Maternal-Fetal Medicine Practice Questions

Q: A primigravida woman at 26 weeks gestation, presented with a BP of 150/90 mm Hg. Which test should be done next?

Urine dipstick. ***Urine dipstick***- The initial requirement for diagnosing **preeclampsia** is the presence of new-onset hypertension (BP > 140/90) plus **proteinuria** (or signs of end-organ damage).- The urine dipstick is the quickest and easiest initial test to rapidly screen for the presence of **proteinuria** and establish the correct diagnostic category (Gestational Hypertension vs. Preeclampsia).*Uric acid*- Elevated **serum uric acid** is often associated with preeclampsia severity, correlating with increased poor maternal and fetal outcomes.- However, it is not the standard *initial* diagnostic screening test needed to define the condition itself, which primarily requires checking for proteinuria.*Liver function test*- LFTs (AST and ALT) are performed to evaluate for signs of **severe preeclampsia** or **HELLP syndrome**, indicated by elevated transaminases.- While crucial for assessing severity, the initial step after noting hypertension is to screen for **proteinuria**, not necessarily end-organ damage markers.*Complete blood count*- A CBC is necessary to check for signs of severity, specifically **thrombocytopenia** (platelet count < 100,000/µL), which defines severe preeclampsia or HELLP syndrome.- Like LFTs, this is part of the workup for *severity* or *end-organ damage*, but the priority after detecting hypertension is confirming proteinuria via an initial screening test.

Q: A 32-year-old woman at 32 weeks gestation presents with sudden-onset severe abdominal pain and vaginal bleeding. She has a history of cocaine use. On examination, the uterus is tender, firm, and woody hard. Fetal heart sounds are absent. Blood pressure is 90/60 mmHg, pulse 120/min. What is the most likely diagnosis?

Placental abruption. ***Placental abruption*** - The sudden onset of severe, painful vaginal bleeding, coupled with a **tender, rigid, or 'woody' hard uterus**, is the classic triad for severe placental abruption. - **Cocaine use** is a major risk factor, causing intense vasoconstriction of the decidual spiral arteries, leading to ischemia, hemorrhage, and premature separation of the placenta. *Placenta previa* - Typically presents with **painless bright red vaginal bleeding** in the third trimester, often spontaneously resolving. - The uterus remains **soft or non-tender** on palpation, completely contradicting the painful, woody hard uterus described. *Uterine rupture* - While causing severe pain and maternal shock, rupture is usually associated with a history of prior **C-section or uterine surgery**. - The findings typically include **loss of fetal station** and a non-tender, distorted uterus, sometimes allowing palpation of fetal parts in the abdomen, rather than a uniformly woody hard uterus. *Vasa previa* - Characterized by **painless bleeding** that occurs secondary to the rupture of unprotected fetal vessels over the cervix, usually coinciding with amniotomy or membrane rupture. - The bleeding is **fetal in origin**, and while it leads rapidly to fetal demise (as seen here), it is not associated with severe maternal pain or a rigid, tender uterus.

Q: Which of the following does not cause fetal bradycardia?

Maternal fever. ***Maternal fever*** - Maternal fever causes **fetal tachycardia** or fetal heart rate acceleration, as the physiological response to fever is increased metabolism and heart rate. - The resulting fetal tachycardia is often a sign of impending or current **maternal infection** (e.g., chorioamnionitis). *Abruptio placenta* - Associated with acute fetal distress due to placental separation, leading to fetal **hypoxia** and **acidosis**. - Fetal hypoxia triggers a reflex bradycardia (late decelerations with bradycardia) to conserve oxygen and energy. *Meconium passage/staining* - Passage of meconium in utero is often a sign of **fetal distress** or hypoxia during labor. - Severe fetal distress and resultant cerebral hypoxia/acidosis can lead to prolonged or terminal **fetal bradycardia**. - Note: Meconium aspiration syndrome occurs postnatally, but meconium-stained amniotic fluid indicates antecedent fetal compromise. *Fetal head compression* - Leads to a transient increase in **intracranial pressure**, stimulating the **vagus nerve** mediated by the baroreceptors. - This **vagal stimulation** results in a brief, reflex slowdown of the fetal heart rate, known as **early decelerations**.

Q: Use of magnesium sulfate (MgSO4) in pre-eclampsia has all of the following effects except:

Prevent abruption of placenta. ***Prevent abruption of placenta*** - **Magnesium sulfate (MgSO4)** is primarily a **CNS depressant** (anticonvulsant) and a vasodilator, and its use is not directly associated with preventing **placental abruption**. - Placental abruption is linked to factors like short umbilical cord, trauma, and **severe hypertension**, which MgSO4 does not consistently mitigate. ***Neuroprotection*** - Administered to women at high risk of imminent **preterm birth** (less than 32 weeks), MgSO4 has a proven benefit in reducing the risk of developing **cerebral palsy** in the neonate. - This neuroprotective effect is thought to be mediated by stabilizing the blood-brain barrier and its **antioxidant properties**. ***Decrease seizure incidence*** - MgSO4 is the **drug of choice** for both the prophylaxis and treatment of seizures (eclampsia) in women with **severe pre-eclampsia**. - It works by decreasing **acetylcholine release** at the neuromuscular junction and acting as a central anticonvulsant. ***Prevent preterm labour*** - MgSO4 is a weak **tocolytic agent** and can be used to temporarily suppress uterine contractions in women presenting with threatened **preterm labor**. - Although effective for short-term suppression, it is not the primary tocolytic agent and is most famously used for its **neuroprotective** and anti-seizure properties.

Q: A 36-week pregnant woman is diagnosed with preeclampsia and started on magnesium sulfate therapy. According to the Pritchard regimen, what is the total loading dose of magnesium sulfate administered initially?

14 grams. ***14 grams*** - The **Pritchard regimen** mandates a total initial loading dose of **14 grams** of magnesium sulfate to rapidly achieve therapeutic serum levels and prevent seizures in severe preeclampsia or eclampsia. - This total dose comprises **4 grams** administered intravenously (IV) over 5-10 minutes, followed immediately by **10 grams** intramuscularly (IM) (5 grams into each buttock). *4 grams* - **4 grams** represents only the initial **intravenous component** of the loading dose, which is necessary for rapid onset of action. - This amount alone is insufficient to sustain the required therapeutic plasma concentration for an adequate duration, necessitating the added IM component. *10 grams* - **10 grams** represents the large intramuscular (IM) component of the loading dose (5g in each buttock), which provides a slow-release depot. - While crucial for the maintenance of therapeutic levels, it does not account for the immediate-acting IV component, hence failing to represent the total loading dose. *5 grams* - **5 grams** is the dose administered into a **single buttock** during the IM loading component (10g total IM) or the dose used for subsequent **maintenance therapy** (5g IM every 4 hours). - This dose, by itself, is far below the required total loading dose necessary to control acute symptoms of preeclampsia/eclampsia.

Q: Identify the type of conjoined twins shown below.

Omphalopagus. ***Omphalopagus*** - The image shows two infants joined at the **abdomen**, which is characteristic of omphalopagus conjoined twins. - This type often involves shared organs in the abdomen, such as the **liver** or **intestines**. *Craniopagus* - This type of conjoined twin is characterized by fusion at the **head** or **cranium**. - The twins in the image are clearly not joined at the head. *Ischiopagus* - Ischiopagus twins are conjoined at the **ischium** or **pelvis**, with varying degrees of shared lower body structures. - The fusion in the image is higher, at the abdominal region, not the pelvis. *Pygopagus* - Pygopagus twins are joined at the **sacrum** or **buttocks**, typically facing opposite directions. - The image shows twins joined at the front of their bodies, not the back.

Q: A patient presents with vaginal bleeding in the first trimester. Histopathological examination of the products of conception reveals the findings shown in the image below. What is the most likely diagnosis?

Partial mole. ***Partial mole*** - A partial mole is **triploid** (69,XXX, 69,XXY, or 69,XYY) and contains **fetal/embryonic tissue** alongside molar changes in the placenta. - It results from **fertilization of one ovum by two sperm** or by one diploid sperm, leading to both maternal and paternal genetic contributions. *Androgenetic complete mole* - Complete moles are **diploid** (46,XX or 46,XY) with **purely paternal genetic origin** and contain **no fetal tissue** by definition. - They present as **grape-like vesicles** without any embryonic or fetal structures, which contradicts the presence of fetal tissue in this image. *Biparental complete mole* - This extremely rare variant of complete mole has **genetic material from both parents** but still results in **no fetal development**. - Like all complete moles, it lacks **fetal tissue or embryonic structures**, making it inconsistent with the image findings. *Circumvallate placenta with IUD* - A circumvallate placenta involves **folded placental margins** where the chorionic plate is smaller than the basal plate, unrelated to molar pregnancy. - An **intrauterine device (IUD)** is a contraceptive device and would not be associated with the molar tissue changes described.

Q: The image shows the X-ray abdomen of a 30-yearold SLE patient, who cannot feel her baby moving for the past 7 days. All are correct about the condition shown except:

Elevated fibrinogen. ***Elevated fibrinogen*** - This is the **INCORRECT** statement (answer to this EXCEPT question). - In fetal demise with retained dead fetus, fibrinogen levels typically **DECREASE, not increase**. - **Hypofibrinogenemia** occurs due to **consumption coagulopathy** from the release of thromboplastic substances from dead fetal tissue into maternal circulation. - If the dead fetus is retained for prolonged periods (>4-5 weeks), there is risk of **DIC (Disseminated Intravascular Coagulation)** with depletion of clotting factors including fibrinogen. - While SLE itself may have inflammatory markers, the statement "elevated fibrinogen" does not apply to the fetal demise scenario shown. *Hyperflexion of spine* - **CORRECT** finding in fetal demise with Spalding's sign. - The X-ray shows **overlapping of fetal skull bones** (Spalding's sign) indicating fetal death. - Loss of **fetal muscle tone** after death causes the spine to become **hyperflexed and curled**, visible on imaging. - This is a characteristic radiological finding of retained dead fetus. *Single fetus* - **CORRECT** observation from the X-ray. - The image clearly shows skeletal structures of **one fetus only**. - The fetal skull and spine outline confirm a single intrauterine fetal demise. *Anti-Beta 2 glycoprotein antibody* - **CORRECT** association in this clinical scenario. - Patient has **SLE** with fetal demise, strongly suggesting **Antiphospholipid Syndrome (APS)**. - **Anti-β2-glycoprotein I antibodies** are one of the diagnostic criteria for APS. - APS causes **recurrent pregnancy loss** and **fetal death after 10 weeks** due to **placental thrombosis**. - This antibody should be tested in SLE patients with adverse pregnancy outcomes.

Q: What is incorrect about the neonate shown:

Occipitoanterior presentation is common. ***Occipitoanterior presentation is common*** - Anencephaly, shown in the image, is associated with an **increased incidence of breech presentation** or other abnormal presentations, not occipitoanterior. - The absence of the cranial vault and brain tissue can affect the fetal head's ability to engage and present in the optimal occipitoanterior position. *Impaired swallowing reflex* - The absence of a developed brainstem in anencephaly leads to a **severely impaired or absent swallowing reflex**. - This prevents the fetus from swallowing amniotic fluid, which is a major contributor to polyhydramnios. *Polyhydramnios* - Due to the **impaired fetal swallowing reflex** in anencephaly, there is an accumulation of amniotic fluid. - The inability of the fetus to properly reabsorb amniotic fluid leads to an excessive volume of amniotic fluid. *Small adrenals* - In anencephaly, the **fetal pituitary gland is underdeveloped or absent**, which leads to a lack of ACTH stimulation. - This results in **hypoplasia (small size)** of the fetal adrenal glands because the adrenal cortex depends on ACTH for its development and function.

Q: A gynecologist noted that fetal head is difficult to push down into the pelvis at 36 weeks of gestation. Antenatal USG done shows presence of:

Congenital hydrocephalus. ***Congenital hydrocephalus*** - The ultrasound image shows significantly **enlarged ventricles (V)** indicated by the arrows, which is characteristic of **hydrocephalus**. - **Fetal head pushing down into the pelvis** in late pregnancy can be difficult if the head is abnormally large due to hydrocephalus, making it a plausible finding. *Snowstorm appearance of antenatal USG* - A **snowstorm appearance** on antenatal ultrasound is pathognomonic for **complete hydatidiform mole**, which is a placental abnormality, not a fetal head anomaly. - This finding would not explain difficulty pushing the fetal head into the pelvis. *Spinal dysraphism* - **Spinal dysraphism** involves malformations of the spinal cord and its coverings (e.g., spina bifida), and while it can be associated with hydrocephalus (e.g., Arnold-Chiari malformation), the primary USG finding for dysraphism itself is a defect in the spine. - The image provided specifically highlights **enlarged cerebral ventricles**, not a spinal defect. *Increased nuchal translucency* - **Increased nuchal translucency** refers to an abnormal accumulation of fluid behind the fetal neck in the first trimester, typically associated with chromosomal abnormalities like **Down syndrome** or cardiac defects. - While an important early marker, it is not directly related to difficulty descending the fetal head or the ventricular enlargement seen in the image.

Question 1

A primigravida woman at 26 weeks gestation, presented with a BP of 150/90 mm Hg. Which test should be done next?

Accepted Answer

Urine dipstick

Answer

Uric acid

Answer

Liver function test

Answer

Complete blood count

Question 2

A 32-year-old woman at 32 weeks gestation presents with sudden-onset severe abdominal pain and vaginal bleeding. She has a history of cocaine use. On examination, the uterus is tender, firm, and woody hard. Fetal heart sounds are absent. Blood pressure is 90/60 mmHg, pulse 120/min. What is the most likely diagnosis?

Accepted Answer

Placental abruption

Answer

Placenta previa

Answer

Vasa previa

Answer

Uterine rupture

Question 3

Which of the following does not cause fetal bradycardia?

Accepted Answer

Maternal fever

Answer

Fetal head compression

Answer

Abruptio placenta

Answer

Meconium passage

Question 4

Use of magnesium sulfate (MgSO4) in pre-eclampsia has all of the following effects except:

Accepted Answer

Prevent abruption of placenta

Answer

Prevent preterm labour

Answer

Neuroprotection

Answer

Decrease seizure incidence

Question 5

A 36-week pregnant woman is diagnosed with preeclampsia and started on magnesium sulfate therapy. According to the Pritchard regimen, what is the total loading dose of magnesium sulfate administered initially?

Accepted Answer

14 grams

Answer

5 grams

Answer

4 grams

Answer

10 grams

Question 6

Identify the type of conjoined twins shown below.

Accepted Answer

Omphalopagus

Answer

Craniopagus

Answer

Ischiopagus

Answer

Pygopagus

Question 7

A patient presents with vaginal bleeding in the first trimester. Histopathological examination of the products of conception reveals the findings shown in the image below. What is the most likely diagnosis?

Accepted Answer

Partial mole

Answer

Biparental complete mole

Answer

Circumvallate placenta with IUD

Answer

Androgenetic complete mole

Question 8

The image shows the X-ray abdomen of a 30-yearold SLE patient, who cannot feel her baby moving for the past 7 days. All are correct about the condition shown except:

Accepted Answer

Elevated fibrinogen

Answer

Hyperflexion of spine

Answer

Single fetus

Answer

Anti-Beta 2 glycoprotein antibody

Question 9

What is incorrect about the neonate shown:

Accepted Answer

Occipitoanterior presentation is common

Answer

Impaired swallowing reflex

Answer

Polyhydramnios

Answer

Small adrenals

Question 10

A gynecologist noted that fetal head is difficult to push down into the pelvis at 36 weeks of gestation. Antenatal USG done shows presence of:

Accepted Answer

Congenital hydrocephalus

Answer

Snowstorm appearance of antenatal USG

Answer

Spinal dysraphism

Answer

Increased nuchal translucency

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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