Maternal-Fetal Medicine Practice Questions

Q: The following conditions are associated with molar pregnancy except:

Gestational diabetes. **Gestational diabetes** - Gestational diabetes is not directly associated with a **molar pregnancy**. Its pathogenesis is related to **insulin resistance** and pancreatic beta-cell dysfunction during pregnancy. - While both conditions can occur during pregnancy, there is no increased risk of gestational diabetes in the presence of a molar pregnancy. *Thyrotoxicosis* - **Molar pregnancies** produce very high levels of **human chorionic gonadotropin (hCG)**, which has a structural similarity to thyroid-stimulating hormone (TSH). - This high hCG can stimulate the thyroid gland, leading to **hyperthyroidism** or thyrotoxicosis in some patients. *Hyperemesis gravidarum* - The extremely high levels of **hCG** produced in a **molar pregnancy** are strongly linked to the severity of nausea and vomiting experienced during pregnancy. - This often manifests as **hyperemesis gravidarum**, which is more common and severe in molar pregnancies due to the exaggerated hormonal response. *Pregnancy induced hypertension* - Patients with **molar pregnancies** are at an increased risk of developing **pregnancy-induced hypertension (PIH)**, often presenting earlier in gestation than typical pre-eclampsia. - The precise mechanism is thought to involve the abnormal placental development and exaggerated maternal inflammatory response associated with molar tissue.

Q: A pregnant woman in third trimester has normal blood pressure in the arms when standing and sitting but drops to 90/50 when lying down. What is the likely cause?

Compression of inferior vena cava. ***Compression of inferior vena cava*** - In the third trimester, the **gravid uterus** can compress the **inferior vena cava (IVC)** when the woman lies supine, reducing **venous return** to the heart. - This decreased preload leads to a drop in **cardiac output** and consequently a fall in **blood pressure** (supine hypotensive syndrome). *Compression of uterine artery* - Compression of the uterine artery would primarily affect **placental blood flow** and fetal well-being, but it is not the direct cause of the mother's systemic hypotension. - **Uterine artery compression** does not significantly impact overall systemic blood pressure in the mother. *Compression of aorta* - While the gravid uterus can compress the **aorta** (aortocaval compression), this typically leads to reduced blood flow to the lower extremities and uterus, not a generalized drop in systemic blood pressure, as collateral circulation usually compensates. - **Aortic compression** can cause a difference in blood pressure between the upper and lower extremities, but the scenario describes a drop in overall systemic pressure when recumbent. *Compression of internal iliac artery* - Compression of the internal iliac artery would mainly affect blood supply to the **pelvic organs** and gluteal region, but it does not account for the significant drop in systemic blood pressure observed in the supine position. - This compression would not cause a generalized reduction in **venous return** to the heart, which is the primary mechanism for supine hypotension.

Q: A 30-year-old woman presents with three-month amenorrhoea, pain abdomen for the last two days and fainting attacks for the last eight hours. On examination, her pulse rate is 102/min, and she has (1+) pallor. On abdominal palpation, she has tenderness. She is provisionally diagnosed with ectopic pregnancy. The most likely site of implantation within the fallopian tube is in the

Ampullary region of the tube. ***Ampullary region of the tube*** - The **ampulla** is the **widest and most tortuous part** of the fallopian tube, making it the most common site for egg fertilization and subsequent **ectopic implantation** (around 70-80% of cases). - Its larger lumen initially accommodates the growing embryo, but eventually, rupture and symptoms like **abdominal pain, amenorrhea**, and **fainting** (due to hemorrhage) occur. *Interstitial region of the tube* - Implantation in the **interstitial portion** (within the uterine wall) is less common but carries the highest risk of **massive hemorrhage** as it is surrounded by a rich vascular supply from the uterus. - Rupture usually occurs later, and symptoms can be more catastrophic due to its proximity to the uterine vessels. *Isthmic region of the tube* - The **isthmus** is the **narrowest part** of the fallopian tube. Ectopic pregnancies here are less common than in the ampulla but tend to rupture earlier due to the limited space. - Symptoms often present acutely and earlier in gestation compared to ampullary pregnancies due to the confined space. *Infundibular region of the tube* - Implantation in the **infundibulum** (fimbrial end) is the rarest site of tubal ectopic pregnancy, often described as an **abdominal pregnancy** if the ovum expels from the tube and implants elsewhere in the abdomen. - This location presents unique diagnostic and management challenges, often leading to later diagnosis and atypical symptoms.

Q: The incidence of congenital fetal anomalies is highest when a pregnancy is complicated by

Maternal diabetes. ***Maternal diabetes*** - **Poorly controlled maternal diabetes** significantly increases the risk of various congenital anomalies due to the teratogenic effects of hyperglycemia. - This includes defects like **sacral agenesis**, cardiovascular malformations, neural tube defects, and renal anomalies. *Hydramnios detectable on clinical examination* - **Hydramnios (polyhydramnios)**, an excess of amniotic fluid, is often associated with fetal anomalies, particularly those affecting swallowing (e.g., esophageal atresia) or urination. - However, it is a *marker* or *consequence* of a potential anomaly, rather than the primary cause of the highest incidence of anomalies. *Congenital heart disease of the mother* - While maternal congenital heart disease can influence pregnancy outcomes and may have a genetic component, it does not, by itself, lead to the highest overall incidence of *fetal congenital anomalies* compared to uncontrolled diabetes. - The risk of congenital heart disease in the fetus of a mother with congenital heart disease is increased, but this is a specific risk, not a broad increase in all anomalies. *Intrauterine growth retardation of the foetus* - **Intrauterine growth restriction (IUGR)** is a condition where the fetus is smaller than expected for its gestational age and is a common complication in pregnancies with underlying issues. - IUGR can be *caused* by placental insufficiency, genetic disorders, or infections, some of which may also cause congenital anomalies, but IUGR itself is not the condition that directly leads to the highest incidence of congenital anomalies.

Q: In the rhesus-negative mothers, the factors which influence the development of rhesus incompatibility include all except

Maternal age >35 years. ***Maternal age >35 years*** - **Maternal age** is not a direct factor influencing the development or severity of Rh incompatibility. The immune response to fetal Rh antigens is independent of the mother's age. - Rh sensitization occurs due to fetal-maternal hemorrhage, causing the mother's immune system to produce **antibodies** against Rh-positive red blood cells, which is not age-dependent. *Amniocentesis* - **Amniocentesis** can lead to **fetal-maternal hemorrhage** by puncturing the placental or fetal vessels, introducing fetal red blood cells into the maternal circulation. - This exposure can trigger the formation of **anti-D antibodies** in an Rh-negative mother if the fetus is Rh-positive, thereby increasing the risk of sensitization. *Incoordinate uterine action* - **Incoordinate uterine action**, especially during labor, can increase the risk of **fetal-maternal hemorrhage** due to increased uterine manipulation, trauma, or prolonged labor, leading to greater placental surface disruption. - Greater exposure to fetal red blood cells then enhances the likelihood of **Rh sensitization** in an Rh-negative mother carrying an Rh-positive fetus. *Placental abruption* - **Placental abruption**, the premature separation of the placenta from the uterine wall, significantly increases the risk of **fetal-maternal hemorrhage**. - A larger volume of fetal blood entering the maternal circulation substantially elevates the chances of an Rh-negative mother becoming **sensitized** and developing **anti-D antibodies**.

Q: A 30-year-old woman with history of previous three abortions, has been found to have antiphospholipid antibodies. What will be the treatment of choice in the subsequent pregnancy?

Aspirin and Heparin. ***Aspirin and Heparin*** - A history of recurrent abortions with positive **anti-phospholipid antibodies** indicates **antiphospholipid syndrome (APS)**. The combination of **aspirin** and **heparin (low molecular weight heparin is preferred)** is the treatment of choice to prevent further thrombotic events, including miscarriage, in pregnant women with APS. - Aspirin helps **reduce platelet aggregation**, while heparin **anticoagulates** by inhibiting clotting factors, thereby improving pregnancy outcomes. *Corticosteroids* - Corticosteroids like **prednisone** may be used in specific autoimmune conditions where inflammation is a primary concern, but they are not the primary treatment for preventing thrombotic events in APS and can have significant side effects in pregnancy. - They are generally reserved for cases with refractory symptoms or other autoimmune comorbidities. *Aspirin* - While **low-dose aspirin** is part of the treatment regimen for APS in pregnancy, it is **insufficient on its own** to prevent recurrent pregnancy losses associated with the thrombotic complications of the syndrome. - Aspirin primarily inhibits **platelet aggregation**, but **heparin** is crucial for its additional anticoagulation effects to address the hypercoagulable state. *Heparin* - **Heparin (low molecular weight)** is a critical component of treatment for APS in pregnancy to prevent thrombosis. However, it is optimally used in combination with **low-dose aspirin**. - Using heparin alone might not fully address all aspects of the prothrombotic state in APS, especially those related to platelet activation.

Q: A young female patient presents with a history of two months amenorrhoea and complaints of severe lower abdominal pain, syncopal attacks and minimal per vaginal bleeding. On examination, she has tachycardia and appears pale. The clinical diagnosis is

Ectopic pregnancy. ***Ectopic pregnancy*** - The combination of **amenorrhoea**, severe **lower abdominal pain**, **syncopal attacks**, and signs of **hypovolemic shock** (tachycardia, pallor) strongly indicates a ruptured ectopic pregnancy. - Minimal per vaginal bleeding is common, and the syncopal episodes are due to **hemoperitoneum** and resulting hypovolemia. *Missed abortion* - A missed abortion typically involves **no symptoms of acute distress** or shock. Patients often present with absent fetal heart tones on ultrasound, but without acute pain or significant bleeding initially. - There would be no signs of hypovolemia such as tachycardia or syncopal attacks, as the bleeding is usually contained within the uterus or minimal. *Molar pregnancy* - While a molar pregnancy can present with amenorrhoea and vaginal bleeding, it typically causes symptoms like **excessive nausea and vomiting**, and a **grape-like vesicular discharge**. - It does not usually cause acute, severe abdominal pain or hypovolemic shock unless there is a rare complication like uterine perforation, which is not the primary presentation. *Inevitable abortion* - An inevitable abortion presents with **vaginal bleeding** and **cervical dilatation**, often accompanied by abdominal cramping. - While there can be significant bleeding, it is usually not associated with acute, severe pain or rapid onset of **hypovolemic shock** and syncopal attacks as seen with a ruptured ectopic pregnancy.

Q: An elderly gravida with 36-weeks pregnancy presents with severe pregnancy induced hypertension (PIH), severe abdominal pain, per vaginal bleeding and loss of foetal movements. The diagnosis is

Abruptio placenta. ***Abruptio placenta*** - The combination of **severe abdominal pain**, **vaginal bleeding**, **loss of fetal movements**, and **severe pregnancy-induced hypertension (PIH)** in an elderly gravida at 36 weeks is a classic presentation of **abruptio placenta** (placental abruption). - Severe PIH is a significant **risk factor for placental abruption**, and the pain, bleeding, and fetal distress are due to premature separation of the placenta from the uterine wall. *Vasa praevia* - Characterized by **painless, bright red vaginal bleeding** of fetal origin that typically occurs when the membranes rupture, associated with **fetal distress** or bradycardia. - While there is bleeding and fetal distress mentioned in the question, the presence of **severe abdominal pain** and **PIH** is not typical of vasa praevia, which presents with painless bleeding. *Rupture of uterus* - Uterine rupture usually presents with sudden, **excruciating abdominal pain**, **loss of uterine contractions**, **cessation of labor progress**, and often a **palpable fetal part** outside the uterus if the rupture is complete. - While severe pain and loss of fetal movements are present, the absence of prior uterine surgery (like a C-section) or high parity as risk factors, and the specific association with **severe PIH** pointing strongly to abruption, makes this less likely. *Placenta praevia* - Typically presents with **painless, bright red vaginal bleeding** in the second or third trimester, without associated abdominal pain. - The presence of **severe abdominal pain** and **loss of fetal movements** rules out placenta previa, as these are not characteristic symptoms.

Q: A 30-year-old third gravida, who has a 3-year-old child and had undergone a MTP one year ago, has presented with 30-weeks pregnancy. She complains of having vaginal bleeding 2 hours ago. She has not received any antenatal care. Her pulse is 78 beats per minute, and the BP is 102/58 mmHg. The most appropriate management will include: 1. Ultrasonographic evaluation 2. Watch for labour 3. Hospitalisation and bed rest 4. Speculum examination of vagina and cervix 5. I.V. fluid drip Select the appropriate combination:

1, 3 and 5. ***1, 3 and 5*** - This patient presents with **third-trimester vaginal bleeding** without prior antenatal care, which is a significant red flag requiring immediate investigation and management. An **ultrasonographic evaluation** is crucial to determine the cause of bleeding, especially to rule out **placenta previa** or **abruptio placentae**, which dictate further management. - **Hospitalization and bed rest** are essential to stabilize the patient, monitor the bleeding, and prepare for potential complications. Initiating an **I.V. fluid drip** is critical for maintaining **hemodynamic stability**, especially given her low blood pressure of 102/58 mmHg, and for providing immediate venous access. *2, 3 and 4* - **Watching for labor** without first establishing the cause of bleeding is inappropriate and potentially dangerous, as active management might be needed. - A **speculum examination** should *not* be the initial step before an ultrasound, as a digital or speculum exam in cases of undiagnosed placenta previa can provoke severe hemorrhage. *1 and 2* - While an **ultrasound (1)** is necessary to diagnose the cause of bleeding, **watching for labor (2)** without further intervention or stabilization is insufficient for a woman with third-trimester bleeding, especially with no prior antenatal care. - This option misses crucial components like hospitalization, bed rest, and IV fluids, which are part of initial stabilization. *1, 4 and 5* - **Ultrasonographic evaluation (1)** and **I.V. fluid drip (5)** are appropriate, but **speculum examination of the vagina and cervix (4)** should be avoided until placenta previa is ruled out by ultrasound. - A digital or speculum exam could exacerbate bleeding if **placenta previa** is present, making this a potentially harmful step in the initial management.

Q: A multiparous patient has been diagnosed to have foetal demise on a sonographic examination at 16 weeks of pregnancy. The ideal method for termination is

High vaginal insertion of dinoprostone gel. ***High vaginal insertion of dinoprostone gel*** - **Dinoprostone gel** (PGE2) is a **prostaglandin** that softens the cervix and stimulates uterine contractions, making it an ideal agent for medical induction in cases of fetal demise, particularly in the second trimester. - Its **vaginal insertion** allows for controlled, localized delivery and absorption, promoting efficient uterine evacuation while minimizing systemic side effects. *Extra-amniotic ethacridine* - **Ethacridine lactate** is typically used for **mid-trimester abortion** by direct instillation into the extra-amniotic space. - While effective, it carries a higher risk of infection and uterine rupture compared to prostaglandin administration for fetal demise at 16 weeks. *Dilation and evacuation (D&E)* - **D&E** is a surgical procedure commonly used for **second-trimester abortions**, involving cervical dilation and surgical removal of uterine contents. - While an option, medical induction with prostaglandins is generally preferred for **fetal demise** at 16 weeks due to lower risks of uterine injury and adhesions, as well as providing a more natural expulsion process. *Hysterectomy with tubectomy* - **Hysterectomy with tubectomy** (removal of the uterus and fallopian tubes) is a major surgical procedure that is **not indicated** for termination of pregnancy due to fetal demise. - It is reserved for severe medical conditions or desires for permanent sterilization, given its irreversible nature and significant surgical risks.

Question 1

The following conditions are associated with molar pregnancy except:

Accepted Answer

Gestational diabetes

Answer

Thyrotoxicosis

Answer

Hyperemesis gravidarum

Answer

Pregnancy induced hypertension

Question 2

A pregnant woman in third trimester has normal blood pressure in the arms when standing and sitting but drops to 90/50 when lying down. What is the likely cause?

Accepted Answer

Compression of inferior vena cava

Answer

Compression of uterine artery

Answer

Compression of aorta

Answer

Compression of internal iliac artery

Question 3

A 30-year-old woman presents with three-month amenorrhoea, pain abdomen for the last two days and fainting attacks for the last eight hours. On examination, her pulse rate is 102/min, and she has (1+) pallor. On abdominal palpation, she has tenderness. She is provisionally diagnosed with ectopic pregnancy. The most likely site of implantation within the fallopian tube is in the

Accepted Answer

Ampullary region of the tube

Answer

Interstitial region of the tube

Answer

Isthmic region of the tube

Answer

Infundibular region of the tube

Question 4

The incidence of congenital fetal anomalies is highest when a pregnancy is complicated by

Accepted Answer

Maternal diabetes

Answer

Hydramnios detectable on clinical examination

Answer

Congenital heart disease of the mother

Answer

Intrauterine growth retardation of the foetus

Question 5

In the rhesus-negative mothers, the factors which influence the development of rhesus incompatibility include all except

Accepted Answer

Maternal age >35 years

Answer

Amniocentesis

Answer

Incoordinate uterine action

Answer

Placental abruption

Question 6

A 30-year-old woman with history of previous three abortions, has been found to have antiphospholipid antibodies. What will be the treatment of choice in the subsequent pregnancy?

Accepted Answer

Aspirin and Heparin

Answer

Corticosteroids

Answer

Aspirin

Answer

Heparin

Question 7

A young female patient presents with a history of two months amenorrhoea and complaints of severe lower abdominal pain, syncopal attacks and minimal per vaginal bleeding. On examination, she has tachycardia and appears pale. The clinical diagnosis is

Accepted Answer

Ectopic pregnancy

Answer

Missed abortion

Answer

Molar pregnancy

Answer

Inevitable abortion

Question 8

An elderly gravida with 36-weeks pregnancy presents with severe pregnancy induced hypertension (PIH), severe abdominal pain, per vaginal bleeding and loss of foetal movements. The diagnosis is

Accepted Answer

Abruptio placenta

Answer

Vasa praevia

Answer

Rupture of uterus

Answer

Placenta praevia

Question 9

A 30-year-old third gravida, who has a 3-year-old child and had undergone a MTP one year ago, has presented with 30-weeks pregnancy. She complains of having vaginal bleeding 2 hours ago. She has not received any antenatal care. Her pulse is 78 beats per minute, and the BP is 102/58 mmHg.

The most appropriate management will include:

1. Ultrasonographic evaluation
2. Watch for labour
3. Hospitalisation and bed rest
4. Speculum examination of vagina and cervix
5. I.V. fluid drip

Select the appropriate combination:

Accepted Answer

1, 3 and 5

Answer

2, 3 and 4

Answer

1 and 2

Answer

1, 4 and 5

Question 10

A multiparous patient has been diagnosed to have foetal demise on a sonographic examination at 16 weeks of pregnancy. The ideal method for termination is

Accepted Answer

High vaginal insertion of dinoprostone gel

Answer

Extra-amniotic ethacridine

Answer

Dilation and evacuation (D&E)

Answer

Hysterectomy with tubectomy

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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