Maternal-Fetal Medicine — MCQs

A 32-year-old primigravida at 39 weeks of gestational age has a blood pressure reading of 150/100 mmHg obtained during a routine visit, which is an elevation from her baseline blood pressure of 120/70 mmHg. She denies any headache, visual changes, nausea, vomiting, or abdominal pain. Her repeat BP is 160/90 mmHg, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?

Q1329

At what gestational age should a pregnancy with cholestasis of pregnancy be terminated?

Q1330

What does the presence of a macerated fetus indicate in a clinical context?

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 1321: A pregnant woman developed idiopathic cholestatic jaundice. Which clinical feature is most characteristically associated with this presentation?

A. SGOT, SGPT levels typically remain below 60 IU.
B. Markedly elevated levels of alkaline phosphatase are observed.
C. Serum bilirubin levels typically remain below 5mg/dl.
D. Intense itching is commonly observed. (Correct Answer)

Explanation: ***Intense itching is commonly observed.*** - **Pruritus**, or intense itching, is the most common and often the earliest symptom of **intrahepatic cholestasis of pregnancy (ICP)**, the idiopathic cholestatic jaundice of pregnancy. - The itching in ICP is often generalized, worse at night, and without a skin rash, and it is thought to be caused by the accumulation of **bile acids** in the skin. *SGOT, SGPT levels typically remain below 60 IU.* - While liver transaminases (AST/SGOT and ALT/SGPT) can be mildly elevated in ICP, they generally **do not remain below 60 IU**; levels typically range from slightly elevated to several hundred IU/L. - Significant elevations (e.g., >800 IU/L) would point towards other causes of liver injury, such as viral hepatitis. *Markedly elevated levels of alkaline phosphatase are observed.* - **Alkaline phosphatase (ALP)** is commonly elevated in pregnancy due to its production by the placenta, making it a less specific marker for cholestasis in this context. - While ALP can be elevated in ICP, a "markedly elevated" level would typically be 2-4 times the upper limit of normal, and even higher values can be due to placental isoenzymes, not necessarily reflecting the severity of cholestasis alone. *Serum bilirubin levels typically remain below 5mg/dl.* - Serum bilirubin levels can be elevated in ICP, but they **do not always remain below 5 mg/dL**; while often within this range (typically less than 6 mg/dL), higher levels can occur in more severe cases. - **Hyperbilirubinemia** in ICP is predominantly conjugated (direct) bilirubin, and its elevation contributes to the jaundice.

Question 1322: Which of the following is a component of the triple test for Down syndrome?

A. Maternal Alpha-fetoprotein (Correct Answer)
B. Maternal PAPP-A
C. Maternal Progesterone
D. Maternal Inhibin A

Explanation: ***Maternal Alpha-fetoprotein*** - The **triple test** for Down syndrome assesses **maternal serum levels** of alpha-fetoprotein (AFP), unconjugated estriol (uE3), and human chorionic gonadotropin (hCG). - In pregnancies affected by **Down syndrome**, **maternal AFP levels** are typically lower than normal. *Maternal PAPP-A* - **Pregnancy-associated plasma protein A (PAPP-A)** is a component of the **first-trimester screening** (dual test), not the second-trimester triple test. - Low levels of **PAPP-A** in the first trimester are associated with an increased risk of Down syndrome. *Maternal Progesterone* - **Progesterone** is a hormone crucial for maintaining pregnancy and is not typically used as a marker in routine **screening tests for Down syndrome**. - Its levels can be monitored in cases of threatened miscarriage or to assess corpus luteum function. *Maternal Inhibin A* - **Inhibin A** is a component of the **quad screen** (which includes AFP, uE3, hCG, and Inhibin A), not the triple test. - Elevated **Inhibin A levels** are associated with an increased risk of Down syndrome in the second trimester.

Question 1323: At what time after fertilization does division occur to result in monochorionic monoamniotic twins?

A. Before 4 days
B. 4-8 days
C. 8-12 days (Correct Answer)
D. After 12 days

Explanation: ***8-12 days*** - Division between 8 to 12 days after fertilization results in **monochorionic monoamniotic (MCMA) twins**, meaning they share both the placenta and the amniotic sac. - This timing indicates that split occurs after the differentiation of the inner cell mass but before the formation of the amniotic sac. *Before 4 days* - Division before 4 days (at the **morula stage**) typically leads to **dichorionic diamniotic (DCDA) twins**, each with their own placenta and amniotic sac. - This early split allows for complete separation of both chorionic and amniotic structures. *4-8 days* - Division between 4 and 8 days (at the **blastocyst stage**) typically results in **monochorionic diamniotic (MCDA) twins**. - These twins share a chorion and placenta but have separate amniotic sacs. *After 12 days* - Division after 12 days after fertilization is associated with an increased risk of **conjoined twins**. - At this late stage, the embryonic disc has already formed, making complete separation difficult and often leading to incomplete division. - Most references cite division **after day 13** as the threshold for conjoined twins, though timing may vary slightly between sources.

Question 1324: In an antepartum cardiotocogram, consider the following findings: absence of deceleration and a sinusoidal pattern. Which of the following findings indicates fetal well-being?

A. Both findings indicate fetal well-being
B. Absence of deceleration only (Correct Answer)
C. Absence of deceleration and sinusoidal pattern
D. Sinusoidal pattern only

Explanation: ***Absence of deceleration only*** - The **absence of decelerations** (late or variable) on a cardiotocogram (CTG) is generally considered a sign of **fetal well-being**, indicating adequate placental perfusion and oxygenation. - This suggests that the fetus is not experiencing significant hypoxic stress during contractions or in response to umbilical cord compression. *Both findings indicate fetal well-being* - A **sinusoidal pattern** is a sign of severe fetal compromise, not well-being, and indicates urgent intervention is needed. - Therefore, combining it with the absence of decelerations does not result in an overall indication of fetal well-being. *Absence of deceleration and sinusoidal pattern* - This option incorrectly groups the **absence of decelerations** (fetal well-being) with a **sinusoidal pattern** (fetal distress). - A sinusoidal pattern is a distinct, ominous finding associated with severe fetal anemia, hypoxemia, and acidosis. *Sinusoidal pattern only* - A **sinusoidal pattern** on a CTG is a highly abnormal and concerning finding, indicative of severe **fetal anemia**, **hypoxemia**, or **acidosis**. - It is a strong indicator of **fetal distress** and requires immediate assessment and intervention, not fetal well-being.

Question 1325: Which of the following is NOT a recognized risk factor associated with macrosomia?

A. Prolonged Pregnancy
B. Previous large infant
C. Short Stature (Correct Answer)
D. Maternal obesity

Explanation: ***Short Stature*** - **Short stature** in mothers is generally associated with an **increased risk of small-for-gestational-age (SGA)** infants due to potential pelvic inlet limitations and reduced uterine capacity, not macrosomia. - While short stature can influence birth outcomes, it is not considered a direct or independent **risk factor for delivering a macrosomic infant**. *Maternal obesity* - **Maternal obesity** leads to increased **glucose and insulin levels** in the mother, crossing the placenta and stimulating fetal growth, significantly increasing the risk of macrosomia. - Obese mothers often have **larger placental nutrient transfer capacity**, contributing to excessive fetal growth. *Prolonged Pregnancy* - **Prolonged pregnancy** (post-term pregnancy) allows more time for continuous fetal growth and deposition of fat, which directly increases the likelihood of a fetus becoming **macrosomic**. - Fetuses in prolonged pregnancies continue to gain weight, and **fetal growth restriction** is less common in this context than continued growth. *Previous large infant* - A history of a **previous large infant** strongly indicates a maternal predisposition (e.g., genetic factors, undiagnosed glucose intolerance) to carrying and delivering larger babies in subsequent pregnancies. - This is one of the most significant risk factors, as **recurrence rates for macrosomia** are high.

Question 1326: All the following are indications for termination of pregnancy in APH patient except:

A. Continuous bleeding
B. Transverse lie (Correct Answer)
C. 37 weeks
D. IUD

Explanation: ***Transverse lie*** - A **transverse lie** is an **abnormal fetal presentation** that requires a **cesarean section** for delivery, but it is **not an indication for delivery** in the context of an APH (Antepartum Hemorrhage) patient. - While it determines the **mode of delivery** (cesarean vs vaginal), it does not by itself indicate the need to deliver the baby due to hemorrhage. - The timing of delivery in APH is based on maternal-fetal compromise, not fetal presentation. *Continuous bleeding* - **Continuous, active vaginal bleeding** in an APH patient is an **absolute indication for delivery** to save the mother's life. - Uncontrolled hemorrhage can lead to **maternal shock**, disseminated intravascular coagulation (DIC), and maternal mortality if delivery is not expedited. *37 weeks* - If a patient with APH, especially due to **placenta previa**, reaches **37 weeks gestation**, delivery is indicated because the fetus has achieved **term maturity**. - Continuing the pregnancy beyond this point increases the risk of further hemorrhagic complications without additional fetal benefit. *IUD (Intrauterine Death)* - The presence of an **intrauterine fetal demise** in an APH patient is an indication for **delivery**. - A dead fetus, especially with ongoing bleeding, can lead to maternal coagulopathy and infection if retained. - Delivery prevents these maternal complications.

Question 1327: Pregnancy is contraindicated in which of the following cardiac conditions?

A. Mitral regurgitation
B. Aortic stenosis
C. Mitral stenosis
D. Primary pulmonary hypertension (Correct Answer)

Explanation: ***Primary pulmonary hypertension*** - Pregnancy is **contraindicated** in primary pulmonary hypertension due to the significant risk of **maternal mortality**, which can be as high as 30-50%. - The physiological changes of pregnancy, such as increased **cardiac output** and blood volume, exacerbate pulmonary vascular resistance and can lead to **right heart failure** and sudden death. *Mitral stenosis* - While mitral stenosis can cause complications in pregnancy, it is not an absolute contraindication for all cases, especially if it is **mild to moderate** and well-managed. - The main concern is the increased **blood volume** and heart rate during pregnancy, which can worsen pulmonary congestion, but careful monitoring can often mitigate risks. *Aortic stenosis* - Severe aortic stenosis can be problematic during pregnancy due to the heart's inability to increase **cardiac output** adequately in response to increased demand. - However, pregnancy is typically not absolutely contraindicated, and management often involves close monitoring and in some cases, **balloon valvuloplasty** before or during pregnancy. *Mitral regurgitation* - Mitral regurgitation is generally **well-tolerated** during pregnancy because the reduced systemic vascular resistance in pregnancy makes it easier for blood to flow forward into the aorta, actually reducing the regurgitant volume. - While severe cases require careful monitoring, it is generally **not a contraindication** to pregnancy.

Question 1328: A 32-year-old primigravida at 39 weeks of gestational age has a blood pressure reading of 150/100 mmHg obtained during a routine visit, which is an elevation from her baseline blood pressure of 120/70 mmHg. She denies any headache, visual changes, nausea, vomiting, or abdominal pain. Her repeat BP is 160/90 mmHg, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?

A. Preeclampsia
B. Chronic hypertension with superimposed preeclampsia
C. Eclampsia
D. Gestational hypertension (Correct Answer)

Explanation: ***Gestational hypertension*** - This patient presents with **new-onset hypertension** (BP > 140/90 mmHg) after 20 weeks of gestation, without **proteinuria** or signs of **end-organ damage**. - The absence of proteinuria and severe features distinguishes it from preeclampsia, making gestational hypertension the most likely diagnosis. *Preeclampsia* - Preeclampsia requires new-onset hypertension combined with **proteinuria** (≥300 mg in 24 hours or protein/creatinine ratio ≥0.3) or signs of **end-organ dysfunction**, neither of which are described here. - While hypertension is present, the **lack of proteinuria** or other severe features rules out this diagnosis. *Chronic hypertension with superimposed preeclampsia* - This diagnosis applies to women with **pre-existing hypertension** (diagnosed before pregnancy or before 20 weeks) who then develop new-onset proteinuria or worsening hypertension with severe features. - The patient's baseline blood pressure was normal (120/70 mmHg), indicating no chronic hypertension, and no proteinuria or severe features are present. *Eclampsia* - Eclampsia is defined by the occurrence of **generalized tonic-clonic seizures** in a woman with preeclampsia, which is a life-threatening obstetric emergency. - The patient described has no signs of seizures or even severe preeclampsia.

Question 1329: At what gestational age should a pregnancy with cholestasis of pregnancy be terminated?

A. 34 weeks
B. 36 weeks
C. 38 weeks (Correct Answer)
D. 40 weeks

Explanation: ***38 weeks*** - For pregnancies complicated by **cholestasis of pregnancy**, induction of labor at **38 weeks** is generally recommended. - This timing balances the risk of stillbirth associated with cholestasis against the risks of **preterm birth**. *34 weeks* - Induction at 34 weeks would be considered **too early** unless there are additional severe complications, as it increases the risk of **neonatal morbidity** associated with prematurity. - While cholestasis does increase stillbirth risk, this risk significantly rises **after 37-38 weeks**, making earlier induction unnecessary in most cases. *36 weeks* - Induction at 36 weeks is generally considered **too early** given the potential for **neonatal complications** related to prematurity. - The elevated risk of adverse fetal outcomes in cholestasis of pregnancy typically occurs closer to term, making 38 weeks a more optimal balance. *40 weeks* - Allowing pregnancy to continue to 40 weeks with **cholestasis of pregnancy** would be associated with an **unacceptable increased risk of stillbirth**. - The risk of adverse perinatal outcomes, including **sudden fetal death**, significantly rises in pregnancies with cholestasis that extend beyond 38 weeks.

Question 1330: What does the presence of a macerated fetus indicate in a clinical context?

A. Fetal distress
B. Stillborn (Correct Answer)
C. Live born
D. Intrauterine Growth Restriction (IUGR)

Explanation: ***Stillborn*** - A **macerated fetus** refers to a fetus that has undergone **autolysis** due to prolonged retention in utero after fetal death. - The presence of maceration is a definitive sign that the fetus was **stillborn** and not alive at the time of delivery. *Fetal distress* - **Fetal distress** indicates a fetus that is currently experiencing **compromise during labor** or prior, but is still alive. - While fetal distress can precede fetal death, its presence alone does not imply maceration or a stillborn outcome at the time of diagnosis. *Live born* - A **live born** infant shows any sign of life (e.g., breathing, heartbeat, umbilical cord pulsation, definite voluntary muscle movement) after complete expulsion or extraction from its mother. - The descriptor "macerated" directly contradicts the definition of a live birth, as **maceration occurs post-mortem**. *Intrauterine Growth Restriction (IUGR)* - **IUGR** describes a fetus that has not reached its **growth potential** in utero. - While IUGR can be a risk factor for stillbirth, **maceration** itself is not a diagnostic feature of IUGR but rather a post-mortem finding.

Practice by Chapter

Fetal Assessment Techniques

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Hypertensive Disorders in Pregnancy

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Intrauterine Growth Restriction

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Multiple Gestation

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Rh Isoimmunization and Other Blood Group Incompatibilities

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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

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Management of Medical Disorders in Pregnancy

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