Endocrinology of Pregnancy Practice Questions

Q: Which of the following hormones is NOT secreted by the placenta?

Insulin. **Explanation:** The placenta acts as a sophisticated transient endocrine organ, producing a wide array of protein and steroid hormones to maintain pregnancy. **Why Insulin is the Correct Answer:** Insulin is a peptide hormone produced exclusively by the **beta cells of the Islets of Langerhans in the pancreas**. While the placenta produces hormones that significantly influence maternal glucose metabolism (like Human Placental Lactogen/hPL), it does **not** synthesize insulin. Furthermore, maternal insulin does not cross the placental barrier; the fetus relies entirely on its own pancreatic production for glycemic control. **Analysis of Incorrect Options:** * **hCG (Human Chorionic Gonadotropin):** This is the first hormone secreted by the syncytiotrophoblast. It is essential for maintaining the corpus luteum in early pregnancy. * **TRH (Thyrotropin-Releasing Hormone):** The placenta produces various hypothalamic-like releasing hormones, including TRH, GnRH, and CRH. These function locally to regulate placental hormone secretion. * **ACTH (Adrenocorticotropic Hormone):** The placenta synthesizes POMC-derived peptides, including ACTH. Unlike pituitary ACTH, placental ACTH is relatively resistant to feedback suppression by glucocorticoids. **High-Yield Clinical Pearls for NEET-PG:** * **hPL (Human Placental Lactogen):** Also known as Human Chorionic Somatomammotropin (hCS), it is the primary hormone responsible for the **diabetogenic state** of pregnancy (insulin resistance). * **Progesterone:** Often called the "hormone of pregnancy," the placenta takes over its production from the corpus luteum at approximately **7–9 weeks** (Luteo-placental shift). * **Estriol (E3):** The dominant estrogen in pregnancy; its synthesis requires the **fetal adrenal gland** (DHEAS) and **fetal liver** (16-alpha-hydroxylation), making it a marker of feto-placental well-being.

Q: During the first trimester of pregnancy, the risk of fetal malformation in a pregnant woman with insulin-dependent diabetes is best predicted by:

Glycosylated hemoglobin levels. **Explanation:** **1. Why Glycosylated Hemoglobin (HbA1c) is the Correct Answer:** The risk of congenital malformations in diabetic pregnancies is directly proportional to the degree of glycemic control during the period of **organogenesis** (the first 8 weeks post-conception). HbA1c reflects the average blood glucose levels over the preceding 8–12 weeks. High periconceptional HbA1c levels (especially >8.5–10%) are strongly associated with an increased risk of major anomalies, such as **Sacral Agenesis** (most specific) and **Congenital Heart Defects** (most common). Therefore, it serves as the best retrospective predictor of the intrauterine environment during the critical window of development. **2. Why Other Options are Incorrect:** * **A. Blood sugar values:** These provide a "snapshot" of glucose levels at a single point in time. They fluctuate daily and do not provide a reliable long-term record of control during the organogenesis period. * **C. Serum alpha-fetoprotein (MSAFP):** This is a screening tool used in the **second trimester** (15–20 weeks) to detect neural tube defects or aneuploidies; it does not predict the risk of malformation during the first trimester. * **D. Serum unconjugated estriol:** This is a component of the Triple/Quadruple marker screen used in the second trimester to assess fetal well-being and chromosomal risks, not early malformation risk. **3. NEET-PG High-Yield Pearls:** * **Most common malformation:** Ventricular Septal Defect (VSD) / Transposition of Great Arteries (TGA). * **Most specific malformation:** Caudal Regression Syndrome (Sacral Agenesis). * **Target HbA1c:** Ideally, HbA1c should be **<6.5%** before conception to minimize the risk of malformations to that of the general population. * **Diabetic Embryopathy:** Refers to malformations occurring in the first trimester due to pre-gestational diabetes (Type 1 or 2).

Q: A 30-year-old G3P2 obese woman at 26 weeks' gestation with no significant past medical history states that diabetes runs in her family. Her other pregnancies were uncomplicated. The results of a 3-hour glucose tolerance test show the following glucose levels: fasting: 90 mg/dL, 1 hour: 195 mg/dL, 2 hours: 155 mg/dL, 3 hours: 145 mg/dL. As a result, she is diagnosed with gestational diabetes. She is counselled to start diet modification and exercise to control her glycemic levels. 3 weeks after her diagnosis, she presents her values: Fasting: 95 mg/dL, 1 hr postprandial: 185 mg/dL. What is the best management?

Start insulin. **Explanation:** The patient has been diagnosed with **Gestational Diabetes Mellitus (GDM)** based on her 3-hour Glucose Tolerance Test (GTT) results (exceeding thresholds for 1-hour and 2-hour values). The primary goal in GDM management is to maintain euglycemia to prevent maternal and fetal complications. **1. Why "Start Insulin" is correct:** The first-line management for GDM is Medical Nutrition Therapy (MNT) and exercise for 1–2 weeks. However, if glycemic targets are not met, pharmacological intervention is mandatory. The target values (per ACOG/ADA) are: * **Fasting:** <95 mg/dL * **1-hour postprandial:** <140 mg/dL * **2-hour postprandial:** <120 mg/dL In this case, despite 3 weeks of diet modification, her 1-hour postprandial value is **185 mg/dL** (well above the <140 mg/dL limit). **Insulin** remains the gold standard and first-line pharmacological treatment for GDM as it does not cross the placenta and provides precise glycemic control. **2. Why other options are incorrect:** * **A. Continue diet modification:** Diet has already failed to achieve targets after 3 weeks. Delaying treatment increases the risk of macrosomia and preeclampsia. * **C. Repeat GTT:** Once GDM is diagnosed, GTT is not repeated during pregnancy; management shifts to monitoring capillary blood glucose. * **D. Start metformin:** While used in some guidelines, insulin is preferred in NEET-PG contexts as the first-line agent when MNT fails. Metformin crosses the placenta. **High-Yield Clinical Pearls for NEET-PG:** * **Screening:** Best done at **24–28 weeks** gestation. * **DIPSI Criteria:** A single-step test using 75g glucose; a 2-hour value **≥140 mg/dL** is diagnostic. * **Most common fetal complication:** Macrosomia (due to fetal hyperinsulinemia). * **Postpartum:** Patients with GDM should be screened for Type 2 DM **6–12 weeks postpartum** using a 75g OGTT.

Q: All of the following are true about human chorionic gonadotrophin EXCEPT:

hCG promotes apoptosis in nontrophoblastic neoplasia.. **Explanation:** Human Chorionic Gonadotrophin (hCG) is a glycoprotein hormone produced by the syncytiotrophoblast. Understanding its physiological and pathological roles is crucial for NEET-PG. **Why Option C is the Correct Answer (The False Statement):** hCG does not promote apoptosis; rather, it is associated with **anti-apoptotic** properties. In nontrophoblastic neoplasias (such as certain bladder, lung, or cervical cancers), the production of the β-subunit of hCG is often linked to increased tumor aggressiveness, cell survival, and resistance to therapy by inhibiting apoptosis. **Analysis of Other Options:** * **Option A:** hCG is indeed a **glycosylated peptide (glycoprotein)**. It consists of an $\alpha$-subunit (identical to LH, FSH, and TSH) and a $\beta$-subunit (unique to hCG, providing biological specificity). * **Option B:** hCG is produced following implantation. Implantation typically occurs 6–10 days after ovulation (LH surge). Therefore, hCG can be detected in maternal serum as early as **7–9 days after the LH surge** (or 8–11 days after conception). * **Option D:** In the second-trimester quadruple screen for **Down Syndrome (Trisomy 21)**, maternal serum **hCG and Inhibin-A levels are characteristically elevated**, while AFP and uE3 are decreased. **NEET-PG High-Yield Pearls:** * **Doubling Time:** In early normal pregnancy, hCG levels double every 48–72 hours. * **Peak Levels:** hCG reaches its peak concentration at **8–10 weeks** of gestation (approx. 100,000 mIU/mL) and then declines to a plateau. * **Biological Function:** Its primary role is to maintain the **corpus luteum**, ensuring continued progesterone production until the luteal-placental shift occurs (around 7–9 weeks). * **Very High hCG:** Seen in molar pregnancy, multiple gestations, and Down syndrome. * **Low hCG for Gestational Age:** Seen in ectopic pregnancy or impending abortion.

Q: What are the normal fasting plasma glucose levels during a 75g Glucose Tolerance Test (GTT) in pregnancy?

<92 mg/dL. The correct answer is **B. <92 mg/dL**. ### **Explanation** The diagnosis of Gestational Diabetes Mellitus (GDM) has evolved significantly. According to the **IADPSG (International Association of Diabetes and Pregnancy Study Groups)** and **WHO** criteria, a one-step 75g Oral Glucose Tolerance Test (OGTT) is used. In pregnancy, fasting glucose levels are naturally lower than in non-pregnant individuals due to continuous fetal glucose consumption and increased maternal volume of distribution. The diagnostic thresholds for a 75g OGTT are: * **Fasting:** <92 mg/dL * **1-hour:** <180 mg/dL * **2-hour:** <153 mg/dL * *Note: If any one value is met or exceeded, GDM is diagnosed.* ### **Analysis of Incorrect Options** * **Option A (≤105 mg/dL):** This was the older fasting threshold used in the **NDDG (National Diabetes Data Group)** criteria for the 100g 3-hour OGTT. It is no longer the standard for the 75g test. * **Option C (≤140 mg/dL):** This is the standard threshold for a **1-hour 50g Glucose Challenge Test (GCT)** used in two-step screening. It is not a fasting value. * **Option D (≤120 mg/dL):** This is often the target for **2-hour postprandial** glucose monitoring in managed GDM patients, not a diagnostic fasting threshold. ### **High-Yield Clinical Pearls for NEET-PG** 1. **DIPSI Criteria:** In India, the DIPSI (Diabetes in Pregnancy Study Group India) recommends a single-step 75g GTT regardless of the last meal. A 2-hour value **≥140 mg/dL** is diagnostic of GDM. 2. **Hormonal Basis:** Human Placental Lactogen (hPL) is the primary hormone responsible for insulin resistance in pregnancy, peaking in the third trimester. 3. **Best Time to Screen:** Routine screening is performed between **24–28 weeks** of gestation.

Q: What is the optimal value of glycosylated hemoglobin in a woman with diabetes preconceptionally?

<6.5%. **Explanation:** The goal of preconceptional counseling in diabetic women is to achieve euglycemia before organogenesis begins (which starts around the 3rd to 5th week of gestation). **1. Why <6.5% is correct:** The risk of major congenital malformations (such as sacral agenesis, neural tube defects, and cardiac anomalies) is directly proportional to the maternal HbA1c levels during the first trimester. An **HbA1c <6.5%** is the internationally recognized target (ADA and ACOG guidelines) because it minimizes the risk of embryopathy to a level comparable to the non-diabetic population. Achieving this value ensures that the metabolic environment is stable before the patient conceives. **2. Why other options are incorrect:** * ** 9% is associated with a very high risk (up to 20-25%) of major malformations. In clinical practice, an HbA1c >10% is often considered a relative contraindication to pregnancy until better control is achieved. **High-Yield Clinical Pearls for NEET-PG:** * **Most common malformation:** Cardiac anomalies (specifically Ventricular Septal Defects). * **Most specific malformation:** Caudal Regression Syndrome (Sacral Agenesis). * **HbA1c Target during pregnancy:** Ideally <6.0% (if achievable without significant hypoglycemia). * **Folic Acid:** Diabetic women should take a higher dose (5 mg/day) pre-conceptionally to reduce the risk of Neural Tube Defects.

Q: Which of the following is FALSE regarding hyperemesis gravidarum?

Small heart is an incidental finding.. ### Explanation **Hyperemesis Gravidarum (HG)** is a severe form of nausea and vomiting in pregnancy characterized by dehydration, electrolyte imbalance, and weight loss. **1. Why Option C is the Correct (False) Statement:** The finding of a **"small heart"** on X-ray or autopsy in patients with severe HG is **not an incidental finding**. It is a pathological sign of **brown atrophy of the heart**, resulting from prolonged starvation, severe malnutrition, and chronic dehydration. The heart undergoes atrophy due to the body's catabolic state, where it breaks down its own tissues for energy. **2. Analysis of Other Options:** * **Option A (Allergic basis):** This is a recognized theory. HG is sometimes considered an immunological or allergic reaction to the "foreign" proteins of the chorionic villi or fetal antigens. * **Option B (Hormonal imbalance):** This is the most widely accepted etiology. High levels of **hCG** (especially in molar pregnancies or twins) and **Estrogen** are strongly associated with the severity of vomiting. * **Option D (Wernicke’s encephalopathy):** This is a dreaded complication of HG. Persistent vomiting leads to **Vitamin B1 (Thiamine) deficiency**. The classic triad includes ataxia, ophthalmoplegia, and confusion. **3. High-Yield Clinical Pearls for NEET-PG:** * **Metabolic Profile:** HG typically causes **Metabolic Alkalosis** (due to loss of HCl) with **Hypokalemia** and **Hyponatremia**. * **Ketonuria:** The presence of ketones in urine is a hallmark of HG, indicating starvation. * **Liver Function:** Mild elevation of serum bilirubin and transaminases may occur. * **Management:** The first-line drug is **Pyridoxine (Vit B6) + Doxylamine**. If Wernicke’s is suspected, always give Thiamine **before** IV Dextrose to prevent worsening of neurological symptoms.

Question 1

Which of the following hormones is NOT secreted by the placenta?

Accepted Answer

Insulin

Answer

hCG

Answer

TRH

Answer

ACTH

Question 2

During the first trimester of pregnancy, the risk of fetal malformation in a pregnant woman with insulin-dependent diabetes is best predicted by:

Accepted Answer

Glycosylated hemoglobin levels

Answer

Blood sugar values

Answer

Serum alpha-fetoprotein levels

Answer

Serum unconjugated estriol levels

Question 3

A 30-year-old G3P2 obese woman at 26 weeks' gestation with no significant past medical history states that diabetes runs in her family. Her other pregnancies were uncomplicated. The results of a 3-hour glucose tolerance test show the following glucose levels: fasting: 90 mg/dL, 1 hour: 195 mg/dL, 2 hours: 155 mg/dL, 3 hours: 145 mg/dL. As a result, she is diagnosed with gestational diabetes. She is counselled to start diet modification and exercise to control her glycemic levels. 3 weeks after her diagnosis, she presents her values: Fasting: 95 mg/dL, 1 hr postprandial: 185 mg/dL. What is the best management?

Accepted Answer

Start insulin

Answer

Continue diet modification

Answer

Repeat GTT

Answer

Start metformin

Question 4

All of the following are true about human chorionic gonadotrophin EXCEPT:

Accepted Answer

hCG promotes apoptosis in nontrophoblastic neoplasia.

Answer

It is a glycosylated peptide hormone.

Answer

It is detected in serum 7-9 days after the LH surge.

Answer

Elevated hCG levels are seen in Down syndrome.

Question 5

Hypothyroidism in pregnancy is least likely associated with which of the following complications?

Accepted Answer

Polyhydramnios

Answer

Recurrent abortions

Answer

Pregnancy induced hypertension (PIH)

Answer

Prematurity

Question 6

A pregnant woman at 8 weeks gestation presents with a random blood glucose level of 177 mg/dL. What is the recommended treatment?

Accepted Answer

Insulin

Answer

Phenformin

Answer

Sulfonylurea

Answer

Glipizide

Question 7

What are the normal fasting plasma glucose levels during a 75g Glucose Tolerance Test (GTT) in pregnancy?

Accepted Answer

<92 mg/dL

Answer

<=105 mg/dL

Answer

<=140 mg/dL

Answer

<=120 mg/dL

Question 8

What is the optimal value of glycosylated hemoglobin in a woman with diabetes preconceptionally?

Accepted Answer

<6.5%

Answer

<7.5%

Answer

<8.1%

Answer

<9%

Question 9

What is the most common effect of congenital adrenal hyperplasia?

Accepted Answer

Female pseudohermaphroditism

Answer

Male pseudohermaphroditism

Answer

True hermaphroditism

Answer

Gonadal dysgenesis

Question 10

Which of the following is FALSE regarding hyperemesis gravidarum?

Accepted Answer

Small heart is an incidental finding.

Answer

Allergic basis is suggested.

Answer

Hormonal imbalance may be a cause.

Answer

May show manifestations of Wernicke's encephalopathy.

Endocrinology of Pregnancy — MCQs

Endocrinology of Pregnancy — MCQs

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