Maternal-Fetal Medicine — MCQs

A 30-year-old obese woman with diabetes mellitus presents at 19 weeks' gestation. She notes recent lack of adherence to her diabetic regimen but is now motivated to improve. Her ophthalmologic examination and ECG are normal. Urinalysis is negative for proteinuria. Laboratory studies show: Hemoglobin A1c: 10.8%; Glucose: 222 mg/dL; TSH: 1.0 mIU/mL; Free T4: 1.7 ng/dL; Creatinine: 1.1 mg/dL. In which of the following conditions is the risk of development the same in diabetics as in the general population?

Q244Medium

Which of the following is NOT true about gestational diabetes mellitus complicating pregnancy?

Q245Medium

A 20-year-old married woman with a history of congenital heart disease presents for pre-conceptional counseling. Which of the following is the most likely adverse event she might face during pregnancy?

Q246Easy

Which is the smallest fetal diameter?

Q247Medium

A patient at 17 weeks gestation is diagnosed with intrauterine fetal demise on ultrasound. She presents 5 weeks after the scan without expelling the fetus, reporting occasional spotting. What is the primary risk for this patient?

Q248Easy

A primigravida in the 2nd trimester tested positive for toxoplasmosis. Vertical transmission of toxoplasmosis MOST commonly occurs in which trimester?

Q249Medium

Which of the following statements regarding listeriosis in pregnancy is FALSE?

Q250Medium

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

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 241: Ultrasound is useful in a diabetic mother in all the following except one?

A. Confirm fetal maturity (Correct Answer)
B. Detect fetal malformation
C. Detect hydramnios
D. Diagnose hydrocephalus

Explanation: **Explanation:** In diabetic pregnancies, ultrasound is a vital tool for monitoring, but it is **not reliable for confirming fetal maturity**, particularly lung maturity. 1. **Why Option A is correct:** In diabetic mothers, there is a significant **dissociation between fetal size and functional maturity**. Due to maternal hyperglycemia, the fetus often experiences accelerated growth (macrosomia). An ultrasound may show a large fetus with advanced biometry, but the fetal lungs may still be immature. Hyperinsulinemia in the fetus inhibits the production of surfactant by type II pneumocytes. Therefore, fetal maturity must be confirmed via gestational age dating or amniocentesis (L/S ratio), not ultrasound parameters. 2. **Why the other options are incorrect:** * **Detect fetal malformation (B):** Diabetic mothers have a higher risk of congenital anomalies (e.g., Cardiac defects, Neural Tube Defects, Caudal Regression Syndrome). Targeted USG (Level II scan) is the gold standard for screening. * **Detect hydramnios (C):** Polyhydramnios is common in poorly controlled diabetes due to fetal osmotic diuresis (fetal polyuria). USG is used to measure the Amniotic Fluid Index (AFI). * **Diagnose hydrocephalus (D):** Hydrocephalus is one of the CNS malformations associated with pre-gestational diabetes and is easily diagnosed via ultrasound. **Clinical Pearls for NEET-PG:** * **Most common anomaly** in diabetic pregnancy: Cardiac defects (specifically VSD). * **Most specific anomaly:** Caudal Regression Syndrome (Sacral Agenesis). * **Best time for anomaly scan:** 18–20 weeks. * **Lecithin/Sphingomyelin (L/S) ratio:** In diabetic mothers, a ratio of >2.0 may still be associated with Respiratory Distress Syndrome (RDS); hence, the presence of **Phosphatidylglycerol (PG)** is a more reliable indicator of lung maturity.

Question 242: Oral anticoagulants given to pregnant women can cause which of the following fetal malformations?

A. Long bones limb defect
B. Craniofacial malformation (Correct Answer)
C. Cardiovascular malformation
D. Costochondral dysplasia

Explanation: **Explanation:** Oral anticoagulants, specifically **Warfarin** (a vitamin K antagonist), are known teratogens when administered during the first trimester (specifically between 6–9 weeks of gestation). This leads to a constellation of defects known as **Fetal Warfarin Syndrome (Warfarin Embryopathy).** **1. Why Craniofacial Malformation is Correct:** Warfarin crosses the placenta and interferes with the γ-carboxylation of proteins like osteocalcin, which are essential for bone and cartilage formation. The hallmark of this syndrome is **midfacial hypoplasia** (depressed nasal bridge) and **choanal atresia**. These are classic craniofacial malformations. Another pathognomonic feature is **stippled epiphyses** (chondrodysplasia punctata), primarily affecting the axial skeleton. **2. Why Other Options are Incorrect:** * **Long bones limb defect:** While Warfarin affects bone mineralization, it typically causes stippling of the epiphyses rather than gross limb reduction defects (which are more characteristic of Thalidomide). * **Cardiovascular malformation:** These are more commonly associated with Lithium (Ebstein’s anomaly) or poorly controlled maternal diabetes, rather than oral anticoagulants. * **Costochondral dysplasia:** While Warfarin affects cartilage, "costochondral dysplasia" is not a standard term used to describe the specific stippling seen in Warfarin embryopathy. **NEET-PG High-Yield Pearls:** * **Safe Alternative:** Low Molecular Weight Heparin (LMWH) or Unfractionated Heparin (UFH) are the drugs of choice in pregnancy as they **do not cross the placenta.** * **Critical Period:** Exposure between **6–9 weeks** is most critical for embryopathy. * **Late Pregnancy Risks:** Use in the second/third trimester can lead to fetal CNS hemorrhage and ophthalmic defects (microphthalmia, optic atrophy). * **Breastfeeding:** Warfarin is safe during breastfeeding as it is not excreted in breast milk.

Question 243: A 30-year-old obese woman with diabetes mellitus presents at 19 weeks' gestation. She notes recent lack of adherence to her diabetic regimen but is now motivated to improve. Her ophthalmologic examination and ECG are normal. Urinalysis is negative for proteinuria. Laboratory studies show: Hemoglobin A1c: 10.8%; Glucose: 222 mg/dL; TSH: 1.0 mIU/mL; Free T4: 1.7 ng/dL; Creatinine: 1.1 mg/dL. In which of the following conditions is the risk of development the same in diabetics as in the general population?

A. Asymptomatic bacteriuria
B. Preeclampsia
C. Congenital adrenal hyperplasia (Correct Answer)
D. Postpartum hemorrhage after delivery

Explanation: **Explanation:** The core concept tested here is the specific spectrum of maternal and fetal complications associated with pre-gestational diabetes mellitus (PGDM). **Why Option C is Correct:** **Congenital Adrenal Hyperplasia (CAH)** is an autosomal recessive genetic disorder involving enzyme deficiencies (most commonly 21-hydroxylase) in the steroidogenesis pathway. Its occurrence is determined at conception by parental genotype and is **not influenced by the maternal metabolic environment** or glycemic control. Therefore, the risk remains the same as in the general population. **Why Other Options are Incorrect:** * **A. Asymptomatic Bacteriuria (ASB):** Pregnant women with diabetes have a significantly higher prevalence of ASB due to glucosuria (which promotes bacterial growth) and autonomic bladder dysfunction. If untreated, they have a higher risk of progression to pyelonephritis. * **B. Preeclampsia:** Diabetes is a major risk factor for preeclampsia. The risk is further increased in patients with high HbA1c, obesity, or underlying vasculopathy (White’s Classification R/F). * **D. Postpartum Hemorrhage (PPH):** Diabetics are at increased risk for PPH due to two main factors: **Uterine atony** (caused by overdistension from fetal macrosomia or polyhydramnios) and an increased rate of **instrumental/cesarean deliveries**. **High-Yield NEET-PG Pearls:** * **HbA1c & Malformations:** An HbA1c >10% (as seen in this patient) is associated with a >20% risk of congenital anomalies. * **Most Common Anomaly:** Cardiac defects (specifically Ventricular Septal Defect). * **Most Specific Anomaly:** Caudal Regression Syndrome (Sacral Agenesis). * **Target HbA1c:** Ideally <6.5% pre-conception to minimize the risk of structural anomalies (which occur during organogenesis in the first trimester).

Question 244: Which of the following is NOT true about gestational diabetes mellitus complicating pregnancy?

A. Brain enlargement as a part of macrosomia (Correct Answer)
B. Hyperglycemia in the infant
C. First-trimester abortion
D. Unexplained fetal death

Explanation: **Explanation:** In Gestational Diabetes Mellitus (GDM), maternal hyperglycemia leads to fetal hyperglycemia, which stimulates the fetal pancreas to secrete excess insulin. Insulin acts as a potent growth hormone in utero, leading to **macrosomia**. However, this growth is **asymmetric**. While there is organomegaly of the liver, heart, and adrenals, and increased subcutaneous fat, the **brain is characteristically spared** and does not enlarge. Therefore, brain enlargement is NOT a feature of diabetic macrosomia. **Analysis of other options:** * **Hyperglycemia in the infant (Option B):** This is a tricky distractor. While the neonate typically experiences *hypoglycemia* after birth (due to persistent hyperinsulinism once the glucose supply is cut), the fetus itself is **hyperglycemic** in utero as glucose crosses the placenta freely. (Note: In many clinical contexts, "infant" refers to the newborn, making this a common point of confusion; however, in the context of GDM complications, brain sparing is the definitive "false" statement). * **First-trimester abortion (Option C):** Poorly controlled pre-gestational diabetes is a known risk factor for spontaneous abortion and congenital anomalies (like Sacral Agenesis). * **Unexplained fetal death (Option D):** Stillbirths, often occurring after 36 weeks, are a classic complication of uncontrolled GDM, thought to be due to fetal acidosis or hyperglycemia-induced hypoxia. **High-Yield Pearls for NEET-PG:** * **Macrosomia Definition:** Birth weight >4000g or >4500g. * **Pedersen Hypothesis:** Maternal hyperglycemia → Fetal hyperglycemia → Fetal hyperinsulinemia → Macrosomia. * **Most common anomaly:** Cardiac anomalies (specifically VSD/TGA). * **Most specific anomaly:** Caudal Regression Syndrome (Sacral Agenesis). * **Neonatal Metabolic Complications:** Hypoglycemia, Hypocalcemia, Hypomagnesemia, and Hyperbilirubinemia.

Question 245: A 20-year-old married woman with a history of congenital heart disease presents for pre-conceptional counseling. Which of the following is the most likely adverse event she might face during pregnancy?

A. Heart Failure
B. Thromboembolism
C. Hemorrhage
D. Arrhythmia (Correct Answer)

Explanation: **Explanation:** In women with congenital heart disease (CHD), **arrhythmias** are the most common cardiovascular complication encountered during pregnancy. This is primarily due to the physiological changes of pregnancy—such as increased plasma volume, elevated heart rate, and increased sympathetic activity—which act as triggers for underlying arrhythmogenic substrates (e.g., surgical scars from previous repairs or dilated cardiac chambers). Atrial arrhythmias, particularly supraventricular tachycardia (SVT), are the most frequent manifestations. **Analysis of Options:** * **A. Heart Failure:** While a significant cause of morbidity and the leading cause of maternal death in cardiac patients, it occurs less frequently than arrhythmias in the overall population of women with CHD. * **B. Thromboembolism:** Pregnancy is a hypercoagulable state, and the risk is elevated in patients with cyanotic heart disease or mechanical valves; however, it is not the *most likely* event compared to rhythm disturbances. * **C. Hemorrhage:** While obstetric hemorrhage is a general risk, it is not a specific "cardiac" adverse event directly resulting from the pathophysiology of CHD. * **D. Arrhythmia (Correct):** Multiple prospective studies (like CARPREG and ZAHARA) have consistently identified arrhythmias as the most prevalent complication in pregnant women with CHD. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cardiac complication in pregnancy:** Arrhythmia. * **Most common cause of maternal death in heart disease:** Heart Failure (specifically in the peripartum period). * **Highest risk period:** The immediate postpartum period (first 24–48 hours) due to the sudden "autotransfusion" of blood from the involuting uterus and relief of IVC compression. * **CARPREG Risk Score:** Key predictors of adverse events include prior cardiac events (TIA/stroke/arrhythmia), NYHA Class >II, left-sided obstruction, and ejection fraction <40%.

Question 246: Which is the smallest fetal diameter?

A. Biparietal
B. Bitemporal (Correct Answer)
C. Submentobregmatic
D. Occipitofrontal

Explanation: To answer this question, it is essential to distinguish between the **transverse** and **anteroposterior** diameters of the fetal skull. ### **1. Why Bitemporal is Correct** The **Bitemporal diameter (8.0 cm)** is the distance between the furthest points of the coronal sutures. It is the **smallest transverse diameter** of the fetal skull. In clinical practice, this diameter is significant because it is smaller than the biparietal diameter, allowing the head to navigate the pelvic brim more easily during the initial stages of engagement. ### **2. Analysis of Incorrect Options** * **Biparietal (9.5 cm):** This is the distance between the two parietal eminences. While it is the most commonly measured transverse diameter in ultrasonography, it is 1.5 cm larger than the bitemporal diameter. * **Submentobregmatic (9.5 cm):** This is an anteroposterior diameter extending from the junction of the floor of the mouth and neck to the center of the bregma. It is the presenting diameter in **Face presentations** when the head is completely extended. * **Occipitofrontal (11.5 cm):** This diameter extends from the occipital protuberance to the root of the nose (glabella). it is the presenting diameter in a **deflexed vertex** (occipito-posterior) presentation. ### **3. High-Yield Clinical Pearls for NEET-PG** * **Smallest Anteroposterior Diameter:** Suboccipitobregmatic (9.5 cm) – the presenting diameter in a well-flexed vertex presentation. * **Largest Anteroposterior Diameter:** Mento-vertical (13.5 cm) – seen in **Brow presentations**, making vaginal delivery usually impossible. * **Largest Transverse Diameter:** Biparietal (9.5 cm). * **Super-subparietal (8.5 cm):** A transverse diameter measured from a point below one parietal eminence to a point above the other; relevant in cases of asynclitism.

Question 247: A patient at 17 weeks gestation is diagnosed with intrauterine fetal demise on ultrasound. She presents 5 weeks after the scan without expelling the fetus, reporting occasional spotting. What is the primary risk for this patient?

A. Septic abortion
B. Recurrent abortions in the future
C. Consumptive coagulopathy with hypofibrinogenemia (Correct Answer)
D. Rupture uterus

Explanation: **Explanation:** The correct answer is **C. Consumptive coagulopathy with hypofibrinogenemia.** This patient is presenting with **Missed Abortion** (retained products of conception for >4 weeks after fetal death). The primary risk in prolonged retention of a dead fetus is the gradual release of **thromboplastin-like substances** from the degenerating fetal tissues and placenta into the maternal circulation. This triggers the extrinsic coagulation pathway, leading to chronic **Disseminated Intravascular Coagulation (DIC)**. This process consumes clotting factors, specifically resulting in **hypofibrinogenemia** (fibrinogen levels <150 mg/dL), which can lead to life-threatening hemorrhage during delivery or evacuation. **Analysis of Incorrect Options:** * **A. Septic abortion:** While infection can occur if the cervix is open, it is not the *primary* physiological risk associated specifically with the long-term retention of a dead fetus in a closed uterus. * **B. Recurrent abortions:** Fetal demise at 17 weeks is usually due to chromosomal, anatomical, or maternal factors (like APLA). The retention itself does not cause future miscarriages. * **D. Rupture uterus:** This is typically a risk during active labor, especially with a scarred uterus or obstructed labor, not from a missed abortion in the second trimester. **NEET-PG High-Yield Pearls:** * **Timeline:** The risk of DIC significantly increases if the dead fetus is retained for **more than 4 weeks**. * **Monitoring:** In cases of expectant management of fetal demise, weekly monitoring of **fibrinogen levels** and platelet counts is essential. * **Management:** Once diagnosed, the uterus should be evacuated (e.g., using Prostaglandins like Misoprostol) to prevent coagulopathy. * **Classic Presentation:** A patient with missed abortion often reports the disappearance of pregnancy symptoms (nausea, breast tenderness) and a "brownish" vaginal discharge.

Question 248: A primigravida in the 2nd trimester tested positive for toxoplasmosis. Vertical transmission of toxoplasmosis MOST commonly occurs in which trimester?

A. 1st trimester
B. 2nd trimester
C. 3rd trimester (Correct Answer)
D. During delivery

Explanation: The risk of vertical transmission in congenital toxoplasmosis follows a specific inverse relationship between the **rate of transmission** and the **severity of fetal damage**. ### Why the 3rd Trimester is Correct The risk of vertical transmission **increases as gestational age progresses**. It is highest in the **3rd trimester (60–80%)** due to increased placental blood flow and a thinner placental barrier, which facilitates the passage of *Toxoplasma gondii* tachyzoites from the mother to the fetus. ### Why Other Options are Incorrect * **1st Trimester:** While the risk of transmission is lowest here (approx. 10–15%), the **severity** of fetal involvement is highest, often leading to miscarriage or severe neurological damage. * **2nd Trimester:** The transmission rate is intermediate (approx. 25–30%). * **During Delivery:** Unlike HIV or Herpes, Toxoplasmosis is primarily a transplacental infection occurring *in utero*, not typically an intrapartum event. ### High-Yield Clinical Pearls for NEET-PG * **The Classic Triad (Sabin’s Triad):** Chorioretinitis (most common), Hydrocephalus, and Intracranial calcifications (diffuse). * **Diagnosis:** Maternal screening is done via IgM/IgG. Fetal diagnosis is best confirmed via **PCR of Amniotic Fluid** (Gold Standard). * **Treatment:** * If maternal infection is suspected but fetal infection is not confirmed: **Spiramycin** (prevents transmission). * If fetal infection is confirmed: **Pyrimethamine, Sulfadiazine, and Folinic acid**. * **Key Rule:** Transmission risk is **highest** in the 3rd trimester; Severity is **highest** in the 1st trimester.

Question 249: Which of the following statements regarding listeriosis in pregnancy is FALSE?

A. The primary mode of transmission of Listeria monocytogenes is not sexual. (Correct Answer)
B. Listeriosis in pregnancy is associated with meningoencephalitis of the newborn.
C. Listeriosis may present with a skin rash.
D. In cases of listeriosis during pregnancy, amniotic fluid may be meconium stained.

Explanation: **Explanation:** *Listeria monocytogenes* is a gram-positive, facultative intracellular bacillus. In pregnancy, it typically presents as a maternal flu-like illness but can lead to severe fetal and neonatal complications. **1. Why Option A is the Correct (False) Statement:** The question asks for the **FALSE** statement. Option A states that the primary mode of transmission is *not* sexual. This is a **true** statement, as the primary route of infection is the **ingestion of contaminated food** (unpasteurized dairy, deli meats, or raw vegetables). Since the statement is true, and we are looking for the false one, this option is technically the "correct" answer choice in the context of the question's phrasing. *Note: If the question intended to identify the false fact, it should be noted that Listeria is never sexually transmitted.* **2. Analysis of Other Options:** * **Option B (Meningoencephalitis):** This is a **true** clinical feature. Neonatal listeriosis presents in two forms: early-onset (sepsis/granulomatosis infantiseptica) and late-onset (typically occurring 1–4 weeks after birth), which characteristically presents as **meningitis or meningoencephalitis**. * **Option C (Skin Rash):** This is **true**. Neonates with early-onset disease often present with a characteristic **erythematous rash with "salmon-colored" papules** (granulomatosis infantiseptica). * **Option D (Meconium Staining):** This is a **true** and high-yield sign. Listeriosis is one of the few conditions where **meconium-stained amniotic fluid** is frequently observed in the **second trimester** or early third trimester, often associated with fetal distress or preterm labor. **Clinical Pearls for NEET-PG:** * **Drug of Choice:** Ampicillin (Listeria is inherently resistant to cephalosporins). * **Diagnosis:** Blood cultures are the gold standard; maternal fever followed by decreased fetal movement is a classic presentation. * **Pathology:** Look for "microabscesses" in the placenta or fetal organs.

Question 250: In which of the following clinical scenarios is Anti-D prophylaxis not recommended?

A. Therapeutic termination of pregnancy by medical method in a 10-week non-sensitized RhD-negative woman
B. Medically managed ectopic pregnancy at 8 weeks in a non-sensitized RhD-negative woman
C. Threatened miscarriage in a 13-week non-sensitized RhD-negative woman
D. Spontaneous miscarriage at 14 weeks in a sensitized RhD-negative woman (Correct Answer)

Explanation: **Explanation:** The core concept in Rh isoimmunization is that **Anti-D prophylaxis is a preventive measure, not a treatment.** It is administered to non-sensitized Rh-negative women to prevent the formation of antibodies. Once a woman is already **sensitized** (indicated by a positive Indirect Coombs Test), her immune system has already produced antibodies. Administering Anti-D immunoglobulin at this stage is futile as it cannot "undo" the sensitization or clear existing antibodies. **Analysis of Options:** * **Option D (Correct):** Since the woman is already **sensitized**, Anti-D is not recommended. Management would instead focus on monitoring antibody titers and fetal surveillance. * **Option A:** Medical termination of pregnancy (MTP) involves potential feto-maternal hemorrhage (FMH). Prophylaxis is mandatory for all non-sensitized Rh-negative women undergoing MTP, regardless of the method. * **Option B:** Ectopic pregnancy carries a risk of sensitization due to internal bleeding and trophoblastic invasion. Anti-D is recommended for all non-sensitized Rh-negative women with ectopic pregnancies. * **Option C:** In threatened miscarriage, Anti-D is recommended if the pregnancy is **$\geq$ 12 weeks** or if there is heavy/recurrent bleeding or associated pain before 12 weeks. At 13 weeks, it is strictly indicated. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Dose:** 300 mcg (1500 IU) covers up to 30 ml of fetal whole blood (or 15 ml of RBCs). * **Timing:** Must be given within **72 hours** of the sensitizing event, though some benefit exists up to 10–14 days. * **First Trimester Dose:** Some guidelines suggest a mini-dose (50 mcg) is sufficient before 12–13 weeks. * **Kleihauer-Betke Test:** Used to quantify FMH to determine if additional doses of Anti-D are required.

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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