Maternal-Fetal Medicine Practice Questions

Q: What is the most important factor in the management of preeclampsia?

Severity of hypertension. **Explanation:** The management of preeclampsia is primarily dictated by the **severity of hypertension** and the **gestational age** of the fetus. The degree of blood pressure elevation is the most critical factor because it directly correlates with the risk of life-threatening maternal complications, such as cerebrovascular accidents (hemorrhagic stroke), placental abruption, and hypertensive encephalopathy. Management protocols (e.g., the decision to initiate antihypertensives like Labetalol or Hydralazine and the timing of delivery) are triggered by specific blood pressure thresholds (≥160/110 mmHg). **Analysis of Incorrect Options:** * **Proteinuria:** While essential for the classic diagnosis of preeclampsia, the *amount* of proteinuria does not correlate with clinical outcomes and is no longer used to define "severity" or guide management decisions according to ACOG and NHBPEP guidelines. * **Convulsions:** This defines **Eclampsia**. While critical, management aims to prevent this stage. Once convulsions occur, the diagnosis changes, and the management shifts to emergency seizure control (Magnesium Sulfate). * **Pedal Edema:** This is common in normal pregnancies and is no longer included in the diagnostic criteria for preeclampsia due to its lack of specificity. **Clinical Pearls for NEET-PG:** * **Target BP:** In severe preeclampsia, the goal is to maintain systolic BP between 140–150 mmHg and diastolic BP between 90–100 mmHg. * **Drug of Choice (DOC):** For seizure prophylaxis in preeclampsia with severe features is **Magnesium Sulfate** (Pritchard Regimen). * **Definitive Treatment:** Delivery of the fetus and placenta remains the only cure for preeclampsia. * **New Criteria:** Preeclampsia can now be diagnosed *without* proteinuria if other "severe features" (thrombocytopenia, renal insufficiency, liver dysfunction, or visual symptoms) are present.

Q: In the second trimester of pregnancy, the diagnosis of IUGR (Intrauterine Growth Restriction) is best made by assessing which of the following parameter?

Abdominal Circumference (AC). **Explanation:** The diagnosis of Intrauterine Growth Restriction (IUGR) relies on identifying a fetus that has failed to reach its biological growth potential. In the second and third trimesters, **Abdominal Circumference (AC)** is the single most sensitive and reliable parameter for diagnosing IUGR. **Why AC is the Correct Answer:** The AC reflects the size of the liver and the amount of subcutaneous fat. In cases of placental insufficiency (the primary cause of IUGR), the fetus undergoes "brain-sparing," where blood flow is diverted away from the viscera to the brain. This leads to a depletion of glycogen stores in the liver and a reduction in abdominal fat, making the AC the first biometric parameter to lag. An AC below the 10th percentile is the hallmark of growth restriction. **Analysis of Incorrect Options:** * **Biparietal Diameter (BPD) & Head Circumference (HC):** Due to the brain-sparing effect, the head size is often preserved until the very late stages of growth restriction (Asymmetric IUGR). Therefore, these are poor indicators for diagnosing IUGR but are useful for calculating the HC/AC ratio. * **Femur Length (FL):** Skeletal growth is generally less affected by nutritional status than soft tissue. While FL is used to estimate fetal weight, it is not a sensitive marker for growth restriction. **Clinical Pearls for NEET-PG:** * **Best parameter for Gestational Age (GA) estimation:** Crown-Rump Length (CRL) in the 1st trimester. * **Best parameter for GA estimation in 2nd trimester:** Biparietal Diameter (BPD). * **Most sensitive indicator of IUGR:** Abdominal Circumference (AC). * **Most sensitive index for Asymmetric IUGR:** HC/AC ratio (it increases in IUGR). * **Ponderal Index:** Used to differentiate between Symmetrical and Asymmetric IUGR.

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: What is the utility of Doppler ultrasonography in the management of twin pregnancies?

All of the above. **Explanation:** Doppler ultrasonography is an indispensable tool in the management of multiple gestations, particularly in assessing hemodynamic changes and placental complications. * **Option A (TTTS):** In Monochorionic Diamniotic (MCDA) twins, Doppler is the gold standard for monitoring Twin-to-Twin Transfusion Syndrome. It evaluates the **Umbilical Artery (UA)**, **Ductus Venosus (DV)**, and **Middle Cerebral Artery (MCA)** to stage the severity (Quintero Staging) and guide interventions like fetoscopic laser photocoagulation. * **Option B (Conjoined Twins):** Doppler is critical in evaluating conjoined twins to determine the extent of shared vascular supply and organ fusion (especially cardiac and hepatic vessels). This assessment is vital for determining viability and planning surgical separation. * **Option C (Chorionicity/Amnionicity):** While B-mode ultrasound identifies the "Lambda" or "T" sign, Doppler helps confirm chorionicity by visualizing placental vascular architecture and the number of yolk sacs/vessels in the cord, which is the most important prognostic factor in twin pregnancies. **Clinical Pearls for NEET-PG:** * **T-sign vs. Lambda sign:** The Lambda (λ) sign indicates Dichorionic twins, while the T-sign indicates Monochorionic twins. * **Twin Anemia Polycythemia Sequence (TAPS):** Diagnosed using **MCA-PSV** (Peak Systolic Velocity) Doppler; look for >1.5 MoM in the donor and <1.0 MoM in the recipient. * **Selective Fetal Growth Restriction (sFGR):** Doppler assessment of the umbilical artery (persistent absent or reversed end-diastolic flow) is used to classify sFGR into Types I, II, and III.

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: What is the gestational age threshold for defining early fetal death?

Less than 20 weeks. **Explanation:** The definition of fetal death is categorized based on the gestational age and weight of the fetus. According to standard obstetric guidelines (ACOG and WHO), **early fetal death** (often synonymous with spontaneous abortion or miscarriage) is defined as the death of a fetus **less than 20 weeks** of gestation or a birth weight of less than 500 grams. * **Why Option B is Correct:** The 20-week threshold is the internationally recognized clinical cutoff. Before this point, the fetus is generally not considered viable. Death occurring at or after 20 weeks is classified as late fetal death or **stillbirth**. * **Why Options A, C, and D are Incorrect:** * **Option A (10 weeks):** While many miscarriages occur before 10 weeks (embryonic period), this is not the formal threshold for defining early fetal death. * **Option C (Less than 28 weeks):** In many developing countries and older classifications, 28 weeks was used as the limit of viability. However, for NEET-PG purposes and modern standards, 20 weeks is the primary benchmark for "early" death. * **Option D (Greater than 20 weeks):** This defines **Intermediate/Late Fetal Death** (Stillbirth), not early fetal death. **High-Yield Clinical Pearls for NEET-PG:** * **Stillbirth:** Fetal death at $\geq$ 20 weeks or $\geq$ 500g. * **Perinatal Period:** Starts at 22 completed weeks (154 days) of gestation and ends 7 completed days after birth. * **Most common cause of early fetal death:** Chromosomal abnormalities (Autosomal trisomies being the most frequent). * **Legal Tip:** In India, the Medical Termination of Pregnancy (MTP) Act now allows termination up to 24 weeks for specific categories, but the biological definition of early fetal death remains <20 weeks.

Q: Hydrops fetalis is associated with which of the following?

Parvovirus B19. **Explanation:** **Hydrops Fetalis** is defined as the abnormal accumulation of fluid in at least two fetal compartments (e.g., ascites, pleural effusion, pericardial effusion, or skin edema). **Why Parvovirus B19 is correct:** Parvovirus B19 is the most common viral cause of non-immune hydrops fetalis. The virus has a specific tropism for **erythroid progenitor cells** (via the P-antigen receptor). It inhibits erythropoiesis, leading to **aplastic anemia**. The resulting profound fetal anemia causes high-output cardiac failure, which leads to hepatic congestion, decreased albumin production, and subsequent fluid extravasation (hydrops). **Why other options are incorrect:** * **Hepatitis B:** While it can be transmitted vertically (HBsAg+ mothers), it is typically asymptomatic in the fetus and does not cause structural anomalies or hydrops. * **Malaria:** Maternal malaria (especially *P. falciparum*) is associated with placental insufficiency, low birth weight, and intrauterine growth restriction (IUGR), but not typically hydrops. * **Tuberculosis:** Congenital TB is rare and usually presents postnatally with hepatosplenomegaly and respiratory distress, rather than hydrops. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of Hydrops:** Historically Rh-isoimmunization (Immune); currently, **Non-immune Hydrops (NIHF)** is more common due to RhoGAM. * **Diagnosis:** Ultrasound is the gold standard. **Middle Cerebral Artery (MCA) Peak Systolic Velocity** is the best non-invasive screening tool to detect fetal anemia. * **Management:** If hydrops is due to Parvovirus, the treatment of choice is **Intrauterine Blood Transfusion (IUT)**. * **Mirror Syndrome:** A rare condition where the mother "mirrors" the fetal hydrops, developing edema and preeclampsia-like symptoms.

Q: In a case of ectopic pregnancy, medical treatment is contraindicated if?

Significant hemoperitoneum is present. **Explanation:** Medical management of ectopic pregnancy, primarily using **Methotrexate**, is reserved for hemodynamically stable patients. The presence of **significant hemoperitoneum** (Option C) indicates a ruptured ectopic pregnancy or active internal bleeding. This is a surgical emergency requiring immediate laparoscopy or laparotomy; medical management in this scenario is strictly contraindicated as it would delay life-saving intervention. **Analysis of Incorrect Options:** * **Option A (Sac size 3.0 cm):** Medical management is generally considered appropriate if the gestational sac diameter is ** 1500 mIU/ml):** While success rates are higher when hCG is low, the traditional cutoff for contraindication is **> 5000 mIU/ml**. A level of 1500 mIU/ml is well within the range for medical therapy. * **Option D (Absent fetal activity):** The **presence** of fetal cardiac activity is a relative contraindication to medical management (as it predicts a higher failure rate). Its absence actually makes the patient a *better* candidate for Methotrexate. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications to Methotrexate:** Hemodynamic instability, signs of rupture (hemoperitoneum), breastfeeding, immunodeficiency, and significant hepatic/renal/hematologic dysfunction. * **Ideal Candidate:** Hemodynamically stable, hCG < 5000 mIU/ml, sac size < 3.5 cm, and no fetal cardiac activity. * **Dosing:** Most commonly the **Single-dose regimen** (50 mg/m² IM). * **Monitoring:** hCG levels are measured on Day 4 and Day 7. A drop of **≥ 15%** between Day 4 and 7 indicates success.

Question 1

What is the most important factor in the management of preeclampsia?

Accepted Answer

Severity of hypertension

Answer

Proteinuria

Answer

Convulsions

Answer

Pedal edema

Question 2

In the second trimester of pregnancy, the diagnosis of IUGR (Intrauterine Growth Restriction) is best made by assessing which of the following parameter?

Accepted Answer

Abdominal Circumference (AC)

Answer

Head Circumference (HC)

Answer

Biparietal Diameter (BPD)

Answer

Femur Length (FL)

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

Pregnancy is better avoided in all of the following congenital heart diseases, EXCEPT:

Accepted Answer

Mitral stenosis

Answer

Cyanotic heart disease

Answer

Pulmonary hypertension

Answer

Marfan syndrome with a dilated aortic root

Question 5

What is the utility of Doppler ultrasonography in the management of twin pregnancies?

Accepted Answer

All of the above

Answer

Monitoring for twin-to-twin transfusion syndrome

Answer

Assessing the viability and separation of conjoined twins

Answer

Confirming the presence and chorionicity/amnionicity of twin gestations

Question 6

Placenta previa should be suspected in the 3rd trimester in case of?

Accepted Answer

Painless vaginal bleeding

Answer

Unengaged head

Answer

Painful uterine bleeding

Answer

Painful vaginal bleeding

Question 7

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 8

What is the gestational age threshold for defining early fetal death?

Accepted Answer

Less than 20 weeks

Answer

10 weeks

Answer

Less than 28 weeks

Answer

Greater than 20 weeks

Question 9

Hydrops fetalis is associated with which of the following?

Accepted Answer

Parvovirus B19

Answer

Hepatitis B

Answer

Malaria

Answer

Tuberculosis

Question 10

In a case of ectopic pregnancy, medical treatment is contraindicated if?

Accepted Answer

Significant hemoperitoneum is present

Answer

Sac size is 3.0 cm

Answer

Serum HCG levels > 1500 miu/ml

Answer

Absent fetal activity

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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