Maternal-Fetal Medicine Practice Questions

Q: A 35-week multigravida presents with epigastric pain, headache, visual symptoms, and proteinuria of 3+. What is the next step in management?

Start magnesium sulfate therapy. ### Explanation **Correct Answer: D. Start magnesium sulfate therapy** The patient presents with **Severe Preeclampsia** (35 weeks gestation, proteinuria, and "imminent symptoms" like epigastric pain, headache, and visual disturbances). These symptoms indicate cerebral and hepatic involvement, signaling an extremely high risk of progressing to **Eclampsia** (seizures). In any case of severe preeclampsia or eclampsia, the **immediate priority is stabilization**. Magnesium sulfate ($MgSO_4$) is the drug of choice for seizure prophylaxis and treatment. According to standard protocols (Pritchard or Zuspan), stabilization with $MgSO_4$ and blood pressure control must occur *before* proceeding to delivery, regardless of the planned mode of birth. **Why other options are incorrect:** * **A & C:** While delivery is the definitive treatment for preeclampsia, it should only be initiated *after* the mother is stabilized with $MgSO_4$. The mode of delivery (C-section vs. Induction) depends on obstetric indications (e.g., Bishop’s score, fetal distress); severe preeclampsia itself is not an absolute indication for a Cesarean section. * **B:** While steroids are indicated for fetal lung maturity before 34 weeks, this patient is at **35 weeks**. Furthermore, in the presence of "imminent symptoms," stabilization and delivery take precedence over waiting 48 hours for steroid efficacy. **Clinical Pearls for NEET-PG:** * **Drug of Choice for Seizures:** Magnesium sulfate (Superior to Diazepam/Phenytoin). * **Therapeutic Range:** 4–7 mEq/L. * **First Sign of Toxicity:** Loss of Patellar Reflex (Knee jerk) at 7–10 mEq/L. * **Antidote:** 10 ml of 10% Calcium Gluconate (administered IV over 10 mins). * **Management Goal:** In severe preeclampsia >34 weeks, stabilize and deliver. If <34 weeks and stable, conservative management can be considered.

Q: What is the single best prognostic indicator of successful treatment with single-dose Methotrexate?

Serum b-hCG level. **Explanation:** The primary goal of medical management in ectopic pregnancy is to inhibit the rapidly dividing trophoblastic cells. **Serum β-hCG level** is the single most important predictor of treatment success with Methotrexate (MTX). 1. **Why Serum β-hCG is the best indicator:** MTX is a folic acid antagonist that inhibits DNA synthesis. Its efficacy is directly related to the metabolic activity and volume of the trophoblastic tissue. Higher baseline β-hCG levels reflect a higher trophoblastic load and a greater risk of treatment failure or tubal rupture. Success rates are >90% when β-hCG is 3.5–4 cm is a relative contraindication, it is less predictive of success than the biochemical activity (hCG). * **Absence of fetal cardiac activity (C):** The presence of cardiac activity is a contraindication to MTX because it indicates advanced development and a high failure rate, but among patients who meet the criteria, the baseline hCG level remains the superior prognostic tool. * **Pain abdomen (D):** This is a clinical symptom. While severe pain may suggest rupture (a contraindication), it is subjective and not a quantitative prognostic indicator. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Candidate for MTX:** Hemodynamically stable, β-hCG 15% decline** between Day 4 and Day 7 indicates successful treatment. * **Contraindications:** Breastfeeding, immunodeficiency, or significant hepatic/renal/pulmonary disease.

Q: Which of the following conditions carries the highest relative risk for placental abruption?

Prior abruption. **Explanation:** Placental abruption (abruptio placentae) is the premature separation of a normally situated placenta. While its etiology is often multifactorial, the most significant risk factor is a history of the condition in a previous pregnancy. **1. Why "Prior Abruption" is Correct:** A history of prior abruption carries the **highest relative risk (RR)**, ranging from **10 to 15 times** higher than the general population. If a woman has had two prior abruptions, the risk of recurrence jumps to approximately 20-25%. This is due to underlying chronic vascular or genetic predispositions that persist across pregnancies. **2. Analysis of Incorrect Options:** * **Chorioamnionitis:** While intra-amniotic infection can lead to inflammation and trigger abruption, its relative risk is significantly lower than a prior history. * **Thrombophilia:** Inherited or acquired thrombophilias (like Factor V Leiden or APS) are associated with placental infarcts and abruption, but they are considered modest risk factors compared to the recurrence risk. * **Preterm Premature Rupture of Membranes (PPROM):** PPROM increases the risk of abruption (RR ~3-9) due to sudden uterine decompression or associated inflammation, but it remains secondary to the risk posed by a prior event. **Clinical Pearls for NEET-PG:** * **Most common risk factor:** Hypertension (Chronic or Gestational/Pre-eclampsia). * **Highest relative risk:** Prior placental abruption. * **Modifiable risk factors:** Smoking (doubles the risk) and Cocaine use (causes acute vasospasm). * **Classic Triad:** Painful vaginal bleeding, uterine tenderness (rigidity), and fetal distress. * **Couvelaire Uterus:** A complication where retroplacental blood infiltrates the myometrium, seen during C-section as a bluish/purplish discoloration.

Q: Which ultrasound finding has the highest association with aneuploidy?

Cystic hygroma. **Explanation:** **Cystic hygroma** is the correct answer because it has the strongest association with chromosomal abnormalities (aneuploidy) among the listed options. It is a congenital malformation of the lymphatic system, typically presenting as a fluid-filled sac in the posterior neck. Approximately **50-60%** of fetuses diagnosed with cystic hygroma in the first trimester have an underlying aneuploidy, most commonly **Turner syndrome (45,X)**, followed by Trisomy 21, 18, and 13. **Analysis of Incorrect Options:** * **Nuchal Translucency (NT):** While an increased NT is a major screening marker for Trisomy 21, it is often transient and can be seen in normal fetuses. Its association with aneuploidy is significant but statistically lower than that of a true cystic hygroma. * **Choroid Plexus Cyst (CPC):** These are considered "soft markers." While they are associated with Trisomy 18, the vast majority (over 95%) of CPCs occur in chromosomally normal fetuses and usually resolve by 26 weeks. * **Single Umbilical Artery (SUA):** This is the most common umbilical cord anomaly. While it increases the risk for renal and cardiac anomalies, its isolated presence has a very low correlation with aneuploidy. **Clinical Pearls for NEET-PG:** * **Turner Syndrome** is the most common association with cystic hygroma in the second trimester. * If a cystic hygroma is detected, the next best step is **karyotyping** (via CVS or Amniocentesis). * **Hydrops fetalis** often develops as a complication of cystic hygroma, leading to a poor prognosis.

Q: All of the following factors are used to assess intrauterine growth retardation, EXCEPT?

Fetal movements. **Explanation:** The diagnosis and assessment of **Intrauterine Growth Restriction (IUGR)** rely on objective measurements of fetal size and growth velocity. **Why Fetal Movements is the Correct Answer:** Fetal movements (Kick counts) are a subjective measure of **fetal well-being** and placental function, rather than a parameter for assessing growth. While a decrease in movements may indicate fetal distress in a growth-restricted fetus, it does not help in diagnosing or quantifying the degree of growth retardation itself. **Analysis of Incorrect Options:** * **Fundal Height:** This is the primary **clinical screening tool**. A symphysis-fundal height (SFH) lag of more than 3 cm compared to the gestational age suggests IUGR. * **Abdominal Circumference (AC):** This is the **most sensitive** sonographic parameter for diagnosing IUGR. Since the liver is the first organ to be affected by malnutrition (depletion of glycogen stores), the AC reduces significantly. * **Head Size (Biparietal Diameter/Head Circumference):** These are used to differentiate between **Symmetrical** (small head) and **Asymmetrical** (head-sparing) IUGR. The HC/AC ratio is a classic marker used in this assessment. **High-Yield Clinical Pearls for NEET-PG:** * **Best parameter for IUGR:** Abdominal Circumference (AC). * **Best parameter for Gestational Age:** Crown-Rump Length (CRL) in the 1st trimester. * **Ponderal Index:** Used to identify malnourished fetuses (Asymmetrical IUGR). * **Gold Standard for Monitoring:** Doppler Velocimetry (specifically the Umbilical Artery) is the best tool to manage IUGR and decide the timing of delivery.

Q: What is the investigation of choice for recurrent abortion in the first trimester?

Karyotyping. **Explanation:** Recurrent pregnancy loss (RPL) is defined as two or more consecutive spontaneous abortions. In the **first trimester**, the most common cause of sporadic miscarriage is chromosomal abnormalities. When these losses become recurrent, parental chromosomal anomalies (most commonly **balanced reciprocal translocations**) are a significant underlying factor. **1. Why Karyotyping is the Investigation of Choice:** Parental **Karyotyping** is the gold standard investigation to identify structural chromosomal rearrangements. If one parent carries a balanced translocation, they are phenotypically normal but produce unbalanced gametes, leading to recurrent embryonic aneuploidy and subsequent first-trimester loss. **2. Analysis of Incorrect Options:** * **SLE antibodies (Antiphospholipid Antibodies):** While Antiphospholipid Syndrome (APLAs) is a major cause of RPL, it is more classically associated with second-trimester losses or specific late-term complications (though it can cause early loss). Karyotyping remains the primary genetic screen for early-first-trimester recurrence. * **HIV testing:** HIV is not a recognized cause of recurrent pregnancy loss. * **TORCH infection screening:** This is a common misconception. TORCH infections (Toxoplasmosis, Rubella, CMV, Herpes) cause **sporadic** fetal loss or malformations, but they do **not** cause recurrent abortions because the mother develops immunity after the initial infection. **Clinical Pearls for NEET-PG:** * **Most common cause of 1st-trimester abortion:** Fetal chromosomal anomaly (Autosomal trisomy is the most common; specifically Trisomy 16). * **Most common parental anomaly in RPL:** Balanced reciprocal translocation. * **Uterine causes:** Septate uterus is the most common uterine anomaly associated with RPL. * **Investigation Timing:** Karyotyping should be performed on both parents and, if possible, the products of conception (POC).

Q: Which of the following maternal factors is most commonly associated with first-trimester pregnancy loss?

Advanced maternal age. **Explanation:** **1. Why Advanced Maternal Age (AMA) is the correct answer:** Advanced maternal age (typically defined as ≥35 years) is the most significant maternal risk factor for first-trimester pregnancy loss. The underlying medical concept is the **decline in oocyte quality and quantity**. As maternal age increases, there is a higher incidence of **meiotic non-disjunction**, leading to fetal chromosomal abnormalities (aneuploidies). Since approximately 50–70% of all first-trimester miscarriages are caused by chromosomal anomalies (most commonly autosomal trisomies), AMA directly correlates with the highest risk of loss. **2. Why the other options are incorrect:** * **Incompetent Cervix:** This is a classic cause of **second-trimester** (mid-trimester) pregnancy loss, characterized by painless cervical dilatation and membrane prolapse, rather than first-trimester loss. * **Intrauterine Infection:** While infections (like TORCH or bacterial vaginosis) can cause sporadic loss, they are much less common than chromosomal causes in the first trimester. * **Hyperemesis Gravidarum:** This condition involves severe nausea and vomiting. While it can lead to maternal dehydration and electrolyte imbalance, it is generally associated with *favorable* pregnancy outcomes and is not a cause of miscarriage. **3. NEET-PG High-Yield Pearls:** * **Most common cause of 1st-trimester miscarriage:** Fetal chromosomal anomalies (Aneuploidy). * **Most common specific chromosomal anomaly:** Autosomal Trisomy (Trisomy 16 is the most common specific trisomy found in abortuses). * **Most common single chromosomal anomaly:** Monosomy X (Turner Syndrome, 45,X). * **Risk of miscarriage:** At age 20-24, the risk is ~10%; by age 45, the risk exceeds 50-75%.

Q: A 32-year-old primigravida, at 35 weeks gestation, is admitted to the antenatal ward. Her blood pressure is found to be 160/110 mmHg, and her urine does not contain albumin. Which of the following drugs should not be used in her management?

Furosemide. ### Explanation **Correct Option: A (Furosemide)** The patient presents with **Severe Gestational Hypertension** (BP ≥160/110 mmHg without proteinuria). In hypertensive disorders of pregnancy (HDP), there is a paradoxical state of **pathological plasma volume contraction** despite systemic edema. **Furosemide (a loop diuretic)** is generally contraindicated because it further depletes intravascular volume, leading to decreased placental perfusion and potential fetal compromise. Diuretics are strictly reserved for specific complications like **acute pulmonary edema** or congestive heart failure in pregnancy. **Analysis of Incorrect Options:** * **B. Hydralazine:** A potent vasodilator used frequently in the acute management of severe hypertension in pregnancy (hypertensive crisis). It is a safe and effective second-line agent. * **C. Labetalol:** A combined alpha and beta-blocker. It is considered the **first-line intravenous drug** for the acute management of severe hypertension in pregnancy due to its rapid onset and favorable safety profile. * **D. Methyldopa:** A centrally acting alpha-2 agonist. It is the **drug of choice for chronic hypertension** in pregnancy due to its long-term safety record, though it is less effective for acute hypertensive emergencies due to its slow onset of action. **NEET-PG High-Yield Pearls:** * **Drug of Choice (DOC) for Chronic Hypertension in Pregnancy:** Methyldopa. * **DOC for Acute Hypertensive Crisis in Pregnancy:** IV Labetalol (Hydralazine is an alternative). * **DOC for Eclampsia Prophylaxis/Treatment:** Magnesium Sulfate ($MgSO_4$). * **ACE Inhibitors/ARBs:** Strictly contraindicated in pregnancy (cause fetal renal dysgenesis and skull defects). * **Target BP in Pregnancy:** Aim to maintain Systolic 140–150 mmHg and Diastolic 90–100 mmHg to prevent maternal cerebrovascular accidents without compromising placental blood flow.

Question 1

A 35-week multigravida presents with epigastric pain, headache, visual symptoms, and proteinuria of 3+. What is the next step in management?

Accepted Answer

Start magnesium sulfate therapy

Answer

Immediate cesarean section

Answer

Betamethasone for fetal lung maturity

Answer

Induction of labor for vaginal delivery

Question 2

A 4-month pregnant lady on regular treatment with valproate asks for advice regarding continuing the drug during pregnancy. What is the best course of action?

Accepted Answer

Change to carbamazepine

Answer

Immediately stop valproate and start lamotrigine

Answer

Continue valproate and monitor blood levels

Answer

Slowly taper the dose of valproate

Question 3

What is the single best prognostic indicator of successful treatment with single-dose Methotrexate?

Accepted Answer

Serum b-hCG level

Answer

Gestational sac size

Answer

Absence of fetal cardiac activity

Answer

Pain abdomen

Question 4

A young lady presents with acute abdominal pain and a history of 1 1/2 months of amenorrhea. On ultrasound examination, there is a collection of fluid in the pouch of Douglas and an empty gestational sac. What is the most likely diagnosis?

Accepted Answer

Ectopic pregnancy

Answer

Pelvic hematocele

Answer

Threatened abortion

Answer

Twisted ovarian cyst

Question 5

Which of the following conditions carries the highest relative risk for placental abruption?

Accepted Answer

Prior abruption

Answer

Chorioamnionitis

Answer

Thrombophilia

Answer

Preterm rupture of membranes

Question 6

Which ultrasound finding has the highest association with aneuploidy?

Accepted Answer

Cystic hygroma

Answer

Choroid plexus cyst

Answer

Nuchal translucency

Answer

Single umbilical artery

Question 7

All of the following factors are used to assess intrauterine growth retardation, EXCEPT?

Accepted Answer

Fetal movements

Answer

Head size

Answer

Fundal height

Answer

Abdominal circumference

Question 8

What is the investigation of choice for recurrent abortion in the first trimester?

Accepted Answer

Karyotyping

Answer

Systemic Lupus Erythematosus (SLE) antibodies

Answer

Human Immunodeficiency Virus (HIV) testing

Answer

TORCH infection screening

Question 9

Which of the following maternal factors is most commonly associated with first-trimester pregnancy loss?

Accepted Answer

Advanced maternal age

Answer

Incompetent cervix

Answer

Intrauterine infection

Answer

Hyperemesis gravidarum

Question 10

A 32-year-old primigravida, at 35 weeks gestation, is admitted to the antenatal ward. Her blood pressure is found to be 160/110 mmHg, and her urine does not contain albumin. Which of the following drugs should not be used in her management?

Accepted Answer

Furosemide

Answer

Hydralazine

Answer

Labetalol

Answer

Methyldopa

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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