Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 1011: On ultrasonography low-lying placenta is labelled when implantation in the lower uterine segment is such that:

A. Placental edge does not reach the internal os and remains 2 cm wide perimeter around the os (Correct Answer)
B. Placental edge does not reach the internal os and remains 3 cm wide perimeter around the os
C. Placental edge does not reach the internal os and remains 4 cm wide perimeter around the os
D. Internal os is covered partially or fully by the placenta

Explanation: ***Placental edge does not reach the internal os and remains 2 cm wide perimeter around the os*** - A **low-lying placenta** is diagnosed when the placental edge is **within 2 cm of the internal cervical os** but does not cover it. - This definition is crucial for distinguishing it from a placenta previa, where the placenta covers the os. *Placental edge does not reach the internal os and remains 3 cm wide perimeter around the os* - This distance is **beyond the typical definition** of a low-lying placenta, which specifies a closer proximity to the internal os. - A placenta with an edge 3 cm from the os is generally considered to be of **normal implantation** and not low-lying. *Placental edge does not reach the internal os and remains 4 cm wide perimeter around the os* - Similar to 3 cm, a 4 cm distance from the internal os means the placenta is **not considered low-lying** and has a safe margin from the cervix. - Such a placental position is typically associated with **no increased risk** of complications during delivery due to its position relative to the os. *Internal os is covered partially or fully by the placenta* - This description corresponds to a **placenta previa**, which is a more serious condition than a low-lying placenta. - In placenta previa, the placenta obstructs the birth canal, potentially leading to **significant antepartum hemorrhage**.

Question 1012: A woman presents with abdominal pain and nausea with amenorrhea of 5-6 weeks. Ectopic pregnancy can be diagnosed if:

A. Beta hCG > 2000 IU/L with no gestational sac in the uterus on transvaginal sonography (Correct Answer)
B. Beta hCG ˂1000 IU/L with endometrial thickness of 14mm
C. Beta hCG >3000 IU/L with empty uterus on transvaginal sonography
D. Serum progesterone > 25 ng/ml

Explanation: ***Beta hCG > 2000 IU/L with no gestational sac in the uterus on transvaginal sonography*** - This criterion represents the **discriminatory zone** for transvaginal sonography, where a gestational sac should be visible if the pregnancy is intrauterine. - The absence of an intrauterine gestational sac with a **hCG level above 2000 IU/L** is highly suggestive of an **ectopic pregnancy** or a complete miscarriage. *Beta hCG ˂1000 IU/L with endometrial thickness of 14mm* - A **hCG level below 1000 IU/L** is generally too low to confidently rule out an intrauterine pregnancy, as a gestational sac might not yet be visible. - An endometrial thickness of **14mm** can be normal in early pregnancy or in cases of miscarriage, not specifically indicative of ectopic pregnancy on its own. *Beta hCG >3000 IU/L with empty uterus on transvaginal sonography* - While an **empty uterus** with a high hCG level is concerning, 3000 IU/L is a higher threshold than typically used for the **discriminatory zone**. - Using a higher threshold might delay diagnosis, as an ectopic pregnancy could be present below this level but above the standard 2000 IU/L threshold. *Serum progesterone > 25 ng/ml* - A **serum progesterone level > 25 ng/ml** generally indicates a **healthy intrauterine pregnancy** and makes an ectopic pregnancy unlikely. - Low progesterone levels (typically < 5 ng/ml) are more associated with non-viable pregnancies, including ectopic pregnancies or miscarriages.

Question 1013: A pregnant woman with 30 weeks gestation presents with BP 166/110 mmHg with pulmonary edema with convulsions. The woman is given magnesium sulphate. The following drug should be avoided:

A. Intravenous Labetalol
B. Intravenous Hydralazine
C. Intravenous Frusemide
D. Sublingual Nifedipine (Correct Answer)

Explanation: ***Sublingual Nifedipine*** - **Sublingual nifedipine should be avoided** in this clinical scenario due to the risk of severe **drug interaction with magnesium sulfate**. - Both nifedipine (a calcium channel blocker) and magnesium sulfate have **vasodilatory effects**, and their combination can lead to **precipitous hypotension**, **neuromuscular blockade**, and **cardiovascular collapse**. - Sublingual administration causes **rapid and unpredictable absorption**, making blood pressure control difficult and potentially compromising **uteroplacental perfusion**. - Current guidelines recommend **avoiding sublingual nifedipine** when magnesium sulfate is being administered for seizure prophylaxis in eclampsia. - If nifedipine is needed, the **oral route** is preferred with careful monitoring. *Intravenous Labetalol* - **Labetalol** is a **first-line antihypertensive** for severe hypertension in pregnancy and pre-eclampsia/eclampsia. - It is a combined **alpha and beta-adrenergic blocker** that effectively lowers blood pressure without compromising uteroplacental blood flow. - Safe to use with magnesium sulfate and indicated in this scenario. *Intravenous Hydralazine* - **Hydralazine** is another **first-line agent** for acute severe hypertension in pregnancy. - It acts as a direct **arterial vasodilator** and is safe and effective in eclampsia. - Compatible with magnesium sulfate therapy and appropriate for this patient. *Intravenous Frusemide* - While diuretics are generally **used cautiously** in pre-eclampsia (as it is primarily a vasospastic disorder, not volume overload), **frusemide is not contraindicated** when there is documented **pulmonary edema**. - In this case with clinical pulmonary edema, frusemide may actually be **indicated** to manage fluid overload. - The concern is over-diuresis leading to further hemoconcentration and placental hypoperfusion, but it is not absolutely avoided. - Can be used safely with magnesium sulfate when clinically indicated for pulmonary edema.

Question 1014: A 26 year old primigravida presents with blood pressure of 160/110 mmHg, proteinurea and congestive heart failure. Which drug is not useful in this situation?

A. Diuretics (Correct Answer)
B. Nifedipine
C. Methyl-dopa
D. Labetalol

Explanation: ***Diuretics*** - In uncomplicated pre-eclampsia, **diuretics** are generally **avoided** because they can reduce plasma volume and placental perfusion, potentially worsening maternal hypovolemia. - However, in this case with **congestive heart failure**, the situation is complex. Traditional teaching suggests diuretics should be avoided in pre-eclampsia, and they are considered "not useful" as a primary antihypertensive. - In pre-eclampsia, the priority is to control blood pressure with safer agents and deliver the baby, rather than manage fluid overload with diuretics, which may worsen the underlying pathophysiology. - The question tests knowledge that diuretics are not considered a standard or useful treatment for pre-eclampsia, even when CHF is present. *Nifedipine* - **Nifedipine** is a calcium channel blocker that is highly effective and commonly used to manage severe hypertension in pregnancy, including pre-eclampsia. - It causes **vasodilation**, rapidly lowering blood pressure while maintaining placental blood flow. - It is a **useful** first-line agent in this scenario. *Methyl-dopa* - **Methyl-dopa** is an alpha-2 adrenergic agonist considered safe and effective for managing hypertension in pregnancy. - While more commonly used for chronic hypertension, it can be **useful** in pre-eclampsia management. - It has an excellent safety profile for both mother and fetus. *Labetalol* - **Labetalol** is a combined alpha- and beta-blocker that is a preferred agent for acute severe hypertension in pregnancy. - It rapidly reduces blood pressure with minimal impact on uterine blood flow. - It is highly **useful** in this high-risk scenario and is commonly used in pre-eclampsia with severe features.

Question 1015: A 30 year old G2P1L0 with history of anencephaly in previous pregnancy has a nuchal fold thickness of 2.5 mm with other normal fetal parameters. She may be having:

A. Trisomy 21
B. Normal pregnancy (Correct Answer)
C. Spina bifida
D. Trisomy 18

Explanation: ***Normal pregnancy*** - **Nuchal fold thickness (NFT)** of 2.5 mm is **well within the normal range** (normal cutoff: < 6 mm). - NFT is measured in the **second trimester (15-22 weeks)** as a marker for chromosomal abnormalities, particularly **Trisomy 21**. - A measurement of 2.5 mm with **other normal fetal parameters** indicates a **normal pregnancy**. - The history of anencephaly (a neural tube defect) in the previous pregnancy does not increase the risk of chromosomal abnormalities in the current pregnancy, though **folic acid supplementation** and careful monitoring are recommended. *Trisomy 21* - Trisomy 21 (Down syndrome) is associated with **increased nuchal fold thickness > 6 mm** in the second trimester. - First trimester markers include **increased nuchal translucency (NT) > 3.0 mm**, hypoplastic nasal bone, and abnormal ductus venosus flow. - The current NFT of 2.5 mm is **normal** and does not suggest Trisomy 21. *Spina bifida* - **Spina bifida** is a **neural tube defect** that would be detected by elevated maternal serum **alpha-fetoprotein (MSAFP)** and specific ultrasound findings. - Characteristic ultrasound signs include the **lemon sign** (frontal bone scalloping) and **banana sign** (cerebellar abnormality). - **Nuchal fold thickness is not a marker for spina bifida** - it is used for aneuploidy screening. - While the patient has a history of anencephaly (another neural tube defect), the current fetal parameters are normal. *Trisomy 18* - Trisomy 18 (Edwards syndrome) is associated with **increased nuchal translucency in the first trimester** (often > 5.0 mm) and increased NFT in the second trimester. - Multiple severe fetal anomalies are typically present: **intrauterine growth restriction (IUGR)**, **cardiac defects**, **clenched hands**, **rocker-bottom feet**, and **choroid plexus cysts**. - The **normal nuchal fold thickness** (2.5 mm) and **normal other fetal parameters** make Trisomy 18 unlikely.

Question 1016: A 24 year old married lady presents with sudden onset right iliac fossa pain. On examination she has marked pallor and is hypotensive. What is the most likely diagnosis?

A. Small bowel perforation
B. Twisted ovarian cyst
C. Ruptured ectopic pregnancy (Correct Answer)
D. Appendicular perforation

Explanation: ***Ruptured ectopic pregnancy*** - The sudden onset of **right iliac fossa pain** in a young, married woman, accompanied by **marked pallor** and **hypotension**, strongly suggests **hypovolemic shock** due to internal bleeding. - This clinical picture is classic for a **ruptured ectopic pregnancy**, which is a life-threatening obstetric emergency, often presenting with collapse. *Small bowel perforation* - While small bowel perforation can cause sudden abdominal pain and may lead to shock, it typically presents with signs of **peritonitis** (e.g., rebound tenderness, guarding) and often **fever**, not primarily with marked pallor and hypotension indicating severe internal bleeding. - The pain is usually more generalized initially and may be associated with signs of **sepsis** rather than immediate hemorrhagic shock. *Twisted ovarian cyst* - A twisted ovarian cyst causes sudden, severe **unilateral lower abdominal pain**, often with nausea and vomiting. - While it can cause significant pain, it typically does not lead to rapid, profound **hypotension** and **marked pallor** indicative of massive blood loss, as seen with a ruptured ectopic pregnancy. *Appendicular perforation* - Appendicular perforation is a complication of appendicitis, usually preceded by periumbilical pain migrating to the **right iliac fossa**, often with **fever**, anorexia, and localized peritonitis. - While it can cause shock due to sepsis, it is less likely to present with such rapid and severe signs of **hemorrhagic shock** (marked pallor and hypotension) without preceding appendicitis symptoms.

Question 1017: Which of the statements regarding anemia in pregnancy is NOT true?

A. If mother is severely anemic, the fetus is also severely anemic (Correct Answer)
B. Iron deficiency anemia is most common in Tropics
C. Faulty dietary habit is one of the factors responsible for anemia
D. Mild anemia is most common

Explanation: ***If mother is severely anemic, the fetus is also severely anemic*** - The **placenta** actively transports iron and other essential nutrients to the fetus, even when the mother is severely anemic, to ensure fetal development. - This protective mechanism means that while maternal anemia can affect fetal growth and development, it does not typically result in **severe fetal anemia** unless there are additional complications. *Iron deficiency anemia is most common in Tropics* - **Iron deficiency anemia** is indeed very common in tropical regions, largely due to dietary factors, increased parasitic infections (like hookworm), and **malaria**, which further depletes iron stores and affects red blood cell production. *Faulty dietary habit is one of the factors responsible for anemia* - A diet **lacking in iron-rich foods** (e.g., red meat, fortified cereals) and **vitamin C** (which aids iron absorption) is a primary cause of iron deficiency anemia. - **Vegetarian or vegan diets** that are not properly supplemented can also contribute to iron deficiency. *Mild anemia is most common* - Due to the **physiological hemodilution** that occurs during pregnancy (plasma volume increases more than red blood cell mass), a mild decrease in hemoglobin concentration is common. - This **physiological anemia** is usually not associated with adverse outcomes if the hemoglobin level remains within an acceptable range.

Question 1018: Which one of the following regarding amniotic fluid is true?

A. It is decreased in gestational diabetes
B. The volume is highest at 28 weeks
C. It reveals information about fetal lung maturity and wellbeing (Correct Answer)
D. It is decreased in duodenal atresia in baby

Explanation: **_It reveals information about fetal lung maturity and wellbeing_** - Amniotic fluid analysis, specifically looking at the **lecithin-to-sphingomyelin (L/S) ratio** and the presence of **phosphatidylglycerol**, helps assess fetal lung maturity. - It also provides genetic information through **amniocentesis**, which can indicate fetal wellbeing by detecting chromosomal abnormalities or infections. *It is decreased in gestational diabetes* - **Gestational diabetes** is typically associated with **polyhydramnios** (excessive amniotic fluid volume) due to fetal hyperglycemia leading to increased fetal urination. - Oligohydramnios (decreased amniotic fluid) can occur in cases of uncontrolled diabetes with associated fetal renal anomalies or placental insufficiency, but it is not the primary association with gestational diabetes. *The volume is highest at 28 weeks* - The **amniotic fluid volume** typically peaks around **32-34 weeks of gestation**, not 28 weeks. - After this peak, the volume gradually decreases until term due to changes in production and reabsorption. *It is decreased in duodenal atresia in baby* - **Duodenal atresia** and other high gastrointestinal obstructions prevent the fetus from swallowing and absorbing amniotic fluid, leading to an **increase in amniotic fluid volume (polyhydramnios)**. - Oligohydramnios is more commonly associated with conditions like renal agenesis or chronic uteroplacental insufficiency.

Question 1019: Pregnancy can be terminated at any gestation if the fetus is diagnosed to have:

A. Anencephaly (Correct Answer)
B. Duodenal atresia
C. Bilateral talipes
D. Hydrocephalus

Explanation: ***Anencephaly*** - Anencephaly is a **lethal congenital anomaly** where the brain and skull do not develop properly. - Due to the **incompatible-with-life prognosis**, termination of pregnancy at any gestation is medically justified and often offered. *Duodenal atresia* - **Duodenal atresia** is a treatable condition where the duodenum is blocked. - It is **surgically correctable** after birth and does not warrant termination of pregnancy at any stage. *Bilateral talipes* - **Bilateral talipes** (clubfoot) is a common musculoskeletal birth defect that can be corrected with conservative management (e.g., Ponseti method) or surgery. - It is **not life-threatening** and does not justify termination of pregnancy. *Hydrocephalus* - While hydrocephalus can be severe, its prognosis is variable and often depends on the underlying cause and severity. - Many cases of **hydrocephalus are manageable** with shunting procedures, and it is not universally considered a condition that warrants termination at any gestation.

Question 1020: Cardiac diseases in pregnancy which have major risk of maternal mortality are: 1. Pulmonary hypertension 2. Aortic coarctation with valvular involvement 3. Atrial septal defect 4. Mitral stenosis Select the correct answer using the code given below:

A. 1 and 4
B. 2 and 3
C. 1 and 2 (Correct Answer)
D. 3 and 4

Explanation: ***1 and 2*** - **Pulmonary hypertension** is classified as WHO Class IV (highest risk) with maternal mortality rates of 30-50%. It represents a contraindication to pregnancy due to the inability to accommodate increased cardiac output and hemodynamic changes. - **Aortic coarctation with valvular involvement** is also high-risk (WHO Class III-IV) due to increased risk of aortic dissection, rupture, heart failure, and stroke from the hemodynamic stress of pregnancy, particularly when complicated by valvular disease. - This combination represents the two conditions with the **highest and most consistently documented maternal mortality risk**. *1 and 4* - **Pulmonary hypertension** carries extremely high risk as noted above. - **Mitral stenosis** risk is severity-dependent: severe MS (valve area <1.0 cm²) is WHO Class III-IV with significant mortality risk (5-15%), while mild-moderate MS is lower risk with proper management. - While this combination includes high-risk conditions, **aortic coarctation with valvular involvement** (option 2) generally carries higher and more consistent risk than mitral stenosis, particularly compared to non-severe MS cases. *2 and 3* - **Aortic coarctation with valvular involvement** is high-risk as described above. - **Atrial septal defect (ASD)** is typically WHO Class II (low risk) and well-tolerated during pregnancy unless complicated by Eisenmenger syndrome or pulmonary hypertension. - This pairing incorrectly combines a high-risk condition with a generally low-risk condition. *3 and 4* - **Atrial septal defect (ASD)** is generally low-risk (WHO Class II) in uncomplicated cases. - **Mitral stenosis** varies by severity, but even severe MS carries lower mortality risk than pulmonary hypertension or complicated aortic coarctation. - This option incorrectly identifies conditions that do not consistently represent the **major/highest** maternal mortality risk compared to pulmonary hypertension and aortic coarctation with valvular involvement.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

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Multiple Gestation

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Rh Isoimmunization and Other Blood Group Incompatibilities

Practice Questions

Intrauterine Fetal Therapy

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Prenatal Diagnosis and Genetic Counseling

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Placental Abnormalities

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Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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