Maternal-Fetal Medicine — MCQs

A term baby is to be delivered via cesarean section to a mother with multiple medical problems including seizures (treated with phenytoin), rheumatic heart disease (treated with penicillin), hypertension (treated with propranolol), and deep vein thrombosis (treated with heparin). Which of the following medications is most likely to cause harm in this newborn at delivery?

Q106Easy

Diagnosis of fetal blood cells in maternal circulation is done by which method?

Q107Medium

A pregnant mother presents with a history of delivering a previous child with Congenital Adrenal Hyperplasia (CAH). What is the best management protocol for the current pregnancy?

Q108Easy

Suspected ectopic pregnancy is best diagnosed by?

Q109Easy

What is the effect of preeclampsia on the glomerular filtration rate?

Q110Easy

Which one of the following is not associated with diabetes in pregnancy?

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 101: Which of the following features is NOT suggestive of severe eclampsia?

A. Blood pressure > 160/110 mmHg (Correct Answer)
B. Proteinuria of > 5 grams in 24 hours
C. Oliguria of < 500 ml in 24 hours
D. Thrombocytopenia

Explanation: This question tests your understanding of the diagnostic criteria for **Severe Preeclampsia** (often referred to as severe features of eclampsia when seizures occur). ### **Why Option A is the Correct Answer** The question asks which feature is **NOT** suggestive of "severe" disease. According to the latest ACOG and NHBPEP guidelines, a blood pressure of **≥ 160/110 mmHg** is a diagnostic criterion for severe preeclampsia. Therefore, a blood pressure of **> 160/110 mmHg** (Option A) is indeed a feature of severe disease. *Note: In the context of NEET-PG, this question often appears as a "except" type. If the options provided are all features of severe disease, the "least" severe or the one that has been removed from the latest classification is chosen. However, technically, all options listed are features of severe preeclampsia.* ### **Analysis of Other Options** * **B. Proteinuria > 5g/24h:** Traditionally, massive proteinuria (>5g) was a criteria for severity. While recent guidelines emphasize that the *amount* of proteinuria does not necessarily correlate with outcomes, it remains a classic textbook feature of severe disease. * **C. Oliguria < 500ml/24h:** Reduced renal perfusion leading to oliguria is a hallmark of end-organ damage in severe preeclampsia. * **D. Thrombocytopenia:** A platelet count **< 100,000/mm³** is a definitive "severe feature" indicating hematologic involvement (part of HELLP syndrome). ### **NEET-PG High-Yield Pearls** * **Severe Features include:** BP ≥160/110, Progressive renal insufficiency (Serum Creatinine >1.1 mg/dL), Cerebral/Visual disturbances (headache, scotoma), Pulmonary edema, and Epigastric/Right upper quadrant pain (due to liver capsule stretch). * **Update:** The 24-hour urine protein amount (formerly >5g) has been **removed** from the ACOG criteria for severity, but it is still frequently tested in Indian competitive exams. * **Drug of Choice:** Magnesium Sulfate ($MgSO_4$) is the DOC for both prophylaxis and treatment of eclamptic seizures (Pritchard Regimen).

Question 102: What is the exclusive complication of monochorionic twins?

A. Cord entanglement
B. Twin-to-twin transfusion syndrome (Correct Answer)
C. Discordant growth
D. Abortion

Explanation: **Explanation:** The defining feature of **monochorionic (MC) placentation** is the presence of **vascular anastomoses** (arterio-venous, arterio-arterial, or veno-venous) on the placental surface that connect the circulations of the two fetuses. **Twin-to-Twin Transfusion Syndrome (TTTS)** is the correct answer because it is caused specifically by an imbalance in these deep **arterio-venous (AV) anastomoses**. Blood is shunted from a "donor" twin to a "recipient" twin, leading to a sequence of polyhydramnios-oligohydramnios. This hemodynamic complication cannot occur in dichorionic twins because their placentas are separate and lack these shared vascular connections. **Analysis of Incorrect Options:** * **A. Cord entanglement:** This is an exclusive complication of **monoamniotic** twins (a subset of monochorionic twins where both fetuses share one amniotic sac). While all monoamniotic twins are monochorionic, not all monochorionic twins are monoamniotic. * **C. Discordant growth:** This refers to a significant weight difference between twins. It can occur in **both** monochorionic (due to TTTS or unequal placental sharing) and dichorionic twins (due to genetic factors or individual placental insufficiency). * **D. Abortion:** Spontaneous pregnancy loss can occur in any pregnancy, whether singleton, dichorionic, or monochorionic. **High-Yield Clinical Pearls for NEET-PG:** * **Quintero Staging** is used to classify the severity of TTTS (Stage I: Oligo/Polyhydramnios to Stage V: Death of one or both fetuses). * **TAPS (Twin Anemia Polycythemia Sequence):** Another MC-exclusive complication caused by slow transfusion through tiny diameter anastomoses. * **TRAP (Twin Reversed Arterial Perfusion) Sequence:** Also exclusive to MC twins, involving an "acardiac" twin. * **Lambda sign (T-sign):** On ultrasound, the absence of the Lambda sign (presence of **T-sign**) confirms monochorionicity.

Question 103: What are the effects of smoking during pregnancy?

A. Intrauterine Growth Restriction (IUGR) (Correct Answer)
B. Pregnancy-Induced Hypertension (PIH)
C. Malpresentation
D. Postpartum Hemorrhage (PPH)

Explanation: **Explanation:** Smoking during pregnancy is a high-yield topic in NEET-PG, primarily associated with adverse perinatal outcomes due to chronic placental insufficiency. **Why Option A is Correct:** The primary mechanism behind **Intrauterine Growth Restriction (IUGR)** in smokers is twofold: 1. **Carbon Monoxide (CO):** CO has a higher affinity for hemoglobin than oxygen, forming carboxyhemoglobin. This reduces the oxygen-carrying capacity of maternal blood, leading to fetal hypoxia. 2. **Nicotine:** Nicotine acts as a potent vasoconstrictor, reducing uterine blood flow and impairing the transfer of essential nutrients across the placenta. Collectively, these factors lead to a significant reduction in birth weight (on average 150–200g less) and increased risk of Small for Gestational Age (SGA) infants. **Why Other Options are Incorrect:** * **Option B (PIH):** Interestingly, smoking is statistically associated with a *decreased* risk of preeclampsia/PIH, likely due to the inhibition of certain inflammatory pathways, though this is not a reason to encourage smoking. * **Option C (Malpresentation):** This is typically associated with factors like placenta previa, uterine anomalies, or polyhydramnios, rather than smoking. * **Option D (PPH):** While smoking increases the risk of Abruptio Placentae and Placenta Previa (which can cause antepartum hemorrhage), it is not a direct primary cause of Postpartum Hemorrhage (PPH). **High-Yield Clinical Pearls for NEET-PG:** * **Placental Complications:** Smoking is a major risk factor for **Placenta Previa** and **Abruptio Placentae**. * **Membranes:** It is strongly linked to **Preterm Premature Rupture of Membranes (PPROM)** and preterm labor. * **Long-term:** Increased risk of **Sudden Infant Death Syndrome (SIDS)** and childhood respiratory infections. * **Congenital Anomalies:** Specifically associated with an increased risk of **Orofacial clefts**.

Question 104: What is the risk of mother-to-child HIV transmission in a pregnant woman at the time of delivery and after delivery in a non-breastfeeding woman?

A. 5-10%
B. 10-15%
C. 15-30% (Correct Answer)
D. More than 50%

Explanation: **Explanation:** The risk of Mother-to-Child Transmission (MTCT) of HIV occurs in three distinct phases: in-utero (antenatal), during labor and delivery (intranatal), and through breastfeeding (postnatal). **1. Why 15-30% is correct:** In the absence of any medical intervention (Antiretroviral Therapy - ART) and assuming the mother **does not breastfeed**, the cumulative risk of transmission is approximately **15-30%**. * **Antenatal risk:** ~5-10% * **Intranatal risk:** ~10-20% (The majority of transmission occurs during labor due to exposure to infected maternal blood and vaginal secretions). Combining these two phases results in the 15-30% range. If breastfeeding were included, the risk would increase to 30-45%. **2. Analysis of Incorrect Options:** * **Option A (5-10%):** This represents only the antenatal (in-utero) risk or the risk in a woman on highly effective ART with a suppressed viral load. * **Option B (10-15%):** This is too low for a woman not receiving any intervention; it underestimates the significant risk during the intrapartum period. * **Option D (>50%):** This is an overestimation. Even without treatment, the majority of infants born to HIV-positive mothers do not contract the virus. **3. NEET-PG High-Yield Pearls:** * **Most common timing of transmission:** Intrapartum (during labor/delivery). * **Effect of ART:** With effective ART and viral suppression (<50 copies/mL), the transmission risk can be reduced to **less than 1%**. * **Mode of Delivery:** Elective Cesarean Section (at 38 weeks) reduces risk if the viral load is >1000 copies/mL or unknown. * **Feeding:** In India, exclusive breastfeeding is recommended for the first 6 months if replacement feeding is not "Acceptable, Feasible, Affordable, Sustainable, and Safe" (AFASS). However, the question specifically specifies a **non-breastfeeding** woman.

Question 105: A term baby is to be delivered via cesarean section to a mother with multiple medical problems including seizures (treated with phenytoin), rheumatic heart disease (treated with penicillin), hypertension (treated with propranolol), and deep vein thrombosis (treated with heparin). Which of the following medications is most likely to cause harm in this newborn at delivery?

A. Penicillin
B. Phenytoin
C. Propranolol (Correct Answer)
D. Heparin

Explanation: **Explanation:** The correct answer is **Propranolol**. **Why Propranolol is the correct answer:** Propranolol is a non-selective beta-blocker. When administered to a pregnant woman near term, it crosses the placenta and can cause significant neonatal complications. The primary concern at delivery is **neonatal hypoglycemia, bradycardia, and respiratory depression**. Beta-blockers interfere with the fetal/neonatal physiological response to the stress of delivery (catecholamine surge), leading to a failure to maintain heart rate and blood glucose levels immediately after birth. **Why the other options are incorrect:** * **Penicillin:** It is the drug of choice for many infections in pregnancy and for rheumatic heart disease prophylaxis. It is non-teratogenic and generally safe for the newborn. * **Phenytoin:** While phenytoin is a known teratogen (causing Fetal Hydantoin Syndrome if used in the first trimester) and can cause neonatal Vitamin K deficiency, its acute effect *at the moment of delivery* is less life-threatening compared to the acute metabolic and cardiac suppression caused by beta-blockers. * **Heparin:** Heparin (both UFH and LMWH) does **not** cross the placenta due to its large molecular weight. Therefore, it does not cause any direct anticoagulant effect or harm to the newborn. **Clinical Pearls for NEET-PG:** * **Beta-blockers in pregnancy:** Labetalol is the preferred antihypertensive because it has less association with fetal growth restriction (IUGR) compared to Atenolol or Propranolol. * **Heparin vs. Warfarin:** Heparin is safe (doesn't cross the placenta); Warfarin is contraindicated (crosses the placenta and is teratogenic/causes fetal hemorrhage). * **Neonatal Monitoring:** Any neonate born to a mother on beta-blockers must be monitored for at least 48–72 hours for "the 3 Bs": **B**radycardia, **B**ronchospasm (respiratory distress), and **B**lood sugar (hypoglycemia).

Question 106: Diagnosis of fetal blood cells in maternal circulation is done by which method?

A. Direct Coomb's test
B. Indirect Coomb's test (Correct Answer)
C. Amniocentesis
D. Placental sampling

Explanation: **Explanation:** The diagnosis of fetal blood cells (or more accurately, the maternal response to them) in the maternal circulation is primarily assessed using the **Indirect Coomb’s Test (ICT)**. **1. Why Indirect Coomb’s Test (ICT) is Correct:** In Rh-negative mothers carrying an Rh-positive fetus, fetal red blood cells (RBCs) can enter the maternal circulation (fetomaternal hemorrhage). This triggers the mother’s immune system to produce antibodies against the Rh (D) antigen. The ICT is used to detect these **circulating, unbound antibodies** in the maternal serum. A positive ICT indicates that isoimmunization has occurred, confirming that the mother has been exposed to fetal Rh-positive cells. **2. Why Other Options are Incorrect:** * **Direct Coomb’s Test (DCT):** This is performed on the **newborn’s cord blood** (or fetal blood) to detect antibodies already bound to the surface of fetal RBCs. It is used to diagnose Hemolytic Disease of the Newborn (HDN), not maternal sensitization. * **Amniocentesis:** While used to assess fetal lung maturity or bilirubin levels (via Liley’s chart), it does not detect fetal cells in the maternal circulation. * **Placental Sampling (CVS):** This is a prenatal diagnostic tool for genetic abnormalities and does not screen for maternal isoimmunization. **Clinical Pearls for NEET-PG:** * **Kleihauer-Betke (KB) Test:** This is the specific test used to **quantify** the volume of fetal-to-maternal hemorrhage to determine the required dose of Anti-D. * **Critical Titer:** In a sensitized pregnancy, an ICT titer of **1:16** (at most centers) is considered the threshold for initiating intensive fetal monitoring (e.g., MCA-PSV Doppler). * **Prophylaxis:** Routine Anti-D (300 mcg) is administered at 28 weeks gestation and within 72 hours of delivery to non-sensitized Rh-negative mothers.

Question 107: A pregnant mother presents with a history of delivering a previous child with Congenital Adrenal Hyperplasia (CAH). What is the best management protocol for the current pregnancy?

A. Start prednisolone after establishing whether the fetus is affected by Chorionic Villous Sampling
B. Start dexamethasone as soon as pregnancy is confirmed (Correct Answer)
C. Start dexamethasone after determining the sex of the fetus by Karyotyping
D. Start prednisolone after determining the sex of the fetus with USG

Explanation: **Explanation:** The primary goal in managing a pregnancy at risk for **Congenital Adrenal Hyperplasia (CAH)**, specifically 21-hydroxylase deficiency, is to prevent the **virilization of a female fetus**. **Why Option B is Correct:** Virilization of the external genitalia in a female fetus begins as early as **7–9 weeks of gestation**. To effectively suppress the fetal pituitary-adrenal axis and prevent the overproduction of adrenal androgens, treatment must be initiated **before** this window. Therefore, **Dexamethasone (20 mcg/kg/day)** must be started as soon as the pregnancy is confirmed (ideally before 6 weeks). Dexamethasone is used because, unlike prednisolone, it crosses the placenta without being inactivated by the enzyme 11β-hydroxysteroid dehydrogenase type 2. **Why Other Options are Incorrect:** * **Options C & D:** Waiting for fetal sex determination (via Karyotyping at 10–12 weeks or USG at 18–20 weeks) is too late. By the time the sex is known, irreversible virilization (ambiguous genitalia) may have already occurred. * **Option A:** Chorionic Villous Sampling (CVS) is performed at 10–12 weeks. Waiting for these results to start treatment misses the critical window for preventing genital ambiguity. * **Prednisolone (Options A & D):** This is ineffective for fetal treatment because it is metabolized by the placenta and does not reach the fetus in therapeutic concentrations. **Clinical Pearls for NEET-PG:** * **Inheritance:** CAH is an **Autosomal Recessive** disorder. If both parents are carriers, the risk of an affected fetus is 1 in 4 (25%), but the risk of an *affected female* is only 1 in 8 (12.5%). * **Management Strategy:** Treat all at-risk pregnancies early; if the fetus is later confirmed to be male or an unaffected female via CVS/Karyotyping, dexamethasone is discontinued. * **Drug of Choice:** Dexamethasone (crosses placenta). * **Side Effects:** Long-term maternal use can lead to weight gain, striae, and gestational diabetes.

Question 108: Suspected ectopic pregnancy is best diagnosed by?

A. MRI
B. TVS (Correct Answer)
C. X-ray abdomen supine
D. HSG

Explanation: **Explanation:** The diagnosis of ectopic pregnancy relies on the combination of clinical suspicion, serial serum β-hCG levels, and imaging. **Transvaginal Sonography (TVS)** is the **gold standard and investigation of choice** for diagnosing ectopic pregnancy. **Why TVS is the Correct Answer:** TVS has high sensitivity and specificity because it allows for better visualization of the pelvic structures compared to transabdominal scans. The diagnosis is confirmed when an extrauterine gestational sac (with or without a yolk sac or fetal pole) is visualized. Even if an ectopic mass is not directly seen, the absence of an intrauterine pregnancy (IUP) when β-hCG levels are above the **discriminatory zone** (usually 1,500–2,000 mIU/mL) strongly suggests an ectopic pregnancy. **Why Other Options are Incorrect:** * **MRI:** While highly accurate, it is expensive, time-consuming, and not readily available in emergency settings. It is reserved for complex cases like abdominal or interstitial pregnancies. * **X-ray Abdomen:** This is contraindicated in early pregnancy due to radiation risk and cannot visualize soft tissue structures like an ectopic sac. * **HSG (Hysterosalpingography):** This is used to evaluate tubal patency in infertility workups. It is contraindicated in suspected pregnancy as it can displace the pregnancy or cause uterine contractions. **NEET-PG High-Yield Pearls:** * **Most common site:** Ampulla of the Fallopian tube. * **Most common site for rupture:** Isthmus (due to narrow lumen). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on curettage, indicating a hormonal response to pregnancy without an intrauterine sac. * **Pseudosac:** A midline fluid collection in the uterus (decidual cast) that can be mistaken for an IUP on TVS.

Question 109: What is the effect of preeclampsia on the glomerular filtration rate?

A. Increases
B. Decreases (Correct Answer)
C. Remains the same
D. May increase or decrease

Explanation: **Explanation:** In a normal pregnancy, the Glomerular Filtration Rate (GFR) typically increases by 40–50% due to increased plasma volume and renal blood flow. However, in **preeclampsia**, the underlying pathophysiology is systemic endothelial dysfunction and vasospasm. The characteristic renal lesion in preeclampsia is **Glomerular Endotheliosis**. This involves swelling of the glomerular endothelial cells and subendothelial deposits of fibrin-like material, which physically narrows the capillary lumens and reduces the surface area available for filtration. Consequently, renal plasma flow decreases and the **GFR decreases** (typically by 30–40% compared to normal pregnancy levels). This reduction in GFR leads to an increase in serum uric acid (an early marker) and, in severe cases, elevated serum creatinine. **Analysis of Options:** * **A. Increases:** This is incorrect. While GFR increases in a healthy pregnancy, the pathological changes of preeclampsia reverse this trend. * **C. Remains the same:** This is incorrect. The structural damage (endotheliosis) and vasospasm significantly alter renal hemodynamics. * **D. May increase or decrease:** This is incorrect. The physiological hallmark of preeclampsia is a consistent reduction in GFR compared to the expected hyperfiltration of pregnancy. **NEET-PG High-Yield Pearls:** * **Glomerular Endotheliosis** is the pathognomonic renal lesion of preeclampsia. * **Hyperuricemia** (due to decreased GFR and increased tubular reabsorption) is often the first biochemical sign and correlates with the severity of the disease. * Proteinuria in preeclampsia is primarily due to increased glomerular permeability to proteins. * Unlike most renal diseases, the filtration fraction in preeclampsia is often decreased because the reduction in GFR is more pronounced than the reduction in renal plasma flow.

Question 110: Which one of the following is not associated with diabetes in pregnancy?

A. Sacral agenesis of the fetus
B. Advanced placental grading (Correct Answer)
C. Baby weight > 3.5 kg
D. Hydramnios

Explanation: **Explanation:** In diabetes complicating pregnancy, the placenta typically undergoes **delayed maturation** rather than advanced grading. **1. Why "Advanced Placental Grading" is the correct answer:** Advanced placental maturation (Grade III) is usually associated with conditions causing placental insufficiency and ischemia, such as **Pregnancy-Induced Hypertension (PIH)** or post-dated pregnancy. In contrast, maternal diabetes leads to a large, edematous, and immature placenta. Histologically, there is a persistence of cytotrophoblastic cells and delayed villous maturation, which can impair oxygen transfer despite the increased placental size. **2. Analysis of Incorrect Options:** * **Sacral Agenesis:** This is the **most specific** congenital anomaly associated with maternal diabetes (though not the most common, which is VSD). It is part of Caudal Regression Syndrome. * **Baby weight > 3.5 kg:** Maternal hyperglycemia leads to fetal hyperinsulinemia. Insulin acts as a growth hormone, causing fetal macrosomia (typically defined as >4 kg or >4.5 kg, but >3.5 kg is a common clinical threshold for concern). * **Hydramnios:** Polyhydramnios occurs in approximately 25% of diabetic pregnancies. It is primarily caused by **fetal osmotic diuresis** resulting from fetal hyperglycemia, leading to increased amniotic fluid production. **Clinical Pearls for NEET-PG:** * **Most common anomaly:** Ventricular Septal Defect (VSD). * **Most specific anomaly:** Sacral agenesis/Caudal regression syndrome. * **HbA1c Goal:** Ideally <6.0% pre-conception to minimize the risk of anomalies. * **Neonatal Complications:** Hypoglycemia, Hypocalcemia, Hyperbilirubinemia, and Polycythemia. (Note: Hyperglycemia is *not* a neonatal complication; the baby becomes hypoglycemic once the maternal glucose supply is cut off).

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

Practice Questions

Multiple Gestation

Practice Questions

Rh Isoimmunization and Other Blood Group Incompatibilities

Practice Questions

Intrauterine Fetal Therapy

Practice Questions

Prenatal Diagnosis and Genetic Counseling

Practice Questions

Placental Abnormalities

Practice Questions

Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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