Maternal-Fetal Medicine Practice Questions

Q: On Doppler, the most ominous sign indicating fetal compromise is:

Absent diastolic flow. ***Absent diastolic flow*** - This indicates a severe increase in **vascular resistance** within the placental circulation, signifying significant fetal compromise. - The absence of forward flow during diastole means the fetus is receiving **minimal blood supply** during relaxation, leading to hypoxia and acidosis. *↑ pulsatility index in umbilical artery* - An elevated pulsatility index (PI) suggests increased resistance to blood flow in the **placental circulation**, indicating compromise. - However, it is generally less severe than absent or reversed diastolic flow, which are later stages of fetal compromise. *↑ S/D blood flow ratio* - An increased S/D ratio in the umbilical artery signifies **higher resistance** to blood flow, often due to placental insufficiency. - While concerning, it is considered an earlier indicator of compromise compared to the complete absence of diastolic flow. *↑ Cerebral artery flow* - Increased cerebral artery flow (often decreased PI in the middle cerebral artery) is a sign of **brain-sparing effect**, where the fetus redistributes blood flow to essential organs. - This is a compensatory mechanism and, while indicating compromise, means the fetus is still able to adapt to some extent, unlike absent diastolic flow which represents decompensation.

Q: A pregnant woman comes at 40 weeks' gestation, with a fundal height measuring 34 cm. USG shows a maximum vertical pocket of liquor less than 2 cm and an AFI of 3 cm. Which of the following statements is false regarding the management of this case scenario?

If cervix is unripe, immediate LSCS should be considered. ***If cervix is unripe, immediate LSCS should be considered.*** - This statement is **false**. In cases of **oligohydramnios** at term, particularly with a favorable cervix, **labor induction** is generally preferred over immediate C-section. - An unripe cervix does not automatically necessitate an immediate C-section; rather, cervical ripening agents (e.g., prostaglandins) can be used to prepare the cervix for induction. *Do induction if vaginal delivery is not contraindicated* - This is a **correct management strategy** for oligohydramnios at term, provided there are no contraindications to vaginal birth (e.g., placenta previa, severe fetal distress pre-labor). - **Induction** allows for controlled labor and delivery with close fetal monitoring. *During labour, cord compression is common in these patients* - This statement is **true**. **Oligohydramnios** (AFI ≤ 5 cm or maximum vertical pocket < 2 cm) significantly increases the risk of **umbilical cord compression** during labor. - Reduced amniotic fluid means less cushioning protection for the umbilical cord, leading to potential variable decelerations and fetal compromise. *Strict intrapartum fetal surveillance* - This statement is **true** and crucial for managing oligohydramnios during labor. Given the increased risk of **fetal compromise** (e.g., from cord compression), continuous electronic fetal monitoring is essential. - This allows for early detection of **fetal distress** and timely intervention, if necessary.

Q: Cholestasis may lead to the following complications except:

Maternal jaundice. ***Maternal jaundice*** - While cholestasis, particularly **intrahepatic cholestasis of pregnancy (ICP)**, can cause **pruritus and elevated bile acids**, clinically significant **maternal jaundice is uncommon** (occurring in only 10-25% of cases, typically mild). - Maternal jaundice is more of a **clinical manifestation** rather than a serious **complication** of concern in cholestasis. - In contrast, the **major complications of cholestasis are fetal in nature** and represent the primary clinical concerns requiring active management. *Intrauterine fetal death* - **Elevated bile acids** in the maternal circulation cross the placenta and become toxic to the fetus, significantly increasing the risk of **sudden intrauterine fetal death (IUFD)**. - The mechanism involves **fetal cardiac arrhythmias** and myocardial dysfunction due to bile acid accumulation in cardiac cells. - This is the **most serious complication** and the reason for close monitoring and early delivery in cholestasis. *Meconium stained liquor* - Cholestasis is associated with increased incidence of **meconium-stained amniotic fluid** due to fetal distress. - Elevated bile acids are thought to stimulate **fetal gut motility** and cause premature passage of meconium. - This reflects fetal compromise and increased risk of meconium aspiration syndrome. *Preterm labour* - Women with cholestasis have significantly higher rates of **spontaneous preterm labor**, necessitating planned early delivery (typically around 37 weeks). - Bile acids may have **direct effects on uterine contractility** through alterations in prostaglandin metabolism and myometrial sensitivity. - This is a recognized complication requiring obstetric intervention and monitoring.

Q: A confirmatory scan should be performed at what time in a G2P1 female detected with major placenta previa at 28 weeks on ultrasound (TVS).

At 32 weeks. ***At 32 weeks*** - The **RCOG Green-top Guideline No. 27** and **ACOG guidelines** recommend a confirmatory scan at **32 weeks** for placenta previa detected in the second trimester. - By 32 weeks, the **lower uterine segment** has developed sufficiently to accurately assess whether the placenta previa has resolved or persists. - This timing allows adequate time for **delivery planning** if the previa persists, including scheduling elective cesarean section and arranging appropriate resources. - Approximately **90% of low-lying placentas** identified at 20 weeks will have resolved by 32 weeks due to the development of the lower segment. *At 34 weeks* - While this provides a later assessment, it is **not the standard recommended timing** according to international guidelines. - Delaying the confirmatory scan to 34 weeks reduces the time available for optimal **delivery planning and counseling** if the previa persists. - The standard protocol is 32 weeks for confirmation, with a possible additional scan at 36 weeks if needed for final delivery planning. *At 36 weeks* - This is often used as a **final pre-delivery assessment** if placenta previa persists at 32 weeks, not as the initial confirmatory scan. - Waiting until 36 weeks for the first confirmatory scan may be too late for optimal management, especially if the patient experiences **antepartum hemorrhage**. - By guideline recommendations, 36 weeks is the timing for determining the **exact mode and timing of delivery**, not the initial confirmation. *At onset of labor* - This is a **dangerous approach** that could lead to catastrophic hemorrhage for both mother and fetus. - **Vaginal examination** in the presence of placenta previa can cause severe bleeding and is contraindicated. - Placenta previa requires **planned cesarean section**, which must be arranged well in advance based on earlier ultrasound confirmation, not determined at labor onset.

Q: Which antihypertensive is considered the first-line treatment in pregnancy?

Labetalol. ***Labetalol*** - **Labetalol** is a **beta-blocker** with **alpha-blocking activity** and is widely considered a **first-line agent** for **hypertension in pregnancy** due to its established safety profile and effectiveness. - It effectively **lowers blood pressure** without significantly compromising **placental perfusion** or causing adverse fetal effects, making it a preferred choice for both **chronic and gestational hypertension**. - Along with **methyldopa**, labetalol is recommended as a first-line agent by major guidelines, with **labetalol increasingly preferred** in modern practice due to its more rapid onset and better tolerability. *Hydralazine* - **Hydralazine** is a **direct arterial vasodilator** typically used for **acute severe hypertension in pregnancy**, such as in **preeclampsia with severe features** or **eclampsia**. - While effective in emergent situations, it is generally **not favored as first-line treatment** for chronic management due to reflex tachycardia and the need for frequent dosing. *Propranolol* - **Propranolol** is a **non-selective beta-blocker** that is **less preferred** for chronic hypertension in pregnancy compared to other options like labetalol or methyldopa. - Its use has been associated with concerns regarding **fetal growth restriction** and **neonatal bradycardia**, especially with prolonged use. *Alpha methyl dopa* - **Alpha methyl dopa** is a **centrally acting alpha-2 adrenergic agonist** that has the **longest safety record** for **hypertension in pregnancy** and is considered a **first-line agent** by WHO and other international guidelines. - While it has extensive safety data spanning decades, **labetalol is often preferred in current practice** due to its more rapid onset of action, better maternal tolerability, and lower incidence of side effects like sedation.

Q: A 3rd gravida with normal previous two pregnancies. What is the best test to diagnose Rh sensitization in an Rh-negative mother?

Indirect Coombs' test. ***Indirect Coombs' test*** - The **indirect Coombs' test** (or **indirect antiglobulin test, IAT**) is the **gold standard** for detecting **Rh antibodies** in the **mother's serum**, indicating **Rh sensitization**. - This test detects **free antibodies** circulating in maternal blood that can cross the placenta and attack fetal Rh-positive red blood cells. - A positive result means the mother has developed **anti-D antibodies** against Rh-positive fetal RBCs, which can cause **hemolytic disease of the fetus and newborn (HDFN)**. - Performed at **first antenatal visit**, **28 weeks**, and **after delivery** in Rh-negative mothers to guide **RhoGAM administration**. *Direct Coombs' test* - The **direct Coombs' test** (or **direct antiglobulin test, DAT**) is performed on the **infant's red blood cells** after birth, not the mother's serum. - It detects antibodies **already bound** to neonatal RBCs, confirming if hemolysis is occurring in the newborn. - This does **not diagnose maternal sensitization** but rather assesses the **severity of HDFN** in the affected infant. *Rh Antigen test* - This test determines the **Rh status** (positive or negative) of an individual by detecting the presence of the **D antigen** on red blood cells. - It identifies **who is at risk** (Rh-negative mother with Rh-positive baby) but does **not detect antibodies** or confirm sensitization. - It is a prerequisite screening test, not a diagnostic test for sensitization. *Rh Sensitization test* - This is a **non-specific descriptive term**, not an actual standardized laboratory test. - While the clinical goal is to assess for "Rh sensitization," the **specific test** that accomplishes this is the **indirect Coombs' test**.

Q: What examination will confirm premature rupture of membranes in a 34-week pregnant patient with complaints of leaking vaginal discharge?

Speculum examination. ***Speculum examination*** - A **sterile speculum examination** allows direct visualization of the cervix and vaginal vault to identify **pooling of amniotic fluid** or fluid leaking from the cervical os. - It also enables collection of samples for **nitrazine testing** (to confirm alkaline pH) and **ferning test** (to observe characteristic fern-like crystallization of amniotic fluid). *Digital vaginal examination* - This is generally **avoided** in suspected premature rupture of membranes (PROM) due to the increased risk of **introducing infection** into the birth canal, especially if the patient is not in active labor. - It does not directly visualize the leakage of fluid and is less sensitive for diagnosing PROM than speculum examination. *Ultrasound examination* - While ultrasound can assess **amniotic fluid volume**, which might be reduced in PROM, it is not a direct diagnostic test for the rupture itself. - A normal fluid volume does not rule out a small leak, and a low volume can have other causes. *Urine analysis* - Urine analysis is used to detect conditions like **urinary tract infections** or **proteinuria**, but it does not provide information about the integrity of the amniotic sac. - It cannot differentiate amniotic fluid from urine or vaginal secretions.

Q: Which of the following is not seen in hypertensive disorders of pregnancy?

Macrosomia. ***Macrosomia*** - **Macrosomia** (large-for-gestational-age infant) is typically associated with **gestational diabetes,** not hypertensive disorders of pregnancy. - Hypertensive disorders often lead to **fetal growth restriction** due to reduced placental blood flow. *Eclampsia* - **Eclampsia** is defined by **new-onset grand mal seizures** in a woman with preeclampsia, underscoring its direct link to hypertensive disorders. - It represents a severe manifestation of **preeclampsia**, a hypertensive disorder, and is therefore seen in these conditions. *HELLP syndrome* - **HELLP syndrome** (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe obstetric complication considered a variant of **preeclampsia**. - It is a life-threatening condition directly associated with **hypertensive disorders of pregnancy.** *Proteinuria* - **Proteinuria** is a hallmark diagnostic criterion for **preeclampsia**, indicating kidney involvement and endothelial dysfunction. - Its presence is crucial in defining and classifying **hypertensive disorders of pregnancy.**

Q: A 27-year-old primigravida presents with pre-eclampsia, with a blood pressure of 150/100 mmHg at 32 weeks of gestation. If there are no complications, the pregnancy should be best terminated at:

37 completed weeks.. ***37 completed weeks.*** - For women with **pre-eclampsia without severe features** and **no complications**, delivery is typically recommended at **37 weeks of gestation**. - This timing balances the risks of prematurity with the potential for disease progression or complications if the pregnancy continues. *40 completed weeks.* - Continuing the pregnancy until 40 weeks in a pre-eclamptic patient, even without severe features, increases the risk of **maternal and fetal complications**. - There is a higher likelihood of disease progression, **placental insufficiency**, and adverse outcomes beyond 37 weeks in such cases. *35 completed weeks.* - Delivery at 35 completed weeks would be considered **late preterm** and is generally reserved for cases of **pre-eclampsia with severe features** or other complications. - While pre-eclampsia is present, the absence of complications or severe features indicates that the benefits of prolonging the pregnancy to improve fetal lung maturity outweigh the risks at this stage. *34 completed weeks.* - Delivery at 34 completed weeks is considered **moderately preterm** and is usually indicated for **severe pre-eclampsia** or other urgent medical conditions. - In a patient with mild pre-eclampsia and no complications, extending the pregnancy to at least 37 weeks allows for further optimal fetal development.

Question 1

On Doppler, the most ominous sign indicating fetal compromise is:

Accepted Answer

Absent diastolic flow

Answer

↑ pulsatility index in umbilical artery

Answer

↑ S/D blood flow ratio

Answer

↑ Cerebral artery flow

Question 2

A pregnant woman comes at 40 weeks' gestation, with a fundal height measuring 34 cm. USG shows a maximum vertical pocket of liquor less than 2 cm and an AFI of 3 cm. Which of the following statements is false regarding the management of this case scenario?

Accepted Answer

If cervix is unripe, immediate LSCS should be considered

Answer

Do induction if vaginal delivery is not contraindicated

Answer

During labour, cord compression is common in these patients

Answer

Strict intrapartum fetal surveillance

Question 3

Cholestasis may lead to the following complications except:

Accepted Answer

Maternal jaundice

Answer

Meconium stained liquor

Answer

Preterm labour

Answer

Intrauterine fetal death

Question 4

A confirmatory scan should be performed at what time in a G2P1 female detected with major placenta previa at 28 weeks on ultrasound (TVS).

Accepted Answer

At 32 weeks

Answer

At 36 weeks

Answer

At onset of labor

Answer

At 34 weeks

Question 5

Which of the following statements is true regarding twin-to-twin transfusion syndrome?

Accepted Answer

The recipient twin develops hydramnios more often than does the donor twin.

Answer

The donor twin is more likely to develop widespread thromboses

Answer

The donor twin usually suffers from anemia.

Answer

Gross differences may be observed between donor and recipient placentas

Question 6

Which antihypertensive is considered the first-line treatment in pregnancy?

Accepted Answer

Labetalol

Answer

Hydralazine

Answer

Propranolol

Answer

Alpha methyl dopa

Question 7

A 3rd gravida with normal previous two pregnancies. What is the best test to diagnose Rh sensitization in an Rh-negative mother?

Accepted Answer

Indirect Coombs' test

Answer

Direct Coombs' test

Answer

Rh Antigen test

Answer

Rh Sensitization test

Question 8

What examination will confirm premature rupture of membranes in a 34-week pregnant patient with complaints of leaking vaginal discharge?

Accepted Answer

Speculum examination

Answer

Digital vaginal examination

Answer

Ultrasound examination

Answer

Urine analysis

Question 9

Which of the following is not seen in hypertensive disorders of pregnancy?

Accepted Answer

Macrosomia

Answer

HELLP syndrome

Answer

Proteinuria

Answer

Eclampsia

Question 10

A 27-year-old primigravida presents with pre-eclampsia, with a blood pressure of 150/100 mmHg at 32 weeks of gestation. If there are no complications, the pregnancy should be best terminated at:

Accepted Answer

37 completed weeks.

Answer

35 completed weeks.

Answer

40 completed weeks.

Answer

34 completed weeks.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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