High-Risk Pregnancy Management — MCQs
A hypertensive patient wants to conceive. Which of the following medications needs to be stopped before pregnancy?
The following cost-effective investigations are routinely recommended in the screening of antenatal mothers, EXCEPT:
What is the management of eclampsia at 34 weeks of pregnancy?
Which is not a risk factor for gestational hypertension
Placenta grade 3, 35+3 weeks pregnancy, and absent end diastolic flow Doppler; next management is:
Which of the following statements about gestational diabetes mellitus (GDM) is true?
What maternal condition is commonly associated with congenital heart defects in the fetus?
As per the Government of India guidelines, the daily dose of elemental iron recommended for prophylaxis during pregnancy is
Calculate the maternal mortality ratio (MMR) for the year 2023, given the following data: - Total live births: 4,000 - Women who died: 6 (1 due to a road traffic accident (RTA), 1 due to sepsis, 1 due to obstructed labor, 1 due to eclampsia, 1 due to ectopic pregnancy, and 1 due to a snake bite)
Consider the following statements: Statement-I: While calculating the number of expected pregnancies per year in an area, a correction factor (usually 10%) is added to the expected number of live births in the year in the area. Statement-II: All the pregnancies in the area may not be registered by the health worker in the area. Which one of the following is correct in respect of the above statements?
High-Risk Pregnancy Management Indian Medical PG Practice Questions and MCQs
Question 1: A hypertensive patient wants to conceive. Which of the following medications needs to be stopped before pregnancy?
- A. ACE inhibitors (Correct Answer)
- B. Alpha Methyl dopa
- C. Calcium Channel Blockers
- D. Labetalol
- E. Hydralazine
Explanation: ***ACE inhibitors*** - **ACE inhibitors** are **teratogenic** and can cause **fetal kidney damage**, **oligohydramnios**, and **fetal death** if used during pregnancy. - They should be discontinued before conception or immediately upon pregnancy confirmation, and an alternative safe antihypertensive should be initiated. *Alpha Methyl dopa* - **Alpha-methyldopa** is considered one of the **first-line agents** for managing **hypertension in pregnancy** due to its established safety profile. - It reduces peripheral resistance without significantly affecting renal or uteroplacental blood flow. *Calcium Channel Blockers* - **Calcium channel blockers (CCBs)** like nifedipine and amlodipine are **generally considered safe** for use during pregnancy, especially dihydropyridines. - They are often used as **second-line treatments** for managing hypertension in pregnant women. *Labetalol* - **Labetalol** is a **beta-blocker** that is widely used and considered **safe** for treating **hypertension in pregnancy**. - It effectively lowers blood pressure without significant adverse effects on the fetus. *Hydralazine* - **Hydralazine** is a direct vasodilator that is **safe** for use in pregnancy and is commonly used for **acute management** of severe hypertension in pregnant women. - It has a long history of safe use during pregnancy without teratogenic effects.
Question 2: The following cost-effective investigations are routinely recommended in the screening of antenatal mothers, EXCEPT:
- A. Blood sugar levels for GDM
- B. VDRL for syphilis
- C. Urine analysis for bacteriuria
- D. Echocardiography for cardiac disease (Correct Answer)
Explanation: ***Echocardiography for cardiac disease*** - **Echocardiography** is not a *routinely recommended* screening investigation for all antenatal mothers due to its cost and the relatively low prevalence of significant congenital heart disease requiring universal screening. - It is typically performed only if there are **specific risk factors** or suspicious findings suggesting cardiac pathology. *Blood sugar levels for GDM* - Screening for **gestational diabetes mellitus (GDM)** with blood sugar levels (e.g., glucose challenge test) is routinely recommended due to the potential maternal and fetal complications if untreated. - GDM is a common condition that can be effectively managed with early diagnosis, making screening a **cost-effective** preventive measure. *VDRL for syphilis* - Screening for **syphilis** using tests like VDRL (Venereal Disease Research Laboratory) is a standard and *routinely recommended* antenatal investigation. - Early detection and treatment of syphilis in pregnant women prevent serious adverse outcomes such as **congenital syphilis**, which can cause severe fetal morbidity and mortality. *Urine analysis for bacteriuria* - **Urine analysis** for **asymptomatic bacteriuria** is routinely recommended during pregnancy because untreated bacteriuria can lead to pyelonephritis, preterm labor, and low birth weight. - It is a simple, **cost-effective** test with significant benefits for maternal and fetal health.
Question 3: What is the management of eclampsia at 34 weeks of pregnancy?
- A. Continue convulsions and wait for 37 weeks to complete.
- B. Wait for spontaneous labor.
- C. Continue blood pressure management.
- D. Administer antihypertensives, anticonvulsants, and consider termination of pregnancy. (Correct Answer)
Explanation: **Administer antihypertensives, anticonvulsants, and consider termination of pregnancy.** - In eclampsia, emergent management includes immediate administration of **magnesium sulfate** as an anticonvulsant and **antihypertensives** (e.g., labetalol, hydralazine, nifedipine) to control blood pressure. - Given the gestational age of 34 weeks and the occurrence of eclampsia, **delivery of the fetus** is often indicated to resolve the maternal condition, regardless of fetal lung maturity. *Continue convulsions and wait for 37 weeks to complete.* - Allowing **convulsions to continue** is extremely dangerous for both mother and fetus, increasing risks of aspiration, trauma, hypoxemia, and placental abruption. - Eclampsia is a severe complication of pregnancy that necessitates immediate intervention and **should not be passively observed** until full term. *Wait for spontaneous labor.* - **Delaying delivery** while waiting for spontaneous labor in eclampsia significantly prolongs the mother's exposure to the severe complications of the condition. - Eclampsia is an ** obstetric emergency** where prompt delivery, often via induction or C-section, is the definitive cure. *Continue blood pressure management.* - While **blood pressure management** is a crucial component of eclampsia treatment, it is insufficient on its own. - Eclampsia specifically involves **seizures**, which require anticonvulsant therapy (magnesium sulfate) in addition to antihypertensives, and the ultimate treatment is delivery.
Question 4: Which is not a risk factor for gestational hypertension
- A. Primigravida
- B. Factor V Leiden mutation
- C. Smoking (Correct Answer)
- D. Low maternal age
Explanation: ***Smoking*** - **Smoking** paradoxically shows a *protective effect* against gestational hypertension and preeclampsia, making it the correct answer as it is NOT a risk factor for gestational hypertension. - This well-documented phenomenon may be related to smoking's vasodilatory effects and reduced production of anti-angiogenic factors. - However, smoking carries numerous other serious risks including **intrauterine growth restriction (IUGR)**, **placental abruption**, **preterm birth**, and **perinatal mortality**. *Primigravida* - **Primigravida** (first pregnancy) is a well-established risk factor for gestational hypertension and preeclampsia. - First-time exposure to paternal antigens and incomplete immune tolerance may contribute to this increased risk. - The risk decreases in subsequent pregnancies with the same partner. *Factor V Leiden mutation* - The **Factor V Leiden mutation** is the most common inherited thrombophilia and significantly increases the risk of gestational hypertension and preeclampsia. - This mutation causes resistance to activated protein C, leading to a hypercoagulable state that can impair placental perfusion. - Associated with increased risk of venous thromboembolism during pregnancy. *Low maternal age* - **Low maternal age** (adolescent pregnancy, <20 years) is actually a recognized *risk factor* for gestational hypertension. - Young mothers may have incomplete physical and cardiovascular maturity to handle pregnancy-related physiological changes. - Adolescent pregnancies are associated with higher rates of hypertensive disorders of pregnancy.
Question 5: Placenta grade 3, 35+3 weeks pregnancy, and absent end diastolic flow Doppler; next management is:
- A. Monitor
- B. Terminate after 37 weeks
- C. Dexamethasone and terminate after 48 hours (Correct Answer)
- D. Consult pediatrician and plan immediate delivery
Explanation: ***Dexamethasone and terminate after 48 hours*** - Absent end diastolic flow (AEDF) at 35+3 weeks indicates **severe uteroplacental insufficiency** and significant fetal compromise, requiring intervention. - Administering **dexamethasone** (corticosteroids) for 48 hours helps to accelerate **fetal lung maturity** before delivery, reducing the risk of respiratory distress syndrome. *Monitor* - Simply monitoring is an inappropriate and potentially harmful management strategy given the presence of **absent end diastolic flow**, which reflects **critical fetal hypoxia**. - Delaying intervention in cases of AEDF significantly increases the risk of **fetal demise** and severe morbidity. *Terminate after 37 weeks* - Waiting until 37 weeks is too long. **Absent end diastolic flow** at 35+3 weeks significantly increases the risk of **fetal compromise** and death if delivery is delayed. - The goal is to balance the risks of prematurity with the risks of continued intrauterine compromise. *Consult pediatrician and plan immediate delivery* - While immediate delivery might be considered in some scenarios of fetal distress, delivering without prior **corticosteroid administration** (dexamethasone) at 35+3 weeks would increase the risk of **neonatal respiratory distress syndrome**. - The 48-hour window allows for **fetal lung maturation** while still addressing the urgent need for delivery due to AEDF.
Question 6: Which of the following statements about gestational diabetes mellitus (GDM) is true?
- A. It is always associated with a previous history of IUGR.
- B. There is no recurrence of GDM in future pregnancies.
- C. There is no risk of developing overt diabetes in the future.
- D. Gestational diabetes mellitus is first recognized during pregnancy. (Correct Answer)
Explanation: ***Gestational diabetes mellitus is first recognized during pregnancy.*** - GDM is defined as **glucose intolerance** that is first recognized or diagnosed during pregnancy, regardless of whether it requires insulin or persists after pregnancy. - This definition distinguishes it from **pre-existing type 1 or type 2 diabetes** diagnosed before conception. *It is always associated with a previous history of IUGR.* - GDM is primarily associated with an increased risk of **macrosomia** (large-for-gestational-age babies) due to high maternal glucose levels stimulating fetal insulin production and growth. - While other pregnancy complications can occur, **intrauterine growth restriction (IUGR)** is not a typical or consistent association with GDM. *There is no recurrence of GDM in future pregnancies.* - Women who have had GDM in one pregnancy have a **significantly increased risk** (30-50%) of developing it again in subsequent pregnancies. - This recurrence risk highlights the underlying predisposition to glucose intolerance. *There is no risk of developing overt diabetes in the future.* - A history of GDM is a strong predictor for developing **type 2 diabetes** later in life, with up to 50% of women developing it within 5-10 years post-delivery. - It also carries a small increased risk of developing **type 1 diabetes** in some individuals.
Question 7: What maternal condition is commonly associated with congenital heart defects in the fetus?
- A. ACE inhibitor
- B. GDM
- C. Pregestational DM (Correct Answer)
- D. Valproate
Explanation: ***Pregestational DM*** - **Pre-existing diabetes** in the mother is a significant risk factor for various **congenital anomalies**, including **congenital heart defects**, due to suboptimal glycemic control during early embryogenesis. - Poorly controlled **maternal hyperglycemia** leads to increased oxidative stress and altered cellular metabolism in the developing fetus, impacting cardiovascular development. *ACE inhibitor* - **ACE inhibitors** are teratogenic, primarily causing **renal dysfunction** (e.g., renal tubular dysplasia, oligohydramnios, anuria) and **fetal growth restriction**, especially when used in the second and third trimesters. - While they can have adverse fetal effects, their association with **congenital heart defects** is less pronounced compared to other teratogenic exposures. *GDM* - **Gestational diabetes mellitus (GDM)** typically develops in the second or third trimester when major organogenesis is complete, making its association with **structural congenital anomalies**, including heart defects, significantly lower than pregestational diabetes. - GDM is more commonly associated with fetal **macrosomia**, **hypoglycemia**, and respiratory distress syndrome at birth. *Valproate* - **Valproate** is a known teratogen associated with a specific pattern of anomalies, most notably **neural tube defects** (e.g., spina bifida), and facial dysmorphisms. - While it can be associated with an increased risk of some congenital heart defects, its primary and most significant fetal risk is **neural tube defects**.
Question 8: As per the Government of India guidelines, the daily dose of elemental iron recommended for prophylaxis during pregnancy is
- A. 150 mg/day for 100 days
- B. 200 mg/day for 100 days
- C. 100 mg/day for 100 days (Correct Answer)
- D. 50 mg/day for 100 days
Explanation: ***100 mg/day for 100 days*** - As per the **Government of India guidelines**, the recommended daily dose of **elemental iron** for prophylaxis during pregnancy is 100 mg/day. - This dose is typically continued for at least **100 days** to ensure adequate iron stores and prevent iron deficiency anemia. *150 mg/day for 100 days* - This dose exceeds the **recommended daily prophylactic** amount of elemental iron specified by Indian government guidelines. - While higher doses may be used for **therapeutic treatment** of existing iron deficiency anemia, it is not the standard for prophylaxis. *200 mg/day for 100 days* - This amount is significantly higher than the standard **prophylactic recommendation** for elemental iron during pregnancy in India. - Such a high dose would typically only be prescribed for **treating severe anemia**, not for routine prevention. *50 mg/day for 100 days* - This dose is lower than the **recommended daily amount** for effective iron prophylaxis according to the Government of India guidelines. - Such a dose might be **insufficient** to maintain adequate iron levels and prevent anemia during pregnancy.
Question 9: Calculate the maternal mortality ratio (MMR) for the year 2023, given the following data: - Total live births: 4,000 - Women who died: 6 (1 due to a road traffic accident (RTA), 1 due to sepsis, 1 due to obstructed labor, 1 due to eclampsia, 1 due to ectopic pregnancy, and 1 due to a snake bite)
- A. 75 per 100,000 live births
- B. 150 per 100,000 live births
- C. 100 per 100,000 live births (Correct Answer)
- D. 125 per 100,000 live births
Explanation: ***Correct: 100 per 100,000 live births*** - The **maternal mortality ratio (MMR)** includes deaths directly or indirectly due to pregnancy, childbirth, or within 42 days of termination of pregnancy, **excluding accidental or incidental causes**. - In this scenario, **4 maternal deaths** are identified: sepsis (direct), obstructed labor (direct), eclampsia (direct), and ectopic pregnancy (direct). - **Excluded deaths**: RTA and snake bite are **incidental/accidental deaths** not related to pregnancy complications. - **Calculation**: MMR = (4 / 4,000) × 100,000 = **100 per 100,000 live births** *Incorrect: 75 per 100,000 live births* - This would incorrectly count only **3 maternal deaths** instead of 4, suggesting underestimation or exclusion of a valid maternal death (e.g., ectopic pregnancy). - Represents a **miscalculation** that underestimates maternal mortality burden. *Incorrect: 150 per 100,000 live births* - This would incorrectly include **6 deaths** (all deaths including RTA and snake bite), failing to exclude incidental causes. - Including **non-maternal accidental deaths** inflates MMR and misrepresents actual maternal health outcomes. *Incorrect: 125 per 100,000 live births* - This would incorrectly count **5 deaths**, suggesting inclusion of one incidental death (either RTA or snake bite). - Fails to properly identify and exclude **both incidental deaths**, leading to an overestimated ratio.
Question 10: Consider the following statements: Statement-I: While calculating the number of expected pregnancies per year in an area, a correction factor (usually 10%) is added to the expected number of live births in the year in the area. Statement-II: All the pregnancies in the area may not be registered by the health worker in the area. Which one of the following is correct in respect of the above statements?
- A. Statement-II is incorrect but Statement-I is correct.
- B. Statement-I is correct but Statement-II is incorrect.
- C. Statement-I and Statement-II are independently correct, and Statement-II is a correct explanation for Statement-I.
- D. Statement-I and Statement-II are independently correct, but Statement-II is not a correct explanation for Statement-I. (Correct Answer)
Explanation: ***Statement-I and Statement-II are independently correct, but Statement-II is not a correct explanation for Statement-I.*** - Statement-I is correct because a **10% correction factor** is added to expected live births to calculate expected pregnancies in an area. - The **primary reason** for this correction factor is to account for **pregnancy wastage** (spontaneous abortions, induced abortions, stillbirths) that do not result in live births. - Statement-II is also correct as **under-registration of pregnancies** is a real challenge in health surveillance systems. - However, Statement-II does **NOT correctly explain** Statement-I because the correction factor is primarily meant to account for **pregnancy outcomes that don't lead to live births**, not for under-registration issues. - Under-registration would require a different type of adjustment in the surveillance system, not the correction factor applied to convert live births to expected pregnancies. *Statement-I and Statement-II are independently correct, and Statement-II is a correct explanation for Statement-I.* - While both statements are correct, Statement-II is **not the correct explanation** for Statement-I. - The correction factor exists primarily to account for **pregnancy wastage** (miscarriages, abortions, stillbirths), not for under-registration of pregnancies. - Under-registration is a separate data quality issue that affects the accuracy of all health statistics. *Statement-II is incorrect but Statement-I is correct.* - Statement-II is **correct** as incomplete registration of pregnancies is a well-documented challenge in community health programs. - Therefore, this option is incorrect. *Statement-I is correct but Statement-II is incorrect.* - Statement-II is **correct** as under-registration of pregnancies does occur in health surveillance systems. - Therefore, this option is incorrect.
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