The gold standard test for antenatal surveillance of the pregnancy at-risk for an adverse pregnancy outcome with the lowest false negative rate is:

• a)
  

  Biophysical Profile

  
  
• b)
  

  CTG only

  
  
• c)
  

  CTG and an estimation of the amniotic fluid volume

  
  
• d)
  

  Contractions stress test

The studies that have correlated ultrasound estimates of amniotic fluid volume with a dye-determined or directly measured amniotic fluid volume at the time of Caesarean delivery have observed which of the following?

• a)
  

  The ultrasound estimate of amniotic fluid volume is correlated well with high volumes of amniotic fluid (polyhydramnios)

  
  
• b)
  

  The ultrasound estimate of amniotic fluid volume is correlated well with low volumes of amniotic fluid volume (oligohydramnios)

  
  
• c)
  

  The ultrasound estimate of amniotic fluid volume is correlated well with normal volumes of amniotic fluid

  
  
• d)
  

  The ultrasound estimate of amniotic fluid volume is not correlated with low, normal, or high volumes of amniotic fluid.

The following statement(s) is/are true about umbilical artery Doppler?

• a)
  

  Increased impedance correlates with neonatal mortality.

  
  
• b)
  

  Accurate CTG interpretation irrespective of umbilical artery Doppler findings has been shown to improve neonatal mortality.

  
  
• c)
  

  Umbilical artery Doppler is best assessed in a free loop of cord.

  
  
• d)
  

  Impedance values are higher at the fetal end of the cord and lower at the placental end.

  
  
• e)
  

  The timing of umbilical artery Doppler changes is similar in early or late onset FGR.

The following is/are true regarding Middle cerebral artery (MCA) Doppler?

• a)
  

  The cerebro-placental ratio (CPR) is strongly predictive for perinatal morbidity in late onset FGR.

  
  
• b)
  

  A reduced MCA to umbilical Doppler impedance ratio is associated with the risk of Caesarean section in labour in the presence of normal umbilical artery Doppler.

  
  
• c)
  

  A reduced MCA to umbilical Doppler impedance ratio is associated with the risk of Caesarean section in labour in the presence of abnormal umbilical artery Doppler.

  
  
• d)
  

  MCA Doppler interpretation is important in advising timing of delivery in early onset FGR.

  
  
• e)
  

  The CPR is a better marker for timing of delivery than MCA Doppler alone.

A pregnant woman presents at 10 weeks’ with a high temperature (38°C) and ongoing asthenia for 2 weeks. CMV serology is performed; which of the following is/are true regarding this serology?

• a)
  

  IgG and IgM are both negative: the diagnosis of recent CMV primary infection is unlikely

  
  
• b)
  

  IgG are positive and IgM are negative: the diagnosis of recent CMV primary infection is unlikely

  
  
• c)
  

  IgG and IgM are both positive: it might be a recent CMV primary infection

  
  
• d)
  

  The presence of positive CMV IgM ascertains the diagnosis of a recent primary infection

  
  
• e)
  

  In case of positive IgM, an IgG avidity test must be performed to confirm or to exclude recent primary infection

A pregnant woman has a primary CMV infection diagnosed based on clinical symptoms at 17 weeks of gestation. Although, there are no abnormal features on prenatal ultrasound the patient wishes an amniocentesis for prenatal diagnosis.

• a)
  

  The amniocentesis could be done at 21 weeks

  
  
• b)
  

  The amniocentesis should be done after 23 weeks

  
  
• c)
  

  CMV PCR in the amniotic fluid is the gold-standard diagnosis

  
  
• d)
  

  The women should be warned of the possibility of a 5% to 10% false negative rate of the amniocentesis at diagnosing fetal infection at birth.

  
  
• e)
  

  If CMV-PCR is negative in the amniotic fluid, the amniocentesis should be repeated 3 weeks later

Prenatal ultrasound performed at 26 weeks’ shows: hyperechogenic bowel grade 2, hepato-splenomegly and unilateral ventriculo-megaly measured at 12 mm. Which of the following is are true?

• a)
  

  CMV- PCR in amniotic fluid should not be performed because CMV serology shows negative IgG and negative IgM

  
  
• b)
  

  CMV-PCR in amniotic fluid should be done because CMV serology shows positive IgG and negative IgM

  
  
• c)
  

  CMV-PCR in amniotic fluid should not be done because CMV serology showed positive IgG and negative IgM two years ago

  
  
• d)
  

  A negative CMV PCR in amniotic fluid excludes fetal congenital CMV infection

  
  
• e)
  

  A positive CMV PCR in amniotic fluid confirms CMV fetal infection

When diagnosing a twin pregnancy at 11 weeks’ gestation as calculated from the last menstrual period (LMP), the sonographer should do which of the following?

• a)
  

  Take the smallest Crown-Rump Length (CRL) to recalculate gestational age

  
  
• b)
  

  Look for the T-sign to determine chorionicity

  
  
• c)
  

  Reassure the pregnant woman that twin-twin transfusion syndrome is unlikely to occur when the embryos have identical nuchal translucencies (NT)

  
  
• d)
  

  Distinguish between an empty and a full lambda sign

  
  
• e)
  

  Perform color Doppler examination of direction of blood flow in the aorta to exclude TRAPS

When detecting a monochorionic twin with discordant estimated fetal weight of more than 25% at 23 weeks’ gestation, the obstetric caregiver should do which of the following?

• a)
  

  Perform Doppler examination of the umbilical artery and ductus venosus to determine the prognosis

  
  
• b)
  

  Refer the patient to a fetal therapy centre for laser coagulation of the vascular anastomoses

  
  
• c)
  

  Look for the presence of a large arterio-arterial anastomosis to estimate the risk of acute demise of both twins

  
  
• d)
  

  Perform an MRI to exclude brain damage in the larger twin

  
  
• e)
  

  Refer the patient to a fetal medicine center for counselling on prognosis and options for intervention.

The current best practice in managing monoamniotic twin pregnancies includes:

• a)
  

  Detailed ultrasound examination for structural anomalies

  
  
• b)
  

  Ultrasound examination at least every two weeks including measurement of the deepest pocket of amniotic fluid and evaluation of bladder filling of both twins

  
  
• c)
  

  Induction of labour after a course of corticosteroids at 36 weeks’ gestation when the first twin is in cephalic position

  
  
• d)
  

  Immediate version and extraction of the second twin after vaginal birth of the first twin

  
  
• e)
  

  Admission to hospital from 24 weeks onwards and daily Doppler to look for notching in the umbilical arteries

In relation to the epidemiology of stillbirth which of the following is/are true?

• a)
  

  The absolute risk of all cause stillbirth in high income countries is <1 in 1000

  
  
• b)
  

  Globally, i.e. combining low, middle and high income countries, ≤10% of stillbirths follow intrapartum intra-uterine fetal death

  
  
• c)
  

  Maternal risk factors explain more than 50% of the variation in stillbirth risk in the USA

  
  
• d)
  

  More than 90% of stillbirths are associated with fetal growth restriction

  
  
• e)
  

  If a post mortem has been performed, a minority of stillbirths have a clear and well-defined cause of death

In relation to biochemical markers of stillbirth risk:

• a)
  

  Low levels of PAPP-A in the first trimester are associated with an increased risk of stillbirth due to placental causes

  
  
• b)
  

  The use of urinary oestriol was shown to be ineffective in an appropriately powered randomised controlled trial

  
  
• c)
  

  Elevated levels of maternal serum AFP are associated with stillbirth due to neural tube defects and anterior abdominal wall defects, but are not predictive of the risk of loss in normally formed infants

  
  
• d)
  

  Low levels of PAPP-A in the third trimester have been shown to be associated with the risk of unexplained stillbirth

  
  
• e)
  

  Measurement of the sFlt-1/PlGF ratio should be performed in women presenting with reduced fetal movements

In relation to induction of labour:

• a)
  

  Induction can safely be performed at any stage of pregnancy from 37 weeks onwards

  
  
• b)
  

  Level 1 evidence indicates that induction of labour results in a 10-15% reduction in the risk of caesarean delivery

  
  
• c)
  

  Level 1 evidence indicates that induction of labour at term and post-term reduces the risk of perinatal mortality by ≥50%

  
  
• d)
  

  Level 1 evidence indicates that, among nulliparous women aged 35 and above, routine induction of labour had no effect on the risk of Caesarean delivery.

  
  
• e)
  

  It should not be considered in a woman presenting at 40 weeks gestational age with her first presentation with reduced fetal movements.

In relation to universal late pregnancy ultrasound:

• a)
  

  Level 1 evidence indicates that universal late pregnancy ultrasound reduces the risk of perinatal morbidity related to fetal growth restriction

  
  
• b)
  

  The meta-analysis of RCTs of universal late pregnancy ultrasound has >90% power to detect a 50% reduction in the risk of stillbirth in screen positive women, assuming a positive likelihood ratio of 10 or greater

  
  
• c)
  

  It has been implemented in some countries despite no clear positive evidence of clinical effectiveness

  
  
• d)
  

  It could not plausibly cause harm, directly or indirectly.

  
  
• e)
  

  If performed at 28 and 36 weeks, increases the detection of SGA infants by about 3-fold compared with selective use of ultrasound.

The antenatal CTG at term:

• a)
  

  Is classified as unreactive if there are no accelerations seen in 40 minutes

  
  
• b)
  

  Requires 3 accelerations within 20 minutes to be classified as reactive

  
  
• c)
  

  Is classified as pathological if a single deceleration is present on a 30 minute tracing

  
  
• d)
  

  May show no accelerations for periods of over 90 minutes in the normal fetus

  
  
• e)
  

  When reactive has a false positive rate of 2% within 24 hours of the trace.

With regard to fetal states

• a)
  

  Fetal behavioural states cannot be recognised on an antenatal CTG trace

  
  
• b)
  

  The 4F state has a defined and easily identified baseline

  
  
• c)
  

  The 1F state will always have variability on the baseline of > 2 beats per minute (bpm)

  
  
• d)
  

  The 2F state is associated with accelerations with fetal body movements in the term fetus

  
  
• e)
  

  They are irrelevant to CTG interpretation.

With regards to the CTG in the severely preterm fetus (i.e. less than 32 weeks)

• a)
  

  Accelerations may be seen in a proportion of fetuses

  
  
• b)
  

  The baseline is typically lower than that in the term fetus

  
  
• c)
  

  The tracing is uninterpretable in over 20% of cases

  
  
• d)
  

  V shaped decelerations lasting for 15 seconds are a sign of fetal compromise

  
  
• e)
  

  Outcome data is based on large published trials

The following statement(s) is/are true about the cerebroplacental ratio (CPR):

• a)
  

  The CPR is an independent predictor of the risk of stillbirth

  
  
• b)
  

  There is a positive linear relationship between the uterine artery Doppler pulsatility index (PI) in the third trimester and CPR values

  
  
• c)
  

  The CPR is calculated as the umbilical artery PI divided by the middle cerebral artery (MCA) PI

  
  
• d)
  

  The combination of the estimated fetal weight, CPR and uterine Doppler in the third trimester can identify the majority of fetuses at risk of stillbirth

  
  
• e)
  

  The CPR can identify the fetus at risk among small babies only

The following statement(s) is/are true about fetal growth restriction (FGR)

• a)
  

  All small fetuses suffer from a degree of FGR

  
  
• b)
  

  FGR is a risk factor for stillbirth, perinatal mortality and neonatal morbidity, hypoxic ischemic encephalopathy and cerebral palsy

  
  
• c)
  

  Being small in size (weight less than the 10 ^th centile) is an essential criteria to define FGR

  
  
• d)
  

  The majority of fetuses with FGR at term demonstrate abnormal umbilical artery Doppler

  
  
• e)
  

  The CPR is considered as a marker of those fetuses suffering from FGR at term

The following statement(s) correctly describe the role of uterine artery Doppler:

• a)
  

  The uterine artery Doppler is a better predictor of FGR when recorded in the first, compared to the second, trimester

  
  
• b)
  

  The uterine artery Doppler recorded in the third trimester has no additive value in identifying the fetuses at risk at term

  
  
• c)
  

  The uterine artery Doppler is significantly associated with the risk of stillbirth

  
  
• d)
  

  The uterine artery Doppler is significantly associated with the risk of stillbirth, even after adjusting for estimated fetal weight and CPR

  
  
• e)
  

  When performed longitudinally, the uterine artery Doppler recorded in the third trimester is likely to be a better predictor of the fetuses at risk at term, when compared to the second trimester uterine artery Doppler

Which of these parameters is required for the distinction of fetal growth restriction versus small for gestational age:

• a)
  

  Reduced amniotic fluid

  
  
• b)
  

  Abnormal cerebroplacental ratio (Doppler).

  
  
• c)
  

  Abnormal uterine artery Doppler.

  
  
• d)
  

  Estimated fetal weight <3rd centile.

  
  
• e)
  

  Reduced fetal movements on scan

Which Doppler parameters are virtually always normal in late-onset fetal growth restriction?

• a)
  

  Umbilical artery only.

  
  
• b)
  

  Ductus venosus only.

  
  
• c)
  

  Middle cerebral artery only.

  
  
• d)
  

  Umbilical artery and ductus venosus

  
  
• e)
  

  Umbilical artery, ductus venosus and uterine artery

A small fetus (estimated fetal weight on 2nd centile) presents with the following results on ultrasound and Doppler at 37 weeks: normal cerebro-placental ratio (thus normal umbilical artery and middle cerebral artery Dopplers), normal uterine artery Doppler, normal ductus venosus Doppler, and normal amniotic fluid index. Cardiotocography and biophysical profile are normal. What would be your recommendation for clinical management?

• a)
  

  Follow-up in 2 weeks.

  
  
• b)
  

  Follow-up in 1 week.

  
  
• c)
  

  Elective delivery within the next few days.

  
  
• d)
  

  Elective Caesarean section

  
  
• e)
  

  No further follow up as Dopplers are normal

The following is/are true regarding macrosomia and large for gestational age (LGA)?

• a)
  

  Fetal macrosomia may be defined as a birth weight >4000 g

  
  
• b)
  

  Fetal macrosomia complicates over 10% of all pregnancies in the United States of America

  
  
• c)
  

  Clinical evaluation is based solely on maternal fundal height assessment.

  
  
• d)
  

  When fundal height assessment is performed on an individual basis using a customized chart greater accuracy can be obtained.

  
  
• e)
  

  Ultrasound estimation of fetal weight (EFW) is generally accurate and has acceptable specificity

Inaccurate prediction of macrosomia is associated with which of the following?

• a)
  

  Increased Caesarean section rates

  
  
• b)
  

  Increased failed inductions

  
  
• c)
  

  Increased respiratory complications in newborns

  
  
• d)
  

  Increased chorioamnionitis

  
  
• e)
  

  Increased fetal birth injury

Fetal macrosomia is associated with increased risks of which of the following?

• a)
  

  Caesarean section

  
  
• b)
  

  Trauma to the birth canal

  
  
• c)
  

  Fetal trauma

  
  
• d)
  

  Negative birth experience

  
  
• e)
  

  Increased analgesic requirements

The following is/are correct further regarding macrosomia:

• a)
  

  A direct correlation has been observed between maternal weight gain and the incidence of secondary Caesarean section when vaginal delivery was initially planned

  
  
• b)
  

  There is a direct correlation between increasing birth weight and a higher incidence of secondary Caesarean section

  
  
• c)
  

  There is a direct correlation between increasing birth weight and a higher incidence of assisted vaginal delivery

  
  
• d)
  

  It has been shown that women with a familial history of DM have a higher rate of fetal macrosomia, defined as a birth weight >4000 g, compared with controls

  
  
• e)
  

  It has been shown that women with a familial history of DM had a higher rate of Caesarean section compared with controls

Based on American data which of the following is/are true regarding macrosomia?

• a)
  

  The prevalence of newborns weighing at least 4000g increased by 10% in seven years

  
  
• b)
  

  The prevalence of newborns weighing at least 5000g has increased by 19% in seven years

  
  
• c)
  

  The post-test probability of detecting a macrosomic fetus in an uncomplicated pregnancy is >80% with ultrasound estimation of birth weight

  
  
• d)
  

  The post-test probability of detecting a macrosomic fetus in an uncomplicated pregnancy is between 40% to 50% with clinical estimates.

  
  
• e)
  

  Among diabetic patients the post-test probability of identifying a newborn weighing >4000 g clinically and by ultrasound is over 60%.

The following is/are considered risk factors for macrosomia:

• a)
  

  Genetic factors

  
  
• b)
  

  Pre-gestational body mass index (BMI)

  
  
• c)
  

  Excessive weight gain during pregnancy

  
  
• d)
  

  Gestational diabetes mellitus (GDM)

  
  
• e)
  

  Pre-existing Type 1 diabetes mellitus

The following is/are true regarding risk factors for macrosomia:

• a)
  

  It has been demonstrated that fasting plasma glucose (FPG) in late pregnancy (30-32 weeks of gestation) is a determinant of newborn macrosomia

  
  
• b)
  

  It has been demonstrated that fasting plasma insulin in late pregnancy (30-32 weeks of gestation) is a determinant of newborn macrosomia

  
  
• c)
  

  It has been demonstrated that insulin resistance in late pregnancy (30-32 weeks of gestation) is a determinant of newborn macrosomia

  
  
• d)
  

  If an increase in FPG is observed from early to late pregnancy, there is a significant increase in the risk of newborn macrosomia

  
  
• e)
  

  Among women with GDM, maternal FPG concentrations during pregnancy are significantly and positively associated with offspring birth size after adjusting for maternal pre-pregnancy BMI.