Maternal-Fetal Medicine Practice Questions

Q: Which drug is known to cause placental abruption?

Cocaine. **Cocaine** - **Cocaine** use during pregnancy is strongly associated with an increased risk of **placental abruption** due to its vasoconstrictive effects on uterine blood vessels. - Its potent **vasoconstrictive properties** lead to uterine ischemia and contractions, which can cause the placenta to detach prematurely from the uterine wall. *Methadone* - While methadone use during pregnancy is associated with risks such as **neonatal abstinence syndrome**, it is not a primary cause of **placental abruption**. - It is often used as a maintenance therapy for opioid-dependent pregnant women to avoid the fluctuating levels of illicit drug use, which can have more severe consequences. *Amphetamine* - Amphetamine use can lead to adverse pregnancy outcomes like **preterm birth** and **low birth weight** due to its stimulant effects. - Although it causes vasoconstriction, its association with **placental abruption** is less direct and less pronounced compared to cocaine. *Fluoxetine* - Fluoxetine, an **SSRI antidepressant**, generally has a relatively safe profile in pregnancy, although some studies suggest a small increased risk of persistent **pulmonary hypertension** in neonates. - It is not known to be a cause of **placental abruption**.

Q: Cardiac output increases maximum at which week?

30-32 wks. ***30-32 wks*** - **Cardiac output** in healthy pregnant women typically reaches its maximum increase of **30-50%** above pre-pregnancy levels between **28 and 32 weeks** of gestation. - This peak output is sustained until term, primarily driven by a significant increase in **stroke volume** and a moderate increase in **heart rate**. *26-28 wks* - While cardiac output steadily rises throughout pregnancy, the **peak increase** is generally not observed as early as **26-28 weeks**. - At this stage, the increase is substantial but is still progressing towards its **maximum point**. *32-34 wks* - The maximal cardiac output is usually achieved **before** this period, typically by **32 weeks**. - From **32 weeks** onwards, cardiac output tends to **plateau**, not increase further. *34-36 wks* - By **34-36 weeks**, cardiac output has generally already reached its peak and **stabilized**. - There is typically no further increase in cardiac output during this timeframe; rather, it is maintained at its maximal level.

Q: What is the most common cause of hydrops fetalis in current medical practice?

Cardiac malformations. ***Cardiac malformations*** - **Cardiovascular abnormalities** are the **most common cause** of **non-immune hydrops fetalis** in current medical practice, accounting for **20-40%** of cases - Includes **structural heart defects** (septal defects, valvular abnormalities) and **arrhythmias** (supraventricular tachycardia, complete heart block) - These conditions lead to **heart failure** and **increased hydrostatic pressure**, causing fluid accumulation in fetal tissues and body cavities - With the near-elimination of Rh disease through immunoprophylaxis, cardiac causes have emerged as the leading etiology *Chromosomal abnormalities* - Account for **10-20%** of non-immune hydrops cases - **Turner syndrome (45,X)** is the most common chromosomal cause, associated with **cystic hygroma** and **lymphatic dysgenesis** - Other chromosomal conditions include **trisomy 21, 18, and 13**, which can cause hydrops through associated cardiac defects or other mechanisms - While significant, chromosomal causes are less common than cardiovascular causes overall *Fetal infections (e.g., parvovirus B19)* - Infections account for **5-10%** of non-immune hydrops cases - **Parvovirus B19** is the most common infectious cause, leading to severe **fetal anemia** through bone marrow suppression - Other infectious agents include **CMV**, **toxoplasmosis**, and **syphilis** - The TORCH screening helps identify treatable infectious causes *Rh incompatibility (historically significant)* - Historically the **leading cause** before the 1970s, accounting for most hydrops cases - Now accounts for **<10%** of cases due to routine **Rho(D) immune globulin (RhoGAM)** administration at 28 weeks and postpartum - Causes **immune hydrops** through maternal antibodies crossing the placenta and destroying fetal red blood cells, leading to severe anemia and heart failure - Still important in under-immunized populations or cases of missed prophylaxis

Q: Which of the following statements about the contraction stress test (CST) is MOST accurate?

Negative test is associated with good fetal outcome. ***Negative test is associated with good fetal outcome*** - A **negative CST** indicates that there are no late or significant variable decelerations in response to uterine contractions, suggesting the fetus can tolerate labor. - This finding is strongly correlated with **fetal well-being** and a low likelihood of fetal distress in the near future, with a **negative predictive value of approximately 99%**. *Invasive method* - The CST is considered a **non-invasive test**, as it involves external monitoring of fetal heart rate and uterine contractions. - No instruments are inserted into the body, differentiating it from truly invasive procedures like **amniocentesis**. *Detects fetal well being* - While the CST provides valuable information, it specifically assesses **uteroplacental function and fetal oxygenation reserve** during the stress of contractions, rather than comprehensive fetal well-being. - It identifies fetuses at risk for **uteroplacental insufficiency** but does not evaluate other parameters of fetal health. - Other tests like the **biophysical profile** offer a more comprehensive assessment of fetal well-being, including parameters like fetal breathing, movement, tone, and amniotic fluid volume. *Oxytocin is never used in the test* - **Oxytocin** is frequently used to induce uterine contractions if spontaneous contractions are insufficient for the test (oxytocin challenge test or OCT). - Alternatively, **nipple stimulation** can be used to achieve adequate contractions for the CST.

Q: What is the most common site for ectopic pregnancies?

Ampulla. ***Ampulla*** - The **ampulla** of the fallopian tube is the most common site for ectopic pregnancies, accounting for about **70-80% of all cases**. - Its **wider lumen** and **tortuous path** can delay the ovum's transit, increasing the likelihood of implantation there. *Isthmus* - The **isthmus** is the second most common site for ectopic pregnancies, accounting for about **12% of cases**. - Pregnancies in this narrow, muscular part of the tube are more prone to **early rupture** due to limited distensibility. *Fimbriae* - **Fimbrial** ectopic pregnancies are rare, accounting for approximately **5% of cases**. - These occur when the fertilized egg implants on the **finger-like projections** at the end of the fallopian tube. *Interstitial/Cornual* - **Interstitial** or **cornual** pregnancies are uncommon but serious, making up about **2-4% of ectopic pregnancies**. - They occur in the portion of the fallopian tube that passes through the **muscular wall of the uterus** and carry a higher risk of hemorrhage due to rich vascularity.

Q: Which of the following is the MOST CRITICAL indication for Acyclovir use during pregnancy?

Treatment of disseminated herpes. ***Treatment of disseminated herpes*** - **Disseminated herpes** in pregnancy is a severe, life-threatening condition for both the mother and the fetus, making acyclovir use critically indicated. - This systemic infection can lead to **visceral organ involvement**, **encephalitis**, and significantly increased maternal and fetal morbidity and mortality. - Immediate treatment with intravenous acyclovir is essential to prevent **multi-organ failure** and death. *Treatment of chickenpox in the first trimester* - While chickenpox in the first trimester can be serious, leading to **congenital varicella syndrome**, acyclovir's role here is primarily to mitigate maternal illness, not as critical as disseminated herpes. - The risk of congenital varicella syndrome for the fetus is relatively low (around 0.4%) after maternal infection in the first trimester. *Prophylaxis for recurrent herpes during pregnancy* - **Prophylactic acyclovir** in the third trimester is commonly used to prevent recurrent genital herpes and reduce the risk of **neonatal herpes**, but it is not as acutely critical as treating disseminated disease. - This intervention aims to prevent transmission during delivery rather than managing an immediate, life-threatening maternal or fetal condition. *Prevention of cytomegalovirus infection in pregnancy* - Acyclovir has **minimal activity against CMV** and is not indicated for CMV prevention or treatment. - **Ganciclovir** or **valganciclovir** are the antivirals used for CMV, not acyclovir.

Q: A hypertensive pregnant woman at 34 weeks presents with a history of abdominal pain, bleeding per vaginum, and loss of fetal movements. On examination, the uterus is contracted with increased uterine tone, and fetal heart sounds are absent. Which of the following is the most likely diagnosis?

Abruptio placenta. ***Abruptio placenta*** - The classic presentation of **abruptio placenta** includes **abdominal pain**, **vaginal bleeding**, **increased uterine tone**, and **loss of fetal movements** in a patient with **hypertension**. - **Hypertension** is a significant risk factor for abruptio placenta, and the absence of fetal heart sounds suggests **fetal demise**, which can occur due to severe abruption. *Polyhydramnios* - Characterized by an **excessive accumulation of amniotic fluid**, which leads to an abnormally large uterus. - It usually presents with **uterine distension** and shortness of breath, not abdominal pain, vaginal bleeding, or increased uterine tone. *Placenta previa* - Typically presents with **painless vaginal bleeding** in the second or third trimester. - The uterus is usually **soft and non-tender**, unlike the increased uterine tone seen in abruptio placenta. *Premature labour* - Defined by **regular uterine contractions** causing cervical change before 37 weeks of gestation. - While contractions cause abdominal pain, it does not typically present with significant **vaginal bleeding** or sustained **increased uterine tone** as described.

Q: Most sensitive diagnostic test for ectopic pregnancy is which one?

Transvaginal USG. ***Transvaginal USG*** - **Transvaginal ultrasonography (TVS)** is considered the most sensitive diagnostic test because it can directly visualize the presence or absence of an intrauterine pregnancy and detect an ectopic gestational sac or mass. - It allows for early detection of an ectopic pregnancy, often even before symptoms become severe, by identifying findings like an **adnexal mass**, **free fluid in the cul-de-sac**, or an **empty uterus** in the presence of positive hCG. *Serial monitoring of beta HCG* - While serial monitoring of **beta-hCG** levels is a crucial component in the diagnosis of ectopic pregnancy, particularly for early pregnancy of unknown location (PUL), it is not the most sensitive single diagnostic test. - It helps in discerning between a normal intrauterine pregnancy, an ectopic pregnancy, or a miscarriage based on the **rate of hCG rise**, but it does not directly localize the pregnancy. *Culdocentesis* - **Culdocentesis** involves aspirating fluid from the pouch of Douglas to detect non-clotting blood, which suggests a ruptured ectopic pregnancy. - It is an invasive procedure and has significantly decreased in use due to the availability of highly sensitive imaging techniques like TVS; it primarily identifies rupture rather than diagnosing the intact ectopic pregnancy itself. *MRI* - **Magnetic Resonance Imaging (MRI)** can be used to diagnose ectopic pregnancy, especially in complex or unusual locations, but it is typically reserved for cases where ultrasound is inconclusive or technically difficult. - It is **more expensive** and less readily available than TVS, and its sensitivity for routine ectopic pregnancy diagnosis does not surpass that of a high-quality TVS.

Q: All of the following are associated with breech presentation at normal full-term pregnancy, except:

Placenta accreta. ***Placenta accreta*** - **Placenta accreta** is a condition where the placenta abnormally adheres to the uterine wall, which is typically associated with previous uterine surgery (e.g., C-sections) and **placenta previa**, not breech presentation. - While both can increase risks in pregnancy, there is no direct causal link or strong association between **placenta accreta** and **breech presentation** in a full-term pregnancy. *Fetal malformation* - **Fetal malformations**, particularly those affecting neural tube development, neuromuscular control, or fetal head/neck flexibility, can lead to a reduced ability of the fetus to turn into a cephalic presentation. - Conditions like **hydrocephalus** or **anencephaly** can hinder the spontaneous version to a head-down position. *Uterine anomaly* - **Uterine anomalies** such as a **septate uterus**, **bicornuate uterus**, or **fibroids** can alter the shape of the uterine cavity, restricting fetal movement and preventing the fetus from assuming a cephalic presentation. - These structural abnormalities can physically limit the space available for the fetus to turn. *Cornual implantation of placenta* - **Cornual implantation** or **fundal implantation** of the placenta can reduce the available space in the lower uterine segment, making it difficult for the fetus to turn and maintain a cephalic presentation. - The placenta's position can exert pressure or create an unfavorable environment that encourages the fetus to remain in a breech position.

Q: On USG finding of cystic hygroma in a fetus is suggestive of:

Turner's syndrome. ***Turner's syndrome*** - **Cystic hygroma** is a significant fetal ultrasound marker most classically associated with **Turner's syndrome (45,X)**, due to lymphatic system abnormalities (failure of lymphatic channels to connect with the jugular vein). - Other findings in Turner's syndrome may include fetal hydrops, renal anomalies, and coarctation of the aorta. *Down's syndrome* - While **nuchal translucency** can be increased in Down's syndrome, a frank **cystic hygroma** is less specific and less commonly seen than in Turner's syndrome. - Other markers for Down's syndrome include **duodenal atresia**, **heart defects**, and **shortened long bones**. *Marfan's syndrome* - This is a **connective tissue disorder** not typically associated with cystic hygroma in utero. - Fetal manifestations are rare but can include significant **cardiac defects** like aortic root dilation. *Klinefelter's syndrome* - **Klinefelter's syndrome (47,XXY)** generally has subtle or no prenatal ultrasound findings. - **Cystic hygroma** is not a characteristic feature of this condition.

Question 1

Which drug is known to cause placental abruption?

Accepted Answer

Cocaine

Answer

Amphetamine

Answer

Fluoxetine

Answer

Methadone

Question 2

Cardiac output increases maximum at which week?

Accepted Answer

30-32 wks

Answer

26-28 wks

Answer

34-36 wks

Answer

32-34 wks

Question 3

What is the most common cause of hydrops fetalis in current medical practice?

Accepted Answer

Cardiac malformations

Answer

Fetal infections (e.g., parvovirus B19)

Answer

Chromosomal abnormalities

Answer

Rh incompatibility (historically significant)

Question 4

Which of the following statements about the contraction stress test (CST) is MOST accurate?

Accepted Answer

Negative test is associated with good fetal outcome

Answer

Invasive method

Answer

Detects fetal well being

Answer

Oxytocin is never used in the test

Question 5

What is the most common site for ectopic pregnancies?

Accepted Answer

Ampulla

Answer

Isthmus

Answer

Fimbriae

Answer

Interstitial/Cornual

Question 6

Which of the following is the MOST CRITICAL indication for Acyclovir use during pregnancy?

Accepted Answer

Treatment of disseminated herpes

Answer

Treatment of chickenpox in the first trimester

Answer

Prophylaxis for recurrent herpes during pregnancy

Answer

Prevention of cytomegalovirus infection in pregnancy

Question 7

A hypertensive pregnant woman at 34 weeks presents with a history of abdominal pain, bleeding per vaginum, and loss of fetal movements. On examination, the uterus is contracted with increased uterine tone, and fetal heart sounds are absent. Which of the following is the most likely diagnosis?

Accepted Answer

Abruptio placenta

Answer

Polyhydramnios

Answer

Premature labour

Answer

Placenta previa

Question 8

Most sensitive diagnostic test for ectopic pregnancy is which one?

Accepted Answer

Transvaginal USG

Answer

Serial monitoring of beta HCG

Answer

Culdocentesis

Answer

MRI

Question 9

All of the following are associated with breech presentation at normal full-term pregnancy, except:

Accepted Answer

Placenta accreta

Answer

Fetal malformation

Answer

Uterine anomaly

Answer

Cornual implantation of placenta

Question 10

On USG finding of cystic hygroma in a fetus is suggestive of:

Accepted Answer

Turner's syndrome

Answer

Down's syndrome

Answer

Marfan's syndrome

Answer

Klinefelter's syndrome

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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