Maternal-Fetal Medicine Practice Questions

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: 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?

Cervical length assessment. ***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.

Q: Which of the following statements about cardiovascular changes during pregnancy is true?

Increase in left ventricular end diastolic diameter. ***Increase in left ventricular end diastolic diameter*** - Pregnancy leads to a significant increase in **blood volume** (up to 50% by the third trimester), which directly increases **venous return** to the heart. - This increased preload stretches the left ventricle, causing an increase in its **end-diastolic dimension** and volume to accommodate the larger blood volume. *Cardiac output decreases during pregnancy* - **Cardiac output actually increases** significantly during pregnancy, by 30-50%, reaching its peak in the second trimester and remaining high until delivery. - This increase is necessary to meet the metabolic demands of the growing fetus and uteroplacental unit, and is primarily driven by an increase in **stroke volume** and **heart rate**. *Pregnancy causes right axis deviation* - Pregnancy typically causes a **leftward shift of the cardiac axis**, leading to **left axis deviation** (or a more horizontal axis) on an electrocardiogram. - This is due to the elevation of the diaphragm by the gravid uterus, which pushes the heart superiorly and to the left. *None of the options are true* - This statement is incorrect because the increase in **left ventricular end-diastolic diameter** during pregnancy is a well-established physiological change. - The other two options are false, but there is a correct statement among the choices.

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: What is the term used to describe the phenomenon of a fetus making a sound in utero?

Vagitus uterinus. ***Vagitus uterinus*** - This term specifically refers to the phenomenon of a fetus crying or making a sound while still inside the intact **uterus** or during a **breech delivery** before the head is delivered. - It is a rare event, often occurring when air enters the uterus during delivery or a procedure, allowing the vocal cords to vibrate. *Neonatal cry* - This term describes the cry of a **newborn baby** after birth, once completely exposed to the external environment and able to take its first breath of air. - It does not specifically refer to sounds made while still within the uterus. *Fetal vocalization* - This is a more general term that could imply any sound made by a fetus, but it is not the specific medical term for a cry within the uterus. - It lacks the precise historical and medical connotation of sound made from a fetus still in the womb. *Intrauterine sound* - This is a broad term that encompasses any sound originating from within the uterus, such as **fetal heart sounds**, maternal bowel sounds, or blood flow, but not necessarily a vocal cry by the fetus. - It does not specifically refer to the act of crying by the fetus.

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

E. coli. ***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.

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: How many days does it take for a zygote with zona pellucida to reach the uterine cavity after fertilization?

4 days. ***4 days*** - Following fertilization in the **ampulla** of the fallopian tube, the zygote undergoes cleavage divisions as it travels towards the uterus. - The **zona pellucida** remains intact during this journey, and the embryo (typically at the **morula** or early blastocyst stage) enters the uterine cavity around **Day 3-4** post-fertilization. - **Day 4** is the most commonly cited timeframe for entry into the uterine cavity with zona pellucida intact. *2 days* - At 2 days post-fertilization, the embryo is usually in the **2- to 4-cell stage** and is still located within the fallopian tube. - It has not yet completed its journey through the fallopian tube to reach the uterine cavity. *5 days* - By Day 5, the embryo has typically developed into a **blastocyst** and has already been in the uterine cavity for approximately 1-2 days. - This represents a later stage of development after the embryo has already reached the uterine cavity, not the initial arrival time. *6 days* - On Day 6, the blastocyst is typically **hatching out of the zona pellucida** and beginning implantation into the endometrium. - The zona pellucida is no longer intact at this stage, and the embryo has already been in the uterine cavity for approximately 2 days.

Q: According to limited observational studies, in cases where fetal movement has significantly decreased, approximately how long may elapse before fetal heart rate cessation occurs?

12 hrs. ***Correct: 12 hrs*** - Limited observational studies suggest that in cases of significantly decreased fetal movement, **fetal heart rate cessation** may occur approximately **12 hours** later. - This timeframe highlights the urgency of investigating decreased fetal movement to prevent **fetal demise**. - This observation forms the basis for clinical recommendations to evaluate decreased fetal movement **urgently within 12-24 hours**. *Incorrect: 1 hr* - This is generally too short a period; **fetal heart rate cessation** typically does not occur within 1 hour of decreased fetal movement. - While immediate evaluation is crucial for decreased fetal movement, **perinatal outcomes** are rarely impacted this quickly unless direct acute events occur (e.g., placental abruption, cord accident). *Incorrect: 2 hrs* - While **fetal compromise** can occur rapidly, 2 hours is often too short for complete **fetal heart rate cessation** after only decreased movement. - This timeframe still allows for potential **intervention** if the cause of decreased movement is identified quickly. *Incorrect: 6 hrs* - Although more plausible than 1 or 2 hours, 6 hours is still generally considered too short for **fetal cardiac arrest** after significantly decreased movement based on observational data. - Urgent evaluation is still recommended within this window to avoid **adverse fetal outcomes**.

Q: Vasa previa is associated with which type of placental vessel insertion?

Velamentous. ***Velamentous*** - **Vasa previa** occurs when **fetal blood vessels** from a **velamentous cord insertion** cross the internal cervical os, unprotected by placental tissue or Wharton's jelly. - In a **velamentous insertion**, the umbilical cord inserts into the **chorioamniotic membranes** distant from the placental margin, with the vessels then coursing through the membranes to the placenta. *Central* - A **central placental vessel insertion** is the normal and healthy insertion point, typically near the center of the placenta. - This type of insertion is **not associated** with vasa previa, as the vessels are well-protected within the umbilical cord. *Peripheral* - A **peripheral placental vessel insertion** refers to the cord inserting at the margin of the placenta. - While considered marginal, it is **not directly associated** with vasa previa, which specifically involves vessels traversing unprotected membranes over the cervical os. *None of the options* - This option is incorrect because **velamentous cord insertion** is a direct and well-documented cause of vasa previa. - There is a specific and known association between velamentous insertion and vasa previa.

Question 1

After IUFD, when does the mother develop DIC?

Accepted Answer

3-4 weeks

Answer

48 hours

Answer

1-2 weeks

Answer

6 weeks

Question 2

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?

Accepted Answer

Cervical length assessment

Answer

Cervical encerclage

Answer

Evaluation for diabetes mellitus and thyroid disorders

Answer

Tocolytics

Question 3

Which of the following statements about cardiovascular changes during pregnancy is true?

Accepted Answer

Increase in left ventricular end diastolic diameter

Answer

None of the options are true

Answer

Cardiac output decreases during pregnancy

Answer

Pregnancy causes right axis deviation

Question 4

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 5

What is the term used to describe the phenomenon of a fetus making a sound in utero?

Accepted Answer

Vagitus uterinus

Answer

Neonatal cry

Answer

Fetal vocalization

Answer

Intrauterine sound

Question 6

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

Accepted Answer

E. coli

Answer

Staph aureus

Answer

Pseudomonas

Answer

Proteus

Question 7

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 8

How many days does it take for a zygote with zona pellucida to reach the uterine cavity after fertilization?

Accepted Answer

4 days

Answer

2 days

Answer

5 days

Answer

6 days

Question 9

According to limited observational studies, in cases where fetal movement has significantly decreased, approximately how long may elapse before fetal heart rate cessation occurs?

Accepted Answer

12 hrs

Answer

1 hr

Answer

2 hrs

Answer

6 hrs

Question 10

Vasa previa is associated with which type of placental vessel insertion?

Accepted Answer

Velamentous

Answer

Central

Answer

Peripheral

Answer

None of the options

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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