Maternal-Fetal Medicine Practice Questions

Q: What are Spiegelberg's criteria for diagnosis of ovarian pregnancy? 1. Tube on the affected side must be intact 2. Gestational sac must be in the position of ovary 3. Ovary is connected to uterus by utero-ovarian ligament 4. Ovarian tissue must be detected on the wall on histological examination

1, 2, 3 and 4. ***1, 2, 3 and 4*** * **Spiegelberg's criteria** are the established diagnostic criteria for **ovarian pregnancy**, first described in 1878. * All four criteria must be met for diagnosis: **(1) intact fallopian tube** on the affected side (rules out tubal pregnancy), **(2) gestational sac must occupy the position of the ovary**, **(3) the ovary must be connected to the uterus by the utero-ovarian ligament** (confirms normal anatomical position), and **(4) ovarian tissue must be histologically identified in the wall of the gestational sac** (definitive confirmation). * The **histological confirmation** of ovarian tissue is essential for definitive diagnosis and distinguishes it from other ectopic pregnancies. *1, 2 and 3 only* * While these three criteria establish the anatomical location and rule out tubal pregnancy, **histological confirmation** of ovarian tissue within the gestational sac wall (criterion 4) is essential for definitive diagnosis. * Without histological proof, other extrauterine pregnancies (such as advanced tubal pregnancies involving the ovary secondarily) could mimic the clinical and imaging features. *2, 3 and 4 only* * The **intact ipsilateral fallopian tube** (criterion 1) is critical for differentiating primary ovarian pregnancy from tubal pregnancy with secondary ovarian involvement. * Without confirming tube integrity, a tubal ectopic that has eroded into or adhered to ovarian tissue cannot be definitively excluded. *1 and 4 only* * These two criteria alone are insufficient; the gestational sac must be demonstrably located in the position of the ovary (criterion 2) and the ovary must maintain its normal anatomical connection to the uterus (criterion 3). * Missing the specific ovarian location and anatomical confirmation would lead to incomplete diagnosis and potential confusion with other forms of ectopic pregnancy.

Q: Which one of the following is NOT a risk factor for pre-eclampsia ?

Placenta previa. ***Placenta previa*** - **Placenta previa** is a condition where the placenta partially or totally covers the mother's cervix, causing **vaginal bleeding** during pregnancy, but it is **not linked to the development of pre-eclampsia**. - It is a placental implantation abnormality characterized by abnormal location, not a risk factor for the systemic vascular and endothelial dysfunction characteristic of pre-eclampsia. - The pathophysiology involves placental position, not the defective placentation or spiral artery remodeling seen in pre-eclampsia. *Pre-existing vascular disease* - Conditions like **chronic hypertension**, **diabetes mellitus**, and **chronic kidney disease** are well-established risk factors for pre-eclampsia. - These diseases impair endothelial function and increase the likelihood of the systemic inflammatory response and vasospasm seen in pre-eclampsia. - Pre-existing vascular dysfunction predisposes to inadequate placental perfusion and abnormal trophoblast invasion. *Obesity* - **Obesity** (BMI ≥30 kg/m²) is a significant risk factor for pre-eclampsia due to its association with **insulin resistance**, chronic inflammation, and endothelial dysfunction. - Maternal obesity leads to heightened oxidative stress, increased inflammatory cytokines, and impaired angiogenesis, contributing to defective placentation. - The risk increases proportionally with increasing BMI. *Primigravida* - Being a **primigravida** (first pregnancy) is an established risk factor for pre-eclampsia, with primiparous women having 2-3 times higher incidence compared to multiparous women. - This is thought to be due to initial exposure to paternal antigens and less robust maternal immune tolerance to placental antigens. - The risk decreases significantly in subsequent pregnancies with the same partner.

Q: Antepartum haemorrhage is defined as bleeding from genital tract occurring:

After 28 weeks of pregnancy. ***After 28 weeks of pregnancy*** - **Antepartum hemorrhage (APH)** is defined as any bleeding from the genital tract occurring from **28 weeks of gestation** until the onset of labour. - This definition helps differentiate it from bleeding in earlier pregnancy, which is typically classified as **threatened abortion**, **miscarriage**, or other early pregnancy complications. *Before 20 weeks of pregnancy* - Bleeding occurring before 20 weeks of pregnancy is generally referred to as **threatened abortion**, **inevitable abortion**, **incomplete abortion**, or **complete abortion**. - These conditions are distinct from antepartum hemorrhage, which pertains to later stages of pregnancy. *Before 24 weeks of pregnancy* - Similar to before 20 weeks, bleeding before 24 weeks would fall under categories related to **early pregnancy loss or complications**, not antepartum hemorrhage. - The viability of the fetus is often still a critical factor in this gestational range, and management differs. *After 34 weeks of pregnancy* - While bleeding after 34 weeks is a form of antepartum hemorrhage, the definition of APH encompasses any bleeding **from 28 weeks onwards**, making "After 28 weeks of pregnancy" the most accurate and comprehensive definition. - Specifying "after 34 weeks" is too narrow and excludes bleeding events that occur between 28 and 34 weeks which are still considered APH.

Q: Which of the following are contra-indications to external cephalic version in antenatal management of breech presentation? 1. Antepartum haemorrhage 2. Multiple pregnancy 3. Reactive Non Stress Test 4. Severe oligohydramnios

1, 2 and 4. ***1, 2 and 4*** * **Antepartum haemorrhage**, **multiple pregnancy**, and **severe oligohydramnios** are all contraindications to external cephalic version (ECV) due to increased risks of fetal distress, placental abruption, and uterine rupture. * These conditions either compromise fetal well-being directly or make the procedure significantly more dangerous for both mother and fetus. *2, 3 and 4* * This option incorrectly includes a **reactive non-stress test** as a contraindication, which actually indicates fetal well-being and is a prerequisite for ECV. * Excluding **antepartum haemorrhage** as a contraindication is also incorrect, as it poses a significant risk. *1, 2, 3 and 4* * This option is incorrect because a **reactive non-stress test** is a sign of fetal health and is a requirement *before* performing an ECV, not a contraindication. * Including it diminishes the specificity of contraindications for this procedure. *1, 2 and 3* * This option erroneously lists a **reactive non-stress test** as a contraindication, when in reality, it's a reassuring finding critical for proceeding with ECV. * It also omits **severe oligohydramnios** which is a significant contraindication due to the inability to safely manipulate the fetus.

Q: A 32 years old woman with two live children was brought to emergency with history of missed period for 15 days, spotting since 7 days and pain abdomen since 6 hours. Her pulse was 120 per minute, pallor + +, systolic B.P. 80 mm Hg. There was fullness and tenderness on per abdomen examination. Copper T thread was seen through external os on per speculum examination. On p/ v examination, cervical movements were tender, uterus was anteverted, bulky and soft. There was fullness in pouch of Douglas. Most likely, she is suffering from:

Ruptured ectopic pregnancy. ***Ruptured ectopic pregnancy*** - The patient presents with **classic signs of ruptured ectopic pregnancy**: missed period, vaginal spotting, acute abdominal pain, **hypovolemic shock** (tachycardia, hypotension, pallor), and signs of internal bleeding (abdominal fullness, tenderness, cervical motion tenderness, fullness in the pouch of Douglas). - The presence of a **Copper T IUD** further increases the risk of ectopic pregnancy if conception occurs, as IUDs are highly effective at preventing intrauterine pregnancies but less so at preventing ectopic ones. *Pelvic inflammatory disease* - While PID can cause abdominal pain and cervical motion tenderness, it is usually associated with **fever, purulent vaginal discharge**, and a history of sexually transmitted infections, which are not mentioned here. - The **acute hemodynamic instability** (shock) and history of missed period are not typical features of uncomplicated PID. *Missed abortion with infection* - A missed abortion involves a non-viable pregnancy with a closed cervix, and while infection can occur, it typically presents with **fever, foul-smelling discharge**, and abdominal pain that is less acute and severe than seen in this case. - The profound shock and localized fullness in the pouch of Douglas are more indicative of **hemoperitoneum** from a ruptured ectopic pregnancy rather than an infected missed abortion. *Threatened abortion* - Threatened abortion is characterized by vaginal bleeding with a **closed cervix** and a **viable intrauterine pregnancy**, usually without severe pain or signs of shock. - The patient's **hemodynamic instability**, severe abdominal pain, and findings suggestive of internal bleeding rule out a simple threatened abortion.

Q: HELLP syndrome includes the following except:

Leucocytosis. ***Leucocytosis*** - HELLP syndrome is characterized by **hemolysis**, **elevated liver enzymes**, and **low platelet count**. Leucocytosis (an elevated white blood cell count) is **not a defining feature** of HELLP syndrome. - While leucocytosis can occur in conditions associated with inflammation or stress, it is **not a diagnostic criterion** for HELLP syndrome and doesn't represent one of its core components. *Low platelet count* - **Thrombocytopenia** (platelet count below 100,000/microL) is a critical component of HELLP syndrome, representing the "LP" in the acronym. - It results from increased platelet consumption and destruction due to widespread endothelial dysfunction. *Hemolysis* - **Hemolysis** (breakdown of red blood cells) is the "H" in the HELLP acronym. - It is evidenced by findings such as **schistocytes** on peripheral blood smear, elevated **lactate dehydrogenase (LDH)**, and unconjugated **hyperbilirubinemia**. *Elevated liver enzymes* - **Elevated liver enzymes** (e.g., aspartate aminotransferase (AST) and alanine aminotransferase (ALT) being at least twice the upper limit of normal) are the "EL" in HELLP. - This elevation indicates **hepatic dysfunction** and hepatocellular damage, often associated with periportal hemorrhage and fibrin deposition.

Q: Which of the following is the most common cause of abortion during first trimester?

Chromosomal anomalies of foetus. ***Chromosomal anomalies of foetus*** - **Chromosomal anomalies** are the leading cause of **sporadic first-trimester abortions**, accounting for up to 50-70% of cases. - These anomalies, such as **aneuploidy (e.g., trisomy 16, monosomy X)**, often lead to developmental abnormalities incompatible with life. *Antiphospholipid antibody syndrome* - While a significant cause of **recurrent pregnancy loss**, particularly in the second and third trimesters, it is less common than chromosomal anomalies for **sporadic first-trimester abortions**. - It causes abortions through **thrombotic events** in the placental vasculature. *Progesterone deficiency* - **Inadequate progesterone levels** can contribute to early pregnancy loss by compromising endometrial support for the embryo. - However, it is a less frequent cause of first-trimester abortion compared to **chromosomal abnormalities**. *Cervical incompetence* - **Cervical incompetence** primarily causes **second-trimester losses** due to the inability of the cervix to retain the pregnancy under increasing pressure. - It is not a common cause of first-trimester abortion, which is typically due to issues with the early embryo or implantation.

Question 1

Which one of the following statements regarding fetal well being is NOT correct?

Accepted Answer

Modified Biophysical profile includes Non-stress test and fetal breathing

Answer

Mothers perceive 88% of fetal movements

Answer

Daily fetal movement count is a simple reliable method of fetal well being

Answer

Healthy fetus should have minimum of 10 movements in 12 hours period

Question 2

What are Spiegelberg's criteria for diagnosis of ovarian pregnancy?

1. Tube on the affected side must be intact
2. Gestational sac must be in the position of ovary
3. Ovary is connected to uterus by utero-ovarian ligament
4. Ovarian tissue must be detected on the wall on histological examination

Accepted Answer

1, 2, 3 and 4

Answer

1, 2 and 3 only

Answer

2, 3 and 4 only

Answer

1 and 4 only

Question 3

Which one of the following is NOT a risk factor for pre-eclampsia ?

Accepted Answer

Placenta previa

Answer

Pre-existing vascular disease

Answer

Obesity

Answer

Primigravida

Question 4

Antepartum haemorrhage is defined as bleeding from genital tract occurring:

Accepted Answer

After 28 weeks of pregnancy

Answer

Before 20 weeks of pregnancy

Answer

Before 24 weeks of pregnancy

Answer

After 34 weeks of pregnancy

Question 5

Which of the following are contra-indications to external cephalic version in antenatal management of breech presentation?

1. Antepartum haemorrhage
2. Multiple pregnancy
3. Reactive Non Stress Test
4. Severe oligohydramnios

Accepted Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 2, 3 and 4

Answer

1, 2 and 3

Question 6

A 32 years old woman with two live children was brought to emergency with history of missed period for 15 days, spotting since 7 days and pain abdomen since 6 hours. Her pulse was 120 per minute, pallor + +, systolic B.P. 80 mm Hg. There was fullness and tenderness on per abdomen examination. Copper T thread was seen through external os on per speculum examination. On p/ v examination, cervical movements were tender, uterus was anteverted, bulky and soft. There was fullness in pouch of Douglas. Most likely, she is suffering from:

Accepted Answer

Ruptured ectopic pregnancy

Answer

Pelvic inflammatory disease

Answer

Missed abortion with infection

Answer

Threatened abortion

Question 7

Consider the following:

1. Fetal pulmonary hypoplasia
2. Fetal chromosomal anomalies
3. Prostaglandin synthetase inhibitors
4. Amniotic fluid index of 15 cm

Which of the above are associated with oligohydramnios?

Accepted Answer

1, 2 and 3

Answer

2, 3 and 4

Answer

1, 2 and 4

Answer

1, 3 and 4

Question 8

HELLP syndrome includes the following except:

Accepted Answer

Leucocytosis

Answer

Low platelet count

Answer

Hemolysis

Answer

Elevated liver enzymes

Question 9

A patient of ectopic pregnancy had beta-hCG of 5800 IU/ml. Medical management was done by single dose methotrexate. Beta-hCG repeated after 48 hours was found 7000 IU/ml. What will you do further?

Accepted Answer

Repeat the injection of methotrexate

Answer

Operate the patient

Answer

Follow up with Beta-hCG after one week

Answer

Follow up with Beta-hCG after 72 hours

Question 10

Which of the following is the most common cause of abortion during first trimester?

Accepted Answer

Chromosomal anomalies of foetus

Answer

Antiphospholipid antibody syndrome

Answer

Progesterone deficiency

Answer

Cervical incompetence

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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