Maternal-Fetal Medicine Practice Questions

Q: A hypertensive pregnant woman at 34 weeks presents with a history of abdominal pain, bleeding per vaginum, and loss of fetal movements. On examination, the uterus is contracted with increased uterine tone, and fetal heart sounds are absent. Which of the following is the most likely diagnosis?

Abruptio placenta. ***Abruptio placenta*** - The classic presentation of **abruptio placenta** includes **abdominal pain**, **vaginal bleeding**, **increased uterine tone**, and **loss of fetal movements** in a patient with **hypertension**. - **Hypertension** is a significant risk factor for abruptio placenta, and the absence of fetal heart sounds suggests **fetal demise**, which can occur due to severe abruption. *Polyhydramnios* - Characterized by an **excessive accumulation of amniotic fluid**, which leads to an abnormally large uterus. - It usually presents with **uterine distension** and shortness of breath, not abdominal pain, vaginal bleeding, or increased uterine tone. *Placenta previa* - Typically presents with **painless vaginal bleeding** in the second or third trimester. - The uterus is usually **soft and non-tender**, unlike the increased uterine tone seen in abruptio placenta. *Premature labour* - Defined by **regular uterine contractions** causing cervical change before 37 weeks of gestation. - While contractions cause abdominal pain, it does not typically present with significant **vaginal bleeding** or sustained **increased uterine tone** as described.

Q: Supine hypotension syndrome is a characteristic finding of which trimester?

3rd trimester of pregnancy. ***3rd trimester of pregnancy*** - **Supine hypotension syndrome** occurs when the gravid uterus in the supine position compresses the **inferior vena cava**, leading to decreased venous return and subsequent hypotension [1]. - This is most pronounced and symptomatic in the **third trimester** due to the significantly increased size and weight of the uterus and fetus [1]. *First trimester of pregnancy* - During the first trimester, the **uterus is still relatively small** and largely contained within the pelvis, making significant compression of the inferior vena cava unlikely. - Therefore, **supine hypotension syndrome is rare** at this stage. *2nd trimester of pregnancy* - While the uterus grows in the second trimester and begins to extend into the abdominal cavity, its size is generally **not large enough to cause severe inferior vena cava compression** leading to symptomatic supine hypotension. - The syndrome is less common and, if present, usually **milder** than in the third trimester [1]. *All trimesters equally* - This is incorrect because the physiological changes that cause supine hypotension syndrome, specifically the size and weight of the gravid uterus, **vary significantly across trimesters**. - The syndrome is dependent on significant uterine enlargement, which is not present in all trimesters equally [1].

Q: Most sensitive diagnostic test for ectopic pregnancy is which one?

Transvaginal USG. ***Transvaginal USG*** - **Transvaginal ultrasonography (TVS)** is considered the most sensitive diagnostic test because it can directly visualize the presence or absence of an intrauterine pregnancy and detect an ectopic gestational sac or mass. - It allows for early detection of an ectopic pregnancy, often even before symptoms become severe, by identifying findings like an **adnexal mass**, **free fluid in the cul-de-sac**, or an **empty uterus** in the presence of positive hCG. *Serial monitoring of beta HCG* - While serial monitoring of **beta-hCG** levels is a crucial component in the diagnosis of ectopic pregnancy, particularly for early pregnancy of unknown location (PUL), it is not the most sensitive single diagnostic test. - It helps in discerning between a normal intrauterine pregnancy, an ectopic pregnancy, or a miscarriage based on the **rate of hCG rise**, but it does not directly localize the pregnancy. *Culdocentesis* - **Culdocentesis** involves aspirating fluid from the pouch of Douglas to detect non-clotting blood, which suggests a ruptured ectopic pregnancy. - It is an invasive procedure and has significantly decreased in use due to the availability of highly sensitive imaging techniques like TVS; it primarily identifies rupture rather than diagnosing the intact ectopic pregnancy itself. *MRI* - **Magnetic Resonance Imaging (MRI)** can be used to diagnose ectopic pregnancy, especially in complex or unusual locations, but it is typically reserved for cases where ultrasound is inconclusive or technically difficult. - It is **more expensive** and less readily available than TVS, and its sensitivity for routine ectopic pregnancy diagnosis does not surpass that of a high-quality TVS.

Q: A pregnant lady complains of headaches, feeling of excessive tiredness, and drowsiness whenever she lies down in the supine position. Her symptoms are relieved on sitting up and while lying on her side. What is the most likely diagnosis?

Supine hypotensive syndrome. ***Supine hypotensive syndrome*** - This syndrome is characterized by **dizziness**, **lightheadedness**, and sometimes **syncope** when a pregnant woman lies in the supine position. - It occurs due to compression of the **inferior vena cava (IVC)** by the gravid uterus, leading to decreased venous return, reduced cardiac output, and subsequent **hypotension**. *IVC compression* - While **IVC compression** is the physiological mechanism causing supine hypotensive syndrome, it is not the diagnosis itself. - The compression leads to the constellation of symptoms defined as **supine hypotensive syndrome**. *Increased intra-abdominal pressure* - **Increased intra-abdominal pressure** can occur during pregnancy but is not directly responsible for the specific symptoms that resolve with position changes in this manner. - It relates more to discomfort, breathing difficulties, or gastroesophageal reflux rather than acute hypotensive symptoms upon lying supine. *Reduced blood supply to the placenta* - While **hypotension** can indeed lead to **reduced placental blood flow**, this is a *consequence* of the supine hypotensive syndrome, not the primary diagnosis explaining the mother's symptoms. - The mother's symptoms (headache, tiredness, drowsiness) stem from her own systemic hypoperfusion.

Q: All of the following are associated with breech presentation at normal full-term pregnancy, except:

Placenta accreta. ***Placenta accreta*** - **Placenta accreta** is a condition where the placenta abnormally adheres to the uterine wall, which is typically associated with previous uterine surgery (e.g., C-sections) and **placenta previa**, not breech presentation. - While both can increase risks in pregnancy, there is no direct causal link or strong association between **placenta accreta** and **breech presentation** in a full-term pregnancy. *Fetal malformation* - **Fetal malformations**, particularly those affecting neural tube development, neuromuscular control, or fetal head/neck flexibility, can lead to a reduced ability of the fetus to turn into a cephalic presentation. - Conditions like **hydrocephalus** or **anencephaly** can hinder the spontaneous version to a head-down position. *Uterine anomaly* - **Uterine anomalies** such as a **septate uterus**, **bicornuate uterus**, or **fibroids** can alter the shape of the uterine cavity, restricting fetal movement and preventing the fetus from assuming a cephalic presentation. - These structural abnormalities can physically limit the space available for the fetus to turn. *Cornual implantation of placenta* - **Cornual implantation** or **fundal implantation** of the placenta can reduce the available space in the lower uterine segment, making it difficult for the fetus to turn and maintain a cephalic presentation. - The placenta's position can exert pressure or create an unfavorable environment that encourages the fetus to remain in a breech position.

Q: On USG finding of cystic hygroma in a fetus is suggestive of:

Turner's syndrome. ***Turner's syndrome*** - **Cystic hygroma** is a significant fetal ultrasound marker most classically associated with **Turner's syndrome (45,X)**, due to lymphatic system abnormalities (failure of lymphatic channels to connect with the jugular vein). - Other findings in Turner's syndrome may include fetal hydrops, renal anomalies, and coarctation of the aorta. *Down's syndrome* - While **nuchal translucency** can be increased in Down's syndrome, a frank **cystic hygroma** is less specific and less commonly seen than in Turner's syndrome. - Other markers for Down's syndrome include **duodenal atresia**, **heart defects**, and **shortened long bones**. *Marfan's syndrome* - This is a **connective tissue disorder** not typically associated with cystic hygroma in utero. - Fetal manifestations are rare but can include significant **cardiac defects** like aortic root dilation. *Klinefelter's syndrome* - **Klinefelter's syndrome (47,XXY)** generally has subtle or no prenatal ultrasound findings. - **Cystic hygroma** is not a characteristic feature of this condition.

Q: Earliest detectable congenital malformation by ultrasound (USG) is

Anencephaly. ***Anencephaly*** - **Anencephaly** is a severe neural tube defect resulting in the absence of a major portion of the brain, skull, and scalp, which can be reliably visualized as early as **11-12 weeks of gestation** due to the absent cranial vault. - The lack of a normal fetal head pole and the presence of the **"frog-eye" appearance** on ultrasound are characteristic early findings. - It is considered the **earliest consistently detectable major congenital malformation** by ultrasound due to its obvious and unmistakable appearance. *Spina bifida* - **Spina bifida** (an open neural tube defect) is typically detectable later than anencephaly, often around **18-22 weeks of gestation**, as it involves a vertebral arch defect. - While it is a significant congenital malformation, its ultrasound signs, such as the **"lemon sign"** and **"banana sign"**, tend to become apparent as the fetal brain and spinal cord structures further develop. *Meningocoele* - A **meningocoele** is a less severe form of spina bifida where only the meninges protrude through an opening in the spine. - This malformation is generally detected in the **second trimester** (around 18-22 weeks) during detailed anomaly scans, as the sac might be small and difficult to visualize earlier. *Cystic hygroma* - A **cystic hygroma** is a lymphatic malformation, typically a multiloculated cystic mass, most commonly found in the neck region. - While it can be detected early in the **first trimester** (10-14 weeks) during nuchal translucency screening, it is not classified as a major structural malformation in the same category as neural tube defects. - **Anencephaly** is considered the earliest detectable **major congenital malformation** because it is more consistently and reliably visualized as an obvious structural defect compared to cystic hygroma, which may vary in size and detectability.

Q: What is the rate of uterine blood flow at term?

350-400 ml/min. ***350-400 ml/min*** - At term, the **uterine blood flow** significantly increases to meet the metabolic demands of the growing fetus and placenta. - This flow rate ensures adequate **oxygen and nutrient delivery** and waste removal for the uteroplacental unit. *50-75 ml/min* - This rate is characteristic of a **non-gravid uterus**, which has significantly lower metabolic needs. - It does not reflect the dramatic increase in blood supply required to sustain a full-term pregnancy. *150-200 ml/min* - This rate represents an increase from the non-gravid state but is still **insufficient for a term pregnancy**. - Uterine blood flow typically continues to rise progressively throughout gestation. *>600 ml/min* - While uterine blood flow is very high at term, exceeding 600 ml/min is generally an **overestimation of the average rate**. - The typical range for a normal term pregnancy is closer to 350-400 ml/min.

Q: Risk of recurrence of hydatidiform mole in future pregnancy is:

1-4%. ***1-4%*** - The risk of a **recurrent hydatidiform mole** in a subsequent pregnancy is generally cited to be between **1-2%**, with some sources extending it up to 4%. - This risk is significantly higher than that of the general population for a first mole (0.1%), but still relatively low. *8-10%* - This percentage represents a **significantly higher recurrence risk** than what is typically observed for hydatidiform moles. - Such a high risk would be more concerning for **persistent trophoblastic disease** or choriocarcinoma development after an initial mole, rather than for recurrence in a future pregnancy. *4-8%* - While higher than the typical 1-2%, a 4-8% recurrence risk is still considered **elevated** compared to the established data. - This range might be considered if there are **additional risk factors** or a history of multiple previous molar pregnancies, which are not specified in the question. *10-12%* - A 10-12% risk for recurrence of hydatidiform mole is **exceptionally high** and not consistent with current understanding. - Such a high figure would suggest almost certain recurrence, which is not the case for most patients.

Q: Anencephaly can be diagnosed by ultrasound (USG) at

14-18 weeks of gestation. ***14-18 weeks of gestation*** - **Anencephaly**, characterized by the absence of a major portion of the brain and skull, can be reliably diagnosed by **ultrasound (USG)** during this gestational period. - At this stage, the fetal head structures are sufficiently developed to clearly visualize the **absence of the cranium and cerebral hemispheres**. *10-12 weeks of gestation* - While some gross anomalies might be suspected, the developing fetal skull and brain are often **too small** for a definitive diagnosis of anencephaly. - The **ossification of the calvaria** (skull bones) is still incomplete, making it difficult to confidently identify its absence. *20-24 weeks of gestation* - Anencephaly would be clearly detectable by this stage, but it is **later than the optimal window** for early diagnosis and intervention, if desired. - Many screening programs aim for diagnosis before this period to allow for more options for parental decision-making. *24-28 weeks of gestation* - At this advanced stage, the diagnosis of anencephaly would be evident, but it represents a **significantly delayed diagnosis** given the availability of earlier screening methods. - The primary purpose of **antenatal screening** is to detect such severe congenital anomalies in the mid-trimester.

Question 1

A hypertensive pregnant woman at 34 weeks presents with a history of abdominal pain, bleeding per vaginum, and loss of fetal movements. On examination, the uterus is contracted with increased uterine tone, and fetal heart sounds are absent. Which of the following is the most likely diagnosis?

Accepted Answer

Abruptio placenta

Answer

Polyhydramnios

Answer

Premature labour

Answer

Placenta previa

Question 2

Supine hypotension syndrome is a characteristic finding of which trimester?

Accepted Answer

3rd trimester of pregnancy

Answer

First trimester of pregnancy

Answer

2nd trimester of pregnancy

Answer

All trimesters equally

Question 3

Most sensitive diagnostic test for ectopic pregnancy is which one?

Accepted Answer

Transvaginal USG

Answer

Serial monitoring of beta HCG

Answer

Culdocentesis

Answer

MRI

Question 4

A pregnant lady complains of headaches, feeling of excessive tiredness, and drowsiness whenever she lies down in the supine position. Her symptoms are relieved on sitting up and while lying on her side. What is the most likely diagnosis?

Accepted Answer

Supine hypotensive syndrome

Answer

IVC compression

Answer

Increased intra-abdominal pressure

Answer

Reduced blood supply to the placenta

Question 5

All of the following are associated with breech presentation at normal full-term pregnancy, except:

Accepted Answer

Placenta accreta

Answer

Fetal malformation

Answer

Uterine anomaly

Answer

Cornual implantation of placenta

Question 6

On USG finding of cystic hygroma in a fetus is suggestive of:

Accepted Answer

Turner's syndrome

Answer

Down's syndrome

Answer

Marfan's syndrome

Answer

Klinefelter's syndrome

Question 7

Earliest detectable congenital malformation by ultrasound (USG) is

Accepted Answer

Anencephaly

Answer

Spina bifida

Answer

Meningocoele

Answer

Cystic hygroma

Question 8

What is the rate of uterine blood flow at term?

Accepted Answer

350-400 ml/min

Answer

>600 ml/min

Answer

50-75 ml/min

Answer

150-200 ml/min

Question 9

Risk of recurrence of hydatidiform mole in future pregnancy is:

Accepted Answer

1-4%

Answer

8-10%

Answer

4-8%

Answer

10-12%

Question 10

Anencephaly can be diagnosed by ultrasound (USG) at

Accepted Answer

14-18 weeks of gestation

Answer

20-24 weeks of gestation

Answer

24-28 weeks of gestation

Answer

10-12 weeks of gestation

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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