Maternal-Fetal Medicine Practice Questions

Q: A pregnant patient with a prosthetic valve on warfarin should be switched to heparin at

36 weeks. ***36 weeks*** - At **36 weeks of gestation**, a pregnant patient on **warfarin** (due to a prosthetic valve) should be switched to **unfractionated heparin (UFH)** or **low molecular weight heparin (LMWH)**. - This timing is crucial to mitigate the risk of fetal coagulopathy from warfarin exposure during delivery and to allow for safer management of anticoagulation during labor and delivery. *30 weeks* - Switching to heparin at 30 weeks is generally too early and unnecessarily prolongs the period of subcutaneous injections, which can be burdensome for patients. - The primary concern of fetal coagulopathy with warfarin is highest closer to term, making a switch at 36 weeks more appropriate for balancing maternal and fetal risks. *38 weeks* - Switching at 38 weeks significantly increases the risk that labor might occur while the patient is still on warfarin, exposing the fetus to the drug and increasing the risk of maternal bleeding complications during delivery. - It leaves little buffer time for the warfarin's effects to wear off before spontaneous labor might begin. *Onset of labour* - Waiting until the onset of labor to switch from warfarin to heparin is dangerous and inappropriate. - Warfarin has a long half-life, and its anticoagulant effects would still be present during labor and delivery, posing a high risk of fetal hemorrhage (especially intracranial hemorrhage) and significant maternal bleeding.

Q: What are the potential complications in subsequent pregnancies for a woman with a history of gestational trophoblastic disease?

Increased risk of recurrent GTD and pregnancy complications. ***Increased risk of recurrent GTD and pregnancy complications*** - A history of **gestational trophoblastic disease (GTD)** significantly increases the risk of recurrence in subsequent pregnancies, emphasizing the need for close monitoring. - There is also an elevated risk of other **adverse pregnancy outcomes**, including **preterm birth** and **preeclampsia**, following a GTD history. *Neural tube defects* - **Neural tube defects** are congenital anomalies primarily associated with **folate deficiency** and genetic factors, not a prior history of GTD. - They involve incomplete closure of the neural tube during embryonic development, unrelated to trophoblastic tissue. *Cardiac defects* - **Congenital cardiac defects** are multifactorial, linked to genetic predisposition, maternal conditions like **diabetes**, and certain exposures, but not a history of GTD. - They result from abnormal heart development in the early stages of pregnancy. *Skeletal defects* - **Skeletal defects** can be hereditary or related to maternal infections (e.g., rubella), drug exposure (e.g., thalidomide), or specific genetic syndromes, not GTD. - These malformations occur during fetal bone and limb development.

Q: The weight of the placenta at term is

500 gm. ***Correct: 500 gm*** - The average weight of a full-term placenta is approximately **500 grams (1 pound)**. - This weight is typically about **one-sixth of the baby's weight** at term. - Normal range is approximately **450-650 grams**. *Incorrect: 250 gm* - A placenta weighing 250 grams at term would be considered **abnormally small** and could indicate **placental insufficiency** or other complications. - A smaller placenta may not be able to adequately support fetal growth and development. *Incorrect: 750 gm* - A placenta weighing 750 grams at term would be considered **abnormally large**, potentially indicating conditions like **maternal diabetes**, **fetal hydrops**, or **placental edema**. - This represents a significantly enlarged placenta beyond the normal range. *Incorrect: 1000 gm* - A placenta weighing 1000 grams (1 kg) at term would be considered **markedly enlarged**, potentially indicating severe conditions like **maternal diabetes**, **fetal hydrops**, **infection**, or **placentomegaly**. - While larger than average, such weights can occur in pathological pregnancies but are far from the normal 500g in a healthy pregnancy.

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.

Question 1

A pregnant patient with a prosthetic valve on warfarin should be switched to heparin at

Accepted Answer

36 weeks

Answer

Onset of labour

Answer

30 weeks

Answer

38 weeks

Question 2

Which of the following statements regarding the umbilical cord is true?

Accepted Answer

Observation of a single umbilical artery is associated with additional anomalies

Answer

Two arteries and two veins

Answer

One artery and two veins

Answer

Observation of a single umbilical vein is associated with additional anomalies

Question 3

What are the potential complications in subsequent pregnancies for a woman with a history of gestational trophoblastic disease?

Accepted Answer

Increased risk of recurrent GTD and pregnancy complications

Answer

Neural tube defects

Answer

Skeletal defects

Answer

Cardiac defects

Question 4

The weight of the placenta at term is

Accepted Answer

500 gm

Answer

250 gm

Answer

1000 gm

Answer

750 gm

Question 5

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 6

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 7

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 8

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 9

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 10

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

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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