Maternal-Fetal Medicine Practice Questions

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.

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: A pregnant woman developed idiopathic cholestatic jaundice. Which clinical feature is most characteristically associated with this presentation?

Intense itching is commonly observed.. ***Intense itching is commonly observed.*** - **Pruritus**, or intense itching, is the most common and often the earliest symptom of **intrahepatic cholestasis of pregnancy (ICP)**, the idiopathic cholestatic jaundice of pregnancy. - The itching in ICP is often generalized, worse at night, and without a skin rash, and it is thought to be caused by the accumulation of **bile acids** in the skin. *SGOT, SGPT levels typically remain below 60 IU.* - While liver transaminases (AST/SGOT and ALT/SGPT) can be mildly elevated in ICP, they generally **do not remain below 60 IU**; levels typically range from slightly elevated to several hundred IU/L. - Significant elevations (e.g., >800 IU/L) would point towards other causes of liver injury, such as viral hepatitis. *Markedly elevated levels of alkaline phosphatase are observed.* - **Alkaline phosphatase (ALP)** is commonly elevated in pregnancy due to its production by the placenta, making it a less specific marker for cholestasis in this context. - While ALP can be elevated in ICP, a "markedly elevated" level would typically be 2-4 times the upper limit of normal, and even higher values can be due to placental isoenzymes, not necessarily reflecting the severity of cholestasis alone. *Serum bilirubin levels typically remain below 5mg/dl.* - Serum bilirubin levels can be elevated in ICP, but they **do not always remain below 5 mg/dL**; while often within this range (typically less than 6 mg/dL), higher levels can occur in more severe cases. - **Hyperbilirubinemia** in ICP is predominantly conjugated (direct) bilirubin, and its elevation contributes to the jaundice.

Q: Twin pregnancy is least associated with:

Young female. ***Young female*** - **Young maternal age** is generally associated with a *lower* incidence of twin pregnancies, particularly dizygotic twins. - The likelihood of dizygotic twinning *increases with maternal age* up to about 35-39 years. *Multigravida* - **Multiparity** (being a multigravida) is associated with an *increased* likelihood of twin pregnancies. - The chance of having twins increases with each successive pregnancy. *Genetic* - There is a **genetic predisposition** to dizygotic twinning, often running in families. - A family history of twinning, especially on the maternal side, increases the chances of having twins. *Patient receiving fertilization treatment* - **Assisted reproductive technologies (ART)**, such as *in vitro fertilization (IVF)*, significantly *increase* the risk of multiple pregnancies, including twins. - This is due to the transfer of multiple embryos or ovarian stimulation leading to multiple ovulations.

Q: In an antepartum cardiotocogram, consider the following findings: absence of deceleration and a sinusoidal pattern. Which of the following findings indicates fetal well-being?

Absence of deceleration only. ***Absence of deceleration only*** - The **absence of decelerations** (late or variable) on a cardiotocogram (CTG) is generally considered a sign of **fetal well-being**, indicating adequate placental perfusion and oxygenation. - This suggests that the fetus is not experiencing significant hypoxic stress during contractions or in response to umbilical cord compression. *Both findings indicate fetal well-being* - A **sinusoidal pattern** is a sign of severe fetal compromise, not well-being, and indicates urgent intervention is needed. - Therefore, combining it with the absence of decelerations does not result in an overall indication of fetal well-being. *Absence of deceleration and sinusoidal pattern* - This option incorrectly groups the **absence of decelerations** (fetal well-being) with a **sinusoidal pattern** (fetal distress). - A sinusoidal pattern is a distinct, ominous finding associated with severe fetal anemia, hypoxemia, and acidosis. *Sinusoidal pattern only* - A **sinusoidal pattern** on a CTG is a highly abnormal and concerning finding, indicative of severe **fetal anemia**, **hypoxemia**, or **acidosis**. - It is a strong indicator of **fetal distress** and requires immediate assessment and intervention, not fetal well-being.

Q: On transvaginal sonography, which of the following shapes of the cervix indicates preterm labor?

U. ***U*** - A **U-shaped cervix** on transvaginal sonography indicates **significant cervical funneling** and effacement, which is the classic finding strongly predictive of **impending preterm labor**. - This shape represents advanced cervical dilation from the internal os, indicating the cervix is actively shortening and opening, signifying high risk for preterm delivery. *T* - A **T-shaped cervix** typically represents a **normal, closed cervix**, with the internal os remaining intact and funneling absent or minimal. - This shape suggests a **low risk of preterm labor**, as the cervix maintains its structural integrity. *Y* - A **Y-shaped cervix** indicates **mild cervical funneling**, where the internal os has started to open but is not yet significantly dilated. - While it may suggest a **higher risk** of preterm labor than a T-shaped cervix, it is less indicative of imminent preterm labor than a U-shaped cervix. *O* - An **O-shaped cervix** refers to a **completely dilated cervix**, indicating active labor is already established. - This shape signifies that both the internal and external os are widely open, representing an advanced stage of cervical dilation beyond the predictive phase.

Q: All the following are indications for termination of pregnancy in APH patient except:

Transverse lie. ***Transverse lie*** - A **transverse lie** is an **abnormal fetal presentation** that requires a **cesarean section** for delivery, but it is **not an indication for delivery** in the context of an APH (Antepartum Hemorrhage) patient. - While it determines the **mode of delivery** (cesarean vs vaginal), it does not by itself indicate the need to deliver the baby due to hemorrhage. - The timing of delivery in APH is based on maternal-fetal compromise, not fetal presentation. *Continuous bleeding* - **Continuous, active vaginal bleeding** in an APH patient is an **absolute indication for delivery** to save the mother's life. - Uncontrolled hemorrhage can lead to **maternal shock**, disseminated intravascular coagulation (DIC), and maternal mortality if delivery is not expedited. *37 weeks* - If a patient with APH, especially due to **placenta previa**, reaches **37 weeks gestation**, delivery is indicated because the fetus has achieved **term maturity**. - Continuing the pregnancy beyond this point increases the risk of further hemorrhagic complications without additional fetal benefit. *IUD (Intrauterine Death)* - The presence of an **intrauterine fetal demise** in an APH patient is an indication for **delivery**. - A dead fetus, especially with ongoing bleeding, can lead to maternal coagulopathy and infection if retained. - Delivery prevents these maternal complications.

Q: Which of the following is NOT a recognized risk factor associated with macrosomia?

Short Stature. ***Short Stature*** - **Short stature** in mothers is generally associated with an **increased risk of small-for-gestational-age (SGA)** infants due to potential pelvic inlet limitations and reduced uterine capacity, not macrosomia. - While short stature can influence birth outcomes, it is not considered a direct or independent **risk factor for delivering a macrosomic infant**. *Maternal obesity* - **Maternal obesity** leads to increased **glucose and insulin levels** in the mother, crossing the placenta and stimulating fetal growth, significantly increasing the risk of macrosomia. - Obese mothers often have **larger placental nutrient transfer capacity**, contributing to excessive fetal growth. *Prolonged Pregnancy* - **Prolonged pregnancy** (post-term pregnancy) allows more time for continuous fetal growth and deposition of fat, which directly increases the likelihood of a fetus becoming **macrosomic**. - Fetuses in prolonged pregnancies continue to gain weight, and **fetal growth restriction** is less common in this context than continued growth. *Previous large infant* - A history of a **previous large infant** strongly indicates a maternal predisposition (e.g., genetic factors, undiagnosed glucose intolerance) to carrying and delivering larger babies in subsequent pregnancies. - This is one of the most significant risk factors, as **recurrence rates for macrosomia** are high.

Q: A 32-year-old primigravida at 39 weeks of gestational age has a blood pressure reading of 150/100 mmHg obtained during a routine visit, which is an elevation from her baseline blood pressure of 120/70 mmHg. She denies any headache, visual changes, nausea, vomiting, or abdominal pain. Her repeat BP is 160/90 mmHg, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?

Gestational hypertension. ***Gestational hypertension*** - This patient presents with **new-onset hypertension** (BP > 140/90 mmHg) after 20 weeks of gestation, without **proteinuria** or signs of **end-organ damage**. - The absence of proteinuria and severe features distinguishes it from preeclampsia, making gestational hypertension the most likely diagnosis. *Preeclampsia* - Preeclampsia requires new-onset hypertension combined with **proteinuria** (≥300 mg in 24 hours or protein/creatinine ratio ≥0.3) or signs of **end-organ dysfunction**, neither of which are described here. - While hypertension is present, the **lack of proteinuria** or other severe features rules out this diagnosis. *Chronic hypertension with superimposed preeclampsia* - This diagnosis applies to women with **pre-existing hypertension** (diagnosed before pregnancy or before 20 weeks) who then develop new-onset proteinuria or worsening hypertension with severe features. - The patient's baseline blood pressure was normal (120/70 mmHg), indicating no chronic hypertension, and no proteinuria or severe features are present. *Eclampsia* - Eclampsia is defined by the occurrence of **generalized tonic-clonic seizures** in a woman with preeclampsia, which is a life-threatening obstetric emergency. - The patient described has no signs of seizures or even severe preeclampsia.

Q: Pregnancy is contraindicated in which of the following cardiac conditions?

Primary pulmonary hypertension. ***Primary pulmonary hypertension*** - Pregnancy is **contraindicated** in primary pulmonary hypertension due to the significant risk of **maternal mortality**, which can be as high as 30-50%. - The physiological changes of pregnancy, such as increased **cardiac output** and blood volume, exacerbate pulmonary vascular resistance and can lead to **right heart failure** and sudden death. *Mitral stenosis* - While mitral stenosis can cause complications in pregnancy, it is not an absolute contraindication for all cases, especially if it is **mild to moderate** and well-managed. - The main concern is the increased **blood volume** and heart rate during pregnancy, which can worsen pulmonary congestion, but careful monitoring can often mitigate risks. *Aortic stenosis* - Severe aortic stenosis can be problematic during pregnancy due to the heart's inability to increase **cardiac output** adequately in response to increased demand. - However, pregnancy is typically not absolutely contraindicated, and management often involves close monitoring and in some cases, **balloon valvuloplasty** before or during pregnancy. *Mitral regurgitation* - Mitral regurgitation is generally **well-tolerated** during pregnancy because the reduced systemic vascular resistance in pregnancy makes it easier for blood to flow forward into the aorta, actually reducing the regurgitant volume. - While severe cases require careful monitoring, it is generally **not a contraindication** to pregnancy.

Question 1

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

Question 2

Least common type of twins is:

Accepted Answer

Conjoined twins

Answer

Diamniotic-dichorionic twins

Answer

Diamniotic-monochorionic twins

Answer

Monoamniotic-monochorionic twins

Question 3

A pregnant woman developed idiopathic cholestatic jaundice. Which clinical feature is most characteristically associated with this presentation?

Accepted Answer

Intense itching is commonly observed.

Answer

SGOT, SGPT levels typically remain below 60 IU.

Answer

Markedly elevated levels of alkaline phosphatase are observed.

Answer

Serum bilirubin levels typically remain below 5mg/dl.

Question 4

Twin pregnancy is least associated with:

Accepted Answer

Young female

Answer

Genetic

Answer

Patient receiving fertilization treatment

Answer

Multigravida

Question 5

In an antepartum cardiotocogram, consider the following findings: absence of deceleration and a sinusoidal pattern. Which of the following findings indicates fetal well-being?

Accepted Answer

Absence of deceleration only

Answer

Both findings indicate fetal well-being

Answer

Absence of deceleration and sinusoidal pattern

Answer

Sinusoidal pattern only

Question 6

On transvaginal sonography, which of the following shapes of the cervix indicates preterm labor?

Accepted Answer

U

Answer

T

Answer

Y

Answer

O

Question 7

All the following are indications for termination of pregnancy in APH patient except:

Accepted Answer

Transverse lie

Answer

Continuous bleeding

Answer

37 weeks

Answer

IUD

Question 8

Which of the following is NOT a recognized risk factor associated with macrosomia?

Accepted Answer

Short Stature

Answer

Prolonged Pregnancy

Answer

Previous large infant

Answer

Maternal obesity

Question 9

A 32-year-old primigravida at 39 weeks of gestational age has a blood pressure reading of 150/100 mmHg obtained during a routine visit, which is an elevation from her baseline blood pressure of 120/70 mmHg. She denies any headache, visual changes, nausea, vomiting, or abdominal pain. Her repeat BP is 160/90 mmHg, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?

Accepted Answer

Gestational hypertension

Answer

Preeclampsia

Answer

Chronic hypertension with superimposed preeclampsia

Answer

Eclampsia

Question 10

Pregnancy is contraindicated in which of the following cardiac conditions?

Accepted Answer

Primary pulmonary hypertension

Answer

Mitral regurgitation

Answer

Aortic stenosis

Answer

Mitral stenosis

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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