Maternal-Fetal Medicine Practice Questions

Q: Maternal serum alpha-fetoprotein concentration is elevated in all of the following conditions except:

Fetal Down's syndrome. **Explanation:** Maternal Serum Alpha-Fetoprotein (MSAFP) is a glycoprotein produced initially by the yolk sac and later by the fetal liver. It serves as a crucial biomarker in prenatal screening and oncology. **Why Fetal Down’s Syndrome is the Correct Answer:** In pregnancies affected by **Down’s Syndrome (Trisomy 21)**, the MSAFP levels are characteristically **decreased** (usually <0.5 MoM), not elevated. This is often accompanied by low unconjugated estriol (uE3) and elevated levels of Beta-hCG and Inhibin-A (the "Quadruple Test" pattern). The exact mechanism for decreased AFP in Down's syndrome is thought to be related to reduced fetal liver synthesis or delayed maturity of the liver. **Why the other options are incorrect:** * **Hepatoma (Hepatocellular Carcinoma) & Hepatoblastoma:** AFP is a classic tumor marker for primary liver malignancies. It is re-expressed by malignant hepatocytes, leading to significantly elevated serum levels. * **Endodermal Sinus Tumor (Yolk Sac Tumor):** This is a highly malignant germ cell tumor. Since the yolk sac is the primary embryological producer of AFP, these tumors secrete high amounts of AFP, making it a specific marker for diagnosis and monitoring recurrence. **High-Yield Clinical Pearls for NEET-PG:** * **Causes of Elevated MSAFP:** Neural tube defects (Anencephaly, Spina bifida), abdominal wall defects (Omphalocele, Gastroschisis), multiple gestations, and fetal demise. * **Most Common Cause of Elevated MSAFP:** Underestimation of gestational age (wrong dates). * **Causes of Low MSAFP:** Down’s syndrome, Trisomy 18 (Edwards syndrome), gestational trophoblastic disease, and maternal obesity. * **Rule of Thumb:** If the question mentions "Open" defects (NTD), think **High AFP**; if it mentions "Chromosomal" defects (Down's), think **Low AFP**.

Q: Which of the following is NOT associated with an increased risk of thromboembolism in pregnancy?

Blood group O. **Explanation:** Pregnancy is a naturally prothrombotic state due to an increase in clotting factors (I, VII, VIII, IX, X) and a decrease in protein S levels. Understanding the specific risk factors for Venous Thromboembolism (VTE) is crucial for NEET-PG. **Why Blood Group O is the Correct Answer:** Individuals with **Non-O blood groups (A, B, and AB)** have a significantly higher risk (approx. 2–4 times) of thromboembolism compared to those with Blood Group O. This is because Non-O individuals have higher plasma concentrations of **von Willebrand factor (vWF)** and **Factor VIII**, which are stabilized by the A and B antigens. Therefore, Blood Group O is actually "protective" against VTE rather than a risk factor. **Analysis of Other Options:** * **Anemia:** Severe anemia (especially sickle cell disease or acute blood loss requiring transfusion) is associated with an increased risk of VTE due to hyperkinetic circulation and potential endothelial injury. * **Rising Parity:** The risk of VTE increases with parity. Women who are **multiparous (Parity ≥3)** are at a higher risk compared to primigravida women. * **Antithrombin (AT) Deficiency:** This is the **most thrombophilic** of the hereditary thrombophilias. While Factor V Leiden is the most common, AT deficiency carries the highest absolute risk of a thromboembolic event during pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common VTE in pregnancy:** Deep Vein Thrombosis (DVT), usually occurring in the **left leg** (80%) due to compression of the left common iliac vein by the right axial artery (May-Thurner phenomenon). * **Highest risk period:** The **postpartum period** (especially the first 6 weeks) carries a higher daily risk of VTE than pregnancy itself. * **Gold Standard Diagnosis:** Compression Duplex Ultrasound for DVT; CT Pulmonary Angiography (CTPA) or V/Q scan for Pulmonary Embolism.

Q: A 22-year-old pregnant woman presents with fever, and is treated with antibiotics. The fever is not controlled. Further investigation reveals septic pelvic thrombophlebitis. What is the recommended next course of treatment?

Continue antibiotics and start heparin. **Explanation:** **Septic Pelvic Thrombophlebitis (SPT)** is a rare but serious complication of postpartum or post-abortal infections (like endometritis). It occurs when pelvic infection leads to venous stasis and endothelial injury, causing a clot to form in the pelvic veins (most commonly the ovarian veins). **Why Option B is Correct:** The standard management for SPT is the **"Heparin Challenge."** SPT is typically a diagnosis of exclusion in a patient who has persistent fever despite 48–72 hours of broad-spectrum antibiotic therapy. The pathophysiology involves both infection and thrombosis; therefore, the treatment must address both. **Continuing broad-spectrum antibiotics** treats the underlying infection, while **starting intravenous Heparin** prevents further clot propagation. A rapid clinical response (defervescence within 48–72 hours of starting heparin) confirms the diagnosis. **Why Other Options are Incorrect:** * **Option A:** Stopping antibiotics is dangerous as the thrombus is "septic" (infected). Antibiotics are essential to clear the bacteremia. * **Option C:** Surgical embolectomy is reserved for massive pulmonary emboli and is not the primary treatment for pelvic venous thrombosis. * **Option D:** Hysterectomy is only indicated if there is extensive uterine necrosis or a non-responsive uterine abscess, not for isolated SPT. **Clinical Pearls for NEET-PG:** * **Enigma of SPT:** It is often called the "diagnosis of exclusion" for unexplained postpartum fever. * **Most Common Site:** The **Right Ovarian Vein** is involved in ~90% of cases (due to its length and lack of valves). * **Imaging:** Contrast-enhanced CT or MRI is the gold standard for visualizing the thrombus. * **Duration:** Heparin is usually continued for 7–10 days, though some protocols suggest longer if a large clot is visualized.

Q: During pregnancy, there is a reduced risk of which of the following conditions?

Relapse of multiple sclerosis. **Explanation:** The correct answer is **A. Relapse of multiple sclerosis.** **Why it is correct:** Pregnancy is a state of **physiologic immunosuppression** characterized by a shift from a Th1 (pro-inflammatory) to a **Th2 (anti-inflammatory) cytokine profile**. This shift occurs to prevent maternal rejection of the fetal semi-allograft. Since Multiple Sclerosis (MS) is a Th1-mediated autoimmune disease, the high levels of estrogen and progesterone during pregnancy (especially in the third trimester) lead to a significant **reduction in the rate of relapses**. However, it is important to note that the risk of relapse increases significantly in the first 3–6 months postpartum (the "rebound effect"). **Why the other options are incorrect:** * **Bell’s Palsy:** The incidence of Bell’s palsy is actually **increased** during pregnancy, particularly in the third trimester and the immediate postpartum period, likely due to perineural edema or viral reactivation. * **Meningioma:** These tumors often express **progesterone receptors**. The high progesterone levels in pregnancy can cause rapid enlargement or symptomatic worsening of a pre-existing meningioma. * **Chorea:** Known as **Chorea Gravidarum**, this is a rare movement disorder that can be triggered or exacerbated by pregnancy, often associated with a history of Rheumatic fever or SLE/Antiphospholipid syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Autoimmune diseases that improve in pregnancy:** Multiple Sclerosis, Rheumatoid Arthritis (RA), and Psoriasis (due to Th2 shift). * **Autoimmune diseases that may worsen/flare:** Systemic Lupus Erythematosus (SLE) – specifically renal flares. * **Neurological conditions that worsen:** Epilepsy (increased seizure frequency due to hemodilution of drugs), Myasthenia Gravis (variable, but risk of crisis in labor), and Carpal Tunnel Syndrome (due to edema).

Q: Which condition is associated with the highest maternal mortality?

Pulmonary Hypertension. **Explanation:** **Pulmonary Hypertension (PH)**, particularly when associated with Eisenmenger syndrome, carries the highest risk of maternal mortality, with rates historically reported between **30% and 50%**. The physiological changes of pregnancy—specifically the increase in cardiac output and the profound drop in systemic vascular resistance (SVR)—are poorly tolerated. In PH, the fixed pulmonary vascular resistance prevents the right ventricle from increasing output, leading to right heart failure. Furthermore, any drop in SVR can trigger a fatal right-to-left shunt, causing intractable cyanosis and sudden death, most commonly during labor or the early postpartum period. **Analysis of Incorrect Options:** * **Aortic Stenosis (A):** While severe symptomatic aortic stenosis is high-risk (WHO Class IV), the mortality rate (approx. 5-10%) is significantly lower than in Pulmonary Hypertension. * **Ventricular Septal Defect (B):** Small to moderate VSDs are generally well-tolerated in pregnancy (WHO Class II) unless they lead to Eisenmenger syndrome (which then falls under the PH category). * **Tetralogy of Fallot (C):** Repaired ToF carries a low risk. Even unrepaired patients have a lower mortality rate (approx. 2-10%) compared to the extreme risks of PH, provided they do not have severe pulmonary hypertension. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Classification:** Pulmonary Hypertension, Eisenmenger Syndrome, and severe Mitral Stenosis are categorized as **WHO Class IV** (pregnancy is contraindicated). * **Timing of Death:** In cardiac patients, the most dangerous period is the **immediate postpartum (third stage of labor)** due to the "autotransfusion" of blood from the contracting uterus, causing sudden volume overload. * **Management:** The gold standard advice for women with PH is **pre-conception counseling and permanent contraception**. If pregnancy occurs, early termination is medically recommended.

Q: During pregnancy, HIV transmission from mother to child occurs mostly during which period?

During labour and delivery. **Explanation:** The risk of Mother-to-Child Transmission (MTCT) of HIV occurs throughout pregnancy, but the timing is heavily skewed toward the peripartum period. **Why "During Labour and Delivery" is correct:** Approximately **60–75%** of vertical transmission occurs during labour and delivery. This is primarily due to **micro-transfusions** of maternal blood into the fetal circulation during uterine contractions and direct fetal contact with infected **cervicovaginal secretions** and blood in the birth canal. This "ascending infection" or direct exposure is the most significant window for transmission in untreated women. **Why the other options are incorrect:** * **First and Second Trimesters (A & B):** While the virus can cross the placenta early in pregnancy, the risk is relatively low (approx. 5–10%) because the placental barrier is more robust and there is less direct exchange of bodily fluids. * **Third Trimester (C):** Transmission risk increases as the placenta ages and thins, but it still accounts for only a minority of cases compared to the intense exposure during the intrapartum period. **High-Yield Clinical Pearls for NEET-PG:** * **Transmission Rates:** Without intervention, the risk of MTCT is 25–40%. With effective Antiretroviral Therapy (ART) and viral suppression, this risk drops to ** 1000 copies/ml** or unknown near term. * **Prophylaxis:** Nevirapine or Zidovudine is typically administered to the infant for 6–12 weeks post-delivery depending on the risk category.

Question 1

Maternal serum alpha-fetoprotein concentration is elevated in all of the following conditions except:

Accepted Answer

Fetal Down's syndrome

Answer

Hepatoma

Answer

Hepatoblastoma

Answer

Endodermal sinus tumor

Question 2

Which of the following cannot be used to lower mother-to-child HIV transmission?

Accepted Answer

Omitting ergometrine

Answer

Elective Cesarean section

Answer

Antiretroviral therapy (ART)

Answer

Intrapartum nevirapine

Question 3

A pregnant patient in her first trimester presents with an amoebic liver abscess. What is the preferred treatment?

Accepted Answer

Aspiration

Answer

Metronidazole

Answer

Diloxanide furoate

Answer

Chloroquine

Question 4

Which of the following is NOT associated with an increased risk of thromboembolism in pregnancy?

Accepted Answer

Blood group O

Answer

Anemia

Answer

Increased risk with rising parity

Answer

Antithrombin deficiency

Question 5

A 22-year-old pregnant woman presents with fever, and is treated with antibiotics. The fever is not controlled. Further investigation reveals septic pelvic thrombophlebitis. What is the recommended next course of treatment?

Accepted Answer

Continue antibiotics and start heparin

Answer

Stop antibiotics and start heparin

Answer

Surgical embolectomy

Answer

Hysterectomy

Question 6

During pregnancy, there is a reduced risk of which of the following conditions?

Accepted Answer

Relapse of multiple sclerosis

Answer

Bell's palsy

Answer

Meningioma

Answer

Chorea

Question 7

Which condition is associated with the highest maternal mortality?

Accepted Answer

Pulmonary Hypertension

Answer

Aortic Stenosis

Answer

Ventricular Septal Defect

Answer

Tetralogy of Fallot

Question 8

A patient with Stage 1A2 cervical cancer is detected at 26 weeks of gestation. What is the next appropriate management step?

Accepted Answer

Classical Cesarean section followed by Wertheim's hysterectomy at 30-32 weeks gestation

Answer

Lower segment Cesarean section followed by extrafascial hysterectomy at 28 weeks gestation

Answer

Immediate concurrent chemoradiotherapy

Answer

Medical termination of pregnancy

Question 9

Two weeks later, the results of the patient's prenatal labs come back. Her blood type is A, with an anti-D antibody titer of 1:4. What is the most appropriate next step in the management of this patient?

Accepted Answer

Repeat titer in 4 weeks

Answer

Schedule an amniocentesis for amniotic fluid bilirubin at 16 weeks

Answer

Repeat titer in 28 weeks

Answer

Schedule PUBS to determine fetal hematocrit at 20 weeks

Question 10

During pregnancy, HIV transmission from mother to child occurs mostly during which period?

Accepted Answer

During labour and delivery

Answer

First trimester

Answer

Second trimester

Answer

Third trimester

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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