Maternal-Fetal Medicine Practice Questions

Q: Presence of gas in the great vessels of a fetus indicates which of the following?

Fetal death. **Explanation:** The presence of gas in the fetal heart or great vessels (aorta and vena cava) is known as **Robert’s Sign**. This is a classic radiological sign of **intrauterine fetal death (IUFD)**. **Why it occurs:** When a fetus dies, the blood undergoes decomposition and fermentation. This process releases gases (primarily nitrogen, along with some oxygen and carbon dioxide) into the circulatory system. On an X-ray or ultrasound, this appears as linear or branching radiolucency within the fetal trunk. It is one of the earliest signs of fetal death, often appearing within 12 to 24 hours after cessation of the fetal heartbeat. **Analysis of Incorrect Options:** * **A. Fetal distress:** This is a clinical state of hypoxia during labor or pregnancy, usually diagnosed via abnormal fetal heart rate patterns or biophysical profile. It does not involve gas formation. * **B & D. Postmature/Premature fetus:** These terms refer to the gestational age of the fetus (post-term vs. pre-term). Neither condition causes spontaneous gas formation in the vessels unless fetal death has occurred. **High-Yield Clinical Pearls for NEET-PG:** * **Robert’s Sign:** Gas in the fetal great vessels (earliest sign, ~12 hours). * **Spalding’s Sign:** Overlapping of fetal skull bones due to liquefaction of the brain and loss of alignment (appears after 4–7 days). * **Deuel’s Halo Sign:** Elevation of the fetal scalp fat due to edema, creating a "halo" appearance. * **Curvature of the Spine:** Excessive angulation or collapse of the fetal spine due to loss of muscle tone. * **Gold Standard:** Today, the definitive diagnosis of IUFD is made via **ultrasound** by demonstrating the absence of fetal cardiac activity.

Q: Which of the following conditions is NOT associated with twin pregnancy?

Oligohydramnios. In twin pregnancies, the physiological and mechanical demands on the mother and the fetuses are significantly increased, leading to specific complications. **Why Oligohydramnios is the Correct Answer:** Twin pregnancy is typically associated with **Polyhydramnios** (excess amniotic fluid), not oligohydramnios. This occurs due to increased fetal urine production from two fetuses and is especially common in Monochorionic Diamniotic (MCDA) twins as a component of Twin-to-Twin Transfusion Syndrome (TTTS), where the recipient twin develops polyhydramnios. While oligohydramnios can occur in the "stuck twin" (donor) in TTTS, it is a complication of the *syndrome*, whereas the pregnancy as a whole is classically associated with an increased total liquor volume. **Explanation of Incorrect Options:** * **Pre-eclampsia:** The risk is 2–3 times higher in multifetal gestations due to increased placental mass and higher levels of anti-angiogenic factors (sFlt-1). * **Antepartum Hemorrhage (APH):** There is an increased risk of both **Placenta Previa** (due to the larger surface area of the placenta(s) encroaching on the lower segment) and **Abruptio Placentae** (often following the sudden decompression after the birth of the first twin). * **Atonic Uterus:** Overdistension of the myometrium by multiple fetuses and polyhydramnios leads to poor uterine contractility after delivery, making **Postpartum Hemorrhage (PPH)** a major risk. **NEET-PG High-Yield Pearls:** * **Most common complication:** Anemia (Iron deficiency). * **Most common fetal complication:** Prematurity. * **TTTS:** Occurs only in Monochorionic twins; characterized by "Poly-Oli" sequence (Polyhydramnios in recipient, Oligohydramnios in donor). * **Weight gain:** Recommended weight gain for a normal BMI woman with twins is 17–25 kg.

Q: All of the following are predictors of preeclampsia except?

Shake test. **Explanation:** The **Shake Test** (also known as the Foam Stability Index) is a bedside test used to assess **fetal lung maturity**, not to predict preeclampsia. It involves mixing amniotic fluid with 95% ethanol and shaking it; the persistence of a ring of bubbles at the air-liquid interface indicates the presence of sufficient surfactant to prevent Respiratory Distress Syndrome (RDS). **Analysis of Predictors of Preeclampsia:** * **Roll-over Test:** This is a clinical screening test performed between 28–32 weeks of gestation. A rise in diastolic blood pressure of **>15 mmHg** when the patient moves from a left lateral to a supine position indicates a positive test and increased risk for preeclampsia. * **Serum Uric Acid:** Hyperuricemia (due to decreased renal clearance) is one of the earliest biochemical markers of preeclampsia. While it has low sensitivity for prediction, it is a strong indicator of disease severity and fetal prognosis. * **Weight Gain:** Excessive weight gain (>2 kg/month or >0.5 kg/week) in the second trimester is often due to occult edema and fluid retention, serving as an early clinical warning sign before the onset of hypertension and proteinuria. **Clinical Pearls for NEET-PG:** * **Gold Standard for Prediction:** Uterine Artery Doppler (noting the presence of a **diastolic notch** at 20–24 weeks) is a highly specific predictor. * **Biochemical Markers:** Low levels of **PAPP-A** and **PlGF** (Placental Growth Factor), and high levels of **sFlt-1**, are modern predictive markers. * **Prophylaxis:** In patients with positive predictive tests, low-dose **Aspirin (150 mg)** started before 16 weeks reduces the risk of early-onset preeclampsia.

Q: Gas in the aorta after intrauterine fetal death (IUFD) is which sign?

Robert sign. **Explanation:** The correct answer is **Robert sign**. This sign refers to the presence of gas (usually carbon dioxide) within the fetal heart or large vessels, most commonly the **aorta**. It is one of the earliest radiological signs of intrauterine fetal death (IUFD), appearing as early as 12 hours after death. The gas is produced by the decomposition of fetal blood and is typically visualized on an X-ray or ultrasound. **Analysis of Incorrect Options:** * **Spalding sign:** This is the most famous radiological sign of IUFD. it refers to the **overlapping of fetal skull bones** caused by the liquefaction of the brain and loss of intracranial pressure. It usually takes 4–7 days after death to appear. * **Ball sign:** This refers to the **hyperflexion of the fetal spine**, resulting in a "balled-up" appearance. It occurs due to the loss of fetal muscle tone after death. * **Blair-Hartley sign:** This refers to the **constriction of the fetal thorax** or a "collapsed" chest wall, another secondary sign of maceration and loss of internal structural integrity. **NEET-PG High-Yield Pearls:** * **Earliest Sign:** Robert sign (12 hours) is seen earlier than Spalding sign (days). * **Gold Standard:** Today, the diagnosis of IUFD is confirmed via **Ultrasonography (USG)** by demonstrating the absence of fetal heart activity. * **Deuel’s Halo Sign:** Another sign of IUFD where a radiolucent halo appears around the fetal head due to edema of the scalp (subcutaneous fat). * **Clinical context:** Always check for maternal coagulation profile (Fibrinogen levels) if a dead fetus is retained for >4 weeks to monitor for Disseminated Intravascular Coagulation (DIC).

Q: All are true in HELLP syndrome except?

Develops only in cases of maternal hypertension. **Explanation:** HELLP syndrome is a severe multisystem complication, traditionally considered a variant of preeclampsia. The acronym stands for **H**emolysis, **E**levated **L**iver enzymes, and **L**ow **P**latelets. **Why Option D is the correct answer (the false statement):** While HELLP syndrome is strongly associated with preeclampsia, it **does not develop only in cases of maternal hypertension.** Approximately **15–20%** of patients with HELLP syndrome are normotensive and do not exhibit proteinuria at the time of diagnosis. This makes it a "great masquerader," as the absence of hypertension can lead to a dangerous delay in diagnosis. **Analysis of other options (True statements):** * **A. Hemolysis:** This is a hallmark feature, characterized by microangiopathic hemolytic anemia. Peripheral smears show **schistocytes** (fragmented RBCs) and helmet cells. Lab markers include elevated LDH (>600 U/L) and indirect bilirubin. * **B. Elevated Liver Enzymes:** This occurs due to periportal necrosis and hepatic sinusoids being obstructed by fibrin deposits. AST and ALT are typically elevated to ≥70 U/L. * **C. Low Platelets:** Thrombocytopenia (Platelets <100,000/mm³) results from increased platelet consumption and activation. **NEET-PG High-Yield Pearls:** * **Mississippi Classification:** Classifies HELLP based on the nadir of the platelet count (Class 1: <50k, Class 2: 50k–100k, Class 3: 100k–150k). * **Clinical Presentation:** The most common symptom is **epigastric or right upper quadrant pain** (due to Glisson’s capsule stretch). * **Definitive Treatment:** Delivery of the fetus (usually after 34 weeks or if maternal/fetal condition deteriorates). * **Complication:** Beware of **hepatic subcapsular hematoma**; sudden hypotension in a HELLP patient suggests rupture.

Q: A patient who is G3P2L2 with two previous lower segment cesarean sections presents to the OPD with placenta near the internal os. What is the greatest risk for this patient?

Adherent placenta. **Explanation:** The correct answer is **Adherent placenta** (Placenta Accreta Spectrum - PAS). **1. Why Adherent Placenta is correct:** The patient has two major risk factors for PAS: **previous cesarean sections** and **placenta previa** (placenta near the internal os). In a scarred uterus, the decidua basalis is often deficient. This allows the chorionic villi to invade directly into the myometrium. According to the Silver and Landon criteria, the risk of placenta accreta increases exponentially with the number of prior C-sections. For a patient with two previous C-sections and placenta previa, the risk of an adherent placenta is approximately **35–40%**. **2. Why other options are incorrect:** * **Placental abruption:** While previa is a risk factor for bleeding, the specific combination of a prior scar and overlying placenta is the classic triad for *invasion* (accreta), not premature *separation* (abruption). * **Vasa previa:** This involves fetal vessels crossing the internal os, usually associated with velamentous cord insertion or succenturiate lobes, not specifically with previous C-section scars. * **Preterm birth:** While common in previa due to iatrogenic delivery or bleeding, it is a *consequence* of the pathology, whereas adherent placenta is the primary *pathological risk* associated with the scar. **3. NEET-PG High-Yield Pearls:** * **Most important risk factor for PAS:** Previous C-section + Placenta Previa. * **Risk progression:** 1 prior C-section + previa (~11% risk); 2 prior C-sections + previa (~40% risk); 3 prior C-sections + previa (~61% risk). * **Gold Standard Diagnosis:** Antenatal Ultrasound/Color Doppler (look for "placental lacunae" and loss of the retroplacental hypoechoic zone). * **Management:** Planned multidisciplinary cesarean hysterectomy is often the treatment of choice.

Q: Which type of twins has the highest mortality?

Siamese twins. **Explanation:** The correct answer is **Siamese twins (Conjoined twins)**. **1. Why Siamese Twins have the highest mortality:** Conjoined twins represent the most extreme and rarest form of monozygotic twinning, occurring due to the incomplete division of the embryonic disc after day 13 of fertilization. They carry the highest mortality rate (up to 75-90%) due to several factors: * **Structural anomalies:** Shared vital organs (e.g., heart, liver, or brain) often make survival or surgical separation impossible. * **Prematurity:** Most are born preterm. * **Stillbirth:** Approximately 40-60% are stillborn. * **Obstetric complications:** High risk of birth trauma and dystocia during delivery. **2. Analysis of Incorrect Options:** * **Monoamniotic Monochorionic (MoMo):** While high-risk (mortality ~10-20%), the primary risks are cord entanglement and Twin-to-Twin Transfusion Syndrome (TTTS). Mortality is significantly lower than in conjoined twins. * **Diamniotic Dichorionic (DiDi):** These have the lowest risk among twins because each fetus has its own placenta and sac, preventing cord accidents and vascular shunting. * **Binovular twins:** Another term for Dizygotic (fraternal) twins. These are always dichorionic/diamniotic and carry the best prognosis. **3. NEET-PG High-Yield Pearls:** * **Timing of Division:** * 0–72 hours: Dichorionic Diamniotic (DiDi) * 4–8 days: Monochorionic Diamniotic (MoDi) — *Most common type of MZ twins.* * 8–13 days: Monochorionic Monoamniotic (MoMo) * >13 days: Conjoined twins. * **Most common type of conjoined twins:** Thoracopagus (joined at the chest). * **Diagnosis:** Best made via ultrasound in the first trimester (look for the "Lambda sign" in DiDi vs. "T-sign" in MoDi).

Question 1

Presence of gas in the great vessels of a fetus indicates which of the following?

Accepted Answer

Fetal death

Answer

Fetal distress

Answer

Postmature fetus

Answer

Premature fetus

Question 2

Which of the following conditions is NOT associated with twin pregnancy?

Accepted Answer

Oligohydramnios

Answer

Pre-eclampsia

Answer

Antepartum hemorrhage

Answer

Atonic uterus

Question 3

A 32-week pregnant woman, who was HBsAg positive during her first pregnancy 8 years ago, presents with normal LFT, HBsAg positive, HBeAg negative, and HBV DNA of 90,000 copies/ml. Her first child received hepatitis B immunoglobulin and vaccination shortly after birth and is currently HBsAg negative. Which of the following statements is true regarding this current scenario?

Accepted Answer

The patient can be monitored without antivirals, and the baby should receive immunoglobulin and active immunization soon after delivery.

Answer

There is a very high risk of hepatitis B transmission to the baby.

Answer

Entecavir is safe in pregnancy and should be started as early as possible for the mother.

Answer

Antiviral therapy against hepatitis B is contraindicated in pregnancy.

Question 4

A 30 weeks pregnant multigravida presents with hypertension, proteinuria, and pedal edema. Which antihypertensive medication is appropriate for managing the blood pressure in this patient?

Accepted Answer

Labetalol

Answer

Guanethidine

Answer

Atenolol

Answer

Captopril

Question 5

Routine pelvic examination is contraindicated in which of the following conditions?

Accepted Answer

Placenta previa

Answer

Carcinoma cervix

Answer

Cord prolapse

Answer

Pregnancy-induced hypertension

Question 6

All of the following are predictors of preeclampsia except?

Accepted Answer

Shake test

Answer

Roll over test

Answer

Serum uric acid

Answer

Weight gain > 2kg per month

Question 7

Gas in the aorta after intrauterine fetal death (IUFD) is which sign?

Accepted Answer

Robert sign

Answer

Spalding sign

Answer

Ball sign

Answer

Blair-Hartley sign

Question 8

All are true in HELLP syndrome except?

Accepted Answer

Develops only in cases of maternal hypertension

Answer

Hemolysis

Answer

Elevated liver enzymes

Answer

Low platelets

Question 9

A patient who is G3P2L2 with two previous lower segment cesarean sections presents to the OPD with placenta near the internal os. What is the greatest risk for this patient?

Accepted Answer

Adherent placenta

Answer

Placental abruption

Answer

Vasa previa

Answer

Preterm birth

Question 10

Which type of twins has the highest mortality?

Accepted Answer

Siamese twins

Answer

Monoamniotic monochorionic

Answer

Diamniotic dichorionic

Answer

Binovular twins

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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