Maternal-Fetal Medicine Practice Questions

Q: Multiple pregnancy is associated with an increased incidence of the following EXCEPT:

Post date pregnancy. ***Post date pregnancy*** - **Multiple pregnancies** are instead associated with a significantly **increased risk of preterm birth** due to uterine overdistension and increased fetal-placental hormonal signaling. - Due to the high risk of complications for both mother and fetuses, multiple pregnancies are often delivered before the estimated due date or by **elective induction**/ **cesarean section**, making post-date pregnancy extremely rare. *Congenital malformations* - The incidence of **congenital malformations** is **increased in multiple pregnancies**, particularly in **monochorionic twins**, partly due to increased vascular anastomoses and potential for discordant growth or twin-to-twin transfusion syndrome (TTTS). - Both **monozygotic** and **dizygotic twins** have a higher risk of various malformations compared to singletons, including neural tube defects and cardiac anomalies. *Hyperemesis gravidarum* - **Hyperemesis gravidarum (severe nausea and vomiting)** is more common in multiple pregnancies due to higher levels of pregnancy hormones, especially **beta-human chorionic gonadotropin (β-hCG)**. - The increased placental mass in multiple gestations leads to **elevated hCG** levels, which are strongly correlated with the severity of nausea and vomiting. *Pregnancy induced hypertension* - **Pregnancy-induced hypertension (PIH)**, including **gestational hypertension** and **preeclampsia**, is significantly more prevalent in multiple pregnancies. - The **larger placental mass** and increased maternal physiological burden contribute to a higher risk of developing PIH, often with **earlier onset** and **increased severity**.

Q: Which of the following genital infections is associated with preterm labour?

Bacterial vaginosis. ***Bacterial vaginosis*** - Bacterial vaginosis (BV) is strongly associated with an increased risk of **preterm labor** and **premature rupture of membranes** due to the production of proteases and phospholipases by anaerobic bacteria. - The imbalance of vaginal flora, particularly the overgrowth of anaerobic bacteria, can lead to ascending infection and inflammation of the **chorioamniotic membranes**. - BV has the **strongest and most consistent** evidence linking it to preterm birth among genital infections. *Human Papilloma Virus* - HPV infection is primarily known for causing **genital warts** and increasing the risk of **cervical dysplasia** and cancer. - It is not directly linked to an increased risk of preterm labor. *Monilial vaginitis* - Monilial vaginitis, or **vulvovaginal candidiasis** (yeast infection), is a common cause of vaginal discomfort, itching, and discharge. - While uncomfortable, it is not consistently associated with an increased risk of preterm labor or other adverse pregnancy outcomes. *Trichomonas vaginalis* - *Trichomonas vaginalis* infection is a sexually transmitted infection that can cause **vaginitis**, cervicitis, and urethritis. - While some studies suggest a possible association with adverse pregnancy outcomes, the evidence is **inconsistent and significantly weaker** compared to bacterial vaginosis, making BV the most established cause of preterm labor among these options.

Q: Medical management of tubal ectopic pregnancy can be done in the following EXCEPT:

β HCG level more than 10,000 IU. ***β HCG level more than 10,000 IU*** - A **β-HCG level greater than 5,000-10,000 IU/L** is generally considered a contraindication for successful medical management of ectopic pregnancy with methotrexate. - Higher β-hCG levels are associated with a **larger ectopic mass**, making it less likely to respond to medical treatment and increasing the risk of rupture. *Period of gestation 5 weeks* - A **gestational age of 5 weeks** is often within the timeframe where medical treatment with methotrexate can be highly effective. - Early diagnosis and intervention within the first 6-7 weeks of gestation are crucial for successful medical management. *Absent foetal cardiac activity* - The **absence of fetal cardiac activity** is a favorable prognostic indicator for medical management, as it suggests the tissue is less viable and more likely to respond to methotrexate. - Methotrexate targets rapidly dividing cells, and the lack of a heartbeat indicates less metabolic activity. *Gestational sac diameter 3 cm.* - An **ectopic sac diameter of 3 cm** (or less than 3.5-4 cm) is generally within the size limits for successful medical management. - Larger sac diameters increase the risk of treatment failure and rupture, pushing towards surgical intervention.

Q: A 26 year old primigravida presents with blood pressure of 160/110 mmHg, proteinurea and congestive heart failure. Which drug is not useful in this situation?

Diuretics. ***Diuretics*** - In uncomplicated pre-eclampsia, **diuretics** are generally **avoided** because they can reduce plasma volume and placental perfusion, potentially worsening maternal hypovolemia. - However, in this case with **congestive heart failure**, the situation is complex. Traditional teaching suggests diuretics should be avoided in pre-eclampsia, and they are considered "not useful" as a primary antihypertensive. - In pre-eclampsia, the priority is to control blood pressure with safer agents and deliver the baby, rather than manage fluid overload with diuretics, which may worsen the underlying pathophysiology. - The question tests knowledge that diuretics are not considered a standard or useful treatment for pre-eclampsia, even when CHF is present. *Nifedipine* - **Nifedipine** is a calcium channel blocker that is highly effective and commonly used to manage severe hypertension in pregnancy, including pre-eclampsia. - It causes **vasodilation**, rapidly lowering blood pressure while maintaining placental blood flow. - It is a **useful** first-line agent in this scenario. *Methyl-dopa* - **Methyl-dopa** is an alpha-2 adrenergic agonist considered safe and effective for managing hypertension in pregnancy. - While more commonly used for chronic hypertension, it can be **useful** in pre-eclampsia management. - It has an excellent safety profile for both mother and fetus. *Labetalol* - **Labetalol** is a combined alpha- and beta-blocker that is a preferred agent for acute severe hypertension in pregnancy. - It rapidly reduces blood pressure with minimal impact on uterine blood flow. - It is highly **useful** in this high-risk scenario and is commonly used in pre-eclampsia with severe features.

Q: A 30 year old G2P1L0 with history of anencephaly in previous pregnancy has a nuchal fold thickness of 2.5 mm with other normal fetal parameters. She may be having:

Normal pregnancy. ***Normal pregnancy*** - **Nuchal fold thickness (NFT)** of 2.5 mm is **well within the normal range** (normal cutoff: < 6 mm). - NFT is measured in the **second trimester (15-22 weeks)** as a marker for chromosomal abnormalities, particularly **Trisomy 21**. - A measurement of 2.5 mm with **other normal fetal parameters** indicates a **normal pregnancy**. - The history of anencephaly (a neural tube defect) in the previous pregnancy does not increase the risk of chromosomal abnormalities in the current pregnancy, though **folic acid supplementation** and careful monitoring are recommended. *Trisomy 21* - Trisomy 21 (Down syndrome) is associated with **increased nuchal fold thickness > 6 mm** in the second trimester. - First trimester markers include **increased nuchal translucency (NT) > 3.0 mm**, hypoplastic nasal bone, and abnormal ductus venosus flow. - The current NFT of 2.5 mm is **normal** and does not suggest Trisomy 21. *Spina bifida* - **Spina bifida** is a **neural tube defect** that would be detected by elevated maternal serum **alpha-fetoprotein (MSAFP)** and specific ultrasound findings. - Characteristic ultrasound signs include the **lemon sign** (frontal bone scalloping) and **banana sign** (cerebellar abnormality). - **Nuchal fold thickness is not a marker for spina bifida** - it is used for aneuploidy screening. - While the patient has a history of anencephaly (another neural tube defect), the current fetal parameters are normal. *Trisomy 18* - Trisomy 18 (Edwards syndrome) is associated with **increased nuchal translucency in the first trimester** (often > 5.0 mm) and increased NFT in the second trimester. - Multiple severe fetal anomalies are typically present: **intrauterine growth restriction (IUGR)**, **cardiac defects**, **clenched hands**, **rocker-bottom feet**, and **choroid plexus cysts**. - The **normal nuchal fold thickness** (2.5 mm) and **normal other fetal parameters** make Trisomy 18 unlikely.

Q: A 24 year old married lady presents with sudden onset right iliac fossa pain. On examination she has marked pallor and is hypotensive. What is the most likely diagnosis?

Ruptured ectopic pregnancy. ***Ruptured ectopic pregnancy*** - The sudden onset of **right iliac fossa pain** in a young, married woman, accompanied by **marked pallor** and **hypotension**, strongly suggests **hypovolemic shock** due to internal bleeding. - This clinical picture is classic for a **ruptured ectopic pregnancy**, which is a life-threatening obstetric emergency, often presenting with collapse. *Small bowel perforation* - While small bowel perforation can cause sudden abdominal pain and may lead to shock, it typically presents with signs of **peritonitis** (e.g., rebound tenderness, guarding) and often **fever**, not primarily with marked pallor and hypotension indicating severe internal bleeding. - The pain is usually more generalized initially and may be associated with signs of **sepsis** rather than immediate hemorrhagic shock. *Twisted ovarian cyst* - A twisted ovarian cyst causes sudden, severe **unilateral lower abdominal pain**, often with nausea and vomiting. - While it can cause significant pain, it typically does not lead to rapid, profound **hypotension** and **marked pallor** indicative of massive blood loss, as seen with a ruptured ectopic pregnancy. *Appendicular perforation* - Appendicular perforation is a complication of appendicitis, usually preceded by periumbilical pain migrating to the **right iliac fossa**, often with **fever**, anorexia, and localized peritonitis. - While it can cause shock due to sepsis, it is less likely to present with such rapid and severe signs of **hemorrhagic shock** (marked pallor and hypotension) without preceding appendicitis symptoms.

Question 1

Multiple pregnancy is associated with an increased incidence of the following EXCEPT:

Accepted Answer

Post date pregnancy

Answer

Congenital malformations

Answer

Hyperemesis gravidarum

Answer

Pregnancy induced hypertension

Question 2

Which of the following genital infections is associated with preterm labour?

Accepted Answer

Bacterial vaginosis

Answer

Human Papilloma Virus

Answer

Monilial vaginitis

Answer

Trichomonas vaginalis

Question 3

Medical management of tubal ectopic pregnancy can be done in the following EXCEPT:

Accepted Answer

β HCG level more than 10,000 IU

Answer

Period of gestation 5 weeks

Answer

Absent foetal cardiac activity

Answer

Gestational sac diameter 3 cm.

Question 4

A case of ante-partum haemorrhage is seen at a Primary Health Centre. The treatment will consist of:

Accepted Answer

Assessment of general condition of the patient, intravenous drip and reference to a hospital

Answer

Packing the vagina to stop the bleeding and then reference to a hospital

Answer

Internal podalic version and delivery

Answer

Vaginal examination and reference to a hospital only if diagnosed as placenta praevia

Question 5

On ultrasonography low-lying placenta is labelled when implantation in the lower uterine segment is such that:

Accepted Answer

Placental edge does not reach the internal os and remains 2 cm wide perimeter around the os

Answer

Placental edge does not reach the internal os and remains 3 cm wide perimeter around the os

Answer

Placental edge does not reach the internal os and remains 4 cm wide perimeter around the os

Answer

Internal os is covered partially or fully by the placenta

Question 6

A woman presents with abdominal pain and nausea with amenorrhea of 5-6 weeks. Ectopic pregnancy can be diagnosed if:

Accepted Answer

Beta hCG > 2000 IU/L with no gestational sac in the uterus on transvaginal sonography

Answer

Beta hCG ˂1000 IU/L with endometrial thickness of 14mm

Answer

Beta hCG >3000 IU/L with empty uterus on transvaginal sonography

Answer

Serum progesterone > 25 ng/ml

Question 7

A pregnant woman with 30 weeks gestation presents with BP 166/110 mmHg with pulmonary edema with convulsions. The woman is given magnesium sulphate. The following drug should be avoided:

Accepted Answer

Sublingual Nifedipine

Answer

Intravenous Labetalol

Answer

Intravenous Hydralazine

Answer

Intravenous Frusemide

Question 8

A 26 year old primigravida presents with blood pressure of 160/110 mmHg, proteinurea and congestive heart failure. Which drug is not useful in this situation?

Accepted Answer

Diuretics

Answer

Nifedipine

Answer

Methyl-dopa

Answer

Labetalol

Question 9

A 30 year old G2P1L0 with history of anencephaly in previous pregnancy has a nuchal fold thickness of 2.5 mm with other normal fetal parameters. She may be having:

Accepted Answer

Normal pregnancy

Answer

Trisomy 21

Answer

Spina bifida

Answer

Trisomy 18

Question 10

A 24 year old married lady presents with sudden onset right iliac fossa pain. On examination she has marked pallor and is hypotensive. What is the most likely diagnosis?

Accepted Answer

Ruptured ectopic pregnancy

Answer

Small bowel perforation

Answer

Twisted ovarian cyst

Answer

Appendicular perforation

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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