Maternal-Fetal Medicine Practice Questions

Q: Which of the following is NOT a common cause of maternal death in patients with hypertensive disorders of pregnancy?

Chronic renal failure. ***Chronic renal failure*** - While chronic kidney disease can worsen during pregnancy and complicate hypertensive disorders, it is **NOT a common direct cause of maternal death** in hypertensive disorders of pregnancy. - The acute complications that arise (such as **acute kidney injury**, **eclampsia**, or **severe pre-eclampsia**) are the actual life-threatening events, rather than pre-existing chronic renal failure itself. - In contrast to the other options listed, **chronic renal failure** as a primary cause of maternal mortality is significantly less frequent in the setting of hypertensive disorders of pregnancy. *Cardiac failure* - **Pre-eclampsia** and **eclampsia** significantly increase cardiac workload and can lead to **acute heart failure**, especially with pre-existing cardiac disease or severe hypertension. - This is a **well-recognized and common cause** of maternal death in patients with severe hypertensive disorders of pregnancy. *ARDS* - **Acute Respiratory Distress Syndrome (ARDS)** is a severe complication of **pre-eclampsia** and **eclampsia**, often due to pulmonary edema from capillary leak and fluid overload. - It is a **critical and potentially fatal** respiratory complication representing one of the common causes of maternal death in severe hypertensive disorders. *Cerebral hemorrhage* - **Severe hypertension** in **pre-eclampsia** and **eclampsia** can lead to hemorrhagic stroke. - **Cerebral hemorrhage** is a **leading cause of maternal mortality** in women with severe hypertensive disorders of pregnancy, particularly eclampsia.

Q: What is the approximate fetal weight to placental weight ratio at 24 weeks of gestation?

2:1. ***2:1*** - The fetal weight to placental weight ratio at **24 weeks of gestation** varies across different references, with this ratio being cited in some older literature. - However, **current obstetric literature** suggests the ratio at 24 weeks is typically **higher (approximately 5:1 to 6:1)**, as the fetus (600-700g) significantly outweighs the placenta (100-120g) by this stage. - At 24 weeks, the fetus undergoes **rapid growth**, while placental growth rate has stabilized, leading to an increasing fetal-to-placental weight ratio. *1.5:1* - This ratio suggests the **fetus is only slightly heavier** than the placenta. - Such a ratio is typically observed **earlier in pregnancy (around 16-18 weeks)**, when placental mass is still relatively large compared to fetal mass. *3:1* - This ratio would indicate the fetus is **three times heavier** than the placenta. - While closer to physiologic values at 24 weeks, this still **underestimates** the typical fetal-to-placental weight ratio at this gestational age. *4:1* - This ratio suggests the fetus is **four times heavier** than the placenta. - This is **more consistent with mid-to-late second trimester** values and approaches the expected range, though current evidence suggests even higher ratios (5-6:1) at 24 weeks. **Note:** The fetal-to-placental weight ratio progressively increases throughout pregnancy, starting below 1:1 in early pregnancy and reaching 6-7:1 at term. Standard teaching suggests ratios of 5-6:1 at 24 weeks, though variation exists across references.

Q: What is the typical placenta-to-baby weight ratio at term?

1 : 6. ***1 : 6*** * The placenta-to-baby weight ratio at term is typically 1:6, meaning the placenta weighs approximately one-sixth of the baby's weight. * This ratio reflects the normal physiological balance required for adequate **fetal growth** and **nutrient exchange**. *1 : 3* * A 1:3 ratio would imply a proportionally much **larger placenta** relative to the baby's weight, which is not typical at term. * Such a ratio might be seen in cases of placental abnormalities or fetal growth restriction, but not as a normal physiological state. *1 : 4* * A 1:4 ratio indicates a **larger placenta** than physiologically normal at term, suggesting potential placental issues. * This is not the standard ratio observed in healthy pregnancies at term. *1 : 5* * While closer to the normal range than 1:3 or 1:4, a 1:5 ratio still suggests a slightly **larger placenta** than average. * The most commonly accepted healthy average at term is 1:6.

Q: Least common site of ectopic pregnancy in the fallopian tubes is?

Interstitium. ***Interstitium*** - The **interstitial portion** of the fallopian tube is the narrowest and thickest part, making it the least common site for an ectopic pregnancy within the tube itself. - While less frequent, interstitial pregnancies are associated with a **higher risk of rupture** and hemorrhage due to the surrounding myometrial tissue. *Ampulla* - The **ampulla** is the most common site of ectopic pregnancy in the fallopian tube, accounting for about 80% of all tubal ectopics. - Its wider diameter and convoluted lumen easily trap the fertilized egg. *Infundibulum* - The **infundibulum**, or fimbrial end, is a relatively common site for ectopic pregnancies after the ampulla, accounting for about 5% of cases. - Pregnancies here are often referred to as **fimbrial ectopic pregnancies**. *Isthmus* - The **isthmus** is the second most common site for tubal ectopic pregnancies, accounting for approximately 12% of cases. - This section is narrower than the ampulla but still more hospitable than the interstitial portion.

Q: Which of the following statements about MgSO4 is false?

Not used as antihypertensive. ***Not used as antihypertensive*** - This statement is **false** because **Magnesium sulfate (MgSO4)** is indeed used for its **antihypertensive** properties, especially in obstetric emergencies like **preeclampsia** and **eclampsia**, where it helps lower blood pressure. - While its primary role in these conditions is seizure prevention, its **vasodilatory effects** contribute to blood pressure reduction. *Deep tendon reflexes are monitored for toxicity* - This statement is **true**. The primary sign of impending **Magnesium sulfate toxicity** is the **loss of deep tendon reflexes**, particularly the patellar reflex. - Monitoring reflexes is crucial for safe administration and to prevent serious complications like **respiratory depression**. *It acts as a membrane stabilizer and neuroprotector* - This statement is **true**. MgSO4 is thought to exert its **anticonvulsant** effect by acting as a **membrane stabilizer** and a **neuroprotector**. - It reduces neuronal excitability, blocks glutamate receptors, and antagonizes calcium influx, thereby protecting brain cells from damage. *Duration of therapy may differ between eclampsia and preeclampsia* - This statement is **true**. The **loading dose** (4-6g IV) and **maintenance dose** (1-2g/hr) of MgSO4 are typically the same for both conditions. - However, the **duration of therapy** differs based on clinical presentation: eclampsia treatment requires continuation for 24 hours after the last seizure, while preeclampsia may require shorter durations. - Eclampsia may also necessitate longer monitoring to prevent recurrent seizures.

Q: Risk period for maximum fetal damage due to congenital rubella infection?

First trimester of pregnancy. ***First trimester of pregnancy*** - The **organogenesis** phase occurs predominantly in the first trimester, making the developing fetus highly vulnerable to teratogens like the **rubella virus**. - Infection during this period (especially **weeks 1-12**) leads to the highest incidence and most severe forms of **congenital rubella syndrome (CRS)**, affecting major organs such as the heart, eyes, and brain. *Second trimester of pregnancy* - While fetal infection can still occur, the risk of severe congenital anomalies significantly decreases as most major organs have already formed. - Infections in the second trimester are more likely to result in **fetal growth restriction** or later-onset defects rather than the classic CRS triad. *Third trimester of pregnancy* - Infection during the third trimester typically carries a very low risk of congenital malformations. - The primary concern during this period is **perinatal transmission** leading to neonatal infection rather than structural birth defects. *Risk is same throughout the pregnancy* - This statement is incorrect because the vulnerability of the fetus to rubella virus varies greatly depending on the stage of development, with the **first trimester** being the most critical period. - The developing organs in early pregnancy are far more susceptible to damage from viral replication and inflammation.

Q: A patient with juvenile myoclonic epilepsy on valproate comes to you at 5 months of pregnancy with a normal level II scan. What will you advise?

Continue the drug in the same dose. ***Continue the drug in the same dose*** - As the patient is already at **5 months of pregnancy** with a **normal level II scan**, the risk of major congenital malformations has largely passed. - **Maintaining seizure control** is crucial during pregnancy, as uncontrolled seizures pose significant risks to both the mother and fetus. *Change the drug* - Changing an antiepileptic drug during pregnancy, especially in the second trimester, can lead to a **loss of seizure control** and potentially expose the fetus to a new drug with unknown risks. - The period of highest risk for **major congenital malformations** from valproate exposure is during the first trimester. *Decrease the dose of the drug* - Decreasing the dose of valproate could lead to **breakthrough seizures**, which are dangerous for both the mother and the fetus. - **Plasma drug levels** often decrease in pregnancy due to increased volume of distribution and metabolism, potentially requiring a stable or even increased dose to maintain therapeutic levels. *Increase the dose of the drug* - Increasing the dose without clear clinical indication (e.g., breakthrough seizures or subtherapeutic levels) could increase the risk of **dose-dependent side effects** for both mother and fetus. - While therapeutic drug monitoring for valproate is often done in pregnancy, a **normal level II scan** does not automatically warrant a dose increase.

Q: A woman presents to you at 36 weeks of gestation with complaints of breathlessness and excessive abdominal distension. Fetal movements are normal. On examination, fetal parts are not easily felt and fetal heartbeat is heard but it is muffled. Her symphysis fundal height is 41 cm. Her abdomen is tense but not tender. What is the most likely diagnosis?

Polyhydramnios. ***Polyhydramnios*** - The patient's symptoms of **breathlessness**, **excessive abdominal distension**, a **symphysis fundal height of 41 cm at 36 weeks** (indicating a significantly larger than expected uterus), and **muffled fetal heart tones** are classic signs of polyhydramnios. - **Difficulty feeling fetal parts** is also consistent with excess amniotic fluid, which cushions the fetus and makes palpation harder. *Abruptio placenta* - This condition typically presents with sudden onset of **painful vaginal bleeding**, uterine tenderness, and fetal distress, none of which are described here. - While the abdomen might be tense due to uterine contractions or concealed bleeding, the lack of pain and bleeding makes this diagnosis unlikely. *Hydrocephalus of fetus* - Fetal hydrocephalus would primarily manifest as an **abnormally large fetal head** upon ultrasound, potentially leading to a higher fundal height. - However, it wouldn't directly explain the generalized excessive abdominal distension or the difficulty in feeling fetal parts due to fluid, though it could be a cause of polyhydramnios itself, it is not the most likely primary diagnosis from the given options directly addressing the symptoms. *Oligohydramnios* - This condition is characterized by **too little amniotic fluid**, which would result in a **smaller than expected symphysis fundal height** and an easily palpable fetus. - The patient's symptoms, particularly the excessive distension and high fundal height, directly contradict the features of oligohydramnios.

Q: A female patient presents to you with six weeks of amenorrhea, associated with abdominal pain and vaginal bleeding with normal blood pressure. Investigations revealed beta-hCG to be 1400 mIU/mL. An ultrasound scan was done which showed a trilaminar endometrium with normal adnexa. What is the next best step in the management of this patient?

Repeat beta – hCG after 48 hours. ***Repeat beta – hCG after 48 hours*** - With a beta-hCG of 1400 mIU/mL and no intrauterine pregnancy visible on ultrasound, repeating **beta-hCG after 48 hours** is crucial to assess its doubling time, which helps differentiate between a normal intrauterine pregnancy, ectopic pregnancy, or miscarriage. - An hCG level of 1400 mIU/mL is below the discriminatory zone (typically 1500-2000 mIU/mL) where an intrauterine gestational sac should be visible, making serial measurements essential. *Repeat ultrasound after 5 days* - While a repeat ultrasound may eventually be necessary, waiting 5 days without an interim hCG measurement could delay diagnosis and management, especially if the hCG levels are rising rapidly or are in a concerning range. - The current beta-hCG level is below the **discriminatory zone**, meaning a gestational sac would likely still not be visible even after 5 days, making hCG follow-up a more immediate and informative step. *Measurement of serum progesterone* - **Serum progesterone** levels can indicate overall pregnancy viability, but they do not specifically localize the pregnancy or differentiate between an intrauterine pregnancy and an ectopic pregnancy as effectively as serial hCG levels. - A single low progesterone level could indicate a non-viable pregnancy (either intrauterine or ectopic), but it does not guide immediate management for distinguishing between locations. *Laparoscopy* - **Laparoscopy** is an invasive surgical procedure and is not the first diagnostic step unless there are signs of ruptured ectopic pregnancy or hemodynamic instability, which are not present in this patient (normal blood pressure, mild symptoms). - It would be premature to proceed with laparoscopy without further biochemical or sonographic evidence of an ectopic pregnancy or clear signs of clinical deterioration.

Question 1

Which of the following is NOT a common cause of maternal death in patients with hypertensive disorders of pregnancy?

Accepted Answer

Chronic renal failure

Answer

Cardiac failure

Answer

ARDS

Answer

Cerebral hemorrhage

Question 2

What is the approximate fetal weight to placental weight ratio at 24 weeks of gestation?

Accepted Answer

2:1

Answer

1.5:1

Answer

3:1

Answer

4:1

Question 3

What is the recommended management for intrauterine hydronephrosis detected at 32-34 weeks of gestation?

Accepted Answer

Serial USG monitoring and evaluation for associated anomalies

Answer

Intrauterine drainage

Answer

Immediate delivery

Answer

Postnatal evaluation at 3 weeks

Question 4

What is the typical placenta-to-baby weight ratio at term?

Accepted Answer

1 : 6

Answer

1 : 3

Answer

1 : 4

Answer

1 : 5

Question 5

Least common site of ectopic pregnancy in the fallopian tubes is?

Accepted Answer

Interstitium

Answer

Ampulla

Answer

Infundibulum

Answer

Isthmus

Question 6

Which of the following statements about MgSO4 is false?

Accepted Answer

Not used as antihypertensive

Answer

It acts as a membrane stabilizer and neuroprotector

Answer

Deep tendon reflexes are monitored for toxicity

Answer

Duration of therapy may differ between eclampsia and preeclampsia

Question 7

Risk period for maximum fetal damage due to congenital rubella infection?

Accepted Answer

First trimester of pregnancy

Answer

Second trimester of pregnancy

Answer

Third trimester of pregnancy

Answer

Risk is same throughout the pregnancy

Question 8

A patient with juvenile myoclonic epilepsy on valproate comes to you at 5 months of pregnancy with a normal level II scan. What will you advise?

Accepted Answer

Continue the drug in the same dose

Answer

Increase the dose of the drug

Answer

Change the drug

Answer

Decrease the dose of the drug

Question 9

A woman presents to you at 36 weeks of gestation with complaints of breathlessness and excessive abdominal distension. Fetal movements are normal. On examination, fetal parts are not easily felt and fetal heartbeat is heard but it is muffled. Her symphysis fundal height is 41 cm. Her abdomen is tense but not tender. What is the most likely diagnosis?

Accepted Answer

Polyhydramnios

Answer

Abruptio placenta

Answer

Hydrocephalus of fetus

Answer

Oligohydramnios

Question 10

A female patient presents to you with six weeks of amenorrhea, associated with abdominal pain and vaginal bleeding with normal blood pressure. Investigations revealed beta-hCG to be 1400 mIU/mL. An ultrasound scan was done which showed a trilaminar endometrium with normal adnexa. What is the next best step in the management of this patient?

Accepted Answer

Repeat beta – hCG after 48 hours

Answer

Laparoscopy

Answer

Repeat ultrasound after 5 days

Answer

Measurement of serum progesterone

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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