Maternal-Fetal Medicine Practice Questions

Q: A 36-week pregnant woman is diagnosed with preeclampsia and started on magnesium sulfate therapy. According to the Pritchard regimen, what is the total loading dose of magnesium sulfate administered initially?

14 grams. ***14 grams*** - The **Pritchard regimen** mandates a total initial loading dose of **14 grams** of magnesium sulfate to rapidly achieve therapeutic serum levels and prevent seizures in severe preeclampsia or eclampsia. - This total dose comprises **4 grams** administered intravenously (IV) over 5-10 minutes, followed immediately by **10 grams** intramuscularly (IM) (5 grams into each buttock). *4 grams* - **4 grams** represents only the initial **intravenous component** of the loading dose, which is necessary for rapid onset of action. - This amount alone is insufficient to sustain the required therapeutic plasma concentration for an adequate duration, necessitating the added IM component. *10 grams* - **10 grams** represents the large intramuscular (IM) component of the loading dose (5g in each buttock), which provides a slow-release depot. - While crucial for the maintenance of therapeutic levels, it does not account for the immediate-acting IV component, hence failing to represent the total loading dose. *5 grams* - **5 grams** is the dose administered into a **single buttock** during the IM loading component (10g total IM) or the dose used for subsequent **maintenance therapy** (5g IM every 4 hours). - This dose, by itself, is far below the required total loading dose necessary to control acute symptoms of preeclampsia/eclampsia.

Q: Identify the type of conjoined twins shown below.

Omphalopagus. ***Omphalopagus*** - The image shows two infants joined at the **abdomen**, which is characteristic of omphalopagus conjoined twins. - This type often involves shared organs in the abdomen, such as the **liver** or **intestines**. *Craniopagus* - This type of conjoined twin is characterized by fusion at the **head** or **cranium**. - The twins in the image are clearly not joined at the head. *Ischiopagus* - Ischiopagus twins are conjoined at the **ischium** or **pelvis**, with varying degrees of shared lower body structures. - The fusion in the image is higher, at the abdominal region, not the pelvis. *Pygopagus* - Pygopagus twins are joined at the **sacrum** or **buttocks**, typically facing opposite directions. - The image shows twins joined at the front of their bodies, not the back.

Q: A patient presents with vaginal bleeding in the first trimester. Histopathological examination of the products of conception reveals the findings shown in the image below. What is the most likely diagnosis?

Partial mole. ***Partial mole*** - A partial mole is **triploid** (69,XXX, 69,XXY, or 69,XYY) and contains **fetal/embryonic tissue** alongside molar changes in the placenta. - It results from **fertilization of one ovum by two sperm** or by one diploid sperm, leading to both maternal and paternal genetic contributions. *Androgenetic complete mole* - Complete moles are **diploid** (46,XX or 46,XY) with **purely paternal genetic origin** and contain **no fetal tissue** by definition. - They present as **grape-like vesicles** without any embryonic or fetal structures, which contradicts the presence of fetal tissue in this image. *Biparental complete mole* - This extremely rare variant of complete mole has **genetic material from both parents** but still results in **no fetal development**. - Like all complete moles, it lacks **fetal tissue or embryonic structures**, making it inconsistent with the image findings. *Circumvallate placenta with IUD* - A circumvallate placenta involves **folded placental margins** where the chorionic plate is smaller than the basal plate, unrelated to molar pregnancy. - An **intrauterine device (IUD)** is a contraceptive device and would not be associated with the molar tissue changes described.

Q: The image shows the X-ray abdomen of a 30-yearold SLE patient, who cannot feel her baby moving for the past 7 days. All are correct about the condition shown except:

Elevated fibrinogen. ***Elevated fibrinogen*** - This is the **INCORRECT** statement (answer to this EXCEPT question). - In fetal demise with retained dead fetus, fibrinogen levels typically **DECREASE, not increase**. - **Hypofibrinogenemia** occurs due to **consumption coagulopathy** from the release of thromboplastic substances from dead fetal tissue into maternal circulation. - If the dead fetus is retained for prolonged periods (>4-5 weeks), there is risk of **DIC (Disseminated Intravascular Coagulation)** with depletion of clotting factors including fibrinogen. - While SLE itself may have inflammatory markers, the statement "elevated fibrinogen" does not apply to the fetal demise scenario shown. *Hyperflexion of spine* - **CORRECT** finding in fetal demise with Spalding's sign. - The X-ray shows **overlapping of fetal skull bones** (Spalding's sign) indicating fetal death. - Loss of **fetal muscle tone** after death causes the spine to become **hyperflexed and curled**, visible on imaging. - This is a characteristic radiological finding of retained dead fetus. *Single fetus* - **CORRECT** observation from the X-ray. - The image clearly shows skeletal structures of **one fetus only**. - The fetal skull and spine outline confirm a single intrauterine fetal demise. *Anti-Beta 2 glycoprotein antibody* - **CORRECT** association in this clinical scenario. - Patient has **SLE** with fetal demise, strongly suggesting **Antiphospholipid Syndrome (APS)**. - **Anti-β2-glycoprotein I antibodies** are one of the diagnostic criteria for APS. - APS causes **recurrent pregnancy loss** and **fetal death after 10 weeks** due to **placental thrombosis**. - This antibody should be tested in SLE patients with adverse pregnancy outcomes.

Q: What is incorrect about the neonate shown:

Occipitoanterior presentation is common. ***Occipitoanterior presentation is common*** - Anencephaly, shown in the image, is associated with an **increased incidence of breech presentation** or other abnormal presentations, not occipitoanterior. - The absence of the cranial vault and brain tissue can affect the fetal head's ability to engage and present in the optimal occipitoanterior position. *Impaired swallowing reflex* - The absence of a developed brainstem in anencephaly leads to a **severely impaired or absent swallowing reflex**. - This prevents the fetus from swallowing amniotic fluid, which is a major contributor to polyhydramnios. *Polyhydramnios* - Due to the **impaired fetal swallowing reflex** in anencephaly, there is an accumulation of amniotic fluid. - The inability of the fetus to properly reabsorb amniotic fluid leads to an excessive volume of amniotic fluid. *Small adrenals* - In anencephaly, the **fetal pituitary gland is underdeveloped or absent**, which leads to a lack of ACTH stimulation. - This results in **hypoplasia (small size)** of the fetal adrenal glands because the adrenal cortex depends on ACTH for its development and function.

Q: A gynecologist noted that fetal head is difficult to push down into the pelvis at 36 weeks of gestation. Antenatal USG done shows presence of:

Congenital hydrocephalus. ***Congenital hydrocephalus*** - The ultrasound image shows significantly **enlarged ventricles (V)** indicated by the arrows, which is characteristic of **hydrocephalus**. - **Fetal head pushing down into the pelvis** in late pregnancy can be difficult if the head is abnormally large due to hydrocephalus, making it a plausible finding. *Snowstorm appearance of antenatal USG* - A **snowstorm appearance** on antenatal ultrasound is pathognomonic for **complete hydatidiform mole**, which is a placental abnormality, not a fetal head anomaly. - This finding would not explain difficulty pushing the fetal head into the pelvis. *Spinal dysraphism* - **Spinal dysraphism** involves malformations of the spinal cord and its coverings (e.g., spina bifida), and while it can be associated with hydrocephalus (e.g., Arnold-Chiari malformation), the primary USG finding for dysraphism itself is a defect in the spine. - The image provided specifically highlights **enlarged cerebral ventricles**, not a spinal defect. *Increased nuchal translucency* - **Increased nuchal translucency** refers to an abnormal accumulation of fluid behind the fetal neck in the first trimester, typically associated with chromosomal abnormalities like **Down syndrome** or cardiac defects. - While an important early marker, it is not directly related to difficulty descending the fetal head or the ventricular enlargement seen in the image.

Q: The following diagram shows:

Concealed abruptio. ***Concealed abruptio*** - The image shows **blood pooling behind the placenta** with no visible external bleeding. This is the hallmark of a **concealed placental abruption** (abruptio placentae). - In this type, blood collects between the placenta and uterine wall (retroplacental hematoma), with no passage through the cervix, increasing intramyometrial pressure and risk of severe maternal-fetal complications. - Accounts for approximately **20% of placental abruptions** and is associated with more severe outcomes due to lack of external warning signs. *Revealed abruptio* - In a revealed abruption (external hemorrhage), the **blood escapes through the cervix** and is visible externally as vaginal bleeding. - This is the most common presentation (~80% of cases), where the hemorrhage tracks downward between the membranes and uterine wall. - While still serious, external bleeding allows for earlier clinical recognition compared to concealed abruption. *Subchorionic abruptio* - This is **not standard medical terminology**. The correct term is either "subchorionic hematoma" (bleeding between chorion and decidua) or "retroplacental hematoma." - Subchorionic hematomas are typically seen in early pregnancy and represent a different entity from acute placental abruption. - The image shows classic concealed abruption with retroplacental blood collection, not a subchorionic collection. *Subamniotic abruptio* - This is **not a recognized classification** of placental abruption in standard obstetric terminology. - Placental abruption is classified as concealed (no external bleeding), revealed (external bleeding), or mixed based on the pathway of blood. - "Subamniotic" would theoretically mean beneath the amnion, which does not describe the pathophysiology of placental separation from the decidua basalis.

Q: The optical density of amniotic fluid at 450 nm peak was plotted on Liley's chart and falls in zone marked as C. Which of the following statements is correct?

Fetus is severely affected. ***Fetus is severely affected*** - A reading falling in **Zone C** on **Liley's chart** indicates a significantly increased concentration of bilirubin in the amniotic fluid. - This high bilirubin level is a direct marker of **severe hemolytic disease in the fetus**, requiring immediate intervention. *Fetus is unlikely to be affected* - This statement is incorrect because Zone A indicates mild or no hemolysis, and Zone B indicates moderate disease. **Zone C** explicitly signifies **severe fetal affection**. - A finding in Zone C rules out the possibility of the fetus being unaffected or only mildly affected by hemolytic disease. *Repeat amniocentesis after 2 weeks* - Given the severity indicated by Zone C, waiting two weeks for a repeat amniocentesis would be too long and could delay critical interventions. - Immediate action, such as **frequent monitoring**, **intrauterine transfusion**, or **early delivery**, is typically required when findings are in Zone C. *Recalibrate the colorimeter used for measuring optical density* - While proper calibration is crucial for accurate results, assuming a calibration error is the cause without further evidence is inappropriate, especially with a critical finding. - The primary interpretation of a Zone C result is severe fetal compromise, not simply a measurement error; thus, immediate clinical response is warranted rather than re-calibration.

Q: The following curve is used in evaluation of:

Rh incompatibility. ***Rh incompatibility*** - The curve shown represents **spectrophotometric analysis of amniotic fluid at 450 nm (ΔOD450)**, known as the **Liley curve** or **Queenan curve**. - This measures **bilirubin concentration** in amniotic fluid to assess the **severity of fetal hemolytic anemia** in **Rh isoimmunization**. - The ΔOD450 value is plotted against gestational age to categorize disease severity into zones (Liley zones 1, 2, and 3) and guide management decisions regarding timing of delivery or intrauterine transfusion. - This is the **gold standard** for monitoring fetuses at risk of hemolytic disease of the newborn. *Fetal maturity* - Fetal lung maturity is assessed using different amniotic fluid tests: **lecithin/sphingomyelin (L/S) ratio**, **phosphatidylglycerol (PG)**, **foam stability index**, or **lamellar body count**. - These tests measure surfactant components, not bilirubin, and do NOT use ΔOD450 spectrophotometry. - While both involve amniotic fluid analysis, the techniques and purposes are completely different. *Nonprogression of labor* - Labor progression is monitored using a **partogram** (cervicograph), which plots cervical dilation and fetal descent against time. - This has no relation to amniotic fluid spectrophotometry. *Fetal distress* - Fetal distress is evaluated using **continuous fetal heart rate monitoring (cardiotocography)**, **biophysical profile**, and **umbilical artery Doppler**. - While severe fetal anemia from Rh disease can cause distress, the ΔOD450 curve specifically assesses the underlying hemolytic process, not acute distress.

Q: What is the type of placenta previa shown below?

Type 4. ***Type 4*** - Type 4 placenta previa, also known as **complete or central placenta previa**, occurs when the **placenta completely covers the internal cervical os**. - This type necessitates a **cesarean section** delivery due to the complete obstruction of the birth canal. *Type 1* - Type 1 placenta previa, or **low-lying placenta**, means the placenta is in the lower uterine segment but **does not reach the cervical os**. - It often resolves by term as the uterus grows, potentially allowing a **vaginal delivery**. *Type 2* - Type 2 placenta previa, or **marginal placenta previa**, indicates the placental edge **reaches the internal cervical os** but does not cover it. - While a vaginal delivery might be possible, there's an increased risk of **hemorrhage**. *Type 3* - Type 3 placenta previa, or **partial placenta previa**, is where the placenta **partially covers the internal cervical os** but not completely. - This type also typically requires a **cesarean section** due to the obstruction.

Question 1

A 36-week pregnant woman is diagnosed with preeclampsia and started on magnesium sulfate therapy. According to the Pritchard regimen, what is the total loading dose of magnesium sulfate administered initially?

Accepted Answer

14 grams

Answer

5 grams

Answer

4 grams

Answer

10 grams

Question 2

Identify the type of conjoined twins shown below.

Accepted Answer

Omphalopagus

Answer

Craniopagus

Answer

Ischiopagus

Answer

Pygopagus

Question 3

A patient presents with vaginal bleeding in the first trimester. Histopathological examination of the products of conception reveals the findings shown in the image below. What is the most likely diagnosis?

Accepted Answer

Partial mole

Answer

Biparental complete mole

Answer

Circumvallate placenta with IUD

Answer

Androgenetic complete mole

Question 4

The image shows the X-ray abdomen of a 30-yearold SLE patient, who cannot feel her baby moving for the past 7 days. All are correct about the condition shown except:

Accepted Answer

Elevated fibrinogen

Answer

Hyperflexion of spine

Answer

Single fetus

Answer

Anti-Beta 2 glycoprotein antibody

Question 5

What is incorrect about the neonate shown:

Accepted Answer

Occipitoanterior presentation is common

Answer

Impaired swallowing reflex

Answer

Polyhydramnios

Answer

Small adrenals

Question 6

A gynecologist noted that fetal head is difficult to push down into the pelvis at 36 weeks of gestation. Antenatal USG done shows presence of:

Accepted Answer

Congenital hydrocephalus

Answer

Snowstorm appearance of antenatal USG

Answer

Spinal dysraphism

Answer

Increased nuchal translucency

Question 7

The following diagram shows:

Accepted Answer

Concealed abruptio

Answer

Revealed abruptio

Answer

Subchorionic abruptio

Answer

Subamniotic abruptio

Question 8

The optical density of amniotic fluid at 450 nm peak was plotted on Liley's chart and falls in zone marked as C. Which of the following statements is correct?

Accepted Answer

Fetus is severely affected

Answer

Fetus is unlikely to be affected

Answer

Repeat amniocentesis after 2 weeks

Answer

Recalibrate the colorimeter used for measuring optical density

Question 9

The following curve is used in evaluation of:

Accepted Answer

Rh incompatibility

Answer

Nonprogression of labor

Answer

Fetal distress

Answer

Fetal maturity

Question 10

What is the type of placenta previa shown below?

Accepted Answer

Type 4

Answer

Type 1

Answer

Type 2

Answer

Type 3

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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