Maternal-Fetal Medicine Practice Questions

Q: A 28-year-old woman, gravida 4 para 3 living 2 abortion 1, at 35 weeks of gestation with a monochorionic monoamniotic twin pregnancy was admitted for safe confinement. Three days following admission, the Non-stress test (NST) showed the following finding: What is the finding shown in the NST?

Variable deceleration. ***Variable deceleration*** - **Variable decelerations** are the hallmark finding in **monochorionic monoamniotic (MoMo)** twin pregnancies due to high risk of **cord entanglement** between the twins sharing the same amniotic sac. - These decelerations have **variable timing, duration, and depth** in relation to uterine contractions, caused by **intermittent cord compression** from entangled umbilical cords. *Reactive NST* - A **reactive NST** shows **two or more fetal heart rate accelerations** of at least 15 bpm lasting 15 seconds within a 20-minute period. - This finding indicates **fetal well-being** and adequate **oxygenation**, which would not be expected with cord entanglement in MoMo twins. *Early deceleration* - **Early decelerations** are **gradual decreases** in fetal heart rate that **mirror uterine contractions**, starting and ending with the contraction. - They result from **fetal head compression** during contractions and are considered **physiologic**, not pathologic like cord entanglement. *Sinusoidal pattern* - **Sinusoidal pattern** shows a **smooth, sine wave-like** undulating baseline with **regular oscillations** of 5-15 bpm. - This pattern is associated with **severe fetal anemia**, **Rh isoimmunization**, or **fetal-maternal hemorrhage**, not cord compression.

Q: Which of the following is NOT associated with hydramnios?

Renal agenesis. **Explanation:** The correct answer is **Renal agenesis**. To understand this, one must recall the physiology of amniotic fluid: from the second trimester onwards, fetal urine is the primary contributor to amniotic fluid volume. 1. **Why Renal Agenesis is the correct answer:** In renal agenesis (Potter’s Syndrome), the fetal kidneys fail to develop. Consequently, there is no urine production, leading to **Oligohydramnios** (decreased fluid), not hydramnios. This lack of fluid often results in pulmonary hypoplasia and limb deformities due to compression. 2. **Analysis of Incorrect Options:** * **Premature labor:** Hydramnios causes overdistension of the uterus. This stretches the myometrium, leading to increased uterine irritability and the premature onset of contractions. * **Gestational diabetes:** Maternal hyperglycemia leads to fetal hyperglycemia, which causes **osmotic diuresis** in the fetus (increased fetal polyuria), resulting in hydramnios. * **Increased amniotic fluid:** This is the literal definition of hydramnios (Amniotic Fluid Index >24 cm or Single Deepest Pocket >8 cm). **High-Yield Clinical Pearls for NEET-PG:** * **Common Causes of Polyhydramnios:** Fetal structural anomalies that interfere with swallowing (e.g., Esophageal/Duodenal atresia, Anencephaly), Maternal Diabetes, and Rh-isoimmunization. * **Common Causes of Oligohydramnios:** Renal agenesis, Posterior Urethral Valves (in males), Premature Rupture of Membranes (PROM), and Placental Insufficiency. * **Amniotic Fluid Index (AFI):** Normal range is 5–24 cm. 24 cm is Polyhydramnios.

Q: The "lambda sign" or "twin peak sign" is seen in which type of twin pregnancy?

Dichorionic diamniotic. ### Explanation The **Lambda sign** (also known as the **Twin Peak sign**) is a crucial sonographic marker used to determine chorionicity in twin pregnancies, typically between 10 and 14 weeks of gestation. **1. Why Dichorionic Diamniotic (DCDA) is correct:** In a DCDA pregnancy, each fetus has its own placenta and gestational sac. Where the two placentas meet, the intervening membrane is thick because it consists of four layers (two layers of chorion and two layers of amnion). This results in a **triangular projection of placental tissue** extending into the base of the inter-twin membrane, resembling the Greek letter lambda (λ). This sign confirms that there are two separate placentas (even if they appear fused). **2. Why the other options are incorrect:** * **Diamniotic Monochorionic (MCDA):** These twins share a single placenta. The inter-twin membrane is thin (only two layers of amnion) and joins the placenta abruptly without any intervening placental tissue. This creates a **"T-sign"** rather than a lambda sign. * **Monoamniotic Monochorionic (MCMA):** These twins share both a placenta and an amniotic sac. There is no inter-twin membrane at all; therefore, neither the lambda nor the T-sign is present. ### High-Yield Clinical Pearls for NEET-PG: * **Timing:** Chorionicity is most accurately determined in the **first trimester** (10–14 weeks). As the pregnancy progresses, the lambda sign may disappear (the "vanishing lambda sign"), making early scans vital. * **Membrane Thickness:** A membrane thickness of **>2 mm** usually indicates DCDA, while **<2 mm** suggests MCDA. * **Significance:** Determining chorionicity is the most important step in managing twin pregnancies, as monochorionic twins are at high risk for **Twin-to-Twin Transfusion Syndrome (TTTS)**.

Q: Cord blood gas and pH analysis is done in the following circumstances, except?

Antepartum hemorrhage. **Explanation:** Umbilical cord blood gas (UCBG) analysis is the objective "gold standard" for assessing the metabolic status of a newborn at the time of delivery. It is primarily indicated when there is a high suspicion of **fetal acidemia** or intrapartum hypoxia. **Why Antepartum Hemorrhage (APH) is the correct answer:** APH (e.g., placenta previa or abruptio placentae) is a clinical diagnosis and an obstetric emergency. While severe abruption can lead to fetal distress, APH itself is not a direct indication for cord gas analysis unless it results in a low APGAR score or fetal distress during labor. The analysis is performed to document the newborn's condition *after* delivery, not as a routine response to maternal bleeding. **Analysis of Incorrect Options:** * **Low 5-minute APGAR score:** This is a primary indication. A score <7 necessitates UCBG to differentiate between birth asphyxia (metabolic acidosis) and other causes of depression (e.g., maternal sedation). * **Maternal thyroid disease:** Maternal thyrotoxicosis or Graves' disease can lead to fetal/neonatal thyrotoxicosis or goiter. Cord blood is often sampled here to check fetal thyroid function (T4/TSH) and acid-base status. * **Severe Fetal Growth Restriction (FGR):** FGR fetuses have chronic placental insufficiency and reduced reserve, making them highly susceptible to intrapartum hypoxia and acidosis. **NEET-PG High-Yield Pearls:** * **Sampling:** Ideally taken from the **umbilical artery** (reflects fetal status) rather than the vein (reflects placental status). * **Normal pH:** Approximately 7.20–7.30. * **Pathological Acidemia:** Defined as a pH **<7.00** and a base deficit **≥12 mmol/L**. This threshold is strongly associated with an increased risk of neurological deficits (e.g., Cerebral Palsy). * **Indications:** Abnormal FHR patterns (Category III), operative delivery for fetal distress, and multiple gestations.

Q: With regards to acute pyelonephritis in pregnancy, all of the following are true except:

Left kidney is involved in 50% of patients.. **Explanation:** Acute pyelonephritis is one of the most common medical complications of pregnancy, occurring in approximately 1–2% of pregnancies. **Why Option A is the Correct Answer (The False Statement):** In pregnancy, the **right kidney** is involved in the majority of cases (70–80%), not the left. This is due to **dextrorotation of the uterus**, which causes mechanical compression of the right ureter at the pelvic brim. Additionally, the right ovarian vein complex, which is dilated during pregnancy, crosses the right ureter, further contributing to stasis. While bilateral involvement occurs in about 25% of cases, isolated left-sided involvement is rare. **Analysis of Other Options:** * **Option B:** **E. coli** is indeed the most common isolate, responsible for 70–80% of cases, followed by *Klebsiella pneumoniae* and *Proteus*. * **Option C:** It is more common in the **later half of pregnancy** (second and third trimesters). This is because the physiological changes—progesterone-induced ureteral smooth muscle relaxation and mechanical obstruction by the enlarging uterus—peak during this period. * **Option D:** Pyelonephritis **responds well to aminoglycosides** (like Gentamicin) often used in combination with Ampicillin or Cephalosporins. Intravenous hydration and antibiotics are the standard of care. **High-Yield Clinical Pearls for NEET-PG:** * **Physiological Hydroureter:** More prominent on the right side. * **Complication:** The most serious complication is **ARDS** (due to endotoxin-induced alveolar damage) and septic shock. * **Screening:** Asymptomatic bacteriuria must be treated in pregnancy to prevent progression to pyelonephritis (occurs in 25% of untreated cases). * **Recurrence:** Patients require suppressive antibiotic therapy (e.g., Nitrofurantoin) for the remainder of the pregnancy after an acute episode.

Q: A woman presents with right-sided lower abdominal pain and mild vaginal bleeding at 6 weeks of gestation. Her general condition is satisfactory, and a urine hCG test is positive. Transvaginal ultrasound reveals an adnexal mass measuring 30 mm in diameter without cardiac activity, and no intrauterine pregnancy is seen. What is the most appropriate management?

Intramuscular methotrexate. **Explanation:** The clinical presentation of abdominal pain, vaginal bleeding, and an empty uterus on ultrasound with a positive hCG is classic for an **Ectopic Pregnancy**. **Why Intramuscular Methotrexate is correct:** Medical management with Methotrexate (MTX) is the treatment of choice in hemodynamically stable patients who meet specific criteria. This patient is a prime candidate because: 1. **Hemodynamic stability:** Her general condition is "satisfactory." 2. **Mass size:** The adnexal mass is ≤ 3.5 cm (30 mm). 3. **Fetal Cardiac Activity:** Absent (a prerequisite for MTX). 4. **Gestational age:** Early presentation (6 weeks). **Why the other options are incorrect:** * **Laparoscopic Salpingectomy (A):** This involves removing the fallopian tube. It is indicated for ruptured ectopic pregnancy, hemodynamic instability, or when medical management fails/is contraindicated. * **Laparoscopic Salpingo-oophorectomy (B):** This involves removing both the tube and the ovary. It is rarely indicated for ectopic pregnancy unless there is extensive ovarian involvement or torsion. * **Laparoscopic Salpingotomy (C):** This is a fertility-preserving surgery where the tube is opened and the products are removed. While an option for stable patients desiring future fertility, medical management (MTX) is less invasive and preferred when the mass is < 3.5 cm. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) + Serum β-hCG. * **Discriminatory Zone:** The β-hCG level (usually 1500–2000 mIU/mL) at which an intrauterine sac should be visible on TVS. * **MTX Contraindications:** Breastfeeding, immunodeficiency, ruptured ectopic, or hepatic/renal/hematologic dysfunction. * **Most common site:** Ampulla of the Fallopian tube. * **Most common site for rupture:** Isthmus (due to narrow lumen).

Q: In gestational hypertension, hypertension should resolve by how many weeks in the postpartum period?

12 weeks. **Explanation:** **1. Why 12 Weeks is Correct:** Gestational hypertension is defined as the new onset of hypertension (Systolic BP ≥140 mmHg or Diastolic BP ≥90 mmHg) after 20 weeks of gestation in a previously normotensive woman, without proteinuria or features of end-organ dysfunction. By definition, this condition is **transient**. According to ACOG and NHBPEP guidelines, the blood pressure must return to normal by **12 weeks postpartum**. If hypertension persists beyond 12 weeks, the diagnosis is revised to **Chronic Hypertension**. **2. Why Other Options are Incorrect:** * **A (2 weeks) & B (6 weeks):** While many patients see a resolution of BP within the first few days or weeks after delivery, these timeframes are too short to be the diagnostic cutoff. Six weeks marks the end of the traditional puerperium, but the physiological changes of pregnancy can take longer to stabilize. * **C (8 weeks):** This is an arbitrary timeframe and does not align with the standardized diagnostic criteria used in international obstetric guidelines. **3. Clinical Pearls & High-Yield Facts for NEET-PG:** * **Transient Hypertension:** If BP resolves by 12 weeks postpartum, the retrospective diagnosis is "Transient Hypertension of Pregnancy." * **Chronic Hypertension:** Hypertension present *before* pregnancy or diagnosed *before* 20 weeks of gestation is termed Chronic Hypertension. * **Preeclampsia:** If gestational hypertension is accompanied by proteinuria (>300mg/24hrs) or signs of end-organ damage (e.g., thrombocytopenia, elevated liver enzymes), it is classified as Preeclampsia. * **Risk Factor:** Women with gestational hypertension have a higher risk of developing essential hypertension and cardiovascular disease later in life.

Q: A G2P1 patient on warfarin presents at 38 weeks in labor. What is the next step in management?

Stop warfarin and proceed with cesarean section.. **Explanation:** The management of a patient on warfarin in active labor is a critical scenario due to the risk of **fetal intracranial hemorrhage**. Warfarin crosses the placenta and induces a fetal anticoagulant state. During the mechanical stress of labor—specifically during passage through the birth canal—the fetus is at an extremely high risk of internal bleeding. **1. Why Option B is Correct:** When a patient presents in labor while taking warfarin, the priority is to minimize fetal trauma. **Cesarean section** is the preferred mode of delivery because it is associated with less mechanical trauma to the fetal head compared to vaginal delivery, thereby reducing the risk of intracranial hemorrhage. Warfarin should be stopped immediately to manage maternal bleeding risks, and reversal agents (like Vitamin K or PCC) may be considered for the mother. **2. Why Other Options are Incorrect:** * **Option A:** Vaginal delivery is contraindicated because the fetal coagulation factors are depleted, making the risk of birth-trauma-induced hemorrhage unacceptably high. * **Options C & D:** While heparin is the preferred anticoagulant during pregnancy (as it does not cross the placenta), switching to heparin *at the time of active labor* at 38 weeks does not reverse the **existing fetal anticoagulation** caused by the warfarin already in the fetal system. It takes several days for fetal clotting factors to normalize after stopping warfarin. **High-Yield Clinical Pearls for NEET-PG:** * **Warfarin Embryopathy:** Occurs with exposure between 6–9 weeks (features: nasal hypoplasia, stippled epiphyses). * **Switching Protocol:** Ideally, warfarin should be switched to Heparin (LMWH or UFH) at **36 weeks** of gestation to allow fetal clotting factors to recover before labor begins. * **Breastfeeding:** Warfarin is **not** excreted in breast milk and is safe for postpartum anticoagulation.

Question 1

In which of the following clinical scenarios is Anti-D prophylaxis not recommended?

Accepted Answer

Spontaneous miscarriage at 14 weeks in a sensitized RhD-negative woman

Answer

Therapeutic termination of pregnancy by medical method in a 10-week non-sensitized RhD-negative woman

Answer

Medically managed ectopic pregnancy at 8 weeks in a non-sensitized RhD-negative woman

Answer

Threatened miscarriage in a 13-week non-sensitized RhD-negative woman

Question 2

What is the most common congenital heart disease during pregnancy?

Accepted Answer

Atrial Septal Defect (ASD)

Answer

Ventricular Septal Defect (VSD)

Answer

Tetralogy of Fallot (TOF)

Answer

Aortic Stenosis (AS)

Question 3

A 28-year-old woman, gravida 4 para 3 living 2 abortion 1, at 35 weeks of gestation with a monochorionic monoamniotic twin pregnancy was admitted for safe confinement. Three days following admission, the Non-stress test (NST) showed the following finding: What is the finding shown in the NST?

Accepted Answer

Variable deceleration

Answer

Reactive NST

Answer

Early deceleration

Answer

Sinusoidal pattern

Question 4

Which of the following is NOT associated with hydramnios?

Accepted Answer

Renal agenesis

Answer

Premature labor

Answer

Gestational diabetes

Answer

Increased amniotic fluid

Question 5

The "lambda sign" or "twin peak sign" is seen in which type of twin pregnancy?

Accepted Answer

Dichorionic diamniotic

Answer

Diamniotic monochorionic

Answer

Monochorionic monoamniotic

Answer

None of the above

Question 6

Cord blood gas and pH analysis is done in the following circumstances, except?

Accepted Answer

Antepartum hemorrhage

Answer

Low 5-minute APGAR score

Answer

Maternal thyroid disease

Answer

Severe fetal growth restriction

Question 7

With regards to acute pyelonephritis in pregnancy, all of the following are true except:

Accepted Answer

Left kidney is involved in 50% of patients.

Answer

Most common isolate is E. coli.

Answer

More common in the later half of pregnancy.

Answer

Responds to aminoglycosides.

Question 8

A woman presents with right-sided lower abdominal pain and mild vaginal bleeding at 6 weeks of gestation. Her general condition is satisfactory, and a urine hCG test is positive. Transvaginal ultrasound reveals an adnexal mass measuring 30 mm in diameter without cardiac activity, and no intrauterine pregnancy is seen. What is the most appropriate management?

Accepted Answer

Intramuscular methotrexate

Answer

Laparoscopic salpingectomy

Answer

Laparoscopic salpingo-oophorectomy

Answer

Laparoscopic salpingotomy

Question 9

In gestational hypertension, hypertension should resolve by how many weeks in the postpartum period?

Accepted Answer

12 weeks

Answer

2 weeks

Answer

6 weeks

Answer

8 weeks

Question 10

A G2P1 patient on warfarin presents at 38 weeks in labor. What is the next step in management?

Accepted Answer

Stop warfarin and proceed with cesarean section.

Answer

Stop warfarin and proceed with vaginal delivery.

Answer

Replace warfarin with heparin and proceed with vaginal delivery.

Answer

Replace warfarin with heparin and proceed with cesarean section.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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