Maternal-Fetal Medicine Practice Questions

Q: Which one of the following statements is not correct regarding the haemodynamic changes occurring during a pregnancy?

The systemic vascular resistance is increased. ***The systemic vascular resistance is increased*** - During normal pregnancy, **systemic vascular resistance (SVR)** actually **decreases** due to vasodilation induced by factors like **prostaglandins** and **nitric oxide**. - A decrease in systemic vascular resistance helps accommodate the increased blood volume and cardiac output, ensuring adequate perfusion to the uteroplacental unit and other organs. *The cardiac output is increased* - **Cardiac output (CO)** progressively **increases** during pregnancy, peaking in the second and third trimesters. - This increase is primarily due to a rise in both **heart rate** and **stroke volume**. *The serum colloid pressure is decreased* - **Serum colloid osmotic pressure** (oncotic pressure) **decreases** in pregnancy due to a disproportionate increase in plasma volume relative to the increase in albumin production. - This leads to **dilutional hypoalbuminemia**, contributing to physiological edema. *The stroke volume is increased* - **Stroke volume (SV)** significantly **increases** during pregnancy, driven by increased end-diastolic volume and enhanced myocardial contractility. - This rise in stroke volume is a major contributor to the overall increase in cardiac output.

Q: Foetal anaemia can be detected non-invasively by Doppler ultrasonography on the basis of an increase in the

Peak systolic velocity of the middle cerebral artery. ***Peak systolic velocity of the middle cerebral artery*** - **Foetal anaemia** causes increased **cardiac output** and redistribution of blood flow to vital organs, leading to an increase in **peak systolic velocity (PSV)** in the **middle cerebral artery (MCA)**. - This increased velocity indicates **cerebral vasodilation**, a compensatory mechanism to maintain oxygen delivery to the foetal brain in situations of hypoxia due to anaemia. *SD ratio in the anterior cerebral artery* - The **SD ratio (systolic/diastolic ratio)** is more commonly used in umbilical artery flow. A higher SD ratio in cerebral arteries typically suggests increased downstream resistance, which is not characteristic of foetal anaemia. - In foetal anaemia, the cerebral arteries would typically show **decreased resistance**, leading to a lower, not higher, SD ratio. *SD ratio in the umbilical artery* - An increased **SD ratio in the umbilical artery** often indicates **placental insufficiency** or **foetal growth restriction**, not necessarily **foetal anaemia**. - While placental insufficiency can lead to foetal anaemia, the direct Doppler marker for anaemia is the MCA PSV, reflecting the foetal response to hypoxia. *Peak systolic velocity of the anterior cerebral artery* - While both anterior and middle cerebral arteries are part of the cerebral circulation, the **middle cerebral artery (MCA)** is the most widely validated and sensitive vessel for detecting changes in **foetal blood flow** due to **anaemia**. - Changes in the anterior cerebral artery's PSV are not as reliably linked to the diagnosis of foetal anaemia as those in the MCA.

Q: In a woman with molar pregnancy with a uterus size of 28 weeks, the treatment of choice is

Suction evacuation. ***Suction evacuation*** - For **molar pregnancy**, especially with a large uterine size (28 weeks in this case), **suction evacuation** is the treatment of choice to remove the abnormal trophoblastic tissue. - This method is preferred due to its safety and efficacy in emptying the uterus while minimizing complications like hemorrhage or uterine perforation. *Hysteroscopy* - **Hysteroscopy** is primarily used for diagnosing and treating intrauterine pathologies such as polyps or fibroids, and for endometrial assessment. It is not the primary treatment for molar pregnancy. - It involves inserting a scope into the uterus and is not designed for the large-volume tissue removal required in a molar pregnancy of this size. *Hysterectomy* - **Hysterectomy** (surgical removal of the uterus) is generally reserved for rare cases of recurrent molar pregnancy, when the patient desires no future fertility, or in the context of invasive molar disease or choriocarcinoma. It is not the initial treatment of choice. - It is an overly aggressive approach for an initial presentation of molar pregnancy, especially if the patient wishes to preserve fertility. *Medical induction with prostaglandins* - **Medical induction** using prostaglandins is typically used for therapeutic abortion or managing missed abortions, but it is contraindicated in molar pregnancy. - Prostaglandins can lead to vigorous uterine contractions and potentially cause a rapid expulsion of molar tissue into the systemic circulation, increasing the risk of **trophoblastic embolization** and choriocarcinoma.

Q: A fourth-gravida with three living children presents at 38 weeks of pregnancy with abdominal pain and vaginal bleeding. On examination, the uterus is tense and tender, and the foetal heart sounds are absent. What is the probable diagnosis?

Accidental haemorrhage. ***Accidental haemorrhage*** - The combination of **abdominal pain**, **vaginal bleeding**, a **tense and tender uterus**, and **absent fetal heart sounds** strongly indicates accidental hemorrhage (placental abruption). - This condition involves the premature separation of the **placenta** from the uterine wall, leading to concealed or revealed bleeding and frequently resulting in fetal demise. *Vasa praevia* - Characterized by **fetal blood vessels** crossing the cervical os, making the fetus vulnerable to hemorrhage. - While it causes **painless vaginal bleeding**, it typically does not present with a **tense and tender uterus** or immediate fetal demise unless there is membrane rupture. *Ectopic pregnancy* - Occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. - Presents with **abdominal pain** and **vaginal bleeding**, but this occurs in the **first trimester**, not at 38 weeks of pregnancy. *Placenta praevia* - Involves the placenta covering the cervical os, leading to **painless vaginal bleeding**. - Unlike accidental hemorrhage, the uterus is typically **soft and non-tender**, and fetal heart sounds are usually present.

Q: A pregnant woman with 10 weeks gestation is diagnosed to have an ovarian cyst of 11 cm diameter. The best timing for the removal of the ovarian cyst is

In the second trimester (14-20 weeks). ***In the second trimester (14-20 weeks)*** - The **second trimester** is the optimal timing for elective surgery during pregnancy as **organogenesis is complete** (reducing teratogenic risk) but the uterus is not yet too large to complicate surgery. - An **11 cm ovarian cyst** is large and unlikely to resolve spontaneously, warranting surgical intervention rather than expectant management. *At the time of caesarean section* - This approach assumes a **planned C-section** is indicated, which is not supported at 10 weeks gestation when mode of delivery cannot be predetermined. - Delaying surgery until an uncertain future C-section risks **complications** like torsion, rupture, or further cyst growth during pregnancy. *Immediately* - **First trimester surgery** carries higher risk of **miscarriage** and potential teratogenic effects during the critical organogenesis period. - While immediate intervention might prevent complications, the risks of surgery at 10 weeks outweigh the benefits for an asymptomatic cyst. *Immediately after delivery* - Post-delivery surgery involves increased **vascularity** and complications related to **uterine involution** and tissue changes. - This timing requires a **separate surgical procedure** and anesthetic exposure, increasing overall morbidity compared to planned second trimester surgery.

Q: In a gravid woman with placenta praevia, the following fetal complications are known to increase 1. Congenital malformations 2. Intrauterine growth retardation 3. Prematurity Select the correct answer from the code given below :

1, 2 and 3. ***1, 2 and 3*** - **Placenta praevia** is associated with an increased risk of **congenital malformations**, with studies showing a 2-3 fold increased risk compared to normal placentation. This includes CNS anomalies, cardiovascular defects, and musculoskeletal malformations. - **Intrauterine growth retardation (IUGR)** is a known complication due to impaired placental perfusion and suboptimal placental function in the lower uterine segment. - **Prematurity** is significantly increased with placenta praevia, often necessitating early delivery due to antepartum hemorrhage or other maternal-fetal complications. *1 and 2 only* - This option incorrectly excludes **prematurity**, which is one of the most significant fetal complications of placenta praevia. - Preterm delivery is often required due to recurrent bleeding episodes. *1 and 3 only* - This option incorrectly excludes **IUGR**, which is a well-documented complication. - The lower uterine segment has relatively poor vascularization, contributing to placental insufficiency. *2 and 3 only* - This option incorrectly excludes **congenital malformations**. - Multiple population-based studies have demonstrated an association between placenta praevia and increased rates of fetal anomalies, particularly involving the CNS and cardiovascular systems.

Q: During a routine prenatal visit, a 22-week gravid woman is found to be affected with ankle oedema and new onset hypertension. The urine analysis reveals marked proteinuria. Which of the following, if it were to occur, would substantiate the diagnosis of eclampsia?

Seizures. ***Seizures*** - The development of **new-onset generalized tonic-clonic seizures** in a patient with pre-existing pre-eclampsia (hypertension and proteinuria during pregnancy) is the defining criterion for **eclampsia**. - These seizures are not attributable to other causes and are a severe complication of pre-eclampsia, indicating central nervous system involvement. *Molar pregnancy* - While molar pregnancy can be associated with early-onset and more severe pre-eclampsia due to high hCG levels and abnormal placental development, it is not a direct diagnostic criterion for **eclampsia** itself. - Eclampsia specifically refers to the occurrence of seizures in the context of pre-eclampsia, regardless of the underlying cause of the pre-eclampsia. *Thrombocytopenia* - **Thrombocytopenia** (platelet count <100,000/µL) is a potential complication of severe pre-eclampsia and a component of **HELLP syndrome** (Hemolysis, Elevated Liver enzymes, Low Platelets). - While it indicates worsening disease, the presence of thrombocytopenia alone does not define eclampsia; eclampsia is characterized by the occurrence of **seizures**. *Hyperuricaemia* - **Hyperuricaemia** (elevated serum uric acid) is a common finding in pre-eclampsia and often correlates with the severity of the disease. - However, it is a biochemical marker of kidney dysfunction and increased oxidative stress, not a defining diagnostic feature of **eclampsia**, which is specifically marked by the onset of **seizures**.

Q: In a pregnancy complicated by heart disease, which of the following is/are contraindicated? 1. External cephalic version 2. LSCS 3. Corrective surgery of the heart lesion 4. Prophylactic intravenous meth-ergine at the birth of anterior shoulder Select the correct answer from the code given below :

1 and 4 only. ***1 and 4 only*** - **External cephalic version (ECV)** is generally contraindicated in pregnancy complicated by heart disease because the procedure can induce uterine contractions, maternal stress, and potential hemodynamic instability, which may precipitate cardiac decompensation in susceptible patients. - **Prophylactic intravenous methergine (methylergonovine)** is **absolutely contraindicated** in patients with heart disease due to its potent **vasoconstrictive effects** leading to increased systemic vascular resistance, hypertension, and elevated afterload, which can precipitate acute cardiac failure or pulmonary edema. *1 only* - This option incorrectly identifies only ECV as contraindicated while missing the important contraindication of **methergine**, which is strongly contraindicated due to its cardiovascular effects. - Methergine-induced vasoconstriction can cause dangerous hemodynamic changes in cardiac patients. *1 and 3 only* - While ECV is contraindicated, **corrective cardiac surgery** is NOT contraindicated during pregnancy when indicated for maternal survival or significant functional improvement. - Cardiac surgery can be safely performed during pregnancy (ideally in second trimester) with cardiopulmonary bypass when maternal benefit outweighs risks, making this a potential therapeutic intervention rather than a contraindication. *1, 2, 3 and 4* - **LSCS (Lower Segment Cesarean Section)** is NOT contraindicated in heart disease; in fact, it is often the **preferred mode of delivery** in severe cardiac conditions (NYHA Class III-IV) to avoid the hemodynamic stress of prolonged labor and bearing down efforts. - Similarly, corrective cardiac surgery is not contraindicated when medically necessary.

Q: A nulliparous woman presents with acute lower abdominal pain. She has a history of missed periods. The ultrasound examination shows an empty uterus. The cervical movements are very tender. The vital signs are stable. How will you manage her?

Admit her for observation. ***Admit her for observation*** - The patient presents with classic symptoms of a **potential ectopic pregnancy** (missed periods, lower abdominal pain, empty uterus on ultrasound, cervical motion tenderness). However, her **vital signs are stable**, indicating she is currently hemodynamically stable. - Admission for observation allows for close monitoring of vital signs, serial **beta-hCG measurements**, and repeat ultrasounds to confirm the diagnosis and assess for any signs of rupture, enabling timely intervention if needed. *Start a pitocin drip* - **Pitocin (oxytocin)** is used to induce labor or manage postpartum hemorrhage, as it contracts the uterus. - In a suspected ectopic pregnancy with an empty uterus, administering oxytocin would be ineffective and potentially harmful if a **tubal pregnancy** is present. *Treat her as a case of Pelvic Inflammatory Disease.* - While PID can cause lower abdominal pain and cervical motion tenderness, the history of **missed periods** and an **empty uterus on ultrasound** strongly suggest pregnancy complications rather than infection. - Treating for PID without ruling out ectopic pregnancy could lead to a catastrophic delay in managing a ruptured ectopic pregnancy. *Perform a laparotomy* - A laparotomy is an **invasive surgical procedure** typically reserved for confirmed or highly suspected cases of ruptured ectopic pregnancy or other acute abdominal emergencies. - Given the patient's **stable vital signs** and the possibility of a non-ruptured ectopic or even a miscarriage, immediate laparotomy is premature without further diagnostic assessment.

Q: Antimicrobial prophylaxis is essential for a woman in labour who has

Heart disease. ***Heart disease*** - Historically, women with certain types of heart disease, especially those with **valvular abnormalities** or a history of **infective endocarditis**, were considered to require antimicrobial prophylaxis during labor and delivery. - **Important Note**: Current guidelines (AHA 2007 onwards, ACOG) **no longer recommend routine antimicrobial prophylaxis** for prevention of infective endocarditis during uncomplicated vaginal delivery or cesarean section, even in women with valvular heart disease. - Prophylaxis may still be indicated if there are **infected tissues**, **chorioamnionitis**, or other **infectious complications** during delivery. - This question reflects **older clinical practice** when antimicrobial prophylaxis was more broadly recommended for cardiac patients during labor. *Hypertension* - **Hypertension** during labor, whether **chronic** or **gestational**, does not increase the risk of infectious complications requiring antimicrobial prophylaxis. - Management focuses on **blood pressure control** and monitoring for complications like pre-eclampsia or eclampsia. *Diabetes mellitus* - While women with **diabetes mellitus** may have slightly increased infection risk, it is **not an indication** for routine antimicrobial prophylaxis during labor for endocarditis prevention. - Prophylaxis during labor is indicated for **Group B Streptococcus (GBS) colonization** or specific obstetric indications, not diabetes itself. *Renal disease* - **Renal disease** itself is **not an indication** for antimicrobial prophylaxis during labor. - Management focuses on monitoring the renal condition and managing fluid and electrolyte balance during pregnancy and delivery.

Question 1

Which one of the following statements is not correct regarding the haemodynamic changes occurring during a pregnancy?

Accepted Answer

The systemic vascular resistance is increased

Answer

The cardiac output is increased

Answer

The serum colloid pressure is decreased

Answer

The stroke volume is increased

Question 2

Foetal anaemia can be detected non-invasively by Doppler ultrasonography on the basis of an increase in the

Accepted Answer

Peak systolic velocity of the middle cerebral artery

Answer

SD ratio in the anterior cerebral artery

Answer

Peak systolic velocity of the anterior cerebral artery

Answer

SD ratio in the umbilical artery

Question 3

In a woman with molar pregnancy with a uterus size of 28 weeks, the treatment of choice is

Accepted Answer

Suction evacuation

Answer

Hysteroscopy

Answer

Hysterectomy

Answer

Medical induction with prostaglandins

Question 4

A fourth-gravida with three living children presents at 38 weeks of pregnancy with abdominal pain and vaginal bleeding. On examination, the uterus is tense and tender, and the foetal heart sounds are absent. What is the probable diagnosis?

Accepted Answer

Accidental haemorrhage

Answer

Vasa praevia

Answer

Ectopic pregnancy

Answer

Placenta praevia

Question 5

A pregnant woman with 10 weeks gestation is diagnosed to have an ovarian cyst of 11 cm diameter. The best timing for the removal of the ovarian cyst is

Accepted Answer

In the second trimester (14-20 weeks)

Answer

Immediately

Answer

Immediately after delivery

Answer

At the time of caesarean section

Question 6

In a gravid woman with placenta praevia, the following fetal complications are known to increase

1. Congenital malformations 
2. Intrauterine growth retardation 
3. Prematurity

Select the correct answer from the code given below :

Accepted Answer

1, 2 and 3

Answer

1 and 2 only

Answer

1 and 3 only

Answer

2 and 3 only

Question 7

During a routine prenatal visit, a 22-week gravid woman is found to be affected with ankle oedema and new onset hypertension. The urine analysis reveals marked proteinuria. Which of the following, if it were to occur, would substantiate the diagnosis of eclampsia?

Accepted Answer

Seizures

Answer

Molar pregnancy

Answer

Thrombocytopenia

Answer

Hyperuricaemia

Question 8

In a pregnancy complicated by heart disease, which of the following is/are contraindicated?
1. External cephalic version
2. LSCS
3. Corrective surgery of the heart lesion
4. Prophylactic intravenous meth-ergine at the birth of anterior shoulder
Select the correct answer from the code given below :

Accepted Answer

1 and 4 only

Answer

1 only

Answer

1 and 3 only

Answer

1, 2, 3 and 4

Question 9

A nulliparous woman presents with acute lower abdominal pain. She has a history of missed periods. The ultrasound examination shows an empty uterus. The cervical movements are very tender. The vital signs are stable. How will you manage her?

Accepted Answer

Admit her for observation

Answer

Start a pitocin drip

Answer

Treat her as a case of Pelvic Inflammatory Disease.

Answer

Perform a laparotomy

Question 10

Antimicrobial prophylaxis is essential for a woman in labour who has

Accepted Answer

Heart disease

Answer

Hypertension

Answer

Diabetes mellitus

Answer

Renal disease

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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