Maternal-Fetal Medicine Practice Questions

Q: Which of the following procedures is not performed in a case of complete hydatidiform mole (CHM)?

Caesarean section. ***Caesarean section*** - Caesarean section is **NOT performed** for the management of complete hydatidiform mole (CHM). - The standard treatment for CHM is **suction evacuation (suction curettage)**, which is the procedure of choice for removing molar tissue from the uterus. - Caesarean section is a surgical procedure for **delivering a fetus**, not for evacuating gestational trophoblastic disease. - There is **no indication** for Caesarean section in CHM management, even in cases of large molar volume. *Abortion (Suction evacuation)* - **Suction evacuation/curettage** is the primary and definitive treatment for complete hydatidiform mole. - This procedure involves removing the abnormal trophoblastic tissue from the uterus under ultrasound guidance. - It is sometimes referred to as therapeutic abortion in the medical literature. - **Oxytocin infusion** is typically started after evacuation begins to minimize bleeding. *Blood transfusion* - CHM can present with **significant vaginal bleeding**, potentially leading to severe anemia. - **Blood transfusion** may be necessary to correct anemia and stabilize hemodynamic status. - Pre-operative **hemoglobin assessment** and blood grouping/cross-matching are routine in CHM management. *Urine microscopy and culture sensitivity* - While not a routine part of CHM management, this test **may be performed** if there are clinical signs of urinary tract infection. - Patients with CHM may have urinary symptoms due to uterine enlargement or other complications. - This is **not a standard procedure** for all CHM cases but may be indicated based on clinical presentation.

Q: Sonography of a term multigravida shows an amniotic fluid index of 3 cm. The fetus may have which condition?

Renal agenesis. ***Renal agenesis*** - An **Amniotic Fluid Index (AFI)** of 3 cm indicates **oligohydramnios**, which is a severely reduced amount of amniotic fluid. - **Fetal urine production** is a major source of amniotic fluid in the second half of pregnancy, and conditions like renal agenesis or severe renal obstruction prevent urine formation, leading to oligohydramnios. *Esophageal atresia* - This condition is associated with **polyhydramnios** (excess amniotic fluid) because the fetus cannot swallow the amniotic fluid. - Oligohydramnios is typically not seen with esophageal atresia. *Spina bifida* - **Neural tube defects** like spina bifida are not typically associated with oligohydramnios. - They are sometimes linked to **polyhydramnios** if there is impaired fetal swallowing due to brainstem involvement, or normal amniotic fluid levels. *Chorioangioma of the placenta* - A **chorioangioma** is a benign placental tumor that can rarely cause **polyhydramnios** due to increased blood flow to the tumor, leading to increased transudation of fluid. - It would not lead to **oligohydramnios**.

Q: Which of the following is NOT a characteristic of the recipient twin in a monochorionic twin gestation affected by twin-twin transfusion syndrome?

Hypovolemia. ***Hypovolemia*** - The recipient twin in twin-twin transfusion syndrome (TTTS) experiences **hypervolemia** due to excessive blood flow from the donor twin, not hypovolemia. - This increased blood volume leads to **polycythemia** and volume overload. - Hypovolemia is actually a characteristic of the **donor twin**, not the recipient. *Thrombosis* - The recipient twin has **polycythemia** and increased blood viscosity due to hypervolemia, which increases the risk of **thrombosis**. - This hyperviscosity can lead to **vascular occlusions** in various organs. *Polyhydramnios* - The recipient twin characteristically develops **polyhydramnios** (excessive amniotic fluid) due to increased urine output from hypervolemia. - This is one of the **classic ultrasound findings** in TTTS, with the recipient showing a large fluid-filled sac. *Heart failure* - The recipient twin's heart has to pump an increased volume of blood, leading to **cardiac overload** and hypertrophy. - This chronic workload can eventually result in **congestive heart failure** and hydrops fetalis.

Q: Vasa previa in a term gestation is managed by __________.

Immediate LSCS. ***Immediate LSCS*** - **Vasa previa** is an obstetric complication where fetal blood vessels course unprotected within the membranes over the cervical os. - Due to the high risk of **fetal exsanguination** and mortality with membrane rupture, immediate and planned **Lower Segment Cesarean Section (LSCS)** is the safest management. *Rapid induction and delivery by forceps* - **Vaginal delivery**, even with rapid induction, is contraindicated in vasa previa due to the high risk of fetal blood vessel rupture when membranes fully rupture or during cervical dilation. - The use of **forceps** would further increase the risk of trauma to the unprotected fetal vessels. *Expectant management and vaginal delivery* - **Expectant management** until labor begins or membranes rupture carries an extremely high risk of fetal death due to hemorrhage. - **Vaginal delivery** is absolutely contraindicated because the pressure from the presenting part and the process of cervical dilation will inevitably lead to rupture of the unprotected fetal vessels. *Rapid induction and delivery by vacuum* - Similar to forceps, **vacuum extraction** increases the risk of trauma to the fetal vessels due to increased pressure on the presenting part during delivery. - **Rapid induction** still leaves the fetus vulnerable to vessel rupture during labor and vaginal delivery.

Q: A 30-year-old primigravida at 36 weeks of pregnancy presents with a blood pressure of 160/110 mmHg, 3+ urinary albumin, and a platelet count of 80,000/mm3. What is the most appropriate management option?

Magnesium sulfate for seizure prophylaxis. ***Magnesium sulfate for seizure prophylaxis*** - This patient has **severe preeclampsia** (BP ≥160/110 mmHg, significant proteinuria, thrombocytopenia), making her at **high risk for eclamptic seizures**. - **Magnesium sulfate** is the **first-line treatment** and must be initiated immediately for **seizure prophylaxis** in severe preeclampsia. - According to **ACOG and RCOG guidelines**, magnesium sulfate should be started **before delivery** and is the most critical immediate intervention to prevent maternal mortality and morbidity. - While delivery is the definitive treatment for preeclampsia, magnesium sulfate must be administered first to stabilize the patient. *Urgent LSCS* - At **36 weeks with severe preeclampsia**, delivery is indicated within 24-48 hours, but **cesarean section is not automatically required**. - The **mode of delivery** depends on **obstetric factors** (cervical favorability, fetal presentation, previous cesarean, etc.), not the preeclampsia diagnosis itself. - With a platelet count of **80,000/mm³**, vaginal delivery is generally safe (platelets >50,000/mm³ are adequate for labor). - **Labor induction** would be appropriate first-line unless there are specific obstetric contraindications to vaginal delivery. *Labetalol for hypertension* - **Antihypertensive therapy** is important to prevent maternal stroke when BP is ≥160/110 mmHg. - However, **magnesium sulfate takes priority** as the immediate life-saving intervention for seizure prevention. - Labetalol would be administered concurrently but is not the single most appropriate answer. *Labour induction* - Labor induction is an appropriate method of delivery for severe preeclampsia at ≥34 weeks gestation. - However, **before proceeding with delivery**, the patient must be **stabilized with magnesium sulfate** and antihypertensives. - Induction would follow after initial stabilization with magnesium sulfate.

Q: A 20-year-old woman has been brought to the casualty with a blood pressure of 70/40 mmHg, a pulse rate of 120/min, and a positive urine pregnancy test. She should be managed by:

Immediate laparotomy for ruptured ectopic pregnancy. ***Immediate laparotomy for ruptured ectopic pregnancy*** - The patient presents with classic signs of **hypovolemic shock (BP 70/40 mmHg, pulse 120/min)** in the setting of a positive pregnancy test, strongly indicating a **ruptured ectopic pregnancy**. - This is a **life-threatening emergency** requiring immediate surgical intervention to control bleeding and stabilize the patient. *Laparoscopy for diagnosis* - While laparoscopy can be used for diagnosis and treatment of ectopic pregnancy, it is **contraindicated in unstable patients** due to the increased risk associated with pneumoperitoneum and a longer operative time compared to laparotomy for an actively bleeding rupture. - In a hemodynamically unstable patient, the priority is rapid control of hemorrhage, which is often best achieved via **laparotomy**. *Resuscitation without surgical intervention* - Resuscitation is crucial, but it must be performed **concurrently with preparations for immediate surgical intervention**. - Resuscitation alone will not address the source of internal bleeding, which can lead to further deterioration and death. *Culdocentesis for fluid analysis* - **Culdocentesis** involves aspirating fluid from the pouch of Douglas to check for hemoperitoneum, but it is an **invasive procedure with limited diagnostic utility** in the age of ultrasound. - More importantly, it **delays definitive management** and offers no therapeutic benefit in an unstable patient with suspected ruptured ectopic pregnancy.

Q: What is the most serious complication of maternal varicella infection during late pregnancy?

Severe neonatal varicella in the newborn.. ***Severe neonatal varicella in the newborn.*** - If a pregnant mother contracts **varicella** in the last 5 days before delivery or up to 2 days postpartum, the newborn is at risk for **severe, disseminated neonatal varicella**, which can be fatal. - This is because the mother does not have enough time to produce and transfer protective **antibodies** to the fetus before birth. - Mortality rates can reach 20-30% without treatment, making this the most serious complication of late pregnancy maternal varicella infection. *Affects the limbs more than the trunk.* - This statement refers to **congenital varicella syndrome**, which occurs with maternal infection in the first 20 weeks of pregnancy, not late pregnancy. - Congenital varicella syndrome characteristically presents with **skin scarring** in a dermatomal distribution, **limb hypoplasia**, and neurologic and ocular defects. *May cause pneumonitis.* - While **varicella pneumonitis** is a serious complication for the **mother** if infected during pregnancy, it is not a complication affecting the **newborn** due to late pregnancy maternal infection. - The question asks about complications of maternal infection during late pregnancy, and the most serious outcome for the **fetus/newborn** is severe neonatal varicella, not maternal pneumonitis. *Is commonly seen in a congenital form.* - **Congenital varicella syndrome** (the "congenital form") is rare and results from maternal infection during the **first 20 weeks of gestation**, not late pregnancy. - Late pregnancy infection leads to **neonatal varicella**, which is a distinct and often more severe acute entity compared to the chronic congenital syndrome.

Q: Which of the following measures is NOT effective in reducing perinatal HIV transmission?

Breastfeeding. ***Breastfeeding*** - Breastfeeding is **NOT effective in reducing perinatal HIV transmission** - in fact, it is a route of HIV transmission from mother to child. - In resource-rich settings, HIV-positive mothers are advised against breastfeeding because breast milk can transmit HIV, with transmission risk of 5-20% through prolonged breastfeeding. - While breastfeeding offers nutritional and immunological benefits, the risk of HIV transmission outweighs these benefits when safe alternatives (formula feeding) are available. - **This is the correct answer** to the question asking what is "NOT effective" in reducing transmission. *Delivery by elective cesarean section* - An **elective cesarean section** before the onset of labor or rupture of membranes significantly reduces the risk of vertical HIV transmission. - This method avoids the neonate's exposure to maternal blood and genital secretions during vaginal delivery. - Reduces transmission risk by approximately 50% when used alone, and even more when combined with ART. *Antiretroviral therapy to the neonate* - Administering **antiretroviral therapy (ART)** to the neonate, typically within hours of birth and continuing for 4-6 weeks, is crucial in preventing HIV infection. - This post-exposure prophylaxis can prevent establishment of HIV infection that may have been acquired during delivery or in utero. - Reduces transmission risk significantly, especially when maternal viral load is high. *Intrapartum antiretroviral therapy* - **Intrapartum antiretroviral therapy** involves administering ART to the mother during labor and delivery. - This helps reduce the maternal viral load at the time of birth, thereby minimizing the risk of HIV transmission to the neonate. - Part of the comprehensive approach to prevent mother-to-child transmission (PMTCT).

Q: A female with 6 weeks of amenorrhea presents with an ovarian cyst that requires surgical intervention. The optimal timing for surgery is:

Ovariotomy at second trimester. ***Ovariotomy at second trimester*** - The **second trimester (14-28 weeks)** is the optimal time for surgical management of ovarian cysts in pregnancy requiring intervention. - During this period, the risk of **miscarriage** is significantly reduced compared to the first trimester, as the placenta has taken over progesterone production. - Fetal organogenesis is complete, and the uterus size allows for adequate surgical access with minimal risk of injury. - Most functional cysts (corpus luteum) have resolved spontaneously by this time, so persistent cysts are more likely to be true neoplasms requiring removal. *Immediate ovariotomy* - Performing **immediate surgery** at 6 weeks of amenorrhea carries a high risk of **miscarriage** due to surgical stress and anesthesia effects. - At this early stage of pregnancy, the corpus luteum is essential for progesterone production, and its disruption could threaten pregnancy viability. - Surgery in the first trimester should be reserved only for acute complications like **torsion** or **rupture**. *Ovariotomy 24 hours after delivery* - Waiting until 24 hours after delivery would delay treatment unnecessarily for a cyst requiring intervention, potentially leading to complications like **torsion**, **rupture**, or **hemorrhage** during pregnancy. - If the cyst is large or suspicious, allowing it to persist throughout pregnancy increases maternal morbidity risk. - However, expectant management throughout pregnancy is appropriate for simple, asymptomatic cysts. *Ovariotomy with cesarean* - Performing **ovariotomy concurrently with Cesarean section** significantly increases operative time, blood loss, and risk of postpartum complications. - This approach is only justified if the cyst is causing obstruction of labor or has highly suspicious features for malignancy. - Routine combination of these procedures is not recommended for benign ovarian pathology.

Question 1

Which of the following procedures is not performed in a case of complete hydatidiform mole (CHM)?

Accepted Answer

Caesarean section

Answer

Blood transfusion

Answer

Urine microscopy and culture sensitivity

Answer

Abortion

Question 2

Sonography of a term multigravida shows an amniotic fluid index of 3 cm. The fetus may have which condition?

Accepted Answer

Renal agenesis

Answer

Esophageal atresia

Answer

Spina bifida

Answer

Chorioangioma of the placenta

Question 3

A 28-week pregnant female presents with fetal distress on examination, and the MCA Doppler study is as follows. What should be the next step in management?

Accepted Answer

Give steroid cover, monitor with Doppler and BPP, and plan delivery.

Answer

Immediate termination of pregnancy

Answer

Give steroid and take up for CS immediately

Answer

Go for normal vaginal delivery as baby is very small

Question 4

Which of the following is NOT a characteristic of the recipient twin in a monochorionic twin gestation affected by twin-twin transfusion syndrome?

Accepted Answer

Hypovolemia

Answer

Heart failure

Answer

Thrombosis

Answer

Polyhydramnios

Question 5

Vasa previa in a term gestation is managed by __________.

Accepted Answer

Immediate LSCS

Answer

Rapid induction and delivery by forceps

Answer

Expectant management and vaginal delivery

Answer

Rapid induction and delivery by vacuum

Question 6

A 30-year-old primigravida at 36 weeks of pregnancy presents with a blood pressure of 160/110 mmHg, 3+ urinary albumin, and a platelet count of 80,000/mm3. What is the most appropriate management option?

Accepted Answer

Magnesium sulfate for seizure prophylaxis

Answer

Labetalol for hypertension

Answer

Labour induction

Answer

Urgent LSCS

Question 7

A 20-year-old woman has been brought to the casualty with a blood pressure of 70/40 mmHg, a pulse rate of 120/min, and a positive urine pregnancy test. She should be managed by:

Accepted Answer

Immediate laparotomy for ruptured ectopic pregnancy

Answer

Laparoscopy for diagnosis

Answer

Resuscitation without surgical intervention

Answer

Culdocentesis for fluid analysis

Question 8

What is the most serious complication of maternal varicella infection during late pregnancy?

Accepted Answer

Severe neonatal varicella in the newborn.

Answer

Affects the limbs more than the trunk.

Answer

May cause pneumonitis.

Answer

Is commonly seen in a congenital form.

Question 9

Which of the following measures is NOT effective in reducing perinatal HIV transmission?

Accepted Answer

Breastfeeding

Answer

Delivery by elective cesarean section

Answer

Antiretroviral therapy to the neonate

Answer

Intrapartum antiretroviral therapy

Question 10

A female with 6 weeks of amenorrhea presents with an ovarian cyst that requires surgical intervention. The optimal timing for surgery is:

Accepted Answer

Ovariotomy at second trimester

Answer

Ovariotomy with cesarean

Answer

Ovariotomy 24 hours after delivery

Answer

Immediate ovariotomy

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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