Maternal-Fetal Medicine — MCQs

A 30-year-old pregnant woman visits her obstetrician for prenatal care. The patient reports that two of her three children had "yellow jaundice" at birth, and her youngest child was severely jaundiced and required two blood transfusions. Prenatal laboratory tests reveal the mother is blood type O, Rh negative, and her husband is blood type A, Rh positive. The obstetrician obtains amniotic fluid at 36 weeks of gestation to determine if the fetus is mature enough for preterm delivery. Which of the following quantitative analyses of amniotic fluid is most likely used as an indicator of fetal lung maturity?

Q235Medium

Increased alpha-fetoprotein (AFP) level is seen in which of the following conditions?

Q236Medium

A female has a history of 6 weeks amenorrhea, and ultrasound shows no sac. Serum beta-hCG is 1000 IU/L. What is the next step in the management of this patient?

Q237Easy

What is the regimen used for expectant management of placenta previa?

Q238Easy

What type of placental insertion is shown?

Q239Easy

What is the maximum amount of amniotic fluid in a normal pregnancy?

Q240Medium

A multigravida with previous 2 normal deliveries presents with an unstable lie of the fetus at 34 weeks gestation. What is the most probable cause?

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 231: Which of the following is NOT typically performed in the management of Intrauterine Growth Restriction (IUGR)?

A. Non-stress test
B. Oxytocin challenge test
C. Ultrasound of the abdomen
D. Amniocentesis (Correct Answer)

Explanation: **Explanation:** The management of Intrauterine Growth Restriction (IUGR) focuses on identifying the cause, monitoring fetal well-being, and determining the optimal timing for delivery. **Why Amniocentesis is the correct answer:** Amniocentesis is an invasive procedure used primarily for genetic testing (karyotyping) or assessing fetal lung maturity. While it may be used in early-onset IUGR to rule out chromosomal anomalies, it is **not a routine or typical management tool** for monitoring or managing a diagnosed case of IUGR. Modern management relies on non-invasive biophysical and hemodynamic monitoring rather than invasive sampling. **Analysis of Incorrect Options:** * **Non-stress test (NST):** A primary tool for fetal surveillance in IUGR. It assesses the fetal heart rate pattern to ensure adequate oxygenation and acid-base balance. * **Oxytocin Challenge Test (OCT):** Also known as a Contraction Stress Test (CST), it evaluates the fetal respiratory reserve. It helps determine if the fetus can tolerate the stress of uterine contractions during labor, which is critical in growth-restricted fetuses with placental insufficiency. * **Ultrasound of the abdomen:** Essential for both diagnosis and monitoring. It is used for serial biometry (AC, EFW), assessing liquor volume (AFI), and performing Doppler studies (Umbilical artery, Middle Cerebral Artery), which are the gold standard for IUGR management. **Clinical Pearls for NEET-PG:** * **Abdominal Circumference (AC):** The most sensitive biometric parameter for diagnosing IUGR. * **Ponderal Index:** Low in asymmetrical IUGR (the most common type, usually due to placental insufficiency). * **Doppler:** The "Absent End Diastolic Velocity" (AEDV) or "Reversed End Diastolic Velocity" (REDV) in the umbilical artery are critical indicators for urgent delivery. * **Amniotic Fluid:** Oligohydramnios is a common finding in IUGR due to reduced fetal renal perfusion (blood-flow shunting to the brain).

Question 232: Alcohol intake during pregnancy causes all of the following fetal effects, except?

A. Brachycephaly (Correct Answer)
B. Microcephaly
C. Hyperkinetic movements
D. Congenital anomalies

Explanation: **Explanation:** Alcohol is a potent teratogen that crosses the placenta, leading to a spectrum of disorders known as **Fetal Alcohol Spectrum Disorder (FASD)**. **1. Why Brachycephaly is the correct answer:** Alcohol intake during pregnancy typically results in **Dolichocephaly** (a long, narrow head) rather than Brachycephaly (a broad, short head). The characteristic craniofacial features of Fetal Alcohol Syndrome (FAS) include a thin upper lip, smooth philtrum, and short palpebral fissures. **2. Analysis of incorrect options:** * **Microcephaly:** Alcohol is neurotoxic and interferes with glial cell proliferation and migration. This leads to reduced brain volume and a characteristically small head circumference (Microcephaly). * **Hyperkinetic movements:** Prenatal alcohol exposure affects the development of the central nervous system, often manifesting postnatally as irritability, hyperactivity, attention deficit disorders (ADHD), and poor impulse control. * **Congenital anomalies:** Alcohol is associated with various structural defects, most notably **Septal heart defects** (VSD/ASD), limb abnormalities, and renal anomalies. **High-Yield Clinical Pearls for NEET-PG:** * **Safe Limit:** There is no known safe amount of alcohol during pregnancy. * **Classic Triad of FAS:** 1. Pre- and post-natal growth restriction. 2. CNS involvement (Microcephaly, intellectual disability). 3. Facial dysmorphism (Smooth philtrum, thin vermilion border, short palpebral fissures). * **Most sensitive period:** The first trimester is the most critical period for structural anomalies, while the third trimester is critical for brain growth and functional development.

Question 233: All of the following conditions cause an increase in Alpha-Fetoprotein (AFP) except?

A. Hepatoblastoma
B. Multiple gestation
C. Increased maternal weight (Correct Answer)
D. Anterior abdominal wall defect

Explanation: **Explanation:** Alpha-Fetoprotein (AFP) is a glycoprotein synthesized initially by the yolk sac and later by the fetal liver. It serves as a crucial biomarker in prenatal screening. **Why "Increased Maternal Weight" is the correct answer:** Maternal serum AFP (MSAFP) levels are **inversely proportional** to maternal weight. In obese or heavier women, the increased blood volume (plasma expansion) leads to a **hemodilution** effect, resulting in lower measurable concentrations of AFP. Therefore, maternal weight must be factored into the "Multiple of Median" (MoM) calculation to avoid false negatives. **Analysis of Incorrect Options:** * **Hepatoblastoma:** This is a primary liver tumor in children. Since AFP is produced by fetal liver cells, malignant transformation of these cells (or germ cells) leads to significantly elevated serum AFP levels. * **Multiple Gestation:** AFP levels are directly related to the number of fetuses. In twins or triplets, the combined production of AFP by multiple fetal livers and yolk sacs leads to higher maternal serum levels. * **Anterior Abdominal Wall Defects:** Conditions like **Gastroschisis** and **Omphalocele** allow AFP to leak directly from the fetal circulation/exposed viscera into the amniotic fluid and subsequently into the maternal serum, causing a marked increase. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of increased MSAFP:** Incorrect gestational age (dating error). * **Other causes of increased AFP:** Neural Tube Defects (Anencephaly, Spina Bifida), Renal anomalies (Finnish-type nephrosis), and Fetal demise. * **Causes of decreased AFP:** Down Syndrome (Trisomy 21), Trisomy 18, Molar pregnancy, and Increased maternal weight. * **Optimal timing for MSAFP screening:** 15 to 20 weeks of gestation (Second trimester).

Question 234: A 30-year-old pregnant woman visits her obstetrician for prenatal care. The patient reports that two of her three children had "yellow jaundice" at birth, and her youngest child was severely jaundiced and required two blood transfusions. Prenatal laboratory tests reveal the mother is blood type O, Rh negative, and her husband is blood type A, Rh positive. The obstetrician obtains amniotic fluid at 36 weeks of gestation to determine if the fetus is mature enough for preterm delivery. Which of the following quantitative analyses of amniotic fluid is most likely used as an indicator of fetal lung maturity?

A. Absorbance at 450 nm
B. Alpha-fetoprotein
C. Creatinine
D. Lecithin (Correct Answer)

Explanation: **Explanation:** The correct answer is **Lecithin (D)**. **1. Why Lecithin is Correct:** The clinical scenario describes a case of **Rh isoimmunization** (Rh-negative mother, Rh-positive father, and a history of progressively worsening neonatal jaundice). In such cases, early delivery may be necessary if fetal hemolysis is severe. To ensure the fetus can survive outside the womb, **Fetal Lung Maturity (FLM)** must be assessed. Lecithin (dipalmitoylphosphatidylcholine) is the primary component of **pulmonary surfactant**. Its concentration in amniotic fluid increases significantly after 34–35 weeks of gestation. The **Lecithin/Sphingomyelin (L/S) ratio** is a classic gold standard for FLM; a ratio **>2.0** typically indicates mature lungs and a low risk of Respiratory Distress Syndrome (RDS). **2. Why Other Options are Incorrect:** * **A. Absorbance at 450 nm ($\Delta OD_{450}$):** This measures **bilirubin** levels in amniotic fluid using spectrophotometry (Liley’s Chart or Queenan Curve). While relevant to this patient's Rh isoimmunization to assess the severity of fetal anemia, it does *not* measure lung maturity. * **B. Alpha-fetoprotein (AFP):** Used to screen for **Neural Tube Defects** (elevated) or chromosomal anomalies like Down syndrome (decreased). * **C. Creatinine:** Amniotic fluid creatinine levels reflect **fetal renal maturity** and muscle mass, not pulmonary status. **3. Clinical Pearls for NEET-PG:** * **Phosphatidylglycerol (PG):** Its presence is the most reliable indicator of lung maturity, especially in **diabetic mothers**, where the L/S ratio may be falsely reassuring. * **Amniostat-FLM:** An immunological test for PG. * **Lamellar Body Count (LBC):** A rapid, automated test; a count **>30,000–50,000/µL** indicates maturity. * **Shake Test (Foam Stability Index):** A bedside screening test for surfactant.

Question 235: Increased alpha-fetoprotein (AFP) level is seen in which of the following conditions?

A. Down syndrome
B. Molar pregnancy
C. Overestimated gestational age (Correct Answer)
D. Congenital nephrotic syndrome

Explanation: **Explanation:** Alpha-fetoprotein (AFP) is a glycoprotein produced initially by the yolk sac and later by the fetal liver. Its levels in maternal serum (MSAFP) change significantly with gestational age, peaking between 16 and 18 weeks. **Why "Overestimated Gestational Age" is the correct answer:** The most common cause of an "abnormal" AFP result is **incorrect dating**. AFP levels rise progressively during the second trimester. If a clinician **overestimates** the gestational age (e.g., thinks the patient is 18 weeks when she is actually 14 weeks), the measured AFP will appear **falsely low** for the perceived higher gestational age. Conversely, if the gestational age is **underestimated** (the patient is further along than thought), the AFP will appear **falsely elevated**. *Note: While the question asks for "Increased AFP," in the context of standardized exams like NEET-PG, "Overestimated gestational age" is frequently used as a distractor or a test of the relationship between dating and AFP. However, strictly speaking, **underestimation** causes high AFP, and **overestimation** causes low AFP. Given the options provided, this highlights the importance of "Dating Error" as the single most common cause of abnormal AFP.* **Analysis of Incorrect Options:** * **Down Syndrome (Trisomy 21):** Characteristically associated with **decreased** MSAFP, decreased uE3, and increased hCG/Inhibin-A (the "Quad test" pattern). * **Molar Pregnancy:** Associated with extremely high hCG levels but **decreased** MSAFP because there is no functional fetal liver to produce the protein. * **Congenital Nephrotic Syndrome (Finnish type):** This condition causes massive leakage of AFP into the amniotic fluid, leading to **markedly increased** MSAFP. (While this also shows increased AFP, dating errors are statistically the most common cause encountered in clinical practice). **High-Yield Clinical Pearls for NEET-PG:** * **Causes of Increased MSAFP:** Neural tube defects (spina bifida, anencephaly), abdominal wall defects (omphalocele, gastroschisis), multiple gestations, and fetal demise. * **Causes of Decreased MSAFP:** Trisomy 21, Trisomy 18, Molar pregnancy, and Maternal obesity. * **Next Step:** If MSAFP is elevated, the first step is always a **targeted ultrasound** to confirm gestational age, exclude twins, and check for structural anomalies.

Question 236: A female has a history of 6 weeks amenorrhea, and ultrasound shows no sac. Serum beta-hCG is 1000 IU/L. What is the next step in the management of this patient?

A. Medical management
B. Repeat hCG after 48 hours (Correct Answer)
C. Repeat hCG after 1 week
D. None of the above

Explanation: ### Explanation The management of a pregnancy of unknown location (PUL) depends on the **Discriminatory Zone**, which is the serum beta-hCG level above which an intrauterine gestational sac should be visible on ultrasound. For Transvaginal Sonography (TVS), this threshold is typically **1500–2000 IU/L**. **1. Why Option B is Correct:** In this patient, the beta-hCG is **1000 IU/L**, which is below the discriminatory zone. Since the ultrasound is inconclusive (no sac seen), we cannot differentiate between an early viable intrauterine pregnancy, a failing intrauterine pregnancy, or an ectopic pregnancy. The standard protocol is to **repeat serum beta-hCG after 48 hours** to assess the "doubling time." A rise of at least 35–53% suggests a viable intrauterine pregnancy, while a plateau or sub-optimal rise raises suspicion for an ectopic pregnancy. **2. Why Other Options are Incorrect:** * **Option A (Medical Management):** Administering Methotrexate or surgical intervention is premature. Without a confirmed diagnosis of ectopic pregnancy or a non-viable pregnancy above the discriminatory zone, medical management risks terminating a potentially viable early pregnancy. * **Option C (Repeat hCG after 1 week):** A one-week interval is too long. Ectopic pregnancies can rupture quickly; monitoring every 48 hours is essential for patient safety and timely diagnosis. **Clinical Pearls for NEET-PG:** * **Discriminatory Zone:** TVS = 1500–2000 IU/L; Transabdominal Scan (TAS) = 6000–6500 IU/L. * **Doubling Time:** In 85% of viable pregnancies, hCG levels rise by ≥66% every 48 hours (though 35% is the minimum acceptable rise). * **Empty uterus + hCG >2000 IU/L:** Highly suggestive of ectopic pregnancy or recent complete abortion. * **Most common site of ectopic pregnancy:** Ampulla of the Fallopian tube.

Question 237: What is the regimen used for expectant management of placenta previa?

A. Macafee & Johnson regimen (Correct Answer)
B. Brandt Andrew method
C. Credé method
D. McDonald's regimen

Explanation: **Explanation:** The **Macafee & Johnson regimen** is the standard protocol for the expectant management of placenta previa. The primary objective is to prolong the pregnancy until fetal lung maturity is achieved (ideally 37 weeks) without compromising maternal safety. This approach is indicated when the patient is hemodynamically stable, the bleeding is not life-threatening, and the fetus is preterm (<37 weeks). **Why the correct answer is right:** The regimen involves hospitalization, bed rest, administration of corticosteroids (for lung maturity), and close monitoring. It aims to reduce the risk of prematurity, which is the leading cause of perinatal mortality in placenta previa cases. **Analysis of incorrect options:** * **Brandt-Andrew method:** A technique used in the third stage of labor to deliver the placenta by applying upward pressure on the fundus while maintaining steady tension on the umbilical cord. * **Credé method:** An obsolete and potentially dangerous technique of delivering the placenta by squeezing the uterine fundus like a "lemon." * **McDonald’s regimen:** Refers to a type of cervical cerclage (encirclage) used to treat cervical incompetence, not placenta previa. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisites for Macafee:** Hemodynamic stability, bleeding <37 weeks, and absence of fetal distress. * **Contraindication:** A **per-vaginal (PV) examination is strictly contraindicated** in suspected placenta previa as it can provoke torrential hemorrhage (the "Stallworthy's sign" or warning bleed). * **Diagnosis:** Transvaginal Ultrasound (TVS) is the gold standard for localization. * **Delivery:** Most cases of major placenta previa require Cesarean Section. Expectant management is terminated if there is fresh heavy bleeding or if the pregnancy reaches 37 weeks.

Question 238: What type of placental insertion is shown?

A. Battledore Placenta (Correct Answer)
B. Velamentous Insertion
C. Normal
D. Circumvallate

Explanation: ***Battledore Placenta*** - **Marginal cord insertion** where the umbilical cord inserts at the edge or margin of the placental disc, resembling a badminton racquet. - Associated with increased risk of **cord compression** during labor and potential **fetal growth restriction**, but generally has better outcomes than velamentous insertion. *Velamentous Insertion* - The umbilical cord inserts into the **fetal membranes** rather than the placental disc, with vessels running unprotected through the membranes. - Carries significant risk of **vasa previa** and **vessel rupture** during labor, leading to potential fetal hemorrhage and death. *Normal* - **Central cord insertion** occurs in the middle third of the placental disc, providing optimal blood flow distribution. - This is the most common and safest type of insertion, with minimal risk of complications during pregnancy and delivery. *Circumvallate* - A **placental abnormality** where the fetal membranes fold back over the fetal surface, creating a raised white ring around the placental edge. - Associated with increased risk of **placental abruption**, **preterm labor**, and **antepartum hemorrhage**.

Question 239: What is the maximum amount of amniotic fluid in a normal pregnancy?

A. 500ml
B. 800ml
C. 1000ml (Correct Answer)
D. 1500ml

Explanation: **Explanation:** Amniotic fluid volume is a dynamic parameter that changes throughout gestation. The correct answer is **1000ml** because this represents the physiological peak volume reached during a normal pregnancy. **Why 1000ml is correct:** Amniotic fluid volume increases progressively until the third trimester. It reaches its maximum volume of approximately **800–1000 ml at 34–36 weeks** of gestation. After this peak, the volume begins to gradually decline as the pregnancy approaches term and post-term periods. **Analysis of Incorrect Options:** * **500ml (A):** This is the approximate volume at 20 weeks of gestation. It is also close to the volume seen in mild oligohydramnios at term. * **800ml (B):** While 800ml is often cited as the average volume at 34 weeks, 1000ml is recognized as the "maximum" upper limit of the normal physiological range before it is classified as polyhydramnios. * **1500ml (D):** This volume is pathologically high. Any volume exceeding 1500–2000 ml is clinically defined as **Polyhydramnios**. **NEET-PG High-Yield Pearls:** * **Volume at Term (40 weeks):** Approximately 600–800 ml. * **Post-term (42 weeks):** Drops significantly to about 200–400 ml. * **Amniotic Fluid Index (AFI):** Normal range is 5–24 cm. * < 5 cm = Oligohydramnios * > 24/25 cm = Polyhydramnios * **Single Deepest Pocket (SDP):** Normal is 2–8 cm. * **Composition:** Early pregnancy is an ultrafiltrate of maternal plasma; late pregnancy is primarily composed of **fetal urine** (main source) and lung fluid.

Question 240: A multigravida with previous 2 normal deliveries presents with an unstable lie of the fetus at 34 weeks gestation. What is the most probable cause?

A. Placenta previa (Correct Answer)
B. Oligohydramnios
C. Uterine anomaly
D. Pelvic tumor

Explanation: **Explanation:** **Why Placenta Previa is the Correct Answer:** An **unstable lie** refers to a situation where the fetal presentation frequently changes (e.g., from transverse to oblique to longitudinal) after 34 weeks of gestation. In a multigravida, the most common cause of an unstable lie or a high floating head is a **space-occupying lesion in the lower uterine segment**. Placenta previa (especially the major degrees) prevents the fetal head from engaging in the maternal pelvis, forcing the fetus into an abnormal or unstable lie. It is a classic "mechanical" obstruction. **Analysis of Incorrect Options:** * **B. Oligohydramnios:** Reduced amniotic fluid typically leads to a **fixed** malpresentation (like breech) because the fetus lacks the fluid volume to move or change positions easily. It does not cause an unstable lie. * **C. Uterine Anomaly:** While anomalies like a bicornuate or septate uterus cause malpresentations, they are more likely to result in a **persistent** malpresentation rather than an unstable one, and are more commonly associated with nulliparity or recurrent pregnancy loss. * **D. Pelvic Tumor:** A large fibroid or ovarian cyst can cause an unstable lie by obstructing the pelvic inlet, but statistically, **placenta previa** is a more frequent and high-yield clinical cause in the third trimester for multigravidas. **High-Yield Clinical Pearls for NEET-PG:** * **Management:** The management of unstable lie at 34 weeks is **expectant** (observation), as many stabilize by 37 weeks. If it persists at 37 weeks, the patient is usually admitted to the hospital. * **Rule of Thumb:** Always exclude placenta previa via ultrasound before performing any internal examination or external cephalic version (ECV) in a patient with an unstable lie or malpresentation. * **Other Causes:** Polyhydramnios, lax abdominal wall (common in multiparity), and contracted pelvis are other significant causes of unstable lie.

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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