Maternal-Fetal Medicine Practice Questions

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: 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: 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: HCG levels at which Expectant management of Ectopic pregnancy can be done :

1000 IU/L. ***1000 IU/L*** - Expectant management for ectopic pregnancy is most appropriate when **hCG levels are < 1000-1500 IU/L and declining**. - This approach is suitable for **hemodynamically stable** patients with no signs of rupture, minimal symptoms, and a small ectopic pregnancy on ultrasound. - The key requirement is that **hCG levels must be declining**, indicating spontaneous resolution. - **1000 IU/L** represents the safest and most widely accepted threshold for expectant management. *2500 IU/L* - An hCG level of **2500 IU/L** is generally **too high** for expectant management of ectopic pregnancy. - Most guidelines recommend expectant management only when hCG is **< 1000-1500 IU/L** (some extend to < 2000 IU/L). - At 2500 IU/L, the risk of **rupture** is significantly higher, and active intervention (medical or surgical) is typically indicated. *10000 IU/L* - An hCG level of **10,000 IU/L** is far too high for expectant management. - Such elevated levels indicate a **larger, active ectopic pregnancy** with high rupture risk. - This level typically requires **immediate medical (methotrexate) or surgical intervention**. *5000 IU/L* - An hCG level of **5000 IU/L** is well above the threshold for expectant management. - At this level, **medical treatment with methotrexate or surgical management** is indicated. - The risk of rupture and treatment failure with conservative approaches is too high for expectant management.

Q: Which of the following is NOT an indication for the administration of Betamethasone to preterm patients?

Prevent postpartum hemorrhage (PPH). ***Prevent postpartum hemorrhage (PPH)*** - **Betamethasone** is a **corticosteroid** primarily used in preterm labor to accelerate fetal lung development and reduce the risk of neonatal complications, not to prevent **postpartum hemorrhage**. - **Postpartum hemorrhage (PPH)** is typically managed with uterine massage, oxytocics (e.g., oxytocin, methylergonovine), or other interventions aimed at uterine contraction and hemostasis. *Fetal lung maturity* - **Betamethasone** is widely administered to pregnant individuals at risk of preterm delivery to promote **fetal lung maturation** by stimulating surfactant production. - This reduces the incidence and severity of **respiratory distress syndrome (RDS)** in premature infants. *Prevents periventricular leukomalacia* - **Antenatal corticosteroids** like **betamethasone** have been shown to reduce the risk of **periventricular leukomalacia (PVL)**, a form of brain injury in preterm infants. - This protective effect is thought to be mediated by improving fetal cerebral vascular stability and reducing inflammation. *Decrease intraventricular hemorrhage* - Administration of **betamethasone** significantly reduces the risk and severity of **intraventricular hemorrhage (IVH)** in preterm neonates. - This benefit is primarily due to the stabilization of cerebral vasculature and reduced fluctuations in cerebral blood flow.

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: What is the earliest sign of fetal death?

Absence of fetal heart sounds. ***Absence of fetal heart sounds*** - **Absence of fetal heart sounds** detected by **Doppler ultrasound** or **real-time ultrasound** is the **earliest and most definitive sign** of fetal death. - Cardiac activity ceases **immediately at the moment of fetal demise**, making this the **primary diagnostic criterion** for intrauterine fetal death. - **Ultrasound showing absent cardiac activity** is the gold standard for confirming fetal death and can detect it within minutes to hours. *Absence of fetal movements* - Absence of fetal movements is often the **first maternal perception** of potential fetal demise, typically noticed within hours to days. - However, it is **subjective and non-specific**, as fetal movements can naturally decrease during sleep cycles or may be less perceptible in some pregnancies. - While important for prompting further evaluation, it is not as definitive as absent cardiac activity on ultrasound. *Spalding sign* - The **Spalding sign** (overlapping of fetal skull bones) is a **late radiological sign** of fetal death that appears **1-2 weeks post-mortem**. - It occurs due to **brain liquefaction and decomposition**, causing collapse of the cranial vault and overlapping of skull sutures. - This is a **confirmatory sign of prolonged fetal demise**, not an early indicator. *Adipocere formation* - **Adipocere formation** (saponification of soft tissues) is a **very late post-mortem change** occurring **weeks to months** after death. - It represents advanced decomposition in a moist environment and is rarely seen in modern obstetric practice due to early detection and intervention. - This is the latest sign among all the options listed.

Q: Monozygotic twin with one healthy baby born at term and one dead mummified fetus is suggestive of?

Fetus papyraceous. ***Fetus papyraceous*** - This term describes a **mummified fetus** that has been flattened and compressed due to the growth of a co-twin, often observed in **monochorionic twin pregnancies** where one twin dies in utero. - The presence of one healthy, term baby and one dead, mummified fetus is the classic presentation of **fetus papyraceous**. *Fetus acardiacus* - This is a rare anomaly where one twin, typically in a **monochorionic-monoamniotic pregnancy**, lacks a functional heart and other upper body structures, relying on the healthy twin's circulation. - An acardiac twin would present as an underdeveloped, often malformed structure, not a mummified, flattened fetus. *Hydatidiform mole* - A **hydatidiform mole** is an abnormal pregnancy characterized by the growth of many cysts (grape-like vesicles) within the uterus, resulting from an issue with fertilization, often leading to a non-viable pregnancy. - It does not involve the presence of a healthy twin alongside a dead mummified one. *Vanishing twin* - **Vanishing twin syndrome** occurs when one of two or more embryos or fetuses in a multiple pregnancy dies and is completely reabsorbed by the mother or the surviving twin. - While it involves the death of a twin, the reabsorption typically means there's no mummified fetus remaining by the time of birth; if a remnant is found, it's typically much smaller and not described as "papyraceous."

Question 1

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 2

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 3

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 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

HCG levels at which Expectant management of Ectopic pregnancy can be done :

Accepted Answer

1000 IU/L

Answer

10000 IU/L

Answer

5000 IU/L

Answer

2500 IU/L

Question 7

Which of the following is NOT an indication for the administration of Betamethasone to preterm patients?

Accepted Answer

Prevent postpartum hemorrhage (PPH)

Answer

Prevents periventricular leukomalacia

Answer

Fetal lung maturity

Answer

Decrease intraventricular hemorrhage

Question 8

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 9

What is the earliest sign of fetal death?

Accepted Answer

Absence of fetal heart sounds

Answer

Adipocere formation

Answer

Absence of fetal movements

Answer

Spalding sign

Question 10

Monozygotic twin with one healthy baby born at term and one dead mummified fetus is suggestive of?

Accepted Answer

Fetus papyraceous

Answer

Fetus acardiacus

Answer

Hydatidiform mole

Answer

Vanishing twin

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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