Maternal-Fetal Medicine Practice Questions

Q: A 28-year-old woman at 32 weeks of gestation presents with vaginal bleeding and no pain. Ultrasound shows placenta previa. What is the initial management?

Expectant management. ***Expectant management*** - In a stable patient with **placenta previa** at 32 weeks and no signs of fetal distress or severe hemorrhage, the correct management **strategy** is expectant management (watchful waiting) rather than immediate delivery. - This involves **hospitalization** with close monitoring including **maternal vital signs**, amount of bleeding, and fetal well-being (e.g., nonstress tests). - **Corticosteroids should be administered immediately** as part of expectant management to promote fetal lung maturity, given the risk of preterm delivery. - The goal is to reach 36-37 weeks gestation when elective cesarean delivery can be performed safely. *Immediate delivery* - **Immediate delivery** is only indicated in cases of **severe hemorrhage**, maternal hemodynamic instability, or fetal distress. - At 32 weeks, delivering without urgent indication significantly increases neonatal morbidity and mortality. *Magnesium sulfate* - **Magnesium sulfate** may be used for **tocolysis** if uterine contractions are present or for **neuroprotection** before anticipated preterm delivery (to reduce risk of cerebral palsy). - However, it is not the primary initial management strategy compared to expectant management with monitoring. *Corticosteroids* - **Corticosteroids** (betamethasone or dexamethasone) are indeed administered immediately to promote **fetal lung maturity**. - However, this option alone is incomplete as an answer because it doesn't encompass the **overall management approach** (expectant vs immediate delivery), which is the key decision point. - Corticosteroids are an essential **component** of expectant management, not a separate strategy.

Q: What is the most appropriate management for a fetus diagnosed with non-immune hydrops due to fetal anemia?

Intrauterine transfusion. ***Intrauterine transfusion*** - Non-immune hydrops due to **fetal anemia** requires **intrauterine transfusion** as the most effective treatment. - This procedure directly addresses the underlying cause by providing healthy red blood cells, which can reverse heart failure and hydrops. - Common causes of anemia-induced hydrops include **parvovirus B19 infection**, **α-thalassemia**, and **fetomaternal hemorrhage**. *Immediate delivery* - While delivery might be considered in some severe cases close to term, it is generally not the initial management for hydrops, especially in **preterm fetuses**, as it introduces risks associated with prematurity. - The focus is often on treating the underlying *fetal condition* in utero to improve outcomes before delivery. *Corticosteroid administration* - Corticosteroids are primarily used to **accelerate fetal lung maturity** in anticipation of preterm delivery. - They do not address the *underlying cause* of anemia-induced hydrops and therefore are not the primary, most appropriate management. *Observation and serial ultrasounds* - This approach is generally insufficient for anemia-induced hydrops, which indicates **fetal compromise** and has a high mortality rate if left untreated. - While monitoring is part of management, active intervention with **intrauterine transfusion** to treat the **underlying anemia** is crucial for improving fetal outcomes.

Q: A 28-year-old primigravida at 38 weeks of gestation presents with intense itching, particularly on the palms and soles, without a rash. Liver function tests reveal abnormalities. What is the most likely diagnosis?

Intrahepatic cholestasis of pregnancy. ***Intrahepatic cholestasis of pregnancy*** - This condition typically presents in the **late second or third trimester** with generalized pruritus, predominantly on the **palms and soles**, without a primary rash. - **Elevated liver function tests** (LFTs), particularly bile acids, are characteristic, confirming the diagnosis. *Pruritic urticarial papules and plaques of pregnancy (PUPPP)* - PUPPP presents with **urticarial papules and plaques** that start in the striae of the abdomen and spread, which is different from the rash-less itching on palms/soles in this case. - Liver function tests are typically **normal** in PUPPP, distinguishing it from conditions with hepatic involvement. *Pemphigoid gestationis* - This is an **autoimmune blistering disease** of pregnancy, characterized by intensely pruritic urticarial lesions and blisters, usually starting around the periumbilical region. - While it causes severe itching, the key feature of **blisters** is absent in the patient's presentation, and liver involvement is not a primary feature. *Acute fatty liver of pregnancy* - This is a severe, life-threatening condition presenting with nausea, vomiting, abdominal pain, jaundice, and often **hypoglycemia** and **hepatic encephalopathy**. - While LFTs are abnormal and jaundice may cause itching, the primary symptom is not isolated pruritus without a rash, and the overall clinical picture is much more severe.

Q: Which medication is preferred for treating urinary tract infections in pregnant women during the second trimester: nitrofurantoin or trimethoprim-sulfamethoxazole?

Nitrofurantoin is preferred.. ***Nitrofurantoin is preferred.*** - **Nitrofurantoin** is generally considered safe and effective for treating UTIs during the **second trimester** of pregnancy. - Its use avoids the risks associated with other antibiotics during earlier or later stages of pregnancy. *Both are equally effective.* - While both can be effective against common UTI pathogens, their **safety profiles differ significantly** during pregnancy. - **Trimethoprim-sulfamethoxazole** carries specific risks during pregnancy that make it less preferred. *Neither is recommended.* - Untreated UTIs in pregnancy can lead to serious complications such as **pyelonephritis**, **preterm labor**, and **low birth weight**. - Appropriate antibiotic treatment is crucial and recommended to prevent such adverse outcomes. *Trimethoprim-sulfamethoxazole is preferred.* - **Trimethoprim** is a **folate antagonist**, posing a risk of **neural tube defects** in the first trimester. - **Sulfamethoxazole** can displace **bilirubin** from albumin, increasing the risk of **kernicterus** in the third trimester, making it generally avoided in later pregnancy as well.

Q: A 25-year-old woman presents with a history of recurrent miscarriages. Blood tests reveal elevated anticardiolipin antibodies. What is the best treatment approach to prevent further pregnancy complications?

Daily aspirin and low-molecular-weight heparin. ***Daily aspirin and low-molecular-weight heparin*** - **Anticardiolipin antibodies** are associated with **antiphospholipid syndrome (APS)**, which causes recurrent miscarriages due to thrombosis in the placental circulation. - The combination of **low-dose aspirin** and **low-molecular-weight heparin (LMWH)** is the standard of care for pregnant women with APS to prevent thrombotic events and improve live birth rates. *Methotrexate therapy* - **Methotrexate** is an immunosuppressant and anti-proliferative agent, primarily used in conditions like **rheumatoid arthritis** or certain cancers. - It is **contraindicated in pregnancy** due to its teratogenic effects and would not prevent miscarriages in APS; instead, it would cause fetal harm. *Intravenous immunoglobulin* - **Intravenous immunoglobulin (IVIG)** is a therapy used for certain autoimmune conditions or immunodeficiencies. - While it has been explored for recurrent pregnancy loss in some autoimmune contexts, it is **not the first-line or standard treatment** for APS-related recurrent miscarriages, which primarily benefit from antithrombotic therapy. *Steroid pulse therapy* - **Steroid pulse therapy** involves high doses of corticosteroids over a short period and is typically used for severe flares of autoimmune diseases. - There is **no evidence** to support its effectiveness as a primary treatment for preventing recurrent miscarriages in **antiphospholipid syndrome**, and it carries significant side effects.

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: At what gestational age is the establishment of fetoplacental circulation observed?

20 to 22 days. ***20 to 22 days*** - The **fetoplacental circulation** begins to establish around **day 21** as **lacunae** form within the **syncytiotrophoblast** and are filled with maternal blood, establishing the uteroplacental circulation. - At this point, the embryonic blood vessels connect with the **chorionic villi**, facilitating the exchange of nutrients and waste products. *12 to 14 days* - During this period, the **implantation** of the blastocyst is occurring, and the **syncytiotrophoblast** is invading the uterine wall. - **Lacunae** are just starting to form, but a functional fetoplacental circulation is not yet established. *6 to 8 days* - This stage is primarily characterized by the **implantation of the blastocyst** into the endometrium. - There is no developed circulatory system or placental connection at this very early point. *24 to 26 days* - By this time, the **fetoplacental circulation** is already **well-established and functional**, actively exchanging substances between mother and embryo. - Initial establishment occurs earlier, around days 20-22.

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.

Question 1

A 28-year-old woman at 32 weeks of gestation presents with vaginal bleeding and no pain. Ultrasound shows placenta previa. What is the initial management?

Accepted Answer

Expectant management

Answer

Immediate delivery

Answer

Magnesium sulfate

Answer

Corticosteroids

Question 2

What is the most appropriate management for a fetus diagnosed with non-immune hydrops due to fetal anemia?

Accepted Answer

Intrauterine transfusion

Answer

Immediate delivery

Answer

Corticosteroid administration

Answer

Observation and serial ultrasounds

Question 3

A 28-year-old primigravida at 38 weeks of gestation presents with intense itching, particularly on the palms and soles, without a rash. Liver function tests reveal abnormalities. What is the most likely diagnosis?

Accepted Answer

Intrahepatic cholestasis of pregnancy

Answer

Pruritic urticarial papules and plaques of pregnancy (PUPPP)

Answer

Pemphigoid gestationis

Answer

Acute fatty liver of pregnancy

Question 4

Which medication is preferred for treating urinary tract infections in pregnant women during the second trimester: nitrofurantoin or trimethoprim-sulfamethoxazole?

Accepted Answer

Nitrofurantoin is preferred.

Answer

Both are equally effective.

Answer

Neither is recommended.

Answer

Trimethoprim-sulfamethoxazole is preferred.

Question 5

A 25-year-old woman presents with a history of recurrent miscarriages. Blood tests reveal elevated anticardiolipin antibodies. What is the best treatment approach to prevent further pregnancy complications?

Accepted Answer

Daily aspirin and low-molecular-weight heparin

Answer

Methotrexate therapy

Answer

Intravenous immunoglobulin

Answer

Steroid pulse therapy

Question 6

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 7

Which drug is commonly used to promote fetal lung maturity?

Accepted Answer

Betamethasone

Answer

Hydrocortisone

Answer

Dexamethasone

Answer

Prednisolone

Question 8

At what gestational age is the establishment of fetoplacental circulation observed?

Accepted Answer

20 to 22 days

Answer

12 to 14 days

Answer

6 to 8 days

Answer

24 to 26 days

Question 9

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 10

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

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

On this page

Practice by Chapter

Want unlimited practice?