Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 1131: What is essential for confirming the diagnosis of placental abruption?

A. MRI (Magnetic Resonance Imaging)
B. Ultrasound
C. Laboratory investigations (e.g., blood tests)
D. Initial clinical assessment (history and examination) (Correct Answer)

Explanation: ***Initial clinical assessment (history and examination)*** - The diagnosis of **placental abruption** is primarily clinical, based on sudden onset of **vaginal bleeding**, **abdominal pain**, and often a **tender, rigid uterus** on examination. - The **characteristic clinical presentation** (history and physical findings) is the cornerstone for confirming the diagnosis and guiding immediate management. - Clinical assessment has the highest diagnostic utility in acute settings and should be performed immediately. *Ultrasound* - **Ultrasound** has limited sensitivity (25-50%) for detecting acute placental abruption, as fresh blood clots can be isoechoic to the placenta. - It is more useful in **ruling out placenta previa** and assessing fetal well-being, rather than confirming abruption itself. - A negative ultrasound does **not exclude** placental abruption. *MRI (Magnetic Resonance Imaging)* - **MRI** is highly sensitive for detecting placental abruption, but it is not used for **acute diagnosis** due to its cost, time commitment, and limited availability in emergency settings. - Its role is mostly reserved for cases with **diagnostic uncertainty** or for research purposes. *Laboratory investigations (e.g., blood tests)* - **Laboratory tests** such as complete blood count (CBC), coagulation profile, and fibrinogen levels help assess the **maternal hemodynamic status** and screen for disseminated intravascular coagulation (DIC). - These tests are crucial for guiding treatment and managing complications, but they do not **confirm the diagnosis** of placental abruption itself.

Question 1132: A 27-year-old woman at 10 weeks of gestation presents with painless vaginal bleeding. An ultrasound reveals an intrauterine gestational sac without a fetal pole, and her β-hCG levels are decreasing. What is the most appropriate management option?

A. Dilation and curettage
B. Methotrexate therapy
C. Progesterone supplementation
D. Expectant management (Correct Answer)

Explanation: ***Expectant management*** - With **decreasing β-hCG levels** and an **empty gestational sac**, a **missed abortion** is likely, and expectant management allows the body to pass the tissue naturally, avoiding invasive procedures. - This approach is appropriate for hemodynamically stable patients without signs of infection, and most will spontaneously complete the abortion within a few weeks. *Dilation and curettage* - This is an **invasive surgical procedure** generally reserved for cases of incomplete abortion with heavy bleeding, infection, or patient preference for a quicker resolution. - Performing D&C prematurely in a stable patient with decreasing hCG and no immediate complications might be an **overly aggressive initial management**. *Methotrexate therapy* - **Methotrexate** is primarily used for **ectopic pregnancies** or **gestational trophoblastic disease**. - It is **not indicated** for an intrauterine pregnancy arrest (missed abortion) when expectant management or surgical evacuation are safer and more appropriate options. *Progesterone supplementation* - **Progesterone** is sometimes used in cases of threatened abortion with documented **low progesterone levels** in the hope of maintaining the pregnancy. - However, in this scenario, the presence of an **empty gestational sac** and **decreasing β-hCG levels** indicates that the pregnancy is no longer viable, making progesterone supplementation ineffective.

Question 1133: Which condition is not typically associated with polyhydramnios?

A. Twin-twin transfusion syndrome
B. Anencephaly
C. Renal agenesis (Correct Answer)
D. Diabetes mellitus

Explanation: ***Renal agenesis*** - **Renal agenesis** leads to **oligohydramnios** (too little amniotic fluid) because fetal kidneys are crucial for producing amniotic fluid through urine. - The absence of kidneys means the fetus cannot contribute fluid, resulting in insufficient amniotic fluid volume. *Diabetes mellitus* - Maternal **diabetes mellitus** can cause **fetal hyperglycemia**, leading to an increase in fetal urination and thus **polyhydramnios**. - High glucose levels in the fetal blood are filtered by the kidneys, increasing osmotic diuresis and urine output. *Twin-twin transfusion syndrome* - In **twin-twin transfusion syndrome (TTTS)**, the recipient twin often develops **polyhydramnios** due to increased blood volume and subsequent diuresis. - The donor twin, conversely, typically experiences **oligohydramnios**. *Anencephaly* - **Anencephaly** is a neural tube defect where the fetus lacks a developed brain, leading to impaired swallowing reflexes. - Impaired swallowing prevents the fetus from adequately reabsorbing amniotic fluid, contributing to **polyhydramnios**.

Question 1134: 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?

A. Placenta previa (Correct Answer)
B. Abruptio placentae
C. Vasa previa
D. Uterine rupture

Explanation: ***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.

Question 1135: Which of the following ultrasound findings is characteristic of a molar pregnancy?

A. Snowstorm appearance of the uterine contents (Correct Answer)
B. Increased nuchal translucency
C. Echogenic bowel
D. Choroid plexus cyst

Explanation: ***Snowstorm appearance of the uterine contents*** - The **"snowstorm" appearance** or **"cluster of grapes" appearance** on ultrasound is the **pathognomonic finding** for **hydatidiform mole** (molar pregnancy). - The uterine cavity is filled with **multiple anechoic vesicles** representing **edematous chorionic villi** with hydropic degeneration. - In a **complete mole**, there is **no identifiable fetus or fetal tissue** - only abnormal placental proliferation with a diploid androgenetic karyotype (46,XX or 46,XY, all paternal origin). - In a **partial mole**, there may be **fetal tissue** present but the fetus is typically **non-viable** with severe abnormalities and a triploid karyotype (69,XXY or 69,XXX). - Molar pregnancy carries risks of **persistent gestational trophoblastic disease** and **choriocarcinoma**, requiring close follow-up of β-hCG levels. *Increased nuchal translucency* - **Increased nuchal translucency (NT)** measured at 11-14 weeks gestation is a marker for **chromosomal abnormalities** such as **trisomy 21 (Down syndrome)**, **trisomy 18**, and **trisomy 13**. - Also associated with **cardiac defects** and other structural anomalies in an otherwise developing fetus. - This is **not related to molar pregnancy**, which involves abnormal trophoblastic proliferation rather than fetal chromosomal abnormalities. *Echogenic bowel* - **Echogenic bowel** refers to fetal intestines that appear as bright as bone on second-trimester ultrasound. - Associated with **cystic fibrosis**, **congenital infections** (CMV, toxoplasmosis), **intra-amniotic bleeding**, **fetal aneuploidy**, and **intestinal obstruction**. - This is a **fetal finding** and is **not characteristic of molar pregnancy**, which is a disorder of placental tissue. *Choroid plexus cyst* - **Choroid plexus cysts** are fluid-filled spaces within the choroid plexus of the fetal lateral ventricles, typically detected in the second trimester. - Most are **isolated benign findings** that resolve spontaneously by the third trimester. - When found in association with other anomalies, may be a **soft marker for trisomy 18** (Edwards syndrome). - **Not related to molar pregnancy**, which involves trophoblastic rather than fetal abnormalities.

Question 1136: 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?

A. Immediate cesarean delivery
B. Detailed ultrasound (Correct Answer)
C. MRI of the pelvis
D. Administration of tocolytics

Explanation: ***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.

Question 1137: A pregnant woman at 14 weeks of gestation shows increased nuchal thickness on ultrasound. Which test is NOT included in the second trimester quadruple test for Down's syndrome?

A. hCG
B. Inhibin A
C. PAPP-A (Correct Answer)
D. AFP

Explanation: ***PAPP-A*** - **Pregnancy-associated plasma protein-A (PAPP-A)** is a marker included in the **first-trimester screening** for Down syndrome, primarily performed between weeks 10 and 14 of gestation. - The question specifies the **second-trimester quadruple screen**, therefore, PAPP-A is **NOT part of this test**. - This is the **correct answer** as it is the only marker listed that is NOT included in the second-trimester quadruple test. *AFP* - **Alpha-fetoprotein (AFP)** is one of the four markers measured in the **quadruple screen** during the second trimester. - Low levels of AFP, combined with other markers, can indicate an increased risk of **Down syndrome**. *hCG* - **Human chorionic gonadotropin (hCG)** is another marker included in the **second-trimester quadruple screen**. - **Elevated levels of hCG** are associated with an increased risk for Down syndrome. *Inhibin A* - **Inhibin A** is the fourth marker in the **quadruple screen**, alongside AFP, hCG, and **unconjugated estriol (uE3)**. - **Elevated levels of Inhibin A** in the second trimester are suggestive of an increased risk of Down syndrome. **Note:** The complete second-trimester quadruple screen includes: AFP, hCG, unconjugated estriol (uE3), and Inhibin A. PAPP-A is used only in first-trimester screening.

Question 1138: Which condition in pregnancy is characterized by new-onset hypertension and proteinuria after 20 weeks of gestation?

A. Gestational diabetes
B. Pre-eclampsia (Correct Answer)
C. Chronic hypertension
D. Gestational trophoblastic disease

Explanation: ***Pre-eclampsia*** - **Pre-eclampsia** is characterized by new-onset **hypertension** (systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg) and **proteinuria** (≥ 0.3 g in a 24-hour urine collection) after 20 weeks of gestation. - While **edema** was previously considered a cardinal sign, it is no longer part of the diagnostic criteria; however, it is a common finding. *Gestational diabetes* - **Gestational diabetes** is characterized by **glucose intolerance** that first appears or is recognized during pregnancy. - It does not involve **hypertension** or **proteinuria** as primary diagnostic features. *Chronic hypertension* - **Chronic hypertension** refers to hypertension that exists **before pregnancy** or develops before 20 weeks of gestation. - It does not primarily involve new-onset **proteinuria** after 20 weeks, which differentiates it from pre-eclampsia. *Gestational trophoblastic disease* - **Gestational trophoblastic disease** (e.g., hydatidiform mole) is characterized by abnormal proliferation of **trophoblastic tissue** in the uterus. - While it can sometimes be associated with **hypertension** and **proteinuria** (especially in cases of complete hydatidiform mole with a very large uterus), these are not its primary defining features; rather, it is diagnosed by high beta-hCG levels and characteristic ultrasound findings.

Question 1139: What is the most common early symptom of a molar pregnancy?

A. Pelvic pain
B. Rapid uterine growth
C. Painless vaginal bleeding (Correct Answer)
D. Hyperemesis gravidarum

Explanation: ***Painless vaginal bleeding*** - This is the most common early symptom of a molar pregnancy, often presenting as **dark brown** to **bright red spotting** or bleeding. - The bleeding results from the abnormal placental tissue, which lacks normal blood vessels and is prone to hemorrhage. *Hyperemesis gravidarum* - While **severe nausea and vomiting** can occur in molar pregnancies due to excessively high **hCG levels**, it is not typically the *earliest* symptom. - Many normal pregnancies also experience nausea and vomiting, making it less specific as an initial indicator. *Pelvic pain* - **Pelvic pain** is not a characteristic early symptom of molar pregnancy. - Pain is more commonly associated with complications such as uterine rupture or the expulsion of molar tissue later in the presentation. *Rapid uterine growth* - **Uterine size larger than expected for gestational age** is a classic sign of molar pregnancy, but it usually becomes noticeable later in the first or second trimester, not as an *early* symptom. - This rapid growth is due to the proliferation of hydropic villi within the uterus.

Question 1140: What is the recommended management strategy for a pregnant woman at 28 weeks of gestation diagnosed with asymptomatic placenta previa?

A. Immediate cesarean delivery
B. Natural vaginal delivery
C. Induction of labor at 34 weeks
D. Scheduled cesarean delivery between 36-37 weeks if no bleeding occurs (Correct Answer)

Explanation: ***Scheduled cesarean delivery between 36-37 weeks if no bleeding occurs*** - For **asymptomatic placenta previa** at 28 weeks, expectant management with a planned **cesarean delivery between 36 and 37+6 weeks** is the standard to allow fetal maturity while minimizing maternal and fetal risks. - If bleeding occurs, immediate re-evaluation and potential earlier delivery might be necessary, but without active bleeding, deferring delivery is preferred. *Immediate cesarean delivery* - This is reserved for cases of **active, heavy vaginal bleeding** or signs of fetal distress, which are not mentioned in this scenario. - Delivering at 28 weeks unnecessarily subjects the fetus to risks of **prematurity** when expectant management is feasible and safer. *Natural vaginal delivery* - **Vaginal delivery is contraindicated** in placenta previa because the placenta covers the cervix, which would lead to severe and potentially fatal **hemorrhage** when the cervix dilates. - The placenta would detach before the fetus is delivered, cutting off fetal oxygen supply. *Induction of labor at 34 weeks* - Induction of labor is contraindicated due to the risk of severe **hemorrhage** associated with placenta previa. - Delivering at 34 weeks would lead to a **premature birth**, increasing the risk of neonatal complications, and is not indicated in an asymptomatic case.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

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Intrauterine Growth Restriction

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Multiple Gestation

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Rh Isoimmunization and Other Blood Group Incompatibilities

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Intrauterine Fetal Therapy

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Prenatal Diagnosis and Genetic Counseling

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Placental Abnormalities

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Preterm Labor and Delivery

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Management of Medical Disorders in Pregnancy

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