Endocrinology of Pregnancy — MCQs

Endocrinology of Pregnancy Indian Medical PG Practice Questions and MCQs

Question 101: 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?

A. Recurrent abortions
B. Polyhydramnios (Correct Answer)
C. IUGR (Intrauterine Growth Restriction)
D. Preterm labour

Explanation: ### **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.

Question 102: What change is typically noticed in diastolic blood pressure during pregnancy?

A. Decline of 10-20 mm of Hg
B. Decline of 5-10 mm of Hg (Correct Answer)
C. Elevation of 10-20 mm of Hg
D. Elevation of 5-10 mm of Hg

Explanation: **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.

Question 103: Which of the following statements regarding epilepsy in pregnancy is true?

A. Seizure frequency decreases in the majority of patients.
B. Monotherapy is preferred over polydrug therapy. (Correct Answer)
C. There is no increased incidence of epilepsy in the offspring.
D. Breastfeeding is contraindicated.

Explanation: **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).

Question 104: When heparin is administered during pregnancy, which of the following supplements should be added?

A. Iron folic acid
B. Copper
C. Calcium (Correct Answer)
D. Zinc

Explanation: **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.

Question 105: 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?

A. Reduced placental flow
B. Increased intragastric pressure
C. Increased intracranial pressure
D. Inferior vena caval compression (Correct Answer)

Explanation: ### 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.

Question 106: What is the drug of choice for treating hyperthyroidism in pregnancy?

A. Propylthiouracil (Correct Answer)
B. Carbimazole
C. Propranolol
D. Lugol's iodine

Explanation: ### Explanation Hyperthyroidism in pregnancy is most commonly caused by Graves' disease. The management requires balancing maternal health with fetal safety, as antithyroid drugs cross the placenta. **Why Propylthiouracil (PTU) is the Correct Answer:** PTU is the **drug of choice in the first trimester**. It is preferred during organogenesis because it is more highly protein-bound than Methimazole/Carbimazole, resulting in less placental transfer. Most importantly, it avoids the rare but serious **embryopathy** associated with Methimazole, such as *Aplasia cutis* (congenital skin defects) and *Choanal atresia*. **Analysis of Incorrect Options:** * **B. Carbimazole:** This is a prodrug of Methimazole. While it is more potent and has a longer half-life, it is avoided in the first trimester due to its teratogenic potential (Methimazole embryopathy). However, it is often the drug of choice in the **second and third trimesters** to avoid PTU-induced maternal hepatotoxicity. * **C. Propranolol:** This is a beta-blocker used only for symptomatic relief (tachycardia/palpitations) or during a thyroid storm. Long-term use in pregnancy is avoided as it is associated with fetal growth restriction (IUGR), neonatal hypoglycemia, and bradycardia. * **D. Lugol’s Iodine:** This is used pre-operatively to vascularize the gland or in thyroid storms. It is contraindicated for long-term use in pregnancy as it can cause fetal goiter and hypothyroidism (Wolff-Chaikoff effect). **High-Yield NEET-PG Pearls:** * **Switching Therapy:** The current recommendation is PTU for the 1st trimester, then switching to Methimazole/Carbimazole for the remainder of the pregnancy. * **Target Levels:** Aim to keep maternal Free T4 at the **upper limit of the normal range** using the lowest possible dose to prevent fetal hypothyroidism. * **HCG & Thyroid:** HCG has a structural similarity to TSH; thus, transient "Gestational Transient Thyrotoxicosis" can occur in the first trimester (especially in twin pregnancies or hyperemesis gravidarum), which usually requires no treatment.

Question 107: Glucosuria noted during a routine antenatal investigation indicates the need for what next step?

A. Treatment for gestational diabetes
B. Dietary modification
C. Insulin therapy
D. Glucose tolerance test (Correct Answer)

Explanation: **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.

Question 108: A 27-year-old obese woman presents with oligomenorrhea, infertility, and hirsutism. What is the most likely diagnosis?

A. Polycystic ovarian syndrome (Correct Answer)
B. Endometriosis
C. Pelvic inflammatory disease
D. Turner's syndrome

Explanation: ### Explanation **Correct Answer: A. Polycystic Ovarian Syndrome (PCOS)** The clinical triad of **oligomenorrhea** (irregular cycles), **infertility** (due to chronic anovulation), and **hirsutism** (clinical hyperandrogenism), especially in an **obese** patient, is the classic presentation of PCOS. The underlying pathophysiology involves a derangement in the hypothalamic-pituitary-ovarian axis, leading to increased LH pulse frequency and an elevated LH:FSH ratio. This stimulates the ovarian theca cells to produce excess androgens. Peripheral conversion of androgens in adipose tissue (obesity) further exacerbates the hormonal imbalance, creating a vicious cycle of insulin resistance and hyperinsulinemia. **Why the other options are incorrect:** * **B. Endometriosis:** Typically presents with the "3 Ds": Dysmenorrhea, Dyspareunia, and Dyschezia. While it causes infertility, it does not cause hirsutism or obesity. * **C. Pelvic Inflammatory Disease (PID):** An acute or chronic infection presenting with pelvic pain, vaginal discharge, and fever. It causes infertility via tubal factor (blockage) but does not involve endocrine disturbances like hirsutism. * **D. Turner’s Syndrome (45, XO):** Characterized by primary amenorrhea, short stature, and streak ovaries. These patients have hypergonadotropic hypogonadism (low estrogen, high FSH) and lack secondary sexual characteristics, which contradicts the hirsutism seen here. **High-Yield Clinical Pearls for NEET-PG:** * **Rotterdam Criteria:** Diagnosis requires 2 out of 3: (1) Oligo/Anovulation, (2) Hyperandrogenism (Clinical/Biochemical), (3) Polycystic ovaries on USG (≥12 follicles or volume >10ml). * **Gold Standard Investigation:** Serum LH:FSH ratio (usually >2:1 or 3:1). * **Treatment of Choice:** * Infertility: **Letrozole** (First-line) or Clomiphene Citrate. * Hirsutism/Irregular cycles: Combined Oral Contraceptive Pills (OCPs). * Metabolic issues: Weight loss and Metformin.

Question 109: Which cardiovascular change is physiological in the last trimester of pregnancy?

A. Middiastolic murmur
B. Occasional atrial fibrillation
C. Shift of apical impulse laterally and upwards in the left 4th intercostal space (Correct Answer)
D. Cardiomegaly

Explanation: ### Explanation **Correct Answer: C. Shift of apical impulse laterally and upwards in the left 4th intercostal space** **1. Why Option C is Correct:** During the third trimester, the enlarging uterus causes significant elevation of the diaphragm. This mechanical displacement pushes the heart **upwards and to the left**, rotating it on its long axis. Consequently, the apical impulse (apex beat) is displaced to the **4th intercostal space**, lateral to the midclavicular line. This is a normal physiological finding and should not be mistaken for cardiac pathology. **2. Why Other Options are Incorrect:** * **A. Middiastolic murmur:** While a soft systolic murmur (Grade I or II) is common due to increased blood flow across valves, a **diastolic murmur is always pathological** in pregnancy and warrants further investigation (e.g., echocardiography). * **B. Occasional atrial fibrillation:** AF is never physiological. Pregnancy may predispose patients to benign arrhythmias like premature atrial or ventricular contractions, but atrial fibrillation usually indicates underlying structural heart disease (e.g., Mitral Stenosis). * **D. Cardiomegaly:** While there is a slight increase in cardiac silhouette on X-ray due to displacement and increased stroke volume, true **cardiomegaly (ventricular hypertrophy) is pathological**. **3. NEET-PG High-Yield Pearls:** * **Cardiac Output:** Increases by 40–50%, peaking at 28–32 weeks. * **Blood Pressure:** Diastolic BP decreases more than systolic BP, reaching its nadir in the second trimester. * **ECG Changes:** Left axis deviation and flattened or inverted T-waves in Lead III are common physiological findings. * **Heart Sounds:** Loud S1 and a physiological S3 (due to rapid ventricular filling) are common. * **Supine Hypotension Syndrome:** Caused by aortocaval compression by the gravid uterus; managed by the left lateral position.

Question 110: What is the typical increase in kidney size during pregnancy?

A. 0.5 cm
B. 1.5 cm (Correct Answer)
C. 2 cm
D. 2.5 cm

Explanation: **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.

Practice by Chapter

Endocrine Changes in Normal Pregnancy

Practice Questions

Thyroid Disorders in Pregnancy

Practice Questions

Diabetes in Pregnancy

Practice Questions

Adrenal Disorders in Pregnancy

Practice Questions

Pituitary Disorders in Pregnancy

Practice Questions

Hyperemesis Gravidarum

Practice Questions

Hormonal Regulation of Labor

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Pharmacokinetics of Hormones in Pregnancy

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Fetal Endocrine Development

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Placental Hormones

Practice Questions

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