Maternal-Fetal Medicine Practice Questions

Q: A woman at 30 weeks of gestation is diagnosed with deep vein thrombosis (DVT). Which of the following is the most appropriate treatment for this patient?

Low Molecular Weight Heparin (LMWH). ***Low Molecular Weight Heparin (LMWH)*** - **LMWH** is the preferred anticoagulant for DVT during pregnancy because it does **not cross the placenta**, making it safe for the fetus. - It also has a **predictable anticoagulant response** and a lower risk of **heparin-induced thrombocytopenia (HIT)** compared to unfractionated heparin. *Warfarin* - **Warfarin is teratogenic**, especially during the first trimester, and can cause **fetal warfarin syndrome**, which includes skeletal and central nervous system abnormalities. - It can also lead to **fetal bleeding** and miscarriage at any stage of pregnancy. *Apixaban* - **Apixaban** is a **direct oral anticoagulant (DOAC)**, and its safety in pregnancy has not been established. - There is insufficient data regarding its **placental transfer** and potential fetal effects, making its use generally contraindicated in pregnant women. *Fondaparinux* - While **fondaparinux** is an indirect Factor Xa inhibitor and might be considered in cases of heparin allergy or intolerance, its **safety profile in pregnancy is not as well-established** as LMWH. - It is generally reserved for situations where LMWH cannot be used, and its use requires careful consideration due to limited data.

Q: A G2P1L1 woman with a history of previous cesarean section presents with complications related to the placenta. The image below shows the gross appearance of the uterus with abnormal placental attachment to the uterine wall. What is the most likely diagnosis?

Placenta accreta. ***Placenta accreta*** - This diagnosis is strongly suggested by the image showing the **placenta adhered directly to the myometrium**, without invading through the uterine muscular wall. - The history of a **previous cesarean section** is a significant risk factor for placenta accreta, as prior uterine surgery can alter endometrial integrity. *Placenta abruption* - This condition involves the **premature separation of the placenta** from the uterine wall after 20 weeks of gestation but before birth. - It is characterized by symptoms such as **abdominal pain**, **vaginal bleeding**, and **uterine tenderness**, which are not directly depicted by abnormal placental attachment in the image. *Placenta percreta* - This represents the most severe form of abnormal placental adherence, where the **chorionic villi invade through the entire uterine wall** and into adjacent organs like the bladder. - While it shares risk factors with accreta, the image showing attachment "to the uterine wall" rather than invasion *through* it makes percreta less likely. *Placenta previa* - In this condition, the **placenta implants over or near the internal cervical os**, potentially blocking the birth canal. - The image describes abnormal placental attachment *to the uterine wall*, not its position relative to the cervix, differentiating it from placenta previa.

Q: A woman presents with a history of recurrent abortions at 8,11 , and 22 weeks, with normal fetal cardiac activity in all three pregnancies. She also has a history of preeclampsia in her last pregnancy. What is the most probable cause?

Antiphospholipid Antibody Syndrome (APLA). ***Antiphospholipid Antibody Syndrome (APLA)*** - The presentation of **recurrent abortions** (especially with normal fetal cardiac activity) and a history of **preeclampsia** is highly characteristic of Antiphospholipid Antibody Syndrome (APLA). - In APLA, antibodies cause **thrombosis** in the placental vasculature, leading to placental insufficiency, fetal loss, and complications like preeclampsia. *Syphilis* - While syphilis can cause fetal loss, it typically presents with **hydrops fetalis**, hepatosplenomegaly, and bone abnormalities, rather than recurrent losses with normal cardiac activity in the early stages. - Untreated syphilis usually leads to congenital syphilis or stillbirths later in pregnancy, not necessarily early recurrent abortions with good fetal heart tones. *Gestational Diabetes Mellitus (GDM)* - GDM is associated with complications like **macrosomia**, polyhydramnios, and an increased risk of shoulder dystocia, but it is not a direct cause of recurrent early and mid-trimester abortions with normal fetal cardiac activity. - While poorly controlled diabetes can affect fetal development and pregnancy outcomes, it does not typically manifest as recurrent unexplained fetal demise with this specific presentation. *TORCH infections* - TORCH infections (Toxoplasmosis, Other [syphilis, varicella-zoster, parvovirus B19], Rubella, Cytomegalovirus, and Herpes simplex virus) can cause congenital anomalies and fetal death. - However, they would usually present with specific fetal abnormalities, signs of infection, or hydrops, and not typically with recurrent, apparently healthy fetal losses followed by preeclampsia, as often seen in APLA.

Q: A woman with eclampsia is started on magnesium sulfate. What is the first sign of magnesium sulfate toxicity?

Loss of knee jerk. ***Loss of knee jerk*** - **Diminished or absent deep tendon reflexes**, particularly the knee jerk, is the **earliest clinical sign** of magnesium sulfate toxicity. - This occurs at serum magnesium levels between **7-10 mEq/L** (8.5-12 mg/dL) due to magnesium's depressant effect on the nervous system and neuromuscular transmission. *Respiratory depression* - **Respiratory depression** is a more severe and later sign of magnesium toxicity, occurring at higher serum levels (typically >12 mEq/L). - It indicates significant central nervous system depression and potential for respiratory arrest, usually after reflexes are already lost. *Hypotension* - While magnesium sulfate can cause **vasodilation** and a subsequent drop in blood pressure, it is generally **not the first sign of toxicity** and often occurs concurrently with other mild to moderate signs. - Hypotension may be part of the therapeutic effect to reduce blood pressure in eclampsia, rather than an initial indicator of toxicity. *Reduced muscle tone* - **Reduced muscle tone** or **flaccidity** is also a consequence of magnesium's neuromuscular blocking effect but typically manifests **after the loss of deep tendon reflexes**. - It signifies more profound neuromuscular impairment, closer to the progression towards respiratory depression.

Q: The given image depicts:

Both succenturiate lobe and velamentous insertion. ***Both succenturiate lobe and velamentous insertion*** - The image clearly depicts two distinct placental lobes (**succenturiate lobes**), with a smaller accessory lobe separate from the main placental body. - The **umbilical vessels** are also seen running through the fetal membranes before reaching the placental tissue, which is characteristic of **velamentous insertion**. *Normal placenta* - A normal placenta consists of a **single, unified organ** directly attached to the decidua, with the umbilical cord inserting centrally or eccentrically into this main mass. - The **umbilical cord** in a normal placenta would insert directly into the placental tissue, not into the membranes. *Succenturiate lobe* - A succenturiate lobe (or accessory lobe) refers to one or more small lobes of the placenta located at a distance from the main placental body. - While a succenturiate lobe is present, the image also shows the umbilical vessels traversing the membranes, indicating an additional anomaly known as **velamentous insertion**, making this option incomplete. *Velamentous insertion of the cord* - Velamentous insertion is characterized by the **umbilical blood vessels** separating before reaching the placental disc, traveling through the fetal membranes. - While velamentous insertion is evident, the presence of a **separate accessory lobe** makes this option incomplete as it doesn't account for both depicted abnormalities.

Q: A 30-year-old pregnant female diagnosed with fibroid presented with fever, mild leukocytosis, and pain at 28 weeks. What is the likely cause?

Red degeneration of fibroid. ***Red degeneration of fibroid*** - **Red degeneration** (also known as carneous degeneration) is common in pregnancy due to rapid fibroid growth outstripping its blood supply, leading to **ischemic necrosis** and causing pain, fever, and leukocytosis. - This complication typically occurs during the **second and third trimesters** due to hormonal changes and increased vascularity, consistent with the 28-week presentation. *Fibroid infection* - While possible, **fibroid infection** is a rarer complication, often secondary to other procedures or prolonged degeneration. - It would likely present with more pronounced signs of infection, such as higher fever, significant leukocytosis, and possibly discharge or septic symptoms, which are not explicitly stated as severe here. *Fibroid torsion* - **Torsion** usually occurs with pedunculated fibroids when the stalk twists, leading to acute, severe pain and potentially necrosis. - This presentation does not specifically mention a pedunculated fibroid or the sudden, sharp, localized pain typically associated with torsion of an appendage. *Labor pain* - At 28 weeks, **labor pain** would indicate preterm labor, which would typically involve regular, escalating uterine contractions and cervical changes. - The symptoms of fever and leukocytosis are not characteristic of uncomplicated labor pain, suggesting an underlying inflammatory or degenerative process with the fibroid.

Q: Least chance of perinatal transmission?

Hepatitis A. ***Hepatitis A*** - Perinatal transmission of **hepatitis A virus (HAV)** is rare because it's primarily transmitted via the **fecal-oral route**. - While HAV can be present in blood during the viremic phase, the risk of maternal-fetal transmission is negligible due to the short duration of viremia and antibodies usually present in immune mothers. *HSV* - **Herpes simplex virus (HSV)** has a significant risk of perinatal transmission, especially during **vaginal delivery** if the mother has active genital lesions. - Neonatal herpes can lead to severe disseminated disease, central nervous system involvement, or skin, eye, and mouth disease. *Rubella* - **Rubella virus** can cause congenital rubella syndrome (CRS) if the mother is infected during pregnancy, leading to severe birth defects. - This highly teratogenic virus readily crosses the **placenta**, particularly in the first trimester. *CMV* - **Cytomegalovirus (CMV)** is the most common cause of congenital viral infection, with often asymptomatic mothers transmitting the virus to the fetus. - Perinatal transmission can occur *in utero*, during **delivery**, or through **breastfeeding**.

Q: All are the causes of non-immune hydrops except?

ABO incompatibility. ***ABO incompatibility*** - **ABO incompatibility** is a common cause of **immune hydrops fetalis** due to antibody-mediated hemolytic anemia. - Immune hydrops involves red blood cell destruction caused by maternal antibodies crossing the placenta, which is not characteristic of non-immune hydrops. *Thalassemia* - **Alpha-thalassemia major (Hb Barts hydrops fetalis)** is a severe form of thalassemia frequently leading to **non-immune hydrops** due to profound anemia. - The severe chronic anemia leads to **high-output cardiac failure**, diffuse edema, and ascites. *Cardiovascular causes* - **Structural heart defects** and **arrhythmias** can impair fetal circulation and cardiac function, leading to **non-immune hydrops**. - Conditions like **hypoplastic left heart syndrome** or **supraventricular tachycardia** can cause fluid overload and edema. *Parvovirus* - **Parvovirus B19 infection** in the fetus can cause severe **anemia** by targeting erythroid progenitor cells, resulting in bone marrow suppression. - This severe fetal anemia frequently leads to **non-immune hydrops** as a consequence of heart failure.

Q: A primigravida in her 10th week of gestation presents with spotting. On examination, the uterus corresponds to 12 weeks. Transvaginal ultrasound was done and it is given below. What is your diagnosis?

Hydatidiform mole. ***Hydatidiform mole*** - The ultrasound image shows a **"snowstorm" appearance**, characterized by multiple echogenic vesicles or cystic spaces within the uterine cavity, which is pathognomonic for a hydatidiform mole. - The clinical presentation of **vaginal spotting**, a uterus size **larger than expected for gestational age** (12 weeks uterus size at 10 weeks gestation), and possibly elevated hCG levels (though not given here) are all highly suggestive of a molar pregnancy. *Blighted ovum* - A blighted ovum, also known as an anembryonic pregnancy, involves a **gestational sac without an embryo**. - The ultrasound typically shows an empty gestational sac and does not feature the characteristic "snowstorm" pattern of a hydatidiform mole. *Ectopic pregnancy* - An ectopic pregnancy occurs when the **fertilized egg implants outside the uterus**, most commonly in the fallopian tube. - The ultrasound would typically show an **empty uterus** and a gestation outside the uterine cavity, usually with a mass in the adnexa, which is not seen here. *Missed abortion* - A missed abortion is characterized by the **death of the embryo or fetus but retention** within the uterus. - Ultrasound would show a **fetus without cardiac activity** or a gestational sac that is smaller than expected, without the typical vesicular pattern of a mole.

Question 1

A woman at 30 weeks of gestation is diagnosed with deep vein thrombosis (DVT). Which of the following is the most appropriate treatment for this patient?

Accepted Answer

Low Molecular Weight Heparin (LMWH)

Answer

Warfarin

Answer

Apixaban

Answer

Fondaparinux

Question 2

A G2P1L1 woman with a history of previous cesarean section presents with complications related to the placenta. The image below shows the gross appearance of the uterus with abnormal placental attachment to the uterine wall. What is the most likely diagnosis?

Accepted Answer

Placenta accreta

Answer

Placenta abruption

Answer

Placenta percreta

Answer

Placenta previa

Question 3

A woman presents with a history of recurrent abortions at 8,11 , and 22 weeks, with normal fetal cardiac activity in all three pregnancies. She also has a history of preeclampsia in her last pregnancy. What is the most probable cause?

Accepted Answer

Antiphospholipid Antibody Syndrome (APLA)

Answer

Syphilis

Answer

Gestational Diabetes Mellitus (GDM)

Answer

TORCH infections

Question 4

A woman with eclampsia is started on magnesium sulfate. What is the first sign of magnesium sulfate toxicity?

Accepted Answer

Loss of knee jerk

Answer

Respiratory depression

Answer

Hypotension

Answer

Reduced muscle tone

Question 5

The given image depicts:

Accepted Answer

Both succenturiate lobe and velamentous insertion

Answer

Normal placenta

Answer

Succenturiate lobe

Answer

Velamentous insertion of the cord

Question 6

Which of the following is not true about lupus nephritis in pregnancy?

Accepted Answer

Ecosprin, methotrexate, cyclophosphamide, corticosteroids, azathioprine are safe in pregnancy

Answer

Pregnancy to be planned once the disease has been quiescent for at least 6 months and there is no evidence of renal dysfunction

Answer

High dose corticosteroids for lupus flare in pregnancy is safe

Answer

Immunosuppression can be continued during pregnancy

Question 7

A 30-year-old pregnant female diagnosed with fibroid presented with fever, mild leukocytosis, and pain at 28 weeks. What is the likely cause?

Accepted Answer

Red degeneration of fibroid

Answer

Fibroid infection

Answer

Fibroid torsion

Answer

Labor pain

Question 8

Least chance of perinatal transmission?

Accepted Answer

Hepatitis A

Answer

HSV

Answer

Rubella

Answer

CMV

Question 9

All are the causes of non-immune hydrops except?

Accepted Answer

ABO incompatibility

Answer

Thalassemia

Answer

Cardiovascular causes

Answer

Parvovirus

Question 10

A primigravida in her 10th week of gestation presents with spotting. On examination, the uterus corresponds to 12 weeks. Transvaginal ultrasound was done and it is given below. What is your diagnosis?

Accepted Answer

Hydatidiform mole

Answer

Blighted ovum

Answer

Ectopic pregnancy

Answer

Missed abortion

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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