Maternal-Fetal Medicine Practice Questions

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.

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: At what gestational age should a pregnancy with cholestasis of pregnancy be terminated?

38 weeks. ***38 weeks*** - For pregnancies complicated by **cholestasis of pregnancy**, induction of labor at **38 weeks** is generally recommended. - This timing balances the risk of stillbirth associated with cholestasis against the risks of **preterm birth**. *34 weeks* - Induction at 34 weeks would be considered **too early** unless there are additional severe complications, as it increases the risk of **neonatal morbidity** associated with prematurity. - While cholestasis does increase stillbirth risk, this risk significantly rises **after 37-38 weeks**, making earlier induction unnecessary in most cases. *36 weeks* - Induction at 36 weeks is generally considered **too early** given the potential for **neonatal complications** related to prematurity. - The elevated risk of adverse fetal outcomes in cholestasis of pregnancy typically occurs closer to term, making 38 weeks a more optimal balance. *40 weeks* - Allowing pregnancy to continue to 40 weeks with **cholestasis of pregnancy** would be associated with an **unacceptable increased risk of stillbirth**. - The risk of adverse perinatal outcomes, including **sudden fetal death**, significantly rises in pregnancies with cholestasis that extend beyond 38 weeks.

Q: Which delivery method is associated with the least risk of HIV transmission during childbirth?

Cesarean section. ***Cesarean section*** - **Elective Cesarean section** (scheduled at 38 weeks) reduces the risk of **mother-to-child HIV transmission** when maternal **viral load is >1000 copies/mL** or unknown near delivery. - It avoids exposure to maternal blood and genital secretions during passage through the birth canal. - With effective **antiretroviral therapy (ART)** and viral suppression (<50 copies/mL), vaginal delivery is safe and C-section offers **no additional benefit**. - Among delivery methods compared without considering viral suppression, C-section has the **lowest transmission risk**. *Forceps delivery* - **Forceps delivery** increases risk of fetal trauma and scalp lacerations, potentially increasing exposure to maternal blood. - May cause **vaginal lacerations** in the mother, increasing blood exposure. - Should be avoided when possible in HIV-positive mothers, especially with detectable viral loads. *ARM (Artificial Rupture of Membranes)* - **ARM** prolongs duration of ruptured membranes, increasing fetal exposure time to potentially infected genital tract secretions. - Removes the protective barrier of intact membranes. - While not a delivery method per se, prolonged rupture of membranes (>4 hours) is associated with **increased transmission risk**. *Vacuum delivery* - **Vacuum delivery** can cause scalp abrasions, cephalohematomas, or subgaleal hemorrhage, creating portals for viral entry. - Increases trauma to both fetal scalp and maternal birth canal. - Should be avoided in HIV-positive mothers when other options are available.

Q: Fetal tachycardia is defined as a heart rate greater than ___ bpm.

160. ***160*** - A fetal heart rate greater than **160 bpm** for more than 10 minutes is defined as **fetal tachycardia**. - This threshold helps differentiate normal variations from sustained elevations, which can indicate fetal distress. *140* - A heart rate of 140 bpm falls within the **normal range** for fetal heart rate, which is typically between 110 and 160 bpm. - This rate does not indicate tachycardia and is usually considered reassuring. *180* - While 180 bpm is certainly tachycardic, the generally accepted clinical definition of fetal tachycardia begins at **160 bpm**. - A heart rate at 180 bpm would be considered **marked tachycardia** and a more urgent finding. *200* - A fetal heart rate of 200 bpm represents **severe tachycardia** and would be a significant indicator of fetal compromise. - The threshold for defining tachycardia is lower at **160 bpm**, making 200 bpm an extreme elevation.

Q: What does the presence of a macerated fetus indicate in a clinical context?

Stillborn. ***Stillborn*** - A **macerated fetus** refers to a fetus that has undergone **autolysis** due to prolonged retention in utero after fetal death. - The presence of maceration is a definitive sign that the fetus was **stillborn** and not alive at the time of delivery. *Fetal distress* - **Fetal distress** indicates a fetus that is currently experiencing **compromise during labor** or prior, but is still alive. - While fetal distress can precede fetal death, its presence alone does not imply maceration or a stillborn outcome at the time of diagnosis. *Live born* - A **live born** infant shows any sign of life (e.g., breathing, heartbeat, umbilical cord pulsation, definite voluntary muscle movement) after complete expulsion or extraction from its mother. - The descriptor "macerated" directly contradicts the definition of a live birth, as **maceration occurs post-mortem**. *Intrauterine Growth Restriction (IUGR)* - **IUGR** describes a fetus that has not reached its **growth potential** in utero. - While IUGR can be a risk factor for stillbirth, **maceration** itself is not a diagnostic feature of IUGR but rather a post-mortem finding.

Q: A 29-year-old G3P2 woman at 34 weeks' gestation is involved in a serious car accident, loses consciousness briefly, and presents to the emergency department awake and alert with a severe headache, abdominal, and pelvic pain. Her vital signs include a blood pressure of 150/90 mm Hg, heart rate of 120/min, temperature of 37.4°C (99.3°F), and respiratory rate of 22/min. Fetal heart rate is 155/min. Physical examination reveals minor bruises on the abdomen and limbs, blood in the vault upon vaginal inspection, and strong, frequent uterine contractions. Which of the following is most likely a complication of her current condition?

DIC. ***DIC*** - The combination of **abruptio placentae** (suggested by trauma, pain, vaginal bleeding, and contractions) with potential severe bleeding from uterine rupture or injury from the car accident, significantly increases the risk of **Disseminated Intravascular Coagulation (DIC)**. - **DIC** is a life-threatening condition initiated by massive activation of the coagulation system, leading to widespread microthrombi formation and subsequent consumption of clotting factors and platelets, resulting in simultaneous **bleeding and thrombosis**. *IUGR* - **Intrauterine Growth Restriction (IUGR)** is a chronic complication typically developing over weeks or months, caused by placental insufficiency or fetal conditions. - It is unlikely to be an acute complication directly resulting from a traumatic event at 34 weeks gestation. *Subarachnoid hemorrhage* - While trauma can cause **subarachnoid hemorrhage**, the primary obstetric complications described (abdominal pain, vaginal bleeding, uterine contractions following trauma) point more strongly towards placental or uterine injury. - The patient's **headache** and brief loss of consciousness could be due to concussion, but the obstetric findings are more immediately concerning for distinct complications. *Vasa previa* - **Vasa previa** is an anatomical anomaly where fetal blood vessels within the membranes cross the internal cervical os, unprotected by placental tissue or Wharton's jelly. - This condition presents with painless vaginal bleeding upon rupture of membranes and **fetal distress**, usually in labor, but is not directly caused by trauma.

Q: Which of the following conditions is least likely to be associated with polyhydramnios?

B/L renal agenesis. ***B/L renal agenesis*** - **Bilateral renal agenesis** (Potter syndrome) leads to **oligohydramnios** (reduced amniotic fluid) because the fetal kidneys are unable to produce urine, which is the primary source of amniotic fluid in the latter half of pregnancy. - The lack of amniotic fluid secondary to failed fetal urine production causes **pulmonary hypoplasia** and characteristic facial features. *Anencephaly* - **Anencephaly** is a major **neural tube defect** characterized by the absence of a large part of the brain and skull. - This condition often leads to **polyhydramnios** because the fetus cannot properly swallow amniotic fluid due to impaired neurological function or dysfunction of the swallowing reflex. *Open spina bifida* - **Open spina bifida** can cause **polyhydramnios** due to neurologic dysfunction affecting fetal swallowing. - The exposed neural tissue can also continuously leak cerebrospinal fluid into the amniotic sac, although impaired swallowing is the primary mechanism. *Tracheoesophageal fistula* - A **tracheoesophageal fistula** (TEF) often presents with **polyhydramnios** because it interferes with the normal passage of amniotic fluid into the fetal gastrointestinal tract. - The fetus is unable to swallow and absorb amniotic fluid effectively, leading to its accumulation in the amniotic sac.

Q: Pregnancy-associated risk factors for pre-eclampsia include all except which of the following?

Rh incompatibility. ***Rh incompatibility*** - **Rh incompatibility** is a risk factor for **hemolytic disease of the newborn** and not typically a direct risk factor for **pre-eclampsia**. - Its pathophysiology involves an immune response against fetal red blood cells, distinct from the placental dysfunction seen in pre-eclampsia. *Multiple pregnancy* - **Multiple pregnancies** significantly increase the risk of pre-eclampsia due to a larger placental mass and increased demands on the maternal cardiovascular system. - The elevated placental burden leads to greater production of anti-angiogenic factors, contributing to the development of the disorder. *Fetal structural abnormalities* - While not all **fetal structural abnormalities** increase pre-eclampsia risk, those associated with **poor placental development** or dysfunction, like certain genetic syndromes, can elevate the risk. - This connection is related to impaired placental development and function, similar to severe cases of pre-eclampsia without overt fetal anomalies. *Trisomy 13* - **Trisomy 13** (Patau syndrome) is strongly associated with an increased risk of severe and early-onset **pre-eclampsia**. - The presence of this chromosomal abnormality often leads to significant placental dysfunction and shallow trophoblast invasion, which are hallmarks of pre-eclampsia.

Q: All of the following can cause disseminated intravascular coagulation (DIC) during pregnancy, except:

Diabetes mellitus. ***Diabetes mellitus*** - While diabetes can lead to various pregnancy complications (e.g., pre-eclampsia, macrosomia), it is **not a direct cause of Disseminated Intravascular Coagulation (DIC)**. - DIC results from widespread activation of the coagulation system, which is typically triggered by massive tissue injury, release of thromboplastin-like substances, or severe systemic inflammation, none of which are directly initiated by diabetes itself. *Amniotic fluid embolism* - This condition involves the entry of **amniotic fluid components into the maternal circulation**, triggering a severe anaphylactoid reaction and widespread activation of the coagulation cascade. - It rapidly leads to profound **DIC**, characterized by massive hemorrhage and cardiovascular collapse. *Intrauterine death* - A fetus retained in utero for an extended period after death can release **thromboplastin-like substances** from the decaying placental and fetal tissues into the maternal circulation. - This continuous release can **activate the coagulation system**, leading to chronic and then acute DIC. *Abruptio placentae* - This involves the **premature separation of the placenta from the uterine wall**, which causes significant retroplacental hemorrhage and exposes maternal blood to large amounts of **tissue factor (thromboplastin)** from the decidua. - The massive release of tissue factor into the maternal circulation strongly **activates the extrinsic coagulation pathway**, making it a major cause of DIC in pregnancy.

Question 1

Pregnancy is contraindicated in which of the following cardiac conditions?

Accepted Answer

Primary pulmonary hypertension

Answer

Mitral regurgitation

Answer

Aortic stenosis

Answer

Mitral stenosis

Question 2

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 3

At what gestational age should a pregnancy with cholestasis of pregnancy be terminated?

Accepted Answer

38 weeks

Answer

34 weeks

Answer

36 weeks

Answer

40 weeks

Question 4

Which delivery method is associated with the least risk of HIV transmission during childbirth?

Accepted Answer

Cesarean section

Answer

Forceps delivery

Answer

ARM

Answer

Vacuum delivery

Question 5

Fetal tachycardia is defined as a heart rate greater than ___ bpm.

Accepted Answer

160

Answer

140

Answer

180

Answer

200

Question 6

What does the presence of a macerated fetus indicate in a clinical context?

Accepted Answer

Stillborn

Answer

Fetal distress

Answer

Live born

Answer

Intrauterine Growth Restriction (IUGR)

Question 7

A 29-year-old G3P2 woman at 34 weeks' gestation is involved in a serious car accident, loses consciousness briefly, and presents to the emergency department awake and alert with a severe headache, abdominal, and pelvic pain. Her vital signs include a blood pressure of 150/90 mm Hg, heart rate of 120/min, temperature of 37.4°C (99.3°F), and respiratory rate of 22/min. Fetal heart rate is 155/min. Physical examination reveals minor bruises on the abdomen and limbs, blood in the vault upon vaginal inspection, and strong, frequent uterine contractions. Which of the following is most likely a complication of her current condition?

Accepted Answer

DIC

Answer

IUGR

Answer

Subarachnoid hemorrhage

Answer

Vasa previa

Question 8

Which of the following conditions is least likely to be associated with polyhydramnios?

Accepted Answer

B/L renal agenesis

Answer

Anencephaly

Answer

Open spina bifida

Answer

Tracheoesophageal fistula

Question 9

Pregnancy-associated risk factors for pre-eclampsia include all except which of the following?

Accepted Answer

Rh incompatibility

Answer

Fetal structural abnormalities

Answer

Trisomy 13

Answer

Multiple pregnancy

Question 10

All of the following can cause disseminated intravascular coagulation (DIC) during pregnancy, except:

Accepted Answer

Diabetes mellitus

Answer

Intrauterine death

Answer

Abruptio placentae

Answer

Amniotic fluid embolism

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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