Maternal-Fetal Medicine Practice Questions

Q: A 28-year-old primigravida with 32 weeks of gestation presents with profuse vaginal discharge since yesterday. She was advised USG, which showed a single live intrauterine gestational sac with FL and AC corresponding to the weeks of gestation and AFI as adequate. What is the diagnosis?

Normal vaginal discharge. ***Normal vaginal discharge*** - Profuse vaginal discharge is a common and **physiological occurrence** in pregnancy due to increased estrogen levels and blood flow to the vagina. - The ultrasound findings of **adequate amniotic fluid index (AFI)** rule out rupture of membranes, and no other symptoms of infection are reported. *Preterm Premature Rupture of Membranes (PPROM)* - PPROM would present with a significant reduction in the **amniotic fluid index (AFI)** on ultrasound, which is noted as adequate in this case. - The discharge in PPROM is typically **amniotic fluid**, which is clear and watery, unlike mere profuse vaginal discharge. *Trichomoniasis* - This infection typically causes a **frothy, greenish-yellow discharge** with a foul odor, along with vulvar itching and irritation. - These characteristic symptoms are not mentioned in the patient's presentation. *Candidiasis* - Vaginal candidiasis usually presents with a **thick, white, cottage cheese-like discharge** accompanied by intense itching and burning. - The patient's description of discharge is simply "profuse," without these specific characteristics.

Q: Most common antigen involved in erythroblastosis fetalis is:

D antigen in Rh group. ***D antigen in Rh group*** - The **D antigen** is the most immunogenic of the Rh antigens and is responsible for the vast majority of cases of **erythroblastosis fetalis** (hemolytic disease of the fetus and newborn). - When an **Rh-negative mother** is exposed to Rh-positive fetal blood (usually during previous pregnancies or transfusions), she can form antibodies against the D antigen, which can then cross the placenta in subsequent pregnancies and attack Rh-positive fetal red blood cells. *C antigen in Rh group* - While the **C antigen** is part of the Rh blood group system, antibodies to it are much less common and typically cause less severe hemolytic disease compared to anti-D antibodies. - The C antigen is less immunogenic than the D antigen, meaning it is less likely to provoke an immune response in an Rh-negative individual. *E antigen in Rh group* - Similar to the C antigen, the **E antigen** is another Rh antigen, but antibodies against it (anti-E) are also less frequently implicated in severe erythroblastosis fetalis than anti-D. - Antibodies to E can cause hemolytic disease, but their clinical significance is usually milder than that of anti-D. *Duffy antigen* - The **Duffy antigen system** is separate from the Rh system and is known for its role in resistance to certain malarial parasites (e.g., *Plasmodium vivax*). - Although antibodies to Duffy antigens (anti-Fya, anti-Fyb) can cause **hemolytic disease of the fetus/newborn**, they are a far less common cause of erythroblastosis fetalis than antibodies to the Rh D antigen.

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 of the following statements is true regarding placental site trophoblastic disease?

It secretes human placental lactogen. ***It secretes human placental lactogen*** - Placental site trophoblastic tumor (PSTT) characteristically consists of intermediate trophoblasts which secrete **human placental lactogen (hPL)**. - Unlike choriocarcinoma, PSTT secretes relatively low levels of **human chorionic gonadotropin (hCG)**. *Has a highly malignant potential* - PSTT generally has a **good prognosis** if the disease is confined to the uterus, with a survival rate of over 95%. - It has a low metastatic potential compared to choriocarcinoma, with metastases occurring in only about 15% of cases. *Mainly contains syncytiotrophoblasts* - PSTT is composed predominantly of **intermediate trophoblasts** that infiltrate the myometrium, rather than syncytiotrophoblasts or cytotrophoblasts. - The distinctive feature is the proliferation of these intermediate trophoblasts at the implantation site. *The treatment of choice is hysterectomy followed by chemotherapy* - **Hysterectomy** is generally the primary treatment for PSTT confined to the uterus, and it often cures the disease. - **Chemotherapy** is usually reserved for metastatic or recurrent disease, or in cases of extensive local invasion, and is not a routine follow-up after an uncomplicated hysterectomy.

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: IgM appears in fetus at what gestational age -

20 weeks. ***20 weeks*** - The fetal immune system begins to develop around **20 weeks of gestation**, at which point the fetus starts producing its own **IgM antibodies**. - **IgM** is the first antibody isotype produced by the developing fetal **B lymphocytes** and is important for early immune responses. *10 weeks* - While some components of the immune system may start to differentiate earlier, **IgM production** at a functional level is not yet established at **10 weeks of gestation**. - At this early stage, the fetal immune system is still primarily in its **developmental phase**, with major organogenesis occurring. *30 weeks* - By **30 weeks**, the fetus has already been producing IgM for several weeks, and the immune system is more mature, capable of a more robust **antibody response**. - While **IgG** levels are significantly increasing due to maternal transfer at this stage, **IgM production** began earlier. *at birth* - At birth, a neonate has circulating **IgM antibodies**, which are indicative of prior fetal immune activation and are measurable in umbilical cord blood. - However, the initial production of **fetal IgM** occurs much earlier in gestation, not at the time of birth.

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.

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 a potential risk for pregnant women who undertake long journeys with prolonged sitting?

Deep vein thrombosis. ***Deep vein thrombosis*** - **Pregnancy** is a **hypercoagulable state** due to increased levels of clotting factors (fibrinogen, factors VII, VIII, X) and decreased protein S activity. - **Prolonged sitting** during long journeys causes **venous stasis** in the lower extremities, which is a key component of **Virchow's triad** for thrombosis (stasis, hypercoagulability, endothelial injury). - **DVT** is the **direct and most specific pathological consequence** of prolonged immobilization during travel in pregnancy. - The risk of **VTE in pregnancy** is **4-5 times higher** than in non-pregnant women, with travel-related DVT being a recognized complication. *Venous thromboembolism* - VTE is an **umbrella term** that encompasses both **DVT and pulmonary embolism**. - While technically correct as a broader category, DVT is the **more specific and direct answer** to what prolonged sitting causes. - In medical education and clinical practice, identifying the **specific pathology** (DVT) is more appropriate than using the general category (VTE). *Pulmonary embolism* - PE is a **complication** of DVT, occurring when a thrombus dislodges and embolizes to the pulmonary circulation. - PE is a **secondary consequence**, not the **primary risk** from prolonged sitting itself. - The direct mechanism of prolonged sitting → venous stasis → **DVT formation** → potential embolization to lungs. *Leg swelling* - **Leg swelling** (edema) is a **symptom**, not a pathological diagnosis. - While leg edema can indicate DVT, it's also common in normal pregnancy due to increased venous pressure and fluid retention. - The question asks for a **risk** (pathological condition), not a symptom.

Question 1

A 28-year-old primigravida with 32 weeks of gestation presents with profuse vaginal discharge since yesterday. She was advised USG, which showed a single live intrauterine gestational sac with FL and AC corresponding to the weeks of gestation and AFI as adequate. What is the diagnosis?

Accepted Answer

Normal vaginal discharge

Answer

Candidiasis

Answer

Trichomoniasis

Answer

Preterm Premature Rupture of Membranes (PPROM)

Question 2

Most common antigen involved in erythroblastosis fetalis is:

Accepted Answer

D antigen in Rh group

Answer

C antigen in Rh group

Answer

E antigen in Rh group

Answer

Duffy antigen

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 of the following statements is true regarding placental site trophoblastic disease?

Accepted Answer

It secretes human placental lactogen

Answer

Has a highly malignant potential

Answer

Mainly contains syncytiotrophoblasts

Answer

The treatment of choice is hysterectomy followed by chemotherapy

Question 5

Which of the following is not associated with maternal age?

Accepted Answer

Post maturity

Answer

Preterm labour

Answer

Aneuploidy

Answer

Hydatidiform mole

Question 6

IgM appears in fetus at what gestational age -

Accepted Answer

20 weeks

Answer

10 weeks

Answer

30 weeks

Answer

at birth

Question 7

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

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 a potential risk for pregnant women who undertake long journeys with prolonged sitting?

Accepted Answer

Deep vein thrombosis

Answer

Venous thromboembolism

Answer

Pulmonary embolism

Answer

Leg swelling

Question 10

What is the management of eclampsia at 34 weeks of pregnancy?

Accepted Answer

Administer antihypertensives, anticonvulsants, and consider termination of pregnancy.

Answer

Continue convulsions and wait for 37 weeks to complete.

Answer

Wait for spontaneous labor.

Answer

Continue blood pressure management.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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