Maternal-Fetal Medicine Practice Questions

Q: A female presents with 6 weeks of amenorrhea, experiencing vaginal bleeding and slight abdominal pain. A urine pregnancy test is positive, and her hCG level is 2800 IU/L. A mass measuring 3 x 2.5 cm is observed on the left adnexa. She is hemodynamically stable. What is the most appropriate management for this patient?

Single-dose methotrexate injection. ***Single-dose methotrexate injection*** - The patient presents with a **hemodynamically stable ectopic pregnancy**, as suggested by the positive pregnancy test, amenorrhea, vaginal bleeding, abdominal pain, an hCG level of 2800 IU/L, and an adnexal mass. - A single-dose methotrexate injection is the **first-line medical management** for ectopic pregnancies in stable patients, particularly when hCG levels are typically below 5000 IU/L and the mass size is less than 4 cm (or 3.5 cm in some guidelines). *Oral methotrexate* - **Oral methotrexate** is not typically used for the treatment of ectopic pregnancy due to unpredictable absorption and less reliable therapeutic efficacy compared to intramuscular administration. - The **intramuscular route** is preferred to ensure consistent systemic exposure and effectiveness in dissolving the ectopic gestation. *Serial methotrexate + leucovorin rescue* - **Leucovorin rescue** is used to mitigate the adverse effects of high-dose methotrexate, typically in cancer chemotherapy, and is not indicated for the standard treatment of ectopic pregnancy. - Serial doses of methotrexate without leucovorin may be given if the initial single dose fails, but **leucovorin is not part of the standard initial treatment protocol** for ectopic pregnancy. *Salpingectomy* - **Salpingectomy (surgical removal of the fallopian tube)** is indicated for ectopic pregnancies that are **hemodynamically unstable**, ruptured, too large for medical management (e.g., >4 cm), or in cases where medical management with methotrexate fails or is contraindicated. - Since this patient is **hemodynamically stable** and meets the criteria for medical management, surgery is not the most appropriate initial management.

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.

Q: A 22-year-old primigravida visits ANC OPD with 20 weeks POG. On examination uterine height reveals a 16-week size. USG shows reduced liquor. What will be the diagnosis?

Bilateral renal agenesis. ***Renal agenesis*** - **Bilateral renal agenesis** leads to **oligohydramnios** because the fetal kidneys are the primary producers of amniotic fluid after 16 weeks of gestation. - The reduced amniotic fluid (liquor) is consistent with the decreased uterine size (16-week size at 20 weeks POG) and is a hallmark of this condition, often resulting in **Potter sequence**. *Bartter’s syndrome* - This is a rare, inherited renal tubulopathy characterized by significant electrolyte disturbances (hypokalemia, metabolic alkalosis, hypercalciuria) due to impaired ion transport. - While it affects kidney function, it does not typically cause severe **oligohydramnios** or **renal agenesis** and would not explain the small uterine size in this scenario. *Liddle syndrome* - This is a rare genetic disorder characterized by early-onset hypertension, hypokalemia, and metabolic alkalosis, due to constitutive activation of the epithelial sodium channel (ENaC) in the collecting ducts. - It does not involve structural kidney abnormalities or significantly impact amniotic fluid volume during pregnancy to cause the described findings. *Fetal anemia* - Fetal anemia can lead to complications such as **hydrops fetalis**, which would typically cause **polyhydramnios** or a uterine size larger than expected due to fluid accumulation, not oligohydramnios or a smaller uterine size. - Reduced liquor and a small uterine size are not characteristic presentations of fetal anemia.

Q: A patient with recurrent abortion is diagnosed to have antiphospholipid syndrome. What will be the treatment?

Aspirin and Low molecular weight Heparin. ***Aspirin and Low molecular weight Heparin*** - The combination of **low-dose aspirin (75-100 mg daily)** and **low molecular weight heparin (LMWH)** is the **standard of care** for pregnant women with antiphospholipid syndrome (APS) to prevent recurrent pregnancy loss. - **Aspirin** inhibits platelet aggregation and reduces thrombosis, while **LMWH** provides anticoagulation to prevent placental thrombosis and improve pregnancy outcomes. - This combination has been shown to **increase live birth rates** from approximately 40% (untreated) to **70-80%** in women with APS. *Aspirin alone* - While aspirin is part of the treatment regimen, **aspirin monotherapy is insufficient** for preventing recurrent pregnancy loss in patients with established APS. - Randomized controlled trials have demonstrated that adding heparin to aspirin **significantly improves live birth rates** compared to aspirin alone. *Aspirin, Low molecular weight Heparin, and Prednisolone* - **Corticosteroids (prednisolone)** are **not recommended** as routine treatment for recurrent pregnancy loss in APS patients due to potential maternal complications (gestational diabetes, hypertension, infection) and fetal risks. - Corticosteroids might be considered only in specific cases with coexisting autoimmune conditions (e.g., SLE), but they are **not first-line therapy** for APS-related pregnancy loss. *No treatment required* - **Antiphospholipid syndrome (APS)** is a significant cause of recurrent pregnancy loss due to placental thrombosis and impaired placental function. - **Untreated APS** carries a **high risk** (>70%) of pregnancy loss, along with increased risks of fetal growth restriction, preeclampsia, and preterm delivery, making treatment **essential** for a successful pregnancy outcome.

Q: Vertical transmission of HIV is highest with-

High viral RNA load. ***High viral RNA load*** - A **high maternal viral load** (HIV RNA copies per milliliter of blood) is the most significant risk factor for **mother-to-child transmission (MTCT)** of HIV. The higher the viral load, the greater the likelihood of the virus being transmitted to the infant. - This is because a higher viral load indicates more circulating virus that can cross the **placenta** during gestation, be exchanged during labor and delivery, or be transmitted through breast milk. *Elective caesarean section* - An **elective caesarean section (C-section)** is a method used to *reduce* the risk of vertical transmission of HIV, especially when the maternal viral load is high. It *does not increase* the risk. - By avoiding passage through the birth canal, C-section minimizes the infant's exposure to maternal blood and genital secretions. *Breast feeding* - **Breastfeeding** is a known route of vertical HIV transmission and significantly increases the risk compared to formula feeding in HIV-positive mothers who are not on antiretroviral therapy (ART). - However, the overall *highest risk* factor *before* deciding on infant feeding is the *maternal viral load*, which dictates the likelihood of transmission via any route (intrauterine, intrapartum, or postpartum). *Term delivery* - **Term delivery** (vaginal delivery at term) carries a higher risk of vertical HIV transmission compared to an elective C-section, especially in mothers with high viral loads. - However, the *primary determinant* of this risk, even during vaginal delivery, is the **maternal viral load**. A mother with a well-controlled, low viral load at term has a significantly reduced risk of transmission even during vaginal delivery.

Q: A 40 year old G2P1 woman with 18 weeks of amenorrhea comes with a dilated cervix. The cervical length is 15 mm. In spite of explaining the risks, she insisted on cerclage. Which of the following is a contraindication for cervical cerclage?

Ruptured membranes. ***Ruptured membranes*** - **Ruptured membranes** are an **absolute contraindication** to cervical cerclage because the protective barrier against infection is lost. - Placing a cerclage after membrane rupture would trap bacteria within the uterus, leading to serious complications such as **chorioamnionitis** and **sepsis**. - Once membranes rupture, the focus shifts to prevention of infection and preparation for delivery rather than cervical reinforcement. *Prolapse of membranes into the vagina* - This represents a **relative contraindication** rather than an absolute one; cerclage can still be attempted in selected cases with appropriate technique. - While bulging or prolapsed membranes make the procedure more technically challenging and increase risks of membrane rupture, the membranes can sometimes be reduced back before cerclage placement. - This scenario requires careful patient counseling about increased risks, but is not an absolute contraindication if the patient insists and understands the complications. *Advanced maternal age* - **Advanced maternal age** (40 years in this case) is **not a contraindication** for cerclage at all. - The decision for cerclage is based on cervical findings and obstetric history showing cervical insufficiency, not on maternal age. - Age may be a risk factor for other pregnancy complications, but does not preclude cerclage if indicated. *Fetal fibronectin positive* - A **positive fetal fibronectin** test indicates increased risk of preterm labor but is **not a contraindication** to cerclage. - It may prompt closer monitoring or influence timing of intervention, but doesn't rule out cerclage if there's a strong indication based on cervical insufficiency. - Prophylactic or rescue cerclage can still be performed despite positive fetal fibronectin if clinically indicated.

Q: Chromosome number of partial hydatidiform mole is-

69 chromosomes. ***69 chromosomes*** - A **partial hydatidiform mole** typically results from **dispermy** (fertilization of one ovum by two sperm), leading to a **triploid karyotype** (69 chromosomes). - This triploidy usually consists of **69, XXY** or **69, XXX**, with the paternal contribution being twice the maternal. *46 XX* - This is a normal diploid female karyotype and is the typical chromosome number for a **complete hydatidiform mole** if the maternal chromosomes are lost and the paternal chromosomes duplicate. - In a complete mole, there is **no fetal tissue**, unlike in a partial mole. *45 XO* - This karyotype, known as **Turner syndrome**, is characterized by the absence of one sex chromosome. - It does not represent a hydatidiform mole but is a chromosomal abnormality associated with developmental disorders. *47 chromosomes (XXY)* - This karyotype is characteristic of **Klinefelter syndrome**, a sex chromosome aneuploidy in males (47,XXY). - While it involves an extra sex chromosome, it is not associated with partial hydatidiform moles, which are triploid with 69 chromosomes.

Q: The major contributor to amniotic fluid after 20 weeks of gestation is:

Fetal urine. ***Fetal urine*** - After **20 weeks of gestation**, the **fetal kidneys** are fully functional, and fetal urination becomes the primary source of amniotic fluid. - This contribution is crucial for the **volume of amniotic fluid** and plays a vital role in **fetal lung development** by allowing the fetus to "breathe" the fluid. *Ultrafiltrate of maternal plasma* - While an ultrafiltrate of maternal plasma contributes to the early amniotic fluid volume, its significance diminishes as the **fetal kidneys mature** past 20 weeks. - This source primarily provides water and dissolved solutes, but not a substantial volume. *Fluid from fetal lungs* - Fluid produced by the fetal lungs also contributes to amniotic fluid, but its volume is considerably smaller than that from **fetal urine**, especially after 20 weeks. - It mainly includes pulmonary surfactants and other specific proteins important for lung maturation. *Fetal skin* - Before **keratinization** of the fetal skin (around 20-22 weeks), the skin is permeable and allows for transepidermal fluid transport, contributing to amniotic fluid. - However, once **keratinization** is complete, the skin becomes impermeable, and its contribution to amniotic fluid becomes negligible.

Q: A female patient collapses soon after delivery. There is profuse bleeding and features of disseminated intravascular coagulation. Which of the following is the most likely etiology?

Amniotic fluid embolism. ***Amniotic fluid embolism as a complication of pregnancy*** - **Amniotic fluid embolism** is a rare but catastrophic complication where amniotic fluid enters the maternal circulation, leading to sudden **cardiovascular collapse**, **respiratory distress**, and **disseminated intravascular coagulation (DIC)**. - The rapid onset of symptoms after delivery, along with profuse bleeding and features of DIC, is highly characteristic of this condition. *Uterine atony* - **Uterine atony** is the most common cause of **postpartum hemorrhage**, typically leading to profuse bleeding due to the uterus's inability to contract. - While it causes significant bleeding, it does not typically cause the triad of sudden cardiovascular collapse, respiratory distress, and DIC seen in amniotic fluid embolism. *Peripartum cardiomyopathy as a cause of collapse* - **Peripartum cardiomyopathy** can lead to heart failure and cardiovascular collapse, but it typically develops **gradually** in the peripartum period. - It does not directly cause profuse bleeding or DIC; rather, its complications might include thromboembolic events, which are distinct from the primary events described. *Rupture of the uterus during delivery* - **Uterine rupture** causes significant hemorrhage and can lead to maternal collapse. - However, it primarily results in **external or internal bleeding** from the rupture site and does not typically trigger the widespread systemic inflammatory response and DIC as rapidly or profoundly as an amniotic fluid embolism.

Question 1

A female presents with 6 weeks of amenorrhea, experiencing vaginal bleeding and slight abdominal pain. A urine pregnancy test is positive, and her hCG level is 2800 IU/L. A mass measuring 3 x 2.5 cm is observed on the left adnexa. She is hemodynamically stable. What is the most appropriate management for this patient?

Accepted Answer

Single-dose methotrexate injection

Answer

Oral methotrexate

Answer

Serial methotrexate + leucovorin rescue

Answer

Salpingectomy

Question 2

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

Question 3

A 22-year-old primigravida visits ANC OPD with 20 weeks POG. On examination uterine height reveals a 16-week size. USG shows reduced liquor. What will be the diagnosis?

Accepted Answer

Bilateral renal agenesis

Answer

Bartter’s syndrome

Answer

Liddle syndrome

Answer

Fetal anemia

Question 4

A patient with recurrent abortion is diagnosed to have antiphospholipid syndrome. What will be the treatment?

Accepted Answer

Aspirin and Low molecular weight Heparin

Answer

Aspirin alone

Answer

Aspirin, Low molecular weight Heparin, and Prednisolone

Answer

No treatment required

Question 5

Vertical transmission of HIV is highest with-

Accepted Answer

High viral RNA load

Answer

Elective caesarean section

Answer

Breast feeding

Answer

Term delivery

Question 6

A 40 year old G2P1 woman with 18 weeks of amenorrhea comes with a dilated cervix. The    cervical length is 15 mm. In spite of explaining the risks, she insisted on cerclage. Which of the    following is a contraindication for cervical cerclage?

Accepted Answer

Ruptured membranes

Answer

Advanced maternal age

Answer

Fetal fibronectin positive

Answer

Prolapse of membranes into the vagina

Question 7

Chromosome number of partial hydatidiform mole is-

Accepted Answer

69 chromosomes

Answer

46 XX

Answer

45 XO

Answer

47 chromosomes (XXY)

Question 8

What maternal condition is commonly associated with congenital heart defects in the fetus?

Accepted Answer

Pregestational Diabetes Mellitus (DM)

Answer

Gestational Diabetes Mellitus (GDM)

Answer

Maternal use of Valproate

Answer

Maternal use of ACE inhibitors

Question 9

The major contributor to amniotic fluid after 20 weeks of gestation is:

Accepted Answer

Fetal urine

Answer

Fetal skin

Answer

Ultrafiltrate of maternal plasma

Answer

Fluid from fetal lungs

Question 10

A female patient collapses soon after delivery. There is profuse bleeding and features of    disseminated intravascular coagulation. Which of the following is the most likely etiology?

Accepted Answer

Amniotic fluid embolism

Answer

Uterine atony

Answer

Peripartum cardiomyopathy

Answer

Rupture of the uterus during delivery

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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