Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 171: All of the following factors are used to assess intrauterine growth retardation, EXCEPT?

A. Fetal movements (Correct Answer)
B. Head size
C. Fundal height
D. Abdominal circumference

Explanation: **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.

Question 172: Which of the following maternal factors is most commonly associated with first-trimester pregnancy loss?

A. Advanced maternal age (Correct Answer)
B. Incompetent cervix
C. Intrauterine infection
D. Hyperemesis gravidarum

Explanation: **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%.

Question 173: 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?

A. Furosemide (Correct Answer)
B. Hydralazine
C. Labetalol
D. Methyldopa

Explanation: ### 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 174: What is the treatment of choice for an unruptured tubal pregnancy with a serum p-hCG titre of 2000 IU/mL?

A. Single dose of methotrexate (Correct Answer)
B. Variable dose of methotrexate
C. Expectant management
D. Laparoscopic salpingostomy

Explanation: **Explanation:** The treatment of choice for an unruptured ectopic pregnancy depends on the patient's hemodynamic stability and specific biochemical/ultrasonographic criteria. In this case, the patient is a candidate for **medical management with a single dose of methotrexate (MTX)**. **1. Why Option A is Correct:** Medical management with methotrexate (50 mg/m²) is indicated for hemodynamically stable women with an unruptured mass. The **Royal College of Obstetricians and Gynaecologists (RCOG)** and **ACOG** guidelines suggest MTX is most effective when: * Serum β-hCG is <3000 IU/L (some guidelines say <5000 IU/L). * The ectopic mass is <3.5–4 cm. * There is no fetal cardiac activity. * The patient is compliant with follow-up. A β-hCG of 2000 IU/mL falls well within the ideal range for a high success rate with a single-dose regimen. **2. Why Other Options are Incorrect:** * **Option B (Variable/Multi-dose):** This regimen (MTX with Leucovorin rescue) is generally reserved for interstitial pregnancies or cases where the single-dose regimen fails. It carries a higher risk of side effects. * **Option C (Expectant Management):** This is only considered if β-hCG levels are very low (<1000 IU/L) and spontaneously declining, as the risk of rupture remains high at 2000 IU/L. * **Option D (Laparoscopic Salpingostomy):** This is the surgical treatment of choice for unruptured ectopic pregnancy but is typically reserved for patients who have contraindications to MTX, are hemodynamically unstable, or have β-hCG levels >5000 IU/L. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of ectopic:** Ampulla (Fallopian tube). * **Most common site of rupture:** Isthmus (occurs early, ~6–8 weeks). * **MTX Mechanism:** Folic acid antagonist that inhibits Dihydrofolate Reductase, stopping DNA synthesis in rapidly dividing trophoblastic cells. * **Follow-up:** After MTX, β-hCG levels are measured on Day 4 and Day 7. A decline of **>15%** between Day 4 and Day 7 indicates successful treatment.

Question 175: What is the preventive dose of anti-D gamma globulin given to a mother?

A. 200 mcg
B. 300 mcg (Correct Answer)
C. 400 mcg
D. 500 mcg

Explanation: **Explanation:** The standard preventive dose of Anti-D gamma globulin (RhoGAM) for a non-sensitized Rh-negative mother is **300 mcg** (equivalent to 1500 IU). This dose is administered intramuscularly to prevent Rh isoimmunization by neutralizing fetal Rh-positive red blood cells that may enter the maternal circulation. **Why 300 mcg is correct:** A 300 mcg dose is specifically designed to neutralize up to **30 mL of fetal whole blood** (or 15 mL of fetal packed red cells). This volume is sufficient to cover the majority of feto-maternal hemorrhages (FMH) occurring during a standard delivery or third-trimester events. **Analysis of Incorrect Options:** * **A. 200 mcg:** This is an insufficient dose for standard third-trimester prophylaxis or delivery. However, a lower dose of **50 mcg** is often used for first-trimester events (e.g., abortion before 12 weeks), as the fetal blood volume is much smaller. * **C & D. 400 mcg / 500 mcg:** These doses exceed the standard prophylactic requirement. While higher doses are administered if a Kleihauer-Betke (KB) test confirms a massive FMH (>30 mL), they are not the "standard" preventive dose. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Routine antenatal prophylaxis is given at **28 weeks** gestation. Postpartum, it must be given within **72 hours** of delivery if the neonate is Rh-positive. * **Kleihauer-Betke Test:** Used to quantify the volume of FMH to determine if additional doses of Anti-D are required. * **Route:** Intramuscular (IM) is standard. * **Indirect Coombs Test (ICT):** Must be negative in the mother before administration (indicating she is not yet sensitized).

Question 176: Which of the following methods does not improve fetoplacental function in women with IUGR?

A. Allyl estranol (Correct Answer)
B. High protein diet
C. Left lateral position
D. Intermittent O2 therapy

Explanation: **Explanation:** Intrauterine Growth Restriction (IUGR) is primarily managed by improving uteroplacental blood flow and optimizing maternal nutrition. **Why Allyl estranol is the correct answer:** Allyl estranol is a synthetic progestogen. While it was historically used to prevent miscarriage or preterm labor, large-scale clinical trials and Cochrane reviews have proven that it has **no role** in improving fetoplacental function or treating IUGR. It does not increase placental perfusion or fetal weight. In modern obstetrics, its use for growth restriction is considered obsolete and ineffective. **Why the other options are incorrect:** * **High protein diet:** Maternal malnutrition is a modifiable risk factor. Supplementing the mother with a balanced, high-protein diet ensures adequate amino acid transfer to the fetus, which is essential for cellular growth and improving fetal weight. * **Left lateral position:** This is a fundamental nursing intervention. It prevents **aortocaval compression** by the gravid uterus, thereby increasing venous return to the heart, improving cardiac output, and maximizing uterine artery blood flow to the placenta. * **Intermittent O2 therapy:** Administering oxygen to the mother increases the oxygen concentration gradient across the placenta. This can temporarily improve fetal oxygenation and is sometimes used in cases of suspected fetal distress or severe growth restriction. **Clinical Pearls for NEET-PG:** * **Bed Rest:** The most effective non-pharmacological "treatment" for IUGR is bed rest in the left lateral position. * **Low-dose Aspirin (75-150 mg):** If started before 16 weeks, it can help prevent IUGR in high-risk women by improving trophoblastic invasion. * **Definitive Management:** The only definitive "cure" for IUGR is delivery once the fetus has reached a viable age or if fetal surveillance (Doppler/NST) indicates compromise.

Question 177: All of the following are complications in a pregnant woman with systemic lupus erythematosus (SLE) disease except?

A. Preterm labor
B. Thrombophilia
C. Post-term delivery (Correct Answer)
D. Eclampsia

Explanation: **Explanation:** Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disorder that significantly impacts pregnancy outcomes. The core pathophysiology involves immune complex deposition and vasculitis, which compromises placental function. **Why Post-term delivery is the correct answer:** In SLE, the primary concern is **placental insufficiency** caused by decidual vasculopathy. This leads to complications that necessitate early delivery, either due to spontaneous onset (preterm labor) or medical induction (fetal distress/preeclampsia). Therefore, SLE is associated with **preterm delivery**, not post-term delivery. **Analysis of Incorrect Options:** * **Preterm Labor:** This is a hallmark complication of SLE, occurring in up to 30-50% of cases due to premature rupture of membranes, placental abruption, or iatrogenic delivery for maternal/fetal indications. * **Thrombophilia:** SLE is frequently associated with **Antiphospholipid Syndrome (APS)**. The presence of Lupus Anticoagulant or Anticardiolipin antibodies creates a hypercoagulable state, leading to venous/arterial thrombosis and placental infarctions. * **Eclampsia:** SLE patients have a significantly higher risk of **Preeclampsia and Eclampsia**. Differentiating between a "Lupus Nephritis flare" and "Preeclampsia" is a common clinical challenge; however, both conditions predispose the patient to hypertensive crises and seizures. **High-Yield Clinical Pearls for NEET-PG:** * **Best time to conceive:** When SLE has been in remission for at least **6 months**. * **Neonatal Lupus:** Caused by transplacental passage of **Anti-Ro (SS-A)** and **Anti-La (SS-B)** antibodies. The most serious permanent complication is **Congenital Heart Block**. * **Drug of Choice:** **Hydroxychloroquine** is safe and should be continued throughout pregnancy to prevent flares. * **Flare Marker:** Low complement levels (**C3, C4**) usually indicate an SLE flare rather than preeclampsia.

Question 178: What advice should be given to an HIV-positive primigravida near term regarding labor and delivery?

A. Treatment should be started before labor.
B. Avoid mixing of blood intrapartum.
C. Vaginal delivery is preferred.
D. Cesarean section would decrease transmission of HIV to the baby. (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Cesarean section would decrease transmission of HIV to the baby.** **Medical Concept:** The risk of Mother-to-Child Transmission (MTCT) of HIV is highest during the intrapartum period due to exposure to infected maternal blood and cervicovaginal secretions. **Elective (Planned) Cesarean Section (ELCS)** at 38 weeks, before the onset of labor or rupture of membranes, significantly reduces this risk by avoiding the birth canal and minimizing fetal exposure to maternal fluids. Current guidelines (NACO/ACOG) recommend ELCS particularly if the viral load is high (>1000 copies/mL) or unknown near term. **Analysis of Incorrect Options:** * **Option A:** While ART should ideally be started as soon as HIV is diagnosed (regardless of CD4 count), the question asks for advice **near term**. Starting treatment only at this stage is late; the focus shifts to the mode of delivery to prevent transmission. * **Option B:** While avoiding the mixing of blood (e.g., avoiding episiotomy, fetal scalp electrodes, or forceps) is a standard intrapartum precaution, it is a *component* of management rather than the primary definitive advice for reducing transmission compared to the benefit of a C-section. * **Option C:** Vaginal delivery is only preferred if the viral load is **undetectable (<50 copies/mL)** or very low. In a general clinical scenario or where viral load is not suppressed, C-section is safer for the neonate. **High-Yield Clinical Pearls for NEET-PG:** * **Zidovudine (AZT):** The drug of choice for intrapartum prophylaxis (given IV during labor/delivery). * **Breastfeeding:** In India (NACO guidelines), exclusive breastfeeding is recommended for 6 months if replacement feeding is not "Acceptable, Feasible, Affordable, Sustainable, and Safe" (AFASS). However, **mixed feeding** must be strictly avoided. * **Neonatal Prophylaxis:** Nevirapine syrup is typically given to the infant for 6 weeks. * **Timing of ELCS:** Performed at **38 weeks** to prevent spontaneous labor or ROM.

Question 179: What is the most common presentation in twin pregnancies?

A. Vertex + Transverse
B. Both Vertex (Correct Answer)
C. Vertex + Breech
D. Both Breech

Explanation: **Explanation:** In twin pregnancies, the presentation of the fetuses is determined by the available intrauterine space and the tendency of the fetuses to accommodate the oval shape of the uterus. **1. Why "Both Vertex" is correct:** Cephalic (Vertex) presentation is the most common presentation for a single fetus (95%), and this trend continues in multifetal gestations. **Vertex-Vertex** is the most frequent combination, occurring in approximately **40–50%** of all twin pregnancies. This is the most favorable presentation for a planned vaginal delivery, provided there are no other contraindications. **2. Analysis of Incorrect Options:** * **Vertex + Breech (Option C):** This is the second most common presentation, occurring in about **30–35%** of cases. While common, it is statistically less frequent than both being vertex. * **Vertex + Transverse (Option A):** This occurs in approximately **10%** of cases. It is less common because the transverse lie is unstable and usually converts to longitudinal as the pregnancy progresses. * **Both Breech (Option D):** This is relatively rare, occurring in only about **10%** of twin pregnancies. **3. High-Yield Clinical Pearls for NEET-PG:** * **Management Rule:** If the first twin (Twin A) is non-vertex, a Cesarean Section is generally indicated regardless of the presentation of Twin B. * **Internal Podalic Version:** This is a classic obstetric maneuver that may be used for the delivery of a **second twin** (Twin B) if it is in a non-vertex presentation (like transverse) after the successful vaginal birth of Twin A. * **Locked Twins:** A rare but serious complication (1 in 1000 twin births) most commonly seen when **Twin A is Breech and Twin B is Vertex**. Their chins become interlocked, necessitating a C-section.

Question 180: What is the most common indirect cause of maternal mortality?

A. Sepsis
B. Hemorrhage
C. Obstructed labor
D. Anemia (Correct Answer)

Explanation: **Explanation:** Maternal mortality causes are classified into two categories: **Direct** (obstetric complications) and **Indirect** (pre-existing or co-existing diseases aggravated by pregnancy). **Why Anemia is Correct:** In the context of **indirect causes**, **Anemia** is the leading cause of maternal mortality globally and in India. It contributes to death not only through direct cardiac failure but also by lowering the patient's threshold to tolerate blood loss, making even a minor postpartum hemorrhage (PPH) fatal. It also increases susceptibility to infections. **Analysis of Incorrect Options:** * **Hemorrhage (Option B):** This is the **most common direct cause** of maternal mortality (specifically Postpartum Hemorrhage). It is the leading cause of maternal death overall, but it is classified as a direct obstetric cause, not indirect. * **Sepsis (Option A):** This is a major **direct cause**, often resulting from poor hygiene during labor or unsafe abortions. * **Obstructed Labor (Option C):** This is a **direct cause** leading to complications like uterine rupture or maternal exhaustion. **NEET-PG High-Yield Pearls:** * **Most common cause of Maternal Mortality (Overall):** Hemorrhage (Direct). * **Most common Indirect cause:** Anemia (followed by Heart Disease). * **Most common cause of Anemia in pregnancy:** Iron Deficiency Anemia. * **Maternal Mortality Ratio (MMR):** Calculated as maternal deaths per 1,00,000 live births. * **Target:** Under the Sustainable Development Goals (SDG), the target is to reduce MMR to less than 70 per 1,00,000 live births by 2030.

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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