Maternal-Fetal Medicine Practice Questions

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.

Q: Cause of Fetal growth restriction may be: 1. Chromosomal abnormality 2. Congenital abnormality 3. Abnormal cord insertion Which of the statements given above is/are correct?

1, 2 and 3. ***Correct: 1, 2 and 3*** All three statements represent established causes of **Fetal Growth Restriction (FGR)**: - **Chromosomal abnormalities** (trisomy 13, 18, 21, Turner syndrome) cause **intrinsic poor growth potential** of the fetus by disrupting normal cellular development and metabolism, directly leading to FGR. - **Congenital abnormalities** (cardiac defects, renal malformations, CNS anomalies) impair fetal development and nutrient utilization through structural and functional deficits, resulting in FGR. - **Abnormal cord insertion** (velamentous or marginal cord insertion) compromises the efficiency of **nutrient and oxygen transfer** from the placenta to the fetus by reducing vascular support, thus causing placental insufficiency and FGR. *Incorrect: 1 and 3 only* This incorrectly excludes **congenital abnormalities**, which are a well-established independent cause of FGR. Structural malformations directly impair fetal growth through metabolic and functional deficits. *Incorrect: 1 and 2 only* This incorrectly excludes **abnormal cord insertion**, which directly impacts placental function and nutrient supply—a key pathway for uteroplacental insufficiency leading to FGR. *Incorrect: 2 and 3 only* This incorrectly excludes **chromosomal abnormalities**, which are a major genetic cause of intrinsic FGR. Chromosomal defects (e.g., trisomies) are fundamental causes of impaired fetal growth potential.

Q: The Maternal serum α-fetoprotein level is elevated in all EXCEPT:

Down syndrome. ***Down syndrome*** - In **Down syndrome (Trisomy 21)**, the maternal serum **alpha-fetoprotein (MSAFP) level is typically decreased**, not elevated. - This characteristic **low MSAFP** is a key marker used in screening for Down syndrome in the second trimester. *Omphalocele* - **Omphalocele** involves the protrusion of abdominal organs through an umbilical defect, covered by a membrane. - Due to the **exposed fetal gut**, there is leakage of **alpha-fetoprotein** into the amniotic fluid and maternal circulation, leading to **elevated MSAFP**. *Intra uterine death* - In cases of **intrauterine fetal death**, there can be a release of fetal alpha-fetoprotein into the maternal circulation due to **fetal tissue breakdown**. - This often results in a **transient elevation of MSAFP levels**. *Neural tube defect* - **Neural tube defects (NTDs)**, such as **anencephaly** and **spina bifida**, are characterized by incomplete closure of the neural tube. - The **exposed neural tissue** allows **alpha-fetoprotein** to leak directly into the amniotic fluid and then into the maternal bloodstream, causing a significant **elevation of MSAFP**.

Q: A 25 year old G2P1L1, Rh –ve woman presented at 30 weeks gestation to the antenatal clinic, the indirect Coomb's test (ICT) was found to be positive. What would be the next line of management?

ICT titers to be closely monitored at weekly intervals. **ICT titers to be closely monitored at weekly intervals** - A **positive Indirect Coombs Test (ICT)** in an Rh-negative pregnant woman indicates the presence of maternal antibodies against fetal Rh antigens. The next step is to monitor the **titer** to assess the risk of **hemolytic disease of the fetus and newborn (HDFN)**. - Serial monitoring of ICT titers, typically every 2-4 weeks, helps to determine if the antibody levels are increasing, which would indicate a heightened risk to the fetus and necessitate further intervention. *Anti D to be given* - **Anti-D immunoglobulin** is administered to prevent **sensitization** in Rh-negative mothers who have not yet formed antibodies. - Since the ICT is already positive, the mother has already been **sensitized** and produced antibodies, making Anti-D administration ineffective at this stage. *Baby is to be delivered as soon as possible* - Premature delivery carries significant risks for the neonate due to **immaturity of organ systems**. - Delivery is usually reserved for cases of severe fetal compromise, not simply a positive ICT without further evidence of fetal anemia. *Amniocentesis for estimation of bilirubin by Liley's chart is to be done* - **Amniocentesis** for bilirubin estimation using **Liley's chart** is an invasive procedure that carries risks, including **infection** and **fetal loss**. - It is typically reserved for cases where **ICT titers are critically high** or there is evidence of fetal anemia on **Doppler ultrasound**, not as the initial management step for a positive ICT.

Q: Consider the following statements regarding pregnancy with Rh isoimmunization: 1. Indirect coombs test is performed in mother 2. Methergin is withheld at delivery of anterior shoulder 3. Middle cerebral artery peak systolic velocity is an accurate method to predict fetal anemia Which of the statements given above are correct?

1 and 3 only. ***1 and 3 only*** - The **indirect Coombs test (IAT)** is performed on the mother's serum to detect **Rh antibodies**, which is essential for diagnosing and monitoring Rh isoimmunization. - **Middle cerebral artery peak systolic velocity (MCA-PSV)** >1.5 MoM is a non-invasive and highly accurate ultrasound method to predict moderate to severe **fetal anemia** in Rh-isoimmunized pregnancies, guiding the need for intrauterine transfusion. - Statement 2 is **incorrect**: While minimizing fetomaternal hemorrhage is important in Rh isoimmunization, there is **no specific evidence-based guideline** that Methergine should be routinely withheld at delivery of the anterior shoulder in Rh-negative mothers. The focus is on **timely Anti-D administration** (within 72 hours postpartum) rather than avoiding specific uterotonics. *1 and 2 only* - Statement 1 is correct, but statement 2 is incorrect. - Methergine (methylergonovine) is not specifically contraindicated in Rh isoimmunization; its main contraindications include **hypertension and preeclampsia** due to vasoconstrictive effects. - Prevention of Rh sensitization focuses on **Anti-D immunoglobulin administration**, not withholding uterotonics. *2 and 3 only* - Statement 3 is correct regarding **MCA-PSV** accuracy for fetal anemia detection. - Statement 2 is incorrect: Methergine withholding is not a standard practice specifically for Rh isoimmunization management. *1, 2 and 3* - Statements 1 and 3 are correct. - Statement 2 is incorrect: There is no established protocol to withhold Methergine at delivery of the anterior shoulder specifically for Rh isoimmunization. Management focuses on **preventing sensitization through Anti-D prophylaxis**, **monitoring with antibody titers**, and **detecting fetal anemia via MCA-PSV**, not on avoiding specific uterotonics.

Q: Which of the following is NOT the hormonal basis for hyperemesis gravidarum?

Excess of Human Placental Lactogen. ***Excess of Human Placental Lactogen*** - **Human placental lactogen (hPL)** is primarily involved in **metabolic adaptation** during pregnancy, promoting insulin resistance and glucose availability for the fetus. - While essential for fetal growth, hPL has **no direct causal link** to the pathophysiology of nausea and vomiting in hyperemesis gravidarum. *High serum levels of Estrogen* - **Elevated estrogen levels** during pregnancy are believed to contribute to nausea and vomiting by affecting **gastrointestinal motility** and the central chemoreceptor trigger zone. - The rapid increase and high concentrations of estrogen correlate with the severity of symptoms in many pregnant women. *Excess of Progesterone* - **High progesterone levels** can cause **relaxation of smooth muscle**, including that of the gastrointestinal tract, leading to delayed gastric emptying and increased gastroesophageal reflux. - These effects can exacerbate nausea and vomiting, making it a contributing factor to hyperemesis gravidarum. *Excess of Chorionic Gonadotropin* - **High levels of human chorionic gonadotropin (hCG)** are strongly implicated in the etiology of hyperemesis gravidarum, with symptoms often correlating with peaks in hCG levels in early pregnancy. - hCG is thought to stimulate the **thyroid gland** (due to structural similarity to TSH) and directly affect the **chemoreceptor trigger zone** in the brain, inducing nausea and vomiting.

Q: Common trisomies resulting in spontaneous abortion are all EXCEPT:

Trisomy 1. ***Trisomy 1*** - **Trisomy 1** is considered **lethal** and results in very early embryonic demise, often before a pregnancy is recognized, making it an extremely rare finding in spontaneous abortions. - The presence of an extra copy of such a large, gene-rich chromosome is **incompatible with early development**. *Trisomy 21* - **Trisomy 21 (Down syndrome)** is the most common autosomal trisomy that can result in a live birth, but it is also a frequent cause of **spontaneous abortion**. - While many pregnancies with Trisomy 21 result in live births, a significant proportion (approximately **75-80%**) end in miscarriage. *Trisomy 18* - **Trisomy 18 (Edwards syndrome)** is a common trisomy found in spontaneous abortions, second only to Trisomy 16. - While it can result in live births, the majority of fetuses with Trisomy 18 **miscarry spontaneously**. *Trisomy 16* - **Trisomy 16** is the most common trisomy identified in early spontaneous abortions, accounting for a large percentage of all chromosomal abnormalities leading to miscarriage. - It is considered **lethal** and is almost exclusively found in miscarried fetuses, with very rare exceptions of mosaic forms.

Q: Which one of the following is NOT a risk factor for the development of placenta previa?

Maternal anaemia. ***Maternal anaemia*** - **Maternal anaemia** is generally considered a *consequence* of conditions like antenatal hemorrhage from placenta previa, rather than a direct risk factor for its development. - While anaemia is common in pregnancy and can exacerbate outcomes, it does not independently increase the likelihood of the placenta implanting abnormally close to or over the cervical os. *Maternal age* - **Advanced maternal age** (typically over 35 years) is a well-established risk factor for placenta previa. - This is thought to be due to an increased incidence of pre-existing uterine abnormalities and degenerative changes in the endometrium. *Previous caesarean section* - A **previous caesarean section** significantly increases the risk of placenta previa due to the presence of a uterine scar. - The placenta may preferentially implant over the scar tissue, which can be less vascular, leading to a lower implantation and potentially previa. *Smoking* - **Smoking** during pregnancy is a recognized risk factor for placenta previa, potentially due to hypoxic-ischemic effects on the endometrium. - It may contribute to abnormal placentation by inducing compensatory placental hypertrophy and extending the placental surface area, increasing the chance of covering the cervical os.

Question 1

Polyhydramnios at term is diagnosed when AFI is more than:

Accepted Answer

25 cm

Answer

15 cm

Answer

20 cm

Answer

10 cm

Question 2

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 3

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

Question 4

Cause of Fetal growth restriction may be:

1. Chromosomal abnormality
2. Congenital abnormality
3. Abnormal cord insertion

Which of the statements given above is/are correct?

Accepted Answer

1, 2 and 3

Answer

1 and 3 only

Answer

1 and 2 only

Answer

2 and 3 only

Question 5

The Maternal serum α-fetoprotein level is elevated in all EXCEPT:

Accepted Answer

Down syndrome

Answer

Omphalocele

Answer

Intra uterine death

Answer

Neural tube defect

Question 6

A 25 year old G2P1L1, Rh –ve woman presented at 30 weeks gestation to the antenatal clinic, the indirect Coomb's test (ICT) was found to be positive. What would be the next line of management?

Accepted Answer

ICT titers to be closely monitored at weekly intervals

Answer

Anti D to be given

Answer

Baby is to be delivered as soon as possible

Answer

Amniocentesis for estimation of bilirubin by Liley's chart is to be done

Question 7

Consider the following statements regarding pregnancy with Rh isoimmunization:

1. Indirect coombs test is performed in mother
2. Methergin is withheld at delivery of anterior shoulder
3. Middle cerebral artery peak systolic velocity is an accurate method to predict fetal anemia Which of the statements given above are correct?

Accepted Answer

1 and 3 only

Answer

1 and 2 only

Answer

2 and 3 only

Answer

1, 2 and 3

Question 8

Which of the following is NOT the hormonal basis for hyperemesis gravidarum?

Accepted Answer

Excess of Human Placental Lactogen

Answer

High serum levels of Estrogen

Answer

Excess of Progesterone

Answer

Excess of Chorionic Gonadotropin

Question 9

Common trisomies resulting in spontaneous abortion are all EXCEPT:

Accepted Answer

Trisomy 1

Answer

Trisomy 21

Answer

Trisomy 18

Answer

Trisomy 16

Question 10

Which one of the following is NOT a risk factor for the development of placenta previa?

Accepted Answer

Maternal anaemia

Answer

Maternal age

Answer

Previous caesarean section

Answer

Smoking

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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