Neurulation and neural tube development US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Neurulation and neural tube development. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Neurulation and neural tube development US Medical PG Question 1: A 21-year-old G3P2 woman presents to her obstetrician at 6 weeks gestation for routine prenatal care. Her past medical history includes obesity and gestational diabetes. She has had two spontaneous vaginal deliveries at term. One infant was macrosomic with hypoglycemia, but otherwise, she has had no complications. Her physician informs her that she must start taking a multivitamin with folic acid daily. The defect that folic acid supplementation protects against arises in tissue that is derived from which germ cell layer?
- A. Mesoderm
- B. Notochord
- C. Endoderm
- D. Mesenchyme
- E. Ectoderm (Correct Answer)
Neurulation and neural tube development Explanation: ***Ectoderm***
- Folic acid supplementation primarily prevents **neural tube defects**, such as **spina bifida** and **anencephaly**.
- The **neural tube**, which forms the brain and spinal cord, is derived from the **ectoderm**.
*Mesoderm*
- The **mesoderm** gives rise to structures like muscle, bone, connective tissue, and the cardiovascular system.
- Defects in mesodermal development are not primarily prevented by folic acid supplementation.
*Notochord*
- The **notochord** is a transient embryonic structure that induces the formation of the neural plate from the ectoderm.
- While critical for nervous system development, it is not a germ cell layer itself, and defects in its development are not directly prevented by folic acid.
*Endoderm*
- The **endoderm** forms the lining of the gastrointestinal and respiratory tracts, as well as glands like the thyroid and pancreas.
- Anomalies of these internal organs are not the primary target of folic acid supplementation.
*Mesenchyme*
- **Mesenchyme** is embryonic connective tissue, largely derived from the mesoderm, but can also come from neural crest (ectoderm).
- It differentiates into connective tissues, blood, and lymphatic vessels; neural tube defects are not considered mesenchymal in origin.
Neurulation and neural tube development US Medical PG Question 2: A 29-year-old primigravid woman at 18 weeks’ gestation comes to the physician for her first prenatal visit. She works as a paralegal and lives with her husband. Her current pregnancy was unexpected, and she did not take any prenatal medications or supplements. Physical examination shows a uterus 2 inches above the umbilicus. The concentration of α-fetoprotein in the maternal serum and concentrations of both α-fetoprotein and acetylcholinesterase in the amniotic fluid are elevated. Ultrasonography of the uterus shows an increased amniotic fluid volume. The fetus most likely has which of the following conditions?
- A. Anencephaly (Correct Answer)
- B. Holoprosencephaly
- C. Spina bifida occulta
- D. Myelomeningocele
- E. Lissencephaly
Neurulation and neural tube development Explanation: ***Anencephaly***
- **Elevated maternal serum α-fetoprotein (MSAFP)** and **amniotic fluid α-fetoprotein (AFAFP)**, along with elevated **acetylcholinesterase (AChE)** in amniotic fluid, are classic markers for **open neural tube defects**. Anencephaly, characterized by the **absence of a major portion of the brain and skull**, is an open neural tube defect.
- The **increased amniotic fluid volume (polyhydramnios)** is due to the fetus's inability to swallow amniotic fluid, a common finding in anencephaly.
*Holoprosencephaly*
- This condition involves incomplete separation of the **prosencephalon (forebrain)**, leading to **severe facial abnormalities** and brain malformations.
- While it is a severe brain malformation, it is typically a **closed neural tube defect** or a developmental anomaly not involving an open lesion, and therefore, it is usually not associated with elevated MSAFP, AFAFP, or AChE.
*Spina bifida occulta*
- This is the **mildest form of spina bifida**, involving a small gap in the vertebrae without protrusion of the spinal cord or meninges.
- It is a **closed neural tube defect** and is typically asymptomatic, often not associated with elevated MSAFP or AFAFP levels.
*Myelomeningocele*
- While a **myelomeningocele** is an **open neural tube defect** that would cause elevated MSAFP, AFAFP, and AChE, it is characterized by the protrusion of the spinal cord and meninges through a vertebral defect.
- The primary characteristic of anencephaly (absence of a major portion of the brain/skull) better fits the severe degree of neural tube defect suggested by the findings, particularly the polyhydramnios due to absent swallowing reflex.
*Lissencephaly*
- This is a brain malformation characterized by a **lack of gyri and sulci**, resulting in a smooth brain surface.
- It is a brain development defect, not an **open neural tube defect**, and as such, it is not associated with elevated MSAFP, AFAFP, or AChE.
Neurulation and neural tube development US Medical PG Question 3: A 25-year-old female comes to her obstetrician’s office for a prenatal visit. She has a transvaginal ultrasound that correlates with her last menstrual period and dates her pregnancy at 4 weeks. She has no complaints except some nausea during the morning that is improving. She comments that she has had some strange food cravings, but has no issues with eating a balanced diet. Her BMI is 23 kg/m^2 and she has gained 1 pound since the start of her pregnancy. She is curious about her pregnancy and asks the physician what her child is now able to do. Which of the following developments is expected of the fetus during this embryological phase?
- A. Formation of male genitalia
- B. Closure of the neural tube (Correct Answer)
- C. Movement of limbs
- D. Creation of the notochord
- E. Cardiac activity visible on ultrasound
Neurulation and neural tube development Explanation: ***Closure of the neural tube***
- At **4 weeks gestation**, the **neural tube** is in the process of closing, forming the precursor for the brain and spinal cord, making this a critical developmental milestone.
- This period is vital for the prevention of neural tube defects like **spina bifida** and **anencephaly**.
*Formation of male genitalia*
- The differentiation of **external genitalia** (male or female) occurs much later, typically around weeks **9-12 of gestation**, much later than the 4-week mark discussed here.
- Prior to this, the genital ridges are bipotential and do not yet show sex-specific characteristics.
*Movement of limbs*
- While limb buds begin to appear around 4-5 weeks, coordinated **limb movements** are typically observed much later, around **10-12 weeks** of gestation, as muscular and neurological systems further develop.
- Early movements are typically subtle and reflex-like, rather than purposeful.
*Creation of the notochord*
- The **notochord** is formed during **gastrulation**, which occurs predominantly in the **third week of gestation**, prior to the 4-week mark.
- It serves as the primary axial support for the embryo and induces the formation of the neural tube.
*Cardiac activity visible on ultrasound*
- **Cardiac activity** typically becomes detectable on transvaginal ultrasound between **5 and 6 weeks gestation**, shortly after the 4-week mark.
- At 4 weeks, the heart tube may have started to form, but discernible beating is usually not yet evident.
Neurulation and neural tube development US Medical PG Question 4: A 52-year-old woman sees you in your office with a complaint of new-onset headaches over the past few weeks. On exam, you find a 2 x 2 cm dark, irregularly shaped, pigmented lesion on her back. She is concerned because her father recently passed away from skin cancer. What tissue type most directly gives rise to the lesion this patient is experiencing?
- A. Neural crest cells (Correct Answer)
- B. Endoderm
- C. Mesoderm
- D. Ectoderm
- E. Neuroectoderm
Neurulation and neural tube development Explanation: ***Neural crest cells***
- The suspected lesion, given its description and the patient's family history of skin cancer, is likely a **melanoma**.
- Melanoma originates from **melanocytes**, which are derived from **neural crest cells** during embryonic development.
*Endoderm*
- The endoderm gives rise to the **lining of the gastrointestinal and respiratory tracts**, as well as organs such as the liver and pancreas.
- It is not involved in the formation of melanocytes or skin lesions like melanoma.
*Mesoderm*
- The mesoderm forms tissues such as **muscle, bone, cartilage, connective tissue**, and the circulatory system.
- It does not directly give rise to melanocytes, which are the cells of origin for melanoma.
*Ectoderm*
- The ectoderm gives rise to the **epidermis, nervous system**, and sensory organs.
- While melanocytes are found in the epidermis, they are specifically derived from the **neural crest (a sub-population of ectoderm)**, not the general ectoderm.
*Neuroectoderm*
- Neuroectoderm specifically refers to the ectoderm that develops into the **nervous system**.
- While neural crest cells originate from the neuroectoderm, "neural crest cells" is a more precise answer for the origin of melanocytes.
Neurulation and neural tube development US Medical PG Question 5: A 32-year-old G2P0A1 woman presents at 36 weeks of gestation for the first time during her pregnancy. The patient has no complaints, currently. However, her past medical history reveals seizure disorder, which is under control with valproic acid and lithium. She has not seen her neurologist during the past 2 years, in the absence of any complaints. She also reports a previous history of elective abortion. The physical examination is insignificant. Her blood pressure is 130/75 mm Hg and pulse is 80/min. The patient is scheduled to undergo regular laboratory tests and abdominal ultrasound. Given her past medical history, which of the following conditions is her fetus most likely going to develop?
- A. Neural tube defects (NTDs) (Correct Answer)
- B. Intrauterine growth restriction
- C. Iron deficiency anemia
- D. Trisomy 21
- E. Limb anomalies
Neurulation and neural tube development Explanation: **Neural tube defects (NTDs)**
* The use of **valproic acid** during pregnancy is significantly associated with an increased risk of **neural tube defects (NTDs)**, such as spina bifida and anencephaly, in the fetus.
* Valproic acid interferes with **folate metabolism**, which is crucial for proper neural tube closure during early fetal development.
*Intrauterine growth restriction*
* While some medications and maternal conditions can cause **intrauterine growth restriction (IUGR)**, valproic acid and lithium are **not primary causes** of IUGR.
* Other factors, such as **placental insufficiency**, severe maternal hypertension, or infections, are more commonly associated with IUGR.
*Iron deficiency anemia*
* **Iron deficiency anemia** is a common maternal condition in pregnancy, but it is **not a direct fetal outcome** of maternal valproic acid or lithium use.
* Fetal anemia might occur due to other causes like **Rh incompatibility** or parvovirus infection.
*Trisomy 21*
* **Trisomy 21 (Down syndrome)** is a **chromosomal anomaly** caused by the presence of an extra copy of chromosome 21.
* It is not related to maternal medication use like valproic acid or lithium; its incidence is primarily correlated with **advanced maternal age**.
*Limb anomalies*
* Although several teratogenic medications can cause **limb anomalies**, **valproic acid** is more strongly linked to **neural tube defects** and certain **cardiac anomalies**.
* **Thalidomide**, for example, is notoriously associated with severe limb malformations.
Neurulation and neural tube development US Medical PG Question 6: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?
- A. "Does the diarrhea typically precede the constipation, or vice-versa?"
- B. "Is the diarrhea foul-smelling?"
- C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
- D. "Are the symptoms worse in the morning or at night?"
- E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)
Neurulation and neural tube development Explanation: ***Can you tell me more about the symptoms you have been experiencing?***
- This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis.
- In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions.
*Does the diarrhea typically precede the constipation, or vice-versa?*
- While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience.
- It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture.
*Is the diarrhea foul-smelling?*
- Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions.
- However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed.
*Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life*
- Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time.
- However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially.
*Are the symptoms worse in the morning or at night?*
- Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related.
- This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.
Neurulation and neural tube development US Medical PG Question 7: A 26-year-old G1P0 woman comes to her maternal and fetal medicine doctor at 15 weeks of gestation in order to be evaluated for fetal developmental abnormalities. Her family has a history of congenital disorders leading to difficulty walking so she was concerned about her child. Amniocentesis shows normal levels of all serum proteins and circulating factors. Despite this, the physician warns that there is a possibility that there may be a neural tube abnormality in this child even though the normal results make it less likely. If this child was born with a neural tube closure abnormality, which of the following findings would most likely be seen in the child?
- A. Protrusion of the meninges and spinal cord through a bony defect
- B. Protrusion of the meninges through a bony defect
- C. Spinal cord able to be seen externally
- D. Tuft of hair or skin dimple on lower back (Correct Answer)
- E. Absence of the brain and calvarium
Neurulation and neural tube development Explanation: ***Tuft of hair or skin dimple on lower back***
- This finding, particularly a **tuft of hair**, **skin dimple**, or **subcutaneous lipoma** on the lower back, is characteristic of **spina bifida occulta**.
- **Spina bifida occulta** is the least severe form of neural tube defect, where there is a bony defect in the vertebrae but the spinal cord and meninges remain within the spinal canal and are not externally evident.
*Protrusion of the meninges and spinal cord through a bony defect*
- This describes a **myelomeningocele**, which is a more severe form of spina bifida where the **spinal cord** and **meninges** protrude through a bony defect.
- Myelomeningocele typically presents with a visible sac on the back containing neural tissue, often leading to neurological deficits.
*Protrusion of the meninges through a bony defect*
- This describes a **meningocele**, where only the **meninges** protrude through a defect in the vertebral column, forming a fluid-filled sac.
- While it involves a visible sac, it does not contain neural tissue, and neurological symptoms are often absent or less severe compared to myelomeningocele.
*Spinal cord able to be seen externally*
- This is characteristic of **myeloschisis** or **rachischisis**, the most severe open neural tube defects where the **spinal cord** is open and exposed to the environment.
- This condition is often incompatible with life or leads to profound neurological impairment.
*Absence of the brain and calvarium*
- This describes **anencephaly**, a severe neural tube defect resulting from failure of closure of the anterior neural tube.
- Anencephaly is a lethal condition where the forebrain and cranial vault are absent, which is distinctly different from a spinal defect.
Neurulation and neural tube development US Medical PG Question 8: A 26-year-old woman comes to the physician because she has not had a menstrual period for 5 weeks. Menarche was at the age of 14 years and menses occurred at regular 30-day intervals. She reports having unprotected sexual intercourse 3 weeks ago. A urine pregnancy test is positive. Which of the following best describes the stage of development of the embryo at this time?
- A. Fetal heart is beating, but cardiac activity is not yet visible on ultrasound
- B. Limb buds have formed, but fetal movements have not begun
- C. Sexual differentiation has begun, but fetal movement has not started
- D. Neural crest has formed, but limb buds have not yet formed (Correct Answer)
- E. Implantation has occurred, but notochord has not yet formed
Neurulation and neural tube development Explanation: ***Neural crest has formed, but limb buds have not yet formed***
- At **5 weeks gestational age (3 weeks post-fertilization)**, neurulation is completing or recently completed
- **Neural crest cells** migrate from the neural folds during weeks 3-4 post-fertilization and are definitely present by this time
- **Limb buds** appear later, around week 4-5 post-fertilization (week 6-7 gestational age), making this the most accurate description for the current developmental stage
*Fetal heart is beating, but cardiac activity is not yet visible on ultrasound*
- The primitive heart tube begins contracting around day 22-23 post-fertilization (early week 4)
- At 3 weeks post-fertilization (5 weeks gestational age), the heart may just be starting to beat, but this timing is less precise
- Cardiac activity becomes visible on transvaginal ultrasound around 5.5-6 weeks gestational age, so this option is close but less precise than the correct answer
*Limb buds have formed, but fetal movements have not begun*
- **Limb buds** typically appear around week 4-5 post-fertilization (week 6-7 gestational age)
- This is **too advanced** for 3 weeks post-fertilization
- While fetal movements aren't perceptible to the mother until 16-20 weeks, they begin much later than the current stage
*Sexual differentiation has begun, but fetal movement has not started*
- **Sexual differentiation** of the gonads begins around week 7 post-fertilization (week 9 gestational age)
- External genitalia differentiation occurs even later (weeks 9-12 post-fertilization)
- This stage is **far too advanced** for the current 3-week post-fertilization timeframe
*Implantation has occurred, but notochord has not yet formed*
- **Implantation** occurs 6-12 days after fertilization, which is approximately 2-3 weeks before a positive pregnancy test
- The **notochord** forms during gastrulation in the **3rd week post-fertilization** (5th week gestational age)
- By the time of this positive pregnancy test (5 weeks gestational age), the notochord has **already formed**, making this statement incorrect
Neurulation and neural tube development US Medical PG Question 9: A 32-year-old G1P0 woman undergoes her 2nd-trimester ultrasound in a community hospital. During her prenatal care, she was found to have mild anemia, low levels of folate, and serum alpha-fetoprotein levels greater than 2 multiples of the median (MoM) on 2 separate occasions. Her 1st-trimester ultrasound was significant for the absence of the intracranial lucency, no visualization of the cisterna magna, and posterior shift of the brain stem. These 2nd-trimester ultrasound reports reveal the widening of the lumbosacral spine ossification centers and the presence of a sac in proximity to the lumbosacral defect. Which of the following statements best describes the congenital defect in the fetus?
- A. Abnormal development of the caudal eminence
- B. Persistence of the anterior accessory neurenteric canal (ANC)
- C. Failure of the caudal neuropore to close (Correct Answer)
- D. Failure of mesenchymal cells to form a neural rod
- E. Failure of the rostral neuropore to close
Neurulation and neural tube development Explanation: ***Failure of the caudal neuropore to close***
- The constellation of findings, including **elevated alpha-fetoprotein (AFP)**, absence of intracranial lucency, no visualization of the cisterna magna, posterior shift of the brain stem, widening lumbosacral spine ossification centers, and a sac near a lumbosacral defect, points to a **neural tube defect**, specifically an **open spina bifida** (myelomeningocele).
- This condition results from the **incomplete closure of the neural tube**, particularly the **caudal neuropore**, which normally closes around day 27-28 of embryonic development.
*Abnormal development of the caudal eminence*
- **Caudal eminence defects** typically manifest as caudal regression syndrome, which involves abnormalities of the sacrum and lower limbs, but usually **not** an open neural tube defect with elevated AFP and characteristic cranial ultrasound findings.
- While there is a lumbosacral defect, the extensive features point away from an isolated caudal eminence issue.
*Persistence of the anterior accessory neurenteric canal (ANC)*
- **Persistent ANC** is a rare condition that can lead to **duplications of the neural tube** or gastrointestinal tract, often associated with a connection between the gut and the neural canal.
- This would not explain the high AFP, absence of intracranial lucency, or the specific sonographic features of an open neural tube defect like spina bifida.
*Failure of mesenchymal cells to form a neural rod*
- The formation of the neural tube is a complex process; while mesenchymal cells are involved in surrounding structures, the neural rod itself primarily forms from the **neuroectoderm**.
- This description does not accurately reflect the embryological origin of spina bifida, which is fundamentally a defect of neural tube closure rather than a failure of neural rod formation.
*Failure of the rostral neuropore to close*
- Failure of the **rostral (cranial) neuropore** to close leads to **anencephaly** or encephalocele, characterized by the absence of a significant portion of the brain and skull.
- While AFP levels would be high, the ultrasound findings of a sac in the lumbosacral region and the specific intracranial findings (e.g., absence of intracranial lucency, posterior shift of the brain stem, which are signs of Arnold-Chiari malformation type II) are much more consistent with a caudal defect like myelomeningocele.
Neurulation and neural tube development US Medical PG Question 10: During the third week of development, the blastocyst undergoes a variety of differentiation processes responsible for the formation of the gastrula and, eventually, the embryo. This differentiation creates cell lineages that eventually become a variety of body systems. What cell lineage, present at this date, is responsible for the formation of the liver?
- A. Neuroectoderm
- B. Syncytiotrophoblasts
- C. Ectoderm
- D. Endoderm (Correct Answer)
- E. Mesoderm
Neurulation and neural tube development Explanation: ***Endoderm***
- The **endoderm** is one of the three primary germ layers that develops during gastrulation and is responsible for forming the lining of the **gastrointestinal tract** and associated organs, including the **liver** and pancreas.
- Liver development begins from an outgrowth of the **foregut endoderm**, which differentiates into hepatocytes and bile duct cells, forming the hepatic parenchyma.
*Neuroectoderm*
- **Neuroectoderm** is a specialized part of the ectoderm that gives rise to the entire **nervous system**, including the brain, spinal cord, and peripheral nerves.
- It does not contribute to the formation of visceral organs like the liver.
*Syncytiotrophoblasts*
- **Syncytiotrophoblasts** are a layer of the **trophoblast** that form part of the placenta, specifically involved in hormone production and nutrient exchange between the mother and fetus.
- They are part of the supporting structures for pregnancy and do not contribute to the embryonic germ layers or organ formation within the embryo itself.
*Ectoderm*
- The **ectoderm** is the outermost germ layer and gives rise to the **epidermis of the skin**, hair, nails, nervous system, and sensory organs.
- While it forms the outer coverings and nervous system, it does not directly form internal organs like the liver.
*Mesoderm*
- The **mesoderm** is the middle germ layer, responsible for forming **muscle**, **bone**, connective tissue, the circulatory system, kidneys, and gonads.
- While mesoderm contributes supporting structures to the liver (blood vessels, connective tissue, hematopoietic cells), the **hepatic parenchyma** (hepatocytes and bile ducts) is derived from the endoderm, making endoderm the primary cell lineage responsible for liver formation.
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