Maternal-Fetal Medicine Practice Questions

Q: Fetal anaemia is monitored by?

MCA-PSV. ***MCA-PSV*** - **Middle Cerebral Artery-Peak Systolic Velocity (MCA-PSV)** is a non-invasive Doppler ultrasound method to assess for fetal anemia. It measures the peak velocity of blood flow in the fetal middle cerebral artery. - In anemic fetuses, blood viscosity decreases, leading to increased cardiac output and higher cerebral blood flow velocity. A value greater than **1.5 Multiples of the Median (MoM)** for gestational age is highly predictive of moderate to severe fetal anemia. *Maternal blood* - Maternal blood testing, such as the **Indirect Coombs Test (ICT)**, is used to detect maternal antibodies against fetal red blood cells, indicating maternal sensitization and risk of fetal hemolysis. - While a rising titer suggests an increased risk, it does not directly quantify the severity of anemia in the fetus itself; it serves as a screening tool to identify pregnancies needing closer surveillance. *Fetal blood* - Fetal blood sampling, performed via **cordocentesis**, is the gold standard for diagnosing and quantifying the degree of fetal anemia by directly measuring fetal hemoglobin. - However, it is an invasive procedure with significant risks (e.g., fetal loss, hemorrhage) and is reserved for confirming severe anemia indicated by non-invasive tests like MCA-PSV, or for therapeutic intervention like intrauterine transfusion. *Amniocentesis* - Historically, amniocentesis was used to measure the level of bilirubin in the amniotic fluid (spectrophotometry at ΔOD450) as an indirect marker of hemolysis. - This invasive method has been largely replaced by the non-invasive, safer, and more accurate MCA-PSV Doppler assessment for monitoring fetal anemia.

Q: Which of the following drugs is not given for hypertension in pregnancy?

Enalapril. ***Correct: Enalapril*** - **Enalapril** is an **Angiotensin-Converting Enzyme (ACE) inhibitor** which is strictly **contraindicated** throughout pregnancy, particularly during the second and third trimesters - The use of ACE inhibitors is associated with severe **fetal renal dysfunction**, resulting in **oligohydramnios**, **pulmonary hypoplasia**, and **fetal death** - ACE inhibitors are **NOT given** for hypertension in pregnancy due to these serious teratogenic effects *Incorrect: Methyldopa* - **Methyldopa**, a centrally acting **alpha-2 agonist**, is historically considered the first-line and safest drug for treating chronic hypertension during pregnancy - Its extensive use has demonstrated a favorable long-term safety profile for the development of the child - It operates by reducing **sympathetic outflow** from the central nervous system, thereby lowering peripheral vascular resistance *Incorrect: Labetalol* - **Labetalol** is a combined **alpha-1 and non-selective beta-blocker** and is a primary first-line choice for treating both chronic and **acute severe hypertension** in pregnant women - It is rapidly effective and safe, maintaining adequate **placental perfusion** - It exerts its antihypertensive effects by acting as a competitive antagonist at both adrenergic receptors *Incorrect: Nifedipine* - **Nifedipine** is a **dihydropyridine calcium channel blocker** frequently used for managing chronic hypertension and treating acute severe hypertension or **preeclampsia** in pregnancy - It is generally considered safe and effective - Its most common use is often an alternative first-line agent to Labetalol or for the management of hypertensive crises via its extended-release formulation

Q: Which findings are most suggestive of tubal pregnancy?

Adnexal mass with empty uterus and fluid in pelvis. ***Adnexal mass with empty uterus and fluid in pelvis***- The visualization of an **adnexal mass** (corresponding to the tubal gestation) and an **empty uterus** confirms the diagnosis of an ectopic pregnancy.- The presence of **free fluid in the pelvis** (hemoperitoneum) is highly suggestive of a ruptured or leaking tubal pregnancy, representing the most urgent presentation.*Ovarian mass with single layer of endometrium*- An **ovarian mass** suggests pathology involving the ovary itself, such as an ovarian ectopic pregnancy or a cyst, rather than the most common site, the fallopian tube.- The **single layer of endometrium** (thin decidual reaction) may occur in ectopic pregnancy due to insufficient hormonal stimulus but is not sufficient evidence for a tubal location.*Adnexal mass with empty uterus*- While this constellation of findings definitely suggests an **ectopic pregnancy**, it is often indicative of an early and **unruptured** tubal pregnancy.- Lacking **free fluid (blood)** in the pelvis makes this option less suggestive of advanced or complicated tubal pregnancy compared to the correct option.*Trilayer endometrium without adnexal mass*- A **trilayer endometrium** is a typical ultrasound finding during the proliferative phase, or it may be seen in a developing intrauterine pregnancy (IUP).- The absence of an **adnexal mass** essentially excludes the possibility of a tubal ectopic pregnancy.

Q: Identify the given image of the placenta previa.

Marginal. ***Marginal*** - The image illustrates **marginal placenta previa**, where the edge of the placenta is at the margin of the **internal cervical os** but does not cover it. - This position can lead to significant bleeding as the cervix dilates and effaces during labor, potentially tearing the placental edge. *Low lying* - A **low-lying placenta** is when the placental edge is implanted in the lower uterine segment, within **2 cm** of the internal os, but not reaching it. - The image clearly shows the placenta is directly at the edge of the os, which is characteristic of marginal, not low-lying previa. *Incomplete* - **Incomplete** or **partial placenta previa** occurs when the placenta partially covers the internal cervical os. - In the given diagram, the cervical os is not covered at all; the placenta only abuts its margin. *Complete* - **Complete placenta previa** is diagnosed when the placenta entirely covers the **internal cervical os**, obstructing the birth canal. - This is the most severe type and is an absolute indication for a **cesarean section**, whereas the image shows an uncovered os.

Q: Identify the given image of the placenta previa. ![img-50.jpeg](img-50.jpeg)

Marginal. ***Marginal*** - In **marginal placenta previa**, the edge of the placenta is at the margin of the **internal cervical os** but does not cover it, which is consistent with the depiction in the image. - This type can lead to **painless, bright red vaginal bleeding**, particularly in the third trimester as the cervix begins to efface and dilate, causing separation of the placental edge. *Low lying* - A **low-lying placenta** is implanted in the lower uterine segment, and its edge is within **2 cm** of the internal os but does not reach the os itself. - The image shows the placenta directly abutting the os, which distinguishes it from a low-lying placenta where there would be a gap. *Incomplete* - **Incomplete** or **partial placenta previa** occurs when the placenta partially covers the internal cervical os. - The provided image clearly shows the cervical os is not covered by any placental tissue, ruling out this diagnosis. *Complete* - In **complete placenta previa**, the placenta entirely covers the internal cervical os, obstructing the birth canal. - This is the most severe form and is not represented in the image, as the os is visibly unobstructed.

Q: Which of the following is the most common location of implantation in ectopic pregnancy? ![img-40.jpeg](img-40.jpeg)

A. ***A*** - Label A points to the **fallopian tube**, which is the site of over 95% of all ectopic pregnancies. The most common specific location within the tube is the **ampulla** (approximately 80% of tubal ectopics). - Risk factors such as **pelvic inflammatory disease (PID)**, previous tubal surgery, or endometriosis can damage the fallopian tube, impeding the transit of the fertilized ovum to the uterus. *D* - Label D indicates the **uterus**, which is the normal site for implantation in a healthy, **intrauterine pregnancy**. - By definition, an ectopic pregnancy is one that implants *outside* the uterine cavity, making this location incorrect. *B* - Label B indicates the **ovary**. An **ovarian ectopic pregnancy** is a rare form of ectopic implantation, constituting about 3% of cases. - This occurs if the egg is fertilized and implants on or within the ovary itself, before it enters the fallopian tube. *C* - Label C points to the **cervix**. A **cervical pregnancy** is a very rare type of ectopic pregnancy, accounting for less than 1% of cases. - This location is particularly dangerous due to a high risk of life-threatening **hemorrhage** because of the cervix's rich vascular supply.

Q: A primigravida woman at 26 weeks gestation, presented with a BP of 150/90 mm Hg. Which test should be done next?

Urine dipstick. ***Urine dipstick***- The initial requirement for diagnosing **preeclampsia** is the presence of new-onset hypertension (BP > 140/90) plus **proteinuria** (or signs of end-organ damage).- The urine dipstick is the quickest and easiest initial test to rapidly screen for the presence of **proteinuria** and establish the correct diagnostic category (Gestational Hypertension vs. Preeclampsia).*Uric acid*- Elevated **serum uric acid** is often associated with preeclampsia severity, correlating with increased poor maternal and fetal outcomes.- However, it is not the standard *initial* diagnostic screening test needed to define the condition itself, which primarily requires checking for proteinuria.*Liver function test*- LFTs (AST and ALT) are performed to evaluate for signs of **severe preeclampsia** or **HELLP syndrome**, indicated by elevated transaminases.- While crucial for assessing severity, the initial step after noting hypertension is to screen for **proteinuria**, not necessarily end-organ damage markers.*Complete blood count*- A CBC is necessary to check for signs of severity, specifically **thrombocytopenia** (platelet count < 100,000/µL), which defines severe preeclampsia or HELLP syndrome.- Like LFTs, this is part of the workup for *severity* or *end-organ damage*, but the priority after detecting hypertension is confirming proteinuria via an initial screening test.

Q: A 32-year-old woman at 32 weeks gestation presents with sudden-onset severe abdominal pain and vaginal bleeding. She has a history of cocaine use. On examination, the uterus is tender, firm, and woody hard. Fetal heart sounds are absent. Blood pressure is 90/60 mmHg, pulse 120/min. What is the most likely diagnosis?

Placental abruption. ***Placental abruption*** - The sudden onset of severe, painful vaginal bleeding, coupled with a **tender, rigid, or 'woody' hard uterus**, is the classic triad for severe placental abruption. - **Cocaine use** is a major risk factor, causing intense vasoconstriction of the decidual spiral arteries, leading to ischemia, hemorrhage, and premature separation of the placenta. *Placenta previa* - Typically presents with **painless bright red vaginal bleeding** in the third trimester, often spontaneously resolving. - The uterus remains **soft or non-tender** on palpation, completely contradicting the painful, woody hard uterus described. *Uterine rupture* - While causing severe pain and maternal shock, rupture is usually associated with a history of prior **C-section or uterine surgery**. - The findings typically include **loss of fetal station** and a non-tender, distorted uterus, sometimes allowing palpation of fetal parts in the abdomen, rather than a uniformly woody hard uterus. *Vasa previa* - Characterized by **painless bleeding** that occurs secondary to the rupture of unprotected fetal vessels over the cervix, usually coinciding with amniotomy or membrane rupture. - The bleeding is **fetal in origin**, and while it leads rapidly to fetal demise (as seen here), it is not associated with severe maternal pain or a rigid, tender uterus.

Q: Which of the following does not cause fetal bradycardia?

Maternal fever. ***Maternal fever*** - Maternal fever causes **fetal tachycardia** or fetal heart rate acceleration, as the physiological response to fever is increased metabolism and heart rate. - The resulting fetal tachycardia is often a sign of impending or current **maternal infection** (e.g., chorioamnionitis). *Abruptio placenta* - Associated with acute fetal distress due to placental separation, leading to fetal **hypoxia** and **acidosis**. - Fetal hypoxia triggers a reflex bradycardia (late decelerations with bradycardia) to conserve oxygen and energy. *Meconium passage/staining* - Passage of meconium in utero is often a sign of **fetal distress** or hypoxia during labor. - Severe fetal distress and resultant cerebral hypoxia/acidosis can lead to prolonged or terminal **fetal bradycardia**. - Note: Meconium aspiration syndrome occurs postnatally, but meconium-stained amniotic fluid indicates antecedent fetal compromise. *Fetal head compression* - Leads to a transient increase in **intracranial pressure**, stimulating the **vagus nerve** mediated by the baroreceptors. - This **vagal stimulation** results in a brief, reflex slowdown of the fetal heart rate, known as **early decelerations**.

Q: Use of magnesium sulfate (MgSO4) in pre-eclampsia has all of the following effects except:

Prevent abruption of placenta. ***Prevent abruption of placenta*** - **Magnesium sulfate (MgSO4)** is primarily a **CNS depressant** (anticonvulsant) and a vasodilator, and its use is not directly associated with preventing **placental abruption**. - Placental abruption is linked to factors like short umbilical cord, trauma, and **severe hypertension**, which MgSO4 does not consistently mitigate. ***Neuroprotection*** - Administered to women at high risk of imminent **preterm birth** (less than 32 weeks), MgSO4 has a proven benefit in reducing the risk of developing **cerebral palsy** in the neonate. - This neuroprotective effect is thought to be mediated by stabilizing the blood-brain barrier and its **antioxidant properties**. ***Decrease seizure incidence*** - MgSO4 is the **drug of choice** for both the prophylaxis and treatment of seizures (eclampsia) in women with **severe pre-eclampsia**. - It works by decreasing **acetylcholine release** at the neuromuscular junction and acting as a central anticonvulsant. ***Prevent preterm labour*** - MgSO4 is a weak **tocolytic agent** and can be used to temporarily suppress uterine contractions in women presenting with threatened **preterm labor**. - Although effective for short-term suppression, it is not the primary tocolytic agent and is most famously used for its **neuroprotective** and anti-seizure properties.

Question 1

Fetal anaemia is monitored by?

Accepted Answer

MCA-PSV

Answer

Amniocentesis

Answer

Maternal blood

Answer

Fetal blood

Question 2

Which of the following drugs is not given for hypertension in pregnancy?

Accepted Answer

Enalapril

Answer

Nifedipine

Answer

Methyldopa

Answer

Labetalol

Question 3

Which findings are most suggestive of tubal pregnancy?

Accepted Answer

Adnexal mass with empty uterus and fluid in pelvis

Answer

Trilayer endometrium without adnexal mass

Answer

Ovarian mass with single layer of endometrium

Answer

Adnexal mass with empty uterus

Question 4

Identify the given image of the placenta previa.

Accepted Answer

Marginal

Answer

Complete

Answer

Low lying

Answer

Incomplete

Question 5

Identify the given image of the placenta previa. ![img-50.jpeg](img-50.jpeg)

Accepted Answer

Marginal

Answer

Incomplete

Answer

Low lying

Answer

Complete

Question 6

Which of the following is the most common location of implantation in ectopic pregnancy? ![img-40.jpeg](img-40.jpeg)

Accepted Answer

A

Answer

D

Answer

B

Answer

C

Question 7

A primigravida woman at 26 weeks gestation, presented with a BP of 150/90 mm Hg. Which test should be done next?

Accepted Answer

Urine dipstick

Answer

Uric acid

Answer

Liver function test

Answer

Complete blood count

Question 8

A 32-year-old woman at 32 weeks gestation presents with sudden-onset severe abdominal pain and vaginal bleeding. She has a history of cocaine use. On examination, the uterus is tender, firm, and woody hard. Fetal heart sounds are absent. Blood pressure is 90/60 mmHg, pulse 120/min. What is the most likely diagnosis?

Accepted Answer

Placental abruption

Answer

Placenta previa

Answer

Vasa previa

Answer

Uterine rupture

Question 9

Which of the following does not cause fetal bradycardia?

Accepted Answer

Maternal fever

Answer

Fetal head compression

Answer

Abruptio placenta

Answer

Meconium passage

Question 10

Use of magnesium sulfate (MgSO4) in pre-eclampsia has all of the following effects except:

Accepted Answer

Prevent abruption of placenta

Answer

Prevent preterm labour

Answer

Neuroprotection

Answer

Decrease seizure incidence

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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