Maternal-Fetal Medicine Practice Questions

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: 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: Which of the following is NOT a component of the biophysical profile?

Placental grading. ***Placental grading*** - **Placental grading** (e.g., Grannum classification) is an ultrasound assessment of placental maturity based on its appearance, but it is **NOT** one of the five standard components of the biophysical profile. - While useful for assessing placental health and maturity, it does not directly reflect **acute fetal well-being** in the same way as the BPP parameters. *Fetal tone* - This **is** one of the five components assessed in a **biophysical profile (BPP)**, specifically looking for at least one episode of active extension with return to flexion. - A normal score for fetal tone indicates **fetal neurological integrity** and adequate oxygenation. *Nonstress test (Fetal heart rate)* - The **nonstress test (NST)** evaluating fetal heart rate accelerations in response to fetal movement **is** one of the five components of the biophysical profile. - It assesses fetal heart rate reactivity as an indicator of **fetal well-being** and adequate oxygenation. *Fetal breathing movements* - **Fetal breathing movements** **are** a component of the biophysical profile, requiring at least one episode of 30 seconds of sustained fetal breathing over 30 minutes. - This parameter assesses neurological function and helps confirm the maturity of the **fetal respiratory system**.

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.

Q: In a patient with gestational diabetes, what is the primary goal of dietary management?

Maintain normal blood glucose levels. ***Maintain normal blood glucose levels*** - The primary goal of dietary management in **gestational diabetes** is to achieve and maintain **euglycemia**, thereby preventing adverse maternal and fetal outcomes. - This involves careful monitoring of **carbohydrate intake** and ensuring appropriate timing and distribution of meals to prevent postprandial hyperglycemia. *Weight loss* - While maintaining a healthy weight is beneficial, **weight loss** is generally not recommended during pregnancy, even in gestational diabetes, as it can be detrimental to fetal growth. - The focus is on **weight management** and preventing excessive weight gain, rather than active weight reduction. *Increase protein intake* - While adequate protein intake is crucial for fetal development, an **excessive increase** in protein intake is not the primary dietary goal for managing gestational diabetes. - The focus is on balancing all macronutrients to control **blood glucose**. *Reduce carbohydrate intake* - While **carbohydrate moderation** is critical for blood glucose control, drastically reducing carbohydrate intake can lead to ketosis and may not provide sufficient energy for the mother and fetus. - The goal is to choose **complex carbohydrates** and distribute them appropriately throughout the day, rather than simply reducing them.

Q: A 28-year-old woman in labor with a history of preeclampsia presents with severe hypertension. What is the appropriate treatment?

Labetalol. ***Labetalol*** - **Labetalol IV** is a **first-line agent** for acute treatment of **severe hypertension in preeclampsia** with rapid onset (5-10 minutes) and predictable dose-response. - It works by blocking both **alpha- and beta-adrenergic receptors**, reducing blood pressure without significantly compromising **uteroplacental blood flow**. - **Advantages**: IV route allows titration, widely available, favorable maternal-fetal safety profile. *Hydralazine* - **Hydralazine IV** is **also a first-line agent** (not second-line) for severe hypertension in preeclampsia, with equal efficacy to labetalol. - **Disadvantages**: Can cause **reflex tachycardia** and **maternal headache/palpitations**, making it harder to distinguish from worsening preeclampsia symptoms. - Onset of action can be **less predictable** with more frequent maternal side effects compared to labetalol. *Nifedipine* - **Nifedipine (immediate-release oral)** is **also a first-line agent** for severe hypertension in pregnancy, with efficacy comparable to IV agents. - **Disadvantages**: Oral route may be less ideal during active labor; can cause **maternal flushing and headache**. - Risk of **hypotension** if combined with magnesium sulfate (commonly used in preeclampsia). *Methyldopa* - **Methyldopa** is used for **chronic hypertension in pregnancy**, NOT for acute severe hypertension. - Its **slow onset of action** (4-6 hours) makes it completely unsuitable for emergency blood pressure control in labor.

Q: A pregnant woman presents with symptoms consistent with Zika virus infection, and ultrasound reveals fetal abnormalities. What is the most appropriate course of action?

Perform amniocentesis to test for Zika virus RNA. ***Perform amniocentesis to test for Zika virus RNA*** - Amniocentesis is recommended to confirm the presence of **Zika virus RNA in amniotic fluid** when fetal abnormalities are detected and Zika infection is suspected. - This diagnostic step provides definitive evidence of **fetal infection**, which is crucial for counseling and management. *Terminate the pregnancy* - **Termination of pregnancy** is a significant decision that requires confirmed diagnosis and thorough counseling, and it is not the immediate first step. - While it may be considered later depending on the severity of fetal abnormalities and parental wishes, diagnostic confirmation is paramount. *Initiate antiviral therapy immediately* - Currently, there is **no specific antiviral therapy** approved or proven effective for treating Zika virus infection in pregnant women or fetuses. - Management is primarily supportive, focusing on monitoring and symptom relief. *Wait for further development and re-evaluate* - Given the presence of **fetal abnormalities** and symptoms consistent with Zika, **waiting for further development** without diagnostic intervention is inappropriate. - Prompt diagnosis is essential to understand the full extent of the infection and prognosticate fetal outcomes.

Q: What is the primary goal of management in a patient with a molar pregnancy?

Complete evacuation of the mole. ***Complete evacuation of the mole*** - The primary goal in managing a molar pregnancy is the complete removal of all **trophoblastic tissue** to prevent persistent gestational trophoblastic disease (GTD) or choriocarcinoma. - This is typically achieved through **suction dilation and curettage (D&C)**, which is the safest and most effective method. *Immediate chemotherapy* - Chemotherapy is not the immediate primary management for a molar pregnancy; it is reserved for patients who develop **persistent GTD** or **choriocarcinoma** after initial evacuation. - The initial approach focuses on removing the abnormal tissue rather than systemic treatment for malignancy unless it develops. *Hysterectomy* - Hysterectomy is generally reserved for patients who have **completed childbearing** and desire definitive treatment to prevent recurrent molar pregnancy or persistent GTD, or in cases of intractable bleeding. - It is not the primary approach for all molar pregnancies, especially in women who desire future fertility. *Preservation of the uterus may be considered in some cases for future fertility.* - While preservation of the uterus is a desirable secondary goal for patients who wish to retain future fertility, it is secondary to the primary goal of **complete mole evacuation**. - The focus is first on safely removing the molar tissue, and then on monitoring to ensure the uterus is healthy for potential future pregnancies.

Q: A 35-year-old woman with a history of preterm labor at 32 weeks presents at 24 weeks with signs of preterm labor. Which treatment is recommended to prevent recurrence?

Progesterone supplementation. ***Correct: Progesterone supplementation*** - **Progesterone** helps maintain uterine quiescence and prevents cervical shortening, which is beneficial for women with a history of spontaneous preterm birth. - For women with a history of **preterm labor**, progesterone supplementation (either vaginal or intramuscular 17-alpha-hydroxyprogesterone caproate) is recommended to reduce the risk of recurrence. - This is supported by **ACOG guidelines** and multiple randomized controlled trials showing reduced risk of recurrent preterm birth. *Incorrect: Corticosteroids* - **Corticosteroids** (e.g., betamethasone or dexamethasone) are administered to women at risk of imminent preterm delivery to accelerate fetal lung maturity. - They are **not used for preventing recurrence** of preterm labor but rather for mitigating complications if preterm birth is unavoidable. - Typically given between 24-34 weeks when delivery is anticipated within 7 days. *Incorrect: Magnesium sulfate* - **Magnesium sulfate** is primarily used as a **neuroprotective agent** for the fetus in cases of anticipated preterm birth before 32 weeks, and for tocolysis to temporarily delay delivery. - It is **not a treatment for preventing recurrent preterm labor** or for long-term maintenance of pregnancy. - Used acutely, not for prophylaxis. *Incorrect: Cerclage* - **Cervical cerclage** is a surgical procedure to reinforce the cervix, typically performed in women with **cervical insufficiency** (a weakened cervix that opens prematurely). - It is indicated if the patient has a history of second-trimester losses due to cervical incompetence or if significant cervical shortening (<25mm) is observed in the current pregnancy. - Not the primary treatment for preventing recurrent preterm labor in the absence of documented cervical insufficiency.

Question 1

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 2

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 3

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 4

Which of the following is NOT a component of the biophysical profile?

Accepted Answer

Placental grading

Answer

Fetal tone

Answer

Fetal heart rate

Answer

Breathing movements

Question 5

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

Question 6

In a patient with gestational diabetes, what is the primary goal of dietary management?

Accepted Answer

Maintain normal blood glucose levels

Answer

Weight loss

Answer

Increase protein intake

Answer

Reduce carbohydrate intake

Question 7

A 28-year-old woman in labor with a history of preeclampsia presents with severe hypertension. What is the appropriate treatment?

Accepted Answer

Labetalol

Answer

Methyldopa

Answer

Nifedipine

Answer

Hydralazine

Question 8

A pregnant woman presents with symptoms consistent with Zika virus infection, and ultrasound reveals fetal abnormalities. What is the most appropriate course of action?

Accepted Answer

Perform amniocentesis to test for Zika virus RNA

Answer

Terminate the pregnancy

Answer

Initiate antiviral therapy immediately

Answer

Wait for further development and re-evaluate

Question 9

What is the primary goal of management in a patient with a molar pregnancy?

Accepted Answer

Complete evacuation of the mole

Answer

Immediate chemotherapy

Answer

Hysterectomy

Answer

Uterine preservation for future fertility

Question 10

A 35-year-old woman with a history of preterm labor at 32 weeks presents at 24 weeks with signs of preterm labor. Which treatment is recommended to prevent recurrence?

Accepted Answer

Progesterone supplementation

Answer

Corticosteroids

Answer

Magnesium sulfate

Answer

Cerclage

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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