Maternal-Fetal Medicine Practice Questions

Q: Which of the following are correct regarding pathological findings of placenta accreta? 1. Absence of decidua basalis 2. Absence of Nitabuch's fibrinoid layer 3. Loss of normal hypoechoic retroplacental myometrial zone in ultrasonography Select the answer using the code given below.

1, 2 and 3. **Correct: 1, 2 and 3** - **Placenta accreta** is pathologically defined by the **direct adherence of villi to the myometrium** due to a deficient or absent decidua. - The absence of both the **decidua basalis** and the **Nitabuch's fibrinoid layer** allows for the abnormal trophoblast invasion and adherence to the myometrium. - On ultrasound, this condition is characterized by the **loss of the normal hypoechoic retroplacental myometrial zone**, which indicates the absence of a clear boundary between the placenta and the uterine wall. - All three findings (statements 1, 2, and 3) are correct pathological and diagnostic features of placenta accreta. *Incorrect: 1 and 3 only* - This option is incomplete as it omits the crucial role of the **Nitabuch's fibrinoid layer** absence in the pathology of placenta accreta. - The Nitabuch's layer normally acts as a protective barrier against deep placental invasion, and its absence is a key pathological feature. *Incorrect: 1 and 2 only* - While both the absence of decidua basalis and Nitabuch's fibrinoid layer are definitive pathological findings, this option fails to include the important **ultrasonographic feature** that aids in antenatal diagnosis. - The **loss of the retroplacental hypoechoic zone** is a critical diagnostic sign in clinical practice. *Incorrect: 2 and 3 only* - This option is incorrect because it overlooks the primary pathological feature of placenta accreta, which is the **absence of the decidua basalis**. - The decidua basalis normally forms the maternal component of the placenta, and its absence is fundamental to the abnormal adherence.

Q: Consider the following statements regarding oligohydramnios: 1. It is defined on USG when maximum vertical pocket of liquor is less than 3 cm. 2. It is defined on USG when AFI is less than 5 cm. 3. It is associated with increased risk of cord compression during labor. 4. It is commonly seen in post-term pregnancies. Select the correct answer using the code given below.

2, 3 and 4. ***2, 3 and 4*** - This option correctly identifies the accurate definitions and associations of **oligohydramnios**. - Statement 2 correctly defines oligohydramnios as **AFI 42 weeks) due to placental insufficiency and reduced fetal urine production. *1 and 2 only* - Statement 1 is **incorrect**: oligohydramnios is defined as maximum vertical pocket (MVP) **< 2 cm**, not < 3 cm. - This option excludes the important clinical associations of cord compression and post-term pregnancy. *1, 2 and 4* - Statement 1 is **incorrect**: the correct cutoff for MVP is **< 2 cm**, not < 3 cm. - This option misses the crucial risk of **cord compression** during labor. *1, 3 and 4* - Statement 1 is **incorrect**: oligohydramnios by MVP method is defined as **< 2 cm**, not < 3 cm. - This option misses the alternative and commonly used definition via **AFI < 5 cm**.

Q: Which of the following are the various treatment options for Twin-Twin Transfusion Syndrome (TTTS)?

All of the options. ***All of the options*** - **Laser photocoagulation**, **septostomy**, and **selective fetal reduction** are established treatment modalities for Twin-Twin Transfusion Syndrome (TTTS). - The choice of treatment depends on the **stage of TTTS**, gestational age, and specific presentation of the twins. *Laser photocoagulation* - This procedure involves using a **laser to ablate the anastomotic vessels** on the chorionic plate, which are responsible for the unequal blood flow between twins. - It is currently considered the **gold standard** for treating severe TTTS, particularly in stages II-IV, offering improved survival rates for both twins compared to other methods. *Septostomy* - **Septostomy** involves creating a small perforation in the dividing membrane between the two amniotic sacs to allow amniotic fluid to equilibrate between the sacs. - This can help decompress severe polyhydramnios in the recipient twin, but it does **not address the underlying vascular anastomoses**. - **Amnioreduction** (serial drainage of excess amniotic fluid) is a related but distinct palliative treatment option. *Selective fetal reduction* - This involves **terminating the life of one of the fetuses** in a multifetal pregnancy to improve the chances of survival for the remaining fetus. - It is typically considered in **severe, refractory cases of TTTS** where other treatments have failed or are not feasible, particularly if one twin has severe anomalies or irreversible damage.

Q: Missed abortion is not diagnosed if

USG shows fetus with cardiac activity. ***USG shows fetus with cardiac activity*** - The presence of **fetal cardiac activity** on ultrasound is the definitive sign of a viable pregnancy, ruling out missed abortion. - Missed abortion is characterized by a **non-viable intrauterine pregnancy** (no cardiac activity) with a closed cervix, and would not be diagnosed if cardiac activity is detected. *uterus is smaller than gestational age* - A uterus consistently smaller than expected for gestational age can be a sign of a **non-viable pregnancy** or **intrauterine growth restriction**, both of which could be associated with missed abortion. - However, this finding alone is not diagnostic and needs confirmation with ultrasound to assess fetal viability. *external os is closed* - A **closed external os** is characteristic of a missed abortion, where the products of conception are retained within the uterus. - In a missed abortion, the cervix often remains closed, preventing the expulsion of the non-viable pregnancy. *vaginal bleed is brownish in colour* - **Brownish vaginal bleeding** indicates old or deoxygenated blood, which is a common symptom of a threatened abortion or missed abortion. - This type of bleeding suggests that the pregnancy may not be progressing normally and often prompts further investigation to assess fetal viability.

Q: Which of the following fetal infections is MOST commonly associated with significant intrauterine growth restriction?

Cytomegalovirus infection. ***Cytomegalovirus infection*** - **Cytomegalovirus (CMV)** is the **most common congenital infection** and the **leading cause of intrauterine growth restriction (IUGR)** among the TORCH infections. - CMV has a direct cytopathic effect on fetal tissues and significantly impairs placental function, leading to severe and consistent growth restriction. - Congenital CMV infection affects approximately **0.5-1% of all live births**, with **IUGR being one of the most prominent features** in symptomatic cases. - Other manifestations include microcephaly, intracranial calcifications, hepatosplenomegaly, sensorineural hearing loss, and neurodevelopmental impairment. *Human papillomavirus infection* - **Human papillomavirus (HPV)** is primarily associated with genital warts and cervical dysplasia in mothers. - While vertical transmission can occur (causing juvenile-onset recurrent respiratory papillomatosis), HPV **does not cause IUGR**. - HPV is **not part of the TORCH infections** and has no association with fetal growth restriction. *Rubella infection* - **Congenital rubella syndrome** is characterized by the classic triad: cataracts, cardiac defects (patent ductus arteriosus), and sensorineural hearing loss. - While rubella **can cause IUGR**, it is far less common in modern practice due to widespread **MMR vaccination**. - The incidence of congenital rubella has dramatically decreased, making it a less frequent cause of IUGR compared to CMV. *Toxoplasmosis* - **Congenital toxoplasmosis** presents with the classic triad: hydrocephalus, intracranial calcifications, and chorioretinitis. - While toxoplasmosis **can contribute to growth restriction**, IUGR is not its most prominent or consistent feature. - **CMV remains the most common and most consistently associated** TORCH infection with significant IUGR in clinical practice.

Q: "Variable decelerations" on an electronic fetal heart rate monitor imply

Umbilical cord compression. ***Umbilical cord compression*** - **Variable decelerations** are characterized by an **abrupt decrease** in fetal heart rate, which varies in timing, depth, and duration relative to uterine contractions. - This pattern is most commonly caused by **umbilical cord compression**, which temporarily reduces blood flow to the fetus, leading to immediate baroreceptor-mediated bradycardia. *Fetal head compression* - **Early decelerations** are typically associated with **fetal head compression** during contractions. - These are characterized by a gradual decrease in fetal heart rate that mirrors the contraction, with the nadir coinciding with the peak of the contraction. *Utero-placental insufficiency* - **Late decelerations** are associated with **utero-placental insufficiency**, indicating inadequate oxygen delivery to the fetus. - These are characterized by a gradual decrease in fetal heart rate that begins after the peak of the contraction and recovers after the contraction has ended. *Fetal anemia* - **Fetal anemia** can lead to a variety of fetal heart rate abnormalities, including **sinusoidal patterns** or **tachycardia**, as the fetus attempts to compensate for reduced oxygen-carrying capacity. - It does not typically present as isolated variable decelerations.

Q: The following changes may be seen in pre-eclampsia except

Hemodilution. ***Hemodilution*** - Pre-eclampsia is characterized by generalized **vasoconstriction** and **reduced plasma volume**, leading to **hemoconcentration**, not hemodilution. - The elevated hematocrit sometimes observed is a consequence of this reduced plasma volume. *Thrombocytopenia* - **Thrombocytopenia** (platelet count < 100,000/µL) is a common finding in severe pre-eclampsia and is part of the HELLP syndrome criteria. - It results from increased platelet consumption and destruction due to widespread endothelial dysfunction. *Decreased antithrombin III* - **Decreased antithrombin III** levels are characteristic of pre-eclampsia, reflecting disseminated intravascular coagulation (DIC) and increased consumption of coagulation factors. - This contributes to the procoagulant state often seen in severe pre-eclampsia. *Elevated uric acid* - **Elevated uric acid** is a common and early biochemical marker in pre-eclampsia, often correlating with disease severity. - It results from reduced renal clearance and increased production, reflecting renal impairment and widespread endothelial dysfunction.

Q: What is the most commonly observed fetal effect in women receiving magnesium sulphate therapy for pre-eclampsia/eclampsia ?

Respiratory depression. ***Respiratory depression*** - Magnesium sulfate readily crosses the placenta, leading to elevated magnesium levels in the fetus, which can cause **central nervous system depression** and **respiratory depression** at birth. - This is the **most commonly observed fetal effect**, manifesting as neonatal hypermagnesemia with respiratory compromise, hypotonia, and decreased reflexes. - The effect is due to magnesium's role as a **neuromuscular blocker**, reducing acetylcholine release at the neuromuscular junction. *Intestinal obstruction* - There is no direct link between maternal magnesium sulfate therapy and an increased risk of **fetal intestinal obstruction**. - Intestinal obstruction in neonates is typically associated with **structural anomalies** or conditions like meconium ileus, not magnesium exposure. *Variability in fetal heart rate pattern* - While magnesium sulfate can cause **decreased fetal heart rate variability** as a monitoring finding, this is not the "most commonly observed fetal effect." - Decreased variability is a **transient monitoring change** during therapy, whereas respiratory depression is a direct clinical effect observed at birth. - The question asks for the most common **fetal effect**, and respiratory depression at delivery is more clinically significant and commonly encountered. *Cerebral palsy* - Magnesium sulfate is actually used as a **neuroprotective agent** in preterm births to **reduce the risk of cerebral palsy**. - It does not cause cerebral palsy; rather, it provides fetal neuroprotection when given for preterm labor <32 weeks gestation.

Question 1

Which of the following are correct regarding pathological findings of placenta accreta?

1. Absence of decidua basalis
2. Absence of Nitabuch's fibrinoid layer
3. Loss of normal hypoechoic retroplacental myometrial zone in ultrasonography Select the answer using the code given below.

Accepted Answer

1, 2 and 3

Answer

1 and 3 only

Answer

1 and 2 only

Answer

2 and 3 only

Question 2

Consider the following statements regarding oligohydramnios:

1. It is defined on USG when maximum vertical pocket of liquor is less than 3 cm.

2. It is defined on USG when AFI is less than 5 cm.

3. It is associated with increased risk of cord compression during labor.

4. It is commonly seen in post-term pregnancies.

Select the correct answer using the code given below.

Accepted Answer

2, 3 and 4

Answer

1 and 2 only

Answer

1, 2 and 4

Answer

1, 3 and 4

Question 3

Which of the following is the MOST CHARACTERISTIC symptom complex of ectopic pregnancy?

1. Acute abdominal pain following amenorrhea
2. Abdominal pain with bleeding P/V
3. Fainting attack with shoulder pain
4. Painless continuous bleeding

Accepted Answer

1. Acute abdominal pain following amenorrhea

Answer

3. Fainting attack with shoulder pain

Answer

4. Painless continuous bleeding

Answer

2. Abdominal pain with bleeding P/V

Question 4

Which of the following are the various treatment options for Twin-Twin Transfusion Syndrome (TTTS)?

Accepted Answer

All of the options

Answer

Laser photocoagulation

Answer

Septostomy

Answer

Selective fetal reduction

Question 5

Missed abortion is not diagnosed if

Accepted Answer

USG shows fetus with cardiac activity

Answer

uterus is smaller than gestational age

Answer

external os is closed

Answer

vaginal bleed is brownish in colour

Question 6

Which of the following fetal infections is MOST commonly associated with significant intrauterine growth restriction?

Accepted Answer

Cytomegalovirus infection

Answer

Human papillomavirus infection

Answer

Rubella infection

Answer

Toxoplasmosis

Question 7

"Variable decelerations" on an electronic fetal heart rate monitor imply

Accepted Answer

Umbilical cord compression

Answer

Fetal head compression

Answer

Utero-placental insufficiency

Answer

Fetal anemia

Question 8

The following changes may be seen in pre-eclampsia except

Accepted Answer

Hemodilution

Answer

Thrombocytopenia

Answer

Decreased antithrombin III

Answer

Elevated uric acid

Question 9

Spiegelberg's criteria for diagnosis of ovarian pregnancy include the following except

Accepted Answer

Gestational sac is connected with infundibulopelvic ligament

Answer

Gestational sac must occupy the position of ovary

Answer

Ovarian tissue should be present in the wall of gestational sac on histopathology

Answer

Tube on the affected side must be intact

Question 10

What is the most commonly observed fetal effect in women receiving magnesium sulphate therapy for pre-eclampsia/eclampsia ?

Accepted Answer

Respiratory depression

Answer

Intestinal obstruction

Answer

Variability in fetal heart rate pattern

Answer

Cerebral palsy

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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