Maternal-Fetal Medicine Practice Questions

Q: What is the recommended treatment for placenta accreta?

Hysterectomy. **Explanation:** **Placenta Accreta** is a life-threatening obstetric complication where the chorionic villi adhere directly to the myometrium due to a partial or total absence of the decidua basalis. **Why Hysterectomy is the Correct Answer:** The gold standard and recommended management for placenta accreta is a **planned cesarean hysterectomy**. Attempting to detach the placenta often leads to massive, uncontrollable postpartum hemorrhage (PPH) because the placenta cannot separate naturally from the uterine wall. To minimize blood loss and maternal morbidity, the uterus is removed with the placenta left *in situ* after the delivery of the fetus. **Analysis of Incorrect Options:** * **A. Manual separation:** This is strictly **contraindicated**. Forcing separation leads to profuse hemorrhage, disseminated intravascular coagulation (DIC), and maternal mortality. * **C. Leave it alone:** While "expectant management" (leaving the placenta to resorb) is an option for women strongly desiring future fertility, it is not the *recommended* primary treatment due to high risks of delayed hemorrhage and severe infection/sepsis. * **D. Hysterectomy and removal of placenta:** This is incorrect because the placenta should **not** be removed prior to or during the hysterectomy. Attempting to remove it first triggers the very bleeding the surgery aims to avoid. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Most common risk factors are a **previous Cesarean section** and **Placenta Previa**. * **Spectrum:** Accreta (adheres to myometrium), Increta (invades myometrium), Percreta (penetrates through serosa/into bladder). * **Diagnosis:** Antenatal diagnosis is primarily via **Ultrasound/Doppler** (look for "Swiss cheese" appearance/placental lacunae and loss of retroplacental hypoechoic zone). * **Management:** If diagnosed antenatally, the surgery is ideally scheduled at **34 0/7–35 6/7 weeks** of gestation.

Q: A 25-year-old female presents to the casualty with a history of amenorrhea for two and a half months and abdominal pain and bleeding per vaginum for one day. On examination, vital parameters and other systems are normal. On speculum examination, bleeding is found to come from the Os. On bimanual examination, the uterus is of 10 weeks size, soft, and the Os admits one finger. What is the most likely diagnosis?

Inevitable abortion. **Explanation:** The clinical presentation of amenorrhea, vaginal bleeding, and abdominal pain in the first trimester suggests a spontaneous abortion. The definitive diagnostic feature in this case is the **dilated internal cervical os** (admits one finger) in the presence of vaginal bleeding. 1. **Inevitable Abortion (Correct):** This is defined as a clinical state where the pregnancy is complicated by vaginal bleeding and abdominal pain, and the **internal os is open**, making the continuation of pregnancy impossible. The uterine size usually corresponds to the period of amenorrhea (10 weeks in this case). 2. **Threatened Abortion (Incorrect):** While bleeding and pain are present, the hallmark of threatened abortion is a **closed internal os**. The pregnancy is potentially viable. 3. **Missed Abortion (Incorrect):** This refers to the retention of a dead fetus in utero for several weeks. Typically, the **internal os is closed**, and the uterine size is **smaller** than the period of amenorrhea. 4. **Incomplete Abortion (Incorrect):** In this condition, some products of conception have been expelled while some remain. The **os is open**, but the uterine size is typically **smaller** than the period of amenorrhea due to partial evacuation. **High-Yield Clinical Pearls for NEET-PG:** * **Os Status is Key:** If the Os is **Closed**, it is either Threatened, Missed, or Complete abortion. If the Os is **Open**, it is either Inevitable or Incomplete abortion. * **Management of Inevitable Abortion:** If 12 weeks, uterine contraction is induced via Oxytocin or Prostaglandins. * **Uterine Size:** In Inevitable abortion, Uterine Size = Period of Amenorrhea. In Incomplete/Missed abortion, Uterine Size < Period of Amenorrhea.

Q: A 25-week pregnant patient presents with severe left calf pain and swelling. The affected area is slightly edematous, with no erythema. A positive Homan sign is noted, raising concern for deep vein thrombosis. Which diagnostic modality should be ordered?

Real-time ultrasonography. **Explanation:** The clinical presentation of unilateral calf pain, swelling, and a positive Homan sign in a pregnant patient is highly suggestive of **Deep Vein Thrombosis (DVT)**. Pregnancy is a hypercoagulable state, increasing the risk of venous thromboembolism (VTE) by 4 to 5-fold. **Why Real-time Ultrasonography is correct:** Compression **Duplex Ultrasonography** (Real-time B-mode imaging combined with color Doppler) is the **first-line diagnostic modality** for suspected DVT in pregnancy. It is non-invasive, lacks ionizing radiation (making it safe for the fetus), and has high sensitivity and specificity (over 95%) for detecting proximal DVT. The primary diagnostic criterion is the **non-compressibility** of the vein under the ultrasound probe. **Why other options are incorrect:** * **MRI (Option A):** While accurate for diagnosing pelvic vein thrombosis, it is expensive, not readily available, and not the initial investigation of choice. * **Computed Tomographic Scanning (Option B):** CT involves significant ionizing radiation exposure to the fetus and requires intravenous contrast, which is generally avoided in pregnancy unless pulmonary embolism is suspected and other tests are inconclusive. * **Venography (Option C):** Once the "gold standard," it is now rarely used because it is invasive, technically difficult, and involves significant fetal radiation exposure. **Clinical Pearls for NEET-PG:** * **Left-sided Predominance:** 80-90% of pregnancy-related DVTs occur in the **left leg** due to "May-Thurner Syndrome" (compression of the left common iliac vein by the right common iliac artery). * **D-dimer:** Its utility is limited in pregnancy because D-dimer levels naturally increase with gestational age, leading to low specificity. * **Treatment:** Low Molecular Weight Heparin (LMWH) is the drug of choice. **Warfarin is contraindicated** due to teratogenicity (except in specific cases like mechanical heart valves).

Q: What is the ideal management for a 37-week pregnant elderly primigravida with placenta previa and active bleeding?

Cesarean section. **Explanation:** The correct management is **Cesarean section** because the patient is at term (37 weeks) and presenting with active bleeding due to placenta previa. In placenta previa, the placenta is implanted over the internal os; as the cervix dilates, the placental attachments are sheared, leading to life-threatening maternal hemorrhage and fetal distress. 1. **Why Cesarean Section is Correct:** At 37 weeks, the fetus is mature. Since the placenta obstructs the birth canal, vaginal delivery is contraindicated as it would cause massive bleeding. Immediate delivery via Cesarean section is the definitive treatment to save both mother and child when there is active bleeding at term. 2. **Why other options are incorrect:** * **Labor induction/Vaginal delivery:** These are contraindicated in placenta previa (especially if the edge is <2cm from the os) because the presenting part cannot engage, and cervical dilation will cause catastrophic hemorrhage. * **Expectant management (MacAfee regime):** This is only indicated if the pregnancy is <37 weeks, the bleeding is slight/stopped, and both mother and fetus are stable. Since this patient is 37 weeks (term) and has active bleeding, expectant management is no longer appropriate. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) is the most accurate and safe method to localize the placenta. * **Contraindication:** Never perform a per-vaginal (PV) examination in a case of antepartum hemorrhage until placenta previa is ruled out, as it can provoke torrential bleeding (the "Stallworthy's sign" may be seen on abdominal exam). * **Elderly Primigravida:** This factor increases the risk of complications, further favoring a controlled surgical delivery.

Q: What is the most important factor affecting the outcome of twin gestation?

Chorionicity. **Explanation:** In twin gestations, **chorionicity** (the number of placentas) is the single most important factor determining both maternal and fetal prognosis. Monochorionic (MC) twins carry significantly higher risks compared to dichorionic (DC) twins due to the presence of vascular anastomoses on the placental surface. These connections can lead to unique, life-threatening complications such as **Twin-to-Twin Transfusion Syndrome (TTTS)**, Twin Anemia-Polycythemia Sequence (TAPS), and Twin Reversed Arterial Perfusion (TRAP) sequence. Additionally, MC twins have higher rates of congenital anomalies, intrauterine growth restriction (IUGR), and fetal demise. **Analysis of Options:** * **Lie of the first/second twin (A & B):** While the presentation (e.g., vertex vs. non-vertex) is crucial for determining the **mode of delivery** (vaginal vs. cesarean), it does not dictate the overall pregnancy outcome or the risk of antenatal complications. * **Placental position (D):** While a low-lying placenta (placenta previa) can cause antepartum hemorrhage, it is a general obstetric complication and not the primary driver of twin-specific morbidity. **High-Yield Clinical Pearls for NEET-PG:** * **Lambda Sign (Twin Peak Sign):** Diagnostic of **Dichorionic** twins on ultrasound (seen at the membrane-placenta junction). * **T-Sign:** Diagnostic of **Monochorionic** twins (thin membrane meeting the placenta at a 90-degree angle). * **Optimal Timing for Chorionicity:** Best determined by ultrasound in the first trimester (**10–14 weeks**). * **Perinatal Mortality:** Is 3–4 times higher in monochorionic twins compared to dichorionic twins.

Question 1

In peripartum cardiomyopathy, cardiac failure can develop anytime during which period?

Accepted Answer

The last month of pregnancy or within 5 months after delivery

Answer

The antenatal period

Answer

The third trimester

Answer

The first 6 weeks postpartum

Question 2

What is the recommended treatment for placenta accreta?

Accepted Answer

Hysterectomy

Answer

Manual separation

Answer

Leave it alone

Answer

Hysterectomy and removal of placenta

Question 3

Cesarean delivery is mandatory in which of the following types of placenta previa?

Accepted Answer

Type 3

Answer

Type 1

Answer

Type 2

Answer

All of the above

Question 4

A 25-year-old female presents to the casualty with a history of amenorrhea for two and a half months and abdominal pain and bleeding per vaginum for one day. On examination, vital parameters and other systems are normal. On speculum examination, bleeding is found to come from the Os. On bimanual examination, the uterus is of 10 weeks size, soft, and the Os admits one finger. What is the most likely diagnosis?

Accepted Answer

Inevitable abortion

Answer

Threatened abortion

Answer

Missed abortion

Answer

Incomplete abortion

Question 5

A 25-week pregnant patient presents with severe left calf pain and swelling. The affected area is slightly edematous, with no erythema. A positive Homan sign is noted, raising concern for deep vein thrombosis. Which diagnostic modality should be ordered?

Accepted Answer

Real-time ultrasonography

Answer

MRI

Answer

Computed tomographic scanning

Answer

Venography

Question 6

What is the ideal management for a 37-week pregnant elderly primigravida with placenta previa and active bleeding?

Accepted Answer

Cesarean section

Answer

Labor induction

Answer

Vaginal delivery

Answer

Expectant management

Question 7

What is the recommended advice for an HIV-positive primigravida near term?

Accepted Answer

Treatment should be initiated before labor.

Answer

Avoid mixing of blood during labor.

Answer

Vaginal delivery is preferred.

Answer

Cesarean section would decrease transmission of HIV to the baby.

Question 8

What is the most important factor affecting the outcome of twin gestation?

Accepted Answer

Chorionicity

Answer

Lie of the first twin

Answer

Lie of the second twin

Answer

Placental position

Question 9

For karyotype analysis of stillborns, what is the recommended tissue sample, excluding which option?

Accepted Answer

Fetal skin

Answer

Umbilical cord segment about 1.5 cm long

Answer

Fetal patella

Answer

Placental block taken below cord insertion

Question 10

Aneuploidy is the most common genetic abnormality, accounting for up to 50% of clinical miscarriages. All are true about aneuploidy, EXCEPT?

Accepted Answer

50-60% of fetuses with trisomy 18 die between 12 weeks and 40 weeks gestation.

Answer

30-40% of fetuses with trisomy 21 die between 12 weeks and 40 weeks gestation.

Answer

The occurrence of triploidy is not related to the progression of maternal age.

Answer

In a previous pregnancy with trisomy 21 due to non-disjunction, the risk in a future pregnancy is 0.75% higher.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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