Maternal-Fetal Medicine Practice Questions

Q: A 23 year old presents with recurrent abortions at 16 weeks gestation. She should be investigated for:

Incompetent cervix. ***Incompetent cervix*** - Recurrent abortions, particularly in the **second trimester** (around 16 weeks gestation), are highly suggestive of an incompetent cervix. - An incompetent cervix dilates painlessly and prematurely without contractions, leading to **fetal loss**. *TORCH infection* - TORCH infections (Toxoplasmosis, Other [syphilis, varicella-zoster, parvovirus B19], Rubella, Cytomegalovirus, and Herpes) typically cause **fetal anomalies** or **early pregnancy loss**, or affect the neonate. - While they can cause miscarriage, recurrent losses at 16 weeks without other symptoms are less characteristic of isolated TORCH infections. *Hepatitis B infection* - **Hepatitis B infection** can be transmitted to the fetus, but it is not a direct cause of recurrent second-trimester abortions. - The primary concern with Hepatitis B in pregnancy is **vertical transmission** to the neonate. *Balanced paternal translocation* - A **balanced translocation** in either parent can lead to recurrent miscarriages, but these typically occur earlier in pregnancy due to genetically unbalanced conceptions. - While possible, the specific timing of 16 weeks recurrent loss points more strongly towards an anatomical issue like an incompetent cervix.

Q: Which one of the following conditions is not associated with oligohydramnios during pregnancy?

Oesophageal atresia. ***Oesophageal atresia*** - **Oesophageal atresia** hinders the fetus from swallowing amniotic fluid, leading to an *increase* in amniotic fluid, a condition known as **polyhydramnios**, not oligohydramnios. - The inability of the fetus to properly absorb and excrete amniotic fluid through the gastrointestinal tract is the primary mechanism. *Post term pregnancy* - In **post-term pregnancies** (beyond 40 weeks), placental function can decline, reducing blood flow to the kidneys which can decrease fetal urine production. - Decreased fetal urine output is a major contributor to **oligohydramnios**. *Ruptured membrane* - A **ruptured membrane** (premature rupture of membranes) directly allows amniotic fluid to leak out of the uterus. - This leakage results in a reduction of the total amniotic fluid volume, causing **oligohydramnios**. *Intrauterine growth restriction* - In **intrauterine growth restriction (IUGR)**, the fetus experiences chronic stress and reduced perfusion due to placental insufficiency. - This often leads to **redistribution of fetal blood flow** away from non-essential organs like kidneys, decreasing urine production and contributing to oligohydramnios.

Q: Which of the following is the type of antepartum haemorrhage where blood loss is foetal?

Vasa previa. ***Vasa previa*** - In **vasa previa**, foetal blood vessels traverse the foetal membranes unprotected across the cervical os, making them vulnerable to rupture during labor or membrane rupture, leading to **foetal blood loss**. - This condition is often suspected when **foetal bradycardia** or sinusoidal heart rate patterns appear following membrane rupture, especially if accompanied by vaginal bleeding. *Circumvallate placenta* - This refers to a placental anomaly where the chorionic plate is smaller than the basal plate, causing the membranes to fold back and create an elevated ring around the umbilical cord insertion. - While it can be associated with higher rates of **antepartum hemorrhage**, preterm labor, or foetal growth restriction, the blood loss is typically maternal in origin, from marginal placental separation. *Placenta previa* - **Placenta previa** occurs when the placenta partially or completely covers the cervical os, leading to painless vaginal bleeding in the second or third trimester. - The hemorrhage in placenta previa is **maternal blood loss** due to the separation of the maternal decidua from the placental villi. *Abruptio placenta* - **Abruptio placenta** involves the premature separation of a normally implanted placenta from the uterine wall. - The bleeding in abruptio placenta is predominantly **maternal blood**, often accumulating between the placenta and uterine wall, and is typically associated with abdominal pain and uterine tenderness.

Q: Polyhydramnios is not caused by which one of the following?

Single kidney. ***Single kidney*** - A single kidney or other renal agenesis conditions typically lead to **oligohydramnios**, not polyhydramnios, because fetal urine production is reduced or absent. - The fetal urinary system is crucial for maintaining amniotic fluid volume, and its malfunction results in decreased fluid. *Spina bifida* - **Neural tube defects** such as spina bifida can contribute to polyhydramnios by affecting fetal swallowing mechanisms or increasing fluid secretion from exposed meninges. - While not the most common cause, severe forms can impair neural control over fetal fluid regulation. *Oesophageal atresia* - This condition prevents the fetus from **swallowing amniotic fluid**, leading to its accumulation in the amniotic sac. - Fetal swallowing is a primary mechanism for amniotic fluid reabsorption, and its mechanical obstruction results in polyhydramnios. *Anencephaly* - **Anencephaly** is a severe **neural tube defect** where the brain and skull fail to develop, often leading to impaired fetal swallowing and excessive urination. - The exposed meninges can also leak cerebrospinal fluid into the amniotic sac, further contributing to polyhydramnios.

Q: Which of the following is not a potentially teratogenic infection if contracted in pregnancy?

Influenza virus. ***Influenza virus*** - While influenza can cause severe illness in pregnant women, it is **not generally considered teratogenic**, meaning it does not typically cause birth defects like the other listed infections. - The primary risks of influenza in pregnancy are severe maternal complications, **preterm birth**, and **low birth weight**, rather than congenital anomalies. *Chicken pox* - Maternal infection with **varicella-zoster virus (chickenpox)** during the first 20 weeks of pregnancy can lead to **Congenital Varicella Syndrome**, characterized by skin scarring, limb hypoplasia, microphthalmia, and neurological deficits. - Infection late in pregnancy can cause **neonatal varicella**, which can be severe and life-threatening for the newborn. *Rubella* - Maternal infection with **rubella (German measles)**, especially during the first trimester, is a well-known cause of **Congenital Rubella Syndrome (CRS)**. - CRS can result in severe birth defects, including **cataracts**, **heart defects** (e.g., patent ductus arteriosus, pulmonary artery stenosis), and **sensorineural hearing loss**. *Cytomegalovirus* - **Congenital cytomegalovirus (CMV)** infection is a leading cause of **non-hereditary sensorineural hearing loss** and neurodevelopmental disabilities. - While many infected infants are asymptomatic at birth, some develop **microcephaly**, periventricular calcifications, hepatosplenomegaly, and **chorioretinitis**.

Q: Polyhydramnios at term is diagnosed when AFI is more than:

25 cm. ***25 cm*** - **Polyhydramnios** is diagnosed when the **Amniotic Fluid Index (AFI)** at term is greater than or equal to **25 cm**. - This indicates an excessive amount of **amniotic fluid**, which can be associated with various maternal or fetal complications. *15 cm* - An AFI of 15 cm is within the **normal range** for amniotic fluid volume. - It does not meet the criteria for either **polyhydramnios** or **oligohydramnios**. *20 cm* - An AFI of 20 cm is considered to be in the **upper normal limit** or **borderline high**, but it does not definitively meet the diagnostic criteria for **polyhydramnios**. - Close monitoring would be indicated, but it's not severe polyhydramnios. *10 cm* - An AFI of 10 cm is also within the **normal range** for amniotic fluid volume. - It is neither indicative of too much nor too little amniotic fluid.

Q: Amniocentesis is called for in all of the following circumstances EXCEPT:

A father aged 50 year or more. ***A father aged 50 year or more*** - Advanced paternal age (typically 40 years or more) may be associated with a slightly increased risk of certain **autosomal dominant disorders** (e.g., achondroplasia, Marfan syndrome) and **schizophrenia** due to an accumulation of de novo mutations in sperm. - However, it is not a direct indication for **amniocentesis** for chromosomal abnormalities in the same way advanced maternal age or a history of chromosomal issues is. *Parents who are known to have chromosomal translocation* - If either parent carries a **balanced chromosomal translocation**, there is a significant risk that the pregnancy could result in an **unbalanced translocation** in the fetus, leading to developmental abnormalities or miscarriage. - **Amniocentesis** is indicated to determine whether the fetus has inherited an unbalanced translocation. *Mother who had a child with Down's syndrome or other chromosomal anomalies* - A prior pregnancy affected by **Down syndrome (Trisomy 21)** or another **chromosomal anomaly** significantly increases the risk of recurrence in subsequent pregnancies. - **Amniocentesis** allows for prenatal diagnosis to detect if the current fetus is affected. *A mother aged 35 years or more* - Advanced maternal age, generally defined as 35 years or older at the time of delivery, is associated with an increased risk of **aneuploidies**, such as **Down syndrome**. - **Amniocentesis** is offered to these mothers for prenatal chromosomal analysis.

Q: Which one of the following regarding fetal growth restriction is NOT true?

Delivery always at 34 weeks. ***Delivery always at 34 weeks*** - The timing of delivery in **fetal growth restriction (FGR)** is highly **individualized** and depends on several factors, including the severity of FGR, gestational age, and results of fetal surveillance tests like Doppler studies and biophysical profiles. It is not an absolute rule to deliver all FGR fetuses at 34 weeks. - Early delivery, especially before term, carries risks of **prematurity**, and the decision is made when the risks of continuing the pregnancy outweigh the risks of early delivery. *Biophysical profile is done* - The **biophysical profile (BPP)** is a common method of fetal surveillance used in pregnancies complicated by FGR to assess fetal well-being, including **fetal movements, tone, breathing, amniotic fluid volume,** and **non-stress test results**. - It helps in making decisions about the timing of delivery and ongoing management. *Umbilical artery Doppler studies are done* - **Umbilical artery Doppler studies** are crucial for monitoring FGR, as they assess placental function and fetal compromise by measuring blood flow in the umbilical artery. - Abnormal Doppler findings, such as **absent** or **reversed end-diastolic flow**, indicate increased placental resistance and are important in guiding management and determining the optimal timing of delivery. *Daily fetal movement count is advised* - **Daily fetal movement counting**, or "kick counts," is an important and simple method of fetal surveillance that women can perform at home to monitor fetal well-being. - A significant decrease in fetal movements can signal **fetal compromise** and warrants further evaluation.

Question 1

A 23 year old presents with recurrent abortions at 16 weeks gestation. She should be investigated for:

Accepted Answer

Incompetent cervix

Answer

TORCH infection

Answer

Hepatitis B infection

Answer

Balanced paternal translocation

Question 2

Which one of the following conditions is not associated with oligohydramnios during pregnancy?

Accepted Answer

Oesophageal atresia

Answer

Post term pregnancy

Answer

Ruptured membrane

Answer

Intrauterine growth restriction

Question 3

Which of the following is the type of antepartum haemorrhage where blood loss is foetal?

Accepted Answer

Vasa previa

Answer

Circumvallate placenta

Answer

Placenta previa

Answer

Abruptio placenta

Question 4

Polyhydramnios is not caused by which one of the following?

Accepted Answer

Single kidney

Answer

Spina bifida

Answer

Oesophageal atresia

Answer

Anencephaly

Question 5

Regarding hypertensive disorders of pregnancy, the following are true except:

Accepted Answer

Urinary dipstick result of +1 is equivalent to urinary protein concentration of 300 mg/dl

Answer

Significant proteinuria is more than/equal to 0.3 g/24hr

Answer

Eclampsia may present in the absence of hypertension

Answer

A protein:creatinine ratio more than 30 mg/mmol is considered significant

Question 6

Which of the following is not a potentially teratogenic infection if contracted in pregnancy?

Accepted Answer

Influenza virus

Answer

Chicken pox

Answer

Rubella

Answer

Cytomegalovirus

Question 7

Polyhydramnios at term is diagnosed when AFI is more than:

Accepted Answer

25 cm

Answer

15 cm

Answer

20 cm

Answer

10 cm

Question 8

Amniocentesis is called for in all of the following circumstances EXCEPT:

Accepted Answer

A father aged 50 year or more

Answer

Parents who are known to have chromosomal translocation

Answer

Mother who had a child with Down's syndrome or other chromosomal anomalies

Answer

A mother aged 35 years or more

Question 9

A 29 year old woman presents in emergency ward with amenorrhea of 6 weeks and pain. Urine pregnancy test shows positive. Examination shows diffuse significant lower abdomen tenderness. The pelvic examination is difficult to accomplish due to guarding. Her Beta-hCG level is 4000 mIU/ml. Transvaginal ultrasound shows no pregnancy in the uterus and no adnexal mass but moderate fluid in abdomen. Which of the following is the next best step?

Accepted Answer

Emergency laparotomy

Answer

Repeat Beta-hCG level in 48 hours

Answer

Institution of methotrexate

Answer

Wait and watch

Question 10

Which one of the following regarding fetal growth restriction is NOT true?

Accepted Answer

Delivery always at 34 weeks

Answer

Biophysical profile is done

Answer

Umbilical artery Doppler studies are done

Answer

Daily fetal movement count is advised

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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