Maternal-Fetal Medicine Practice Questions

Q: Which of the following statements are correct regarding peripartum cardiomyopathy? 1. It is usually seen in multiparous women. 2. Echocardiography shows ejection fraction less than 45%. 3. ACE inhibitors are contraindicated. 4. History of prior heart disease is mostly present. Select the answer using the code given below.

1 and 2 only. ***1 and 2 only*** - **Peripartum cardiomyopathy** (PPCM) is more common in **multiparous women**, particularly those with a history of preeclampsia, hypertension, or multiple pregnancies. - The diagnostic criteria for PPCM include the development of **heart failure** in the last month of pregnancy or within five months postpartum, with an **ejection fraction (EF) less than 45%** (often <40%) and no other identifiable cause. *1, 2 and 3* - While statements 1 and 2 are correct, **ACE inhibitors** are generally **contraindicated during pregnancy** due to teratogenic effects, but **can be used postpartum** for PPCM treatment, especially if not breastfeeding. - The contraindication during pregnancy does not universally apply to the entire peripartum period or postpartum management. *1, 3 and 4* - Statements 1 and 3 are incorrect in parts; while multiparity is a risk factor, statement 3 regarding ACE inhibitors is nuanced as they can be used postpartum. - PPCM is diagnosed in the absence of **prior heart disease**, meaning it is a *new onset* cardiomyopathy; therefore, statement 4 is incorrect. *3 and 4 only* - Both statements 3 and 4 are incorrect because ACE inhibitors can be used postpartum, and PPCM is characterized by the absence of prior heart disease. - The diagnostic criteria for PPCM specifically exclude cases where pre-existing heart disease can explain the heart failure.

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: Determination of alpha-fetoprotein levels in maternal serum is a useful screening tool for

neural tube defects. ***Correct: neural tube defects*** - Elevated maternal serum **alpha-fetoprotein (AFP)** is a key indicator for open **neural tube defects** because the fetal tissue leaks AFP into the amniotic fluid and then into the maternal circulation. - This screening tool is sensitive enough to detect conditions like **spina bifida** and **anencephaly**. - Typically performed at **15-20 weeks gestation** as part of the triple or quad screen. *Incorrect: Duchenne muscular dystrophy* - This is a **genetically inherited X-linked recessive disorder** primarily diagnosed through genetic testing or muscle biopsy, not maternal serum AFP levels. - While **creatine kinase (CK)** levels can be elevated in affected individuals, it is not a prenatal AFP screening target. *Incorrect: phenylketonuria* - **Phenylketonuria (PKU)** is an inborn error of metabolism, typically screened for postnatally using a **newborn heel prick test** to detect elevated phenylalanine levels. - Maternal serum AFP is not used for its detection; the condition is managed by a special diet. *Incorrect: congenital hypothyroidism* - **Congenital hypothyroidism** is identified through **newborn screening programs** that measure levels of **thyroid-stimulating hormone (TSH)** or **thyroxine (T4)** from a heel prick. - Maternal serum AFP has no role in the screening or diagnosis of this condition.

Q: Which of the following is NOT a complication of malaria in pregnancy?

Metabolic alkalosis. ***Metabolic alkalosis*** - **Metabolic alkalosis** is not typically associated with malaria in pregnancy. - Malaria complications usually lead to conditions like **metabolic acidosis** due to lactate production or kidney dysfunction. *Disseminated intravascular coagulation* - **Disseminated intravascular coagulation (DIC)** is a severe complication of malaria, particularly **severe P. falciparum infection**, leading to widespread clot formation and bleeding. - It occurs due to systemic inflammation and endothelial damage caused by malarial parasites. *Hypoglycemia* - **Hypoglycemia** is a common and serious complication of malaria in pregnancy, especially with **P. falciparum infection**. - It results from increased glucose consumption by parasites, impaired gluconeogenesis, and quinine treatment. *Thrombocytopenia* - **Thrombocytopenia** (low platelet count) is a very common complication in both pregnant and non-pregnant patients with malaria. - It is caused by platelet destruction, splenic sequestration, and bone marrow suppression.

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: Which of the following are correct regarding Placental Site Trophoblastic Tumour (PSTT)? 1. Low serum β-hCG 2. Composed mainly of cytotrophoblast 3. Highly responsive to chemo radiation 4. Confined to endometrium without myometrial invasion

1. Low serum β-hCG. ***Low serum β-hCG*** - **PSTT** originates from intermediate trophoblasts, which produce **human placental lactogen (hPL)** rather than **β-hCG**, leading to relatively low serum β-hCG levels. - This low **β-hCG** is a key differentiator from other gestational trophoblastic neoplasms like **choriocarcinoma**. *Confined to endometrium without myometrial invasion* - **PSTT** is known for its **local invasiveness** and frequently invades into the **myometrium**, and may even penetrate the serosa. - Its infiltrative growth pattern can lead to **uterine rupture** and significant **hemorrhage**. *Composed mainly of cytotrophoblast* - **PSTT** is primarily composed of **intermediate trophoblasts**, not cytotrophoblasts. - These intermediate trophoblasts are characterized by their **mononuclear appearance** and distinctive immunohistochemical staining pattern, including positivity for **hPL** and **cytokeratin**. *Highly responsive to chemo radiation* - PSTT is **not highly responsive** to chemotherapy; it often exhibits **chemoresistance**, especially in advanced stages. - Because of its chemoresistance, **surgery** (hysterectomy) is the primary treatment for localized disease, and systemic therapy options are more challenging.

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.

Question 1

Which of the following statements are correct regarding peripartum cardiomyopathy?

1. It is usually seen in multiparous women.
2. Echocardiography shows ejection fraction less than 45%.
3. ACE inhibitors are contraindicated.
4. History of prior heart disease is mostly present. Select the answer using the code given below.

Accepted Answer

1 and 2 only

Answer

1, 2 and 3

Answer

1, 3 and 4

Answer

3 and 4 only

Question 2

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 3

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 4

Determination of alpha-fetoprotein levels in maternal serum is a useful screening tool for

Accepted Answer

neural tube defects

Answer

Duchenne muscular dystrophy

Answer

phenylketonuria

Answer

congenital hypothyroidism

Question 5

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 6

Which of the following is NOT a complication of malaria in pregnancy?

Accepted Answer

Metabolic alkalosis

Answer

Disseminated intravascular coagulation

Answer

Hypoglycemia

Answer

Thrombocytopenia

Question 7

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 8

Which of the following are correct regarding Placental Site Trophoblastic Tumour (PSTT)?

1. Low serum β-hCG
2. Composed mainly of cytotrophoblast
3. Highly responsive to chemo radiation
4. Confined to endometrium without myometrial invasion

Accepted Answer

1. Low serum β-hCG

Answer

4. Confined to endometrium without myometrial invasion

Answer

2. Composed mainly of cytotrophoblast

Answer

3. Highly responsive to chemo radiation

Question 9

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 10

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

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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