Maternal-Fetal Medicine Practice Questions

Q: A pregnant female presents with pain in abdomen. On examination, tenderness is found in right lumbar region. TLC is 12000/cmm and urine examination is normal. The most appropriate diagnostic test is:

Ultrasound abdomen. ***Ultrasound abdomen*** - This is the **safest and preferred initial imaging modality** for abdominal pain in pregnant women, as it avoids **ionizing radiation**. - It can effectively visualize the **appendix**, **gallbladder**, **kidneys**, and **uterus/adnexa**, helping to identify common causes of right lumbar pain like **appendicitis**, **pyelonephritis**, or **adnexal pathology**. *Laparoscopy* - While diagnostic, laparoscopy is an **invasive surgical procedure** and is typically reserved for cases where non-invasive imaging is inconclusive or if a **therapeutic intervention** is required. - It carries risks such as **anesthesia complications** and **uterine injury** in pregnancy, making it unsuitable as a primary diagnostic test. *Non-contrast CT abdomen* - **CT scans** involve **ionizing radiation**, which should be avoided in pregnancy due to potential risks to the **fetus**, especially if a less harmful alternative is available. - While it offers detailed anatomical information, the risk-benefit ratio for a **pregnant patient with a normal urine analysis** does not justify its initial use over ultrasound. *Chest X-ray with abdominal shield* - A **chest X-ray** primarily evaluates the **lungs and heart** and would not provide adequate visualization of the abdominal organs responsible for the right lumbar pain. - While a shield minimizes fetal exposure, the information gained would be **irrelevant to the presenting abdominal symptoms**, making it an inappropriate diagnostic choice.

Q: Snow storm appearance on an ultrasound is seen in:

Vesicular mole. ***Vesicular mole*** - The classic ultrasound finding in a **complete hydatidiform mole** is a **"snowstorm" appearance**, characterized by a uterine cavity filled with echogenic, vesicular tissue and no fetal parts. - This appearance is due to the **swollen chorionic villi** and **trophoblastic proliferation**. *Chronic ectopic pregnancy* - While an ectopic pregnancy involves an implantation outside the uterus, it typically presents with an **adnexal mass**, sometimes with a **"ring of fire" sign** on Doppler, but not a snowstorm pattern within the uterine cavity. - Chronic ectopic pregnancies may show a more complex adnexal mass with varying echogenicity due to hemorrhage and organization, but this is distinct from the diffuse uterine changes in a hydatidiform mole. *Hydatid cyst* - A **hydatid cyst**, caused by *Echinococcus granulosus*, is typically found in the liver or lungs and appears as a **well-defined, anechoic lesion** with possible internal septations or daughter cysts (often called a "water lily" sign if ruptured) but not a diffuse snowstorm pattern within the uterus. - This condition is a parasitic infection, entirely unrelated to pregnancy. *Dermoid cyst* - A **dermoid cyst** (mature cystic teratoma) is an ovarian tumor that typically appears as a **complex adnexal mass** with characteristic features like a **"Rokitansky nodule"**, fat-fluid levels, and highly echogenic components (e.g., hair, teeth). - Its appearance is localized to the ovary and does not mimic the widespread uterine findings of a vesicular mole.

Q: In pregnancies complicated by intrauterine growth restriction (IUGR) with otherwise reassuring fetal surveillance, what is the recommended gestational age for planned delivery to optimize neonatal outcomes?

38 weeks. ***38 weeks*** - For pregnancies complicated by **IUGR (Intrauterine Growth Restriction)** with reassuring fetal surveillance, planned delivery at **38-39 weeks** is recommended by **ACOG guidelines** to optimize neonatal outcomes. - Among the given options, **38 weeks** represents the earliest point in this recommended range, balancing the risks of continued intrauterine compromise with the risks of **prematurity** such as **respiratory distress syndrome**. - This timing is appropriate for **mild to moderate IUGR** without concerning Doppler findings or other complications. *39 weeks* - **39 weeks** is actually within the acceptable range (38-39 weeks) for IUGR delivery per current guidelines. - However, many obstetricians prefer **38 weeks** to minimize the risk of continued **fetal compromise** from **placental insufficiency**, making 38 weeks the more commonly cited benchmark. - The distinction between 38 and 39 weeks is nuanced and depends on individual case factors and surveillance findings. *37 weeks* - Delivery at **37 weeks** is considered **early term** and carries higher risk of **neonatal morbidities**, particularly **respiratory complications** and **hypoglycemia**. - This timing may be appropriate for **severe IUGR** with abnormal **umbilical artery Doppler** findings, **absent or reversed end-diastolic flow**, or other concerning features, but not for routine IUGR with reassuring surveillance. - It is not the standard recommendation for uncomplicated IUGR to optimize outcomes. *40 weeks* - Delivering at **40 weeks** in an IUGR pregnancy is **not recommended** due to increased risk of **stillbirth** and complications from ongoing **placental insufficiency**. - The risks of adverse outcomes escalate with expectant management beyond 38-39 weeks in IUGR pregnancies. - Minimal additional fetal growth occurs beyond this point while risks continue to increase.

Q: A patient at 8 weeks of pregnancy is diagnosed to have a dermoid cyst. It should be removed at:

At 14-16 weeks. ***At 14-16 weeks*** - This period, the **second trimester**, is generally considered the safest time for **non-emergent surgery** during pregnancy. - Waiting until 14-16 weeks allows for the completion of **organogenesis**, reducing the risk of teratogenicity, and the risk of **spontaneous abortion** is lower compared to the first trimester. *Only when it undergoes torsion* - While **torsion** is a significant complication requiring immediate surgical intervention, waiting for it to occur would expose the patient to unnecessary pain, **ischemia**, and potential loss of the **ovary**. - Elective removal at a safer time is preferred to prevent emergencies. *At term along with LSCS* - Removing the cyst at term during a **cesarean section (LSCS)** is not ideal if the cyst is larger than 6 cm due to the increased risk of **torsion, rupture**, or **obstruction of labor** earlier in pregnancy. - If the cyst is small and uncomplicated, some obstetricians may consider this, but it is not the standard approach for a newly diagnosed cyst at 8 weeks. *Immediately* - Performing surgery at **8 weeks of gestation (first trimester)** carries a higher risk of **spontaneous abortion** due to surgical stress, anesthesia, and potentially interfering with critical stages of **embryonic development**. - Unless there is an emergency (like rupture or acute torsion), elective surgery is typically postponed.

Q: How do you manage placenta accreta?

Classical cesarean; hysterectomy. ***Classical cesarean; hysterectomy*** - A **classical cesarean section** (vertical incision in the upper uterine segment) allows for delivery of the fetus without disturbing the **placenta accreta** in the lower uterine segment. - Subsequent **hysterectomy** is often necessary due to the high risk of severe hemorrhage from the morbidly adherent placenta, which cannot be safely separated. *Low vertical cesarean; hysterectomy* - A **low vertical incision** is made in the lower uterine segment, which could potentially incise through the placenta accreta if it extends to that region, leading to significant hemorrhage. - While hysterectomy is likely indicated, the initial uterine incision might complicate management. *Low transverse cesarean; hysterectomy* - A **low transverse incision** is the most common type for routine cesarean sections but is contra-indicated in placenta accreta as the placenta is frequently implanted in the lower uterine segment. - Incising through the **placenta** during a low transverse cut would cause immediate massive hemorrhage, making this approach unsuitable. *Classical cesarean; myometrial resection* - While a **classical cesarean** would be the appropriate initial step for fetal delivery, **myometrial resection** to remove only the affected area of the myometrium is generally insufficient and carries a high risk of residual placental tissue and severe hemorrhage, often necessitating a hysterectomy anyway. - This approach is typically not recommended as a primary definitive management strategy for established placenta accreta.

Q: Retention of urine in a pregnant woman with a retroverted uterus is seen in which week?

12-16 weeks. ***12-16 weeks*** - Between **12-16 weeks**, the uterus typically rises out of the **pelvis**. A **retroverted uterus** can become trapped, causing pressure on the bladder neck and leading to **urinary retention**. - This period aligns with the timing when the growing uterus in a retroverted position would exert maximum pressure on the urethra, leading to **bladder outflow obstruction**. *20-24 weeks* - By **20-24 weeks**, the uterus is usually well out of the **pelvis**, making urinary retention due to uterine retroversion less likely as a primary cause. - If retained beyond 16 weeks, the uterus would likely have **spontaneously corrected its position** or the problem would have presented earlier. *28-32 weeks* - At **28-32 weeks**, the uterus is much larger and would typically be positioned high in the **abdomen**, far removed from the **pelvic outlet**, preventing entrapment. - Urinary retention at this stage may indicate other complications, such as **urinary tract infection** or **neurogenic bladder**, rather than uterine retroversion. *8-10 weeks* - At **8-10 weeks**, the uterus is generally still small and contained within the **pelvis**, and although retroversion is present, it is often not large enough to cause significant pressure on the **bladder neck** or entrapment. - **Urinary symptoms** at this stage are more commonly related to hormonal changes or increased blood flow to the kidneys, often characterized by **urinary frequency** rather than retention.

Q: In current obstetrics practice, what is the best test for monitoring sensitized Rh negative mother?

Middle cerebral artery Doppler wave forms. ***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.

Question 1

A pregnant female presents with pain in abdomen. On examination, tenderness is found in right lumbar region. TLC is 12000/cmm and urine examination is normal. The most appropriate diagnostic test is:

Accepted Answer

Ultrasound abdomen

Answer

Laparoscopy

Answer

Non contrast CT abdomen

Answer

Chest Xray with abdominal shield

Question 2

Snow storm appearance on an ultrasound is seen in:

Accepted Answer

Vesicular mole

Answer

Chronic ectopic pregnancy

Answer

Hydatid cyst

Answer

Dermoid cyst

Question 3

In pregnancies complicated by intrauterine growth restriction (IUGR) with otherwise reassuring fetal surveillance, what is the recommended gestational age for planned delivery to optimize neonatal outcomes?

Accepted Answer

38 weeks

Answer

39 weeks

Answer

37 weeks

Answer

40 weeks

Question 4

What is the WHO definition of abortion?

Accepted Answer

Pregnancy termination or loss occurring before 22 weeks of gestation.

Answer

Pregnancy termination or loss occurring before 24 weeks of gestation.

Answer

Pregnancy termination or loss occurring before 12 weeks of gestation.

Answer

Pregnancy termination or loss occurring before 20 weeks of gestation.

Question 5

Regarding medical treatment of ectopic pregnancy, all are true except:

Accepted Answer

Initial beta HCG is an indicator for the number of doses required

Answer

Best prognostic indicator for success is initial HCG levels

Answer

Perform baseline CBC, LFT, KFT

Answer

Failure rates increase if cardiac activity is present

Question 6

A patient at 8 weeks of pregnancy is diagnosed to have a dermoid cyst. It should be removed at:

Accepted Answer

At 14-16 weeks

Answer

Only when it undergoes torsion

Answer

At term along with LSCS

Answer

Immediately

Question 7

How do you manage placenta accreta?

Accepted Answer

Classical cesarean; hysterectomy

Answer

Low vertical cesarean; hysterectomy

Answer

Low transverse cesarean; hysterectomy

Answer

Classical cesarean; myometrial resection

Question 8

All are signs / features of ectopic pregnancy on USG except –

Accepted Answer

Echogenic mass with multicystic spaces within endometrial cavity

Answer

Hyperechoic rim

Answer

Adnexal mass

Answer

Pseudo sac

Question 9

Retention of urine in a pregnant woman with a retroverted uterus is seen in which week?

Accepted Answer

12-16 weeks

Answer

20-24 weeks

Answer

28-32 weeks

Answer

8-10 weeks

Question 10

In current obstetrics practice, what is the best test for monitoring sensitized Rh negative mother?

Accepted Answer

Middle cerebral artery Doppler wave forms

Answer

Biophysical profile

Answer

Amniotic fluid spectrophotometry

Answer

Fetal blood sampling

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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