Maternal-Fetal Medicine Practice Questions

Q: The image shows different types of placenta in relation to the internal cervical os. Identify the type of placenta previa shown in the highlighted/marked image.

Type II (marginal).. ***Type II (marginal)*** - In **marginal placenta previa**, the placenta reaches the **edge of the internal cervical os** but does not cover it. - This is classified as a minor placenta previa, as depicted in the provided image. *Type I (low-lying)* - A **low-lying placenta** is when the placental edge is within **2 cm of the internal cervical os** but does not reach it. - The image for low-lying placenta shows the edge 1-20 mm from the os, not directly at the edge as in marginal. *Type III (partial)* - **Partial placenta previa** occurs when the placenta **partially covers the internal cervical os**. - The image labeled "Partial placenta previa" illustrates the placenta covering only a portion of the os, which is a major previa. *Type IV (complete)* - **Complete placenta previa** involves the placenta **completely covering the internal cervical os**. - The image labeled "Complete placenta previa" clearly shows the placenta entirely obstructing the os, which is a major previa.

Q: Which drug regimen is given to a pregnant woman with HIV infection?

All of the options. ***All of the options*** - All listed regimens—**Tenofovir disoproxil fumarate (TDF) with emtricitabine (FTC)**, **TDF with lamivudine (3TC)**, and **Abacavir (ABC) with lamivudine (3TC)**—are commonly used and generally safe combinations of **nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)** in pregnant women with HIV. - The choice of regimen depends on factors such as individual patient characteristics, viral resistance patterns, and potential side effects, but all mentioned regimens are considered **first-line options** in various guidelines for preventing mother-to-child transmission (PMTCT). *Tenofovir disoproxil fumarate with emtricitabine* - This combination is a common and effective **NRTI backbone** for HIV treatment, including in pregnancy, offering good efficacy and a generally favorable safety profile. - It is frequently paired with a third agent (e.g., a **non-nucleoside reverse transcriptase inhibitor (NNRTI)** or an **integrase strand transfer inhibitor (INSTI)**) as part of a highly active antiretroviral therapy (HAART) regimen. *Tenofovir disoproxil fumarate with lamivudine* - This is another widely used and effective **NRTI combination** and is also a recommended backbone for pregnant women with HIV. - While similar to TDF/FTC, some guidelines might prefer one over the other based on specific regional recommendations or drug availability. *Abacavir with lamivudine* - **Abacavir/lamivudine** is a well-established NRTI combination that is safe and effective in pregnancy, provided the mother is **HLA-B*5701 negative** to avoid hypersensitivity reactions. - It is considered a suitable alternative to TDF-containing regimens, especially when there are contraindications or intolerances to TDF.

Q: Which drug is commonly used to promote fetal lung maturity?

Betamethasone. ***Betamethasone*** - **Betamethasone** is the preferred corticosteroid for promoting **fetal lung maturity** in women at risk of preterm delivery (24-34 weeks gestation). - It stimulates **surfactant production** in fetal lungs, reducing the risk of **respiratory distress syndrome (RDS)** and neonatal mortality. - Recommended regimen: **12 mg IM, two doses 24 hours apart**. - Evidence suggests betamethasone may have advantages over dexamethasone, including **reduced risk of intraventricular hemorrhage** and possibly better neurodevelopmental outcomes. *Dexamethasone* - **Dexamethasone** is also an effective corticosteroid for fetal lung maturation and is commonly used in many settings. - While both drugs are acceptable, **betamethasone** is generally preferred based on meta-analyses showing slightly better outcomes. - Dexamethasone regimen: 6 mg IM every 12 hours for 4 doses. *Hydrocortisone* - **Hydrocortisone** has poor placental transfer due to metabolism by placental 11β-hydroxysteroid dehydrogenase. - Its shorter half-life and lower potency make it unsuitable for antenatal corticosteroid therapy. - Not used for fetal lung maturation. *Prednisolone* - **Prednisolone** is also extensively metabolized by the placenta and has poor fetal exposure. - Not effective for promoting fetal lung maturity. - Used for maternal conditions but not for fetal indication.

Q: A 30-year-old woman is 14 weeks pregnant and has a history of two painless deliveries at 16 weeks. What is the next line of management?

Cervical length assessment. ***Cervical length assessment*** - With a history of **two painless preterm deliveries at 16 weeks**, the patient is at high risk for **cervical insufficiency** (incompetent cervix). - While this history may warrant **history-indicated cerclage**, many current protocols recommend **cervical length assessment** via transvaginal ultrasound as the next step to objectively evaluate cervical status and guide management decisions. - An **ultrasound-indicated approach** allows for selective cerclage placement if cervical shortening is documented, avoiding unnecessary procedures in some cases. - Cervical length <25 mm before 24 weeks indicates need for intervention. *Cervical encerclage* - **Prophylactic cerclage** (history-indicated) is an evidence-based option for women with ≥2 prior spontaneous second-trimester losses, and can be placed at 12-14 weeks. - However, the **ultrasound-indicated approach** (assess first, then place cerclage if indicated) is also widely accepted and may prevent unnecessary cerclage in patients with adequate cervical length. - Both approaches are supported by evidence; the question favors assessment first. *Evaluation for diabetes mellitus and thyroid disorders* - While **diabetes mellitus** and **thyroid disorders** can contribute to pregnancy complications, they are not the primary cause of recurrent **painless mid-trimester losses**. - The clinical presentation strongly suggests **cervical insufficiency**, which requires specific cervical evaluation and management. - Medical screening is not the most immediate priority in this scenario. *Tocolytics* - **Tocolytics** are used to suppress **preterm labor contractions**. - This patient's history of **painless deliveries** indicates cervical insufficiency rather than preterm labor with contractions, making tocolytics inappropriate for prevention.

Q: A lady with 35 weeks of pregnancy is admitted in view of first episode of painless bout of bleeding yesterday. On examination Hb 10g%, BP 120/70 mmHg, uterus relaxed, and cephalic floating. FHS regular. Next line of management is ?

Wait and watch. ***Correct: Wait and watch*** - The patient presented with **first episode of painless bleeding yesterday** which has now **stopped**, with stable vitals (BP 120/70 mmHg) and regular FHS, suggesting **placenta previa**. - At **35 weeks gestation**, with bleeding resolved and hemodynamic stability, **expectant management** is the appropriate next step to allow fetal maturity to 37-38 weeks. - The goal is to **avoid preterm delivery** complications while monitoring closely for recurrent bleeding. Patient should be kept in hospital with cross-matched blood ready. - **Ultrasound** should be performed to confirm placenta location, and delivery planned at 37-38 weeks if patient remains stable. *Incorrect: Cesarean section* - While Cesarean section is the **definitive mode of delivery** for placenta previa, it is not indicated immediately in this stable patient at 35 weeks. - Indications for emergency Cesarean would include: **active ongoing bleeding**, maternal or fetal compromise, or reaching 37-38 weeks gestation. - Performing Cesarean at 35 weeks would result in unnecessary **preterm delivery complications** when expectant management is safe. *Incorrect: Induction of labor* - **Absolutely contraindicated** in suspected placenta previa due to high risk of torrential hemorrhage as cervix dilates. - Vaginal delivery is not attempted when placenta previa is suspected. *Incorrect: Blood transfusion* - Hemoglobin of **10g%** indicates mild anemia but does not require immediate transfusion in a stable patient. - Blood should be **cross-matched and kept ready** for emergency use, but transfusion is indicated only if bleeding recurs with significant drop in hemoglobin or hemodynamic instability.

Q: Which of the following parameters is most critical to monitor in a patient with pre-eclampsia?

Blood pressure. ***Blood pressure*** - **Hypertension** is the hallmark of pre-eclampsia and directly correlates with the severity of the disease and the risk of complications such as **eclampsia** and **HELLP syndrome**. - Precise and frequent monitoring of blood pressure guides treatment decisions, including the initiation or adjustment of **antihypertensive medications**. *Proteinuria* - While **proteinuria** is a diagnostic criterion for pre-eclampsia, it is not the most critical parameter for ongoing management and predicting immediate adverse outcomes. - The quantity of proteinuria does not reliably predict the severity of maternal or fetal complications. *Platelet count* - **Thrombocytopenia** can occur in severe pre-eclampsia and **HELLP syndrome**, indicating disease progression. - While important for assessing coagulation status, it is a secondary monitoring parameter compared to blood pressure, which is central to diagnosis and acute management. *Liver function tests (LFTs)* - Elevated **LFTs** signify liver involvement, particularly in severe pre-eclampsia and **HELLP syndrome**. - Monitoring LFTs helps in assessing organ damage but is less immediate for day-to-day management decisions than blood pressure, which is the primary driver of intervention.

Q: Earliest sign after IUFD is ?

Gas in great vessel. ***Gas in great vessel*** - The presence of **intravascular gas** (often in the heart or great vessels) is considered the **earliest reliable sonographic sign of fetal death**, appearing within 1-2 hours after demise. - This gas is thought to result from post-mortem **autolysis** and bacterial activity. *Overlapping of skull bones* - Known as **Spalding's sign**, this indicates skull bone collapse due to liquefaction of brain tissue and typically appears **several days (3-7 days)** after fetal demise. - It reflects a more advanced stage of fetal decomposition rather than an immediate post-mortem change. *Hyperflexion of spine* - This sign, along with abnormal fetal posture, can be seen with fetal demise but is generally evident **later than intravascular gas**, as fetal muscle tone diminishes. - It is a less specific and later indicator compared to intravascular gas. *Overcrowding of ribs* - This is an inconsistent and non-specific finding that may be observed in IUFD but does not serve as an **early diagnostic marker**. - It generally reflects changes in fetal soft tissue and skeletal structures due to maceration, occurring much later.

Question 1

The image shows different types of placenta in relation to the internal cervical os. Identify the type of placenta previa shown in the highlighted/marked image.

Accepted Answer

Type II (marginal).

Answer

Type I (low-lying).

Answer

Type III (partial).

Answer

Type IV (complete).

Question 2

A 22-year-old primigravida visits ANC OPD with 20 weeks POG. On examination uterine height reveals a 16-week size. USG shows reduced liquor. What will be the diagnosis?

Accepted Answer

Intrauterine growth restriction (IUGR)

Answer

Premature rupture of membranes (PROM)

Answer

Congenital absence of one or both kidneys

Answer

Polycystic kidney disease

Question 3

Which of the following conditions is least likely to be classified as a high-risk pregnancy?

Accepted Answer

History of manual removal of placenta

Answer

Severe anemia

Answer

Gestational diabetes

Answer

Obesity in pregnancy

Question 4

Which drug regimen is given to a pregnant woman with HIV infection?

Accepted Answer

All of the options

Answer

Tenofovir disoproxil fumarate with emtricitabine

Answer

Tenofovir disoproxil fumarate with lamivudine

Answer

Abacavir with lamivudine

Question 5

Which drug is commonly used to promote fetal lung maturity?

Accepted Answer

Betamethasone

Answer

Hydrocortisone

Answer

Dexamethasone

Answer

Prednisolone

Question 6

A 21-year-old female presents to the emergency ward with 2 months of amenorrhea, abdominal pain, and shock. Her blood pressure is 90/60 mmHg and hemoglobin is 6 gm%. A urine pregnancy test is positive. What is the next immediate line of treatment?

Accepted Answer

Laparotomy

Answer

Medical management

Answer

IV fluids and cross match

Answer

Laparoscopy

Question 7

A 30-year-old woman is 14 weeks pregnant and has a history of two painless deliveries at 16 weeks. What is the next line of management?

Accepted Answer

Cervical length assessment

Answer

Cervical encerclage

Answer

Evaluation for diabetes mellitus and thyroid disorders

Answer

Tocolytics

Question 8

A lady with 35 weeks of pregnancy is admitted in view of first episode of painless bout of bleeding yesterday. On examination Hb 10g%, BP 120/70 mmHg, uterus relaxed, and cephalic floating. FHS regular. Next line of management is ?

Accepted Answer

Wait and watch

Answer

Induction of labor

Answer

Blood transfusion

Answer

Cesarean section

Question 9

Which of the following parameters is most critical to monitor in a patient with pre-eclampsia?

Accepted Answer

Blood pressure

Answer

Proteinuria

Answer

Platelet count

Answer

Liver function tests (LFTs)

Question 10

Earliest sign after IUFD is ?

Accepted Answer

Gas in great vessel

Answer

Hyperflexion of spine

Answer

Overlapping of skull bones

Answer

Overcrowding of ribs

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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