Maternal-Fetal Medicine Practice Questions

Q: Which of the following is not associated with maternal age?

Post maturity. ***Post maturity*** - **Post-maturity** (post-term pregnancy, >42 weeks) does NOT have a consistent or strong association with maternal age in current obstetric literature. - While some older studies suggested associations, modern evidence shows **no significant independent effect of maternal age** on post-term pregnancy rates. - Post-term pregnancy is more related to factors like **first pregnancy**, **prior post-term delivery**, and **fetal sex** (males more common). *Preterm labour* - **Preterm birth is strongly associated with maternal age**, particularly at both extremes: - **Teenage mothers** (<20 years): Increased risk due to biological immaturity and socioeconomic factors - **Advanced maternal age** (≥35 years): Increased risk due to higher rates of maternal complications (hypertension, diabetes) and placental dysfunction - This is well-established in obstetric literature and clinical guidelines. *Aneuploidy* - The risk of **aneuploidy**, particularly **Down syndrome (Trisomy 21)**, **increases dramatically with advancing maternal age**. - At age 35: ~1/350 risk; at age 40: ~1/100 risk; at age 45: ~1/30 risk - Due to age-related decline in oocyte quality causing meiotic errors during egg formation. *Hydatidiform mole* - **Gestational trophoblastic disease** (hydatidiform mole) is strongly associated with **extremes of maternal age**: - **Women >40 years**: 5-10 fold increased risk - **Teenagers**: 1.5-2 fold increased risk - Related to abnormal fertilization events more common at age extremes.

Q: Which of the following ovarian tumors is most prone to undergo torsion during pregnancy?

Dermoid cyst. ***Dermoid cyst*** - **Dermoid cysts**, or mature cystic teratomas, are the **most common ovarian tumors** to undergo torsion, especially during pregnancy due to their mobility and moderate size. - They are often **unilateral** and benign, containing various mature tissues such as hair, teeth, and sebaceous material. *Serous cystadenoma* - While common, **serous cystadenomas** are generally **less mobile** than dermoid cysts and thus have a lower propensity for torsion. - They are typically filled with **clear, watery fluid** and can grow to be quite large. *Mucinous cystadenoma* - **Mucinous cystadenomas** tend to be **larger** than dermoid cysts and are less prone to torsion due to their size and often fixed position within the pelvis. - They are filled with **thick, gelatinous mucin** and can reach massive sizes, sometimes filling the entire abdominal cavity. *Theca lutein cyst* - **Theca lutein cysts** are usually **bilateral** and occur with conditions like **gestational trophoblastic disease** or **ovarian hyperstimulation**. - While they can be large, their often bilateral nature and underlying pathological conditions make them **less likely to independently twist** as a primary event compared to a freely mobile dermoid cyst.

Q: What size of Hegar's dilator, when passed through the internal os, indicates cervical incompetence?

8 or more. ***8 or more*** - The passage of a **Hegar's dilator of size 8 mm or larger** through the internal os without resistance is a classic diagnostic criterion for **cervical incompetence** or insufficiency. - This finding suggests a **weakened cervix** that is unable to withstand the pressure of a growing pregnancy, leading to recurrent mid-trimester pregnancy losses or preterm births. *4* - A Hegar's dilator of size 4 mm is relatively small and can often pass through a normal, non-pregnant **cervical os** without indicating pathology. - This size would not be considered abnormal and does not signify **cervical incompetence**. *6* - While a Hegar's dilator of 6 mm is larger than 4 mm, it is still generally within the range that might pass through a normal cervix, especially in **multiparous women**, without definitively diagnosing incompetence. - The threshold for diagnosing **cervical incompetence** is typically set higher, at 8 mm or more. *10* - While the passage of a 10 mm Hegar's dilator would certainly indicate **cervical incompetence**, the diagnostic cutoff is typically considered to be **8 mm or more**. - Any dilator **equal to or greater than 8 mm** confirms the diagnosis, so 10 mm is not the *only* size indicating incompetence.

Q: Which drug is commonly used in the medical management of ectopic pregnancy?

Methotrexate. ***Correct: Methotrexate*** - **Methotrexate** is a **folic acid antagonist** that inhibits DNA synthesis and cell proliferation, making it effective in terminating early ectopic pregnancies by targeting rapidly dividing trophoblastic cells. - It is typically considered for **hemodynamically stable** patients with unruptured ectopic pregnancies, a beta-hCG level below a certain threshold (e.g., <5,000 mIU/mL), and no cardiac activity in the ectopic mass. - This is the **gold standard** for medical management of ectopic pregnancy meeting specific criteria. *Incorrect: Mifepristone* - **Mifepristone** is an **antiprogestin** primarily used for medical abortion of intrauterine pregnancies, causing detachment of the gestational sac and cervical ripening. - While it can be used in combination with misoprostol for medical abortion, it is **not the primary drug** for managing ectopic pregnancies. *Incorrect: Leuprolide* - **Leuprolide** is a **GnRH agonist** mainly used for conditions like endometriosis, uterine fibroids, and prostate cancer by suppressing ovarian or testicular hormone production. - It is **not used** in the direct medical management of ectopic pregnancy. *Incorrect: Carboprost* - **Carboprost** is a **prostaglandin F2-alpha analog** primarily used to treat **postpartum hemorrhage** by inducing strong uterine contractions. - It is **not indicated** for the treatment of ectopic pregnancy.

Q: In which part of the fallopian tube is there a high chance of rupture in a tubal pregnancy?

Isthmus. ***Isthmus*** - The **isthmus** is the narrowest and most muscular part of the fallopian tube. Due to its limited ability to stretch, an ectopic pregnancy here is highly prone to rupture **earlier** than in other segments (typically 6-8 weeks). - The **isthmic portion's** small lumen and thick muscular wall make rupture a rapid and common complication, often before significant fetal growth, giving it the **highest chance of rupture** when an ectopic pregnancy implants there. *Ampulla* - The **ampulla** is the most common site for ectopic pregnancies (approximately 70%) due to its wider lumen and being the usual site of fertilization. - However, rupture in the ampulla tends to occur **later** than in the isthmus (8-12 weeks) as it can accommodate the growing embryo for a longer period due to its greater distensibility. - While more ectopic pregnancies occur here in absolute numbers, each individual ampullary pregnancy has a **lower chance of rupture** compared to isthmic pregnancies. *Interstitial* - The **interstitial** (or cornual) part is the segment within the uterine wall, making it a rare site for ectopic pregnancies (2-4%). - Ruptures in the interstitial portion occur **latest** (12-16 weeks) but are often the most dangerous, leading to severe hemorrhage due to the surrounding vascularity of the uterus and proximity to uterine and ovarian arteries. *Fimbrial* - The **fimbrial** end is the portion closest to the ovary and is exceedingly rare for ectopic implantation. - Implantation near the fimbriae usually leads to an **"abdominal pregnancy"** if the embryo is extruded, or could result in early "tubal abortion" rather than a true rupture.

Q: Red degeneration of fibroid is seen in which of the following?

Mid pregnancy. ***Mid pregnancy*** - **Red degeneration**, or **carneous degeneration**, is most common during the **second and third trimesters of pregnancy** due to increased metabolic demands of the growing fibroid outstripping its blood supply. - The rapid growth leads to **ischemia**, hemorrhage, and necrosis within the fibroid, causing acute abdominal pain. *Early pregnancy* - While fibroids can grow in early pregnancy, **red degeneration** is less common as the uterine blood supply is generally still adequate to meet the fibroid's metabolic needs. - Other forms of degeneration, like **hyaline degeneration**, are more frequently observed in non-pregnant or early pregnant states. *Puerperium* - In the puerperium, fibroids typically undergo **regression** rather than degeneration, as the hormonal stimulation (estrogen and progesterone) that promoted their growth significantly decreases. - The uterus involutes rapidly, and fibroids often shrink. *Nulliparous women* - Nulliparous women can have fibroids and experience various forms of degeneration, but **red degeneration** specifically is rare outside of pregnancy. - Degeneration in nulliparous women is more commonly **hyaline** or **cystic** degeneration.

Q: What is the most common presenting feature of a complete mole?

Bleeding per vaginum. ***Bleeding per vaginum (Correct)*** - **Vaginal bleeding** in the first or early second trimester is the **most common presenting symptom** of a complete hydatidiform mole, occurring in approximately 80-90% of cases - This bleeding can vary in amount and color, often described as **prune juice-like** discharge with passage of grape-like vesicles in some cases - Typically presents between **6-16 weeks of gestation** as the most frequent initial clinical sign *Vomiting (Incorrect)* - While nausea and vomiting are common in normal pregnancies, this is **not the most common presenting feature** of a complete mole - Vomiting may occur but is less specific and typically occurs after or in conjunction with vaginal bleeding - When severe, it manifests as hyperemesis gravidarum (a separate entity) *Hyperemesis gravidarum (Incorrect)* - This condition, characterized by **severe, persistent nausea and vomiting**, is more prevalent in molar pregnancies due to **excessively high hCG levels** - Occurs in approximately **25-30% of complete moles**, making it a significant but not the most common presentation - It is a **consequence** of the molar pregnancy, often presenting **after** initial bleeding, and is not the most frequent first clinical sign *Amenorrhoea (Incorrect)* - **Amenorrhoea** (absence of menstruation) is a **universal symptom** of any pregnancy, including a molar pregnancy - While it indicates conception, it does **not differentiate** a molar pregnancy from a normal pregnancy or other causes of amenorrhoea - Therefore, it is not the most specific or common **presenting feature** that would lead to diagnosis of a molar pregnancy

Q: What is the best parameter for estimating fetal age by ultrasound in the third trimester?

BPD. ***BPD (Biparietal Diameter)*** - **Biparietal diameter (BPD)** is considered the **best single parameter** among the given options for estimating fetal age in the third trimester, though all parameters become less accurate with advancing gestation. - In the third trimester, BPD accuracy is approximately **±3-4 weeks**, which is why **first trimester dating (CRL) should always be used when available** as it is most accurate (±5-7 days). - BPD is measured at the level of the thalami and cavum septum pellucidum, from outer edge of the proximal skull to the inner edge of the distal skull. - **Note**: Multiple biometric parameters used together improve accuracy more than any single measurement in late pregnancy. *Femur length* - **Femur length (FL)** is highly accurate in the **second trimester** but becomes less reliable in the third trimester due to biological variation. - It can be affected by **skeletal dysplasias** and genetic factors, leading to inaccurate age estimation. - FL is better used for assessing proportionate growth rather than dating in late pregnancy. *Abdominal circumference* - **Abdominal circumference (AC)** is primarily used for assessing **fetal growth and estimating fetal weight**, not for gestational age determination. - It is highly variable and influenced by fetal nutritional status, growth restriction, or macrosomia, making it unreliable for dating. - AC is the **most sensitive parameter for detecting growth abnormalities** (IUGR or LGA). *Intraocular distance* - **Intraocular distance (IOD)** is not a standard biometric parameter for routine gestational age estimation. - It has limited clinical utility and is occasionally used for detecting specific **fetal anomalies** (hypertelorism/hypotelorism) rather than dating. - Standard biometric parameters (BPD, HC, AC, FL) are always preferred for gestational age assessment.

Q: What is the expected rate of turnover of amniotic fluid in a pregnant woman?

500 cc/h. ***500 cc/h*** - The **amniotic fluid** undergoes a rapid and continuous turnover, with approximately **500 cc/h** being exchanged through multiple pathways. - This dynamic process ensures the constant renewal of the fluid, maintaining its critical functions for fetal development and protection. *1L/hr* - A turnover rate of 1 liter per hour is **higher than the physiological range** for normal amniotic fluid dynamics. - Such a high rate would imply an **abnormal fluid exchange**, potentially leading to imbalances. *1500 cc/h* - This rate represents an **extremely high turnover**, significantly exceeding the typical physiological exchange. - Sustained rates this high are **not consistent with normal amniotic fluid physiology** and could indicate underlying pathology. *2L/h* - A turnover rate of 2 liters per hour is **dangerously high** and far beyond the normal capacity for amniotic fluid exchange. - Such a rapid turnover would be **detrimental to fetal well-being** and is not observed in healthy pregnancies.

Q: What is the recommended management for jaundice due to obstetric cholestasis in the third trimester?

Induction of labour at 38 weeks. ***Induction of labour at 38 weeks*** - **Obstetric cholestasis (Intrahepatic Cholestasis of Pregnancy)** is associated with increased risk of **stillbirth**, particularly beyond 37-38 weeks gestation. - Induction at **37-38 weeks** is recommended to balance reducing stillbirth risk while minimizing prematurity complications. - **Current practice**: Timing depends on **bile acid levels** - delivery at 37-38 weeks for bile acids >40 μmol/L, or 38-39 weeks for milder cases (19-39 μmol/L). - This option represents the standard management approach for most cases of obstetric cholestasis. *Induction of labour at 37 weeks* - Delivery at 37 weeks is also acceptable and increasingly preferred, particularly for **severe disease** (bile acids >40 μmol/L) or when there are additional risk factors. - Both 37 and 38 weeks are within the recommended window; the choice depends on **disease severity** and individual risk assessment. - This is not incorrect, but 38 weeks represents a slightly more conservative approach balancing risks. *Induction of labour at 42 weeks* - Waiting until 42 weeks significantly increases the risk of **intrauterine fetal death (IUFD)** in pregnancies complicated by obstetric cholestasis. - Prolonged exposure to **elevated bile acids** is toxic to the fetus and increases stillbirth risk, especially after 37-38 weeks. - This approach is **contraindicated** in obstetric cholestasis. *Wait for spontaneous labour* - Expectant management beyond 38 weeks is considered **unsafe** due to the unpredictable and progressive risk of **sudden intrauterine death**. - Active management with planned delivery at 37-38 weeks is the standard of care to prevent stillbirth. - Waiting for spontaneous labor exposes the fetus to unacceptable risks.

Question 1

Which of the following is not associated with maternal age?

Accepted Answer

Post maturity

Answer

Preterm labour

Answer

Aneuploidy

Answer

Hydatidiform mole

Question 2

Which of the following ovarian tumors is most prone to undergo torsion during pregnancy?

Accepted Answer

Dermoid cyst

Answer

Serous cystadenoma

Answer

Mucinous cystadenoma

Answer

Theca lutein cyst

Question 3

What size of Hegar's dilator, when passed through the internal os, indicates cervical incompetence?

Accepted Answer

8 or more

Answer

4

Answer

6

Answer

10

Question 4

Which drug is commonly used in the medical management of ectopic pregnancy?

Accepted Answer

Methotrexate

Answer

Leuprolide

Answer

Mifepristone

Answer

Carboprost

Question 5

In which part of the fallopian tube is there a high chance of rupture in a tubal pregnancy?

Accepted Answer

Isthmus

Answer

Interstitial

Answer

Fimbrial

Answer

Ampulla

Question 6

Red degeneration of fibroid is seen in which of the following?

Accepted Answer

Mid pregnancy

Answer

Early pregnancy

Answer

Nulliparous women

Answer

Puerperium

Question 7

What is the most common presenting feature of a complete mole?

Accepted Answer

Bleeding per vaginum

Answer

Vomiting

Answer

Hyperemesis gravidarum

Answer

Amenorrhoea

Question 8

What is the best parameter for estimating fetal age by ultrasound in the third trimester?

Accepted Answer

BPD

Answer

Abdominal circumference

Answer

Femur length

Answer

Intraocular distance

Question 9

What is the expected rate of turnover of amniotic fluid in a pregnant woman?

Accepted Answer

500 cc/h

Answer

1 L/h

Answer

1500 cc/h

Answer

2L/h

Question 10

What is the recommended management for jaundice due to obstetric cholestasis in the third trimester?

Accepted Answer

Induction of labour at 38 weeks

Answer

Induction of labour at 37 weeks

Answer

Induction of labour at 42 weeks

Answer

Wait for spontaneous labour

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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