Maternal-Fetal Medicine Practice Questions

Q: What is the expected rate of turnover of amniotic fluid in a pregnant woman?

500 cc/h. ***500 cc/h*** - The **amniotic fluid** undergoes a rapid and continuous turnover, with approximately **500 cc/h** being exchanged through multiple pathways. - This dynamic process ensures the constant renewal of the fluid, maintaining its critical functions for fetal development and protection. *1L/hr* - A turnover rate of 1 liter per hour is **higher than the physiological range** for normal amniotic fluid dynamics. - Such a high rate would imply an **abnormal fluid exchange**, potentially leading to imbalances. *1500 cc/h* - This rate represents an **extremely high turnover**, significantly exceeding the typical physiological exchange. - Sustained rates this high are **not consistent with normal amniotic fluid physiology** and could indicate underlying pathology. *2L/h* - A turnover rate of 2 liters per hour is **dangerously high** and far beyond the normal capacity for amniotic fluid exchange. - Such a rapid turnover would be **detrimental to fetal well-being** and is not observed in healthy pregnancies.

Q: USG of 28 weeks gestation showing oligohydramnios is likely to be due to?

Renal pathway obstruction. ***Renal pathway obstruction*** - **Oligohydramnios** (low amniotic fluid) in the late second or third trimester is often caused by conditions that impair fetal urine production or outflow. - **Renal pathway obstruction** (e.g., posterior urethral valves, bilateral renal agenesis) prevents the fetus from producing or excreting sufficient urine, a primary source of amniotic fluid. *Gastrointestinal obstruction* - **Gastrointestinal obstruction** is more commonly associated with **polyhydramnios** because it impairs the fetal swallowing of amniotic fluid. - Inability to swallow leads to an *accumulation* of amniotic fluid, not a reduction. *Anencephaly* - **Anencephaly** is typically associated with **polyhydramnios** due to impaired swallowing of amniotic fluid. - The exposed brain tissue can also lead to increased fluid transudation. *Neuromuscular disorder* - **Neuromuscular disorders** can cause **polyhydramnios** if they lead to impaired fetal swallowing due to muscle weakness. - If a neuromuscular disorder affects the renal system, it could potentially cause oligohydramnios, but it is not the primary cause of oligohydramnios itself.

Q: What is a potential risk for pregnant women who undertake long journeys with prolonged sitting?

Deep vein thrombosis. ***Deep vein thrombosis*** - **Pregnancy** is a **hypercoagulable state** due to increased levels of clotting factors (fibrinogen, factors VII, VIII, X) and decreased protein S activity. - **Prolonged sitting** during long journeys causes **venous stasis** in the lower extremities, which is a key component of **Virchow's triad** for thrombosis (stasis, hypercoagulability, endothelial injury). - **DVT** is the **direct and most specific pathological consequence** of prolonged immobilization during travel in pregnancy. - The risk of **VTE in pregnancy** is **4-5 times higher** than in non-pregnant women, with travel-related DVT being a recognized complication. *Venous thromboembolism* - VTE is an **umbrella term** that encompasses both **DVT and pulmonary embolism**. - While technically correct as a broader category, DVT is the **more specific and direct answer** to what prolonged sitting causes. - In medical education and clinical practice, identifying the **specific pathology** (DVT) is more appropriate than using the general category (VTE). *Pulmonary embolism* - PE is a **complication** of DVT, occurring when a thrombus dislodges and embolizes to the pulmonary circulation. - PE is a **secondary consequence**, not the **primary risk** from prolonged sitting itself. - The direct mechanism of prolonged sitting → venous stasis → **DVT formation** → potential embolization to lungs. *Leg swelling* - **Leg swelling** (edema) is a **symptom**, not a pathological diagnosis. - While leg edema can indicate DVT, it's also common in normal pregnancy due to increased venous pressure and fluid retention. - The question asks for a **risk** (pathological condition), not a symptom.

Q: What is meant by 'Battledore insertion of placenta'?

Umbilical cord attached to the margin of the placenta. ***Umbilical cord attached to the margin of the placenta*** - In a **Battledore insertion**, the **umbilical cord** inserts into the **edge** or **margin** of the placenta, rather than its center. - This unusual insertion resembles a **battledore**, a type of ancient racket or paddle with a handle at its edge (similar to those used in shuttlecock games). *Placenta attached to the margin of the membranes* - This description is more consistent with a **circumvallate placenta**, where the chorionic plate is smaller than the basal plate, leading to a rolled or folded margin of placental tissue covered by membranes, but it does not describe Battledore insertion. - In circumvallate placenta, the chorionic plate's edge rolls back and is surrounded by a ring of membranes, while Battledore refers specifically to the cord's insertion. *Placenta attached to the center of the uterus* - This simply indicates a **normal location** for the placenta within the uterine cavity and does not describe any abnormal insertion of the umbilical cord or specific characteristics of the placenta itself. - The placenta typically attaches to the uterine wall and can be central, fundal, or anterior/posterior, but this statement doesn't relate to the cord's insertion point. *Umbilical cord attached to the membranes* - This condition is known as **velamentous insertion of the umbilical cord**, where the cord blood vessels fan out within the amniotic membrane before reaching the placental tissue. - Velamentous insertion is a distinct anomaly from Battledore insertion and carries different risks, such as vasa previa and a higher risk of vessel compression or rupture.

Q: Red degeneration of fibroid is seen in which of the following?

Mid pregnancy. ***Mid pregnancy*** - **Red degeneration**, or **carneous degeneration**, is most common during the **second and third trimesters of pregnancy** due to increased metabolic demands of the growing fibroid outstripping its blood supply. - The rapid growth leads to **ischemia**, hemorrhage, and necrosis within the fibroid, causing acute abdominal pain. *Early pregnancy* - While fibroids can grow in early pregnancy, **red degeneration** is less common as the uterine blood supply is generally still adequate to meet the fibroid's metabolic needs. - Other forms of degeneration, like **hyaline degeneration**, are more frequently observed in non-pregnant or early pregnant states. *Puerperium* - In the puerperium, fibroids typically undergo **regression** rather than degeneration, as the hormonal stimulation (estrogen and progesterone) that promoted their growth significantly decreases. - The uterus involutes rapidly, and fibroids often shrink. *Nulliparous women* - Nulliparous women can have fibroids and experience various forms of degeneration, but **red degeneration** specifically is rare outside of pregnancy. - Degeneration in nulliparous women is more commonly **hyaline** or **cystic** degeneration.

Q: What is the recommended management for jaundice due to obstetric cholestasis in the third trimester?

Induction of labour at 38 weeks. ***Induction of labour at 38 weeks*** - **Obstetric cholestasis (Intrahepatic Cholestasis of Pregnancy)** is associated with increased risk of **stillbirth**, particularly beyond 37-38 weeks gestation. - Induction at **37-38 weeks** is recommended to balance reducing stillbirth risk while minimizing prematurity complications. - **Current practice**: Timing depends on **bile acid levels** - delivery at 37-38 weeks for bile acids >40 μmol/L, or 38-39 weeks for milder cases (19-39 μmol/L). - This option represents the standard management approach for most cases of obstetric cholestasis. *Induction of labour at 37 weeks* - Delivery at 37 weeks is also acceptable and increasingly preferred, particularly for **severe disease** (bile acids >40 μmol/L) or when there are additional risk factors. - Both 37 and 38 weeks are within the recommended window; the choice depends on **disease severity** and individual risk assessment. - This is not incorrect, but 38 weeks represents a slightly more conservative approach balancing risks. *Induction of labour at 42 weeks* - Waiting until 42 weeks significantly increases the risk of **intrauterine fetal death (IUFD)** in pregnancies complicated by obstetric cholestasis. - Prolonged exposure to **elevated bile acids** is toxic to the fetus and increases stillbirth risk, especially after 37-38 weeks. - This approach is **contraindicated** in obstetric cholestasis. *Wait for spontaneous labour* - Expectant management beyond 38 weeks is considered **unsafe** due to the unpredictable and progressive risk of **sudden intrauterine death**. - Active management with planned delivery at 37-38 weeks is the standard of care to prevent stillbirth. - Waiting for spontaneous labor exposes the fetus to unacceptable risks.

Q: Which drug is commonly used in the medical management of ectopic pregnancy?

Methotrexate. ***Correct: Methotrexate*** - **Methotrexate** is a **folic acid antagonist** that inhibits DNA synthesis and cell proliferation, making it effective in terminating early ectopic pregnancies by targeting rapidly dividing trophoblastic cells. - It is typically considered for **hemodynamically stable** patients with unruptured ectopic pregnancies, a beta-hCG level below a certain threshold (e.g., <5,000 mIU/mL), and no cardiac activity in the ectopic mass. - This is the **gold standard** for medical management of ectopic pregnancy meeting specific criteria. *Incorrect: Mifepristone* - **Mifepristone** is an **antiprogestin** primarily used for medical abortion of intrauterine pregnancies, causing detachment of the gestational sac and cervical ripening. - While it can be used in combination with misoprostol for medical abortion, it is **not the primary drug** for managing ectopic pregnancies. *Incorrect: Leuprolide* - **Leuprolide** is a **GnRH agonist** mainly used for conditions like endometriosis, uterine fibroids, and prostate cancer by suppressing ovarian or testicular hormone production. - It is **not used** in the direct medical management of ectopic pregnancy. *Incorrect: Carboprost* - **Carboprost** is a **prostaglandin F2-alpha analog** primarily used to treat **postpartum hemorrhage** by inducing strong uterine contractions. - It is **not indicated** for the treatment of ectopic pregnancy.

Q: What is the best parameter for estimating fetal age by ultrasound in the third trimester?

BPD. ***BPD (Biparietal Diameter)*** - **Biparietal diameter (BPD)** is considered the **best single parameter** among the given options for estimating fetal age in the third trimester, though all parameters become less accurate with advancing gestation. - In the third trimester, BPD accuracy is approximately **±3-4 weeks**, which is why **first trimester dating (CRL) should always be used when available** as it is most accurate (±5-7 days). - BPD is measured at the level of the thalami and cavum septum pellucidum, from outer edge of the proximal skull to the inner edge of the distal skull. - **Note**: Multiple biometric parameters used together improve accuracy more than any single measurement in late pregnancy. *Femur length* - **Femur length (FL)** is highly accurate in the **second trimester** but becomes less reliable in the third trimester due to biological variation. - It can be affected by **skeletal dysplasias** and genetic factors, leading to inaccurate age estimation. - FL is better used for assessing proportionate growth rather than dating in late pregnancy. *Abdominal circumference* - **Abdominal circumference (AC)** is primarily used for assessing **fetal growth and estimating fetal weight**, not for gestational age determination. - It is highly variable and influenced by fetal nutritional status, growth restriction, or macrosomia, making it unreliable for dating. - AC is the **most sensitive parameter for detecting growth abnormalities** (IUGR or LGA). *Intraocular distance* - **Intraocular distance (IOD)** is not a standard biometric parameter for routine gestational age estimation. - It has limited clinical utility and is occasionally used for detecting specific **fetal anomalies** (hypertelorism/hypotelorism) rather than dating. - Standard biometric parameters (BPD, HC, AC, FL) are always preferred for gestational age assessment.

Question 1

What is the expected rate of turnover of amniotic fluid in a pregnant woman?

Accepted Answer

500 cc/h

Answer

1 L/h

Answer

1500 cc/h

Answer

2L/h

Question 2

USG of 28 weeks gestation showing oligohydramnios is likely to be due to?

Accepted Answer

Renal pathway obstruction

Answer

Neuromuscular disorder

Answer

Gastrointestinal obstruction

Answer

Anencephaly

Question 3

What is a potential risk for pregnant women who undertake long journeys with prolonged sitting?

Accepted Answer

Deep vein thrombosis

Answer

Venous thromboembolism

Answer

Pulmonary embolism

Answer

Leg swelling

Question 4

What is meant by 'Battledore insertion of placenta'?

Accepted Answer

Umbilical cord attached to the margin of the placenta

Answer

Placenta attached to the margin of the membranes

Answer

Placenta attached to the center of the uterus

Answer

Umbilical cord attached to the membranes

Question 5

Red degeneration of fibroid is seen in which of the following?

Accepted Answer

Mid pregnancy

Answer

Early pregnancy

Answer

Nulliparous women

Answer

Puerperium

Question 6

What is the recommended management for jaundice due to obstetric cholestasis in the third trimester?

Accepted Answer

Induction of labour at 38 weeks

Answer

Induction of labour at 37 weeks

Answer

Induction of labour at 42 weeks

Answer

Wait for spontaneous labour

Question 7

Which drug is commonly used in the medical management of ectopic pregnancy?

Accepted Answer

Methotrexate

Answer

Leuprolide

Answer

Mifepristone

Answer

Carboprost

Question 8

What is the best parameter for estimating fetal age by ultrasound in the third trimester?

Accepted Answer

BPD

Answer

Abdominal circumference

Answer

Femur length

Answer

Intraocular distance

Question 9

Which of the following actions should be avoided during the delivery of an Rh-negative mother?

Accepted Answer

Gently perform manual removal of placenta if necessary

Answer

Withhold ergometrine until after anterior shoulder delivery

Answer

Administer IV fluids

Answer

Apply fundal pressure during second stage of labor

Question 10

What is the management of eclampsia at 34 weeks of pregnancy?

Accepted Answer

Administer antihypertensives, anticonvulsants, and consider termination of pregnancy.

Answer

Continue convulsions and wait for 37 weeks to complete.

Answer

Wait for spontaneous labor.

Answer

Continue blood pressure management.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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