Maternal-Fetal Medicine Practice Questions

Q: A woman has had two second -trimester pregnancy losses. What is the most likely diagnosis?

Cervical insufficiency. ***Cervical insufficiency*** - Characterized by **painless cervical dilation** in the second trimester, leading to recurrent pregnancy loss if left untreated. - Diagnosis is often clinical, based on a history of **painless dilation and expulsion of the fetus** in the second trimester, usually without preceding labor or abruption. *Placental abruption* - Typically presents with **painful vaginal bleeding**, **uterine tenderness**, and fetal distress, rather than painless loss. - It is associated with **advanced maternal age**, hypertension, and trauma, and typically occurs later in pregnancy or presents with acute symptoms. *Placenta previa* - Classically presents with **painless, bright red vaginal bleeding** in the third trimester due to the placenta covering the internal cervical os. - It is a condition of placental position and does not inherently cause recurrent second-trimester pregnancy loss. *Uterine anomalies* - While müllerian duct anomalies (like a **septate uterus**) can cause pregnancy loss, cervical insufficiency is specifically the classic answer for recurrent, painless second-trimester losses in the absence of uterine structural malformations. - Structural anomalies of the uterus are typically diagnosed via imaging (e.g., **HSG** or MRI) rather than being the default diagnosis for isolated second-trimester losses.

Q: Identify the condition based on the following USG:

Monochorionic diamniotic (MCDA). ***Monochorionic diamniotic (MCDA)*** - On ultrasound, this condition typically displays the **'T-sign'** at the inter-twin membrane, indicating that the membrane consists of two layers of amnion without intervening chorion. - It is characterized by a **single placenta** shared by the twins, with each fetus having its own amniotic sac. *Dichorionic diamniotic (DCDA)* - Ultrasound features show the **'lambda sign'** (also known as the **'twin peak sign'**), where the chorionic villi extend into the inter-twin membrane base. - This indicates the presence of two placentas (often fused) and two chorionic and two amniotic sacs. *Monochorionic monoamniotic (MCMA)* - This configuration is identified by the **absence of an inter-twin membrane** between the two fetuses, meaning they float in the same amniotic sac. - It carries a high risk of **cord entanglement** and is the rarest form of monozygotic twinning. *Conjoined twins* - This condition is diagnosed when fetuses remain physically attached to each other after the **13th day** post-fertilization. - Ultrasound shows a shared body part (e.g., thorax, abdomen) and the inability to separate the fetuses or identify an intervening membrane.

Q: A woman with 13 weeks gestation presents with a uterus corresponding to 18 weeks. Ultrasound shows a grape -like mass, with no fetus or amniotic fluid. What is the most appropriate management?

Suction & evacuation. ***Suction & evacuation*** - This is the **treatment of choice** for a hydatidiform mole, efficiently removing the molar tissue while minimizing the risk of uterine perforation or hemorrhage. - It is preferred over other surgical methods because it allows for the **removal of bulky abnormal tissue** associated with gestational trophoblastic disease while preserving future fertility. *Dilatation and curettage* - While similar in terms of cervical dilation, this term generally implies a standard procedure for smaller pregnancies, whereas **suction evacuation** is specifically required for the larger, friable molar tissue. - Relying solely on standard curettage without suction is associated with a higher risk of **incomplete evacuation** and potential **heavy hemorrhage**. *Hysterectomy* - This is **not the primary treatment** and is usually reserved for patients who have completed childbearing and are at a high risk for persistent disease or invasion. - It is generally considered only in cases of **invasive mole** or **choriocarcinoma** in older patients who do not desire future pregnancies, not as the initial management strategy. *Methotrexate therapy* - Methotrexate is a **chemotherapeutic agent** used for the management of **persistent or metastatic gestational trophoblastic neoplasia** (GTN) following the evacuation of the mole. - It is **never the primary treatment** for an untreated hydatidiform mole, as surgical evacuation is mandatory to reduce the tumor burden first.

Q: Which one of the following options is NOT an the indication of medical management in unruptured ectopic pregnancy

Fetal cardiac activity present. ***Fetal cardiac activity present*** - The presence of **viable embryonic cardiac activity** is a relative contraindication to **methotrexate therapy** due to significantly higher failure rates. - First-line medical treatment is most effective when the gestation is early and lacks **cardiac pulsation**. *Serum β -hCG level of 3500 IU/L* - While an initial **β-hCG** level < 5000 IU/L is generally considered an inclusion criterion for medical management, levels above this often suggest higher failure risk. - Since current protocols often accept values up to 5000 IU/L, this value does not strictly mandate surgical intervention over medical management. *Gestational sac size of 3 cm* - A gestational sac diameter of **≤ 3.5 cm** is typically considered a suitable parameter for **methotrexate eligibility**. - Cases exceeding 3.5 to 4 cm are usually prioritized for surgical management due to increased risk of rupture. *Hemodynamically stable mother* - **Hemodynamic stability** is a fundamental prerequisite for considering non-surgical options like **methotrexate**. - Any sign of hemodynamic instability mandates emergent **surgical intervention** (salpingostomy or salpingectomy) to address potential hemorrhage.

Q: Which is the most common complication in monoamniotic twins?

Intertwining. **Explanation:** Monoamniotic-monochorionic (MoMo) twins occur when the zygote divides late, between **8 to 12 days** post-fertilization. Because both fetuses reside in a single amniotic sac without a dividing membrane, they are at unique risk for specific complications. **1. Why "Intertwining" is correct:** **Cord entanglement (Intertwining)** is the most common and characteristic complication of monoamniotic twins, occurring in nearly **100% of cases** in utero. As the fetuses move within the single sac, their umbilical cords inevitably twist around each other. While not always fatal, it can lead to sudden cord occlusion and fetal demise, which is why these pregnancies are managed with intensive monitoring and elective Cesarean delivery (usually at 32–34 weeks). **2. Analysis of Incorrect Options:** * **Discordance (A):** While growth discordance occurs in twins, it is more classically associated with Twin-to-Twin Transfusion Syndrome (TTTS) in diamniotic-monochorionic twins. * **Cord entanglement (B):** In many textbooks and exams, "Intertwining" and "Cord entanglement" are used interchangeably; however, "Intertwining" is the preferred clinical term for the specific phenomenon of the two cords wrapping around one another. * **Conjoined twins (C):** This is a rare complication occurring only if the zygote divides even later (**after 13 days**). While specific to monoamniotic gestations, it is far less common than cord intertwining. **High-Yield Clinical Pearls for NEET-PG:** * **Timing of Division:** 0–72 hours (Di-Di), 4–8 days (Mo-Di), 8–12 days (Mo-Mo), >13 days (Conjoined). * **Management:** MoMo twins require inpatient monitoring from 24–28 weeks and delivery via **LSCS by 32–34 weeks** to prevent late-term fetal death from cord accidents. * **The "T-sign" vs. "Lambda sign":** MoMo twins show **neither**; there is no dividing membrane at all.

Q: What is the approximate recurrence risk for neural tube defects (NTDs) in a subsequent pregnancy, given that the first baby was born with an NTD?

4%. **Explanation:** Neural tube defects (NTDs) follow a **multifactorial inheritance** pattern, meaning they result from a combination of genetic predisposition and environmental factors (most notably folic acid deficiency). **1. Why 4% is correct:** In the general population, the incidence of NTDs is approximately 0.1–0.2% (1 in 1,000). However, once a couple has one child with an NTD (anencephaly, spina bifida, or encephalocele), the risk of recurrence in a subsequent pregnancy increases significantly to approximately **3–5%** (standardized as **4%** for examination purposes). If two previous siblings are affected, the risk rises further to about 10%. **2. Why the other options are incorrect:** * **A (2%):** This underestimates the risk. While recurrence risks vary by geography, 3–5% is the globally accepted range for a single prior affected pregnancy. * **C (10%):** This is the approximate recurrence risk only after **two** previously affected siblings. * **D (20%):** This risk is too high for multifactorial inheritance and would be more characteristic of a high-penetrance autosomal dominant condition. **High-Yield Clinical Pearls for NEET-PG:** * **Prevention:** For the general population, the recommended dose of Folic Acid is **400 mcg (0.4 mg)/day** starting 1 month prior to conception. * **Secondary Prevention (High Risk):** For women with a **previous child with NTD**, the dose is increased to **4 mg/day** (10 times the standard dose). * **Screening:** Maternal Serum Alpha-Fetoprotein (MSAFP) is elevated in open NTDs. The best time for screening is **15–20 weeks** (ideal: 16–18 weeks). * **Diagnosis:** Targeted Level II Ultrasound is the gold standard for detecting structural defects.

Q: Placental enlargement is seen in which of the following infections?

Plasmodium. **Explanation:** **Correct Answer: D. Plasmodium** **Why Plasmodium is correct:** Placental enlargement (placentomegaly) in malaria, particularly *Plasmodium falciparum*, is a hallmark of **Placental Malaria**. The underlying mechanism involves the sequestration of parasitized red blood cells in the intervillous spaces. This triggers a robust maternal inflammatory response, leading to massive infiltration of monocytes and macrophages (intervillositis), fibrin deposition, and basement membrane thickening. These pathological changes significantly increase placental weight and thickness, often correlating with adverse outcomes like intrauterine growth restriction (IUGR) and low birth weight. **Analysis of Incorrect Options:** * **A, B, and C (Toxoplasma, CMV, Parvovirus):** While these infections are part of the TORCH spectrum and can occasionally cause placental edema or "hydrops-like" changes, they are primarily associated with **placental calcifications** (especially CMV and Toxoplasma) or specific fetal effects (e.g., Parvovirus causing fetal anemia and hydrops). In the context of standard PG-level examinations, *Plasmodium* is the classic infectious cause cited for significant placental hypertrophy and weight increase. **High-Yield Clinical Pearls for NEET-PG:** * **Definition of Placentomegaly:** A placental thickness >4 cm in the second/third trimester or a weight >600g at term. * **Other Causes of Placentomegaly:** * **Maternal:** Diabetes Mellitus (most common non-infectious cause), Severe Anemia. * **Fetal:** Rh-Isoimmunization (Hydrops Fetalis), Twin-to-Twin Transfusion Syndrome (recipient), Chromosomal anomalies (Triploidy). * **Tumors:** Chorioangioma. * **Malaria Fact:** Placental malaria is more common and severe in **primigravidae** due to the lack of specific immunity against VAR2CSA-expressing parasites that bind to chondroitin sulfate A in the placenta.

Q: What is the investigation of choice in a pregnant lady at 16 weeks of gestation with a history of delivering a baby with Down syndrome?

Amniocentesis. **Explanation:** The core concept here is distinguishing between **screening** and **diagnostic** tests in a high-risk pregnancy. A history of a prior child with Down syndrome significantly increases the risk of recurrence, necessitating a definitive diagnosis rather than a risk assessment. 1. **Why Amniocentesis is correct:** Amniocentesis is a **diagnostic test** that involves karyotyping fetal cells obtained from amniotic fluid. It is ideally performed between **15–20 weeks** of gestation. Since the patient is at 16 weeks, amniocentesis is the investigation of choice to provide a definitive chromosomal analysis with a high degree of accuracy (>99%). 2. **Why other options are incorrect:** * **Triple screen test:** This is a screening tool (measuring AFP, hCG, and uE3). In a patient with a high-risk history, screening is insufficient; a diagnostic test is required to confirm or rule out the condition. * **Chorionic Villous Sampling (CVS):** While CVS is also a diagnostic test, it is typically performed between **10–13 weeks**. At 16 weeks, the window for CVS has passed, making amniocentesis the appropriate choice. * **Ultrasound (USG):** USG can identify "soft markers" (like nuchal fold thickness) but cannot provide a definitive genetic diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Timing is Key:** CVS (10–13 weeks), Amniocentesis (15–20 weeks), Cordocentesis (>20 weeks). * **Most common chromosomal abnormality** associated with increased maternal age or prior history is Trisomy 21 (Down syndrome). * **Amniocentesis Risk:** The procedure-related risk of miscarriage is approximately 0.5% (1 in 200). * **Quadruple Screen:** Includes Triple Screen + Inhibin A; it is the preferred screening test in the second trimester if invasive testing is declined.

Question 1

A woman has had two second -trimester pregnancy losses. What is the most likely diagnosis?

Accepted Answer

Cervical insufficiency

Answer

Placental abruption

Answer

Placenta previa

Answer

Uterine anomalies

Question 2

Identify the condition based on the following USG:

Accepted Answer

Monochorionic diamniotic (MCDA)

Answer

Dichorionic diamniotic (DCDA)

Answer

Monochorionic monoamniotic (MCMA)

Answer

Conjoined twins

Question 3

A woman with 13 weeks gestation presents with a uterus corresponding to 18 weeks. Ultrasound shows a grape -like mass, with no fetus or amniotic fluid. What is the most appropriate management?

Accepted Answer

Suction & evacuation

Answer

Dilatation and curettage

Answer

Hysterectomy

Answer

Methotrexate therapy

Question 4

Which one of the following options is NOT an the indication of medical management in unruptured ectopic pregnancy

Accepted Answer

Fetal cardiac activity present

Answer

Serum β -hCG level of 3500 IU/L

Answer

Gestational sac size of 3 cm

Answer

Hemodynamically stable mother

Question 5

A 30-year-old woman at 28 weeks gestation with gestational diabetes managed with insulin presents with decreased fetal movement. Fetal monitoring shows category II tracing. Umbilical artery Doppler shows absent end-diastolic flow. Her glucose control has been suboptimal (HbA1c 7.8%). Maternal blood pressure is normal. Synthesize the pathophysiologic relationship between her metabolic condition and the Doppler findings to determine the primary mechanism.

Accepted Answer

Uteroplacental insufficiency from diabetes-induced vasculopathy affecting spiral arteries

Answer

Placental hypertrophy from fetal macrosomia compressing umbilical cord

Answer

Fetal polycythemia from chronic hypoxia increasing blood viscosity

Answer

Maternal ketoacidosis causing direct fetal myocardial depression

Answer

Maternal hyperglycemia causing fetal hyperinsulinemia and increased oxygen consumption

Question 6

Which is the most common complication in monoamniotic twins?

Accepted Answer

Intertwining

Answer

Discordance

Answer

Cord entanglement

Answer

Conjoined twins

Question 7

What is the approximate recurrence risk for neural tube defects (NTDs) in a subsequent pregnancy, given that the first baby was born with an NTD?

Accepted Answer

4%

Answer

2%

Answer

10%

Answer

20%

Question 8

Placental enlargement is seen in which of the following infections?

Accepted Answer

Plasmodium

Answer

Toxoplasma

Answer

Cytomegalovirus (CMV)

Answer

Parvovirus

Question 9

Hemolytic disease of the newborn is least common with which blood group female?

Accepted Answer

O

Answer

A

Answer

B

Answer

AB

Question 10

What is the investigation of choice in a pregnant lady at 16 weeks of gestation with a history of delivering a baby with Down syndrome?

Accepted Answer

Amniocentesis

Answer

Triple screen test

Answer

Chorionic villous sampling

Answer

Ultrasound (USG)

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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