Maternal-Fetal Medicine Practice Questions

Q: Which of the following placental anomalies is characterized by an abnormal attachment of the umbilical cord?

Battledore placenta (Marginal insertion). ### Explanation **Correct Answer: B. Battledore placenta (Marginal insertion)** The umbilical cord normally inserts into the center of the placental mass (eccentric or central insertion) [3]. In a **Battledore placenta**, the cord is attached at or within 2 cm of the **placental margin** [1]. The name is derived from its resemblance to a "battledore" (a historical badminton racket). While often clinically insignificant, it can be associated with preterm labor, fetal distress, or progress to a velamentous insertion. **Analysis of Incorrect Options:** * **A. Succenturiate lobe:** This is an anomaly of **placental morphology**, not cord attachment [2]. It involves one or more small accessory lobes of placental tissue situated at a distance from the main placental mass, connected by fetal vessels running through the membranes [2]. * **C. Horseshoe placenta:** This is a rare morphological variant where the placenta is shaped like a horseshoe, often associated with placenta previa. It does not specifically define an anomaly of cord attachment. **High-Yield Clinical Pearls for NEET-PG:** 1. **Velamentous Insertion:** A more severe attachment anomaly where the cord inserts into the **fetal membranes** (chorioamniotic membranes) rather than the placental mass itself [1]. The vessels run unprotected by Wharton’s jelly. 2. **Vasa Previa:** Often associated with velamentous insertion or succenturiate lobes; fetal vessels cross the internal os [1]. This is a surgical emergency due to the risk of fetal exsanguination upon rupture of membranes. 3. **Placenta Membranacea:** A rare condition where the entire chorionic sac is covered by functional villi, resulting in a thin, membranous placenta [2].

Q: The management of eclampsia includes all except?

Prolongation of pregnancy. **Explanation:** The definitive treatment for eclampsia is the **delivery of the fetus and placenta**, as the pathology originates from placental dysfunction. Once a patient develops eclampsia (generalized tonic-clonic seizures), it is considered an obstetric emergency. **1. Why "Prolongation of pregnancy" is the correct answer (The Exception):** In eclampsia, the goal is stabilization followed by prompt delivery, regardless of gestational age. **Prolongation of pregnancy is contraindicated** because it increases the risk of life-threatening maternal complications such as placental abruption, hepatic rupture, renal failure, and maternal death. Expectant management is only sometimes considered in *pre-eclampsia* far from term, but never in *eclampsia*. **2. Analysis of Incorrect Options:** * **Control of convulsions:** This is the immediate priority. **Magnesium Sulfate (MgSO₄)** is the drug of choice (Pritchard’s or Zuspan’s regimen) to arrest and prevent further seizures. * **Control of blood pressure:** Severe hypertension (≥160/110 mmHg) must be managed to prevent intracranial hemorrhage. Common agents include Labetalol, Hydralazine, or Nifedipine. * **Delivery of the fetus:** This is the only "cure." Once the mother is stabilized (airway secured, seizures controlled, BP lowered), delivery should be initiated. **Clinical Pearls for NEET-PG:** * **Drug of Choice:** MgSO₄ is superior to Diazepam or Phenytoin for eclampsia. * **Therapeutic Range of MgSO₄:** 4–7 mEq/L. * **Toxicity Check:** Always monitor patellar reflex (first to disappear), respiratory rate (>12/min), and urine output (>30ml/hr). * **Antidote:** Calcium Gluconate (10ml of 10% solution IV). * **Mode of Delivery:** Eclampsia is not an absolute indication for Cesarean section; vaginal delivery is preferred if the cervix is favorable and the maternal-fetal status is stable.

Q: What is the drug of choice for the treatment of malaria due to P. Vivax in a 25-year-old pregnant female?

Chloroquine. **Explanation:** The drug of choice for treating uncomplicated **Plasmodium vivax** malaria in pregnancy is **Chloroquine**. It is considered safe in all trimesters of pregnancy and effectively clears the erythrocytic stages of the parasite. **Why the other options are incorrect:** * **Primaquine (Option B):** While Primaquine is used for the radical cure (preventing relapse) of *P. vivax* in non-pregnant patients, it is **strictly contraindicated** in pregnancy. It can cross the placenta and cause life-threatening hemolysis in a fetus with unknown G6PD status. Radical cure is deferred until after delivery. * **Sulfadoxine-pyrimethamine (Option C):** This is primarily used for Intermittent Preventive Treatment (IPTp) or in combination for *P. falciparum*. It is not the first-line treatment for *P. vivax*. * **Quinine (Option D):** Quinine is typically reserved for severe malaria or chloroquine-resistant cases. While safe in pregnancy, it is not the first-line choice for uncomplicated *P. vivax* due to its side-effect profile (cinchonism, hypoglycemia). **High-Yield Clinical Pearls for NEET-PG:** * **Treatment Strategy:** In pregnancy, treat the acute attack of *P. vivax* with Chloroquine and initiate **weekly Chloroquine prophylaxis** (300 mg base) until delivery to prevent relapses. * **Radical Cure:** Primaquine can only be administered **postpartum**, provided the mother and infant (if breastfeeding) are screened for G6PD deficiency. * **P. falciparum in Pregnancy:** According to WHO/NVBDCP guidelines, Artemisinin-based Combination Therapy (**ACT**) is the drug of choice for *P. falciparum* in all trimesters (except Artesunate + Sulfadoxine-Pyrimethamine, which is avoided in the first trimester).

Q: A 32-week pregnant lady presents to the emergency room with continuous bleeding per vaginum. The uterus is painful and tender. What is the most likely diagnosis?

Abruptio placenta. ### Explanation The clinical presentation of **continuous bleeding per vaginum** associated with a **painful and tender uterus** in the third trimester is a classic hallmark of **Abruptio Placenta**. #### Why Abruptio Placenta is Correct: Abruptio placenta refers to the premature separation of a normally situated placenta from the uterine wall. The bleeding is often associated with retroplacental clot formation, which causes uterine irritability, leading to a **"woody hard,"** tender, and painful uterus. Unlike other causes of antepartum hemorrhage (APH), the pain is constant and the bleeding is often "revealed" or "mixed." #### Why Other Options are Incorrect: * **Placenta Previa:** This typically presents as **painless, causeless, and recurrent** bright red bleeding. The uterus remains soft, non-tender, and the fetal parts are easily palpable. * **Circumvallate Placenta:** While it can cause APH and preterm labor, it is a morphological variation of the placenta and does not typically present with the acute uterine tenderness seen in abruption. * **Rupture of Membranes:** This presents as a sudden gush of clear or blood-tinged fluid (liquor), not continuous frank bleeding with uterine tenderness. #### Clinical Pearls for NEET-PG: * **Most common risk factor:** Pregnancy-induced hypertension (PIH) or Preeclampsia. * **Couvelaire Uterus:** A severe form of abruption where blood extravasates into the myometrium, giving the uterus a bluish/purplish mottled appearance. * **Coagulopathy:** Abruptio placenta is the most common cause of **Consumptive Coagulopathy (DIC)** in obstetrics. * **Diagnosis:** Primarily **clinical**. Ultrasound is unreliable for excluding abruption as it only detects about 25-50% of cases (retroplacental clots).

Q: Which of the following does NOT predispose to isoimmunization in an Rh-negative female?

Advanced maternal age. **Explanation:** Rh isoimmunization occurs when an Rh-negative mother is exposed to Rh-positive fetal red blood cells, leading to the production of maternal antibodies. This process requires a **feto-maternal hemorrhage (FMH)** of at least 0.1 mL. **Why Advanced Maternal Age is the Correct Answer:** Advanced maternal age (Option A) is a risk factor for chromosomal abnormalities and certain obstetric complications (like preeclampsia), but it does **not** inherently cause or increase the risk of feto-maternal hemorrhage. Therefore, it does not predispose a woman to isoimmunization. **Analysis of Incorrect Options:** * **Antepartum Hemorrhage (Option B):** Conditions like placental abruption or placenta previa involve the disruption of the placental interface, significantly increasing the risk of fetal blood entering the maternal circulation. * **Cesarean Section (Option C):** Surgical delivery is a major risk factor for FMH compared to vaginal delivery due to the manual removal of the placenta and uterine trauma. * **Post-dated Pregnancy (Option D):** As a pregnancy progresses beyond 40 weeks, the placenta begins to age (senescence), leading to micro-fractures in the chorionic villi. This increases the likelihood of spontaneous "silent" feto-maternal leaks. **NEET-PG High-Yield Pearls:** * **Most common cause of FMH:** Delivery (especially third stage of labor). * **Standard Dose:** 300 mcg of Anti-D IgG can neutralize 15 mL of fetal RBCs (or 30 mL of whole fetal blood). * **Screening:** The **Kleihauer-Betke (KB) test** is used to quantify the volume of FMH to determine if additional Anti-D doses are required. * **Critical Titer:** An Indirect Coombs Test (ICT) titer of **1:16** is generally considered the critical threshold requiring fetal surveillance (e.g., MCA-PSV doppler).

Q: Prenatal diagnosis of Hemophilia is best done by?

PCR. **Explanation:** **Hemophilia A and B** are X-linked recessive disorders caused by mutations in the *F8* and *F9* genes, respectively. The gold standard for prenatal diagnosis is **Polymerase Chain Reaction (PCR)**. 1. **Why PCR is the Correct Answer:** PCR allows for the direct detection of specific genetic mutations (such as the common **Intron 22 inversion** in Hemophilia A). It is the preferred method because it is highly sensitive, rapid, and requires only a minute amount of fetal DNA obtained via **Chorionic Villus Sampling (CVS)** at 10–12 weeks or **Amniocentesis** at 15–18 weeks. Modern techniques like **QF-PCR** (Quantitative Fluorescence PCR) further enhance speed and accuracy. 2. **Analysis of Other Options:** * **Linkage Analysis:** This was the traditional method used when specific mutations were unknown. It tracks the inheritance of polymorphic markers (STRs) within families. It is less preferred today because it requires DNA from multiple family members and is prone to errors due to genetic recombination. * **Cytometry (Flow Cytometry):** This is used for analyzing physical and chemical characteristics of cells (e.g., fetal cell sorting), but it cannot diagnose specific single-gene mutations like Hemophilia. * **Microarray (CMA):** While excellent for detecting submicroscopic chromosomal imbalances (deletions/duplications), it is not the primary tool for detecting the point mutations or inversions typical of Hemophilia. **Clinical Pearls for NEET-PG:** * **Most common mutation in severe Hemophilia A:** Intron 22 inversion (found in ~45% of cases). * **Sampling:** CVS is preferred over amniocentesis for earlier diagnosis (1st trimester). * **Non-invasive Prenatal Diagnosis (NIPD):** Research is shifting toward using cell-free fetal DNA (cffDNA) in maternal plasma to avoid invasive risks, though PCR remains the current clinical standard.

Q: What test is used to differentiate maternal and fetal blood?

APT test. **Explanation:** The **APT test** (Alkali Denaturation Test) is the gold standard for differentiating maternal blood from fetal blood, most commonly used in cases of **Vasa Previa** or when a neonate presents with bloody stools/vomitus. **1. Why APT Test is Correct:** The test relies on the biochemical property that **Fetal Hemoglobin (HbF)** is resistant to denaturation by strong bases, whereas **Adult Hemoglobin (HbA)** is not. When sodium hydroxide (NaOH) is added to the blood sample, maternal blood (HbA) turns yellow-brown (forming alkaline hematin), while fetal blood (HbF) remains pink. **2. Analysis of Incorrect Options:** * **Osmotic Fragility Test:** Used to diagnose Hereditary Spherocytosis by measuring the resistance of RBCs to hemolysis in varying concentrations of saline. * **Bubble Test (Shake Test):** A bedside test used to assess **fetal lung maturity** by checking for the presence of surfactant in amniotic fluid. * **Kleihauer-Betke (KB) Test:** While also based on HbF resistance to acid, it is used to **quantify** the volume of feto-maternal hemorrhage (FMH) in the maternal circulation (e.g., after trauma or for Rh-isoimmunization dosing), rather than differentiating pure samples of blood. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Scenario:** If a pregnant woman has vaginal bleeding and the APT test is **positive (pink)**, the diagnosis is **Vasa Previa** (fetal origin). * **KB Test Formula:** Used to calculate the dose of Anti-D. (Volume of FMH = % of fetal cells × 50). * **L/S Ratio:** The definitive lab test for fetal lung maturity (Normal > 2:1).

Q: What is the management of a 5 cm dermoid cyst that has undergone torsion at 10 weeks of pregnancy?

Immediate removal. **Explanation:** **1. Why Immediate Removal is Correct:** Adnexal torsion is a surgical emergency, regardless of the gestational age. When a dermoid cyst (mature cystic teratoma) undergoes torsion, the blood supply to the ovary is compromised, leading to ischemia, necrosis, and potential peritonitis. In pregnancy, the primary goal is to prevent maternal morbidity and secondary fetal loss due to systemic inflammation or infection. Therefore, **immediate surgical intervention** (preferably laparoscopic detorsion or cystectomy) is mandatory to save the adnexa and stabilize the patient. **2. Why Other Options are Incorrect:** * **A & D (Wait and watch/Serial USG):** These are contraindicated in torsion. Delaying surgery increases the risk of gangrene, rupture of the cyst (which can cause chemical peritonitis in dermoids), and maternal sepsis. * **B (Removal in the 2nd trimester):** While the 2nd trimester (14–16 weeks) is the "elective window" for removing asymptomatic large cysts to prevent future complications, it does not apply to **acute emergencies** like torsion. An acutely twisted cyst cannot wait for the second trimester. **Clinical Pearls for NEET-PG:** * **Most common benign ovarian tumor in pregnancy:** Dermoid cyst (Mature cystic teratoma). * **Most common complication of dermoid in pregnancy:** Torsion (most frequent during the 1st trimester when the uterus rises or postpartum when the uterus involutes). * **Surgical approach:** Laparoscopy is considered safe in the 1st and 2nd trimesters when performed by experts. * **Progesterone Support:** If the corpus luteum is removed during surgery before 10–12 weeks, exogenous progesterone (e.g., micronized progesterone or dydrogesterone) must be supplemented to maintain the pregnancy until placental shift occurs.

Question 1

Which of the following placental anomalies is characterized by an abnormal attachment of the umbilical cord?

Accepted Answer

Battledore placenta (Marginal insertion)

Answer

Succenturiate lobe (Lobate placenta)

Answer

Horseshoe placenta

Answer

None of the above

Question 2

An elderly multiparous woman with intrauterine fetal death was admitted with strong labor pains. The patient suddenly goes into shock with cyanosis, respiratory disturbances, and pulmonary edema. What is the most likely clinical diagnosis?

Accepted Answer

Amniotic fluid embolism

Answer

Rupture of uterus

Answer

Congestive heart failure

Answer

Concealed accidental hemorrhage

Question 3

The management of eclampsia includes all except?

Accepted Answer

Prolongation of pregnancy

Answer

Control of convulsions

Answer

Control of blood pressure

Answer

Delivery of the fetus

Question 4

What is the drug of choice for the treatment of malaria due to P. Vivax in a 25-year-old pregnant female?

Accepted Answer

Chloroquine

Answer

Primaquine

Answer

Sulfadoxine-pyrimethamine

Answer

Quinine

Question 5

The best method of managing the second stage of labor in a patient with heart disease is by?

Accepted Answer

Prophylactic ventouse

Answer

Prophylactic forceps

Answer

Spontaneous delivery with episiotomy

Answer

Cesarean section

Question 6

A 32-week pregnant lady presents to the emergency room with continuous bleeding per vaginum. The uterus is painful and tender. What is the most likely diagnosis?

Accepted Answer

Abruptio placenta

Answer

Circumvallate placenta

Answer

Rupture of membranes

Answer

Placenta previa

Question 7

Which of the following does NOT predispose to isoimmunization in an Rh-negative female?

Accepted Answer

Advanced maternal age

Answer

Antepartum hemorrhage

Answer

Cesarean section

Answer

Post-dated pregnancy

Question 8

Prenatal diagnosis of Hemophilia is best done by?

Accepted Answer

PCR

Answer

Linkage analysis

Answer

Cytometry

Answer

Microarray

Question 9

What test is used to differentiate maternal and fetal blood?

Accepted Answer

APT test

Answer

Osmotic fragility test

Answer

Bubblin test

Answer

Kleihauer-Betke test

Question 10

What is the management of a 5 cm dermoid cyst that has undergone torsion at 10 weeks of pregnancy?

Accepted Answer

Immediate removal

Answer

Wait and watch

Answer

Removal in the 2nd trimester

Answer

Serial ultrasonography monitoring

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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