Maternal-Fetal Medicine Practice Questions

Q: In the context of fetal hypoxia, which parameter of the Biophysical Profile (BPP) is typically affected last?

Fetal tone. ***Fetal tone*** - **Fetal tone** is the last biophysical parameter to be affected by worsening fetal hypoxia as it is controlled by the **lower brainstem and spinal cord**, which are the most primitive centers and spared until late decompensation. - This parameter requires significant and prolonged oxygen deprivation to be compromised, indicating severe fetal compromise. *Fetal breathing movements* - **Fetal breathing movements** are affected relatively early in fetal hypoxia, as they are controlled by the **upper brainstem (pons)** and thus more sensitive to oxygen deprivation. - Absence or decreased frequency of these movements can be an early sign of impending hypoxia. *Fetal movements* - **Gross fetal body movements** are also affected early by oxygen deprivation, as they are controlled by the fetal **cerebral cortex** and subcortical centers. - A reduction in fetal movements often signifies the fetus is conserving energy due to oxygen scarcity. *Non-stress test (NST)* - The **non-stress test (NST)**, which assesses **fetal heart rate accelerations** in response to movement, is typically the *first* parameter to be affected by hypoxia. - Loss of fetal heart rate accelerations occurs early because the **autonomic nervous system and cortical centers**, which control these responses, are highly sensitive to reduced oxygen levels.

Q: What is the most common heart disease in pregnancy?

Mitral Stenosis (MS). **Mitral Stenosis (MS)** - **Mitral stenosis** is the most common form of **rheumatic heart disease**, which is the leading cause of heart disease in pregnant women. - Pregnancy exacerbates MS symptoms due to **increased blood volume** and **cardiac output**, leading to increased left atrial pressure and pulmonary congestion. *Aortic Stenosis (AS)* - While **aortic stenosis** can occur during pregnancy, it is less common than mitral stenosis as a primary cause of symptomatic heart disease. - The fixed outflow obstruction in AS can lead to complications, but its prevalence is lower compared to rheumatic MS. *Mitral Regurgitation (MR)* - **Mitral regurgitation** is generally better tolerated in pregnancy than stenotic lesions due to reduced afterload during gestation. - Although it can cause symptoms, it is not the most common heart disease encountered. *Wolff-Parkinson-White (WPW) syndrome* - **WPW syndrome** is an electrical conduction disorder, not a structural heart disease. - While it can manifest with arrhythmias exacerbated by pregnancy, it is not considered the most common structural heart disease in this population.

Q: Which of the following conditions is NOT contraindicated in pregnancy?

WPW syndrome. **WPW syndrome** - **Wolff-Parkinson-White (WPW) syndrome** is a condition involving an extra electrical pathway in the heart, leading to episodes of rapid heart rate. - While it can cause arrhythmias, severe complications in pregnancy are rare, and it is generally *not* considered an absolute contraindication for pregnancy. *Primary Pulmonary Hypertension* - **Primary Pulmonary Hypertension (PPH)** carries a very high maternal mortality rate (25-50%) due to the physiological changes of pregnancy on the cardiovascular system. - The increased blood volume and cardiac output in pregnancy can lead to severe decompensation and right heart failure in women with PPH. *Eisenmenger's syndrome* - **Eisenmenger's syndrome** is a severe form of pulmonary hypertension with a right-to-left shunt, associated with an extremely high maternal mortality rate (30-50%). - Pregnancy significantly increases the risk of **pulmonary hypertensive crisis**, right heart failure, and thromboembolic events, making it highly contraindicated. *Marfan's with aortic root dilation* - **Marfan's syndrome** with **aortic root dilation** is a significant contraindication due to the high risk of **aortic dissection** and rupture. - The hemodynamic stress of pregnancy, including increased blood volume and cardiac output, places immense strain on the dilated aorta, increasing the risk of life-threatening events.

Q: At what day after fertilization is the utero-placental circulation typically established?

15. ***Day 15 (Correct Answer)*** - **Utero-placental circulation** is established around day 15 after fertilization, coinciding with the development of the **chorionic villi** and their vascularization. - At this stage, the **trophoblast** has invaded the maternal decidua, allowing for the formation of lacunae filled with maternal blood, facilitating early nutrient and waste exchange. - The **primary chorionic villi become vascularized**, creating the functional connection between maternal and fetal circulations. *Day 5 (Incorrect)* - By day 5, the embryo is typically at the **blastocyst stage** and is undergoing **hatching** from the zona pellucida before implantation. - There is no significant utero-placental circulation established at this very early stage; the embryo relies on diffusion for nourishment. *Day 10 (Incorrect)* - Around day 10, the **blastocyst is actively implanting** into the uterine wall, and the trophoblast differentiates into **cytotrophoblast** and **syncytiotrophoblast**. - While lacunae are forming within the syncytiotrophoblast and beginning to fill with maternal blood, a fully established circulatory system with functional villi is not yet present. *Day 20 (Incorrect)* - By day 20, the **utero-placental circulation** is already well-established and functional, having begun several days prior. - This later stage marks a more mature state of placental development, where the villi are more complex and efficient for exchange.

Q: Up to what gestational age is the corpus luteum essential for pregnancy maintenance, such that its surgical excision would result in miscarriage?

8-10 weeks. ***8-10 weeks*** - The corpus luteum produces **progesterone** that is essential for maintaining early pregnancy until the **luteal-placental shift** occurs. - This shift, where the **placenta takes over progesterone production**, typically completes between **7-9 weeks** of gestation. - However, to ensure safety and account for individual variation, the corpus luteum should be considered essential **up to 10 weeks**. - Surgical excision of the corpus luteum **before 10 weeks** carries significant risk of miscarriage, while removal **after 10 weeks** is generally safe as the placenta has established autonomous progesterone production. *Before 6 weeks* - While removal before 6 weeks would certainly cause miscarriage, this is not the **maximum gestational age** at which the corpus luteum remains essential. - The critical dependency extends well beyond 6 weeks. *6-8 weeks* - During this period, the corpus luteum is still **absolutely essential** for progesterone production. - The luteal-placental shift is typically **incomplete** during this timeframe. - Removal would result in miscarriage, but this is still not the maximum safe window. *10-12 weeks* - By 10-12 weeks, the **placenta has fully taken over** progesterone production. - At this stage, the corpus luteum is no longer functionally necessary, and its removal does **not increase miscarriage risk**.

Q: Which of the following procedures is associated with the least risk of feto-maternal hemorrhage?

Amniocentesis. ***Amniocentesis*** - This procedure involves sampling **amniotic fluid**, which is primarily fetal urine and cells, not directly blood. - The needle typically avoids the placenta and fetal vessels, making **feto-maternal hemorrhage less likely** compared to procedures directly accessing fetal blood or placental tissue. - Risk of FMH is approximately **1-2%**, the lowest among invasive prenatal procedures. *Cordocentesis* - This procedure involves direct **percutaneous umbilical blood sampling** from the umbilical cord. - Due to direct needle puncture of fetal blood vessels, the potential for **feto-maternal hemorrhage is 40-50%**. - Highest risk among diagnostic procedures listed. *Chorionic villus sampling* - This procedure involves taking a sample of the **placenta** (chorionic villi), which contains fetal cells and is rich in blood vessels. - Disrupting the placental-uterine interface can lead to **feto-maternal hemorrhage in 10-15%** of cases. - Higher risk than amniocentesis due to placental manipulation. *External cephalic version* - This procedure involves **manual manipulation** of the fetus through the maternal abdomen to convert breech to cephalic presentation. - The mechanical pressure and manipulation can cause **placental separation or disruption**, leading to FMH in approximately **2-6%** of cases. - Risk is higher than amniocentesis due to physical manipulation of the gravid uterus.

Q: Which of the following is a complication of pre-eclampsia?

Eclampsia. ***Eclampsia*** - **Eclampsia** is defined as the occurrence of **generalized tonic-clonic seizures** in a woman with pre-eclampsia that cannot be attributed to other causes - It represents the **direct neurological progression** of pre-eclampsia and is the **most characteristic complication** - Eclampsia occurs in approximately **1-2%** of women with pre-eclampsia and is a **life-threatening emergency** - The seizures result from cerebral vasospasm, edema, and ischemia associated with the hypertensive disorder *HELLP syndrome* - **HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets)** is indeed a **recognized complication** of pre-eclampsia, occurring in **10-20% of severe cases** - However, HELLP represents a **specific multiorgan manifestation** involving hepatic dysfunction and hematological abnormalities, rather than the classic progression pathway - While both are serious complications, **eclampsia** is considered the **prototypical complication** that defines disease progression from pre-eclampsia - HELLP can occur with or without the full clinical picture of severe pre-eclampsia *Postdatism* - **Postdatism** (post-term pregnancy) refers to pregnancy extending beyond **42 weeks of gestation** - This is **completely unrelated** to pre-eclampsia, which is a hypertensive disorder of pregnancy - Pre-eclampsia typically occurs in the **third trimester** and is actually an indication for **delivery**, not prolonged pregnancy *Disseminated Intravascular Coagulation (DIC)* - **DIC** is a severe coagulopathy involving widespread activation of clotting cascades - While DIC can complicate severe pre-eclampsia, it is **not a primary or direct complication** - DIC more commonly develops as a consequence of **eclampsia, HELLP syndrome, placental abruption**, or other severe obstetric emergencies - It represents a **secondary complication** rather than a direct progression of pre-eclampsia itself

Q: At what weeks of gestation does the second wave of trophoblastic invasion occur?

12-15 weeks. ***12-15 weeks*** - The **second wave of trophoblastic invasion** is a crucial event for proper placental development, occurring between **12 and 15 weeks of gestation**. - During this phase, **cytotrophoblast cells** invade the **spiral arteries** in the decidua and inner myometrium, replacing the smooth muscle and elastic tissue with fibrinoid material. *8-11 weeks* - This period primarily encompasses the **first wave of trophoblastic invasion**, where **cytotrophoblast cells** invade the decidual segments of the spiral arteries. - Inadequate first-wave invasion is associated with early pregnancy complications, but the full second wave has not yet occurred. *10-12 weeks* - While this period overlaps with the later part of the first wave and the very beginning of the second, it is not the primary window for the **complete second wave of trophoblastic invasion**. - The most significant remodelling of the deeper spiral arteries occurs slightly later in gestation. *16-20 weeks* - By this gestational stage, the **second wave of trophoblastic invasion** should have largely been completed, and the placental circulation is well-established. - Inadequate remodelling of the spiral arteries by this point is strongly associated with later pregnancy complications like **preeclampsia** and **intrauterine growth restriction (IUGR)**.

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.

Question 1

In the context of fetal hypoxia, which parameter of the Biophysical Profile (BPP) is typically affected last?

Accepted Answer

Fetal tone

Answer

Fetal breathing movements

Answer

Fetal movements

Answer

Non-stress test (NST)

Question 2

What is the most common heart disease in pregnancy?

Accepted Answer

Mitral Stenosis (MS)

Answer

Aortic Stenosis (AS)

Answer

Mitral Regurgitation (MR)

Answer

Wolff-Parkinson-White (WPW) syndrome

Question 3

Which of the following conditions is NOT contraindicated in pregnancy?

Accepted Answer

WPW syndrome

Answer

Marfan's with aortic root dilation

Answer

Primary Pulmonary Hypertension

Answer

Eisenmenger's syndrome

Question 4

At what day after fertilization is the utero-placental circulation typically established?

Accepted Answer

15

Answer

5

Answer

20

Answer

10

Question 5

Up to what gestational age is the corpus luteum essential for pregnancy maintenance, such that its surgical excision would result in miscarriage?

Accepted Answer

8-10 weeks

Answer

Before 6 weeks

Answer

6-8 weeks

Answer

10-12 weeks

Question 6

Which of the following procedures is associated with the least risk of feto-maternal hemorrhage?

Accepted Answer

Amniocentesis

Answer

Chorionic villus sampling

Answer

External cephalic version

Answer

Cordocentesis

Question 7

Which of the following is a complication of pre-eclampsia?

Accepted Answer

Eclampsia

Answer

HELLP syndrome

Answer

Postdatism

Answer

Disseminated Intravascular Coagulation (DIC)

Question 8

At what weeks of gestation does the second wave of trophoblastic invasion occur?

Accepted Answer

12-15 weeks

Answer

10-12 weeks

Answer

16-20 weeks

Answer

8-11 weeks

Question 9

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 10

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)

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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