Maternal-Fetal Medicine Practice Questions

Q: Which sign is seen in ultrasound for monochorionic diamniotic twins?

T sign. ***T sign*** - The **T sign** is visualized on ultrasound when the inter-twin membrane inserts perpendicularly onto the chorionic plate, forming a "T" shape. - This specific finding indicates a **monochorionic twin gestation**, meaning they share a single chorion. *Lambda sign* - The **lambda (or twin peak) sign** is seen in dichorionic twin pregnancies, where the chorion extends into the base of the inter-twin membrane, forming a triangular projection. - This sign signifies the presence of **two separate chorions**, indicating a lower risk compared to monochorionic pregnancies. *Twin peak sign* - The **twin peak sign** is synonymous with the lambda sign and indicates a **dichorionic-diamniotic** twin pregnancy. - It results from the extension of placental tissue into the base of the inter-twin membrane, confirming two separate chorions. *Membrane thickness >2mm* - A **thick inter-twin membrane (>2mm)** is typically associated with **dichorionic-diamniotic** pregnancies due to the presence of two separate chorions and amnions. - In monochorionic-diamniotic pregnancies, the membrane is usually **thin** because it only consists of two amniotic layers.

Q: Which of the following interventions has the STRONGEST evidence for reducing the risk of preeclampsia in high-risk pregnant women?

Low-dose aspirin (75-150 mg daily). ***Low-dose aspirin (75-150 mg daily)*** - **Low-dose aspirin** started before 16 weeks of gestation is the **only intervention with robust evidence** for reducing preeclampsia risk in high-risk women (ACOG, WHO, USPSTF recommendations). - Meta-analyses show **17-25% relative risk reduction** in preeclampsia when started early in pregnancy. - Recommended for women with history of preeclampsia, chronic hypertension, diabetes, kidney disease, or multifetal gestation. - Acts by **improving placental perfusion** and reducing thromboxane-mediated vasoconstriction. *Calcium supplementation (1.5-2g daily)* - **Calcium supplementation** shows benefit in **populations with low dietary calcium intake** (typically <600 mg/day). - Less effective in populations with adequate baseline calcium intake (most developed countries). - **WHO recommends** calcium for women in low-calcium settings but **not as first-line** in general high-risk populations. *Smoking cessation* - **Essential for healthy pregnancy** and reduces risks of placental abruption, preterm birth, and IUGR. - While smoking is associated with adverse outcomes, **cessation has not been proven to directly prevent preeclampsia**. - Some studies paradoxically show lower preeclampsia rates in smokers (confounded by lower PlGF levels), but smoking increases overall maternal-fetal morbidity. *Regular blood pressure monitoring* - **Critical for early detection** and management of hypertensive disorders but **does not prevent** their occurrence. - Allows timely intervention to **prevent progression to severe disease** and eclampsia. - Part of routine antenatal care but is a **surveillance measure, not a preventive intervention**.

Q: Which of the following is a possible cause for the 'lambda' or 'twin peak' sign seen on ultrasound examination of a twin pregnancy?

Dichorionic Diamniotic Twins. ***Dichorionic Diamniotic Twins*** - This type of twinning occurs from two separate fertilization events, resulting in **two placentas** and **two amniotic sacs**. - On ultrasound, this would be represented by separate amniotic membranes and a thick, often triangular, inter-twin membrane (the **'lambda' or 'twin peak' sign**), indicating separate chorions. *Monochorionic Monoamniotic Twins* - These twins share **one placenta** and **one amniotic sac**, meaning there is no separating membrane between them. - This high-risk pregnancy is characterized by a lack of an inter-twin membrane on ultrasound. *Monochorionic Diamniotic Twins* - These twins share **one placenta** but have **two separate amniotic sacs**. - On ultrasound, a thin inter-twin membrane is visible, but this membrane does not contain chorionic tissue (it's often described as a **'T-sign'** where the membrane meets the chorion). *Conjoint Twins* - Conjoined twins are a rare form of monochorionic monoamniotic twins where the embryos **fail to completely separate**. - The ultrasound finding would show shared body parts, not simply specific membrane characteristics.

Q: What is the first-line drug of choice for managing seizures in eclampsia?

Magnesium Sulphate. ***Magnesium Sulphate*** - **Magnesium sulphate** is the **first-line drug of choice** for both the prevention and treatment of seizures in **eclampsia** due to its superior efficacy. - It acts as a **central nervous system depressant** and a **vasodilator**, reducing cerebral edema and improving cerebral perfusion. *Nifedipine* - **Nifedipine** is a **calcium channel blocker** used primarily to manage **hypertension**, especially in **preeclampsia**. - While it can lower blood pressure, it is **not indicated** as a first-line agent for directly treating or preventing **eclamptic seizures**. *Hydralazine* - **Hydralazine** is a **direct-acting vasodilator** used to treat **severe hypertension** in pregnancy, including cases of preeclampsia. - Its primary role is blood pressure control, and it is **not effective** in preventing or treating **eclamptic seizures**. *Labetalol* - **Labetalol** is a **beta-blocker** and **alpha-blocker** used for the management of **hypertension** in pregnancy. - Like other antihypertensives, it addresses blood pressure but **does not have a primary role** in seizure management for **eclampsia**.

Q: Least common type of twins is:

Conjoined twins. ***Conjoined twins*** - Conjoined twins are the **rarest form of twinning**, resulting from an incomplete separation of a monozygotic twin embryo. - They carry the **highest risks** and complications, including stillbirth and complex surgical separation challenges. *Diamniotic-dichorionic twins* - These are the **most common type of twins**, representing about 70-80% of all twin pregnancies, whether fraternal or identical. - Each twin has its **own amniotic sac and placenta**, leading to a relatively lower risk profile compared to monochorionic twins. *Diamniotic-monochorionic twins* - This type accounts for approximately 20-30% of all twin pregnancies and always involves **identical twins** sharing one placenta but having separate amniotic sacs. - They are at higher risk for complications like **twin-to-twin transfusion syndrome (TTTS)** due to shared placental circulation. *Monoamniotic-monochorionic twins* - This is a **rare form of identical twinning**, occurring in about 1% of monozygotic pregnancies, where twins share both the same placenta and the same amniotic sac. - The shared amniotic sac significantly increases the risk of **umbilical cord entanglement**, which can be life-threatening for both fetuses.

Q: Placenta with an umbilical cord attached to its margin is called:

Battledore placenta. ***Battledore placenta*** - This term describes a placenta where the **umbilical cord is inserted at the placental margin** (edge), resembling a badminton battledore. - While generally associated with a normal fetal outcome, it can increase the risk of **fetal growth restriction** and **preterm delivery**. *Circumvallate placenta* - Characterized by the fetal membranes (amnion and chorion) folding back on themselves at the edge of the placenta, forming a **thick, opaque ring**. - This condition is associated with an increased risk of **antepartum bleeding**, **placental abruption**, and **preterm labor**. *Succenturiate placenta* - Involves one or more **accessory placental lobes** that develop separately from the main placental disc, connected by blood vessels running through the membranes. - The primary concern is if an accessory lobe or connecting vessels are retained after birth, potentially leading to **postpartum hemorrhage** or **infection**. *Velamentous placenta* - Occurs when the **umbilical cord vessels branch out into the fetal membranes before reaching the placental disc**, making them unprotected by Wharton's jelly. - This configuration puts the vessels at high risk of **compression or rupture**, especially during labor, which can lead to **fetal hypoxia** or **exsanguination** (vasa previa).

Q: Treatment of choice for a 28-week pregnant female with pain due to a 10 cm x 10 cm fibroid in the fundus is:

Observation and symptomatic treatment. ***Observation and symptomatic treatment*** - For a symptomatic fibroid in a **28-week pregnant woman**, conservative management with **analgesics** and rest is the primary approach to avoid harming the fetus. - Complications from fibroids during pregnancy, such as pain, often resolve with conservative care, and surgical intervention is generally reserved for severe, refractory cases. *Uterine artery embolization* - This procedure is **contraindicated in pregnancy** due to the risk of fetal compromise, including ischemia, miscarriage, or preterm labor. - It is typically used for non-pregnant women with symptomatic fibroids who wish to preserve fertility. *Laparoscopic myomectomy* - **Myomectomy during pregnancy** carries a high risk of significant bleeding, uterine contractions, and potential preterm labor or miscarriage. - While open myomectomy may be considered in rare, dire situations (e.g., torsion of a pedunculated fibroid), laparoscopic surgery is generally avoided due to technical difficulties and risks in a gravid uterus. *Abdominal hysterectomy* - **Hysterectomy** involves removal of the uterus and is a definitive treatment for fibroids, but it is **absolutely contraindicated in a pregnant woman** who desires to carry the pregnancy to term. - This procedure would result in the loss of the fetus and the ability to bear children.

Q: Maximal hepatitis C virus transmission to the fetus in pregnancy depends on

High level of HCV RNA. ***High level of HCV RNA*** - A **high maternal viral load (HCV RNA)** is the most significant risk factor for vertical transmission of hepatitis C virus (HCV) to the fetus. - This indicates greater viral replication and a higher chance of the virus crossing the placental barrier or being transmitted during delivery. *Timing of maternal infection* - While the timing of infection can impact overall disease progression, it is **not the primary determinant** of vertical transmission risk. - The **viral load at the time of delivery** is more critical than when the initial infection occurred. *Method of delivery* - Although there is a **slightly increased risk with vaginal delivery** compared to C-section, the **method of delivery is not the strongest predictor** of HCV transmission. - The benefits of a C-section for preventing HCV transmission are generally considered minimal. *Duration of hepatitis C infection* - The **chronicity or duration of infection** itself does not directly correlate with the risk of vertical transmission as strongly as the actual viral load at the time of delivery. - A long-standing infection with a low or undetectable viral load poses a lower risk than a recent infection with a high viral load.

Q: A pregnant woman developed idiopathic cholestatic jaundice. Which clinical feature is most characteristically associated with this presentation?

Intense itching is commonly observed.. ***Intense itching is commonly observed.*** - **Pruritus**, or intense itching, is the most common and often the earliest symptom of **intrahepatic cholestasis of pregnancy (ICP)**, the idiopathic cholestatic jaundice of pregnancy. - The itching in ICP is often generalized, worse at night, and without a skin rash, and it is thought to be caused by the accumulation of **bile acids** in the skin. *SGOT, SGPT levels typically remain below 60 IU.* - While liver transaminases (AST/SGOT and ALT/SGPT) can be mildly elevated in ICP, they generally **do not remain below 60 IU**; levels typically range from slightly elevated to several hundred IU/L. - Significant elevations (e.g., >800 IU/L) would point towards other causes of liver injury, such as viral hepatitis. *Markedly elevated levels of alkaline phosphatase are observed.* - **Alkaline phosphatase (ALP)** is commonly elevated in pregnancy due to its production by the placenta, making it a less specific marker for cholestasis in this context. - While ALP can be elevated in ICP, a "markedly elevated" level would typically be 2-4 times the upper limit of normal, and even higher values can be due to placental isoenzymes, not necessarily reflecting the severity of cholestasis alone. *Serum bilirubin levels typically remain below 5mg/dl.* - Serum bilirubin levels can be elevated in ICP, but they **do not always remain below 5 mg/dL**; while often within this range (typically less than 6 mg/dL), higher levels can occur in more severe cases. - **Hyperbilirubinemia** in ICP is predominantly conjugated (direct) bilirubin, and its elevation contributes to the jaundice.

Question 1

Which sign is seen in ultrasound for monochorionic diamniotic twins?

Accepted Answer

T sign

Answer

Lambda sign

Answer

Twin peak sign

Answer

Membrane thickness >2mm

Question 2

Which of the following interventions has the STRONGEST evidence for reducing the risk of preeclampsia in high-risk pregnant women?

Accepted Answer

Low-dose aspirin (75-150 mg daily)

Answer

Smoking cessation

Answer

Calcium supplementation (1.5-2g daily)

Answer

Regular blood pressure monitoring

Question 3

Which of the following is a possible cause for the 'lambda' or 'twin peak' sign seen on ultrasound examination of a twin pregnancy?

Accepted Answer

Dichorionic Diamniotic Twins

Answer

Monochorionic Monoamniotic Twins

Answer

Monochorionic Diamniotic Twins

Answer

Conjoint Twins

Question 4

Open neural tube defects are best diagnosed by:

Accepted Answer

Detailed fetal ultrasound examination

Answer

Radiographic imaging techniques

Answer

Screening with maternal serum alpha-fetoprotein

Answer

Measurement of acetylcholinesterase in amniotic fluid

Question 5

What is the first-line drug of choice for managing seizures in eclampsia?

Accepted Answer

Magnesium Sulphate

Answer

Nifedipine

Answer

Hydralazine

Answer

Labetalol

Question 6

Least common type of twins is:

Accepted Answer

Conjoined twins

Answer

Diamniotic-dichorionic twins

Answer

Diamniotic-monochorionic twins

Answer

Monoamniotic-monochorionic twins

Question 7

Placenta with an umbilical cord attached to its margin is called:

Accepted Answer

Battledore placenta

Answer

Circumvallate placenta

Answer

Succenturiate placenta

Answer

Velamentous placenta

Question 8

Treatment of choice for a 28-week pregnant female with pain due to a 10 cm x 10 cm fibroid in the fundus is:

Accepted Answer

Observation and symptomatic treatment

Answer

Uterine artery embolization

Answer

Laparoscopic myomectomy

Answer

Abdominal hysterectomy

Question 9

Maximal hepatitis C virus transmission to the fetus in pregnancy depends on

Accepted Answer

High level of HCV RNA

Answer

Timing of maternal infection

Answer

Method of delivery

Answer

Duration of hepatitis C infection

Question 10

A pregnant woman developed idiopathic cholestatic jaundice. Which clinical feature is most characteristically associated with this presentation?

Accepted Answer

Intense itching is commonly observed.

Answer

SGOT, SGPT levels typically remain below 60 IU.

Answer

Markedly elevated levels of alkaline phosphatase are observed.

Answer

Serum bilirubin levels typically remain below 5mg/dl.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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