Intrauterine Fetal Therapy — MCQs
All are complications of vacuum-assisted delivery over forceps delivery except:
Which of the following is NOT a characteristic of the recipient twin in a monochorionic twin gestation affected by twin-twin transfusion syndrome?
Which of the following is a part of AMTSL?
Which method is most appropriate for cervical ripening in a term pregnancy with oligohydramnios and reactive NST?
Which drug is primarily used to promote fetal lung maturity?
Which of the following are individual indicators of fetal distress?
A 30-year-old multigravida presented with transverse lie with hand prolapse in 2nd stage of labour with dead fetus. The treatment is :
What is the method of delivery for fetuses $A$ and $B$ as shown in the image
Placenta grade 3, 35+3 weeks pregnancy, and absent end diastolic flow Doppler; next management is:
In current obstetrics practice, what is the best test for monitoring sensitized Rh negative mother?
Intrauterine Fetal Therapy Indian Medical PG Practice Questions and MCQs
Question 1: All are complications of vacuum-assisted delivery over forceps delivery except:
- A. Subgaleal hematoma
- B. Intracranial hemorrhage
- C. Cephalohematoma
- D. Transient lateral rectus palsy (Correct Answer)
Explanation: ***Transient lateral rectus palsy*** - **Transient sixth nerve palsy** (lateral rectus palsy) in a neonate is **more commonly associated with forceps delivery**, not vacuum-assisted delivery. - This occurs due to **direct compression of the fetal head** during forceps application, particularly compression of the sixth cranial nerve [4]. - It is **NOT a typical complication of vacuum-assisted delivery over forceps delivery**, making it the correct answer to this EXCEPT question. *Subgaleal hematoma* - This is a **serious and specific complication of vacuum-assisted delivery**, occurring when blood collects in the space between the **galeal aponeurosis** and the **periosteum** [1]. - It is **more common with vacuum extraction than forceps delivery**. - Can lead to significant **blood loss** and **hypovolemic shock** in the neonate. *Intracranial hemorrhage* - **Vacuum extraction is associated with higher rates** of intracranial hemorrhage compared to forceps delivery [1]. - The suction and traction forces can lead to **subdural hemorrhage**, **subarachnoid hemorrhage**, and other intracranial bleeding [2]. - Studies show increased risk with vacuum compared to forceps delivery. *Cephalohematoma* - A **cephalohematoma** (blood collection between **periosteum** and skull bone) is a **classic and common complication of vacuum-assisted delivery** [3]. - It is **more frequent with vacuum extraction than forceps delivery** due to the suction cup causing subperiosteal bleeding. - Resolves spontaneously over weeks to months.
Question 2: Which of the following is NOT a characteristic of the recipient twin in a monochorionic twin gestation affected by twin-twin transfusion syndrome?
- A. Heart failure
- B. Hypovolemia (Correct Answer)
- C. Thrombosis
- D. Polyhydramnios
Explanation: ***Hypovolemia*** - The recipient twin in twin-twin transfusion syndrome (TTTS) experiences **hypervolemia** due to excessive blood flow from the donor twin, not hypovolemia. - This increased blood volume leads to **polycythemia** and volume overload. - Hypovolemia is actually a characteristic of the **donor twin**, not the recipient. *Thrombosis* - The recipient twin has **polycythemia** and increased blood viscosity due to hypervolemia, which increases the risk of **thrombosis**. - This hyperviscosity can lead to **vascular occlusions** in various organs. *Polyhydramnios* - The recipient twin characteristically develops **polyhydramnios** (excessive amniotic fluid) due to increased urine output from hypervolemia. - This is one of the **classic ultrasound findings** in TTTS, with the recipient showing a large fluid-filled sac. *Heart failure* - The recipient twin's heart has to pump an increased volume of blood, leading to **cardiac overload** and hypertrophy. - This chronic workload can eventually result in **congestive heart failure** and hydrops fetalis.
Question 3: Which of the following is a part of AMTSL?
- A. Uterine massage
- B. Controlled cord traction (Correct Answer)
- C. Early cord clamping
- D. Uterotonics after delivery of placenta
Explanation: ***Controlled cord traction*** - **Controlled cord traction (CCT)** is a key component of Active Management of Third Stage of Labor (AMTSL) performed during placental delivery. - This technique involves applying gentle, sustained traction to the umbilical cord while simultaneously providing counter-traction to the fundus (Brandt-Andrews maneuver) to prevent **uterine inversion**. - CCT is performed after administering a uterotonic and is the primary active maneuver for delivering the placenta. *Uterine massage* - **Uterine massage** is also a component of AMTSL, but it is performed **after placental delivery** to ensure adequate uterine contraction and prevent postpartum hemorrhage. - The three components of AMTSL per WHO recommendations are: (1) Uterotonic administration, (2) Controlled cord traction, (3) Uterine massage after placental delivery. - While technically part of AMTSL, **controlled cord traction** is the more specific answer as it refers to the active maneuver during placental separation and delivery itself. *Early cord clamping* - **Early cord clamping** (within 60 seconds of birth) has been removed from AMTSL recommendations in favor of **delayed cord clamping** (1-3 minutes or when pulsation stops). - Current WHO guidelines recommend delayed cord clamping for all births while still performing AMTSL, as delayed clamping provides neonatal benefits without increasing maternal hemorrhage risk. *Uterotonics after delivery of placenta* - **Uterotonics** (oxytocin 10 IU IM/IV) are administered **within 1 minute of birth** of the baby, which is *before* placental delivery, not after. - This prophylactic administration is the cornerstone of AMTSL and reduces postpartum hemorrhage risk by approximately 60%. - Administering uterotonics *after* placental delivery does not constitute proper AMTSL timing.
Question 4: Which method is most appropriate for cervical ripening in a term pregnancy with oligohydramnios and reactive NST?
- A. Dinoprostone gel 0.5mg
- B. Foley catheter (Correct Answer)
- C. Misoprostol 25mcg vaginal
- D. Oxytocin infusion
Explanation: **Foley catheter** - **Mechanical methods** like the Foley catheter are preferred for cervical ripening in the presence of **oligohydramnios** because they do not carry the risk of inducing uterine hyperstimulation, which can further compromise fetal well-being. - The reactive non-stress test (NST) indicates the fetus is currently healthy, but oligohydramnios suggests a need to minimize any potential stress, making mechanical ripening a safer choice. *Dinoprostone gel 0.5mg* - **Prostaglandins** like dinoprostone can increase the risk of **uterine hyperstimulation**, which could be particularly dangerous for a fetus with oligohydramnios as it restricts blood flow and oxygen. - While effective for ripening, the risk profile is higher compared to mechanical methods when fetal compromise (like oligohydramnios) is present. *Misoprostol 25mcg vaginal* - **Misoprostol** is a potent prostaglandin analog that carries a significant risk of **uterine tachysystole** and hyperstimulation. - In cases with **oligohydramnios**, any drug-induced increase in uterine activity could further strain fetal oxygenation and well-being. *Oxytocin infusion* - **Oxytocin** is primarily used for **induction of labor** (to stimulate contractions) and not for cervical ripening directly. - Initiating oxytocin without a ripened cervix is less effective and carries a higher risk of failed induction and potentially C-section, and it does not address the need for cervical changes first.
Question 5: Which drug is primarily used to promote fetal lung maturity?
- A. Folic acid
- B. Dexamethasone (Correct Answer)
- C. Beclomethasone
Explanation: ***Dexamethasone*** - **Dexamethasone** is a synthetic glucocorticoid that rapidly crosses the placenta and stimulates the maturation of fetal lung surfactant production. - It significantly reduces the incidence and severity of **respiratory distress syndrome (RDS)** in preterm infants when administered to the mother. - **Antenatal corticosteroids** (dexamethasone or betamethasone) are given to mothers at risk of preterm delivery between 24-34 weeks of gestation. *Folic acid* - **Folic acid** is a B vitamin crucial for cell growth and DNA synthesis, primarily used to prevent **neural tube defects** in developing fetuses. - It does not have a direct role in promoting fetal lung maturity or surfactant production. *Beclomethasone* - **Beclomethasone** is an inhaled corticosteroid primarily used for the long-term management of **asthma** in children and adults. - While it is a corticosteroid, it is not typically used for systemic administration to the mother to promote fetal lung maturity due to its primary delivery method (inhalation) and limited systemic bioavailability compared to dexamethasone or betamethasone.
Question 6: Which of the following are individual indicators of fetal distress?
- A. Meconium staining
- B. Late deceleration of heart rate
- C. Decrease in fetal scalp blood pH
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - **Meconium staining** of the amniotic fluid, **late decelerations of fetal heart rate**, and a **decrease in fetal scalp blood pH** are all recognized individual indicators of fetal distress. - These signs individually or collectively suggest that the fetus is experiencing **hypoxia** or other adverse conditions. *Meconium staining* - Refers to the presence of **meconium** (the first stool of a newborn) in the **amniotic fluid**, which can indicate fetal stress leading to gasping and passage of meconium. - While concerning, it's not always indicative of severe hypoxia but warrants further assessment. - **Mechanism**: Fetal hypoxia → vagal stimulation → relaxation of anal sphincter → meconium passage. *Late deceleration of heart rate* - **Late decelerations** are symmetric drops in fetal heart rate that begin after the peak of the contraction and return to baseline after the contraction has ended. - They are associated with **uteroplacental insufficiency** and **fetal hypoxia**, reflecting inadequate oxygen delivery to the fetus. - **Significance**: Indicates fetal compromise requiring immediate evaluation and potential intervention. *Decrease in fetal scalp blood pH* - A **low fetal scalp blood pH** (typically below 7.20) indicates **fetal acidosis**, which is a direct sign of **fetal hypoxemia** and distress. - It suggests that the fetus is undergoing anaerobic metabolism due to insufficient oxygen supply. - **Clinical utility**: Provides objective biochemical evidence of fetal compromise when CTG is non-reassuring.
Question 7: A 30-year-old multigravida presented with transverse lie with hand prolapse in 2nd stage of labour with dead fetus. The treatment is :
- A. LSCS
- B. Cleidotomy
- C. Decapitation (Correct Answer)
- D. Craniotomy
Explanation: ***Decapitation*** - **Decapitation** is the treatment of choice for **neglected transverse lie with hand prolapse** when the **fetus is dead** and vaginal delivery is obstructed in the second stage of labor. - This destructive operation involves **severing the fetal neck** to allow delivery of the trunk and head separately, avoiding the maternal risks of cesarean section when fetal salvage is not a consideration. - The presence of a **dead fetus** is a key indication, as it eliminates the need to preserve fetal life and makes destructive procedures ethically and medically appropriate. - **Decapitation** is safer for the mother than LSCS in this scenario, with lower risks of infection, hemorrhage, and future pregnancy complications. *LSCS* - **Cesarean section** would be indicated for a **transverse lie with a LIVE fetus** or if there are contraindications to destructive operations (such as maternal infection risk or failed destructive procedure). - With a **dead fetus**, LSCS exposes the mother to unnecessary surgical risks including anesthesia complications, hemorrhage, infection, and future uterine rupture risk. - The principle of obstetric management is to avoid major surgery when the fetus is already dead and vaginal delivery (even if requiring destructive operations) is feasible. *Cleidotomy* - **Cleidotomy** (cutting the fetal clavicles) is used for **shoulder dystocia** in cephalic presentations to reduce shoulder width and facilitate delivery. - This procedure does not address **transverse lie**, where the fundamental problem is the fetal axis being perpendicular to the maternal axis, not shoulder width. - Cleidotomy would be ineffective as the presenting part (hand/shoulder) cannot engage properly in a transverse lie. *Craniotomy* - **Craniotomy** (perforation and collapse of the fetal skull) is indicated for **cephalic presentations** with a dead fetus where there is cephalopelvic disproportion or hydrocephalus. - In a **transverse lie**, the head is not the presenting part, making craniotomy inappropriate as the primary procedure. - While craniotomy might be used as an adjunct after decapitation to reduce head size, the primary procedure needed is decapitation to resolve the transverse lie.
Question 8: What is the method of delivery for fetuses $A$ and $B$ as shown in the image
- A. LSCS, vaginal
- B. LSCS in both (Correct Answer)
- C. Induce delivery in both
- D. Vaginal, LSCS
Explanation: ***LSCS in both*** - Fetus A is in a **breech presentation**, which is an indication for cesarean section in twin pregnancy, especially when it is the first (presenting) twin. - Once the decision is made to perform a **cesarean section (LSCS)** for fetus A, **both twins must be delivered through the same cesarean incision** during the same operative procedure. - It is **not possible or safe** to deliver one twin by cesarean section and then attempt vaginal delivery for the second twin. Once the uterine incision is made, both babies are delivered through that incision. - This is the standard obstetric practice for twin deliveries requiring cesarean section. *LSCS, vaginal* - This option is **medically incorrect** and represents a misunderstanding of cesarean delivery principles. - Once a cesarean section is initiated for twin A, **both twins are delivered through the uterine incision** during the same surgery. - There is no scenario where one twin is delivered by cesarean and the other vaginally in the same delivery episode - this would be unsafe and is not practiced. *Vaginal, LSCS* - This is incorrect because fetus A (the presenting/first twin) is in **breech presentation**, which typically contraindicates vaginal delivery as the first twin. - In twin pregnancies, when the first twin is breech, **cesarean section is generally recommended** to avoid complications such as head entrapment or cord prolapse. - The mode of delivery for the first twin determines the approach, and a breech first twin usually necessitates cesarean delivery for both. *Induce delivery in both* - Induction of labor aims to initiate contractions but does not address the **breech presentation of fetus A**. - With fetus A in breech presentation, induction would still lead to the need for cesarean section due to the unfavorable presentation of the first twin. - Induction is not an appropriate management strategy when the presenting twin is breech in twin pregnancy.
Question 9: Placenta grade 3, 35+3 weeks pregnancy, and absent end diastolic flow Doppler; next management is:
- A. Monitor
- B. Terminate after 37 weeks
- C. Dexamethasone and terminate after 48 hours (Correct Answer)
- D. Consult pediatrician and plan immediate delivery
Explanation: ***Dexamethasone and terminate after 48 hours*** - Absent end diastolic flow (AEDF) at 35+3 weeks indicates **severe uteroplacental insufficiency** and significant fetal compromise, requiring intervention. - Administering **dexamethasone** (corticosteroids) for 48 hours helps to accelerate **fetal lung maturity** before delivery, reducing the risk of respiratory distress syndrome. *Monitor* - Simply monitoring is an inappropriate and potentially harmful management strategy given the presence of **absent end diastolic flow**, which reflects **critical fetal hypoxia**. - Delaying intervention in cases of AEDF significantly increases the risk of **fetal demise** and severe morbidity. *Terminate after 37 weeks* - Waiting until 37 weeks is too long. **Absent end diastolic flow** at 35+3 weeks significantly increases the risk of **fetal compromise** and death if delivery is delayed. - The goal is to balance the risks of prematurity with the risks of continued intrauterine compromise. *Consult pediatrician and plan immediate delivery* - While immediate delivery might be considered in some scenarios of fetal distress, delivering without prior **corticosteroid administration** (dexamethasone) at 35+3 weeks would increase the risk of **neonatal respiratory distress syndrome**. - The 48-hour window allows for **fetal lung maturation** while still addressing the urgent need for delivery due to AEDF.
Question 10: 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.
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