Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 1181: 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 ?

A. Ectopic pregnancy
B. Abruptio placentae
C. Molar pregnancy (Correct Answer)
D. Intrauterine fetal death (IUFD)

Explanation: ***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 1182: After IUFD, when does the mother develop DIC?

A. 48 hours
B. 1-2 weeks
C. 3-4 weeks (Correct Answer)
D. 6 weeks

Explanation: ***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.

Question 1183: A 30-year-old woman is 14 weeks pregnant and has a history of two painless deliveries at 16 weeks. What is the next line of management?

A. Cervical encerclage
B. Evaluation for diabetes mellitus and thyroid disorders
C. Cervical length assessment (Correct Answer)
D. Tocolytics

Explanation: ***Cervical length assessment*** - With a history of **two painless preterm deliveries at 16 weeks**, the patient is at high risk for **cervical insufficiency** (incompetent cervix). - While this history may warrant **history-indicated cerclage**, many current protocols recommend **cervical length assessment** via transvaginal ultrasound as the next step to objectively evaluate cervical status and guide management decisions. - An **ultrasound-indicated approach** allows for selective cerclage placement if cervical shortening is documented, avoiding unnecessary procedures in some cases. - Cervical length <25 mm before 24 weeks indicates need for intervention. *Cervical encerclage* - **Prophylactic cerclage** (history-indicated) is an evidence-based option for women with ≥2 prior spontaneous second-trimester losses, and can be placed at 12-14 weeks. - However, the **ultrasound-indicated approach** (assess first, then place cerclage if indicated) is also widely accepted and may prevent unnecessary cerclage in patients with adequate cervical length. - Both approaches are supported by evidence; the question favors assessment first. *Evaluation for diabetes mellitus and thyroid disorders* - While **diabetes mellitus** and **thyroid disorders** can contribute to pregnancy complications, they are not the primary cause of recurrent **painless mid-trimester losses**. - The clinical presentation strongly suggests **cervical insufficiency**, which requires specific cervical evaluation and management. - Medical screening is not the most immediate priority in this scenario. *Tocolytics* - **Tocolytics** are used to suppress **preterm labor contractions**. - This patient's history of **painless deliveries** indicates cervical insufficiency rather than preterm labor with contractions, making tocolytics inappropriate for prevention.

Question 1184: A 28-year-old pregnant woman presents with severe hypertension and proteinuria. What is the most appropriate initial management?

A. Emergency cesarean section
B. Induction of labor if stable
C. Anticonvulsant and antihypertensive therapy (Correct Answer)
D. Observation and monitoring

Explanation: ***Anticonvulsant and antihypertensive therapy*** - The patient presents with **severe preeclampsia** (hypertension and proteinuria in pregnancy), which carries a risk of seizures (**eclampsia**). - **Magnesium sulfate** is the first-line anticonvulsant for the prevention and treatment of eclamptic seizures, and **antihypertensive agents** (e.g., labetalol, hydralazine) are necessary to control blood pressure and prevent maternal complications. *Emergency cesarean section* - An emergency cesarean section is indicated for **fetal distress**, **maternal instability** not responsive to conservative management, or **failed induction of labor**. - Without information about fetal compromise or maternal organ dysfunction, immediate surgical delivery is not the initial step. *Induction of labor if stable* - Induction of labor is a consideration for delivery in cases of **preeclampsia at term** or when expectant management is no longer safe. - However, the immediate priority in severe preeclampsia is to stabilize the mother with **anticonvulsant and antihypertensive therapy** first. *Observation and monitoring* - **Close monitoring** is essential in preeclampsia, but simply observing without active intervention in severe cases would be irresponsible. - Severe hypertension and proteinuria require **active management** to prevent progression to eclampsia or other severe maternal and fetal complications.

Question 1185: HCG levels at which Expectant management of Ectopic pregnancy can be done :

A. 10000 IU/L
B. 5000 IU/L
C. 1000 IU/L (Correct Answer)
D. 2500 IU/L

Explanation: ***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.

Question 1186: Most common organism grown in urine culture of a pregnant woman with asymptomatic bacteriuria?

A. E. coli (Correct Answer)
B. Staph aureus
C. Pseudomonas
D. Proteus

Explanation: ***E. coli*** - **_E. coli_** is the most prevalent uropathogen due to its ability to adhere to uroepithelial cells and its common presence in the perianal flora. - It accounts for approximately **80% of all community-acquired urinary tract infections (UTIs)**, including asymptomatic bacteriuria in pregnant women. *Staph aureus* - **_Staphylococcus aureus_** is an uncommon cause of UTIs and is typically associated with **hematogenous spread** in cases of bacteremia. - It is rarely isolated in asymptomatic bacteriuria and would raise suspicion for a systemic infection if found in urine. *Pseudomonas* - **_Pseudomonas aeruginosa_** is generally associated with **nosocomial infections**, catheter-associated UTIs, or patients with structural urinary tract abnormalities or prolonged antibiotic use. - It is not a common cause of asymptomatic bacteriuria in otherwise healthy pregnant women. *Proteus* - **_Proteus_ species**, particularly **_Proteus mirabilis_**, are known for their ability to produce **urease**, which can lead to alkaline urine and the formation of struvite stones. - While they can cause UTIs, they are less common than _E. coli_ in asymptomatic bacteriuria in pregnant women.

Question 1187: What is the earliest sign of fetal death?

A. Adipocere formation
B. Absence of fetal movements
C. Spalding sign
D. Absence of fetal heart sounds (Correct Answer)

Explanation: ***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.

Question 1188: Monozygotic twin with one healthy baby born at term and one dead mummified fetus is suggestive of?

A. Fetus acardiacus
B. Fetus papyraceous (Correct Answer)
C. Hydatidiform mole
D. Vanishing twin

Explanation: ***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 1189: What is the recommended management for a fetus diagnosed with severe anemia in Liley's Zone 3 at 35 weeks of gestation?

A. Preterm delivery of the fetus (Correct Answer)
B. Intrauterine blood transfusion
C. Observation and follow-up
D. Cord blood sampling

Explanation: ***Preterm delivery of the fetus*** - At **35 weeks gestation**, the fetus is in the **late preterm period** with good chances of neonatal survival and minimal complications from prematurity. - For a fetus with **severe anemia in Liley's Zone 3** at this gestational age, **immediate delivery** is the preferred management as it allows for prompt neonatal resuscitation and postnatal blood transfusion. - The risks of **intrauterine transfusion** (fetal bradycardia, bleeding, infection, fetal demise) outweigh the minimal risks of late preterm delivery at 35 weeks. - After delivery, neonatal intensive care can provide **direct transfusion**, phototherapy for hyperbilirubinemia, and comprehensive supportive care. *Intrauterine blood transfusion* - **Intrauterine blood transfusion (IUT)** is the treatment of choice for severe fetal anemia **before 34-35 weeks** of gestation when the risks of prematurity are significant. - At **35 weeks or beyond**, delivery is generally preferred over IUT because the procedural risks are no longer justified by the benefits of prolonging pregnancy. - IUT would be considered if delivery were contraindicated or if there were compelling reasons to delay delivery. *Observation and follow-up* - This approach is completely inappropriate for a fetus with **severe anemia in Liley's Zone 3**, regardless of gestational age. - Zone 3 indicates a high risk of **hydrops fetalis** and **intrauterine fetal demise** without immediate intervention. - Expectant management would result in preventable fetal death or severe hypoxic injury. *Cord blood sampling* - **Cordocentesis** (percutaneous umbilical blood sampling) is a diagnostic procedure to confirm fetal anemia by measuring hemoglobin and hematocrit levels. - While it may be performed before IUT in earlier gestations, at 35 weeks with known Zone 3 anemia, immediate action (delivery) is warranted. - It is not a therapeutic intervention and would only delay definitive management at this gestational age.

Question 1190: Couvelaire uterus is associated with which condition?

A. Placenta previa
B. Abruptio placentae (Correct Answer)
C. Velamentous placenta
D. Placenta accreta

Explanation: ***Abruptio placentae*** - **Couvelaire uterus**, also known as uteroplacental apoplexy, is a complication of severe **abruptio placentae** where blood infiltrates the myometrium, giving the uterus a bruised, purplish appearance. - This condition occurs when the **retroplacental hemorrhage** is extensive enough to dissect into the uterine muscle fibers. *Placenta previa* - **Placenta previa** is characterized by the placenta covering the cervical os, leading to painless vaginal bleeding, and is not associated with myometrial hemorrhage or a Couvelaire uterus. - The bleeding in placenta previa is typically from the placental villi or exposed maternal vessels in the lower uterine segment, not internal uterine dissection. *Placenta accreta* - **Placenta accreta** involves abnormal adherence of the placenta to the uterine wall (into the myometrium), which causes difficulty with placental separation after birth and significant hemorrhage, but not the myometrial infiltration seen in Couvelaire uterus. - The primary issue is the **abnormal invasion** of placental villi into the uterine wall, not bleeding dissecting within the myometrium. *Velamentous placenta* - A **velamentous placenta** is a condition where the umbilical cord inserts into the fetal membranes then courses to the placenta, leaving fetal vessels exposed, which can rupture during labor causing fetal hemorrhage. - It does not involve abnormalities of the uterine wall or extensive myometrial bleeding found in a Couvelaire uterus.

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

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free