Maternal-Fetal Medicine Practice Questions

Q: A 26-year-old obstetric patient presents with infectious mononucleosis-like symptoms during her first trimester. Her heterophil antibody test is negative, but a detailed history reveals the presence of two cats in the household. Laboratory tests confirm infection with Toxoplasma gondii. Several months later, the woman delivers a full-term baby who shows no obvious signs of protozoan parasite infection. What is the most appropriate laboratory test to diagnose acute infection in the neonate, specifically by detecting which isotype of immunoglobulin?

IgM. **Explanation:** The diagnosis of congenital toxoplasmosis relies on understanding the placental transfer of antibodies. **Why IgM is the Correct Answer:** In a neonate, the presence of **IgM** (or IgA) antibodies is the gold standard for diagnosing an acute, congenital infection. This is because IgM antibodies are large pentameric molecules that **cannot cross the placenta**. Therefore, if IgM specific to *Toxoplasma gondii* is detected in the neonate’s serum, it indicates that the fetus produced these antibodies itself in response to an *in utero* infection. **Analysis of Incorrect Options:** * **IgG1 and IgG4 (Options B & C):** These are subclasses of **IgG**. Unlike IgM, IgG is small enough to be actively transported across the placenta from the mother to the fetus (starting in the second trimester). Therefore, detecting IgG in a neonate does not distinguish between a true fetal infection and the passive transfer of maternal immunity. Maternal IgG can persist in the infant for up to 12 months. * **IgA (Option A):** While IgA is also used to diagnose congenital toxoplasmosis (and is sometimes more sensitive than IgM), **IgM** remains the classic, most frequently tested parameter in medical examinations for identifying acute neonatal infection. **Clinical Pearls for NEET-PG:** * **Classic Triad of Congenital Toxoplasmosis:** Chorioretinitis, Hydrocephalus, and Intracranial calcifications (diffuse). * **Transmission Risk:** The risk of transmission increases with gestational age (highest in the 3rd trimester), but the **severity** of fetal damage is highest if infected in the 1st trimester. * **Treatment:** Spiramycin is used to prevent transmission; Pyrimethamine + Sulfadiazine + Folinic acid are used if fetal infection is confirmed. * **Heterophil-negative Mononucleosis:** Always consider *Toxoplasma* or CMV.

Q: Caudal regression syndrome, a rare anomaly, is associated with which maternal complication during pregnancy?

Diabetes. **Explanation:** **Caudal Regression Syndrome (CRS)** is a rare congenital malformation characterized by varying degrees of developmental failure involving the lower spine (sacrum/lumbar vertebrae), spinal cord, and lower limbs. **1. Why Diabetes is the Correct Answer:** Maternal **Pre-gestational Diabetes Mellitus** (Type 1 or Type 2) is the most significant risk factor for CRS. While the most common cardiac anomaly in infants of diabetic mothers (IDM) is a Ventricular Septal Defect (VSD), **Caudal Regression Syndrome is the most specific malformation associated with maternal diabetes.** The risk is increased nearly 200-fold in diabetic pregnancies compared to the general population. The pathogenesis is linked to fetal oxidative stress and disturbed gene expression (like *Hox* genes) during the first trimester due to poor glycemic control. **2. Why Other Options are Incorrect:** * **Epilepsy:** While anti-epileptic drugs (like Valproate) are teratogenic, they are typically associated with Neural Tube Defects (NTDs) like spina bifida, not CRS. * **Hypertension:** Chronic hypertension is associated with fetal growth restriction (IUGR) and placental abruption, but it is not a primary teratogen for structural spinal anomalies. * **SLE:** Maternal SLE is classically associated with **Congenital Complete Heart Block** in the fetus due to the transplacental passage of anti-Ro (SSA) and anti-La (SSB) antibodies. **High-Yield Facts for NEET-PG:** * **Most common anomaly in IDM:** Congenital Heart Disease (specifically VSD). * **Most specific anomaly in IDM:** Caudal Regression Syndrome (Sacral Agenesis). * **Hypertrophic Cardiomyopathy:** Often seen in IDM; involves the interventricular septum and is usually transient. * **Neonatal Complications of IDM:** Hypoglycemia, Hypocalcemia, Hyperbilirubinemia, and Polycythemia.

Q: What is the most effective drug for the treatment of Intrauterine Growth Restriction (IUGR)?

None of the above. **Explanation:** The correct answer is **None of the above** because, currently, there is **no proven pharmacological treatment** to reverse or "cure" established Intrauterine Growth Restriction (IUGR). The management of IUGR focuses primarily on intensive fetal surveillance (Doppler studies, BPP) and timely delivery to prevent intrauterine fetal demise. **Why the other options are incorrect:** * **Aspirin:** Low-dose aspirin (75–150 mg) is highly effective for the **prevention** of placental insufficiency and preeclampsia if started before 16 weeks of gestation in high-risk patients. However, it has no therapeutic benefit once IUGR has already been diagnosed. * **Nitric Oxide (NO) Donors:** While NO is a potent vasodilator, clinical trials (like the use of Sildenafil or Glyceryl Trinitrate) have failed to show significant improvement in fetal growth outcomes or a reduction in perinatal mortality. * **Antioxidants:** Vitamins C and E were once hypothesized to reduce oxidative stress in the placenta, but large-scale studies have shown they do not improve birth weight and may even increase the risk of premature rupture of membranes. **NEET-PG High-Yield Pearls:** 1. **Prevention vs. Treatment:** Aspirin is for *prophylaxis*, not *treatment*. 2. **Definitive Management:** The only "cure" for IUGR is delivery, balanced against the risks of prematurity. 3. **Monitoring Gold Standard:** **Umbilical Artery Doppler** is the most important tool for monitoring IUGR; "Absent or Reversed End Diastolic Flow" (AREDF) is a critical indicator for urgent delivery. 4. **Steroids:** If delivery is planned before 34 weeks, corticosteroids (Betamethasone) must be given to accelerate fetal lung maturity.

Q: A 34-week pregnant patient presents with acute liver failure, coagulopathy, and intrauterine fetal demise. Her blood pressure is normal and viral markers are negative. What is the most probable diagnosis?

Acute fatty liver of pregnancy. **Explanation:** **Acute Fatty Liver of Pregnancy (AFLP)** is a rare but life-threatening emergency occurring in the third trimester. The hallmark of AFLP is **microvesicular steatosis** of hepatocytes, leading to rapid-onset hepatic failure. The clinical presentation in this case—acute liver failure (jaundice, encephalopathy), coagulopathy (DIC), and intrauterine fetal demise (IUFD) in the absence of hypertension—is classic for AFLP. While often associated with preeclampsia, 50% of patients may be normotensive. **Why other options are incorrect:** * **Intrahepatic Cholestasis of Pregnancy (ICP):** Presents with intense pruritus (palms and soles) and elevated bile acids. It does not cause liver failure or coagulopathy. * **Viral Hepatitis:** While the most common cause of jaundice in pregnancy, it is ruled out here by negative viral markers. * **Obstructive Jaundice:** Usually presents with colicky pain and an obstructive enzyme pattern (high ALP/GGT) without acute liver failure or DIC. **High-Yield Clinical Pearls for NEET-PG:** * **Swansea Criteria:** Used for diagnosing AFLP (requires $\geq$ 6 clinical/biochemical features). * **Biochemical Hallmarks:** Hypoglycemia (very characteristic), hyperuricemia, elevated ammonia, and prolonged PT/APTT. * **Genetic Link:** Strongly associated with a fetal deficiency of the enzyme **Long-Chain 3-Hydroxyacyl-CoA Dehydrogenase (LCHAD)**. * **Management:** Immediate stabilization and **urgent delivery**, regardless of gestational age. Liver function typically improves rapidly postpartum.

Q: Single umbilical artery is associated with all of the following except?

Advanced maternal age. **Explanation:** A **Single Umbilical Artery (SUA)**, or 2-vessel cord, occurs when one of the two umbilical arteries is absent (usually the left). It is the most common umbilical cord anomaly, occurring in approximately 1% of singleton pregnancies. **Why "Advanced Maternal Age" is the correct answer:** Unlike many chromosomal anomalies, the incidence of SUA is **not** significantly associated with advanced maternal age. Instead, it is more frequently associated with **young maternal age** (less than 20 years), maternal smoking, and primiparity. **Analysis of Incorrect Options:** * **Polyhydramnios:** SUA is frequently associated with maternal complications like polyhydramnios and pre-eclampsia. Polyhydramnios often occurs due to associated fetal structural anomalies (e.g., esophageal atresia) that interfere with fetal swallowing. * **Fetal Growth Retardation (FGR):** There is a strong correlation between SUA and FGR. Even in the absence of structural malformations, a single artery may lead to placental insufficiency, resulting in a higher incidence of small-for-gestational-age (SGA) infants. * **Increased incidence of fetal malformation:** Approximately 20–30% of fetuses with SUA have associated malformations. The most common involve the **cardiovascular system** (e.g., VSD) and the **genitourinary system** (e.g., renal agenesis). **High-Yield Clinical Pearls for NEET-PG:** * **Most common association:** Renal and Cardiac anomalies. * **Chromosomal link:** SUA is associated with Trisomy 18 (Edwards Syndrome) and Trisomy 13 (Patau Syndrome). * **Management:** If SUA is detected on a mid-trimester scan, a detailed **Targeted Imaging for Fetal Anomalies (TIFFA)** and a **Fetal Echocardiogram** are mandatory. * **Prognosis:** If the SUA is "isolated" (no other anomalies), the neonatal outcome is generally excellent, though serial growth scans are recommended.

Q: Which of the following is NOT a feature of pre-eclampsia?

Vomiting. **Explanation:** Pre-eclampsia is a multisystem disorder characterized by new-onset hypertension (BP ≥ 140/90 mmHg) and proteinuria (or end-organ dysfunction) after 20 weeks of gestation. **Why "Vomiting" is the correct answer:** While nausea and vomiting can occur in severe cases (often associated with HELLP syndrome), **vomiting is not a diagnostic feature or a specific "warning sign"** of pre-eclampsia. It is a non-specific symptom common in pregnancy. In contrast, the other options represent classic diagnostic criteria or "imminent signs" indicating severe pre-eclampsia. **Analysis of Incorrect Options:** * **Option A (BP > 140/90 mmHg):** This is the fundamental diagnostic threshold for gestational hypertension and pre-eclampsia when recorded on two occasions at least 4 hours apart after 20 weeks. * **Option B (Epigastric pain):** This is a "warning sign" of imminent eclampsia. It typically results from hepatic stretching (Glisson’s capsule tension) or subcapsular hematoma, often seen in HELLP syndrome. * **Option D (Visual disturbances and heartburn):** Visual disturbances (scotomata, blurring) indicate cortical irritability or retinal edema. Heartburn/retrosternal pain is often grouped with epigastric pain as a sign of hepatic involvement or severe gastric irritation in pre-eclampsia. **NEET-PG High-Yield Pearls:** 1. **New Definition:** Proteinuria is no longer mandatory for diagnosis if other end-organ dysfunctions (thrombocytopenia, renal insufficiency, impaired liver function, or cerebral symptoms) are present. 2. **Imminent Eclampsia Signs:** Headache (most common), visual disturbances, epigastric pain, and hyperreflexia. 3. **Drug of Choice:** Magnesium Sulfate ($MgSO_4$) is the drug of choice for both prophylaxis and control of convulsions in eclampsia (Pritchard Regimen). 4. **Definitive Treatment:** Delivery of the fetus and placenta.

Q: Polyhydramnios is typically most pronounced during which gestational period?

Third trimester. **Explanation:** Polyhydramnios is defined as an excessive accumulation of amniotic fluid (Amniotic Fluid Index >24 cm or Single Deepest Pocket >8 cm). The correct answer is the **Third Trimester** because amniotic fluid dynamics are volume-dependent on fetal physiological processes that peak late in pregnancy. **Why the Third Trimester is Correct:** Amniotic fluid volume increases progressively throughout pregnancy, reaching its peak (approximately 800–1000 mL) at **34–36 weeks**. From the second trimester onwards, fetal **urine production** becomes the primary source of amniotic fluid, while fetal **swallowing** is the main pathway for resorption. In cases of polyhydramnios (e.g., maternal diabetes, fetal GI atresia, or idiopathic causes), the imbalance between production and resorption becomes most clinically evident and voluminous during the third trimester as fetal urine output reaches its maximum (up to 700–1000 mL/day). **Why Other Options are Incorrect:** * **A & B (First/Early Second Trimester):** During early pregnancy, amniotic fluid is primarily an ultrafiltrate of maternal plasma or fetal serum across non-keratinized skin. The volumes are too small (approx. 30 mL at 10 weeks) for polyhydramnios to be "pronounced." * **C (Latter Second Trimester):** While fluid begins to increase rapidly here, it has not yet reached the physiological peak seen in the third trimester. **NEET-PG High-Yield Pearls:** * **Most common cause:** Idiopathic (approx. 50–60%), followed by Maternal Diabetes. * **Most common fetal anomaly:** Esophageal atresia (due to impaired swallowing). * **Clinical Sign:** "Fluid thrill" on abdominal examination and "Uterus larger than dates." * **Complications:** Preterm labor, Cord prolapse, and Postpartum hemorrhage (due to uterine atony).

Q: The "T sign" is classically associated with which of the following conditions?

Membrane in twin pregnancy. ### Explanation **Correct Answer: D. Membrane in twin pregnancy** The **"T sign"** is a classic ultrasonographic marker used to identify **Monochorionic Diamniotic (MCDA)** twin pregnancies. It refers to the appearance of the inter-twin membrane as it meets the placenta. In MCDA twins, there is no intervening chorionic tissue between the two layers of amnion; the membrane is thin and joins the placenta at a perpendicular angle, resembling the letter "T." In contrast, the **"Lambda sign"** (or Twin-peak sign) is seen in **Dichorionic Diamniotic (DCDA)** pregnancies, where a wedge of chorionic tissue projects between the two layers of the septum, creating a triangular shape. **Analysis of Incorrect Options:** * **A. Genitourinary tuberculosis:** Classically associated with radiological signs like the "Golf hole ureter" or "Putty kidney," but not the T sign. * **B. Polycystic ovarian disease (PCOD):** Characterized by the "String of pearls" appearance (multiple small peripheral follicles) on ultrasound. * **C. Spina bifida:** Associated with the "Lemon sign" (scalloping of frontal bones) and "Banana sign" (curved cerebellum) on fetal head ultrasound. **High-Yield Clinical Pearls for NEET-PG:** * **Timing of Cleavage:** * 0–72 hours: DCDA (Lambda sign) * 4–8 days: MCDA (T sign) * 8–13 days: MoMo (Monochorionic Monoamniotic) * >13 days: Conjoined twins * **Best Time for Chorionicity:** Ultrasound performed between **11 to 13+6 weeks** (first trimester) is the most accurate time to determine chorionicity using these signs. * **Significance:** Identifying the T sign is crucial because MCDA pregnancies are at high risk for **Twin-to-Twin Transfusion Syndrome (TTTS)**.

Q: Which of the following complications is NOT associated with an increased risk in multifetal pregnancy?

Post-term pregnancy. **Explanation:** In multifetal pregnancies, the primary physiological challenge is uterine overdistension and increased metabolic demand. **Post-term pregnancy** is not associated with multifetal gestations because these pregnancies are characterized by a significantly higher risk of **preterm labor and delivery**. The average duration of pregnancy decreases as the number of fetuses increases (approx. 37 weeks for twins, 33 weeks for triplets). Consequently, the clinical concern is prematurity rather than post-term complications. **Analysis of Incorrect Options:** * **Maternal Death:** Multifetal pregnancies carry a 2-to-3-fold higher maternal mortality rate compared to singletons, primarily due to complications like hemorrhage and embolism. * **Preeclampsia:** The increased placental mass in multifetal gestations leads to higher levels of anti-angiogenic factors (like sFlt-1), making hypertensive disorders 2–3 times more common and often more severe. * **Hysterectomy:** There is a significantly higher risk of peripartum hysterectomy due to **postpartum hemorrhage (PPH)** caused by uterine atony (from overdistension) or abnormal placentation (e.g., placenta previa). **High-Yield Clinical Pearls for NEET-PG:** * **Most common complication:** Preterm labor/prematurity. * **Most common presentation:** Vertex-Vertex (approx. 40-50%). * **Weight Gain:** Recommended weight gain for a woman with a normal BMI carrying twins is **17–25 kg** (37–54 lbs). * **Iron Deficiency Anemia:** Risk is significantly higher due to increased fetal demand and expanded maternal plasma volume.

Q: Which of the following is a risk factor for preeclampsia?

Obesity. **Explanation:** Preeclampsia is a multisystem disorder characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. The pathophysiology involves abnormal placentation and systemic endothelial dysfunction. **Why Obesity is the Correct Answer:** Obesity (BMI >30 kg/m²) is a major independent risk factor for preeclampsia. It induces a state of chronic systemic inflammation, oxidative stress, and insulin resistance. These factors contribute to endothelial cell dysfunction, which is the hallmark of preeclampsia development. **Analysis of Incorrect Options:** * **Chronic Hypertension:** While chronic hypertension increases the risk of *superimposed* preeclampsia, it is technically a pre-existing condition. In the context of standard risk factor lists (like ACOG/NICE), obesity and nulliparity are more frequently cited as primary risk factors for the development of the disease itself. * **Smoking:** Interestingly, smoking is considered a **protective factor** against preeclampsia (though it increases other risks like IUGR and abruption). It is thought that nicotine or carbon monoxide may decrease the production of anti-angiogenic factors like sFlt-1. * **Multiparity:** Preeclampsia is primarily a disease of **nulliparity** (first pregnancy). A history of successful, uncomplicated previous pregnancies actually reduces the risk. **High-Yield Clinical Pearls for NEET-PG:** * **Strongest Risk Factor:** A prior history of preeclampsia (7-fold increase). * **Other High-Risk Factors:** Nulliparity, multifetal gestation, maternal age >40, pre-gestational diabetes, and autoimmune diseases (SLE, APS). * **Prophylaxis:** Low-dose Aspirin (75–150 mg) started before 16 weeks is recommended for women with high-risk factors. * **Pathogenesis:** Failure of the second wave of trophoblastic invasion (16–20 weeks), leading to high-resistance spiral arteries.

Question 1

A 26-year-old obstetric patient presents with infectious mononucleosis-like symptoms during her first trimester. Her heterophil antibody test is negative, but a detailed history reveals the presence of two cats in the household. Laboratory tests confirm infection with Toxoplasma gondii. Several months later, the woman delivers a full-term baby who shows no obvious signs of protozoan parasite infection. What is the most appropriate laboratory test to diagnose acute infection in the neonate, specifically by detecting which isotype of immunoglobulin?

Accepted Answer

IgM

Answer

IgA

Answer

IgG1

Answer

IgG4

Question 2

Caudal regression syndrome, a rare anomaly, is associated with which maternal complication during pregnancy?

Accepted Answer

Diabetes

Answer

Epilepsy

Answer

Hypertension

Answer

Systemic Lupus Erythematosus (SLE)

Question 3

What is the most effective drug for the treatment of Intrauterine Growth Restriction (IUGR)?

Accepted Answer

None of the above

Answer

Aspirin

Answer

Nitric oxide donors

Answer

Antioxidants

Question 4

A 34-week pregnant patient presents with acute liver failure, coagulopathy, and intrauterine fetal demise. Her blood pressure is normal and viral markers are negative. What is the most probable diagnosis?

Accepted Answer

Acute fatty liver of pregnancy

Answer

Intrahepatic cholestasis of pregnancy

Answer

Viral hepatitis

Answer

Obstructive jaundice

Question 5

Single umbilical artery is associated with all of the following except?

Accepted Answer

Advanced maternal age

Answer

Polyhydramnios

Answer

Fetal growth retardation

Answer

Increased incidence of fetal malformation

Question 6

Which of the following is NOT a feature of pre-eclampsia?

Accepted Answer

Vomiting

Answer

Blood pressure > 140/90 mmHg after 20 weeks of gestation

Answer

Epigastric pain

Answer

Visual disturbances and heartburn

Question 7

Polyhydramnios is typically most pronounced during which gestational period?

Accepted Answer

Third trimester

Answer

End of the first trimester

Answer

Early part of the second trimester

Answer

Latter part of the second trimester

Question 8

The "T sign" is classically associated with which of the following conditions?

Accepted Answer

Membrane in twin pregnancy

Answer

Genitourinary tuberculosis

Answer

Polycystic ovarian disease (PCOD)

Answer

Spina bifida

Question 9

Which of the following complications is NOT associated with an increased risk in multifetal pregnancy?

Accepted Answer

Post-term pregnancy

Answer

Maternal death

Answer

Preeclampsia

Answer

Hysterectomy

Question 10

Which of the following is a risk factor for preeclampsia?

Accepted Answer

Obesity

Answer

Chronic hypertension

Answer

Smoking

Answer

Multiparity

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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