Maternal-Fetal Medicine Practice Questions

Q: A 30-year-old G1P0 woman at 36 weeks of gestation presents with painless vaginal bleeding. Ultrasound shows the placenta covering the cervical os. What is the diagnosis?

Placenta previa. ***Placenta previa*** - This condition is characterized by the **placenta implantation** over or near the **cervical os**, leading to **painless vaginal bleeding** in the late second or third trimester. - The ultrasound finding of the **placenta covering the cervical os** directly confirms this diagnosis. *Abruptio placentae* - This involves the **premature separation** of the placenta from the uterine wall, typically causing **painful vaginal bleeding** and uterine tenderness. - The patient's bleeding is described as painless, and there is no mention of uterine pain or contractions. *Vasa previa* - Involves **fetal blood vessels** running within the membranes over the cervical os, susceptible to rupture, which leads to **fetal bleeding** and distress. - While it presents as painless vaginal bleeding, the ultrasound specifically shows the **placenta covering the os**, not isolated fetal vessels. *Uterine rupture* - This is a rare, life-threatening event often associated with a **previous C-section scar** or uterine trauma, presenting with sudden, severe abdominal pain, vaginal bleeding, and fetal distress. - The patient's symptoms are painless bleeding, and there is no mention of severe abdominal pain or a history suggestive of increased risk for uterine rupture.

Q: Which imaging modality is the most sensitive for detecting early ectopic pregnancy?

Transvaginal ultrasound. ***Transvaginal ultrasound*** - **Transvaginal ultrasound (TVUS)** provides higher resolution imaging of pelvic organs due to closer proximity to the uterus and adnexa. - This allows for earlier and more accurate detection of an **extrauterine gestational sac** or adnexal mass characteristic of an early ectopic pregnancy. *Transabdominal ultrasound* - **Transabdominal ultrasound (TAUS)** offers lower resolution compared to TVUS, especially in early pregnancy. - It may miss small ectopic pregnancies or fail to accurately characterize a subtle adnexal mass. *MRI* - **MRI** is not typically the first-line imaging modality for suspected ectopic pregnancy due to its higher cost, longer scan time, and limited accessibility in emergency settings. - While it can provide detailed anatomical information, its sensitivity for very early ectopic pregnancies is not superior to TVUS. *CT scan* - **CT scans** involve ionizing radiation, which is generally avoided in pregnancy unless absolutely necessary. - It is not as effective as ultrasound in visualizing the early gestational sac or adnexal structures for ectopic pregnancy diagnosis.

Q: A patient at 28 weeks of gestation presents with a classical cesarean scar and complains of painless spotting. What is the first step in management?

Detailed ultrasound. ***Detailed ultrasound*** - A classical cesarean scar with painless spotting raises concern for **placenta accreta spectrum (PAS) disorders**, where the placenta abnormally adheres to the uterine wall, potentially invading the scar. - A **high-resolution ultrasound** is the initial and most crucial diagnostic step to evaluate placental location, depth of invasion, and proximity to the scar. *Immediate cesarean delivery* - This is an **invasive procedure** and should not be performed without a definitive diagnosis and proper planning, especially given the patient's gestational age of 28 weeks. - An immediate delivery would be indicated for **life-threatening hemorrhage** or **fetal distress**, neither of which is described as the primary complaint in this scenario. *MRI of the pelvis* - While **MRI can provide additional information** for PAS disorders, it is typically used as a **secondary imaging modality** after an inconclusive ultrasound or for surgical planning, not as the first step. - Ultrasound is **more accessible** and often sufficient for initial diagnosis and risk stratification. *Administration of tocolytics* - **Tocolytics are used to suppress uterine contractions** in preterm labor. - This patient is presenting with painless spotting and a concern for PAS, not preterm labor, so tocolytics would be **inappropriate** and potentially **mask critical signs** or delay necessary intervention for the bleeding cause.

Q: A 30-year-old woman at 38 weeks of gestation presents with a sudden onset of severe abdominal pain and a firm, tender uterus. What is the diagnosis?

Abruptio placentae. ***Abruptio placentae*** - **Severe abdominal pain** and a **firm, tender uterus** in a patient at 38 weeks of gestation are classic signs of **abruptio placentae**, where the placenta prematurely detaches from the uterine wall. - This condition often presents with **vaginal bleeding** (though sometimes concealed) and can lead to fetal distress due to placental insufficiency. *Placenta previa* - Characterized by **painless vaginal bleeding** in the second or third trimester, often without abdominal pain or uterine tenderness. - The placenta is abnormally implanted near or over the **cervical os**. *Uterine rupture* - Typically presents with **sudden, severe abdominal pain**, **cessation of uterine contractions**, and often **fetal distress** or loss of fetal heart tones. - A history of prior uterine surgery (e.g., C-section) is a significant risk factor, and the uterus would likely feel soft or boggy rather than firm. *Preterm labor* - Involves regular **uterine contractions** leading to cervical changes before 37 weeks of gestation, usually associated with dull backache, pelvic pressure, or menstrual-like cramps, not sudden severe abdominal pain and uterine tenderness directly. - This patient is at **38 weeks**, so preterm labor is not applicable.

Q: In an emergency cesarean section, a parturient with eclampsia develops sudden hypoxia and hypotension. What is the most likely diagnosis?

Amniotic fluid embolism. ***Amniotic fluid embolism*** - The sudden onset of **hypoxia** and **hypotension** during a cesarean section in a parturient, especially with **eclampsia**, is highly suggestive of an amniotic fluid embolism. - This catastrophic event occurs when **amniotic fluid** enters the maternal circulation, leading to systemic shock, acute respiratory distress, coagulopathy, and often cardiac arrest. *Pulmonary embolism* - While pulmonary embolism can cause sudden **hypoxia** and **hypotension**, it is less likely to present with the rapid and severe systemic collapse typically seen with amniotic fluid embolism in this context. - Risk factors for pulmonary embolism include hypercoagulability, which is enhanced in pregnancy, but the **peripartum setting** points more strongly to an amniotic fluid embolism. *Aspiration pneumonitis* - **Aspiration pneumonitis** would typically present predominantly with **respiratory distress** and coughing, potentially leading to hypoxia, but less commonly with such immediate and severe hypotension. - It results from the inhalation of gastric contents, which can occur during general anesthesia but doesn't fully explain the complete clinical picture of profound **cardiovascular collapse**. *Acute respiratory distress syndrome* - **ARDS** is a syndrome of diffuse lung injury leading to severe **hypoxia** and reduced lung compliance, but it usually develops over hours to days. - The sudden onset of symptoms during the procedure makes ARDS as the primary immediate event less likely, though it can be a **secondary complication** of amniotic fluid embolism.

Q: A 31-year-old G2P1 at 28 weeks of gestation with a known low-lying placenta presents with painless, bright red vaginal bleeding. What is the most likely diagnosis?

Placenta previa. ***Placenta previa*** - The classic presentation of **placenta previa** is **painless, bright red vaginal bleeding** in the second or third trimester. - A **low-lying placenta** noted earlier in pregnancy is a risk factor, as it can migrate to cover the cervical os. *Placental abruption* - Characterized by **painful vaginal bleeding**, often associated with uterine tenderness and contractions. - The bleeding in abruption can be dark red and may be concealed, unlike the bright red blood seen here. *Uterine rupture* - Typically presents with **sudden, severe abdominal pain**, fetal distress, and a loss of uterine tone, often following a prior C-section scar. - Vaginal bleeding may be present but is usually not the primary or only symptom, and pain is a prominent feature. *Vasa previa* - Involves fetal blood vessels running unprotected over the cervical os, leading to **fetal bleeding** when the membranes rupture. - While it can cause painless vaginal bleeding, it is usually associated with **fetal compromise** (e.g., bradycardia) and often occurs at the time of membrane rupture.

Q: What is the effect of glucocorticoid administration in a pregnant woman with preterm labor?

Helps fetal lung maturity. ***Helps fetal lung maturity*** - Glucocorticoids, such as **betamethasone** or **dexamethasone**, accelerate fetal lung maturation by inducing the synthesis and release of **surfactant** in the fetal lungs. - This intervention significantly reduces the incidence and severity of **respiratory distress syndrome (RDS)** in preterm infants. *Increased chances of Intraventricular hemorrhage* - Glucocorticoid administration is associated with a **decreased risk** of **intraventricular hemorrhage (IVH)** in preterm infants, not an increased risk. - This protective effect is thought to be due to improved vascular stability and reduced systemic inflammation. *Increased incidence of neonatal mortality* - Antenatal glucocorticoids have been shown to **reduce neonatal mortality** in preterm infants, primarily by decreasing the rates of RDS, IVH, and **necrotizing enterocolitis (NEC)**. - The benefits of glucocorticoid administration far outweigh the potential risks in the setting of preterm labor. *Reduced Surfactant production* - Glucocorticoids **increase**, rather than reduce, **surfactant production** by stimulating type II pneumocytes in the fetal lungs. - This enhanced surfactant production is crucial for maintaining alveolar stability and preventing lung collapse after birth.

Q: A patient with a history of recurrent early miscarriages is diagnosed with antiphospholipid syndrome. What is the recommended management for her next pregnancy?

Aspirin and heparin. ***Aspirin and heparin*** - The combination of **low-dose aspirin** and **low molecular weight heparin (LMWH)** is the **gold standard** for managing pregnant patients with antiphospholipid syndrome (APS) to prevent recurrent miscarriages. - This therapy aims to **reduce thrombotic events** in the placenta and improve uteroplacental blood flow, which are crucial for a successful pregnancy in APS patients. *Corticosteroids* - While corticosteroids are used in some autoimmune conditions, they are **not recommended as primary treatment** for preventing pregnancy loss in antiphospholipid syndrome. - Their use is generally reserved for inflammatory conditions or specific autoimmune flares, and they carry potential risks in pregnancy. *No specific treatment* - **Untreated antiphospholipid syndrome** in pregnancy carries a **very high risk of recurrent miscarriage**, stillbirth, and other obstetric complications. - Therefore, active management is essential for improving pregnancy outcomes in these patients. *Antibiotic prophylaxis* - **Antibiotic prophylaxis** is typically used to prevent or treat infections and has **no direct role** in preventing recurrent miscarriages due to antiphospholipid syndrome. - The underlying mechanism in APS involves thrombotic tendencies, not infection.

Question 1

A 30-year-old G1P0 woman at 36 weeks of gestation presents with painless vaginal bleeding. Ultrasound shows the placenta covering the cervical os. What is the diagnosis?

Accepted Answer

Placenta previa

Answer

Abruptio placentae

Answer

Vasa previa

Answer

Uterine rupture

Question 2

Which of the following ultrasound findings is characteristic of a molar pregnancy?

Accepted Answer

Snowstorm appearance of the uterine contents

Answer

Increased nuchal translucency

Answer

Echogenic bowel

Answer

Choroid plexus cyst

Question 3

Which imaging modality is the most sensitive for detecting early ectopic pregnancy?

Accepted Answer

Transvaginal ultrasound

Answer

Transabdominal ultrasound

Answer

MRI

Answer

CT scan

Question 4

A patient at 28 weeks of gestation presents with a classical cesarean scar and complains of painless spotting. What is the first step in management?

Accepted Answer

Detailed ultrasound

Answer

Immediate cesarean delivery

Answer

MRI of the pelvis

Answer

Administration of tocolytics

Question 5

A 30-year-old woman at 38 weeks of gestation presents with a sudden onset of severe abdominal pain and a firm, tender uterus. What is the diagnosis?

Accepted Answer

Abruptio placentae

Answer

Placenta previa

Answer

Uterine rupture

Answer

Preterm labor

Question 6

In an emergency cesarean section, a parturient with eclampsia develops sudden hypoxia and hypotension. What is the most likely diagnosis?

Accepted Answer

Amniotic fluid embolism

Answer

Pulmonary embolism

Answer

Aspiration pneumonitis

Answer

Acute respiratory distress syndrome

Question 7

What is the recommended management strategy for a pregnant woman at 28 weeks of gestation diagnosed with asymptomatic placenta previa?

Accepted Answer

Scheduled cesarean delivery between 36-37 weeks if no bleeding occurs

Answer

Immediate cesarean delivery

Answer

Natural vaginal delivery

Answer

Induction of labor at 34 weeks

Question 8

A 31-year-old G2P1 at 28 weeks of gestation with a known low-lying placenta presents with painless, bright red vaginal bleeding. What is the most likely diagnosis?

Accepted Answer

Placenta previa

Answer

Placental abruption

Answer

Uterine rupture

Answer

Vasa previa

Question 9

What is the effect of glucocorticoid administration in a pregnant woman with preterm labor?

Accepted Answer

Helps fetal lung maturity

Answer

Increased chances of Intraventricular hemorrhage

Answer

Increased incidence of neonatal mortality

Answer

Reduced Surfactant production

Question 10

A patient with a history of recurrent early miscarriages is diagnosed with antiphospholipid syndrome. What is the recommended management for her next pregnancy?

Accepted Answer

Aspirin and heparin

Answer

Corticosteroids

Answer

No specific treatment

Answer

Antibiotic prophylaxis

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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