Maternal-Fetal Medicine Practice Questions

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: In a case of DCDA twins at 38 weeks, with the first twin in breech presentation, and the mother having a blood pressure of 140/96 and 1+ proteinuria, what is the preferred management?

Perform cesarean section. ***Perform cesarean section*** - The combination of **DCDA twins** at **38 weeks**, the **first twin in breech presentation**, and maternal **preeclampsia** (BP 140/96, 1+ proteinuria) necessitates prompt delivery via cesarean section. - A **breech presentation** for the first twin significantly increases the risk of complications during vaginal delivery, making a **cesarean section** the safest and preferred route to prevent birth trauma, cord prolapse, and potential fetal distress. - At **38 weeks gestation** with **preeclampsia**, delivery is indicated as the definitive treatment, and cesarean section addresses both the obstetric indication (breech first twin) and maternal condition. *Plan induction of labor at 40 weeks* - This option is inappropriate due to the presence of **preeclampsia** and the **breech presentation** of the first twin, both of which indicate the need for earlier intervention. - Waiting until 40 weeks would expose the mother and fetuses to increased risks associated with prolonged preeclampsia and potential complications from breech vaginal delivery. *Induce labor immediately and deliver if necessary* - While prompt delivery is warranted due to preeclampsia at term, attempting **induction of labor** with a **breech presenting first twin** carries substantial risks for both twins. - **Vaginal delivery of a breech first twin** is generally discouraged in multiple gestations due to increased rates of fetal entrapment, cord prolapse, and other obstetrical emergencies, making cesarean section the safer choice. *Induce labor only if preeclampsia worsens* - This approach fails to address the immediate risks posed by the **breech presenting first twin** and the existing **preeclampsia** at term gestation. - Delaying intervention until the preeclampsia worsens could lead to severe maternal complications such as eclampsia, HELLP syndrome, or placental abruption, and increased fetal compromise.

Q: A primigravida at 22 weeks of gestation presents with profuse vaginal bleeding. Her blood pressure and glucose levels are normal. At which of the following sites can placental implantation lead to this condition?

Over the internal cervical os. ***Over the internal cervical os*** - Implantation over the **internal cervical os** leads to **placenta previa**, which is a common cause of **painless, profuse vaginal bleeding** in the second and third trimesters. - The bleeding occurs as the cervix begins to efface and dilate, detaching the abnormally implanted placenta. *In the fallopian tube* - Implantation in the fallopian tube is known as an **ectopic pregnancy**, typically presenting with **abdominal pain** and bleeding in the **first trimester**, often requiring surgical intervention. - This condition is unlikely to result in profuse vaginal bleeding at 22 weeks of gestation with normal blood pressure. *On the ovary* - **Ovarian pregnancy** is a rare form of ectopic pregnancy that occurs when a fertilized egg implants on the surface of the ovary. - It usually presents with symptoms in the **first trimester**, such as abdominal pain and light spotting, not profuse hemorrhage in the second trimester. *In the abdominal cavity* - **Abdominal pregnancy** is another type of ectopic pregnancy where the fertilized egg implants in the abdominal cavity. - While it can lead to complications such as bleeding and abdominal pain, it is not typically associated with profuse vaginal bleeding as described for a 22-week gestation.

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: Which of the following statement is correct about acute fatty liver of pregnancy?

Mostly seen in last trimester. ***Mostly seen in last trimester*** - **Acute fatty liver of pregnancy (AFLP)** typically manifests in the **third trimester** (weeks 28-40) of gestation or in the immediate postpartum period. - This timing is due to the increased metabolic demands on the liver during late pregnancy, which can exacerbate underlying defects in mitochondrial fatty acid oxidation. *Occurs in 1 in 1000 pregnancies* - AFLP is a **rare** obstetric complication, occurring in approximately **1 in 7,000 to 1 in 16,000** pregnancies, not 1 in 1000. - The incidence of 1 in 1000 would make it far too common and is incorrect. *Not related to the gender of the fetus* - AFLP has been observed to have a higher incidence in pregnancies involving a **male fetus**. - This association is thought to be related to differences in fetal steroid metabolism or the demands placed on maternal liver function by the male fetus. *May be associated with decreased uric acid* - AFLP is typically associated with **elevated serum uric acid levels** (hyperuricemia), not decreased levels. - Other typical findings include elevated liver enzymes, bilirubin, and sometimes severe hypoglycemia.

Q: A transvaginal ultrasound performed at 28 weeks of gestation shows the placental edge reaching but not covering the internal cervical os. Based on the provided image, identify the type of placenta praevia.

Type II.. ***Type II*** - In **Type II placenta previa**, also known as **marginal previa**, the placenta reaches the internal os but does not cover it. - While it touches the internal os, the placenta does not extend beyond it, differentiating it from complete or partial previa. *Type III* - **Type III placenta previa** (partial previa) occurs when the placenta partially covers the internal os but does not completely obstruct it. - This type involves a more significant overlap of the placenta over the cervical opening than what is typically observed in marginal previa. *Type IV* - **Type IV placenta previa** (complete previa) is characterized by the placenta completely covering the internal os. - This is the most severe form, usually requiring a cesarean section due to complete blockage of the birth canal. *Type I* - **Type I placenta previa** (low-lying placenta) means the placenta is implanted in the lower uterine segment but does not reach the internal os. - The placental edge is in close proximity to the os but does not touch it, which is a less severe condition than marginal previa.

Q: A woman at 26 weeks of gestation presents for routine evaluation. On examination, fundal height corresponds to 24 weeks. Ultrasonography revealed decreased amniotic fluid. Which of the following conditions would have led to this presentation?

Renal agenesis. ***Renal agenesis*** - **Renal agenesis** directly leads to **oligohydramnios** (decreased amniotic fluid) because fetal urine is the primary contributor to amniotic fluid volume after 20 weeks of gestation. - This reduction in amniotic fluid subsequently causes a **smaller fundal height** than expected for gestational age. *Tracheoesophageal fistula* - A **tracheoesophageal fistula** is primarily associated with **polyhydramnios** (excessive amniotic fluid) due to the fetus's inability to properly swallow amniotic fluid. - It would not lead to decreased amniotic fluid or a reduced fundal height. *Cardiac abnormalities* - **Cardiac abnormalities** can cause various fetal complications but are not typically a direct cause of **oligohydramnios**. - While severe cardiac issues can indirectly impact fetal growth, they usually do not lead to a significant reduction in amniotic fluid volume. *Ureteral stricture* - A **ureteral stricture** would impair urine flow from the kidney to the bladder, causing **hydronephrosis** of the affected kidney. - While it affects the renal system, if the other kidney is functioning, it generally would not lead to widespread **oligohydramnios** or a significantly reduced fundal height.

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: 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: 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 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 2

In a case of DCDA twins at 38 weeks, with the first twin in breech presentation, and the mother having a blood pressure of 140/96 and 1+ proteinuria, what is the preferred management?

Accepted Answer

Perform cesarean section

Answer

Plan induction of labor at 40 weeks

Answer

Induce labor immediately and deliver if necessary

Answer

Induce labor only if preeclampsia worsens

Question 3

A primigravida at 22 weeks of gestation presents with profuse vaginal bleeding. Her blood pressure and glucose levels are normal. At which of the following sites can placental implantation lead to this condition?

Accepted Answer

Over the internal cervical os

Answer

In the fallopian tube

Answer

On the ovary

Answer

In the abdominal cavity

Question 4

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 5

Which of the following statement is correct about acute fatty liver of pregnancy?

Accepted Answer

Mostly seen in last trimester

Answer

May be associated with decreased uric acid

Answer

Occurs in 1 in 1000 pregnancies

Answer

Not related to the gender of the fetus

Question 6

A transvaginal ultrasound performed at 28 weeks of gestation shows the placental edge reaching but not covering the internal cervical os. Based on the provided image, identify the type of placenta praevia.

Accepted Answer

Type II.

Answer

Type III.

Answer

Type IV.

Answer

Type I.

Question 7

A woman at 26 weeks of gestation presents for routine evaluation. On examination, fundal height corresponds to 24 weeks. Ultrasonography revealed decreased amniotic fluid. Which of the following conditions would have led to this presentation?

Accepted Answer

Renal agenesis

Answer

Tracheoesophageal fistula

Answer

Cardiac abnormalities

Answer

Ureteral stricture

Question 8

Chromosome number of partial hydatidiform mole is-

Accepted Answer

69 chromosomes

Answer

46 XX

Answer

45 XO

Answer

47 chromosomes (XXY)

Question 9

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 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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