Endocrinology of Pregnancy Practice Questions

Q: A primigravida presented with increased fatigue, sleepiness, and cold intolerance. Blood investigations show increased TSH levels. Hypothyroidism in pregnancy is LEAST likely associated with which of the following?

Polyhydramnios. ### **Explanation** Hypothyroidism in pregnancy is a high-yield topic for NEET-PG. It is characterized by an underactive thyroid gland, leading to a metabolic slowdown that affects both maternal health and fetal development. **Why Polyhydramnios is the Correct Answer:** Polyhydramnios (excess amniotic fluid) is **not** typically associated with hypothyroidism. In fact, hypothyroidism is more commonly associated with **Oligohydramnios** (decreased amniotic fluid). This occurs due to reduced fetal renal perfusion and placental insufficiency, which are common sequelae of maternal thyroid hormone deficiency. **Analysis of Incorrect Options:** * **Recurrent Abortions:** Thyroid hormones are essential for maintaining the early decidua. Deficiency leads to impaired implantation and early pregnancy loss. * **IUGR (Intrauterine Growth Restriction):** Maternal thyroxine is crucial for early fetal brain development and general somatic growth before the fetal thyroid begins functioning (around 12 weeks). Hypothyroidism leads to placental dysfunction, resulting in restricted growth. * **Preterm Labour:** Hypothyroidism increases the risk of pregnancy-induced hypertension (PIH) and placental abruption, both of which are major triggers for spontaneous or iatrogenic preterm birth. **Clinical Pearls for NEET-PG:** 1. **Most Common Cause:** Worldwide, iodine deficiency is the leading cause; in iodine-sufficient areas, **Hashimoto’s Thyroiditis** is the most common cause. 2. **Drug of Choice:** Levothyroxine. Requirements typically increase by **30–50%** during pregnancy. 3. **Target TSH:** The goal is to keep TSH <2.5 mIU/L in the first trimester and <3.0 mIU/L in the second and third trimesters. 4. **Complications:** Maternal risks include Preeclampsia and Postpartum Hemorrhage (PPH). Fetal risks include Cretinism and low IQ.

Q: What change is typically noticed in diastolic blood pressure during pregnancy?

Decline of 5-10 mm of Hg. **Explanation:** The correct answer is **B. Decline of 5-10 mm of Hg.** **1. Why the correct answer is right:** During pregnancy, systemic vascular resistance (SVR) decreases significantly due to the vasodilatory effects of **progesterone** and increased production of local vasodilators like **nitric oxide** and prostacyclin. Additionally, the development of the low-resistance uteroplacental circulation acts as an "arteriovenous shunt." While systolic blood pressure (SBP) shows little change, **diastolic blood pressure (DBP)** typically begins to fall in the first trimester, reaching its nadir (lowest point) at **16–24 weeks** of gestation. The average decline is approximately **5–10 mm Hg**. This physiological drop is essential to accommodate the 40–50% increase in blood volume without causing hypertension. **2. Why the incorrect options are wrong:** * **Options C & D (Elevation):** Blood pressure does not normally rise during a healthy pregnancy. An elevation of ≥140/90 mm Hg is diagnostic of hypertensive disorders of pregnancy (e.g., Gestational Hypertension or Preeclampsia). * **Option A (Decline of 10-20 mm Hg):** While a significant drop can occur in some individuals, a 10-20 mm Hg decline is more characteristic of the change in **Mean Arterial Pressure (MAP)** rather than the specific average decline of the diastolic component alone. **Clinical Pearls for NEET-PG:** * **Nadir:** DBP is lowest at mid-pregnancy (20-24 weeks) and returns to pre-pregnancy levels by term. * **Pulse Pressure:** Since DBP falls more than SBP, the pulse pressure (SBP minus DBP) **increases** during pregnancy. * **Positioning:** BP is lowest when the patient is in the **left lateral position** (due to relief of aortocaval compression) and highest when sitting. * **Cardiac Output:** Increases by 30-50%, peaking early at 20-24 weeks.

Q: Which of the following statements regarding epilepsy in pregnancy is true?

Monotherapy is preferred over polydrug therapy.. **Explanation:** **1. Why Monotherapy is Preferred:** The primary goal in managing epilepsy during pregnancy is to achieve seizure control using the lowest effective dose of a single drug. **Monotherapy** is preferred because the risk of major congenital malformations (MCMs) increases significantly with **polytherapy** (the use of multiple anti-epileptic drugs). For example, combining Valproate with other drugs exponentially increases the risk of neural tube defects and cognitive impairment compared to using a single agent. **2. Analysis of Incorrect Options:** * **Option A:** In reality, seizure frequency remains **unchanged in about 50-60%** of patients. It increases in approximately 20-30% of cases, often due to physiological changes (increased volume of distribution, increased renal clearance, or sleep deprivation). * **Option C:** There is a **genetic predisposition**; the incidence of epilepsy in offspring is higher (approx. 2-5%) compared to the general population (approx. 1%). * **Option D:** Breastfeeding is **not contraindicated**. While AEDs are secreted in breast milk, the benefits of breastfeeding generally outweigh the risks. Infants should simply be monitored for sedation or poor feeding. **3. Clinical Pearls for NEET-PG:** * **Pre-conception:** Start **Folic acid (5 mg/day)** at least 3 months prior to conception to reduce NTD risks. * **Drug of Choice:** **Lamotrigine** and **Levetiracetam** are generally considered the safest options. **Valproate** is the most teratogenic and should be avoided if possible. * **Vitamin K:** To prevent hemorrhagic disease of the newborn, 1 mg of Vitamin K is administered to the neonate at birth (especially if the mother is on enzyme-inducing drugs like Phenytoin or Phenobarbital).

Q: When heparin is administered during pregnancy, which of the following supplements should be added?

Calcium. **Explanation:** The correct answer is **Calcium**. **Why Calcium is the correct answer:** Long-term administration of heparin (both Unfractionated Heparin and Low Molecular Weight Heparin) during pregnancy is associated with a risk of **heparin-induced osteoporosis**. Heparin accelerates the loss of bone mineral density by increasing osteoclast activity and decreasing osteoblast function. Since pregnancy itself is a state of high calcium demand for fetal skeletal development, heparin therapy further predisposes the mother to bone loss and fractures. Therefore, supplemental **Calcium (1000–1500 mg/day)** and **Vitamin D** are routinely recommended to mitigate this risk. **Why other options are incorrect:** * **Iron and Folic Acid:** While these are standard supplements for all pregnant women to prevent anemia and neural tube defects, their requirement is not specifically linked to heparin administration. * **Copper and Zinc:** These are trace elements. Heparin does not interfere with their metabolism or absorption, and there is no clinical indication to supplement them specifically due to heparin therapy. **NEET-PG High-Yield Pearls:** * **Drug of Choice:** Heparin (specifically LMWH like Enoxaparin) is the anticoagulant of choice in pregnancy because it **does not cross the placenta** and is not teratogenic (unlike Warfarin, which causes Fetal Warfarin Syndrome). * **Monitoring:** LMWH does not require routine PT/INR or aPTT monitoring. If monitoring is needed (e.g., in renal failure or extreme obesity), **Anti-Xa levels** are measured. * **Side Effects:** The two most important side effects of heparin in pregnancy are **Osteoporosis** and **Heparin-Induced Thrombocytopenia (HIT)**. * **Timing:** Heparin should be discontinued 12–24 hours before planned induction or regional anesthesia to reduce the risk of spinal hematoma.

Q: A 26-year-old primigravida at 32 weeks of gestation experienced faintness and nausea when lying down, which resolved after turning on her side or getting up. These symptoms can be attributed to which of the following?

Inferior vena caval compression. ### Explanation The symptoms described—faintness and nausea while lying supine—are characteristic of **Supine Hypotensive Syndrome** (also known as Aortocaval Compression Syndrome). **1. Why the Correct Answer is Right:** In the third trimester, the gravid uterus is large and heavy. When the patient lies in a supine position, the uterus compresses the **Inferior Vena Cava (IVC)** against the vertebral column. This leads to: * **Decreased venous return** to the heart (reduced preload). * **Decreased cardiac output**, resulting in maternal hypotension. * Reflex symptoms like dizziness, nausea, and syncope. Turning to the **left lateral position** relieves the compression, restores venous return, and resolves the symptoms. **2. Why the Incorrect Options are Wrong:** * **A. Reduced placental flow:** While IVC compression *can* lead to reduced placental perfusion (potentially causing fetal distress), it is a *consequence* of the compression, not the primary cause of the maternal symptoms. * **B. Increased intragastric pressure:** This is common in pregnancy due to the uterus pushing against the stomach and progesterone-induced relaxation of the esophageal sphincter, but it causes **GERD/heartburn**, not faintness or syncope. * **C. Increased intracranial pressure:** This would typically present with persistent headaches, papilledema, or vomiting, and is not positionally relieved by turning on the side in this context. **3. NEET-PG High-Yield Pearls:** * **Left Lateral Position:** This is the "position of choice" in late pregnancy to maximize cardiac output and placental perfusion. * **Aortic Compression:** The uterus also compresses the aorta (Poseiro effect), which may reduce uterine blood flow even if maternal blood pressure remains stable. * **Clinical Tip:** Always advise pregnant women in the third trimester to sleep on their side to prevent stillbirth and maternal hypotension.

Q: Glucosuria noted during a routine antenatal investigation indicates the need for what next step?

Glucose tolerance test. **Explanation:** The correct answer is **D. Glucose tolerance test**. **1. Why the correct answer is right:** During pregnancy, the **Glomerular Filtration Rate (GFR) increases** by approximately 50%, while the renal tubular reabsorption capacity for glucose remains unchanged or slightly decreases. This leads to a lowered renal threshold for glucose, making **isolated glucosuria a common and often physiological finding** in up to 50% of pregnant women. However, because glucosuria can also be a marker for undiagnosed Gestational Diabetes Mellitus (GDM), it cannot be ignored. It serves as a screening signal that necessitates a definitive diagnostic step—the **Glucose Tolerance Test (GTT)**—to differentiate between physiological renal changes and true carbohydrate intolerance. **2. Why the incorrect options are wrong:** * **A & C (Treatment/Insulin):** One cannot initiate treatment or insulin therapy based solely on a urine dipstick. Diagnosis must first be confirmed via standardized blood glucose testing (OGTT/DIPSI). * **B (Dietary modification):** While healthy eating is encouraged, formal dietary modification as a medical intervention for GDM is only prescribed after a confirmed diagnosis. **3. NEET-PG High-Yield Pearls:** * **DIPSI Criteria:** In India, the Diabetes in Pregnancy Study Group India (DIPSI) recommends a 75g oral glucose load regardless of the last meal. A 2-hour plasma glucose **≥140 mg/dL** is diagnostic of GDM. * **Renal Threshold:** In non-pregnant adults, the renal threshold for glucose is ~180 mg/dL; in pregnancy, this threshold drops significantly. * **hPL Factor:** Human Placental Lactogen (hPL) is the primary hormone responsible for the "diabetogenic" state of pregnancy, peaking in the third trimester.

Q: What is the typical increase in kidney size during pregnancy?

1.5 cm. **Explanation:** During pregnancy, the kidneys undergo significant anatomical and physiological changes to accommodate increased metabolic demands. The correct answer is **1.5 cm** (Option B). This increase in renal length is primarily due to an increase in renal vascular volume and interstitial space, rather than an increase in the number of nephrons. **Why 1.5 cm is correct:** The kidneys enlarge by approximately **1 to 1.5 cm** in length. This hypertrophy is driven by increased renal blood flow (which rises by 50–80%) and progesterone-mediated relaxation of the smooth muscles, leading to physiological hydronephrosis and increased renal weight. **Analysis of Incorrect Options:** * **A (0.5 cm):** This value underestimates the significant physiological hypertrophy and vascular engorgement that occurs during a healthy pregnancy. * **C & D (2 cm and 2.5 cm):** While the renal pelvis and calyces can dilate significantly (especially on the right side), an increase in the actual renal parenchyma length beyond 1.5 cm is atypical and might suggest underlying pathology or severe obstructive uropathy. **High-Yield Clinical Pearls for NEET-PG:** * **Right-sided dominance:** Dilation of the renal pelvis and ureters (Hydroureter) is more prominent on the **right side** (80%) due to the dextrorotation of the uterus and the cushioning effect of the sigmoid colon on the left ureter. * **GFR Changes:** Glomerular Filtration Rate (GFR) increases by **50%** by the end of the first trimester. * **Creatinine Levels:** Due to increased GFR, normal serum creatinine levels are lower in pregnancy (**0.4–0.8 mg/dL**). A value of 1.0 mg/dL, which is normal in non-pregnant adults, may indicate renal impairment in a pregnant patient. * **Glucosuria:** It is considered physiological in pregnancy due to increased GFR and reduced tubular reabsorption of glucose.

Question 1

A primigravida presented with increased fatigue, sleepiness, and cold intolerance. Blood investigations show increased TSH levels. Hypothyroidism in pregnancy is LEAST likely associated with which of the following?

Accepted Answer

Polyhydramnios

Answer

Recurrent abortions

Answer

IUGR (Intrauterine Growth Restriction)

Answer

Preterm labour

Question 2

What change is typically noticed in diastolic blood pressure during pregnancy?

Accepted Answer

Decline of 5-10 mm of Hg

Answer

Decline of 10-20 mm of Hg

Answer

Elevation of 10-20 mm of Hg

Answer

Elevation of 5-10 mm of Hg

Question 3

Which of the following statements regarding epilepsy in pregnancy is true?

Accepted Answer

Monotherapy is preferred over polydrug therapy.

Answer

Seizure frequency decreases in the majority of patients.

Answer

There is no increased incidence of epilepsy in the offspring.

Answer

Breastfeeding is contraindicated.

Question 4

When heparin is administered during pregnancy, which of the following supplements should be added?

Accepted Answer

Calcium

Answer

Iron folic acid

Answer

Copper

Answer

Zinc

Question 5

A 26-year-old primigravida at 32 weeks of gestation experienced faintness and nausea when lying down, which resolved after turning on her side or getting up. These symptoms can be attributed to which of the following?

Accepted Answer

Inferior vena caval compression

Answer

Reduced placental flow

Answer

Increased intragastric pressure

Answer

Increased intracranial pressure

Question 6

What is the drug of choice for treating hyperthyroidism in pregnancy?

Accepted Answer

Propylthiouracil

Answer

Carbimazole

Answer

Propranolol

Answer

Lugol's iodine

Question 7

Glucosuria noted during a routine antenatal investigation indicates the need for what next step?

Accepted Answer

Glucose tolerance test

Answer

Treatment for gestational diabetes

Answer

Dietary modification

Answer

Insulin therapy

Question 8

A 27-year-old obese woman presents with oligomenorrhea, infertility, and hirsutism. What is the most likely diagnosis?

Accepted Answer

Polycystic ovarian syndrome

Answer

Endometriosis

Answer

Pelvic inflammatory disease

Answer

Turner's syndrome

Question 9

Which cardiovascular change is physiological in the last trimester of pregnancy?

Accepted Answer

Shift of apical impulse laterally and upwards in the left 4th intercostal space

Answer

Middiastolic murmur

Answer

Occasional atrial fibrillation

Answer

Cardiomegaly

Question 10

What is the typical increase in kidney size during pregnancy?

Accepted Answer

1.5 cm

Answer

0.5 cm

Answer

2 cm

Answer

2.5 cm

Endocrinology of Pregnancy — MCQs

Endocrinology of Pregnancy — MCQs

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