Maternal-Fetal Medicine Practice Questions

Q: What is the impact on the fetus in case of use of Indomethacin in utero in the third trimester?

Early closure of ductus arteriosus. **Explanation:** **Mechanism of Action:** Indomethacin is a non-steroidal anti-inflammatory drug (NSAID) that acts as a non-selective **cyclooxygenase (COX) inhibitor**. In the fetus, the patency of the ductus arteriosus is actively maintained by high levels of circulating **Prostaglandin E2 (PGE2)**. By inhibiting COX enzymes, Indomethacin decreases prostaglandin synthesis, leading to the **premature (early) closure of the ductus arteriosus** in utero. This can result in fetal pulmonary hypertension and right-sided heart failure. **Analysis of Options:** * **Option B (Correct):** As explained, PGE2 inhibition leads to constriction and premature closure of the ductus. This risk increases significantly when used after **32 weeks** of gestation. * **Option A:** Patent Ductus Arteriosus (PDA) is the failure of the ductus to close *after* birth. Interestingly, Indomethacin is used postnatally to *treat* PDA, but its prenatal use causes the opposite (premature closure). * **Options C & D:** Ventricular and Atrial Septal Defects are structural congenital heart diseases related to embryological development in the first trimester. Indomethacin does not cause these malformations when used in the third trimester. **High-Yield Clinical Pearls for NEET-PG:** * **Tocolysis:** Indomethacin is used as a second-line tocolytic for preterm labor, but only before 32 weeks. * **Oligohydramnios:** Another major side effect of Indomethacin is reduced fetal urine output, leading to oligohydramnios (often used therapeutically in polyhydramnios). * **Monitoring:** If used for >48 hours, serial fetal echocardiography is mandatory to monitor the ductal flow and amniotic fluid index. * **Contraindication:** It is generally avoided after 32 weeks due to the high sensitivity of the fetal ductus to prostaglandins at this stage.

Q: Oligohydramnios is seen in which of the following conditions?

Renal agenesis. **Explanation:** **Correct Answer: A. Renal agenesis** The volume of amniotic fluid is a balance between production and removal. From the second trimester onwards, **fetal urine** is the primary source of amniotic fluid. In **Renal agenesis** (Potter sequence), the absence of kidneys leads to a lack of urine production (anuria), resulting in **Oligohydramnios** (Amniotic Fluid Index < 5 cm or Single Deepest Pocket < 2 cm). **Why the other options are incorrect:** * **B. Oesophageal atresia:** Fetal swallowing is the major pathway for amniotic fluid removal. In esophageal atresia, the fetus cannot swallow the fluid, leading to its accumulation and **Polyhydramnios**. * **C. Exomphalos (Omphalocele):** This is a ventral wall defect. It is generally associated with **Polyhydramnios** due to the exudation of fluid from the exposed bowel or associated chromosomal/structural anomalies that interfere with swallowing. * **D. Neural tube defect (NTD):** Open NTDs (like Anencephaly) cause **Polyhydramnios** via two mechanisms: the absence of the swallowing reflex and the transudation of cerebrospinal fluid across the exposed neural membranes. **High-Yield Clinical Pearls for NEET-PG:** * **Potter Sequence:** Renal agenesis → Oligohydramnios → Pulmonary hypoplasia, limb deformities, and flattened facies. * **Amniotic Fluid Index (AFI):** Normal range is 5–25 cm. * **Common causes of Oligohydramnios (DRIPPC):** **D**eath (fetal), **R**enal anomalies, **I**UGR, **P**rom (Premature Rupture of Membranes), **P**ost-term pregnancy, **C**hromosomal anomalies. * **Indomethacin:** A common drug-induced cause of oligohydramnios (due to reduced fetal renal blood flow).

Q: An ectopic pregnancy is shed as?

Decidua vera. In an ectopic pregnancy, the hormonal changes (rising progesterone) stimulate the transformation of the endometrium into **decidua**, despite the embryo being implanted outside the uterine cavity. ### Why Decidua Vera is Correct The endometrium undergoes a "decidual reaction" to prepare for implantation. In a normal intrauterine pregnancy, the decidua is divided into three layers: 1. **Decidua Basalis:** Where the blastocyst implants. 2. **Decidua Capsularis:** Covers the blastocyst. 3. **Decidua Vera (Parietalis):** Lines the remainder of the uterine cavity. In an **ectopic pregnancy**, there is no blastocyst inside the uterus to create the basalis or capsularis layers. Therefore, the entire uterine lining transforms uniformly into **Decidua Vera**. When the ectopic pregnancy fails and hormone levels fall, this lining sloughs off and is shed, often as a single intact piece known as a **decidual cast**. ### Why Other Options are Incorrect * **Decidua Basalis & Capsularis:** These layers only form in response to the physical presence and implantation of the embryo within the uterus. Since the embryo is extrauterine, these specific layers do not exist. * **Decidua Rubra:** This is not a standard anatomical term for the decidual layers; it is likely a distractor derived from "Lochia Rubra" (the bloody discharge seen postpartum). ### NEET-PG Clinical Pearls * **Arias-Stella Reaction:** This is the characteristic histological change seen in the endometrium during ectopic pregnancy, featuring hypersecretory glands and nuclear hypertrophy. * **Decidual Cast:** If a patient presents with abdominal pain and passes a fleshy mass per vaginum, it is often a decidual cast. This must be differentiated from a miscarriage (which would contain chorionic villi). * **Key Distinction:** The absence of chorionic villi on histopathology of the shed tissue is a strong indicator of ectopic pregnancy.

Q: In which of the following conditions, the medical treatment of ectopic pregnancy is contraindicated?

Presence of fetal heart activity. **Explanation:** Medical management of ectopic pregnancy, primarily using **Methotrexate (MTX)**, is reserved for hemodynamically stable patients who meet specific criteria. The presence of **fetal heart activity (Option C)** is a major contraindication because it indicates a high trophoblastic load and a more advanced pregnancy, which significantly increases the risk of treatment failure and tubal rupture. **Analysis of Options:** * **Presence of fetal heart activity (Correct):** This is an absolute contraindication for medical management. MTX is less effective when there is active cardiac motion, necessitating surgical intervention. * **Sac size is 3 cm (Incorrect):** Medical management is generally indicated if the gestational sac diameter is **< 3.5 cm or 4 cm**. A 3 cm sac falls within the acceptable range for MTX. * **Blood in pelvis is 70 mL (Incorrect):** While significant hemoperitoneum (suggesting rupture) is a contraindication, a small amount of free fluid (usually **< 100 mL**) in the pouch of Douglas is common and does not preclude medical treatment. * **Previous ectopic pregnancy (Incorrect):** A history of ectopic pregnancy is not a contraindication. In fact, medical management is often preferred in these cases to avoid further surgical scarring of the fallopian tubes. **NEET-PG High-Yield Pearls:** * **Ideal Candidate for MTX:** Hemodynamically stable, Serum β-hCG < 5000 mIU/mL, Sac size < 3.5 cm, and No fetal cardiac activity. * **Absolute Contraindications:** Ruptured ectopic pregnancy, hemodynamic instability, breastfeeding, immunodeficiency, and significant renal/hepatic/pulmonary disease. * **Dosing:** Most common is the single-dose regimen (50 mg/m² IM). * **Monitoring:** β-hCG levels are measured on Day 4 and Day 7. A drop of **≥ 15%** between Day 4 and 7 indicates successful treatment.

Q: In a normal Non-Stress Test (NST), what is the time period for observing two or three accelerations that peak at 15 bpm or more above the baseline?

20 minutes. ### Explanation **1. Why Option C (20 minutes) is Correct:** A Non-Stress Test (NST) evaluates fetal well-being by observing the fetal heart rate (FHR) response to fetal movement. A **Reactive (Normal) NST** is defined by the presence of **two or more accelerations** within a **20-minute window**. An acceleration is defined as a peak of at least **15 beats per minute (bpm)** above the baseline, lasting for at least **15 seconds** (the "15x15" rule). This indicates a functional fetal autonomic nervous system and adequate oxygenation. **2. Why the Other Options are Incorrect:** * **A (3 minutes) & B (15 minutes):** These durations are too short. Fetal sleep cycles can last up to 40 minutes; therefore, a short observation window might result in a false-positive "non-reactive" result simply because the fetus is sleeping. * **D (60 minutes):** While an NST can be extended to 40 or 60 minutes if the initial 20-minute period is non-reactive (to account for fetal sleep), the standard diagnostic window for defining a reactive test is 20 minutes. **3. High-Yield Clinical Pearls for NEET-PG:** * **The "15x15" Rule:** For pregnancies >32 weeks, accelerations must be ≥15 bpm for ≥15 seconds. For **preterm fetuses (<32 weeks)**, the criteria are lower: **10 bpm for 10 seconds**. * **Non-Reactive NST:** If criteria are not met within 40 minutes, the test is non-reactive. The next step is usually a **Biophysical Profile (BPP)** or a **Contraction Stress Test (CST)**. * **Most Common Cause of Non-Reactive NST:** Fetal sleep cycle. * **Vibroacoustic Stimulation (VAS):** Can be used to "wake" the fetus and shorten the time to a reactive result.

Question 1

What is the impact on the fetus in case of use of Indomethacin in utero in the third trimester?

Accepted Answer

Early closure of ductus arteriosus

Answer

Patent ductus arteriosus

Answer

Ventricular septal defect

Answer

Atrial septal defect

Question 2

When should fibroids in pregnancy be removed?

Accepted Answer

Fibroids in pregnancy should not be removed

Answer

During pregnancy

Answer

During cesarean section

Answer

In the early puerperium

Question 3

Which of the following are risk factors for preeclampsia?

Accepted Answer

Chronic hypertension, obesity, placental ischemia, antiphospholipid syndrome

Answer

Chronic hypertension, obesity, placental ischemia, multigravidae

Answer

Placental ischemia, multigravidae, antiphospholipid syndrome

Answer

Chronic hypertension, multigravidae, antiphospholipid syndrome

Question 4

Oligohydramnios is seen in which of the following conditions?

Accepted Answer

Renal agenesis

Answer

Oesophageal atresia

Answer

Exomphalos

Answer

Neural tube defect

Question 5

An ectopic pregnancy is shed as?

Accepted Answer

Decidua vera

Answer

Decidua basalis

Answer

Decidua capsularis

Answer

Decidua rubra

Question 6

A 28-year-old pregnant lady at 23 weeks of gestation presents to the emergency room with headache, blurring of vision, vomiting, and convulsion. On examination, her blood pressure is 195/150 mm Hg, and she has ankle edema and urinary proteinuria. Intravenous magnesium sulfate was administered and she recovered smoothly. During discharge, which of the following medications will be justified for her management?

Accepted Answer

Metoprolol

Answer

Nifedipine

Answer

Methyldopa

Answer

Olmesartan

Question 7

A patient with systemic lupus erythematosus desires pregnancy. What should her physician advise her regarding pregnancy in lupus patients?

Accepted Answer

There may be an increase in spontaneous abortions and prematurity.

Answer

There is no increased risk to the fetus.

Answer

There may be an increase in cardiovascular malformations.

Answer

There may be an increase in nervous system malformations.

Question 8

In which of the following conditions, the medical treatment of ectopic pregnancy is contraindicated?

Accepted Answer

Presence of fetal heart activity

Answer

Sac size is 3 cm

Answer

Blood in pelvis is 70 mL

Answer

Previous ectopic pregnancy

Question 9

In a normal Non-Stress Test (NST), what is the time period for observing two or three accelerations that peak at 15 bpm or more above the baseline?

Accepted Answer

20 minutes

Answer

3 minutes

Answer

15 minutes

Answer

60 minutes

Question 10

At 29 weeks gestational age, it becomes apparent that the fetus has developed hydrops. All of the following are characteristics of fetal hydrops except?

Accepted Answer

Small placenta

Answer

Polyhydramnios

Answer

Pericardial effusion

Answer

Subcutaneous edema

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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