Maternal-Fetal Medicine Practice Questions

Q: A woman presents with amenorrhea of 2 months duration, lower abdominal pain, facial pallor, fainting, and shock. What is the most likely diagnosis?

Ruptured ectopic pregnancy. **Explanation:** The clinical presentation described is a classic medical emergency in gynecology. The patient exhibits the **"Classic Triad"** of ectopic pregnancy: amenorrhea (2 months), abdominal pain, and signs of internal hemorrhage (pallor, fainting, and shock). **1. Why Ruptured Ectopic Pregnancy is Correct:** A ruptured ectopic pregnancy leads to massive **hemoperitoneum**. The 2-month period of amenorrhea corresponds to the 6–8 week window when a tubal pregnancy (most commonly in the ampulla) typically outgrows the tube and ruptures. The sudden loss of blood into the peritoneal cavity causes acute abdominal pain and **hypovolemic shock**, manifesting as pallor and syncope. **2. Why the other options are incorrect:** * **Ruptured ovarian cyst:** While it causes acute pain and sometimes hemoperitoneum (e.g., ruptured corpus luteum), it is rarely associated with 2 months of amenorrhea or profound shock unless there is massive bleeding. * **Threatened abortion:** This presents with vaginal bleeding and mild cramping, but the cervix remains closed, and there is no shock or signs of intraperitoneal hemorrhage. * **Septic abortion:** This presents with fever, foul-smelling vaginal discharge, and pelvic pain following an incomplete abortion. While shock can occur, it is **septic shock** (fever, tachycardia) rather than hemorrhagic shock. **Clinical Pearls for NEET-PG:** * **Most common site of Ectopic Pregnancy:** Fallopian tube (95%), specifically the **Ampulla**. * **Most common site of Rupture:** Isthmus (occurs early, 6–8 weeks) vs. Ampulla (8–12 weeks). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serum $\beta$-hCG (Discriminatory zone: 1500–2000 mIU/ml). * **Management of Rupture:** Immediate resuscitation and **Emergency Laparotomy** (Salpingectomy).

Q: What is the most common cause of antepartum hemorrhage (APH)?

Abruptio placenta. **Explanation:** **Antepartum Hemorrhage (APH)** is defined as bleeding from or into the genital tract occurring from the 28th week of pregnancy until the birth of the baby. **Why Abruptio Placenta is Correct:** Abruptio placenta (premature separation of a normally situated placenta) is the **most common cause** of APH, accounting for approximately **30-35%** of cases. It is clinically characterized by painful vaginal bleeding, uterine tenderness, and increased uterine tone. It is a significant cause of maternal and perinatal morbidity and is frequently associated with pregnancy-induced hypertension (PIH). **Analysis of Incorrect Options:** * **Placenta Previa:** This is the second most common cause of APH (approx. 20-25%). It is characterized by **painless, causeless, and recurrent** bleeding. The placenta is implanted in the lower uterine segment. * **Vasa Previa:** This is a rare but life-threatening condition where fetal vessels run across the internal os. While it causes APH, the bleeding is **fetal in origin**, and it is much less common than abruption. * **Placenta Accreta:** This refers to an abnormal adherence of the placenta to the myometrium. It typically causes **postpartum hemorrhage (PPH)** during the third stage of labor rather than antepartum hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of APH:** Abruptio Placenta. * **Most common cause of DIC in pregnancy:** Abruptio Placenta. * **Couvelaire Uterus:** A complication of severe concealed abruption where blood extravasates into the myometrium. * **Warning Hemorrhage:** A classic feature of Placenta Previa, not Abruption. * **Stallworthy’s Sign:** Associated with posterior placenta previa.

Q: What is a potential pregnancy complication in a retroverted uterus?

All of the above. In a normal pregnancy, a retroverted uterus typically corrects itself (spontaneously anteverts) by the 12th week of gestation. If it fails to do so, it becomes trapped in the pelvic cavity, leading to **incarceration of the retroverted gravid uterus**. **Explanation of Options:** * **Anterior Sacculation:** This is a compensatory mechanism where the incarcerated posterior wall remains fixed in the pouch of Douglas, and the anterior wall of the uterus stretches excessively to accommodate the growing fetus. This "sac" expands into the abdominal cavity, often displacing the cervix high up behind the symphysis pubis. * **Abortion:** Incarceration leads to increased intrauterine pressure and compromised blood flow. If the uterus cannot expand or correct its position, it may lead to spontaneous miscarriage, typically in the late first or early second trimester. * **Rupture Uterus:** The extreme thinning of the anterior wall (sacculation) during labor or late pregnancy significantly increases the risk of uterine rupture, especially if the condition is unrecognized and the patient undergoes a trial of labor. **NEET-PG High-Yield Pearls:** * **Clinical Presentation:** The classic triad is **pain, paradoxical incontinence** (overflow incontinence due to the cervix pressing against the bladder neck/urethra), and a **palpable pelvic mass**. * **Diagnosis:** On vaginal examination, the cervix is displaced anteriorly and superiorly (often difficult to reach), with a soft mass (the uterine fundus) filling the pouch of Douglas. * **Management:** Most cases resolve with bladder catheterization and manual repositioning (Smith-Hodge pessary). If sacculation is present at term, a **Cesarean Section** is mandatory, as the distorted anatomy makes vaginal delivery dangerous.

Q: Which of the following statements is true regarding preeclampsia?

Endothelial dysfunction is the basic pathology.. **Explanation:** **1. Why the Correct Answer is Right:** The fundamental pathophysiology of preeclampsia is **systemic endothelial dysfunction**. It begins with defective trophoblastic invasion of the spiral arteries (Stage 1), leading to placental hypoxia. This triggers the release of anti-angiogenic factors (like sFlt-1 and soluble endoglin) into the maternal circulation. These factors neutralize VEGF and PlGF, causing widespread endothelial damage (Stage 2). This damage leads to increased vascular permeability (edema), activation of the coagulation cascade (thrombocytopenia), and vasospasm (hypertension and end-organ damage). **2. Why the Other Options are Incorrect:** * **Option A:** Preeclampsia is **not totally preventable**. While low-dose Aspirin (started before 16 weeks) can reduce risk in high-risk patients, the exact etiology remains multifactorial and often unpredictable. * **Option B:** Traditionally, the **diastolic blood pressure** was considered more significant as it reflects peripheral vascular resistance. However, current ACOG/NHBPEP guidelines give equal importance to both systolic (≥140 mmHg) and diastolic (≥90 mmHg) values for diagnosis. * **Option C:** Eclampsia is **not invariably preceded** by preeclampsia symptoms. In about 20-30% of cases, seizures occur without prior warning signs like significant hypertension or proteinuria (atypical eclampsia). **3. High-Yield Clinical Pearls for NEET-PG:** * **Definition:** BP ≥140/90 mmHg after 20 weeks of gestation + proteinuria OR signs of end-organ dysfunction. * **Gold Standard for Proteinuria:** Urinary protein excretion ≥300 mg in a 24-hour collection. * **Predictive Marker:** Increased sFlt-1:PlGF ratio. * **Drug of Choice (DOC):** For seizure prophylaxis/control is **Magnesium Sulfate (MgSO₄)** (Pritchard or Zuspan regimen). * **Definitive Treatment:** Delivery of the fetus and placenta.

Q: A female has a history of 6 weeks amenorrhea, ultrasonography shows an empty sac, and serum hCG is 6500 IU/L. What is the next step in management?

Medical management. **Explanation:** The clinical scenario describes a case of **Early Pregnancy Loss (Anembryonic Pregnancy/Blighted Ovum)**. The diagnosis is confirmed using the concept of the **Discriminatory Zone**. 1. **Why Medical Management is correct:** The discriminatory zone is the serum hCG level above which a gestational sac should be visible on ultrasound. For Transvaginal Sonography (TVS), this is typically **1500–2000 IU/L**. In this patient, the hCG is **6500 IU/L** with an empty sac, which is well above the threshold. According to ACOG and NICE guidelines, a diagnosis of a non-viable pregnancy is made when the Mean Sac Diameter (MSD) is $\geq$ 25 mm with no embryo, or when the hCG is significantly above the discriminatory zone with no intrauterine evidence of a viable pregnancy. Once non-viability is confirmed, management options include expectant, medical (Misoprostol), or surgical (D&C). In NEET-PG contexts, for a stable patient with a confirmed non-viable pregnancy, **Medical Management** is the preferred first-line intervention. 2. **Why other options are incorrect:** * **B & C (Repeat hCG):** These are indicated in "Pregnancy of Unknown Location" (PUL) where hCG is *below* the discriminatory zone. Since the hCG here is 6500 IU/L, the diagnosis is already certain; waiting only delays treatment. * **D (Surgical Management):** While an option, it is usually reserved for patients with heavy bleeding, hemodynamic instability, or those who fail medical management. **High-Yield Clinical Pearls for NEET-PG:** * **Discriminatory Zone:** TVS = 1500–2000 IU/L; TAS (Transabdominal) = 6500 IU/L. * **Failed Pregnancy Criteria (USG):** * CRL $\geq$ 7 mm with no cardiac activity. * MSD $\geq$ 25 mm with no embryo. * **Medical Management Drug of Choice:** Misoprostol (Prostaglandin E1 analogue).

Q: All are true about pre-eclampsia except:

Deep vein thrombosis (DVT). **Explanation:** Pre-eclampsia is a multisystem disorder characterized by widespread endothelial dysfunction and vasospasm. The correct answer is **D (Deep vein thrombosis)** because, while pregnancy itself is a hypercoagulable state, DVT is not a direct pathological component or a classic complication of the pre-eclampsia disease process. **Why the other options are incorrect (Complications of Pre-eclampsia):** * **Cerebral Hemorrhage:** This is the most common cause of maternal death in eclampsia. It results from a loss of cerebrovascular autoregulation due to severe hypertension, leading to hyperperfusion and rupture of small vessels. * **Pulmonary Edema:** Occurs in about 2-5% of severe pre-eclampsia cases. It is caused by increased capillary permeability (leaky endothelium), decreased plasma oncotic pressure (due to proteinuria/hypoalbuminemia), and occasionally left ventricular failure. * **Acute Renal Failure (ARF):** Pre-eclampsia causes a characteristic renal lesion called **Glomerular Endotheliosis**. Severe vasospasm and reduced renal perfusion can lead to acute tubular necrosis (ATN) or, in extreme cases, cortical necrosis. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** BP ≥140/90 mmHg after 20 weeks of gestation with proteinuria or evidence of end-organ dysfunction. * **Pathogenesis:** Failure of secondary trophoblastic invasion of spiral arteries (high resistance remains). * **DOC for Seizure Prophylaxis:** Magnesium Sulfate ($MgSO_4$) – Pritchard or Zuspan regimen. * **Definitive Treatment:** Delivery of the fetus and placenta. * **Predictive Marker:** Low PIGF (Placental Growth Factor) and high sFlt-1 levels.

Q: When is termination of pregnancy indicated in hyperemesis gravidarum?

Decrease in renal output. **Explanation:** Hyperemesis Gravidarum (HG) is a severe form of nausea and vomiting in pregnancy that leads to dehydration, electrolyte imbalance, and weight loss. While modern supportive care makes termination of pregnancy (TOP) rare, it remains a life-saving indication when conservative management fails and multi-organ dysfunction begins. **Why "Decrease in renal output" is the correct answer:** A decrease in renal output (oliguria) signifies severe, decompensated dehydration and the onset of **acute kidney injury (AKI)**. In the context of HG, this indicates that the body’s compensatory mechanisms have failed. Along with other "danger signs" like jaundice (liver failure), retinal hemorrhage, or Wernicke’s encephalopathy (neurological damage), persistent oliguria is a definitive indication for termination to save the mother’s life. **Why the other options are incorrect:** * **A. Presence of acetone in urine:** Ketonuria is a common finding in HG due to starvation and fat metabolism. It is a marker for hospitalization and IV fluid resuscitation, not an indication for termination. * **C. Vomiting persists beyond three months:** While HG typically resolves by 16–20 weeks, persistence alone is not life-threatening. Many women continue to have mild symptoms throughout pregnancy without requiring termination. **NEET-PG High-Yield Pearls:** * **Wernicke’s Encephalopathy:** Caused by Vitamin B1 (Thiamine) deficiency due to prolonged vomiting. Always replenish Thiamine *before* giving Glucose to avoid precipitating this condition. * **Electrolyte Imbalance:** The most common pattern is **Hypokalemic Hypochloremic Metabolic Alkalosis**. * **Mallory-Weiss Tear:** Hematemesis in HG is often due to esophageal mucosal tears from forceful vomiting. * **Drug of Choice:** Pyridoxine (Vitamin B6) + Doxylamine is the first-line pharmacological treatment.

Q: What is the tocolytic of choice in a pregnancy with heart disease?

Nifedipine. **Explanation:** The management of preterm labor in patients with cardiac disease requires a tocolytic with the least hemodynamic impact. **Nifedipine**, a Calcium Channel Blocker (CCB), is the tocolytic of choice in this scenario. It is preferred because it is orally administered, highly effective, and has a relatively safe profile compared to other agents. While it can cause peripheral vasodilation and mild tachycardia, it lacks the severe fluid-loading requirements or significant cardiac stress associated with other classes. **Analysis of Options:** * **Nifedipine (Correct):** It is the first-line tocolytic for most pregnancies, including those with heart disease, due to its ease of use and lower risk of serious maternal cardiovascular complications. * **Magnesium Sulfate:** While used for neuroprotection, it is not the primary tocolytic of choice. In cardiac patients, there is a high risk of **pulmonary edema** and fluid overload, making it a risky option. * **Atosiban:** This oxytocin receptor antagonist is extremely safe for the heart; however, due to its high cost and limited availability in many Indian clinical settings, Nifedipine remains the standard "choice" for exams. (Note: If Nifedipine is not an option, Atosiban is the safest alternative). * **Alcohol:** Historically used, it is now obsolete due to maternal toxicity and poor efficacy. **NEET-PG High-Yield Pearls:** * **Beta-mimetics (Ritodrine/Terbutaline):** Strictly **contraindicated** in heart disease as they cause tachycardia, hypotension, and pulmonary edema. * **Indomethacin:** Avoided after 32 weeks due to the risk of premature closure of the Ductus Arteriosus. * **Drug of choice for Tocolysis (General):** Nifedipine. * **Drug of choice for Tocolysis (Diabetes):** Nifedipine (Avoid Beta-mimetics as they cause hyperglycemia).

Question 1

A 27-year-old G2P1 woman at 34 weeks' gestation presents to the emergency department following a motor vehicle collision. Her heart rate is 130/min and blood pressure is 150/90 mm Hg. She is alert and oriented to person, place, and time. She complains of severe abdominal pain that began immediately after the collision. Physical examination reveals bruising over her abdomen, along with a hypertonic uterus and dark vaginal bleeding. A sonogram reveals a placental abruption, and the fetal heart tracing reveals some decelerations. Emergency laboratory tests reveal an International Normalized Ratio of 2.5, with elevated fibrin degradation products. Which of the following is the most appropriate first step in management?

Accepted Answer

Administer fresh frozen plasma

Answer

Administer a tocolytic

Answer

Administer a corticosteroid

Answer

Deliver the fetus immediately by LSCS

Question 2

A woman presents with amenorrhea of 2 months duration, lower abdominal pain, facial pallor, fainting, and shock. What is the most likely diagnosis?

Accepted Answer

Ruptured ectopic pregnancy

Answer

Ruptured ovarian cyst

Answer

Threatened abortion

Answer

Septic abortion

Question 3

What is the most common cause of antepartum hemorrhage (APH)?

Accepted Answer

Abruptio placenta

Answer

Placenta previa

Answer

Vasa previa

Answer

Placenta accreta

Question 4

Which of the following conditions is associated with an incoagulable state?

Accepted Answer

Abruption placentae

Answer

Acute promyelocytic leukaemia

Answer

Severe falciparum malaria

Answer

Heparin overdose

Question 5

What is a potential pregnancy complication in a retroverted uterus?

Accepted Answer

All of the above

Answer

Anterior sacculation of uterus

Answer

Rupture uterus

Answer

Abortion

Question 6

Which of the following statements is true regarding preeclampsia?

Accepted Answer

Endothelial dysfunction is the basic pathology.

Answer

It is a totally preventable disease.

Answer

A rise in systolic blood pressure is more important than the diastolic.

Answer

Eclampsia is invariably preceded by acute fulminating preeclampsia.

Question 7

A female has a history of 6 weeks amenorrhea, ultrasonography shows an empty sac, and serum hCG is 6500 IU/L. What is the next step in management?

Accepted Answer

Medical management

Answer

Repeat hCG after 48 hours

Answer

Repeat hCG after 1 week

Answer

Surgical management

Question 8

All are true about pre-eclampsia except:

Accepted Answer

Deep vein thrombosis (DVT)

Answer

Cerebral hemorrhage

Answer

Pulmonary edema

Answer

Acute renal failure (ARF)

Question 9

When is termination of pregnancy indicated in hyperemesis gravidarum?

Accepted Answer

Decrease in renal output

Answer

Presence of acetone in urine

Answer

Vomiting persists beyond three months

Answer

All of the above

Question 10

What is the tocolytic of choice in a pregnancy with heart disease?

Accepted Answer

Nifedipine

Answer

Magnesium sulfate

Answer

Atosiban

Answer

Alcohol

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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