Maternal-Fetal Medicine Practice Questions

Q: Which condition is not typically associated with polyhydramnios?

Renal agenesis. ***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**.

Q: 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?

Expectant management. ***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.

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

Initial clinical assessment (history and examination). ***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.

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: 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 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?

PAPP-A. ***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.

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

Painless vaginal bleeding. ***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.

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

Pre-eclampsia. ***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 1

Which condition is not typically associated with polyhydramnios?

Accepted Answer

Renal agenesis

Answer

Twin-twin transfusion syndrome

Answer

Anencephaly

Answer

Diabetes mellitus

Question 2

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?

Accepted Answer

Expectant management

Answer

Dilation and curettage

Answer

Methotrexate therapy

Answer

Progesterone supplementation

Question 3

What is essential for confirming the diagnosis of placental abruption?

Accepted Answer

Initial clinical assessment (history and examination)

Answer

MRI (Magnetic Resonance Imaging)

Answer

Ultrasound

Answer

Laboratory investigations (e.g., blood tests)

Question 4

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 5

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 6

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 7

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?

Accepted Answer

PAPP-A

Answer

hCG

Answer

Inhibin A

Answer

AFP

Question 8

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

Accepted Answer

Painless vaginal bleeding

Answer

Pelvic pain

Answer

Rapid uterine growth

Answer

Hyperemesis gravidarum

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

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

Accepted Answer

Pre-eclampsia

Answer

Gestational diabetes

Answer

Chronic hypertension

Answer

Gestational trophoblastic disease

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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