Maternal-Fetal Medicine — MCQs

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?

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In a pregnancy of 24-28 weeks with premature rupture of membranes, what management is always indicated?

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 251: What is the most common congenital heart disease during pregnancy?

A. Atrial Septal Defect (ASD) (Correct Answer)
B. Ventricular Septal Defect (VSD)
C. Tetralogy of Fallot (TOF)
D. Aortic Stenosis (AS)

Explanation: **Explanation:** The correct answer is **Atrial Septal Defect (ASD)**. In the context of pregnancy, **Atrial Septal Defect (ASD)** is the most frequently encountered congenital heart disease (CHD). This is primarily because ASDs are often asymptomatic or produce only mild symptoms during childhood and adolescence, allowing many women to reach reproductive age without a prior diagnosis or surgical intervention. During pregnancy, the physiological increase in blood volume and cardiac output is generally well-tolerated in patients with uncomplicated ASDs due to the high compliance of the right ventricle. **Analysis of Incorrect Options:** * **Ventricular Septal Defect (VSD):** While VSD is the most common congenital heart defect at **birth**, many small VSDs close spontaneously during childhood, and larger ones are typically repaired surgically before the patient reaches childbearing age. * **Tetralogy of Fallot (TOF):** This is the most common **cyanotic** congenital heart disease. However, it is less common in pregnancy than ASD because it usually requires corrective surgery in infancy. * **Aortic Stenosis (AS):** This is a valvular lesion that is less common than septal defects in the pregnant population and carries a much higher risk of complications due to the fixed cardiac output. **High-Yield Clinical Pearls for NEET-PG:** * **Most common heart disease in pregnancy (overall):** Mitral Stenosis (Rheumatic origin), especially in developing countries. * **Most common congenital heart disease in pregnancy:** ASD (specifically Secundum type). * **Risk of Eisenmenger Syndrome:** Any left-to-right shunt (ASD, VSD, PDA) can reverse if pulmonary hypertension develops. Eisenmenger syndrome carries a high maternal mortality rate (30-50%), and pregnancy is generally contraindicated. * **Anticoagulation:** Patients with mechanical valves or certain arrhythmias require careful management (switching from Warfarin to Heparin/LMWH) to avoid teratogenicity.

Question 252: 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?

A. Reactive NST
B. Variable deceleration (Correct Answer)
C. Early deceleration
D. Sinusoidal pattern

Explanation: ***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.

Question 253: Which of the following is NOT associated with hydramnios?

A. Premature labor
B. Gestational diabetes
C. Renal agenesis (Correct Answer)
D. Increased amniotic fluid

Explanation: **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. <5 cm is Oligohydramnios; >24 cm is Polyhydramnios.

Question 254: Cord blood gas and pH analysis is done in the following circumstances, except?

A. Low 5-minute APGAR score
B. Maternal thyroid disease
C. Severe fetal growth restriction
D. Antepartum hemorrhage (Correct Answer)

Explanation: **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.

Question 255: Which antihypertensive drug is absolutely contraindicated in pregnancy?

A. Enalapril (Correct Answer)
B. Diazoxide
C. Atenolol
D. Nifedipine

Explanation: **Explanation:** **Enalapril (Option A)** is an ACE inhibitor and is **absolutely contraindicated** in pregnancy, particularly during the second and third trimesters. ACE inhibitors and Angiotensin Receptor Blockers (ARBs) interfere with the fetal renin-angiotensin system, which is crucial for renal development. Their use leads to **fetal renal dysgenesis**, which causes oligohydramnios. This lack of amniotic fluid results in the "ACE inhibitor fetopathy" triad: pulmonary hypoplasia, limb contractures, and calvarial (skull) hypoplasia. **Analysis of Incorrect Options:** * **Diazoxide (Option B):** While rarely used today due to the risk of sudden maternal hypotension and fetal hyperglycemia, it is not "absolutely contraindicated" in the same category as ACE inhibitors. * **Atenolol (Option C):** Though generally avoided in pregnancy because it is associated with **fetal growth restriction (IUGR)** and placental smallness, it is not teratogenic or absolutely contraindicated if no other options exist. * **Nifedipine (Option D):** A Calcium Channel Blocker (CCB) that is considered **safe and first-line** for the management of chronic hypertension and pre-eclampsia in pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Drugs of Choice (DOC):** Labetalol (overall DOC), Methyldopa (safest long-term), and Nifedipine. * **Acute Hypertensive Crisis:** IV Labetalol or IV Hydralazine. * **Teratogenic triad of ACE inhibitors:** Renal failure, Oligohydramnios, and Hypocalvaria. * **Diuretics:** Generally avoided in pregnancy as they prevent the physiological expansion of plasma volume.

Question 256: What is the least amount of fetal Rh+ve blood required to cause isoimmunization in an Rh-negative mother?

A. 0.1 ml (Correct Answer)
B. 0.01 ml
C. 0.001 ml
D. 10 ml

Explanation: **Explanation:** **1. Why 0.1 ml is the Correct Answer:** Rh isoimmunization occurs when an Rh-negative mother is exposed to Rh-positive fetal red blood cells (RBCs), leading to the production of anti-D antibodies. Clinical studies have established that the threshold for a primary immune response is remarkably low. As little as **0.1 ml** of Rh-positive fetal blood entering the maternal circulation is sufficient to cause sensitization in approximately 70% of susceptible Rh-negative individuals. This volume is enough to trigger the maternal immune system to recognize the foreign 'D' antigen and initiate the production of IgM (initially) and IgG antibodies. **2. Analysis of Incorrect Options:** * **0.01 ml and 0.001 ml:** While the immune system is sensitive, these volumes are generally considered sub-threshold for a primary immune response. They are insufficient to consistently trigger the cascade of B-cell activation required for isoimmunization. * **10 ml:** This is a significant volume of fetomaternal hemorrhage (FMH). While 10 ml will certainly cause isoimmunization, it is not the *least* amount required. For reference, a standard 300 mcg dose of Anti-D (RhIg) is designed to neutralize up to 15 ml of fetal RBCs (or 30 ml of whole fetal blood). **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common time of sensitization:** During delivery (third stage of labor). * **Kleihauer-Betke (KB) Test:** Used to quantify the volume of fetomaternal hemorrhage to calculate the required dose of Anti-D. * **Standard Prophylaxis:** 300 mcg of Anti-D is given routinely at 28 weeks of gestation and within 72 hours of delivery if the neonate is Rh-positive. * **Immunological Principle:** The primary response is slow (IgM), but the secondary response (in subsequent pregnancies) is rapid and mediated by IgG, which crosses the placenta, leading to Hemolytic Disease of the Fetus and Newborn (HDFN).

Question 257: Which of the following is NOT an indication for termination of pregnancy in hyperemesis gravidarum?

A. Jaundice
B. Oliguria
C. Neurological complications
D. None of the above (Correct Answer)

Explanation: **Explanation:** Hyperemesis Gravidarum (HG) is a severe form of nausea and vomiting in pregnancy that leads to dehydration, electrolyte imbalance, and weight loss. While most cases are managed conservatively with IV fluids and antiemetics, life-threatening complications necessitate the **termination of pregnancy (therapeutic abortion)** to save the mother's life. **Why "None of the above" is correct:** All the conditions listed (Jaundice, Oliguria, and Neurological complications) are recognized **absolute indications** for termination of pregnancy in HG. Since the question asks which is *NOT* an indication, and all three are valid indications, "None of the above" is the correct choice. **Analysis of Options:** * **Jaundice (Option A):** Indicates hepatic involvement or acute yellow atrophy of the liver. Serum bilirubin > 2 mg/dL is a critical warning sign. * **Oliguria (Option B):** Suggests severe dehydration leading to acute renal failure. Persistent proteinuria or rising blood urea/creatinine despite fluid resuscitation are grave signs. * **Neurological Complications (Option C):** This primarily refers to **Wernicke’s Encephalopathy** (due to Vitamin B1/Thiamine deficiency) characterized by the triad of ataxia, ophthalmoplegia, and confusion. Other signs include retinal hemorrhages or nystagmus. **NEET-PG High-Yield Pearls:** * **Wernicke’s Encephalopathy:** Always supplement Thiamine *before* giving Dextrose-containing fluids to avoid precipitating this condition. * **Electrolyte Imbalance:** Hypokalemia is common; however, rapid correction of hyponatremia can lead to **Central Pontine Myelinolysis**. * **Mallory-Weiss Tear:** Hematemesis in HG is often due to mucosal tears at the gastroesophageal junction. * **Criteria for Termination:** Jaundice, Oliguria, Wernicke’s Encephalopathy, Retinal Hemorrhage, and Persistent Tachycardia (>100 bpm) despite treatment.

Question 258: With regards to acute pyelonephritis in pregnancy, all of the following are true except:

A. Left kidney is involved in 50% of patients. (Correct Answer)
B. Most common isolate is E. coli.
C. More common in the later half of pregnancy.
D. Responds to aminoglycosides.

Explanation: **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.

Question 259: 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?

A. Laparoscopic salpingectomy
B. Laparoscopic salpingo-oophorectomy
C. Laparoscopic salpingotomy
D. Intramuscular methotrexate (Correct Answer)

Explanation: **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).

Question 260: In a pregnancy of 24-28 weeks with premature rupture of membranes, what management is always indicated?

A. Steroids
B. Antibiotics
C. Tocolytics
D. All of the above (Correct Answer)

Explanation: **Explanation:** In cases of **Preterm Premature Rupture of Membranes (PPROM)** occurring between 24 and 34 weeks of gestation, the management strategy focuses on prolonging the pregnancy to achieve fetal lung maturity while minimizing the risk of infection. **Why "All of the above" is correct:** 1. **Steroids (Option A):** Administering corticosteroids (e.g., Betamethasone or Dexamethasone) is the most critical intervention. It significantly reduces the risk of Respiratory Distress Syndrome (RDS), Intraventricular Hemorrhage (IVH), and Necrotizing Enterocolitis (NEC) in the neonate. 2. **Antibiotics (Option B):** Prophylactic antibiotics (typically Ampicillin and Erythromycin) are indicated to prolong the latency period (the time from ROM to delivery) and reduce the risk of maternal/neonatal infections like chorioamnionitis. 3. **Tocolytics (Option C):** While controversial for long-term use, short-term tocolysis (48 hours) is indicated to "buy time" for the corticosteroids to exert their maximum effect on fetal lungs and to facilitate maternal transport to a tertiary care center. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Visualization of liquor pooling in the posterior vaginal fornix on sterile speculum exam. * **Nitrazine Test:** Turns blue (alkaline pH of amniotic fluid). * **Fern Test:** Arborization pattern on microscopy (most specific). * **Contraindication:** Digital vaginal exams should be avoided in PPROM to prevent ascending infection unless the patient is in active labor. * **Delivery Timing:** In uncomplicated PPROM, delivery is generally recommended at **34 weeks**. If signs of chorioamnionitis appear, immediate delivery is indicated regardless of gestational age.

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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