenta has 150 ml of blood in the villi system and 350 ml of blood in the intervillous space*** - This statement is incorrect because a **mature placenta** typically holds approximately **350 ml of blood** in the **villi system** and **150 ml of blood** in the **intervillous space**, which is the reverse of what is stated. - The villi system contains the fetal blood, which has a larger volume within the placental unit. *Blood in the intervillous space is completely replaced 3-4 times per minute* - This is a correct statement regarding uteroplacental circulation, as the **high turnover rate** ensures efficient **nutrient and gas exchange** between mother and fetus. - The rapid replacement prevents stagnant blood and facilitates continuous delivery of essential substances. *The villi depend on the maternal blood for their nutrition* - This statement is true because the **chorionic villi**, which are the functional units of the placenta, are bathed in **maternal blood** within the intervillous space. - The placental tissue itself receives its **nutrients and oxygen** directly from this maternal blood supply. *Intervillous blood flow at term is 500-600 ml per minute* - This is an accurate physiological fact. At term, the **maternal blood flow** through the intervillous space is indeed substantial, typically ranging from **500 to 700 ml per minute**, ensuring adequate perfusion for the growing fetus. - This significant blood flow is crucial for meeting the high metabolic demands of the fetus.

Question 1238: What is the best initial management option for ovarian ectopic pregnancy?

A. Expectant management with serial monitoring
B. Emergency laparotomy in all cases
C. Surgical management (laparoscopy if stable, laparotomy if unstable) (Correct Answer)
D. Medical management with methotrexate

Explanation: ***Surgical management (laparoscopy if stable, laparotomy if unstable)*** - **Ovarian ectopic pregnancies** are best managed surgically due to the **high vascularity of the ovary** and significant risk of hemorrhage - The surgical approach is **individualized**: **laparoscopy** is preferred for hemodynamically **stable patients**, while **laparotomy** is indicated for **unstable patients** or those with suspected rupture and massive hemorrhage - Surgery allows for **definitive treatment** with ovarian wedge resection or oophorectomy while preserving fertility when possible *Medical management with methotrexate* - **Methotrexate** has been used in selected cases of ovarian ectopic pregnancy, but success rates are **lower than tubal ectopics** due to increased vascularity - The risk of **treatment failure** with subsequent rupture and hemorrhage limits its routine use - Generally reserved for very early, small, unruptured cases with low hCG levels in carefully selected patients *Expectant management with serial monitoring* - **Expectant management** is rarely appropriate for ovarian ectopic pregnancy due to the high risk of **rupture and life-threatening hemorrhage** - The **highly vascular nature** of ovarian tissue makes spontaneous resolution unpredictable and potentially dangerous - Not recommended as initial management except in rare cases with declining hCG and very small masses *Emergency laparotomy in all cases* - While surgical management is preferred, **laparotomy is not required in all cases** - Hemodynamically **stable patients** can be safely managed with **laparoscopy**, which offers faster recovery and less morbidity - **Emergency laparotomy** is reserved for hemodynamically **unstable patients** or those with signs of massive intraperitoneal hemorrhage

Question 1239: In cervical incompetence, the diameter of the internal os of the cervix is typically greater than -

A. 1 cm
B. 1.5 cm
C. 2.5 cm (Correct Answer)
D. 2 cm

Explanation: ***2.5 cm*** * In **cervical incompetence**, the cervix prematurely dilates and effaces, often leading to second-trimester pregnancy loss or preterm birth. * A classic ultrasound finding suggestive of cervical incompetence is an internal os diameter greater than **2.5 cm** in the second trimester, in the absence of uterine contractions. *1 cm* * A normal internal os diameter is typically less than **1 cm**. A diameter of 1 cm would not be indicative of cervical incompetence without other clinical signs. * This measurement is within the **normal range** for a non-dilating cervix during pregnancy. *1.5 cm* * While 1.5 cm is larger than a typical closed os, it is generally not considered the definitive threshold for diagnosing **cervical incompetence** on its own. * The progression to a wider diameter, usually **2.5 cm or more**, is more clinically significant for diagnosis. *2 cm* * An internal os diameter of 2 cm may raise suspicion but is still often considered a **borderline finding**. * Many clinicians and guidelines use **2.5 cm as the more established cutoff** for identifying significant cervical incompetence.

Question 1240: A 28-year-old primigravida with 32 weeks of gestation presents with profuse vaginal discharge since yesterday. She was advised USG, which showed a single live intrauterine gestational sac with FL and AC corresponding to the weeks of gestation and AFI as adequate. What is the diagnosis?

A. Candidiasis
B. Trichomoniasis
C. Normal vaginal discharge (Correct Answer)
D. Preterm Premature Rupture of Membranes (PPROM)

Explanation: ***Normal vaginal discharge*** - Profuse vaginal discharge is a common and **physiological occurrence** in pregnancy due to increased estrogen levels and blood flow to the vagina. - The ultrasound findings of **adequate amniotic fluid index (AFI)** rule out rupture of membranes, and no other symptoms of infection are reported. *Preterm Premature Rupture of Membranes (PPROM)* - PPROM would present with a significant reduction in the **amniotic fluid index (AFI)** on ultrasound, which is noted as adequate in this case. - The discharge in PPROM is typically **amniotic fluid**, which is clear and watery, unlike mere profuse vaginal discharge. *Trichomoniasis* - This infection typically causes a **frothy, greenish-yellow discharge** with a foul odor, along with vulvar itching and irritation. - These characteristic symptoms are not mentioned in the patient's presentation. *Candidiasis* - Vaginal candidiasis usually presents with a **thick, white, cottage cheese-like discharge** accompanied by intense itching and burning. - The patient's description of discharge is simply "profuse," without these specific characteristics.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

Practice Questions

Multiple Gestation

Practice Questions

Rh Isoimmunization and Other Blood Group Incompatibilities

Practice Questions

Intrauterine Fetal Therapy

Practice Questions

Prenatal Diagnosis and Genetic Counseling

Practice Questions

Placental Abnormalities

Practice Questions

Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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