Maternal-Fetal Medicine Practice Questions

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 baby born at 34 weeks gestation weighs 3kg. Which of the following conditions is this child most likely to develop in the immediate postnatal period?

Anemia. ***Anemia*** - A 3kg baby at 34 weeks is **large for gestational age (LGA)** and often associated with maternal diabetes, leading to initial **polycythemia** due to chronic intrauterine hypoxia and increased erythropoietin production. - After birth, the excess red blood cells undergo rapid **hemolysis**, resulting in **anemia** in the immediate postnatal period as a recognized complication of LGA babies. *APH* - **Antepartum hemorrhage (APH)** is a maternal obstetric complication involving bleeding before delivery, not a condition that develops in the newborn. - This is a **maternal complication** that occurs during pregnancy, not a neonatal condition that the baby would present with after birth. *Diabetes* - While **maternal diabetes** is often the cause of fetal macrosomia, the newborn does not develop diabetes itself in the immediate postnatal period. - These babies are instead at risk for **hypoglycemia**, **respiratory distress**, and **polycythemia** due to fetal hyperinsulinemia, but not diabetes as a presenting condition. *None of the options* - This is incorrect because **anemia** is indeed a valid condition that LGA babies can develop through the **polycythemia-hemolysis cycle**. - While other complications like **hypoglycemia** are more statistically common, anemia remains a recognized sequela among LGA babies in the immediate postnatal period.

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: 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 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: 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: Which of the following is the MOST significant physiological change that occurs during pregnancy?

Increase cardiac output. ***Increase cardiac output*** - **Cardiac output** significantly increases during pregnancy, starting in the first trimester and peaking in the third trimester. This is to meet the increased metabolic demands of the growing fetus, placenta, and maternal organs. - This increase is primarily due to an increase in **stroke volume** and **heart rate**, crucial for maintaining adequate uteroplacental perfusion. *Increase total protein* - While total blood volume increases during pregnancy, **plasma volume** increases disproportionately more than red blood cell mass, leading to hemodilution. - This hemodilution generally causes a *decrease* in total serum protein concentration and albumin levels, rather than an increase. *Increase residual volume* - **Residual volume** (the volume of air remaining in the lungs after maximal exhalation) actually *decreases* during pregnancy. - This decrease is due to the upward displacement of the diaphragm by the gravid uterus and an increase in inspiratory capacity, not an increase in residual volume. *Increase GFR* - **Glomerular filtration rate (GFR)** does significantly increase during pregnancy, often by 30-50% by the second trimester, in response to increased renal blood flow. - While important, the increase in GFR is a consequence of the systemic hemodynamic changes (including increased cardiac output) and is not as *overall* physiologically significant as the **fundamental increase in cardiac output** that drives many other physiological adaptations.

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.

Question 1

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 2

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 3

A baby born at 34 weeks gestation weighs 3kg. Which of the following conditions is this child most likely to develop in the immediate postnatal period?

Accepted Answer

Anemia

Answer

APH

Answer

Diabetes

Answer

None of the options

Question 4

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 5

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 6

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 7

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 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

Which of the following is the MOST significant physiological change that occurs during pregnancy?

Accepted Answer

Increase cardiac output

Answer

Increase total protein

Answer

Increase GFR

Answer

Increase residual volume

Question 10

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

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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