Fetal Monitoring and Fetal Distress — MCQs
Which of the following is NOT included in the resuscitation of a neonate with HR < 60/min?
A woman presents to you at 36 weeks of gestation with complaints of breathlessness and excessive abdominal distension. Fetal movements are normal. On examination, fetal parts are not easily felt and fetal heartbeat is heard but it is muffled. Her symphysis fundal height is 41 cm. Her abdomen is tense but not tender. What is the most likely diagnosis?
Consider the following: 1. Reactive non-stress test, 2. Absence of deceleration, and 3. Sinusoidal pattern. Which of the above findings in an antepartum cardiotocogram indicate fetal well-being?
Fetal tachycardia is defined as a heart rate greater than ___ bpm.
Umbilical artery Doppler is done to assess
Which condition is associated with a sinusoidal heart rate pattern?
Anaesthesia of choice for manual removal of the placenta is?
In current obstetrics practice, what is the best test for monitoring sensitized Rh negative mother?
A G2P1L1 female presents at 28 weeks of gestation with a 1:4 anti-D titre. What is the most appropriate management option?
True about uterine rupture during labor:
Fetal Monitoring and Fetal Distress Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is NOT included in the resuscitation of a neonate with HR < 60/min?
- A. Endotracheal tube intubation
- B. Chest compression
- C. Adrenaline
- D. None of the above (Correct Answer)
Explanation: ***None of the above*** - All listed interventions—**endotracheal tube intubation**, **chest compressions**, and **adrenaline administration**—are standard components of neonatal resuscitation when the heart rate remains below 60 beats/min despite initial steps. - This question asks which is *NOT* included, implying that all options are, in fact, appropriate interventions in this critical scenario. *Endotracheal tube intubation* - This is a critical step in **securing the airway** and ensuring effective positive pressure ventilation when other methods fail or prolonged mechanical ventilation is anticipated. - It's indicated if the heart rate remains below 60 bpm despite adequate bag-mask ventilation and chest compressions. *Chest compression* - **Chest compressions** are initiated when the heart rate is less than 60 bpm *after* 30 seconds of effective positive pressure ventilation. - They are used in conjunction with positive pressure ventilation to improve cardiac output and myocardial perfusion. *Adrenaline* - **Adrenaline** is administered if the heart rate remains below 60 bpm *despite* adequate ventilation and chest compressions. - It acts as a potent **vasopressor** and **cardiac stimulant**, increasing heart rate and contractility.
Question 2: A woman presents to you at 36 weeks of gestation with complaints of breathlessness and excessive abdominal distension. Fetal movements are normal. On examination, fetal parts are not easily felt and fetal heartbeat is heard but it is muffled. Her symphysis fundal height is 41 cm. Her abdomen is tense but not tender. What is the most likely diagnosis?
- A. Abruptio placenta
- B. Hydrocephalus of fetus
- C. Polyhydramnios (Correct Answer)
- D. Oligohydramnios
Explanation: ***Polyhydramnios*** - The patient's symptoms of **breathlessness**, **excessive abdominal distension**, a **symphysis fundal height of 41 cm at 36 weeks** (indicating a significantly larger than expected uterus), and **muffled fetal heart tones** are classic signs of polyhydramnios. - **Difficulty feeling fetal parts** is also consistent with excess amniotic fluid, which cushions the fetus and makes palpation harder. *Abruptio placenta* - This condition typically presents with sudden onset of **painful vaginal bleeding**, uterine tenderness, and fetal distress, none of which are described here. - While the abdomen might be tense due to uterine contractions or concealed bleeding, the lack of pain and bleeding makes this diagnosis unlikely. *Hydrocephalus of fetus* - Fetal hydrocephalus would primarily manifest as an **abnormally large fetal head** upon ultrasound, potentially leading to a higher fundal height. - However, it wouldn't directly explain the generalized excessive abdominal distension or the difficulty in feeling fetal parts due to fluid, though it could be a cause of polyhydramnios itself, it is not the most likely primary diagnosis from the given options directly addressing the symptoms. *Oligohydramnios* - This condition is characterized by **too little amniotic fluid**, which would result in a **smaller than expected symphysis fundal height** and an easily palpable fetus. - The patient's symptoms, particularly the excessive distension and high fundal height, directly contradict the features of oligohydramnios.
Question 3: Consider the following: 1. Reactive non-stress test, 2. Absence of deceleration, and 3. Sinusoidal pattern. Which of the above findings in an antepartum cardiotocogram indicate fetal well-being?
- A. 1 and 2 only (Correct Answer)
- B. 2 and 3 only
- C. 1 and 3 only
- D. 1, 2, 3
Explanation: ***1 and 2 only*** - A **reactive non-stress test (NST)** indicates adequate fetal oxygenation and an intact autonomic nervous system, characterized by accelerations in fetal heart rate. - The **absence of decelerations**, particularly late or variable decelerations, suggests that the fetus is not experiencing significant uteroplacental insufficiency or cord compression. *2 and 3 only* - While the **absence of decelerations** is a positive sign, a **sinusoidal pattern** is a sign of severe fetal compromise. - Therefore, combining the absence of deceleration with a sinusoidal pattern does not indicate fetal well-being. *1 and 3 only* - A **reactive non-stress test** is a good indicator of fetal well-being. - However, the presence of a **sinusoidal pattern** is a concerning sign and indicates severe fetal anemia or hypoxia, not well-being. *1, 2, 3* - A **reactive non-stress test** and the **absence of decelerations** both indicate fetal well-being. - A **sinusoidal pattern**, however, is a non-reassuring finding, often associated with severe fetal anemia, hypoxia, or severe neurological compromise, and therefore does not indicate well-being.
Question 4: Fetal tachycardia is defined as a heart rate greater than ___ bpm.
- A. 140
- B. 160 (Correct Answer)
- C. 180
- D. 200
Explanation: ***160*** - A fetal heart rate greater than **160 bpm** for more than 10 minutes is defined as **fetal tachycardia**. - This threshold helps differentiate normal variations from sustained elevations, which can indicate fetal distress. *140* - A heart rate of 140 bpm falls within the **normal range** for fetal heart rate, which is typically between 110 and 160 bpm. - This rate does not indicate tachycardia and is usually considered reassuring. *180* - While 180 bpm is certainly tachycardic, the generally accepted clinical definition of fetal tachycardia begins at **160 bpm**. - A heart rate at 180 bpm would be considered **marked tachycardia** and a more urgent finding. *200* - A fetal heart rate of 200 bpm represents **severe tachycardia** and would be a significant indicator of fetal compromise. - The threshold for defining tachycardia is lower at **160 bpm**, making 200 bpm an extreme elevation.
Question 5: Umbilical artery Doppler is done to assess
- A. Fetal weight
- B. Fetal oxygenation
- C. Fetal maturity
- D. Placental function (Correct Answer)
Explanation: ***Placental function*** - Umbilical artery Doppler assesses **blood flow resistance** within the placenta, which is a direct indicator of its functional capacity. - Increased resistance, indicated by a high **systolic/diastolic (S/D) ratio** or absent/reversed end-diastolic flow, suggests inadequate placental perfusion and function. *Fetal weight* - Fetal weight is primarily assessed through **ultrasound biometry**, measuring parameters like head circumference, abdominal circumference, and femur length. - While compromised placental function can affect fetal growth, Doppler itself does not directly measure fetal weight. *Fetal oxygenation* - Fetal oxygenation is more directly assessed through **non-stress tests (NST)**, **biophysical profiles (BPP)**, and fetal scalp blood sampling for pH. - Abnormal umbilical artery Doppler findings can *indirectly* suggest potential for reduced oxygenation due to placental insufficiency, but it's not a direct measure. *Fetal maturity* - Fetal maturity, particularly lung maturity, is assessed by analyzing **amniotic fluid** for ratios like **lecithin/sphingomyelin** or presence of **phosphatidylglycerol**. - Umbilical artery Doppler provides no information about fetal organ development or gestational age-related maturity.
Question 6: Which condition is associated with a sinusoidal heart rate pattern?
- A. Placenta previa
- B. Vasa previa (Correct Answer)
- C. Battledore placenta
- D. Succenturiate placenta
Explanation: ***Vasa previa*** - A **sinusoidal heart rate pattern** is a sign of severe **fetal anemia**, often caused by **fetal hemorrhage**. - In vasa previa, unprotected fetal blood vessels course over the cervical os, making them vulnerable to rupture and leading to **fetal bleeding** and subsequent anemia. *Placenta previa* - This condition involves the **placenta covering the cervical os**, primarily causing **painless vaginal bleeding** in the mother. - The bleeding is **maternal blood**, not fetal blood, so it does not directly cause fetal anemia or a sinusoidal heart rate pattern. *Battledore placenta* - In a battledore placenta, the **umbilical cord is inserted marginally** into the placental disk, rather than centrally. - This anatomical variation is generally a benign finding and is not directly associated with fetal hemorrhage or a sinusoidal heart rate pattern. *Succenturiate placenta* - This involves **one or more accessory placental lobes** located separately from the main placental body. - The main concern is a retained lobe after delivery or vessels connecting the lobes, which can cause bleeding, but it is not specifically linked to a sinusoidal heart rate pattern.
Question 7: Anaesthesia of choice for manual removal of the placenta is?
- A. General Anesthesia (GA)
- B. Spinal Anesthesia (Correct Answer)
- C. Epidural Anesthesia
- D. Paracervical Block
Explanation: ***Spinal Anesthesia*** - Provides **rapid onset** and dense sensory and motor block, which is ideal for a quick procedure like manual placental removal. - The **uterine atony** associated with spinal anesthesia, while a concern, is less pronounced or easier to manage than the deep relaxation often seen with general anesthesia, especially with inhaled anesthetics. *General Anesthesia (GA)* - Can lead to significant **uterine relaxation** (atony), increasing the risk of postpartum hemorrhage, especially with volatile anesthetics. - While it provides excellent pain control, the associated risks of airway management, aspiration, and deeper uterine relaxation make it less desirable as a primary choice. *Epidural Anesthesia* - Provides good analgesia but has a **slower onset** of full surgical anesthesia compared to spinal, which may be critical in an urgent situation. - While it can be titrated to achieve surgical depth, it might not provide the rapid, dense motor block required for comfortable and efficient manual removal. *Paracervical Block* - Primarily provides analgesia to the **cervix and lower uterine segment**, but offers insufficient pain relief for the fundal manipulation and full uterine exploration required during manual placental removal. - This block does not adequately anesthetize the entire uterus or provide the necessary muscle relaxation for a comfortable and safe procedure.
Question 8: In current obstetrics practice, what is the best test for monitoring sensitized Rh negative mother?
- A. Biophysical profile
- B. Amniotic fluid spectrophotometry
- C. Middle cerebral artery Doppler wave forms (Correct Answer)
- D. Fetal blood sampling
Explanation: ***Middle cerebral artery Doppler wave forms*** - This is currently the most widely accepted and **non-invasive** method for monitoring **fetal anemia** in Rh-sensitized pregnancies. - An increase in the **peak systolic velocity (PSV)** in the middle cerebral artery indicates that the fetus is increasing cardiac output to compensate for a reduced oxygen-carrying capacity due to anemia. *Biophysical profile* - The biophysical profile assesses various fetal parameters like **movement**, **tone**, **breathing**, and **amniotic fluid volume**, which are often altered late in the course of severe fetal anemia. - It is a **less sensitive** indicator of early or moderate fetal anemia compared to MCA Doppler. *Amniotic fluid spectrophotometry* - This method measures the **bilirubin levels** in amniotic fluid, which correlates with the severity of hemolysis. - It is an **invasive procedure** (amniocentesis) and has largely been replaced by non-invasive MCA Doppler due to associated risks and better predictive value of Doppler. *Fetal blood sampling* - Fetal blood sampling (cordocentesis) provides a direct measurement of **fetal hemoglobin** and other blood parameters. - While definitive, it is a **highly invasive procedure** with significant risks, reserved primarily for confirmation of severe anemia or for direct transfusion, not for routine monitoring.
Question 9: A G2P1L1 female presents at 28 weeks of gestation with a 1:4 anti-D titre. What is the most appropriate management option?
- A. MCA Doppler (Correct Answer)
- B. Caesarean section
- C. Induction of labour
- D. Amniocentesis
Explanation: ***MCA Doppler*** - The presence of anti-D antibodies in a pregnant woman indicates **Rh isoimmunization**, which can lead to **hemolytic disease of the fetus and newborn (HDFN)**. - Even though a titre of **1:4 is below the critical threshold** (usually 1:16 or 1:32), any detectable anti-D titre at 28 weeks warrants **fetal surveillance** to detect early signs of fetal anemia. - **Middle cerebral artery (MCA) Doppler** is the **non-invasive gold standard** for detecting fetal anemia by measuring peak systolic velocity (PSV), which increases in anemic fetuses due to hyperdynamic circulation. - Serial MCA Doppler monitoring allows timely intervention if fetal anemia develops, avoiding unnecessary invasive procedures. *Caesarean section* - This is a mode of delivery and would only be considered if there were severe **fetal compromise** or other obstetric indications after proper monitoring and management. - At 28 weeks gestation with a low anti-D titre, immediate delivery is **not indicated** and would result in significant prematurity risks. *Induction of labour* - Induction of labour is a delivery method that would only be planned at term or for specific indications like severe fetal compromise unresponsive to other interventions. - At **28 weeks gestation**, the focus should be on **monitoring and prolonging pregnancy** while ensuring fetal wellbeing, not on delivery. *Amniocentesis* - Historically used to assess **bilirubin levels (ΔOD450)** in amniotic fluid as an indirect measure of fetal hemolysis, but it is an **invasive procedure** with risks (miscarriage ~1%, infection, worsening sensitization). - **MCA Doppler has largely replaced amniocentesis** for initial and serial assessment of fetal anemia due to its non-invasive nature, high sensitivity, and ability to be repeated safely.
Question 10: True about uterine rupture during labor:
- A. Not associated with fetal distress
- B. Best treated conservatively
- C. Always causes pain
- D. Occurs more with previous cesarean (Correct Answer)
Explanation: ***Occurs more with previous cesarean*** - A prior **cesarean section** poses a significant risk factor for uterine rupture during subsequent labors due to the presence of a uterine scar that can dehisce. - The risk of uterine rupture increases with the number of previous C-sections, especially in cases of short inter-pregnancy intervals or specific types of uterine incisions. *Not associated with fetal distress* - **Fetal distress** is a very common and critical sign of uterine rupture, often manifesting as sudden **severe bradycardia** or **late decelerations** due to placental compromise or direct fetal injury. - The disruption of the uterine wall can lead to **hypoxia, acidosis, and fetal demise** if not urgently addressed. *Best treated conservatively* - **Uterine rupture is a medical emergency** requiring **immediate surgical intervention**, typically a **laparotomy** for repair of the uterus and delivery of the fetus. - Conservative management is generally inappropriate and can lead to **severe maternal hemorrhage, fetal anoxia, and death** due to rapid blood loss and lack of oxygen to the fetus. *Always causes pain* - While often accompanied by **sudden, severe abdominal pain**, uterine rupture can sometimes present with less obvious symptoms, particularly if it's a **dehiscence of an old scar** without complete rupture. - In some cases, the primary sign might be **fetal distress** or **vaginal bleeding** with minimal maternal pain, especially if the mother has an **epidural analgesia** in place masking pain.
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