Maternal-Fetal Medicine Practice Questions

Q: A 25-year-old woman, G2 P1 with a prior cesarean delivery, is in labor. The fetal heart rate monitor shows the tracing seen in the image. What is your diagnosis?

Uterine rupture. ***Uterine rupture*** - **Sudden prolonged fetal bradycardia** in a woman with **prior cesarean delivery** attempting **VBAC** (vaginal birth after cesarean) is highly suggestive of uterine rupture. - The **previous cesarean scar** creates a weak point in the uterine wall that can rupture during labor, causing immediate fetal compromise and maternal hemorrhage. *Cord compression* - Typically presents with **variable decelerations** that correlate with uterine contractions, not sudden prolonged bradycardia. - The fetal heart rate pattern would show **abrupt drops** followed by **rapid return to baseline** between contractions. *Fetal anemia* - Characterized by a **sinusoidal fetal heart rate pattern** with smooth, wave-like oscillations of 5-15 beats per minute. - Would not present as **sudden prolonged bradycardia** but rather as a continuous undulating pattern. *Amniotic fluid embolism* - Primarily causes **sudden maternal cardiovascular collapse** with hypotension, respiratory distress, and coagulopathy. - The fetal heart rate changes are **secondary to maternal compromise**, not the primary presenting feature.

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

Thrombocytosis. **Explanation:** Pre-eclampsia is defined as new-onset hypertension (≥140/90 mmHg) and proteinuria (or organ dysfunction) after 20 weeks of gestation. The distinction between pre-eclampsia and **severe pre-eclampsia** is critical for management decisions. **Why Thrombocytosis is the correct answer:** In severe pre-eclampsia, the underlying pathophysiology involves widespread endothelial damage and microangiopathic hemolytic anemia. This leads to **Thrombocytopenia** (platelet count <100,000/mm³), not thrombocytosis. Low platelets occur due to increased consumption and destruction of platelets within the damaged vasculature. **Analysis of Incorrect Options (Features of Severe Pre-eclampsia):** * **BP 160/110 mmHg:** A systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg on two occasions at least 4 hours apart is a diagnostic criterion for severe features. * **Visual Disturbances:** New-onset cerebral or visual disturbances (e.g., photopsia, scotomata, blurred vision) indicate cerebral edema or occipital lobe ischemia, marking severe disease. * **Oliguria:** Reduced urine output ( 1.1 mg/dL) signifies significant renal impairment. **NEET-PG High-Yield Pearls:** * **HELLP Syndrome:** A severe variant characterized by **H**emolysis, **E**levated **L**iver enzymes, and **L**ow **P**latelets. * **Drug of Choice:** Magnesium Sulfate ($MgSO_4$) is the gold standard for preventing and treating eclamptic seizures. * **Definitive Treatment:** Delivery of the fetus and placenta is the only cure for pre-eclampsia. * **Proteinuria:** While proteinuria is a diagnostic feature of pre-eclampsia, the *amount* of proteinuria (formerly >5g) is no longer used to define "severe" features in current ACOG guidelines, though it remains a clinical marker.

Q: A pregnant female with chronic hypertension whose blood pressure is controlled with antihypertensives should ideally be delivered at which gestational age?

37-39 weeks. **Explanation:** The management of chronic hypertension in pregnancy focuses on balancing the risks of intrauterine growth restriction (IUGR) and placental abruption against the risks of neonatal prematurity. **Why Option B is Correct:** According to ACOG and standard obstetric guidelines, women with **chronic hypertension** that is **well-controlled** with medication and who do not develop superimposed preeclampsia should be delivered between **37 0/7 and 39 6/7 weeks** of gestation. Delivery during this window (early term to full term) minimizes the risk of stillbirth while ensuring fetal lung maturity and reducing neonatal morbidity associated with late-preterm birth. **Analysis of Incorrect Options:** * **Option A (38-39 weeks):** While delivery in this window is acceptable, it is too narrow. The guidelines specifically allow for delivery starting at 37 weeks. * **Option C (36-37 weeks):** This is the timing for chronic hypertension that is **difficult to control** or associated with mild complications. For well-controlled cases, delivering before 37 weeks unnecessarily increases the risk of respiratory distress syndrome (RDS). * **Option D (35-36 weeks):** This range is generally reserved for severe complications, such as superimposed preeclampsia with severe features or fetal growth restriction with abnormal dopplers. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Chronic hypertension is BP ≥140/90 mmHg predating pregnancy or diagnosed before 20 weeks of gestation. * **Drug of Choice:** Labetalol is generally the first-line antihypertensive; Methyldopa and Nifedipine are also used. **ACE inhibitors and ARBs are strictly contraindicated** due to fetal renal dysgenesis. * **Superimposed Preeclampsia:** If a patient with chronic hypertension develops preeclampsia, delivery is usually indicated at **37 weeks** (without severe features) or **immediately upon diagnosis after 34 weeks** (with severe features).

Q: A 30-week pregnant woman presents for an antenatal check-up complaining of mild dyspnea and palpitations. On examination, pedal edema is present. An ejection systolic murmur is noted. ECG shows sinus tachycardia, left axis deviation, and occasional premature ventricular beats. Echocardiogram reveals a small pleural effusion and mild mitral regurgitation. No other relevant findings are present. What is the next line of treatment?

No treatment needed. **Explanation:** The correct answer is **C. No treatment needed**. This question tests the ability to distinguish between physiological cardiovascular changes in pregnancy and pathological heart disease. During pregnancy, blood volume increases by 40–50%, leading to a hyperdynamic circulation. The findings described in the clinical vignette are **normal physiological adaptations** at 30 weeks: * **Symptoms:** Mild dyspnea and palpitations are common due to the enlarging uterus and increased cardiac output. * **Physical Signs:** Dependent pedal edema occurs due to IVC compression. An **ejection systolic murmur** (Grade I/II) is heard in up to 90% of pregnant women due to increased flow across the pulmonary and aortic valves. * **ECG Changes:** Left axis deviation occurs as the diaphragm elevates and shifts the heart's position. Sinus tachycardia and isolated PVCs are common. * **Echocardiogram:** Mild mitral or tricuspid regurgitation and trace pericardial/pleural effusions can be seen due to volume overload and are not necessarily indicative of failure. **Why incorrect options are wrong:** * **Option A:** Diuretics are not indicated as the edema is physiological, not due to congestive heart failure. * **Option B:** Endocarditis prophylaxis is no longer recommended for physiological murmurs or uncomplicated vaginal/cesarean deliveries. * **Option D:** Termination is contraindicated. These findings do not meet the criteria for NYHA Class III/IV heart failure or life-threatening conditions (like Eisenmenger syndrome or severe MS). **Clinical Pearls for NEET-PG:** * **Diastolic murmurs** in pregnancy are **always pathological** and require investigation. * The most common heart disease in pregnancy in India is **Rheumatic Heart Disease (Mitral Stenosis)**. * Cardiac output peaks at **30–34 weeks** and immediately **post-partum** (due to autotransfusion). These are the periods of maximum risk for heart failure.

Q: A patient at 36 weeks of gestation presents with abdominal pain, uterine tenderness, and vaginal bleeding. Her vital signs are stable, and fetal heart tracing is regular. Which of the following steps is NOT required?

Tocolysis to arrest labor. ### Explanation The clinical presentation of abdominal pain, uterine tenderness, and vaginal bleeding in the third trimester is a classic triad for **Abruptio Placentae** (premature separation of the placenta). **1. Why Tocolysis (Option D) is NOT required:** In the management of placental abruption, **tocolysis is strictly contraindicated**. The primary goal is delivery, as the retroplacental clot acts as a uterine irritant, often leading to labor anyway. Attempting to arrest labor with tocolytics in the presence of abruption can lead to worsening hemorrhage, concealment of bleeding, and delay in definitive management, potentially resulting in maternal shock or fetal demise. **2. Why the other options are part of management:** * **Amniotomy/Prostaglandins (Option A):** Vaginal delivery is the preferred route if the fetus is stable. Amniotomy (rupturing membranes) is a priority as it reduces intrauterine pressure, decreases the entry of thromboplastin into maternal circulation (reducing DIC risk), and often accelerates labor. * **Blood Products (Option B):** Abruption is an obstetric emergency with a high risk of sudden, massive hemorrhage and Consumptive Coagulopathy (DIC). Cross-matching and arranging blood products is a mandatory safety step. * **IV Crystalloids/Colloids (Option C):** Aggressive fluid resuscitation is essential to maintain maternal hemodynamic stability and ensure adequate placental perfusion. **Clinical Pearls for NEET-PG:** * **Most common cause of DIC in pregnancy:** Abruptio Placentae. * **Couvelaire Uterus:** A complication of severe abruption where blood extravasates into the myometrium, giving it a bluish/purplish appearance. * **Management Rule:** If the fetus is alive and stable, aim for vaginal delivery (Amniotomy + Oxytocin). If there is fetal distress or maternal instability, proceed to immediate Cesarean Section.

Q: A G1 P0 patient presents with blood pressure of 160/102 mmHg, 3+ proteinuria, and right upper quadrant discomfort at 36 weeks gestation. Following induction of labor, she delivers vaginally and experiences 1500mL blood loss. Her serum creatinine rises from 0.98 mg/dL pre-delivery to 1.42 mg/dL post-delivery. What is the most likely diagnosis?

Acute tubular necrosis. ### Explanation **Correct Answer: D. Acute tubular necrosis (ATN)** The patient presents with **Severe Preeclampsia** (BP 160/102, 3+ proteinuria, RUQ pain) complicated by a massive **Postpartum Hemorrhage (PPH)** of 1500 mL. The core clinical event is the sudden rise in serum creatinine (from 0.98 to 1.42 mg/dL) following significant blood loss. In the context of obstetric hemorrhage and hypovolemia, the most common cause of acute kidney injury (AKI) is **Acute Tubular Necrosis**. The ischemic insult to the renal tubules caused by profound hypotension (from PPH) leads to the rise in creatinine. **Why other options are incorrect:** * **A. Severe preeclampsia:** While the patient meets the criteria for severe preeclampsia, this is the *underlying condition*, not the specific diagnosis for the post-delivery renal deterioration. * **B. Postpartum hemorrhage:** This is the *precipitating event* (the cause), but it does not describe the resulting renal pathology. * **C. Subcapsular liver hematoma:** Although RUQ pain in preeclampsia suggests liver involvement (Glisson’s capsule stretch), it does not explain the acute rise in creatinine following delivery and blood loss. **Clinical Pearls for NEET-PG:** * **Renal Failure in Pregnancy:** The most common cause of AKI in the third trimester is preeclampsia/HELLP syndrome, but the most common cause of *ischemic* AKI (ATN) is obstetric hemorrhage (Abruptio placentae or PPH). * **Creatinine Norms:** Remember that normal serum creatinine in pregnancy is lower (0.4–0.8 mg/dL) due to increased GFR. A value of 1.42 mg/dL represents significant renal impairment. * **Management:** The priority in ATN is fluid resuscitation and maintaining renal perfusion. Most cases are reversible if the primary cause is managed.

Q: A woman with mitral stenosis but no pulmonary hypertension is in labor at 39 weeks of gestation. She has dyspnea on exertion and a pulse rate of 80 bpm. There are no basal crepitations in the lungs. The cervix is 4 cm dilated, and she is having 1-2 uterine contractions in 10 minutes. Which of the following steps is best avoided in her management?

Use of ergometrine in the third stage of labor. In patients with **Mitral Stenosis (MS)**, the primary goal of management is to avoid sudden increases in preload and heart rate to prevent pulmonary edema. ### **Why Ergometrine is Avoided (Correct Answer)** Ergometrine (and Syntometrine) causes **vasoconstriction and a sudden shift of blood** from the peripheral circulation to the central compartment (autotransfusion). In MS, the narrowed mitral valve cannot handle this sudden increase in venous return (preload), leading to a rapid rise in left atrial pressure and a high risk of **acute pulmonary edema**. Therefore, it is strictly contraindicated in cardiac patients. ### **Analysis of Other Options** * **A. Active Management of the Third Stage of Labor (AMTSL):** This is recommended to prevent Postpartum Hemorrhage (PPH). However, in cardiac patients, the uterotonic of choice is **Oxytocin** (slow infusion), not ergometrine. * **B. Augmentation of labor with oxytocin:** This is acceptable if labor is slow. Oxytocin should be given in a concentrated form via an infusion pump to avoid fluid overload. * **C. Epidural analgesia:** This is highly beneficial in MS. It reduces pain-induced tachycardia and decreases preload (via sympathetic blockade), which helps prevent pulmonary congestion. ### **Clinical Pearls for NEET-PG** * **Most common cardiac lesion in pregnancy:** Mitral Stenosis (Rheumatic). * **Most critical period:** Immediately postpartum (due to autotransfusion from the involuting uterus and relief of IVC compression). * **Management of choice for PPH in MS:** Oxytocin (slow IV) or Misoprostol. Avoid Ergometrine and Carboprost (the latter increases pulmonary artery pressure). * **Position:** Labor in the **left lateral position** to optimize venous return and cardiac output.

Question 1

A 30-week pregnant female presents for antenatal Doppler assessment. The findings are shown. What is the recommended management?

Accepted Answer

Admit the patient, provide steroid cover, monitor with Non-stress test (NST) and repeat Doppler, and plan for delivery at 32-34 weeks or earlier if Doppler findings worsen.

Answer

Urgent lower segment cesarean section (LSCS)

Answer

The findings are normal for 30 weeks of pregnancy; the patient can be followed up on an outpatient basis.

Answer

Admit the patient, provide steroid cover, and continue follow-up until 37-38 weeks.

Question 2

A 25-year-old woman, G2 P1 with a prior cesarean delivery, is in labor. The fetal heart rate monitor shows the tracing seen in the image. What is your diagnosis?

Accepted Answer

Uterine rupture

Answer

Cord compression

Answer

Fetal anemia

Answer

Amniotic fluid embolism

Question 3

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

Accepted Answer

Thrombocytosis

Answer

BP 160/110 mmHg

Answer

Visual disturbances

Answer

Oliguria

Question 4

A pregnant female with chronic hypertension whose blood pressure is controlled with antihypertensives should ideally be delivered at which gestational age?

Accepted Answer

37-39 weeks

Answer

38-39 weeks

Answer

36-37 weeks

Answer

35-36 weeks

Question 5

A 30-week pregnant woman presents for an antenatal check-up complaining of mild dyspnea and palpitations. On examination, pedal edema is present. An ejection systolic murmur is noted. ECG shows sinus tachycardia, left axis deviation, and occasional premature ventricular beats. Echocardiogram reveals a small pleural effusion and mild mitral regurgitation. No other relevant findings are present. What is the next line of treatment?

Accepted Answer

No treatment needed

Answer

Start diuretics

Answer

Start endocarditis prophylaxis

Answer

Terminate pregnancy as features are diagnostic of heart failure

Question 6

A patient at 36 weeks of gestation presents with abdominal pain, uterine tenderness, and vaginal bleeding. Her vital signs are stable, and fetal heart tracing is regular. Which of the following steps is NOT required?

Accepted Answer

Tocolysis to arrest labor

Answer

Amniotomy or prostaglandins to induce labor

Answer

Arrange for blood products

Answer

Intravenous crystalloids and colloids

Question 7

A G1 P0 patient presents with blood pressure of 160/102 mmHg, 3+ proteinuria, and right upper quadrant discomfort at 36 weeks gestation. Following induction of labor, she delivers vaginally and experiences 1500mL blood loss. Her serum creatinine rises from 0.98 mg/dL pre-delivery to 1.42 mg/dL post-delivery. What is the most likely diagnosis?

Accepted Answer

Acute tubular necrosis

Answer

Severe preeclampsia

Answer

Postpartum hemorrhage

Answer

Subcapsular liver hematoma

Question 8

A woman with mitral stenosis but no pulmonary hypertension is in labor at 39 weeks of gestation. She has dyspnea on exertion and a pulse rate of 80 bpm. There are no basal crepitations in the lungs. The cervix is 4 cm dilated, and she is having 1-2 uterine contractions in 10 minutes. Which of the following steps is best avoided in her management?

Accepted Answer

Use of ergometrine in the third stage of labor

Answer

Active management of the third stage of labor

Answer

Augmentation of labor with oxytocin

Answer

Use of epidural analgesia for pain relief

Question 9

A 36-year-old multigravida at 34 weeks gestation, with a history of two previous lower segment caesarean sections (LSCS), presents with an unstable lie. What is the most likely diagnosis in this case?

Accepted Answer

Placenta previa

Answer

Oligohydramnios

Answer

Pelvic tumor

Answer

Uterine anomalies

Question 10

A 25-year-old nulliparous woman at 35 weeks' gestation presents with contractions, headache, and visual disturbances. Her pregnancy has been uncomplicated. Her temperature is 37 C, blood pressure is 160/110 mm Hg, pulse is 88/minute, and respirations are 12/minute. Examination reveals a cervix that is 2 cm dilated and 75% effaced, with contractions occurring every 2 minutes. Fetal heart rate is in the 140s and reactive. Urinalysis shows 3+ proteinuria. Laboratory values: leukocytes 9,400/mm3, hematocrit 35%, platelets 101,000/mm3, AST 200 U/L, and ALT 300 U/L. What is the most appropriate next step in management?

Accepted Answer

Administer magnesium sulfate

Answer

Administer oxytocin

Answer

Discharge the patient

Answer

Encourage ambulation

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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