OG8.1-10 | Antenatal Care — Graded Quiz

Correct. BMI ≥35 is a recognised high-risk factor in pregnancy, associated with increased risks of gestational diabetes, pre-eclampsia, venous thromboembolism, and caesarean delivery. The inverted pyramid of care concentrates specialist resources on high-risk women — she should be referred to a higher-level facility with intensified surveillance, not managed at primary level alone. Immediate hospitalisation is not required at this stage as she has no active complications.

ANC risk stratification using the inverted pyramid concentrates specialist care resources on high-risk pregnancies. Recognised high-risk factors include BMI ≥35, previous caesarean, advanced maternal age, multiple pregnancy, hypertension, diabetes, cardiac disease, and renal disease. High-risk women should be referred to an appropriate level of care.

BMI ≥35 is a recognised high-risk factor. The inverted pyramid of care routes high-risk women to specialist facilities with intensified surveillance. This woman requires more than routine primary-level ANC, but immediate hospitalisation is not indicated without active complications.

Correct. Naegele's rule: EDD = LMP + 9 months + 7 days (or equivalently, subtract 3 months and add 7 days). LMP 10 March: subtract 3 months = 10 December, add 7 days = 17 December. From LMP 10 March to examination date 5 June = 12 weeks (March has 31 days; 21 remaining days in March + 30 days April + 31 days May + 5 days June = 87 days ÷ 7 = 12 weeks 3 days, approximately 12 weeks).

Naegele's rule: EDD = LMP − 3 months + 7 days (assumes regular 28-day cycle). The rule is applied to the first day of the LMP. Gestational age is calculated from LMP in completed weeks and days. If the cycle is irregular or longer/shorter than 28 days, the rule requires adjustment.

Naegele's rule: subtract 3 months from LMP and add 7 days. LMP 10 March → 10 December + 7 days = 17 December. Duration from 10 March to 5 June ≈ 87 days ÷ 7 ≈ 12 weeks 3 days. EDD is 17 December; gestational age is approximately 12 weeks.

Correct. Leopold's second manoeuvre assesses fetal lie and which side the back is on. A smooth, resistant, curved structure represents the fetal back; small, irregular, nodular parts represent fetal limbs. Finding the back on the left indicates left occipito-anterior/posterior positioning. This is most commonly associated with cephalic presentation.

Leopold's second manoeuvre (lateral palpation) identifies which side the fetal back is on. A smooth, curved, firm resistance = fetal back; irregular nodular structures = fetal limbs. This determines fetal position. The four Leopold manoeuvres systematically assess: (1) fundal content, (2) lateral position/lie, (3) presenting part, (4) engagement.

In Leopold's second manoeuvre, the smooth, resistant, curved structure is the fetal back, and the nodular, irregular parts are the fetal limbs (hands and feet). Back on the left = fetal spine oriented to the maternal left. Combined with a rounded pole at the fundus (Leopold 1) and engagement at the pelvis, this is consistent with cephalic presentation, back left.

Correct. BPP scoring: reactive NST (+2), fetal tone present (+2), gross movements ≥3 (+2), breathing movement ≥1 episode lasting ≥30 s (+2) = 8/10. Amniotic fluid: the largest single vertical pocket ≥2 cm scores 2; a pool of 3 cm is borderline-adequate and some protocols give +2 here. BPP of 8/10 is generally reassuring, but in the context of persistent reduced fetal movements, close surveillance is warranted. A score of 6/10 would prompt consideration of delivery.

BPP scoring (each parameter 2 points): reactive NST, fetal tone (limb extension-flexion), ≥3 gross body movements, ≥1 breathing episode lasting ≥30 s, amniotic fluid single pocket ≥2 cm. Maximum 10. Score 8–10 = reassuring; 6 = equivocal (repeat or deliver based on gestation); ≤4 = immediate delivery planning.

BPP scoring: each parameter scores 2 if present, 0 if absent. Reactive NST (2 accels ≥15 bpm ×15 s in 20 min = +2); tone normal (+2); ≥3 limb movements (+2); breathing ≥30 s (+2); amniotic fluid single pocket ≥2 cm (+2). Here the NST, tone, movements, and breathing are all normal (+8). Fluid at 3 cm scores +2 under standard BPP criteria. Total = 10/10 is debatable but 8/10 is the conservative score given the clinical context. A score of 6/10 would require delivery planning.

Correct. Diagonal conjugate of 11 cm gives an estimated obstetric conjugate of 9–9.5 cm (11 minus 1.5–2 cm), which is below the normal threshold of ≥10 cm. Combined with height <150 cm (a known risk factor for contracted pelvis), prominent ischial spines (reduced interspinous diameter), and a flat sacrum (reduced AP outlet diameter), this clinical picture strongly suggests contracted pelvis with CPD. Elective caesarean section is the appropriate management.

Clinical pelvimetry: obstetric conjugate = diagonal conjugate − 1.5–2 cm (normal ≥10 cm). A diagonal conjugate <11.5 cm suggests potential inlet contraction. Additional markers of contracted pelvis: height <150 cm, prominent ischial spines, convergent sidewalls, flat/shortened sacrum. CPD confirmed clinically warrants planned caesarean section.

Diagonal conjugate 11 cm → obstetric conjugate approximately 9–9.5 cm (normal ≥10 cm) → inlet is contracted. Height <150 cm, prominent ischial spines, flat sacrum compound the risk. This is contracted pelvis with likely CPD, and elective caesarean section is indicated. Android or platypelloid pelvis descriptions do not fit this constellation of findings.

Correct. Hb 9.6 g/dL at 20 weeks is moderate anaemia in pregnancy (defined as Hb <7 g/dL = severe; 7–10.9 g/dL = moderate; 11 g/dL is the first-trimester threshold). Moderate anaemia responds to therapeutic oral iron (120 mg elemental iron/day — double the prophylactic dose). IV iron is reserved for severe anaemia, malabsorption, or intolerance to oral therapy. Calcium supplementation is important but is not the urgent intervention for anaemia.

Anaemia in pregnancy: mild = Hb 10–10.9 g/dL, moderate = 7–9.9 g/dL, severe = <7 g/dL (first/third trimester threshold 11 g/dL; second trimester 10.5 g/dL). Moderate anaemia: therapeutic oral iron 120 mg elemental iron/day. Severe or unresponsive: IV iron or blood transfusion. Prophylactic dose = 60 mg/day.

Hb 9.6 g/dL = moderate anaemia (WHO: Hb 7.0–10.9 g/dL in pregnancy). The most urgent evidence-based intervention is therapeutic oral iron at 120 mg elemental iron/day (double the prophylactic dose of 60 mg). IV iron is reserved for severe (Hb <7 g/dL), malabsorption, or oral intolerance. Calcium supplementation addresses a separate deficiency.

Correct. Under NHM guidelines: if a woman received a full TT course (2 doses) in a previous pregnancy within the last 3 years, she requires only one booster dose in the current pregnancy. If it has been more than 3 years since the last full course, a full two-dose schedule is given. TT is safe throughout pregnancy.

NHM TT vaccination schedule: previously unimmunised — give TT1 (early as possible) and TT2 (4 weeks later, preferably before 36 weeks). If received 2 doses in a previous pregnancy within 3 years — 1 booster only. If >3 years — full 2-dose course. TT is safe in all trimesters.

NHM TT protocol: if the woman received 2 TT doses in a previous pregnancy within the past 3 years, she needs only 1 booster dose in the current pregnancy. If >3 years since the last full course, restart the 2-dose schedule. TT is not contraindicated in any trimester — it is safe throughout pregnancy.

Correct. Elevated maternal serum AFP (>2.5–3.0 MoM) at 16–20 weeks is associated with open neural tube defects (anencephaly, open spina bifida), abdominal wall defects, multiple pregnancy, and incorrect gestational dating. The first investigation is a detailed anomaly ultrasound scan (mid-trimester morphology scan) to identify structural anomalies. Amniocentesis is invasive and not the first step. First-trimester combined screening is no longer relevant at 18 weeks.

Maternal serum AFP >2.5–3.0 MoM at 16–20 weeks: first investigate with detailed mid-trimester anomaly scan (18–22 weeks) to identify open NTDs, abdominal wall defects, or incorrect dating. Amniocentesis is the next step only if the scan is abnormal or inconclusive. AFP is also elevated in multiple pregnancy, renal abnormalities, and fetomaternal haemorrhage.

Elevated AFP (>2.5 MoM) at 16–20 weeks is a marker for open neural tube defects and other structural anomalies. The immediate next step is a detailed mid-trimester anomaly scan (morphology ultrasound) at 18–22 weeks to identify or exclude structural causes. Invasive testing (amniocentesis) is reserved for abnormal ultrasound findings.

Correct. The Kleihauer-Betke test detects and quantifies fetal red cells in maternal circulation. In an Rh-negative mother, fetomaternal haemorrhage causing entry of Rh-positive fetal cells into maternal blood will cause alloimmunisation unless prevented by anti-D immunoglobulin. The dose is calculated based on the volume of fetomaternal haemorrhage identified. This is the most immediately actionable intervention to protect future pregnancies.

Kleihauer-Betke test quantifies fetal erythrocytes in maternal circulation. In Rh-negative mothers, this guides the dose of anti-D immunoglobulin needed to prevent alloimmunisation. Stillbirth investigation includes maternal blood group, indirect Coombs test, TORCH serology, glucose screen, thrombophilia screening, and fetal post-mortem if consented.

The Kleihauer-Betke test detects fetal red cells in maternal circulation. In an Rh-negative woman, undetected/untreated fetomaternal haemorrhage will cause Rh alloimmunisation, risking haemolytic disease of the fetus and newborn in subsequent pregnancies. The critical action is: check Rh status and give anti-D immunoglobulin in appropriate dose. Future pregnancies are not contraindicated.

Correct. Ultrasound measurement of lower uterine segment (LUS) thickness at 35–38 weeks has been studied as a predictor of scar integrity. A LUS thickness of less than 2.0–2.5 mm (cut-off varies by study) is associated with a significantly increased risk of uterine rupture or dehiscence during TOLAC. While not an absolute contraindication in all guidelines, a measurement of 1.8 mm would typically prompt recommendation of elective repeat caesarean section in the counselling discussion, especially combined with the overall low-probability clinical scenario.

Ultrasound measurement of lower uterine segment thickness at 35–38 weeks: LUS <2.0–2.5 mm is associated with increased risk of uterine scar dehiscence/rupture during TOLAC. This finding, combined with clinical risk factors, informs the shared decision-making discussion. Elective repeat caesarean section is generally recommended when LUS is critically thinned.

Lower uterine segment thickness <2.0–2.5 mm at 35–38 weeks by ultrasound is associated with an increased risk of scar dehiscence/rupture during TOLAC. A measurement of 1.8 mm falls below this threshold and should prompt recommendation of elective repeat caesarean. Masking pain with epidural is not a safe substitute for addressing the mechanical risk.

Correct. BP ≥160/110 mmHg on two readings plus proteinuria and symptoms (headache) at 32 weeks is severe pre-eclampsia — a hypertensive emergency of pregnancy. This woman requires immediate referral to a facility capable of administering MgSO4 (for seizure prophylaxis), antihypertensives (labetalol/hydralazine/oral nifedipine), and consideration of delivery. Delay increases the risk of eclampsia, stroke, and maternal and fetal death.

Severe-feature pre-eclampsia: BP ≥160/110 mmHg on two occasions + proteinuria OR end-organ dysfunction. Symptoms (headache, visual disturbances, epigastric pain) indicate severe features. Immediate management: MgSO4 (Pritchard or Zuspan regimen), antihypertensive (labetalol IV / hydralazine IV / nifedipine oral), and delivery planning at a tertiary centre.

Severe pre-eclampsia (BP ≥160/110 + proteinuria + symptoms) is an obstetric emergency requiring immediate transfer. The threshold for severe-feature hypertension is ≥160/110 mmHg. MgSO4, IV antihypertensives, and delivery planning are needed at a well-equipped centre. The other patients have risks that require monitoring but not immediate emergency transfer.

Correct. The Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act 1994 (PCPNDT Act) specifically prohibits the use of any diagnostic technique, including ultrasound, for the purpose of sex selection/determination. Violations carry criminal penalties. The MTP Act governs termination of pregnancy and does not directly address sex determination at booking.

PCPNDT Act 1994: prohibits sex determination using any diagnostic technique at any gestational age. Extends to pre-conception sex selection. Covers all practitioners, sonographers, and institutions. Never frame any investigation as sex-determination; never suggest or imply the possibility in clinical practice.

The PCPNDT Act 1994 is the specific legislation prohibiting sex determination using any diagnostic technique including ultrasound. This applies to all gestations. The MTP Act governs termination conditions, not sex determination. PCPNDT violations carry criminal penalties.