Maternal-Fetal Medicine Practice Questions

Q: What is the most common type of conjoint twin?

Thoracopagus. ***Thoracopagus*** - This type of conjoint twin, fused at the **thorax** and often sharing a heart and liver, is the **most common** variety, accounting for approximately **40%** of all cases. - The shared organs and complex anatomy often pose significant challenges for separation and survival. *Omphalopagus* - These twins are joined at the **abdomen** and typically share a liver, gastrointestinal tract, or other abdominal organs. - This is the second most common type, representing approximately **30-35%** of conjoint twins. *Craniopagus* - This rare form involves fusion at the **head**, often sharing parts of the skull, dura mater, or even brain tissue. - Due to the intricate neurological connections, craniopagus twins present exceptionally complex medical and ethical challenges, accounting for only **2-6%** of cases. *Rachipagus* - These twins are fused dorsally along the **spine** and typically share portions of the vertebral column and spinal cord. - This is an extremely rare type of conjoint twinning, representing less than **2%** of cases.

Q: A G2P1L1 female presents at 28 weeks of gestation with a 1:4 anti-D titre. What is the most appropriate management option?

MCA Doppler. ***MCA Doppler*** - The presence of anti-D antibodies in a pregnant woman indicates **Rh isoimmunization**, which can lead to **hemolytic disease of the fetus and newborn (HDFN)**. - Even though a titre of **1:4 is below the critical threshold** (usually 1:16 or 1:32), any detectable anti-D titre at 28 weeks warrants **fetal surveillance** to detect early signs of fetal anemia. - **Middle cerebral artery (MCA) Doppler** is the **non-invasive gold standard** for detecting fetal anemia by measuring peak systolic velocity (PSV), which increases in anemic fetuses due to hyperdynamic circulation. - Serial MCA Doppler monitoring allows timely intervention if fetal anemia develops, avoiding unnecessary invasive procedures. *Caesarean section* - This is a mode of delivery and would only be considered if there were severe **fetal compromise** or other obstetric indications after proper monitoring and management. - At 28 weeks gestation with a low anti-D titre, immediate delivery is **not indicated** and would result in significant prematurity risks. *Induction of labour* - Induction of labour is a delivery method that would only be planned at term or for specific indications like severe fetal compromise unresponsive to other interventions. - At **28 weeks gestation**, the focus should be on **monitoring and prolonging pregnancy** while ensuring fetal wellbeing, not on delivery. *Amniocentesis* - Historically used to assess **bilirubin levels (ΔOD450)** in amniotic fluid as an indirect measure of fetal hemolysis, but it is an **invasive procedure** with risks (miscarriage ~1%, infection, worsening sensitization). - **MCA Doppler has largely replaced amniocentesis** for initial and serial assessment of fetal anemia due to its non-invasive nature, high sensitivity, and ability to be repeated safely.

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: The 'T' sign is associated with which condition?

Monochorionic twin pregnancy. ***Monochorionic twin pregnancy*** - The **'T' sign** on ultrasound is highly suggestive of a **monochorionic twin pregnancy**, indicating shared placenta and a thin inter-twin membrane that meets the chorion at a sharp, T-shaped angle. - This sign identifies the absence of a chorionic plate extending into the inter-twin membrane, distinguishing it from thick-membraned dichorionic pregnancies. *Dichorionic twin pregnancy* - Dichorionic pregnancies typically exhibit the **'lambda' or 'twin peak' sign**, where the chorion extends into the inter-twin membrane, creating a triangular projection, not a 'T' shape. - This sign indicates two separate placentas (or fused but distinct placentas) and two chorions, leading to a thicker inter-twin membrane. *Normal singleton pregnancy* - A normal singleton pregnancy involves only one fetus, and therefore no inter-twin membrane or associated signs like the 'T' or 'lambda' sign are present. - The concept of chorionicity and amnionicity is specific to multiple gestations, particularly twin pregnancies. *Multiple gestation* - While a monochorionic twin pregnancy is a type of multiple gestation, the term "multiple gestation" is too broad and does not specifically identify the **'T' sign**. - Multiple gestation can be either monochorionic or dichorionic, and only monochorionic pregnancies are associated with the 'T' sign.

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 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: 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: What is meant by 'Battledore insertion of placenta'?

Umbilical cord attached to the margin of the placenta. ***Umbilical cord attached to the margin of the placenta*** - In a **Battledore insertion**, the **umbilical cord** inserts into the **edge** or **margin** of the placenta, rather than its center. - This unusual insertion resembles a **battledore**, a type of ancient racket or paddle with a handle at its edge (similar to those used in shuttlecock games). *Placenta attached to the margin of the membranes* - This description is more consistent with a **circumvallate placenta**, where the chorionic plate is smaller than the basal plate, leading to a rolled or folded margin of placental tissue covered by membranes, but it does not describe Battledore insertion. - In circumvallate placenta, the chorionic plate's edge rolls back and is surrounded by a ring of membranes, while Battledore refers specifically to the cord's insertion. *Placenta attached to the center of the uterus* - This simply indicates a **normal location** for the placenta within the uterine cavity and does not describe any abnormal insertion of the umbilical cord or specific characteristics of the placenta itself. - The placenta typically attaches to the uterine wall and can be central, fundal, or anterior/posterior, but this statement doesn't relate to the cord's insertion point. *Umbilical cord attached to the membranes* - This condition is known as **velamentous insertion of the umbilical cord**, where the cord blood vessels fan out within the amniotic membrane before reaching the placental tissue. - Velamentous insertion is a distinct anomaly from Battledore insertion and carries different risks, such as vasa previa and a higher risk of vessel compression or rupture.

Question 1

What is the most common type of conjoint twin?

Accepted Answer

Thoracopagus

Answer

Omphalopagus

Answer

Craniopagus

Answer

Rachipagus

Question 2

All are true about uteroplacental circulation except:

Accepted Answer

A mature placenta has 150 ml of blood in the villi system and 350 ml of blood in the intervillous space

Answer

The villi depend on the maternal blood for their nutrition

Answer

Blood in the intervillous space is completely replaced 3-4 times per minute

Answer

Intervillous blood flow at term is 500-600 ml per minute

Question 3

A G2P1L1 female presents at 28 weeks of gestation with a 1:4 anti-D titre. What is the most appropriate management option?

Accepted Answer

MCA Doppler

Answer

Caesarean section

Answer

Induction of labour

Answer

Amniocentesis

Question 4

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

Accepted Answer

Mid pregnancy

Answer

Early pregnancy

Answer

Nulliparous women

Answer

Puerperium

Question 5

The 'T' sign is associated with which condition?

Accepted Answer

Monochorionic twin pregnancy

Answer

Dichorionic twin pregnancy

Answer

Normal singleton pregnancy

Answer

Multiple gestation

Question 6

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 7

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 8

Which of the following actions should be avoided during the delivery of an Rh-negative mother?

Accepted Answer

Gently perform manual removal of placenta if necessary

Answer

Withhold ergometrine until after anterior shoulder delivery

Answer

Administer IV fluids

Answer

Apply fundal pressure during second stage of labor

Question 9

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

Accepted Answer

Methotrexate

Answer

Leuprolide

Answer

Mifepristone

Answer

Carboprost

Question 10

What is meant by 'Battledore insertion of placenta'?

Accepted Answer

Umbilical cord attached to the margin of the placenta

Answer

Placenta attached to the margin of the membranes

Answer

Placenta attached to the center of the uterus

Answer

Umbilical cord attached to the membranes

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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