Maternal-Fetal Medicine Practice Questions

Q: In cases where threatened abortion is associated with ongoing placental insufficiency, what is the most likely fetal complication?

Intrauterine growth restriction (IUGR). ***Intrauterine growth restriction (IUGR)*** - **Placental insufficiency** is the leading cause of **IUGR**, as the placenta fails to deliver adequate oxygen and nutrients to the developing fetus - In threatened abortion associated with ongoing placental insufficiency, the chronic nature of reduced placental function directly impairs fetal growth - IUGR is characterized by fetal weight below the 10th percentile for gestational age and is the most predictable complication of sustained placental dysfunction - This represents a direct cause-and-effect relationship: inadequate placental function → reduced fetal nutrition → growth restriction *Fetal malformation* - Congenital malformations are primarily caused by **genetic abnormalities**, **teratogenic exposures**, or **early developmental errors** during organogenesis - Placental insufficiency does not cause structural malformations, though it may affect fetal growth and development - Malformations would typically be established early in pregnancy, independent of placental function *Preterm labor* - While placental insufficiency can be associated with preterm labor in some cases, this is not the **most likely** or most direct fetal complication - Preterm labor is a maternal-fetal process influenced by multiple factors including infection, cervical insufficiency, and uterine abnormalities - IUGR is a more consistent and direct consequence of chronic placental insufficiency *None of the options* - This is incorrect as **IUGR** is the established and most likely fetal complication when placental insufficiency is ongoing - The direct pathophysiology of placental insufficiency leading to IUGR is well-documented in obstetric literature

Q: Which sign is seen in ultrasound for monochorionic diamniotic twins?

T sign. ***T sign*** - The **T sign** is visualized on ultrasound when the inter-twin membrane inserts perpendicularly onto the chorionic plate, forming a "T" shape. - This specific finding indicates a **monochorionic twin gestation**, meaning they share a single chorion. *Lambda sign* - The **lambda (or twin peak) sign** is seen in dichorionic twin pregnancies, where the chorion extends into the base of the inter-twin membrane, forming a triangular projection. - This sign signifies the presence of **two separate chorions**, indicating a lower risk compared to monochorionic pregnancies. *Twin peak sign* - The **twin peak sign** is synonymous with the lambda sign and indicates a **dichorionic-diamniotic** twin pregnancy. - It results from the extension of placental tissue into the base of the inter-twin membrane, confirming two separate chorions. *Membrane thickness >2mm* - A **thick inter-twin membrane (>2mm)** is typically associated with **dichorionic-diamniotic** pregnancies due to the presence of two separate chorions and amnions. - In monochorionic-diamniotic pregnancies, the membrane is usually **thin** because it only consists of two amniotic layers.

Q: What is the earliest and most conclusive sign of intrauterine fetal death?

Spalding sign. ***Correct: Spalding sign*** - Spalding sign refers to the **overlapping of fetal skull bones** at the sutures, seen on radiological imaging (X-ray or ultrasound). - This occurs due to **liquefaction of the brain tissue** and loss of intracranial support after fetal death. - It is considered the **earliest conclusive radiological sign** of intrauterine fetal death, typically appearing **3-7 days** after fetal demise. - This sign is **highly specific** for fetal death and is widely recognized in obstetric practice. *Incorrect: Intrafetal gas in areas of the great vessels and heart* - Also known as **Robert's sign**, this represents gas formation within the fetal cardiovascular system due to decomposition. - While this is a **definitive sign** of fetal death, it is a **late finding** that typically appears **2-3 weeks after fetal demise**. - It requires significant bacterial decomposition and gas production, making it **not the earliest sign**. *Incorrect: Crowding of ribs* - This sign indicates **collapse of the fetal thoracic cage** due to maceration and loss of soft tissue support. - It is a **late manifestation** of fetal death and appears after more extensive decomposition. - This sign is **less specific** compared to Spalding sign. *Incorrect: Hyperflexion of spine* - **Hyperflexion of the fetal spine** results from loss of muscular tone and ligamentous support after death. - This is also a **late finding** associated with advanced maceration. - It is **not as early or specific** as Spalding sign for diagnosing intrauterine fetal death.

Q: Which of the following interventions has the STRONGEST evidence for reducing the risk of preeclampsia in high-risk pregnant women?

Low-dose aspirin (75-150 mg daily). ***Low-dose aspirin (75-150 mg daily)*** - **Low-dose aspirin** started before 16 weeks of gestation is the **only intervention with robust evidence** for reducing preeclampsia risk in high-risk women (ACOG, WHO, USPSTF recommendations). - Meta-analyses show **17-25% relative risk reduction** in preeclampsia when started early in pregnancy. - Recommended for women with history of preeclampsia, chronic hypertension, diabetes, kidney disease, or multifetal gestation. - Acts by **improving placental perfusion** and reducing thromboxane-mediated vasoconstriction. *Calcium supplementation (1.5-2g daily)* - **Calcium supplementation** shows benefit in **populations with low dietary calcium intake** (typically <600 mg/day). - Less effective in populations with adequate baseline calcium intake (most developed countries). - **WHO recommends** calcium for women in low-calcium settings but **not as first-line** in general high-risk populations. *Smoking cessation* - **Essential for healthy pregnancy** and reduces risks of placental abruption, preterm birth, and IUGR. - While smoking is associated with adverse outcomes, **cessation has not been proven to directly prevent preeclampsia**. - Some studies paradoxically show lower preeclampsia rates in smokers (confounded by lower PlGF levels), but smoking increases overall maternal-fetal morbidity. *Regular blood pressure monitoring* - **Critical for early detection** and management of hypertensive disorders but **does not prevent** their occurrence. - Allows timely intervention to **prevent progression to severe disease** and eclampsia. - Part of routine antenatal care but is a **surveillance measure, not a preventive intervention**.

Q: Which of the following is a possible cause for the 'lambda' or 'twin peak' sign seen on ultrasound examination of a twin pregnancy?

Dichorionic Diamniotic Twins. ***Dichorionic Diamniotic Twins*** - This type of twinning occurs from two separate fertilization events, resulting in **two placentas** and **two amniotic sacs**. - On ultrasound, this would be represented by separate amniotic membranes and a thick, often triangular, inter-twin membrane (the **'lambda' or 'twin peak' sign**), indicating separate chorions. *Monochorionic Monoamniotic Twins* - These twins share **one placenta** and **one amniotic sac**, meaning there is no separating membrane between them. - This high-risk pregnancy is characterized by a lack of an inter-twin membrane on ultrasound. *Monochorionic Diamniotic Twins* - These twins share **one placenta** but have **two separate amniotic sacs**. - On ultrasound, a thin inter-twin membrane is visible, but this membrane does not contain chorionic tissue (it's often described as a **'T-sign'** where the membrane meets the chorion). *Conjoint Twins* - Conjoined twins are a rare form of monochorionic monoamniotic twins where the embryos **fail to completely separate**. - The ultrasound finding would show shared body parts, not simply specific membrane characteristics.

Q: What is the first-line drug of choice for managing seizures in eclampsia?

Magnesium Sulphate. ***Magnesium Sulphate*** - **Magnesium sulphate** is the **first-line drug of choice** for both the prevention and treatment of seizures in **eclampsia** due to its superior efficacy. - It acts as a **central nervous system depressant** and a **vasodilator**, reducing cerebral edema and improving cerebral perfusion. *Nifedipine* - **Nifedipine** is a **calcium channel blocker** used primarily to manage **hypertension**, especially in **preeclampsia**. - While it can lower blood pressure, it is **not indicated** as a first-line agent for directly treating or preventing **eclamptic seizures**. *Hydralazine* - **Hydralazine** is a **direct-acting vasodilator** used to treat **severe hypertension** in pregnancy, including cases of preeclampsia. - Its primary role is blood pressure control, and it is **not effective** in preventing or treating **eclamptic seizures**. *Labetalol* - **Labetalol** is a **beta-blocker** and **alpha-blocker** used for the management of **hypertension** in pregnancy. - Like other antihypertensives, it addresses blood pressure but **does not have a primary role** in seizure management for **eclampsia**.

Q: Least common type of twins is:

Conjoined twins. ***Conjoined twins*** - Conjoined twins are the **rarest form of twinning**, resulting from an incomplete separation of a monozygotic twin embryo. - They carry the **highest risks** and complications, including stillbirth and complex surgical separation challenges. *Diamniotic-dichorionic twins* - These are the **most common type of twins**, representing about 70-80% of all twin pregnancies, whether fraternal or identical. - Each twin has its **own amniotic sac and placenta**, leading to a relatively lower risk profile compared to monochorionic twins. *Diamniotic-monochorionic twins* - This type accounts for approximately 20-30% of all twin pregnancies and always involves **identical twins** sharing one placenta but having separate amniotic sacs. - They are at higher risk for complications like **twin-to-twin transfusion syndrome (TTTS)** due to shared placental circulation. *Monoamniotic-monochorionic twins* - This is a **rare form of identical twinning**, occurring in about 1% of monozygotic pregnancies, where twins share both the same placenta and the same amniotic sac. - The shared amniotic sac significantly increases the risk of **umbilical cord entanglement**, which can be life-threatening for both fetuses.

Q: Treatment of choice for a 28-week pregnant female with pain due to a 10 cm x 10 cm fibroid in the fundus is:

Observation and symptomatic treatment. ***Observation and symptomatic treatment*** - For a symptomatic fibroid in a **28-week pregnant woman**, conservative management with **analgesics** and rest is the primary approach to avoid harming the fetus. - Complications from fibroids during pregnancy, such as pain, often resolve with conservative care, and surgical intervention is generally reserved for severe, refractory cases. *Uterine artery embolization* - This procedure is **contraindicated in pregnancy** due to the risk of fetal compromise, including ischemia, miscarriage, or preterm labor. - It is typically used for non-pregnant women with symptomatic fibroids who wish to preserve fertility. *Laparoscopic myomectomy* - **Myomectomy during pregnancy** carries a high risk of significant bleeding, uterine contractions, and potential preterm labor or miscarriage. - While open myomectomy may be considered in rare, dire situations (e.g., torsion of a pedunculated fibroid), laparoscopic surgery is generally avoided due to technical difficulties and risks in a gravid uterus. *Abdominal hysterectomy* - **Hysterectomy** involves removal of the uterus and is a definitive treatment for fibroids, but it is **absolutely contraindicated in a pregnant woman** who desires to carry the pregnancy to term. - This procedure would result in the loss of the fetus and the ability to bear children.

Question 1

In cases where threatened abortion is associated with ongoing placental insufficiency, what is the most likely fetal complication?

Accepted Answer

Intrauterine growth restriction (IUGR)

Answer

Fetal malformation

Answer

Preterm labor

Answer

None of the options

Question 2

Which sign is seen in ultrasound for monochorionic diamniotic twins?

Accepted Answer

T sign

Answer

Lambda sign

Answer

Twin peak sign

Answer

Membrane thickness >2mm

Question 3

What is the earliest and most conclusive sign of intrauterine fetal death?

Accepted Answer

Spalding sign

Answer

Crowding of ribs

Answer

Hyperflexion of spine

Answer

Intrafetal gas in areas of the great vessels and heart

Question 4

Which of the following statements about HIV transmission in pregnancy is true?

Accepted Answer

With effective ART, the chance of transmission can be reduced to less than 1%.

Answer

Perinatal transmission of HIV is common.

Answer

Pregnancy increases the risk of acquiring HIV.

Answer

LSCS significantly increases the chances of HIV transmission.

Question 5

Open neural tube defects are best diagnosed by:

Accepted Answer

Detailed fetal ultrasound examination

Answer

Radiographic imaging techniques

Answer

Screening with maternal serum alpha-fetoprotein

Answer

Measurement of acetylcholinesterase in amniotic fluid

Question 6

Which of the following interventions has the STRONGEST evidence for reducing the risk of preeclampsia in high-risk pregnant women?

Accepted Answer

Low-dose aspirin (75-150 mg daily)

Answer

Smoking cessation

Answer

Calcium supplementation (1.5-2g daily)

Answer

Regular blood pressure monitoring

Question 7

Which of the following is a possible cause for the 'lambda' or 'twin peak' sign seen on ultrasound examination of a twin pregnancy?

Accepted Answer

Dichorionic Diamniotic Twins

Answer

Monochorionic Monoamniotic Twins

Answer

Monochorionic Diamniotic Twins

Answer

Conjoint Twins

Question 8

What is the first-line drug of choice for managing seizures in eclampsia?

Accepted Answer

Magnesium Sulphate

Answer

Nifedipine

Answer

Hydralazine

Answer

Labetalol

Question 9

Least common type of twins is:

Accepted Answer

Conjoined twins

Answer

Diamniotic-dichorionic twins

Answer

Diamniotic-monochorionic twins

Answer

Monoamniotic-monochorionic twins

Question 10

Treatment of choice for a 28-week pregnant female with pain due to a 10 cm x 10 cm fibroid in the fundus is:

Accepted Answer

Observation and symptomatic treatment

Answer

Uterine artery embolization

Answer

Laparoscopic myomectomy

Answer

Abdominal hysterectomy

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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