Maternal-Fetal Medicine Practice Questions

Q: Which of the following statements regarding cholestasis in pregnancy is false?

Mild jaundice occurs in majority of patients. ***Mild jaundice occurs in majority of patients*** - This statement is **false** because while **pruritus** is a hallmark symptom of **intrahepatic cholestasis of pregnancy (ICP)**, **jaundice** is relatively uncommon, occurring in only **10-25%** of patients, typically those with more severe disease. - The primary clinical manifestation is intense itching, often without visible signs of jaundice. *Recurs in subsequent pregnancy* - **Cholestasis in pregnancy** has a **high recurrence rate**, estimated to be between **45% to 90%** in subsequent pregnancies. - This tendency for recurrence highlights a possible genetic predisposition or hormonal sensitivity. *Ursodeoxycholic acid relieves pruritus* - **Ursodeoxycholic acid (UDCA)** is the **first-line treatment** for cholestasis in pregnancy and is effective in improving biochemical markers and relieving **pruritus**. - It works by altering the bile acid composition, making them less toxic and facilitating their excretion. *Pruritus is the most common symptom of cholestasis in pregnancy* - **Pruritus** is indeed the **most common and prominent symptom** of ICP, occurring in virtually all patients. - Some patients may also experience **fatigue**, **nausea**, **dark urine**, **pale stools**, or **steatorrhea**, although these are less common. - It is also associated with fetal risks such as **preterm birth**, **stillbirth**, and **fetal distress**, which are important complications of the condition.

Q: Which of the following tests on amniotic fluid is most useful in distinguishing between open neural tube defects and ventral wall defects in a fetus?

Acetylcholinesterase. ***Acetylcholinesterase*** - **Acetylcholinesterase (AChE)** is highly specific to neural tissue and its presence in amniotic fluid, combined with elevated AFP, is highly indicative of an **open neural tube defect (NTD)**. - While AFP is elevated in both NTDs and ventral wall defects, **AChE** helps differentiate by confirming neural tissue exposure. *Carcinoembryonic antigen* - **Carcinoembryonic antigen (CEA)** is a tumor marker primarily used in the diagnosis and monitoring of certain cancers, particularly colorectal cancer. - It has no established role in the prenatal diagnosis or differentiation of neural tube defects or ventral wall defects. *Sphingomyelin* - **Sphingomyelin** is a component of pulmonary surfactant and is measured to assess fetal lung maturity, usually in conjunction with lecithin as the **L/S ratio**. - This test is not used for the diagnosis or differentiation of structural birth defects like neural tube defects or ventral wall defects. *Alpha-fetoprotein* - **Alpha-fetoprotein (AFP)** is elevated in maternal serum and amniotic fluid in both **open neural tube defects** and **ventral wall defects** (e.g., gastroschisis, omphalocele). - While useful for screening, **AFP alone cannot distinguish** between these two conditions, as it is non-specific for the type of open defect.

Q: In a macerated baby, the ideal sample for genetic analysis is obtained from:

Placental Tissue. ***Placental Tissue*** - **Placental tissue** (chorionic villi) is preferred for genetic analysis in macerated fetuses because it is less susceptible to **autolysis** and **bacterial contamination** compared to fetal tissues. - The placenta often retains viable cells with intact DNA even when fetal tissues have significantly degraded, making it a more reliable source for **karyotyping** or **molecular genetic studies**. *Clotted fetal blood* - **Clotted fetal blood** from a macerated fetus is generally unsuitable due to significant **cellular degradation** and **DNA fragmentation** caused by autolysis. - The quality of DNA extracted from such a sample would likely be poor, leading to unreliable or unsuccessful genetic testing. *Fibroblast from skin* - While fibroblasts can be cultured from skin, obtaining a viable biopsy from a **macerated fetus** is challenging due to extensive **tissue degradation** and the high risk of **bacterial contamination**. - Successful culture and growth of fibroblasts would be unlikely given the compromised state of the fetal tissue. *Fibroblast from Achilles tendon* - Similar to skin, obtaining viable fibroblasts from the **Achilles tendon** of a macerated fetus is difficult due to widespread **autolysis** and **tissue degeneration**. - The degradation of cells in macerated fetuses significantly reduces the chances of culturing viable cells needed for genetic analysis from any fetal tissue, including tendons.

Q: Which of the following procedures is not performed in a case of complete hydatidiform mole (CHM)?

Caesarean section. ***Caesarean section*** - Caesarean section is **NOT performed** for the management of complete hydatidiform mole (CHM). - The standard treatment for CHM is **suction evacuation (suction curettage)**, which is the procedure of choice for removing molar tissue from the uterus. - Caesarean section is a surgical procedure for **delivering a fetus**, not for evacuating gestational trophoblastic disease. - There is **no indication** for Caesarean section in CHM management, even in cases of large molar volume. *Abortion (Suction evacuation)* - **Suction evacuation/curettage** is the primary and definitive treatment for complete hydatidiform mole. - This procedure involves removing the abnormal trophoblastic tissue from the uterus under ultrasound guidance. - It is sometimes referred to as therapeutic abortion in the medical literature. - **Oxytocin infusion** is typically started after evacuation begins to minimize bleeding. *Blood transfusion* - CHM can present with **significant vaginal bleeding**, potentially leading to severe anemia. - **Blood transfusion** may be necessary to correct anemia and stabilize hemodynamic status. - Pre-operative **hemoglobin assessment** and blood grouping/cross-matching are routine in CHM management. *Urine microscopy and culture sensitivity* - While not a routine part of CHM management, this test **may be performed** if there are clinical signs of urinary tract infection. - Patients with CHM may have urinary symptoms due to uterine enlargement or other complications. - This is **not a standard procedure** for all CHM cases but may be indicated based on clinical presentation.

Q: Sonography of a term multigravida shows an amniotic fluid index of 3 cm. The fetus may have which condition?

Renal agenesis. ***Renal agenesis*** - An **Amniotic Fluid Index (AFI)** of 3 cm indicates **oligohydramnios**, which is a severely reduced amount of amniotic fluid. - **Fetal urine production** is a major source of amniotic fluid in the second half of pregnancy, and conditions like renal agenesis or severe renal obstruction prevent urine formation, leading to oligohydramnios. *Esophageal atresia* - This condition is associated with **polyhydramnios** (excess amniotic fluid) because the fetus cannot swallow the amniotic fluid. - Oligohydramnios is typically not seen with esophageal atresia. *Spina bifida* - **Neural tube defects** like spina bifida are not typically associated with oligohydramnios. - They are sometimes linked to **polyhydramnios** if there is impaired fetal swallowing due to brainstem involvement, or normal amniotic fluid levels. *Chorioangioma of the placenta* - A **chorioangioma** is a benign placental tumor that can rarely cause **polyhydramnios** due to increased blood flow to the tumor, leading to increased transudation of fluid. - It would not lead to **oligohydramnios**.

Q: Vasa previa in a term gestation is managed by __________.

Immediate LSCS. ***Immediate LSCS*** - **Vasa previa** is an obstetric complication where fetal blood vessels course unprotected within the membranes over the cervical os. - Due to the high risk of **fetal exsanguination** and mortality with membrane rupture, immediate and planned **Lower Segment Cesarean Section (LSCS)** is the safest management. *Rapid induction and delivery by forceps* - **Vaginal delivery**, even with rapid induction, is contraindicated in vasa previa due to the high risk of fetal blood vessel rupture when membranes fully rupture or during cervical dilation. - The use of **forceps** would further increase the risk of trauma to the unprotected fetal vessels. *Expectant management and vaginal delivery* - **Expectant management** until labor begins or membranes rupture carries an extremely high risk of fetal death due to hemorrhage. - **Vaginal delivery** is absolutely contraindicated because the pressure from the presenting part and the process of cervical dilation will inevitably lead to rupture of the unprotected fetal vessels. *Rapid induction and delivery by vacuum* - Similar to forceps, **vacuum extraction** increases the risk of trauma to the fetal vessels due to increased pressure on the presenting part during delivery. - **Rapid induction** still leaves the fetus vulnerable to vessel rupture during labor and vaginal delivery.

Q: Which of the following is NOT a characteristic of the recipient twin in a monochorionic twin gestation affected by twin-twin transfusion syndrome?

Hypovolemia. ***Hypovolemia*** - The recipient twin in twin-twin transfusion syndrome (TTTS) experiences **hypervolemia** due to excessive blood flow from the donor twin, not hypovolemia. - This increased blood volume leads to **polycythemia** and volume overload. - Hypovolemia is actually a characteristic of the **donor twin**, not the recipient. *Thrombosis* - The recipient twin has **polycythemia** and increased blood viscosity due to hypervolemia, which increases the risk of **thrombosis**. - This hyperviscosity can lead to **vascular occlusions** in various organs. *Polyhydramnios* - The recipient twin characteristically develops **polyhydramnios** (excessive amniotic fluid) due to increased urine output from hypervolemia. - This is one of the **classic ultrasound findings** in TTTS, with the recipient showing a large fluid-filled sac. *Heart failure* - The recipient twin's heart has to pump an increased volume of blood, leading to **cardiac overload** and hypertrophy. - This chronic workload can eventually result in **congestive heart failure** and hydrops fetalis.

Q: A 30-year-old primigravida at 36 weeks of pregnancy presents with a blood pressure of 160/110 mmHg, 3+ urinary albumin, and a platelet count of 80,000/mm3. What is the most appropriate management option?

Magnesium sulfate for seizure prophylaxis. ***Magnesium sulfate for seizure prophylaxis*** - This patient has **severe preeclampsia** (BP ≥160/110 mmHg, significant proteinuria, thrombocytopenia), making her at **high risk for eclamptic seizures**. - **Magnesium sulfate** is the **first-line treatment** and must be initiated immediately for **seizure prophylaxis** in severe preeclampsia. - According to **ACOG and RCOG guidelines**, magnesium sulfate should be started **before delivery** and is the most critical immediate intervention to prevent maternal mortality and morbidity. - While delivery is the definitive treatment for preeclampsia, magnesium sulfate must be administered first to stabilize the patient. *Urgent LSCS* - At **36 weeks with severe preeclampsia**, delivery is indicated within 24-48 hours, but **cesarean section is not automatically required**. - The **mode of delivery** depends on **obstetric factors** (cervical favorability, fetal presentation, previous cesarean, etc.), not the preeclampsia diagnosis itself. - With a platelet count of **80,000/mm³**, vaginal delivery is generally safe (platelets >50,000/mm³ are adequate for labor). - **Labor induction** would be appropriate first-line unless there are specific obstetric contraindications to vaginal delivery. *Labetalol for hypertension* - **Antihypertensive therapy** is important to prevent maternal stroke when BP is ≥160/110 mmHg. - However, **magnesium sulfate takes priority** as the immediate life-saving intervention for seizure prevention. - Labetalol would be administered concurrently but is not the single most appropriate answer. *Labour induction* - Labor induction is an appropriate method of delivery for severe preeclampsia at ≥34 weeks gestation. - However, **before proceeding with delivery**, the patient must be **stabilized with magnesium sulfate** and antihypertensives. - Induction would follow after initial stabilization with magnesium sulfate.

Q: A female with 6 weeks of amenorrhea presents with an ovarian cyst that requires surgical intervention. The optimal timing for surgery is:

Ovariotomy at second trimester. ***Ovariotomy at second trimester*** - The **second trimester (14-28 weeks)** is the optimal time for surgical management of ovarian cysts in pregnancy requiring intervention. - During this period, the risk of **miscarriage** is significantly reduced compared to the first trimester, as the placenta has taken over progesterone production. - Fetal organogenesis is complete, and the uterus size allows for adequate surgical access with minimal risk of injury. - Most functional cysts (corpus luteum) have resolved spontaneously by this time, so persistent cysts are more likely to be true neoplasms requiring removal. *Immediate ovariotomy* - Performing **immediate surgery** at 6 weeks of amenorrhea carries a high risk of **miscarriage** due to surgical stress and anesthesia effects. - At this early stage of pregnancy, the corpus luteum is essential for progesterone production, and its disruption could threaten pregnancy viability. - Surgery in the first trimester should be reserved only for acute complications like **torsion** or **rupture**. *Ovariotomy 24 hours after delivery* - Waiting until 24 hours after delivery would delay treatment unnecessarily for a cyst requiring intervention, potentially leading to complications like **torsion**, **rupture**, or **hemorrhage** during pregnancy. - If the cyst is large or suspicious, allowing it to persist throughout pregnancy increases maternal morbidity risk. - However, expectant management throughout pregnancy is appropriate for simple, asymptomatic cysts. *Ovariotomy with cesarean* - Performing **ovariotomy concurrently with Cesarean section** significantly increases operative time, blood loss, and risk of postpartum complications. - This approach is only justified if the cyst is causing obstruction of labor or has highly suspicious features for malignancy. - Routine combination of these procedures is not recommended for benign ovarian pathology.

Question 1

Which of the following statements regarding cholestasis in pregnancy is false?

Accepted Answer

Mild jaundice occurs in majority of patients

Answer

Ursodeoxycholic acid relieves pruritus

Answer

Recurs in subsequent pregnancy

Answer

Pruritus is the most common symptom of cholestasis in pregnancy

Question 2

Which of the following tests on amniotic fluid is most useful in distinguishing between open neural tube defects and ventral wall defects in a fetus?

Accepted Answer

Acetylcholinesterase

Answer

Carcinoembryonic antigen

Answer

Alpha-fetoprotein

Answer

Sphingomyelin

Question 3

In a macerated baby, the ideal sample for genetic analysis is obtained from:

Accepted Answer

Placental Tissue

Answer

Clotted fetal blood

Answer

Fibroblast from skin

Answer

Fibroblast from Achilles tendon

Question 4

Which of the following procedures is not performed in a case of complete hydatidiform mole (CHM)?

Accepted Answer

Caesarean section

Answer

Blood transfusion

Answer

Urine microscopy and culture sensitivity

Answer

Abortion

Question 5

Sonography of a term multigravida shows an amniotic fluid index of 3 cm. The fetus may have which condition?

Accepted Answer

Renal agenesis

Answer

Esophageal atresia

Answer

Spina bifida

Answer

Chorioangioma of the placenta

Question 6

Vasa previa in a term gestation is managed by __________.

Accepted Answer

Immediate LSCS

Answer

Rapid induction and delivery by forceps

Answer

Expectant management and vaginal delivery

Answer

Rapid induction and delivery by vacuum

Question 7

Which of the following is NOT a characteristic of the recipient twin in a monochorionic twin gestation affected by twin-twin transfusion syndrome?

Accepted Answer

Hypovolemia

Answer

Heart failure

Answer

Thrombosis

Answer

Polyhydramnios

Question 8

A 28-week pregnant female presents with fetal distress on examination, and the MCA Doppler study is as follows. What should be the next step in management?

Accepted Answer

Give steroid cover, monitor with Doppler and BPP, and plan delivery.

Answer

Immediate termination of pregnancy

Answer

Give steroid and take up for CS immediately

Answer

Go for normal vaginal delivery as baby is very small

Question 9

A 30-year-old primigravida at 36 weeks of pregnancy presents with a blood pressure of 160/110 mmHg, 3+ urinary albumin, and a platelet count of 80,000/mm3. What is the most appropriate management option?

Accepted Answer

Magnesium sulfate for seizure prophylaxis

Answer

Labetalol for hypertension

Answer

Labour induction

Answer

Urgent LSCS

Question 10

A female with 6 weeks of amenorrhea presents with an ovarian cyst that requires surgical intervention. The optimal timing for surgery is:

Accepted Answer

Ovariotomy at second trimester

Answer

Ovariotomy with cesarean

Answer

Ovariotomy 24 hours after delivery

Answer

Immediate ovariotomy

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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