Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 161: What is the most important factor in the management of preeclampsia?

A. Severity of hypertension (Correct Answer)
B. Proteinuria
C. Convulsions
D. Pedal edema

Explanation: **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.

Question 162: In the second trimester of pregnancy, the diagnosis of IUGR (Intrauterine Growth Restriction) is best made by assessing which of the following parameter?

A. Head Circumference (HC)
B. Abdominal Circumference (AC) (Correct Answer)
C. Biparietal Diameter (BPD)
D. Femur Length (FL)

Explanation: **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.

Question 163: What is the single best prognostic indicator of successful treatment with single-dose Methotrexate?

A. Gestational sac size
B. Serum b-hCG level (Correct Answer)
C. Absence of fetal cardiac activity
D. Pain abdomen

Explanation: **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 <2000 mIU/mL, but they drop significantly as levels rise above 5000 mIU/mL. 2. **Analysis of Incorrect Options:** * **Gestational sac size (A):** While a sac size >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 <5000 mIU/mL, no fetal cardiac activity, and sac size <4 cm. * **Dose:** 50 mg/m² (Single-dose regimen). * **Monitoring:** Measure β-hCG on Day 4 and Day 7. A **>15% decline** between Day 4 and Day 7 indicates successful treatment. * **Contraindications:** Breastfeeding, immunodeficiency, or significant hepatic/renal/pulmonary disease.

Question 164: Pregnancy is better avoided in all of the following congenital heart diseases, EXCEPT:

A. Cyanotic heart disease
B. Pulmonary hypertension
C. Marfan syndrome with a dilated aortic root
D. Mitral stenosis (Correct Answer)

Explanation: **Explanation:** In maternal-fetal medicine, cardiac conditions are classified by the **WHO Maternal Cardiovascular Risk** criteria. Pregnancy is generally contraindicated (WHO Class IV) in conditions where the risk of maternal mortality is extremely high (25–50%). **Why Mitral Stenosis (MS) is the correct answer:** While Mitral Stenosis is the most common valvular lesion in pregnancy (often due to Rheumatic Heart Disease), it is **not** an absolute contraindication to pregnancy. Most patients with mild-to-moderate MS can be managed medically with beta-blockers and diuretics. If the stenosis is severe and symptomatic, interventions like **Percutaneous Transvenous Mitral Commisurotomy (PTMC)** can be safely performed during pregnancy (ideally in the second trimester). **Why the other options are contraindicated:** * **Pulmonary Hypertension (e.g., Eisenmenger Syndrome):** This carries the highest risk of maternal mortality (up to 50%). The inability of the pulmonary vasculature to adapt to the 50% increase in cardiac output during pregnancy leads to right heart failure and sudden death. * **Cyanotic Heart Disease (Uncorrected):** Chronic hypoxia leads to poor maternal outcomes and high rates of fetal growth restriction and loss. If the oxygen saturation is <85%, pregnancy is strongly discouraged. * **Marfan Syndrome with Dilated Aortic Root:** If the aortic root diameter exceeds **4 cm (or 4.5 cm)**, there is a high risk of aortic dissection or rupture during pregnancy due to the hyperdynamic circulation and hormonal changes affecting the vessel wall. **High-Yield NEET-PG Pearls:** * **Most common cause of heart disease in pregnancy:** Rheumatic Heart Disease (Mitral Stenosis is the most common lesion). * **Most common congenital heart disease in pregnancy:** ASD (Atrial Septal Defect). * **Highest risk period for heart failure:** Immediate postpartum (due to "autotransfusion" from the uterus and relief of IVC compression). * **Absolute Contraindications (WHO Class IV):** Pulmonary HTN, Severe Systemic Ventricular Dysfunction (EF <30%), Previous Peripartum Cardiomyopathy with residual dysfunction, and Severe Aortic Coarctation.

Question 165: What is the utility of Doppler ultrasonography in the management of twin pregnancies?

A. Monitoring for twin-to-twin transfusion syndrome
B. Assessing the viability and separation of conjoined twins
C. Confirming the presence and chorionicity/amnionicity of twin gestations
D. All of the above (Correct Answer)

Explanation: **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.

Question 166: Placenta previa should be suspected in the 3rd trimester in case of?

A. Painless vaginal bleeding (Correct Answer)
B. Unengaged head
C. Painful uterine bleeding
D. Painful vaginal bleeding

Explanation: **Explanation:** **Placenta Previa** is defined as the implantation of the placenta in the lower uterine segment, over or near the internal os. It is the most common cause of antepartum hemorrhage (APH) in the third trimester. **1. Why "Painless vaginal bleeding" is correct:** The hallmark clinical feature of placenta previa is **painless, causative-less, and recurrent vaginal bleeding**. As the lower uterine segment stretches and thins out during the third trimester, the inelastic placenta separates from its attachment, leading to the opening of uterine-placental sinuses. Because this process is physiological and not associated with uterine hypertonicity or trauma, the bleeding is characteristically painless. **2. Why the other options are incorrect:** * **Unengaged head (Option B):** While an unengaged head or malpresentation (like transverse or breech) is a common *finding* in placenta previa because the placenta occupies the lower segment, it is not the primary clinical symptom that leads to a *suspicion* of the diagnosis. * **Painful uterine/vaginal bleeding (Options C & D):** Painful bleeding is the classic presentation of **Abruptio Placentae** (premature separation of a normally situated placenta). In abruption, the pain is caused by retroplacental hematoma formation and uterine contractions/tetany. **NEET-PG High-Yield Pearls:** * **The "Golden Rule":** Never perform a digital vaginal examination (P/V) in a case of APH until placenta previa is ruled out by ultrasound, as it can provoke torrential hemorrhage (Stallworthy's sign). * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pressed into the pelvic inlet, suggesting a posterior placenta previa. * **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the gold standard for localization (safer and more accurate than transabdominal). * **Management:** If the patient is stable and <37 weeks, follow the **MacAfee & Johnson regimen** (expectant management).

Question 167: Which of the following conditions carries the highest relative risk for placental abruption?

A. Chorioamnionitis
B. Thrombophilia
C. Prior abruption (Correct Answer)
D. Preterm rupture of membranes

Explanation: **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.

Question 168: What is the gestational age threshold for defining early fetal death?

A. 10 weeks
B. Less than 20 weeks (Correct Answer)
C. Less than 28 weeks
D. Greater than 20 weeks

Explanation: **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.

Question 169: Hydrops fetalis is associated with which of the following?

A. Hepatitis B
B. Parvovirus B19 (Correct Answer)
C. Malaria
D. Tuberculosis

Explanation: **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.

Question 170: In a case of ectopic pregnancy, medical treatment is contraindicated if?

A. Sac size is 3.0 cm
B. Serum HCG levels > 1500 miu/ml
C. Significant hemoperitoneum is present (Correct Answer)
D. Absent fetal activity

Explanation: **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 **< 3.5 cm or 4 cm**. A 3.0 cm sac falls within the eligible criteria. * **Option B (Serum HCG > 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.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

Practice Questions

Multiple Gestation

Practice Questions

Rh Isoimmunization and Other Blood Group Incompatibilities

Practice Questions

Intrauterine Fetal Therapy

Practice Questions

Prenatal Diagnosis and Genetic Counseling

Practice Questions

Placental Abnormalities

Practice Questions

Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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