Maternal-Fetal Medicine Practice Questions

Q: A young female patient presents with a history of two months amenorrhoea and complaints of severe lower abdominal pain, syncopal attacks and minimal per vaginal bleeding. On examination, she has tachycardia and appears pale. The clinical diagnosis is

Ectopic pregnancy. ***Ectopic pregnancy*** - The combination of **amenorrhoea**, severe **lower abdominal pain**, **syncopal attacks**, and signs of **hypovolemic shock** (tachycardia, pallor) strongly indicates a ruptured ectopic pregnancy. - Minimal per vaginal bleeding is common, and the syncopal episodes are due to **hemoperitoneum** and resulting hypovolemia. *Missed abortion* - A missed abortion typically involves **no symptoms of acute distress** or shock. Patients often present with absent fetal heart tones on ultrasound, but without acute pain or significant bleeding initially. - There would be no signs of hypovolemia such as tachycardia or syncopal attacks, as the bleeding is usually contained within the uterus or minimal. *Molar pregnancy* - While a molar pregnancy can present with amenorrhoea and vaginal bleeding, it typically causes symptoms like **excessive nausea and vomiting**, and a **grape-like vesicular discharge**. - It does not usually cause acute, severe abdominal pain or hypovolemic shock unless there is a rare complication like uterine perforation, which is not the primary presentation. *Inevitable abortion* - An inevitable abortion presents with **vaginal bleeding** and **cervical dilatation**, often accompanied by abdominal cramping. - While there can be significant bleeding, it is usually not associated with acute, severe pain or rapid onset of **hypovolemic shock** and syncopal attacks as seen with a ruptured ectopic pregnancy.

Q: An elderly gravida with 36-weeks pregnancy presents with severe pregnancy induced hypertension (PIH), severe abdominal pain, per vaginal bleeding and loss of foetal movements. The diagnosis is

Abruptio placenta. ***Abruptio placenta*** - The combination of **severe abdominal pain**, **vaginal bleeding**, **loss of fetal movements**, and **severe pregnancy-induced hypertension (PIH)** in an elderly gravida at 36 weeks is a classic presentation of **abruptio placenta** (placental abruption). - Severe PIH is a significant **risk factor for placental abruption**, and the pain, bleeding, and fetal distress are due to premature separation of the placenta from the uterine wall. *Vasa praevia* - Characterized by **painless, bright red vaginal bleeding** of fetal origin that typically occurs when the membranes rupture, associated with **fetal distress** or bradycardia. - While there is bleeding and fetal distress mentioned in the question, the presence of **severe abdominal pain** and **PIH** is not typical of vasa praevia, which presents with painless bleeding. *Rupture of uterus* - Uterine rupture usually presents with sudden, **excruciating abdominal pain**, **loss of uterine contractions**, **cessation of labor progress**, and often a **palpable fetal part** outside the uterus if the rupture is complete. - While severe pain and loss of fetal movements are present, the absence of prior uterine surgery (like a C-section) or high parity as risk factors, and the specific association with **severe PIH** pointing strongly to abruption, makes this less likely. *Placenta praevia* - Typically presents with **painless, bright red vaginal bleeding** in the second or third trimester, without associated abdominal pain. - The presence of **severe abdominal pain** and **loss of fetal movements** rules out placenta previa, as these are not characteristic symptoms.

Q: A 30-year-old third gravida, who has a 3-year-old child and had undergone a MTP one year ago, has presented with 30-weeks pregnancy. She complains of having vaginal bleeding 2 hours ago. She has not received any antenatal care. Her pulse is 78 beats per minute, and the BP is 102/58 mmHg. The most appropriate management will include: 1. Ultrasonographic evaluation 2. Watch for labour 3. Hospitalisation and bed rest 4. Speculum examination of vagina and cervix 5. I.V. fluid drip Select the appropriate combination:

1, 3 and 5. ***1, 3 and 5*** - This patient presents with **third-trimester vaginal bleeding** without prior antenatal care, which is a significant red flag requiring immediate investigation and management. An **ultrasonographic evaluation** is crucial to determine the cause of bleeding, especially to rule out **placenta previa** or **abruptio placentae**, which dictate further management. - **Hospitalization and bed rest** are essential to stabilize the patient, monitor the bleeding, and prepare for potential complications. Initiating an **I.V. fluid drip** is critical for maintaining **hemodynamic stability**, especially given her low blood pressure of 102/58 mmHg, and for providing immediate venous access. *2, 3 and 4* - **Watching for labor** without first establishing the cause of bleeding is inappropriate and potentially dangerous, as active management might be needed. - A **speculum examination** should *not* be the initial step before an ultrasound, as a digital or speculum exam in cases of undiagnosed placenta previa can provoke severe hemorrhage. *1 and 2* - While an **ultrasound (1)** is necessary to diagnose the cause of bleeding, **watching for labor (2)** without further intervention or stabilization is insufficient for a woman with third-trimester bleeding, especially with no prior antenatal care. - This option misses crucial components like hospitalization, bed rest, and IV fluids, which are part of initial stabilization. *1, 4 and 5* - **Ultrasonographic evaluation (1)** and **I.V. fluid drip (5)** are appropriate, but **speculum examination of the vagina and cervix (4)** should be avoided until placenta previa is ruled out by ultrasound. - A digital or speculum exam could exacerbate bleeding if **placenta previa** is present, making this a potentially harmful step in the initial management.

Q: A multiparous patient has been diagnosed to have foetal demise on a sonographic examination at 16 weeks of pregnancy. The ideal method for termination is

High vaginal insertion of dinoprostone gel. ***High vaginal insertion of dinoprostone gel*** - **Dinoprostone gel** (PGE2) is a **prostaglandin** that softens the cervix and stimulates uterine contractions, making it an ideal agent for medical induction in cases of fetal demise, particularly in the second trimester. - Its **vaginal insertion** allows for controlled, localized delivery and absorption, promoting efficient uterine evacuation while minimizing systemic side effects. *Extra-amniotic ethacridine* - **Ethacridine lactate** is typically used for **mid-trimester abortion** by direct instillation into the extra-amniotic space. - While effective, it carries a higher risk of infection and uterine rupture compared to prostaglandin administration for fetal demise at 16 weeks. *Dilation and evacuation (D&E)* - **D&E** is a surgical procedure commonly used for **second-trimester abortions**, involving cervical dilation and surgical removal of uterine contents. - While an option, medical induction with prostaglandins is generally preferred for **fetal demise** at 16 weeks due to lower risks of uterine injury and adhesions, as well as providing a more natural expulsion process. *Hysterectomy with tubectomy* - **Hysterectomy with tubectomy** (removal of the uterus and fallopian tubes) is a major surgical procedure that is **not indicated** for termination of pregnancy due to fetal demise. - It is reserved for severe medical conditions or desires for permanent sterilization, given its irreversible nature and significant surgical risks.

Q: Which one of the following statements is not correct regarding the haemodynamic changes occurring during a pregnancy?

The systemic vascular resistance is increased. ***The systemic vascular resistance is increased*** - During normal pregnancy, **systemic vascular resistance (SVR)** actually **decreases** due to vasodilation induced by factors like **prostaglandins** and **nitric oxide**. - A decrease in systemic vascular resistance helps accommodate the increased blood volume and cardiac output, ensuring adequate perfusion to the uteroplacental unit and other organs. *The cardiac output is increased* - **Cardiac output (CO)** progressively **increases** during pregnancy, peaking in the second and third trimesters. - This increase is primarily due to a rise in both **heart rate** and **stroke volume**. *The serum colloid pressure is decreased* - **Serum colloid osmotic pressure** (oncotic pressure) **decreases** in pregnancy due to a disproportionate increase in plasma volume relative to the increase in albumin production. - This leads to **dilutional hypoalbuminemia**, contributing to physiological edema. *The stroke volume is increased* - **Stroke volume (SV)** significantly **increases** during pregnancy, driven by increased end-diastolic volume and enhanced myocardial contractility. - This rise in stroke volume is a major contributor to the overall increase in cardiac output.

Q: Foetal anaemia can be detected non-invasively by Doppler ultrasonography on the basis of an increase in the

Peak systolic velocity of the middle cerebral artery. ***Peak systolic velocity of the middle cerebral artery*** - **Foetal anaemia** causes increased **cardiac output** and redistribution of blood flow to vital organs, leading to an increase in **peak systolic velocity (PSV)** in the **middle cerebral artery (MCA)**. - This increased velocity indicates **cerebral vasodilation**, a compensatory mechanism to maintain oxygen delivery to the foetal brain in situations of hypoxia due to anaemia. *SD ratio in the anterior cerebral artery* - The **SD ratio (systolic/diastolic ratio)** is more commonly used in umbilical artery flow. A higher SD ratio in cerebral arteries typically suggests increased downstream resistance, which is not characteristic of foetal anaemia. - In foetal anaemia, the cerebral arteries would typically show **decreased resistance**, leading to a lower, not higher, SD ratio. *SD ratio in the umbilical artery* - An increased **SD ratio in the umbilical artery** often indicates **placental insufficiency** or **foetal growth restriction**, not necessarily **foetal anaemia**. - While placental insufficiency can lead to foetal anaemia, the direct Doppler marker for anaemia is the MCA PSV, reflecting the foetal response to hypoxia. *Peak systolic velocity of the anterior cerebral artery* - While both anterior and middle cerebral arteries are part of the cerebral circulation, the **middle cerebral artery (MCA)** is the most widely validated and sensitive vessel for detecting changes in **foetal blood flow** due to **anaemia**. - Changes in the anterior cerebral artery's PSV are not as reliably linked to the diagnosis of foetal anaemia as those in the MCA.

Q: In a woman with molar pregnancy with a uterus size of 28 weeks, the treatment of choice is

Suction evacuation. ***Suction evacuation*** - For **molar pregnancy**, especially with a large uterine size (28 weeks in this case), **suction evacuation** is the treatment of choice to remove the abnormal trophoblastic tissue. - This method is preferred due to its safety and efficacy in emptying the uterus while minimizing complications like hemorrhage or uterine perforation. *Hysteroscopy* - **Hysteroscopy** is primarily used for diagnosing and treating intrauterine pathologies such as polyps or fibroids, and for endometrial assessment. It is not the primary treatment for molar pregnancy. - It involves inserting a scope into the uterus and is not designed for the large-volume tissue removal required in a molar pregnancy of this size. *Hysterectomy* - **Hysterectomy** (surgical removal of the uterus) is generally reserved for rare cases of recurrent molar pregnancy, when the patient desires no future fertility, or in the context of invasive molar disease or choriocarcinoma. It is not the initial treatment of choice. - It is an overly aggressive approach for an initial presentation of molar pregnancy, especially if the patient wishes to preserve fertility. *Medical induction with prostaglandins* - **Medical induction** using prostaglandins is typically used for therapeutic abortion or managing missed abortions, but it is contraindicated in molar pregnancy. - Prostaglandins can lead to vigorous uterine contractions and potentially cause a rapid expulsion of molar tissue into the systemic circulation, increasing the risk of **trophoblastic embolization** and choriocarcinoma.

Q: A fourth-gravida with three living children presents at 38 weeks of pregnancy with abdominal pain and vaginal bleeding. On examination, the uterus is tense and tender, and the foetal heart sounds are absent. What is the probable diagnosis?

Accidental haemorrhage. ***Accidental haemorrhage*** - The combination of **abdominal pain**, **vaginal bleeding**, a **tense and tender uterus**, and **absent fetal heart sounds** strongly indicates accidental hemorrhage (placental abruption). - This condition involves the premature separation of the **placenta** from the uterine wall, leading to concealed or revealed bleeding and frequently resulting in fetal demise. *Vasa praevia* - Characterized by **fetal blood vessels** crossing the cervical os, making the fetus vulnerable to hemorrhage. - While it causes **painless vaginal bleeding**, it typically does not present with a **tense and tender uterus** or immediate fetal demise unless there is membrane rupture. *Ectopic pregnancy* - Occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. - Presents with **abdominal pain** and **vaginal bleeding**, but this occurs in the **first trimester**, not at 38 weeks of pregnancy. *Placenta praevia* - Involves the placenta covering the cervical os, leading to **painless vaginal bleeding**. - Unlike accidental hemorrhage, the uterus is typically **soft and non-tender**, and fetal heart sounds are usually present.

Q: A pregnant woman with 10 weeks gestation is diagnosed to have an ovarian cyst of 11 cm diameter. The best timing for the removal of the ovarian cyst is

In the second trimester (14-20 weeks). ***In the second trimester (14-20 weeks)*** - The **second trimester** is the optimal timing for elective surgery during pregnancy as **organogenesis is complete** (reducing teratogenic risk) but the uterus is not yet too large to complicate surgery. - An **11 cm ovarian cyst** is large and unlikely to resolve spontaneously, warranting surgical intervention rather than expectant management. *At the time of caesarean section* - This approach assumes a **planned C-section** is indicated, which is not supported at 10 weeks gestation when mode of delivery cannot be predetermined. - Delaying surgery until an uncertain future C-section risks **complications** like torsion, rupture, or further cyst growth during pregnancy. *Immediately* - **First trimester surgery** carries higher risk of **miscarriage** and potential teratogenic effects during the critical organogenesis period. - While immediate intervention might prevent complications, the risks of surgery at 10 weeks outweigh the benefits for an asymptomatic cyst. *Immediately after delivery* - Post-delivery surgery involves increased **vascularity** and complications related to **uterine involution** and tissue changes. - This timing requires a **separate surgical procedure** and anesthetic exposure, increasing overall morbidity compared to planned second trimester surgery.

Q: In a gravid woman with placenta praevia, the following fetal complications are known to increase 1. Congenital malformations 2. Intrauterine growth retardation 3. Prematurity Select the correct answer from the code given below :

1, 2 and 3. ***1, 2 and 3*** - **Placenta praevia** is associated with an increased risk of **congenital malformations**, with studies showing a 2-3 fold increased risk compared to normal placentation. This includes CNS anomalies, cardiovascular defects, and musculoskeletal malformations. - **Intrauterine growth retardation (IUGR)** is a known complication due to impaired placental perfusion and suboptimal placental function in the lower uterine segment. - **Prematurity** is significantly increased with placenta praevia, often necessitating early delivery due to antepartum hemorrhage or other maternal-fetal complications. *1 and 2 only* - This option incorrectly excludes **prematurity**, which is one of the most significant fetal complications of placenta praevia. - Preterm delivery is often required due to recurrent bleeding episodes. *1 and 3 only* - This option incorrectly excludes **IUGR**, which is a well-documented complication. - The lower uterine segment has relatively poor vascularization, contributing to placental insufficiency. *2 and 3 only* - This option incorrectly excludes **congenital malformations**. - Multiple population-based studies have demonstrated an association between placenta praevia and increased rates of fetal anomalies, particularly involving the CNS and cardiovascular systems.

Question 1

A young female patient presents with a history of two months amenorrhoea and complaints of severe lower abdominal pain, syncopal attacks and minimal per vaginal bleeding. On examination, she has tachycardia and appears pale. The clinical diagnosis is

Accepted Answer

Ectopic pregnancy

Answer

Missed abortion

Answer

Molar pregnancy

Answer

Inevitable abortion

Question 2

An elderly gravida with 36-weeks pregnancy presents with severe pregnancy induced hypertension (PIH), severe abdominal pain, per vaginal bleeding and loss of foetal movements. The diagnosis is

Accepted Answer

Abruptio placenta

Answer

Vasa praevia

Answer

Rupture of uterus

Answer

Placenta praevia

Question 3

A 30-year-old third gravida, who has a 3-year-old child and had undergone a MTP one year ago, has presented with 30-weeks pregnancy. She complains of having vaginal bleeding 2 hours ago. She has not received any antenatal care. Her pulse is 78 beats per minute, and the BP is 102/58 mmHg.

The most appropriate management will include:

1. Ultrasonographic evaluation
2. Watch for labour
3. Hospitalisation and bed rest
4. Speculum examination of vagina and cervix
5. I.V. fluid drip

Select the appropriate combination:

Accepted Answer

1, 3 and 5

Answer

2, 3 and 4

Answer

1 and 2

Answer

1, 4 and 5

Question 4

A multiparous patient has been diagnosed to have foetal demise on a sonographic examination at 16 weeks of pregnancy. The ideal method for termination is

Accepted Answer

High vaginal insertion of dinoprostone gel

Answer

Extra-amniotic ethacridine

Answer

Dilation and evacuation (D&E)

Answer

Hysterectomy with tubectomy

Question 5

Which one of the following statements is not correct regarding the haemodynamic changes occurring during a pregnancy?

Accepted Answer

The systemic vascular resistance is increased

Answer

The cardiac output is increased

Answer

The serum colloid pressure is decreased

Answer

The stroke volume is increased

Question 6

Foetal anaemia can be detected non-invasively by Doppler ultrasonography on the basis of an increase in the

Accepted Answer

Peak systolic velocity of the middle cerebral artery

Answer

SD ratio in the anterior cerebral artery

Answer

Peak systolic velocity of the anterior cerebral artery

Answer

SD ratio in the umbilical artery

Question 7

In a woman with molar pregnancy with a uterus size of 28 weeks, the treatment of choice is

Accepted Answer

Suction evacuation

Answer

Hysteroscopy

Answer

Hysterectomy

Answer

Medical induction with prostaglandins

Question 8

A fourth-gravida with three living children presents at 38 weeks of pregnancy with abdominal pain and vaginal bleeding. On examination, the uterus is tense and tender, and the foetal heart sounds are absent. What is the probable diagnosis?

Accepted Answer

Accidental haemorrhage

Answer

Vasa praevia

Answer

Ectopic pregnancy

Answer

Placenta praevia

Question 9

A pregnant woman with 10 weeks gestation is diagnosed to have an ovarian cyst of 11 cm diameter. The best timing for the removal of the ovarian cyst is

Accepted Answer

In the second trimester (14-20 weeks)

Answer

Immediately

Answer

Immediately after delivery

Answer

At the time of caesarean section

Question 10

In a gravid woman with placenta praevia, the following fetal complications are known to increase

1. Congenital malformations 
2. Intrauterine growth retardation 
3. Prematurity

Select the correct answer from the code given below :

Accepted Answer

1, 2 and 3

Answer

1 and 2 only

Answer

1 and 3 only

Answer

2 and 3 only

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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