Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 1151: 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?

A. Immediate delivery
B. Expectant management (Correct Answer)
C. Magnesium sulfate
D. Corticosteroids

Explanation: ***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.

Question 1152: What is the most appropriate management for a fetus diagnosed with non-immune hydrops due to fetal anemia?

A. Immediate delivery
B. Corticosteroid administration
C. Intrauterine transfusion (Correct Answer)
D. Observation and serial ultrasounds

Explanation: ***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.

Question 1153: 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?

A. Pruritic urticarial papules and plaques of pregnancy (PUPPP)
B. Intrahepatic cholestasis of pregnancy (Correct Answer)
C. Pemphigoid gestationis
D. Acute fatty liver of pregnancy

Explanation: ***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.

Question 1154: Which medication is preferred for treating urinary tract infections in pregnant women during the second trimester: nitrofurantoin or trimethoprim-sulfamethoxazole?

A. Both are equally effective.
B. Neither is recommended.
C. Nitrofurantoin is preferred. (Correct Answer)
D. Trimethoprim-sulfamethoxazole is preferred.

Explanation: ***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.

Question 1155: 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?

A. Daily aspirin and low-molecular-weight heparin (Correct Answer)
B. Methotrexate therapy
C. Intravenous immunoglobulin
D. Steroid pulse therapy

Explanation: ***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.

Question 1156: 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?

A. Premature rupture of membranes (PROM)
B. Intrauterine growth restriction (IUGR) (Correct Answer)
C. Congenital absence of one or both kidneys
D. Polycystic kidney disease

Explanation: ***Intrauterine growth restriction (IUGR)*** - The key finding is **uterine size smaller than expected for gestational age** (16-week size at 20 weeks POG), which is the hallmark of IUGR - **Oligohydramnios** (reduced liquor) is commonly associated with IUGR, particularly in cases of placental insufficiency where reduced perfusion affects both fetal growth and amniotic fluid production - IUGR is the **clinical diagnosis** based on size-dates discrepancy and reduced amniotic fluid; further investigations would be needed to identify the underlying cause (placental insufficiency, infections, chromosomal abnormalities, or structural anomalies) - This is the most appropriate diagnosis with the given clinical and ultrasound findings *Congenital absence of one or both kidneys* - **Bilateral renal agenesis** (Potter sequence) would cause severe oligohydramnios but requires **detailed anatomical survey on USG** showing absent kidneys, which is not mentioned in this case - **Unilateral renal agenesis** would NOT cause oligohydramnios as one functioning kidney produces adequate amniotic fluid - This would be a possible underlying etiology requiring further detailed imaging, not the primary clinical diagnosis based on the information provided *Premature rupture of membranes (PROM)* - PROM presents with **history of fluid leakage per vaginum**, which is not mentioned in this case - On examination, there would be evidence of fluid leakage, pooling in posterior fornix, and positive tests (nitrazine test, ferning) - The size-dates discrepancy would be the result of chronic fluid loss, but the absent history makes this unlikely *Polycystic kidney disease* - **Autosomal recessive polycystic kidney disease (ARPKD)** can cause oligohydramnios due to renal dysfunction, but typically presents with **bilaterally enlarged echogenic kidneys** on USG - This would require specific ultrasound findings of enlarged kidneys with cysts, which are not described - Like renal agenesis, this would be an underlying etiology requiring confirmatory imaging

Question 1157: Which of the following conditions is least likely to be classified as a high-risk pregnancy?

A. History of manual removal of placenta (Correct Answer)
B. Severe anemia
C. Gestational diabetes
D. Obesity in pregnancy

Explanation: ***History of manual removal of placenta*** - While a history of manual removal of placenta in a previous pregnancy is noted as a **risk factor** that warrants documentation, it is considered the ***least likely*** among these options to classify the current pregnancy as high-risk. - This is because it represents a **historical obstetric event** from a prior pregnancy, not an **active medical condition** affecting the current pregnancy. If the underlying cause (e.g., retained placenta due to uterine atony) was circumstantial and not due to placental abnormalities, the risk of recurrence may be relatively low. - In contrast, the other options represent **active, ongoing conditions** in the current pregnancy that directly and continuously impact maternal-fetal wellbeing and require active management throughout the pregnancy. - However, note that this history should still be documented and may warrant closer monitoring in the third stage of labor. *Severe anemia* - Severe anemia (Hemoglobin <7 g/dL) is a **definitive high-risk condition** that significantly increases the risk of **maternal complications** (cardiac failure, increased operative risk), **fetal complications** (IUGR, preterm birth, low birth weight), and **postpartum hemorrhage**. - It requires **immediate treatment** with iron supplementation, blood transfusion if needed, and close monitoring throughout pregnancy and delivery. *Gestational diabetes* - Gestational diabetes mellitus (GDM) is a **well-established high-risk condition** that increases the risk of **fetal macrosomia**, **shoulder dystocia**, **preeclampsia**, **polyhydramnios**, and **neonatal hypoglycemia**. - Requires **active management** with dietary modification, glucose monitoring (4-7 times daily), and insulin therapy if needed, making it a clear high-risk classification. *Obesity in pregnancy* - Maternal obesity (BMI ≥30 kg/m²) is classified as a **high-risk condition** associated with increased rates of **gestational hypertension**, **preeclampsia**, **gestational diabetes**, **thromboembolic events**, **cesarean delivery**, and **fetal macrosomia**. - This is an **active condition** throughout pregnancy requiring enhanced antenatal surveillance, glucose screening, and consideration for anesthesia consultation.

Question 1158: At what gestational age is the establishment of fetoplacental circulation observed?

A. 12 to 14 days
B. 20 to 22 days (Correct Answer)
C. 6 to 8 days
D. 24 to 26 days

Explanation: ***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.

Question 1159: At what time frame does peripartum cardiomyopathy typically occur?

A. Within 6 weeks of delivery
B. Within 24 months of delivery
C. Within 5 months of delivery (Correct Answer)
D. Within 7 days of delivery

Explanation: ***Within 5 months of delivery*** - **Peripartum cardiomyopathy** is defined as the development of heart failure with **left ventricular systolic dysfunction** occurring during the **last month of pregnancy or within five months after delivery**. - The postpartum component extends up to **5 months (approximately 20 weeks)** after delivery, making this the most complete answer among the given options. - This timeframe is essential for differentiating **peripartum cardiomyopathy** from other forms of cardiomyopathy. *Within 6 weeks of delivery* - While this represents the traditional postpartum period and many cases do present within 6 weeks, the diagnostic definition of **peripartum cardiomyopathy** extends further to **5 months postpartum**. - This narrower timeframe would miss cases presenting between 6 weeks and 5 months, thus not encompassing the full diagnostic criteria. *Within 24 months of delivery* - This timeframe significantly exceeds the established diagnostic window for **peripartum cardiomyopathy**. - Heart failure presenting beyond 5 months postpartum would likely be classified as **dilated cardiomyopathy** or another form of cardiomyopathy with different underlying causes. *Within 7 days of delivery* - This is too narrow a window and represents only the immediate postpartum period. - While some cases can present acutely in the first week, the diagnostic definition allows for onset up to **5 months postpartum**, and limiting it to 7 days would miss the majority of cases.

Question 1160: Which drug regimen is given to a pregnant woman with HIV infection?

A. Tenofovir disoproxil fumarate with emtricitabine
B. Tenofovir disoproxil fumarate with lamivudine
C. Abacavir with lamivudine
D. All of the options (Correct Answer)

Explanation: ***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.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

Practice Questions

Multiple Gestation

Practice Questions

Rh Isoimmunization and Other Blood Group Incompatibilities

Practice Questions

Intrauterine Fetal Therapy

Practice Questions

Prenatal Diagnosis and Genetic Counseling

Practice Questions

Placental Abnormalities

Practice Questions

Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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