Maternal-Fetal Medicine Practice Questions

Q: Abruptio placentae is a form of antepartum hemorrhage. Which among the following is the clinical classification system for abruptio placentae?

Page classification. **Explanation:** **Abruptio placentae** refers to the premature separation of a normally situated placenta from the uterine wall after 28 weeks of gestation. The **Page classification** is the standard clinical grading system used to assess the severity of abruption based on clinical signs and symptoms: * **Grade 0:** Asymptomatic; diagnosed retrospectively by finding a retroplacental clot after delivery. * **Grade 1 (Mild):** Vaginal bleeding is slight; no signs of maternal shock or fetal distress. * **Grade 2 (Moderate):** Increased bleeding; uterine tenderness and tetany are present. Fetal distress (tachycardia or late decelerations) is common. * **Grade 3 (Severe):** Severe bleeding (may be concealed); uterus is board-like and painful. Maternal shock is present, and fetal death is typical. This is further divided into 3A (without coagulopathy) and 3B (with coagulopathy/DIC). **Analysis of Incorrect Options:** * **Macafee and Johnson Regimen:** This is the protocol for the **expectant management of Placenta Previa**, aimed at prolonging pregnancy until fetal lung maturity is achieved (usually up to 37 weeks). * **Apt Test:** A biochemical test used to differentiate between **maternal and fetal blood**. It is specifically used in cases of suspected **Vasa Previa**, where fetal vessels rupture. **High-Yield Clinical Pearls for NEET-PG:** * **Most common risk factor:** Hypertension (Pregnancy-induced or chronic). * **Classic presentation:** Painful vaginal bleeding with a "woody hard" or "board-like" uterus. * **Couvelaire Uterus:** A complication of severe abruption where blood extravasates into the myometrium, giving the uterus a bluish/purplish mottled appearance. * **Most common cause of DIC in pregnancy:** Abruptio placentae.

Q: Supine hypotension syndrome occurs in which condition?

Advanced pregnancy. ### Explanation **Supine Hypotension Syndrome** (also known as Aortocaval Compression Syndrome) occurs primarily in **advanced pregnancy** (usually after 20 weeks of gestation). #### Why Advanced Pregnancy is Correct: The underlying mechanism is the **mechanical compression** of the **Inferior Vena Cava (IVC)** and the abdominal aorta by the gravid uterus when the woman lies in a supine position. 1. **Venous Return:** Compression of the IVC leads to a significant decrease in venous return to the heart (preload). 2. **Cardiac Output:** Reduced preload results in decreased stroke volume and cardiac output. 3. **Hypotension:** This manifests as a drop in maternal blood pressure, leading to symptoms like dizziness, nausea, pallor, and syncope. It can also cause fetal distress due to reduced placental perfusion. #### Why Other Options are Incorrect: * **Early Pregnancy:** The uterus is still a pelvic organ or not large enough to exert significant pressure on the retroperitoneal vessels. * **Obesity & Ascites:** While these conditions increase intra-abdominal pressure, they rarely cause the acute, posture-dependent vascular collapse seen in pregnancy. The gravid uterus is a unique, solid, and heavy mass that specifically targets the IVC when supine. #### NEET-PG High-Yield Pearls: * **Management:** The immediate treatment is the **Left Lateral Position**, which shifts the uterus off the IVC, restoring venous return. * **Aortic Compression:** While IVC compression causes maternal hypotension, compression of the **Aorta** can lead to "Poseiro Effect" (fetal hypoxemia without maternal hypotension). * **Clinical Tip:** During CPR in a pregnant woman, manual **Left Uterine Displacement (LUD)** is a critical step to ensure effective chest compressions.

Q: Which of the following conditions is the most frequent cause of spontaneous abortion in the first trimester of pregnancy?

Chromosomal abnormalities. **Explanation:** **1. Why Chromosomal Abnormalities is Correct:** Chromosomal abnormalities are the single most common cause of spontaneous abortion, accounting for approximately **50-60%** of all first-trimester miscarriages. Among these, **Autosomal Trisomies** are the most frequent (Trisomy 16 being the most common specific trisomy), followed by Monosomy X (Turner Syndrome) and Polyploidy. These genetic errors usually occur de novo during gametogenesis or early fertilization, leading to non-viable embryos that the body naturally expels. **2. Why Other Options are Incorrect:** * **Abruptio Placentae (A):** This is the premature separation of the placenta, typically occurring in the **third trimester**. It is a cause of antepartum hemorrhage and fetal distress, not first-trimester spontaneous abortion. * **Chorioamnionitis (B):** This is an intra-amniotic infection usually associated with prolonged rupture of membranes. While it can cause mid-trimester loss or preterm labor, it is not the leading cause of early first-trimester miscarriage. * **Placenta Previa (D):** This refers to the placenta covering the internal os. Like abruption, it is a cause of **late-pregnancy bleeding** (antepartum hemorrhage) and does not cause first-trimester spontaneous abortion. **3. NEET-PG High-Yield Pearls:** * **Most common Trisomy in miscarriages:** Trisomy 16. * **Most common single chromosomal anomaly:** Monosomy X (45, X). * **Second most common cause of miscarriage:** Maternal endocrine factors (e.g., Luteal Phase Defect, uncontrolled Diabetes). * **Recurrent Pregnancy Loss (RPL):** Defined as $\geq$ 2 consecutive spontaneous abortions; the most common treatable cause is Antiphospholipid Antibody Syndrome (APS).

Q: When should a pregnant woman with a prosthetic valve be switched to heparin?

36 weeks gestation. **Explanation:** The management of anticoagulation in pregnant women with prosthetic heart valves is a high-stakes clinical scenario. The primary goal is to balance the risk of maternal valve thrombosis with the risk of fetal hemorrhage and teratogenicity. **Why 36 weeks is the correct answer:** Warfarin (Oral Anticoagulant) is highly effective at preventing maternal valve thrombosis but crosses the placenta. If a patient is on Warfarin during labor, the fetus—which has an immature liver and low levels of clotting factors—is at high risk of **intracranial hemorrhage** during the birth process. Therefore, Warfarin must be discontinued and replaced with **Unfractionated Heparin (UFH)** or **Low Molecular Weight Heparin (LMWH)** at **36 weeks gestation**. Heparin does not cross the placenta, ensuring the fetus has normal coagulation status by the time labor begins. **Analysis of Incorrect Options:** * **28 & 32 weeks (A & B):** Switching this early unnecessarily increases the risk of maternal valve thrombosis. Warfarin is superior to Heparin for maternal protection; thus, it is continued as long as safely possible until near-term. * **Postpartum (D):** Waiting until after delivery is dangerous. If the patient goes into labor while on Warfarin, the risk of fetal death due to hemorrhage is extremely high. **High-Yield Clinical Pearls for NEET-PG:** * **Warfarin Embryopathy:** Occurs if Warfarin is used between **6–12 weeks** (features: nasal hypoplasia, stippled epiphyses). * **The "Switch" Protocol:** * ** 36 weeks:** Switch to Heparin (to avoid fetal hemorrhage during delivery). * **Labor Management:** UFH is typically stopped 4–6 hours before delivery; LMWH is stopped 24 hours before. Warfarin is usually restarted 6–12 hours after an uncomplicated delivery.

Q: Late deceleration in fetal heart rate monitoring is suggestive of:

Fetal hypoxia. **Explanation:** **Late decelerations** are characterized by a gradual decrease in fetal heart rate (FHR) that begins *after* the peak of the uterine contraction and returns to baseline only after the contraction has ended. This pattern is a hallmark sign of **uteroplacental insufficiency**. During a contraction, uterine blood flow decreases; if the placental reserve is already low, the fetus experiences a drop in $PO_2$ below the critical threshold. This triggers chemoreceptors, leading to a vagal response and myocardial depression, resulting in **fetal hypoxia** and metabolic acidosis. **Analysis of Incorrect Options:** * **B. Head Compression:** This causes **Early Decelerations**. The pressure on the fetal head increases vagal tone, causing a heart rate dip that mirrors the contraction (the nadir of the FHR coincides with the peak of the contraction). It is considered physiological. * **C. Cord Compression:** This leads to **Variable Decelerations**. These are abrupt in onset and offset and vary in timing relative to contractions. They are the most common type of deceleration seen in labor. * **D. Fetal Death:** While hypoxia can lead to death, late decelerations are a sign of a struggling, live fetus. Fetal death is confirmed by the absence of cardiac activity on ultrasound or Doppler. **High-Yield Clinical Pearls for NEET-PG:** * **VEAL CHOP Mnemonic:** **V**ariable = **C**ord; **E**arly = **H**ead; **A**ccelerations = **O**k (Oxygenated); **L**ate = **P**lacenta. * Late decelerations are categorized as **Category III** (Abnormal) if associated with absent variability, requiring immediate resuscitation or delivery. * The first step in management is "intrauterine resuscitation": Left lateral position, oxygen, IV fluids, and stopping oxytocin.

Q: You are called to the operating room for a patient found to have an abdominal pregnancy with an 18-week fetus and placenta attached to the omentum during surgery for suspected appendicitis. What is the best course of action?

Removal of the fetus only. **Explanation:** The management of abdominal pregnancy is a high-stakes scenario in maternal-fetal medicine. The primary challenge is the **placenta**, which lacks the contractile myometrium of the uterus to control bleeding after separation. **1. Why "Removal of the fetus only" is correct:** In abdominal pregnancies, the placenta often attaches to highly vascular organs (like the omentum, bowel, or major vessels). Attempting to detach the placenta can lead to **uncontrollable, life-threatening hemorrhage**. The standard recommendation is to ligate the umbilical cord close to the placenta and leave the placenta *in situ*. It is then allowed to undergo spontaneous resorption, which can be monitored using serial β-hCG levels and ultrasound. Methotrexate may occasionally be used to accelerate this process. **2. Why the other options are incorrect:** * **Option A:** Removing the placenta is contraindicated unless it is attached to a simple, pedicled structure (like the omentum) that can be easily ligated and removed entirely. However, as a general rule for exams, "leaving the placenta" is the safest answer to prevent surgical catastrophe. * **Option B:** While the cord is ligated, the fetus must be removed to prevent infection, lithopedion formation, or further complications. * **Option D:** Abdominal pregnancy carries a very high risk of maternal mortality and fetal anomalies (due to oligohydramnios). Expectant management until viability is rarely recommended and is extremely hazardous. **Clinical Pearls for NEET-PG:** * **Diagnosis:** Often suggested by "easily palpable fetal parts" and an "empty uterus" on ultrasound. * **Management of Placenta:** If left behind, the patient is at risk for bowel obstruction and infection. * **Most common site:** The Pouch of Douglas. * **Key Rule:** Never attempt to peel the placenta off a vital organ.

Q: All of the following are risk factors for IUGR except?

Maternal diabetes. **Explanation:** The correct answer is **Maternal Diabetes**. In the context of pregnancy, maternal diabetes (especially Gestational Diabetes or Type 2 Diabetes without vascular complications) is typically associated with **fetal macrosomia** (birth weight >4000g) rather than Intrauterine Growth Restriction (IUGR). This occurs because maternal hyperglycemia leads to fetal hyperglycemia, which stimulates the fetal pancreas to produce excess insulin. Since insulin is a potent growth-promoting hormone, it results in excessive fetal fat deposition and organomegaly. **Analysis of other options:** * **Severe Anemia:** Maternal hemoglobin <7 g/dL leads to chronic fetal hypoxia and reduced oxygen delivery to the placenta, which is a well-established cause of IUGR. * **Placental Infarcts:** These represent areas of placental tissue death, reducing the functional surface area for nutrient and gas exchange (placental insufficiency), directly leading to growth restriction. * **In utero infection:** TORCH infections (especially CMV and Rubella) cause IUGR by reducing cell proliferation and causing direct fetal tissue damage. **High-Yield Clinical Pearls for NEET-PG:** * **The Exception:** While diabetes usually causes macrosomia, **Pre-gestational Diabetes with vascular complications** (White’s Classification Class R, F, or H) can cause IUGR due to compromised uterine blood flow. * **Symmetrical vs. Asymmetrical IUGR:** Infections and chromosomal anomalies usually cause *Symmetrical IUGR* (early onset), while placental insufficiency (like infarcts or preeclampsia) causes *Asymmetrical IUGR* (late onset, "head-sparing"). * **Ponderal Index:** Used to differentiate types of IUGR; it is low in asymmetrical IUGR.

Question 1

Abruptio placentae is a form of antepartum hemorrhage. Which among the following is the clinical classification system for abruptio placentae?

Accepted Answer

Page classification

Answer

Macafee regimen

Answer

Johnson regimen

Answer

Apt test

Question 2

The Kleihaeur-Betke test is performed to detect:

Accepted Answer

Fetomaternal hemorrhage

Answer

Cephalopelvic disproportion

Answer

Karyotype of a normal fetus

Answer

Fetal infections

Question 3

In Erythroblastosis fetalis, why is the first child typically spared?

Accepted Answer

Sensitization of Rh-negative mothers by a Rh-positive fetus generally occurs at birth.

Answer

The immune response during a second exposure is rapid.

Answer

Small amounts of fetal blood leak into the maternal circulation at the time of delivery.

Answer

Mothers develop significant titers of anti-Rh agglutinins during the postpartum period.

Question 4

A 20-year-old woman, gravida 3, para 2, has a screening ultrasound at 18 weeks' gestation that shows hydrops fetalis but no malformations. The woman's two previous pregnancies ended at term in live births. The current pregnancy results in a live birth at 36 weeks. Physical examination shows marked hydrops of the neonate and placenta. Laboratory studies show a cord blood hemoglobin level of 9.2 g/dL and total bilirubin concentration of 20.2 mg/dL. Which of the following laboratory findings is most likely to be present in this case?

Accepted Answer

Positive Coombs test result on cord blood

Answer

Diminished glucocerebrosidase activity in fetal cells

Answer

Elevated maternal serum alpha-fetoprotein level

Answer

Positive maternal hepatitis B surface antigen

Question 5

Supine hypotension syndrome occurs in which condition?

Accepted Answer

Advanced pregnancy

Answer

Obesity

Answer

Ascites

Answer

Early pregnancy

Question 6

Which of the following conditions is the most frequent cause of spontaneous abortion in the first trimester of pregnancy?

Accepted Answer

Chromosomal abnormalities

Answer

Abruptio placentae

Answer

Chorioamnionitis

Answer

Placenta previa

Question 7

When should a pregnant woman with a prosthetic valve be switched to heparin?

Accepted Answer

36 weeks gestation

Answer

28 weeks gestation

Answer

32 weeks gestation

Answer

Postpartum

Question 8

Late deceleration in fetal heart rate monitoring is suggestive of:

Accepted Answer

Fetal hypoxia

Answer

Head compression

Answer

Cord compression

Answer

Fetal death

Question 9

You are called to the operating room for a patient found to have an abdominal pregnancy with an 18-week fetus and placenta attached to the omentum during surgery for suspected appendicitis. What is the best course of action?

Accepted Answer

Removal of the fetus only

Answer

Removal of both fetus and placenta

Answer

Laparoscopic ligation of the umbilical cord

Answer

Closely follow until viability and then deliver by laparotomy

Question 10

All of the following are risk factors for IUGR except?

Accepted Answer

Maternal diabetes

Answer

Severe Anemia

Answer

Placental infarcts

Answer

In utero infection

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

On this page

Practice by Chapter

Want unlimited practice?