Maternal-Fetal Medicine Practice Questions

Q: Which of the following is NOT a feature of mild or non-severe pre-eclampsia?

Premonitory symptoms present. ***Premonitory symptoms present*** - The **presence of premonitory symptoms** (such as **severe headache**, **visual disturbances**, **epigastric pain**, or **altered mental status**) is a defining feature of **severe pre-eclampsia**, NOT mild or non-severe pre-eclampsia. - These symptoms indicate impending eclampsia or serious end-organ involvement, which classifies the condition as severe. - This is the correct answer as it is NOT a feature of mild pre-eclampsia. *Diastolic BP <100 mm Hg* - In mild pre-eclampsia, the **diastolic blood pressure** is typically **elevated** (≥90 mmHg) but remains **below 110 mmHg**. - This is a defining characteristic of mild pre-eclampsia, differentiating it from severe pre-eclampsia where diastolic BP is ≥110 mmHg. - This IS a feature of mild pre-eclampsia. *Systolic BP <160 mm Hg* - A **systolic blood pressure** below **160 mmHg** (but ≥140 mmHg) is consistent with mild or non-severe pre-eclampsia. - Severe pre-eclampsia is characterized by a systolic BP of ≥160 mmHg, making this range indicative of milder disease. - This IS a feature of mild pre-eclampsia. *Mild IUGR* - **Mild intrauterine growth restriction (IUGR)** can occur in mild pre-eclampsia due to **placental insufficiency**. - While more severe IUGR is associated with severe pre-eclampsia, mild IUGR can be seen in non-severe cases. - This IS a feature that can occur in mild pre-eclampsia.

Q: Patient with 3 months amenorrhoea, c/o hyperemesis and vaginal bleeding since one month. O/E=uterus 16 weeks with absent fetal heart sound. The diagnosis is ?

Molar pregnancy. ***Molar pregnancy*** - This diagnosis aligns with the presence of **hyperemesis**, **vaginal bleeding**, and a **uterus size larger than expected for gestational age** (16 weeks for 3 months amenorrhoea) with an **absent fetal heart sound**. - **Hyperemesis** is often pronounced due to very high hCG levels produced by the molar tissue. - The **size-dates discrepancy** (uterus larger than expected) is a pathognomonic feature of molar pregnancy. *Ectopic pregnancy* - While it can cause **vaginal bleeding** and **amenorrhoea**, the uterus size is typically **normal or smaller** than expected for gestational age, not 16 weeks. - **Fetal heart sounds** would also be absent but the marked uterine enlargement is the key differentiating factor. *Abruptio placentae* - This typically occurs in the **later stages of pregnancy** (second half or third trimester) and presents with painful vaginal bleeding and uterine tenderness. - The symptoms described, particularly the uterus size discrepancy and hyperemesis in early pregnancy, do not fit abruptio placentae. *Intrauterine fetal death (IUFD)* - While IUFD is characterized by an **absent fetal heart sound** and can occur with spotting, the uterine size would typically be **appropriate for gestational age or smaller**, not significantly larger. - IUFD also does not explain the presence of severe hyperemesis or the size-dates discrepancy.

Q: After IUFD, when does the mother develop DIC?

3-4 weeks. ***3-4 weeks*** - Following intrauterine fetal demise (IUFD), **Disseminated Intravascular Coagulation (DIC)** can develop due to the continuous release of thromboplastin from the degenerating fetal tissue into the maternal circulation. - While the risk is present earlier, significant changes leading to symptomatic DIC typically manifest around **3-4 weeks** after the demise if the fetus is retained. *48 hours* - The development of DIC within **48 hours** of IUFD is less common. - This time frame is generally too short for enough thromboplastin to accumulate and trigger a full DIC syndrome in most cases. *1-2 weeks* - While some changes in coagulation parameters might begin within **1-2 weeks**, overt clinical DIC is usually not observed during this period. - The placental and fetal tissue breakdown products require more time to induce a profound coagulopathy. *6 weeks* - By **6 weeks** after IUFD, if the fetus is still retained, the risk of DIC becomes very high, and the process is usually already well underway or has been identified earlier. - Early management, such as evacuating the uterus, is crucial to prevent DIC from reaching this advanced stage.

Q: What is the drug of choice (DOC) for medical management of ectopic pregnancy?

Methotrexate (Intramuscular). ***Methotrexate (Intramuscular)*** - **Methotrexate** is the **drug of choice** for the medical management of **ectopic pregnancy** that meets specific criteria (e.g., hemodynamically stable, small unruptured ectopic mass, and absence of fetal cardiac activity). - It works by inhibiting **dihydrofolate reductase**, thereby interfering with **DNA synthesis** and cell proliferation of the rapidly dividing trophoblastic tissue. *Actinomycin D* - **Actinomycin D** is an **antineoplastic antibiotic** that is used in the treatment of various cancers, such as Wilms' tumor and gestational trophoblastic disease. - While it has anti-proliferative effects, it is not the standard first-line treatment for **ectopic pregnancy** given the effectiveness and established safety profile of methotrexate. *Prostaglandin F2 alpha* - **Prostaglandin F2 alpha** (e.g., dinoprost) is primarily used for **induction of labor**, **abortion**, or management of **postpartum hemorrhage** due to its myometrial contraction stimulation properties. - It does not specifically target the trophoblastic tissue of an ectopic pregnancy and is not indicated for its medical management. *Mifepristone* - **Mifepristone** is an **anti-progestin** used to induce medical abortion, often in combination with misoprostol. - While it terminates intrauterine pregnancies by blocking progesterone receptors, it is not effective as a standalone treatment for **ectopic pregnancy**, as it does not directly target the ectopic trophoblastic tissue.

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.

Q: With reference to fetal heart rate, a nonstress test is considered reactive when?

Two fetal heart rate accelerations are noted in 20 minutes. **Two fetal heart rate accelerations are noted in 20 minutes** - A **nonstress test (NST)** is considered reactive when there are at least two accelerations of the fetal heart rate within a 20-minute period. - An **acceleration** is defined as an increase in fetal heart rate of at least 15 beats per minute above baseline, lasting for at least 15 seconds (for gestations ≥32 weeks). - This is the **standard definition** of a reactive NST and indicates adequate fetal well-being. *One fetal heart rate acceleration is noted in 20 minutes* - While an acceleration is a positive sign, a **reactive NST** specifically requires at least two accelerations within the 20-minute timeframe. - A single acceleration within 20 minutes would render the NST **non-reactive**, requiring further evaluation or extended monitoring up to 40 minutes. *Two fetal heart rate accelerations are noted in 10 minutes* - While two accelerations occurring in 10 minutes is clinically reassuring and technically occurs within 20 minutes, the **standard definition** for reporting NST reactivity specifically states "two or more accelerations **in** 20 minutes." - The 20-minute observation period is the established timeframe for NST assessment, not 10 minutes. - This option tests knowledge of the precise standard criteria rather than clinical interpretation. *Three fetal heart rate accelerations are noted in 30 minutes* - The standard definition for a **reactive NST** requires assessment within a **20-minute window**, not 30 minutes. - While three accelerations indicate fetal well-being, this exceeds the standard observation period and does not meet the formal definition of a reactive NST within the specified timeframe. - An NST is typically extended to 40 minutes if non-reactive at 20 minutes, but the definition of reactivity remains based on the 20-minute criterion.

Q: Modified biophysical profile is:

NST + AFI. ***Correct Answer: NST + AFI*** - The **modified biophysical profile (mBPP)** consists of a **nonstress test (NST)** and an **amniotic fluid index (AFI)**. - This combination is used to evaluate fetal well-being, with the NST assessing **acute hypoxia** and the AFI reflecting **chronic placental function**. - The mBPP is a **simplified version** of the full biophysical profile, designed for efficient antepartum fetal surveillance. *Incorrect: NST + Fetal Tone* - While both are components of the **full biophysical profile (BPP)**, this specific combination does not define the modified biophysical profile. - **Fetal tone** (flexion/extension of extremities) is a component of the full BPP but is omitted in the modified version to streamline the assessment. *Incorrect: Fetal Tone + AFI* - This combination is not a recognized standard for evaluating fetal well-being. - A **nonstress test (NST)** is a crucial component for assessing **acute fetal oxygenation** and is always included in the modified biophysical profile. *Incorrect: NST + Fetal Tone + AFI* - This combination represents three of the five components of the **full biophysical profile**, which also includes **fetal breathing** and **gross body movements**. - The **modified biophysical profile** specifically simplifies this by including only the **NST** and **AFI**.

Q: A primigravida with 36 weeks of pregnancy is in labor with 3 cm dilatation and minimal uterine contraction. On rupture of membranes, fresh bleeding is noted with late fetal deceleration up to 50 beats/min. The patient was taken for LSCS but fetus could not be saved. No abruptio or placenta previa was seen. The likely diagnosis is ?

Vasa previa. ***Vasa previa*** - The sudden onset of **painless vaginal bleeding** upon membrane rupture, combined with **fetal heart rate deceleration** (bradycardia), is highly suggestive of **vasa previa**. This condition involves fetal vessels coursing within the membranes over the cervical os, unprotected by placental tissue or Wharton's jelly, making them prone to rupture. - The **fetal origin of the bleeding** (leading to fetal hypovolemia and distress) and the absence of placental complications like abruptio or previa further support this diagnosis. *Placenta previa* - This condition involves the **placenta covering the cervical os**, leading to painless bright red bleeding, especially in the third trimester. - However, the question explicitly states "No abruptio or placenta previa was seen," directly ruling out this diagnosis. *Revealed abruptio* - **Placental abruption** is the premature detachment of the placenta, typically causing **painful vaginal bleeding**, uterine tenderness, and often hypertonic contractions. - The scenario describes **minimal uterine contraction** and a lack of overt abdominal pain, and explicitly states "No abruptio or placenta previa was seen," making abruptio unlikely. *Circumvallate placenta* - A **circumvallate placenta** has a folded double layer of amnion and chorion at its margin, which can cause bleeding in pregnancy due to detachment of the rolled margin. - While it can cause bleeding, it typically doesn't present with the acute, severe fetal distress (late decelerations with bradycardia) immediately following membrane rupture that indicates direct fetal blood loss, unlike vasa previa.

Question 1

Which of the following is NOT a feature of mild or non-severe pre-eclampsia?

Accepted Answer

Premonitory symptoms present

Answer

Diastolic BP <100 mm Hg

Answer

Systolic BP< 160 mm Hg

Answer

Mild IUGR

Question 2

Which of the following is the BEST management principle regarding abdominal pregnancy?

Accepted Answer

The placenta can be left in situ at the time of surgery.

Answer

Fetal survival rate approaches 80% with modern care.

Answer

The placenta should always be removed to prevent infection.

Answer

Gastrointestinal symptoms are typically mild and resolve spontaneously.

Question 3

Patient with 3 months amenorrhoea, c/o hyperemesis and vaginal bleeding since one month. O/E=uterus 16 weeks with absent fetal heart sound. The diagnosis is ?

Accepted Answer

Molar pregnancy

Answer

Ectopic pregnancy

Answer

Abruptio placentae

Answer

Intrauterine fetal death (IUFD)

Question 4

After IUFD, when does the mother develop DIC?

Accepted Answer

3-4 weeks

Answer

48 hours

Answer

1-2 weeks

Answer

6 weeks

Question 5

What is the drug of choice (DOC) for medical management of ectopic pregnancy?

Accepted Answer

Methotrexate (Intramuscular)

Answer

Actinomycin D

Answer

Prostaglandin F2 alpha

Answer

Mifepristone

Question 6

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 7

Earliest sign after IUFD is ?

Accepted Answer

Gas in great vessel

Answer

Hyperflexion of spine

Answer

Overlapping of skull bones

Answer

Overcrowding of ribs

Question 8

With reference to fetal heart rate, a nonstress test is considered reactive when?

Accepted Answer

Two fetal heart rate accelerations are noted in 20 minutes

Answer

One fetal heart rate acceleration is noted in 20 minutes

Answer

Two fetal heart rate accelerations are noted in 10 minutes

Answer

Three fetal heart rate accelerations are noted in 30 minutes

Question 9

Modified biophysical profile is:

Accepted Answer

NST + AFI

Answer

NST + Fetal Tone

Answer

Fetal Tone + AFI

Answer

NST + Fetal Tone + AFI

Question 10

A primigravida with 36 weeks of pregnancy is in labor with 3 cm dilatation and minimal uterine contraction. On rupture of membranes, fresh bleeding is noted with late fetal deceleration up to 50 beats/min. The patient was taken for LSCS but fetus could not be saved. No abruptio or placenta previa was seen. The likely diagnosis is ?

Accepted Answer

Vasa previa

Answer

Placenta previa

Answer

Revealed abruptio

Answer

Circumvallate placenta

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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