Maternal-Fetal Medicine Practice Questions

Q: What is the most serious complication of maternal varicella infection during late pregnancy?

Severe neonatal varicella in the newborn.. ***Severe neonatal varicella in the newborn.*** - If a pregnant mother contracts **varicella** in the last 5 days before delivery or up to 2 days postpartum, the newborn is at risk for **severe, disseminated neonatal varicella**, which can be fatal. - This is because the mother does not have enough time to produce and transfer protective **antibodies** to the fetus before birth. - Mortality rates can reach 20-30% without treatment, making this the most serious complication of late pregnancy maternal varicella infection. *Affects the limbs more than the trunk.* - This statement refers to **congenital varicella syndrome**, which occurs with maternal infection in the first 20 weeks of pregnancy, not late pregnancy. - Congenital varicella syndrome characteristically presents with **skin scarring** in a dermatomal distribution, **limb hypoplasia**, and neurologic and ocular defects. *May cause pneumonitis.* - While **varicella pneumonitis** is a serious complication for the **mother** if infected during pregnancy, it is not a complication affecting the **newborn** due to late pregnancy maternal infection. - The question asks about complications of maternal infection during late pregnancy, and the most serious outcome for the **fetus/newborn** is severe neonatal varicella, not maternal pneumonitis. *Is commonly seen in a congenital form.* - **Congenital varicella syndrome** (the "congenital form") is rare and results from maternal infection during the **first 20 weeks of gestation**, not late pregnancy. - Late pregnancy infection leads to **neonatal varicella**, which is a distinct and often more severe acute entity compared to the chronic congenital syndrome.

Q: A 20-year-old woman has been brought to the casualty with a blood pressure of 70/40 mmHg, a pulse rate of 120/min, and a positive urine pregnancy test. She should be managed by:

Immediate laparotomy for ruptured ectopic pregnancy. ***Immediate laparotomy for ruptured ectopic pregnancy*** - The patient presents with classic signs of **hypovolemic shock (BP 70/40 mmHg, pulse 120/min)** in the setting of a positive pregnancy test, strongly indicating a **ruptured ectopic pregnancy**. - This is a **life-threatening emergency** requiring immediate surgical intervention to control bleeding and stabilize the patient. *Laparoscopy for diagnosis* - While laparoscopy can be used for diagnosis and treatment of ectopic pregnancy, it is **contraindicated in unstable patients** due to the increased risk associated with pneumoperitoneum and a longer operative time compared to laparotomy for an actively bleeding rupture. - In a hemodynamically unstable patient, the priority is rapid control of hemorrhage, which is often best achieved via **laparotomy**. *Resuscitation without surgical intervention* - Resuscitation is crucial, but it must be performed **concurrently with preparations for immediate surgical intervention**. - Resuscitation alone will not address the source of internal bleeding, which can lead to further deterioration and death. *Culdocentesis for fluid analysis* - **Culdocentesis** involves aspirating fluid from the pouch of Douglas to check for hemoperitoneum, but it is an **invasive procedure with limited diagnostic utility** in the age of ultrasound. - More importantly, it **delays definitive management** and offers no therapeutic benefit in an unstable patient with suspected ruptured ectopic pregnancy.

Q: A lady with 38 weeks of pregnancy is admitted due to a first episode of painless bleeding yesterday. On examination, her hemoglobin level is 10.5 g%, blood pressure is 124/78 mmHg, the uterus is relaxed, the head is unengaged and floating, and the fetal heart sounds are regular. Ultrasound confirms placenta previa. The next line of management is:

Caesarean section. ***Caesarean section*** - The combination of **painless vaginal bleeding** and an **unengaged, floating fetal head** in a 38-week pregnancy strongly suggests **placenta previa**. - **Placenta previa** is an absolute contraindication to vaginal delivery, necessitating a **Cesarean section** to prevent catastrophic hemorrhage. *Induction of labor* - **Vaginal examination** and, consequently, **induction of labor** are contraindicated in suspected or confirmed placenta previa due to the risk of severe hemorrhage. - Applying pressure to the cervix or performing an artificial rupture of membranes could directly traumatize the placental blood vessels. *Wait and watch* - While initial bleeding might temporarily stop, the risk of a more severe and sudden hemorrhage remains high with **placenta previa**, especially as labor progresses. - At 38 weeks, the fetus is term, and waiting carries unnecessary risks for both mother and fetus without clear benefit. *Blood transfusion* - Although the patient's hemoglobin is slightly low at 10.5 g%, the primary issue is the potential for acute, severe hemorrhage, not chronic anemia requiring immediate transfusion as the definitive management. - A **blood transfusion** might be indicated as supportive care if significant blood loss occurs, but it is not the primary management for placenta previa.

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.

Q: Which of the following measures is NOT effective in reducing perinatal HIV transmission?

Breastfeeding. ***Breastfeeding*** - Breastfeeding is **NOT effective in reducing perinatal HIV transmission** - in fact, it is a route of HIV transmission from mother to child. - In resource-rich settings, HIV-positive mothers are advised against breastfeeding because breast milk can transmit HIV, with transmission risk of 5-20% through prolonged breastfeeding. - While breastfeeding offers nutritional and immunological benefits, the risk of HIV transmission outweighs these benefits when safe alternatives (formula feeding) are available. - **This is the correct answer** to the question asking what is "NOT effective" in reducing transmission. *Delivery by elective cesarean section* - An **elective cesarean section** before the onset of labor or rupture of membranes significantly reduces the risk of vertical HIV transmission. - This method avoids the neonate's exposure to maternal blood and genital secretions during vaginal delivery. - Reduces transmission risk by approximately 50% when used alone, and even more when combined with ART. *Antiretroviral therapy to the neonate* - Administering **antiretroviral therapy (ART)** to the neonate, typically within hours of birth and continuing for 4-6 weeks, is crucial in preventing HIV infection. - This post-exposure prophylaxis can prevent establishment of HIV infection that may have been acquired during delivery or in utero. - Reduces transmission risk significantly, especially when maternal viral load is high. *Intrapartum antiretroviral therapy* - **Intrapartum antiretroviral therapy** involves administering ART to the mother during labor and delivery. - This helps reduce the maternal viral load at the time of birth, thereby minimizing the risk of HIV transmission to the neonate. - Part of the comprehensive approach to prevent mother-to-child transmission (PMTCT).

Q: Which of the following is not a feature of HELLP syndrome?

Eosinophilia. ***Eosinophilia*** - **Eosinophilia** (an increase in eosinophils) is not a characteristic feature of **HELLP syndrome**. - HELLP syndrome is defined by specific hematologic and liver abnormalities, not changes in eosinophil count. *Thrombocytopenia* - **Thrombocytopenia** (platelet count < 100,000/µL) is a defining feature of **HELLP syndrome**. - It results from increased platelet consumption due to microangiopathic hemolysis. *Raised liver enzyme* - **Raised liver enzymes** (AST or ALT ≥ 70 IU/L) are a crucial diagnostic criterion for **HELLP syndrome**, indicating hepatocellular injury. - This elevation reflects liver damage and is often associated with epigastric or right upper quadrant pain. *Hemolytic anemia* - **Hemolytic anemia** (evidenced by an abnormal peripheral blood smear, elevated bilirubin, or low haptoglobin) is another key component of **HELLP syndrome**. - This involves the destruction of red blood cells, leading to anemia and often contributing to the elevated liver enzymes and thrombocytopenia.

Q: Which of the following congenital conditions is most commonly associated with preterm delivery?

Anencephaly. ***Anencephaly*** - This condition is most commonly associated with **polyhydramnios**, an excess of **amniotic fluid**, which can lead to **premature rupture of membranes** and **preterm delivery** - The polyhydramnios occurs due to **impaired fetal swallowing** resulting from the absent brain structures - Due to the **absence of a significant portion of the brain and skull**, fetuses with anencephaly are considered incompatible with life and approximately **50% of pregnancies with anencephaly result in preterm delivery** *Spina bifida* - While it is a **neural tube defect**, it typically does not directly cause **preterm labor or delivery** in the same manner as anencephaly - Most pregnancies with spina bifida proceed to term unless there are associated complications like **polyhydramnios** (which is less common than with anencephaly) - The primary concern with spina bifida is typically its neurological impact, not its direct link to **preterm birth** *Gastroschisis* - This is an **abdominal wall defect** where bowel herniates through a defect lateral to the umbilicus - While **over 50% of gastroschisis cases deliver preterm**, the association is **not as strong or consistent as with anencephaly** - Preterm delivery in gastroschisis may be due to **polyhydramnios, bowel complications**, or **elective early delivery** rather than spontaneous preterm labor *Congenital adrenal hyperplasia* - This is an **endocrine disorder** affecting the **adrenal glands' ability to produce certain hormones** - It does not typically lead to complications such as **polyhydramnios** or directly cause **preterm labor and delivery** - Pregnancies with CAH usually proceed to term without increased risk of preterm delivery

Q: Which of the following are individual indicators of fetal distress?

All of the options. ***All of the options*** - **Meconium staining** of the amniotic fluid, **late decelerations of fetal heart rate**, and a **decrease in fetal scalp blood pH** are all recognized individual indicators of fetal distress. - These signs individually or collectively suggest that the fetus is experiencing **hypoxia** or other adverse conditions. *Meconium staining* - Refers to the presence of **meconium** (the first stool of a newborn) in the **amniotic fluid**, which can indicate fetal stress leading to gasping and passage of meconium. - While concerning, it's not always indicative of severe hypoxia but warrants further assessment. - **Mechanism**: Fetal hypoxia → vagal stimulation → relaxation of anal sphincter → meconium passage. *Late deceleration of heart rate* - **Late decelerations** are symmetric drops in fetal heart rate that begin after the peak of the contraction and return to baseline after the contraction has ended. - They are associated with **uteroplacental insufficiency** and **fetal hypoxia**, reflecting inadequate oxygen delivery to the fetus. - **Significance**: Indicates fetal compromise requiring immediate evaluation and potential intervention. *Decrease in fetal scalp blood pH* - A **low fetal scalp blood pH** (typically below 7.20) indicates **fetal acidosis**, which is a direct sign of **fetal hypoxemia** and distress. - It suggests that the fetus is undergoing anaerobic metabolism due to insufficient oxygen supply. - **Clinical utility**: Provides objective biochemical evidence of fetal compromise when CTG is non-reassuring.

Q: Which condition is associated with a sinusoidal heart rate pattern?

Vasa previa. ***Vasa previa*** - A **sinusoidal heart rate pattern** is a sign of severe **fetal anemia**, often caused by **fetal hemorrhage**. - In vasa previa, unprotected fetal blood vessels course over the cervical os, making them vulnerable to rupture and leading to **fetal bleeding** and subsequent anemia. *Placenta previa* - This condition involves the **placenta covering the cervical os**, primarily causing **painless vaginal bleeding** in the mother. - The bleeding is **maternal blood**, not fetal blood, so it does not directly cause fetal anemia or a sinusoidal heart rate pattern. *Battledore placenta* - In a battledore placenta, the **umbilical cord is inserted marginally** into the placental disk, rather than centrally. - This anatomical variation is generally a benign finding and is not directly associated with fetal hemorrhage or a sinusoidal heart rate pattern. *Succenturiate placenta* - This involves **one or more accessory placental lobes** located separately from the main placental body. - The main concern is a retained lobe after delivery or vessels connecting the lobes, which can cause bleeding, but it is not specifically linked to a sinusoidal heart rate pattern.

Q: In twin pregnancies, what is the minimum percentage difference in size that indicates significant discordance?

25% with the larger twin as index. ***25% with the larger twin as index*** - **Discordant growth** in twin pregnancies is clinically defined as a **25% or greater difference in estimated fetal weight**, calculated using the larger twin as the reference. - This threshold helps predict adverse outcomes related to **unequal placental sharing** or other growth restrictions. *15% with the larger twin as index* - A 15% difference in estimated fetal weight is generally considered **within the normal range** and does not typically indicate significant discordance warranting intervention. - While it represents a difference, it may not be substantial enough to result in increased fetal morbidity or mortality. *15% with the smaller twin as index* - Using the smaller twin as the index for comparison at 15% would likely **overestimate the prevalence of discordance**, as smaller twins naturally contribute to a larger percentage difference when used as the denominator. - This method is not the standard clinical practice for defining significant twin growth discordance. *25% with the smaller twin as index* - Similar to using the smaller twin as the index at 15%, calculating a 25% difference based on the smaller twin would lead to a **misrepresentation of significant discordance**. - The standard definition specifies using the **larger twin's estimated weight** as the denominator for percentage calculation.

Question 1

What is the most serious complication of maternal varicella infection during late pregnancy?

Accepted Answer

Severe neonatal varicella in the newborn.

Answer

Affects the limbs more than the trunk.

Answer

May cause pneumonitis.

Answer

Is commonly seen in a congenital form.

Question 2

A 20-year-old woman has been brought to the casualty with a blood pressure of 70/40 mmHg, a pulse rate of 120/min, and a positive urine pregnancy test. She should be managed by:

Accepted Answer

Immediate laparotomy for ruptured ectopic pregnancy

Answer

Laparoscopy for diagnosis

Answer

Resuscitation without surgical intervention

Answer

Culdocentesis for fluid analysis

Question 3

A lady with 38 weeks of pregnancy is admitted due to a first episode of painless bleeding yesterday. On examination, her hemoglobin level is 10.5 g%, blood pressure is 124/78 mmHg, the uterus is relaxed, the head is unengaged and floating, and the fetal heart sounds are regular. Ultrasound confirms placenta previa. The next line of management is:

Accepted Answer

Caesarean section

Answer

Induction of labor

Answer

Wait and watch

Answer

Blood transfusion

Question 4

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

Question 5

Which of the following measures is NOT effective in reducing perinatal HIV transmission?

Accepted Answer

Breastfeeding

Answer

Delivery by elective cesarean section

Answer

Antiretroviral therapy to the neonate

Answer

Intrapartum antiretroviral therapy

Question 6

Which of the following is not a feature of HELLP syndrome?

Accepted Answer

Eosinophilia

Answer

Raised liver enzyme

Answer

Hemolytic anemia

Answer

Thrombocytopenia

Question 7

Which of the following congenital conditions is most commonly associated with preterm delivery?

Accepted Answer

Anencephaly

Answer

Spina bifida

Answer

Congenital adrenal hyperplasia

Answer

Gastroschisis

Question 8

Which of the following are individual indicators of fetal distress?

Accepted Answer

All of the options

Answer

Meconium staining

Answer

Late deceleration of heart rate

Answer

Decrease in fetal scalp blood pH

Question 9

Which condition is associated with a sinusoidal heart rate pattern?

Accepted Answer

Vasa previa

Answer

Placenta previa

Answer

Battledore placenta

Answer

Succenturiate placenta

Question 10

In twin pregnancies, what is the minimum percentage difference in size that indicates significant discordance?

Accepted Answer

25% with the larger twin as index

Answer

15% with the smaller twin as index

Answer

25% with the smaller twin as index

Answer

15% with the larger twin as index

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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