Maternal-Fetal Medicine Practice Questions

Q: Which antihypertensive is considered the first-line treatment in pregnancy?

Labetalol. ***Labetalol*** - **Labetalol** is a **beta-blocker** with **alpha-blocking activity** and is widely considered a **first-line agent** for **hypertension in pregnancy** due to its established safety profile and effectiveness. - It effectively **lowers blood pressure** without significantly compromising **placental perfusion** or causing adverse fetal effects, making it a preferred choice for both **chronic and gestational hypertension**. - Along with **methyldopa**, labetalol is recommended as a first-line agent by major guidelines, with **labetalol increasingly preferred** in modern practice due to its more rapid onset and better tolerability. *Hydralazine* - **Hydralazine** is a **direct arterial vasodilator** typically used for **acute severe hypertension in pregnancy**, such as in **preeclampsia with severe features** or **eclampsia**. - While effective in emergent situations, it is generally **not favored as first-line treatment** for chronic management due to reflex tachycardia and the need for frequent dosing. *Propranolol* - **Propranolol** is a **non-selective beta-blocker** that is **less preferred** for chronic hypertension in pregnancy compared to other options like labetalol or methyldopa. - Its use has been associated with concerns regarding **fetal growth restriction** and **neonatal bradycardia**, especially with prolonged use. *Alpha methyl dopa* - **Alpha methyl dopa** is a **centrally acting alpha-2 adrenergic agonist** that has the **longest safety record** for **hypertension in pregnancy** and is considered a **first-line agent** by WHO and other international guidelines. - While it has extensive safety data spanning decades, **labetalol is often preferred in current practice** due to its more rapid onset of action, better maternal tolerability, and lower incidence of side effects like sedation.

Q: A 27-year-old primigravida presents with pre-eclampsia, with a blood pressure of 150/100 mmHg at 32 weeks of gestation. If there are no complications, the pregnancy should be best terminated at:

37 completed weeks.. ***37 completed weeks.*** - For women with **pre-eclampsia without severe features** and **no complications**, delivery is typically recommended at **37 weeks of gestation**. - This timing balances the risks of prematurity with the potential for disease progression or complications if the pregnancy continues. *40 completed weeks.* - Continuing the pregnancy until 40 weeks in a pre-eclamptic patient, even without severe features, increases the risk of **maternal and fetal complications**. - There is a higher likelihood of disease progression, **placental insufficiency**, and adverse outcomes beyond 37 weeks in such cases. *35 completed weeks.* - Delivery at 35 completed weeks would be considered **late preterm** and is generally reserved for cases of **pre-eclampsia with severe features** or other complications. - While pre-eclampsia is present, the absence of complications or severe features indicates that the benefits of prolonging the pregnancy to improve fetal lung maturity outweigh the risks at this stage. *34 completed weeks.* - Delivery at 34 completed weeks is considered **moderately preterm** and is usually indicated for **severe pre-eclampsia** or other urgent medical conditions. - In a patient with mild pre-eclampsia and no complications, extending the pregnancy to at least 37 weeks allows for further optimal fetal development.

Q: Which of the following is not seen in hypertensive disorders of pregnancy?

Macrosomia. ***Macrosomia*** - **Macrosomia** (large-for-gestational-age infant) is typically associated with **gestational diabetes,** not hypertensive disorders of pregnancy. - Hypertensive disorders often lead to **fetal growth restriction** due to reduced placental blood flow. *Eclampsia* - **Eclampsia** is defined by **new-onset grand mal seizures** in a woman with preeclampsia, underscoring its direct link to hypertensive disorders. - It represents a severe manifestation of **preeclampsia**, a hypertensive disorder, and is therefore seen in these conditions. *HELLP syndrome* - **HELLP syndrome** (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe obstetric complication considered a variant of **preeclampsia**. - It is a life-threatening condition directly associated with **hypertensive disorders of pregnancy.** *Proteinuria* - **Proteinuria** is a hallmark diagnostic criterion for **preeclampsia**, indicating kidney involvement and endothelial dysfunction. - Its presence is crucial in defining and classifying **hypertensive disorders of pregnancy.**

Q: A 3rd gravida with normal previous two pregnancies. What is the best test to diagnose Rh sensitization in an Rh-negative mother?

Indirect Coombs' test. ***Indirect Coombs' test*** - The **indirect Coombs' test** (or **indirect antiglobulin test, IAT**) is the **gold standard** for detecting **Rh antibodies** in the **mother's serum**, indicating **Rh sensitization**. - This test detects **free antibodies** circulating in maternal blood that can cross the placenta and attack fetal Rh-positive red blood cells. - A positive result means the mother has developed **anti-D antibodies** against Rh-positive fetal RBCs, which can cause **hemolytic disease of the fetus and newborn (HDFN)**. - Performed at **first antenatal visit**, **28 weeks**, and **after delivery** in Rh-negative mothers to guide **RhoGAM administration**. *Direct Coombs' test* - The **direct Coombs' test** (or **direct antiglobulin test, DAT**) is performed on the **infant's red blood cells** after birth, not the mother's serum. - It detects antibodies **already bound** to neonatal RBCs, confirming if hemolysis is occurring in the newborn. - This does **not diagnose maternal sensitization** but rather assesses the **severity of HDFN** in the affected infant. *Rh Antigen test* - This test determines the **Rh status** (positive or negative) of an individual by detecting the presence of the **D antigen** on red blood cells. - It identifies **who is at risk** (Rh-negative mother with Rh-positive baby) but does **not detect antibodies** or confirm sensitization. - It is a prerequisite screening test, not a diagnostic test for sensitization. *Rh Sensitization test* - This is a **non-specific descriptive term**, not an actual standardized laboratory test. - While the clinical goal is to assess for "Rh sensitization," the **specific test** that accomplishes this is the **indirect Coombs' test**.

Q: What examination will confirm premature rupture of membranes in a 34-week pregnant patient with complaints of leaking vaginal discharge?

Speculum examination. ***Speculum examination*** - A **sterile speculum examination** allows direct visualization of the cervix and vaginal vault to identify **pooling of amniotic fluid** or fluid leaking from the cervical os. - It also enables collection of samples for **nitrazine testing** (to confirm alkaline pH) and **ferning test** (to observe characteristic fern-like crystallization of amniotic fluid). *Digital vaginal examination* - This is generally **avoided** in suspected premature rupture of membranes (PROM) due to the increased risk of **introducing infection** into the birth canal, especially if the patient is not in active labor. - It does not directly visualize the leakage of fluid and is less sensitive for diagnosing PROM than speculum examination. *Ultrasound examination* - While ultrasound can assess **amniotic fluid volume**, which might be reduced in PROM, it is not a direct diagnostic test for the rupture itself. - A normal fluid volume does not rule out a small leak, and a low volume can have other causes. *Urine analysis* - Urine analysis is used to detect conditions like **urinary tract infections** or **proteinuria**, but it does not provide information about the integrity of the amniotic sac. - It cannot differentiate amniotic fluid from urine or vaginal secretions.

Q: What is the most important intervention following antenatal maternal HIV diagnosis?

To prevent vertical transmission. ***To prevent vertical transmission*** - The most critical intervention following an antenatal maternal **HIV diagnosis** is to initiate strategies to **prevent mother-to-child (vertical) transmission** of the virus. - This involves **antiretroviral therapy (ART)** for the mother, safe delivery practices, and interventions for the newborn, significantly reducing transmission risk. *To terminate the pregnancy immediately* - **Termination of pregnancy** is generally not recommended solely due to an HIV diagnosis, as effective interventions can prevent vertical transmission. - Abortion is a personal choice and not a standard medical intervention for managing maternal HIV. *To discharge with routine follow-up* - A diagnosis of **maternal HIV** requires immediate and specialized attention, not just routine follow-up, to implement preventative measures. - **Immediate intervention** is necessary to reduce the risk of vertical transmission and manage maternal health. *To isolate the patient from other pregnant women* - **HIV is not transmitted through casual contact**, so there is no medical reason to isolate an HIV-positive pregnant woman from others. - Such isolation would be discriminatory and medically unfounded, as the primary concern is vertical transmission, not horizontal transmission in a healthcare setting.

Q: Which of the following is false about gestational hypertension?

Perinatal mortality remains unaffected. ***Perinatal mortality remains unaffected*** - This statement is false because **gestational hypertension** can significantly *increase* the risk of perinatal morbidity and mortality due to complications like **placental abruption** and **fetal growth restriction**. - While typically less severe than preeclampsia, gestational hypertension is still associated with adverse outcomes for both mother and fetus, including increased rates of **preterm birth** and **intrauterine growth restriction (IUGR)**. *There is a sustained rise of BP > 140/90 mmHg* - This is a diagnostic criterion for gestational hypertension: **systolic blood pressure ≥ 140 mmHg** or **diastolic blood pressure ≥ 90 mmHg** on two occasions at least four hours apart. - This **hypertension** typically appears after **20 weeks of gestation** in a previously normotensive woman, without proteinuria. *Blood pressure returns to normal within 12 weeks of delivery* - By definition, gestational hypertension resolves by **12 weeks postpartum**; if it persists beyond this period, the diagnosis is reclassified as **chronic hypertension**. - This transient nature of **elevated blood pressure** after delivery is a key differentiating feature from chronic hypertension. *It is associated with lower incidence of essential hypertension in the later life as compared to preeclampsia* - While both gestational hypertension and preeclampsia increase the risk of **future chronic hypertension**, the risk is *lower* for women with isolated gestational hypertension compared to those who experienced preeclampsia. - Both conditions are considered risk factors for **cardiovascular disease** later in life, but preeclampsia specifically signals a higher risk.

Q: Placenta previa risk increases with the following except:

Contraceptive use. ***Contraceptive use*** - There is currently **no scientific evidence** to suggest that contraceptive use increases the risk of **placenta previa**. - Contraceptive use is not associated with placental implantation abnormalities in subsequent pregnancies. *Maternal age >35 yrs* - **Advanced maternal age** is a well-established risk factor for placenta previa, as the uterine lining may be less favorable for normal implantation in older women. - The risk of placental abnormalities, including **placenta previa**, increases with each decade of maternal age beyond 35 years. *Multiparity* - **Multiparity**, or having had multiple previous pregnancies, increases the risk of placenta previa. - This is thought to be due to **scarring or changes in the uterine lining** from previous pregnancies and deliveries, leading to preferential implantation in the lower uterine segment. *Previous cesarean section* - **Prior cesarean delivery** is one of the **most significant risk factors** for placenta previa. - Uterine scarring from cesarean section damages the endometrium, leading to abnormal placental implantation. - The risk increases with the **number of previous cesarean sections** and may lead to placenta previa with accreta spectrum disorders.

Q: Fetal lung maturity assessed by all except -

Measurement of alpha-fetoprotein. ***Measurement of alpha-fetoprotein*** - **Alpha-fetoprotein (AFP)** is a marker for **neural tube defects** and **chromosomal abnormalities**, not fetal lung maturity. - While AFP is found in amniotic fluid, its levels do not correlate with the production of **surfactant** or the development of mature lung function. *Lecithin: sphingomyelin ratio* - The **lecithin: sphingomyelin (L:S) ratio** is a classic and reliable indicator of fetal lung maturity. - A ratio of **2:1 or higher** generally suggests sufficient **pulmonary surfactant** production, reducing the risk of **respiratory distress syndrome (RDS)**. *Phosphatidyl choline concentration in amniotic fluid* - **Phosphatidylcholine**, also known as **lecithin**, is a primary component of **surfactant**, which prevents alveolar collapse. - Measuring its concentration, specifically the **disaturated phosphatidylcholine (DSPC)**, directly assesses the lung's ability to produce adequate surfactant. *Lamellar body count* - **Lamellar bodies** are surfactant storage organelles secreted by type II pneumocytes into the amniotic fluid. - A count of **≥50,000/μL** indicates fetal lung maturity, and this test correlates well with the L:S ratio while being faster and more cost-effective.

Question 1

Which antihypertensive is considered the first-line treatment in pregnancy?

Accepted Answer

Labetalol

Answer

Hydralazine

Answer

Propranolol

Answer

Alpha methyl dopa

Question 2

Which of the following statements is true regarding twin-to-twin transfusion syndrome?

Accepted Answer

The recipient twin develops hydramnios more often than does the donor twin.

Answer

The donor twin is more likely to develop widespread thromboses

Answer

The donor twin usually suffers from anemia.

Answer

Gross differences may be observed between donor and recipient placentas

Question 3

A 27-year-old primigravida presents with pre-eclampsia, with a blood pressure of 150/100 mmHg at 32 weeks of gestation. If there are no complications, the pregnancy should be best terminated at:

Accepted Answer

37 completed weeks.

Answer

35 completed weeks.

Answer

40 completed weeks.

Answer

34 completed weeks.

Question 4

Which of the following is not seen in hypertensive disorders of pregnancy?

Accepted Answer

Macrosomia

Answer

HELLP syndrome

Answer

Proteinuria

Answer

Eclampsia

Question 5

A 3rd gravida with normal previous two pregnancies. What is the best test to diagnose Rh sensitization in an Rh-negative mother?

Accepted Answer

Indirect Coombs' test

Answer

Direct Coombs' test

Answer

Rh Antigen test

Answer

Rh Sensitization test

Question 6

What examination will confirm premature rupture of membranes in a 34-week pregnant patient with complaints of leaking vaginal discharge?

Accepted Answer

Speculum examination

Answer

Digital vaginal examination

Answer

Ultrasound examination

Answer

Urine analysis

Question 7

What is the most important intervention following antenatal maternal HIV diagnosis?

Accepted Answer

To prevent vertical transmission

Answer

To discharge with routine follow-up

Answer

To terminate the pregnancy immediately

Answer

To isolate the patient from other pregnant women

Question 8

Which of the following is false about gestational hypertension?

Accepted Answer

Perinatal mortality remains unaffected

Answer

There is a sustained rise of BP > 140/90 mmHg

Answer

Blood pressure returns to normal within 12 weeks of delivery

Answer

It is associated with lower incidence of essential hypertension in the later life as compared to preeclampsia

Question 9

Placenta previa risk increases with the following except:

Accepted Answer

Contraceptive use

Answer

Maternal age >35 yrs

Answer

Multiparity

Answer

Previous cesarean section

Question 10

Fetal lung maturity assessed by all except -

Accepted Answer

Measurement of alpha-fetoprotein

Answer

Phosphatidyl choline concentration in amniotic fluid

Answer

Lecithin: sphingomyelin ratio

Answer

Lamellar body count

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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