Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 271: Which statement concerning polyhydramnios is true?

A. Acute polyhydramnios always leads to labor prior to 28 weeks.
B. The incidence of associated malformations is approximately 3%.
C. Maternal edema, especially of the lower extremities and vulva, is rare.
D. Complications include placental abruption, uterine dysfunction, and postpartum hemorrhage. (Correct Answer)

Explanation: **Explanation:** Polyhydramnios is defined as an Amniotic Fluid Index (AFI) >25 cm or a Single Deepest Pocket (SDP) >8 cm. The correct answer is **D** because the sudden decompression of a massively distended uterus (e.g., during rupture of membranes) can lead to **placental abruption**. Furthermore, the overdistension of the uterine musculature leads to **uterine dysfunction** (hypotonic labor) and impairs postpartum contraction, significantly increasing the risk of **postpartum hemorrhage (PPH)**. **Analysis of Incorrect Options:** * **Option A:** While acute polyhydramnios (sudden onset) is severe and often leads to preterm labor, it does not *always* occur before 28 weeks. Many cases can be managed or occur later in the third trimester. * **Option B:** The incidence of fetal malformations in polyhydramnios is much higher than 3%, ranging from **20% to 40%**. Common associations include anencephaly, esophageal atresia, and tracheoesophageal fistula. * **Option C:** Maternal edema of the lower extremities, vulva, and abdominal wall is actually **common**, not rare. It results from the heavy uterus compressing the pelvic veins and the inferior vena cava. **NEET-PG High-Yield Pearls:** * **Most common cause:** Idiopathic (approx. 50-60%), followed by Maternal Diabetes. * **Congenital anomalies:** Anencephaly is the most common CNS cause (due to lack of swallowing and exposed meninges). * **Management:** Therapeutic amniocentesis (amnionreduction) is indicated if the mother has respiratory distress or severe pain. * **Associated Risk:** Increased risk of cord prolapse during the rupture of membranes due to the high volume of fluid flushing the cord down.

Question 272: Which one of the following medical disorders leads to delayed fetal lung maturity?

A. Heart disease
B. Diabetes (Correct Answer)
C. Thalassemia minor
D. Epilepsy

Explanation: **Explanation:** The correct answer is **Diabetes**. Fetal lung maturity is primarily determined by the production of pulmonary surfactant (phospholipids like lecithin). In pregnancies complicated by maternal diabetes, maternal hyperglycemia leads to **fetal hyperinsulinemia**. High levels of fetal insulin act as a potent antagonist to the action of cortisol on the type II pneumocytes. This inhibits the synthesis of surfactant proteins and phospholipids, specifically delaying the appearance of **Phosphatidylglycerol (PG)**. Consequently, infants of diabetic mothers are at a higher risk of Respiratory Distress Syndrome (RDS) even at relatively mature gestational ages. **Analysis of Incorrect Options:** * **Heart Disease:** Chronic maternal hypoxia or circulatory compromise (as seen in heart disease) acts as a form of chronic fetal stress. Stress triggers the premature release of endogenous fetal glucocorticoids, which actually **accelerates** lung maturity. * **Thalassemia Minor:** This is generally an asymptomatic carrier state and does not significantly alter the intrauterine environment or fetal hormonal milieu to delay lung maturation. * **Epilepsy:** While the medications used (anti-epileptics) may have teratogenic risks, the disorder itself does not interfere with the biochemical pathways of surfactant production. **High-Yield Clinical Pearls for NEET-PG:** * **Accelerated Lung Maturity:** Seen in conditions causing **chronic placental insufficiency** or fetal stress (e.g., Preeclampsia, Chronic Hypertension, IUGR, Premature Rupture of Membranes, and Maternal Smoking). * **Delayed Lung Maturity:** Primarily associated with **Diabetes Mellitus** and **Rh Isoimmunization**. * **Gold Standard:** The presence of **Phosphatidylglycerol (PG)** in amniotic fluid is the most reliable indicator of lung maturity in diabetic pregnancies, as the L/S ratio can sometimes be falsely reassuring.

Question 273: Maternal serum alpha-fetoprotein concentration is elevated in all of the following conditions except:

A. Hepatoma
B. Hepatoblastoma
C. Endodermal sinus tumor
D. Fetal Down's syndrome (Correct Answer)

Explanation: **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**.

Question 274: Which of the following cannot be used to lower mother-to-child HIV transmission?

A. Elective Cesarean section
B. Omitting ergometrine (Correct Answer)
C. Antiretroviral therapy (ART)
D. Intrapartum nevirapine

Explanation: **Explanation:** The goal of preventing mother-to-child transmission (PMTCT) of HIV is to reduce viral exposure during pregnancy, labor, and delivery. **Why "Omitting ergometrine" is the correct answer:** Ergometrine is a powerful uterotonic used to prevent or treat Postpartum Hemorrhage (PPH). It causes **tetanic uterine contractions**, which can theoretically lead to "autotransfusion" of placental blood into the systemic circulation. While this was historically debated, current WHO and national guidelines (including NACO) **do not** recommend omitting ergometrine for HIV-positive mothers. It is not a recognized method to lower transmission; rather, managing PPH remains a priority. In contrast, **Methergine is contraindicated in patients on Protease Inhibitors (like Ritonavir)** due to the risk of exaggerated vasoconstriction (ergot toxicity), but not because of HIV transmission risk itself. **Analysis of Incorrect Options:** * **Elective Cesarean Section:** Reduces transmission by avoiding contact with infected vaginal secretions and preventing "micro-transfusions" during labor contractions, especially if the viral load is >1000 copies/mL. * **Antiretroviral Therapy (ART):** This is the cornerstone of PMTCT. It reduces the maternal viral load, significantly lowering the risk of transmission to <1%. * **Intrapartum Nevirapine:** Historically used as a single dose (SD-NVP) to provide rapid prophylaxis during labor. While now largely replaced by lifelong ART (Option B+), it remains a valid pharmacological intervention to lower transmission. **High-Yield Clinical Pearls for NEET-PG:** * **Most common timing of transmission:** Intrapartum (during labor and delivery). * **Breastfeeding:** In India (NACO guidelines), exclusive breastfeeding for 6 months is recommended despite the risk, as it outweighs the risk of malnutrition/infection from replacement feeding. * **Drug of choice for infant prophylaxis:** Syrup Nevirapine for 6 weeks. * **Avoid:** Artificial Rupture of Membranes (ARM), fetal scalp electrodes, and instrumental delivery (forceps/vaccum) to minimize fetal exposure to maternal blood.

Question 275: Which of the following statements regarding asymptomatic bacteriuria in pregnancy is true?

A. Most cases are usually asymptomatic in pregnancy.
B. If untreated, it progresses to pyelonephritis.
C. Early and prompt treatment prevents abnormalities in the fetus.
D. It increases the chance of premature infant. (Correct Answer)

Explanation: **Explanation:** **Asymptomatic Bacteriuria (ASB)** is defined as the presence of $>10^5$ colony-forming units (CFU)/mL of a single uropathogen in a midstream clean-catch urine specimen from an individual without symptoms of a urinary tract infection (UTI). **Why Option D is Correct:** ASB in pregnancy is a significant risk factor for adverse obstetric outcomes. The inflammatory response triggered by the infection can lead to the release of prostaglandins and cytokines, which stimulate uterine contractions and cervical ripening. This significantly increases the risk of **preterm labor, premature birth, and low birth weight (LBW)** infants. **Analysis of Incorrect Options:** * **Option A:** While the condition is by definition "asymptomatic," the statement is a tautology and does not address the clinical significance or management goals required by the question context. * **Option B:** While approximately 20–40% of untreated ASB cases progress to **acute pyelonephritis**, it is incorrect to say it *always* progresses in all cases. However, the risk is high enough to mandate universal screening. * **Option C:** Treatment primarily prevents maternal complications (pyelonephritis) and prematurity. It does **not** prevent congenital "abnormalities" (structural malformations) in the fetus, as ASB is not a known teratogen. **High-Yield Clinical Pearls for NEET-PG:** * **Most common organism:** *Escherichia coli* (70–80%). * **Screening:** All pregnant women should be screened via **urine culture** at the first prenatal visit (ideally between 12–16 weeks). * **Treatment:** Essential even if asymptomatic. Common drugs include Nitrofurantoin (avoid near term), Amoxicillin, or Cephalexin. * **Goal:** Treatment reduces the risk of pyelonephritis from 30% to <3%.

Question 276: In placenta previa, conservative treatment is not done in which of the following cases?

A. Active labor
B. Anencephaly
C. Dead baby and severe placenta previa
D. All of the above (Correct Answer)

Explanation: **Explanation:** The primary goal of conservative management in placenta previa (known as the **MacAfee and Johnson regimen**) is to prolong pregnancy until fetal maturity is reached (ideally 37 weeks) without compromising maternal safety. This approach is only indicated if the mother is hemodynamically stable, the bleeding has stopped, and the fetus is premature but alive. **Why "All of the Above" is correct:** Conservative management is contraindicated when the risks of continuing the pregnancy outweigh the benefits of fetal maturation. * **Active Labor (Option A):** Once labor starts, the cervix begins to efface and dilate, which inevitably causes massive separation of the placenta and life-threatening hemorrhage. Delivery is mandatory. * **Anencephaly (Option B):** If there is a major lethal congenital anomaly (like anencephaly), there is no clinical benefit in "waiting for maturity" or risking maternal hemorrhage for a fetus that cannot survive. * **Dead baby and severe placenta previa (Option C):** In the presence of intrauterine fetal death (IUFD), the objective of conservative management (fetal maturity) is lost. Furthermore, severe placenta previa (Type III or IV) necessitates delivery (usually by Cesarean section) to prevent maternal exsanguination, regardless of fetal status. **High-Yield Clinical Pearls for NEET-PG:** * **MacAfee Regimen Criteria:** Pregnancy <37 weeks, bleeding is not life-threatening, mother is stable, and the fetus is alive with no gross anomalies. * **Ideal Delivery Timing:** In stable cases of placenta previa, elective delivery is usually planned at **37 weeks**. * **Vaginal Examination:** Digital vaginal examination is **strictly contraindicated** (can cause torrential hemorrhage) unless performed as a "Double Setup Examination" in the operating theater. * **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the gold standard for diagnosing placental localization.

Question 277: What is the most common congenital malformation seen in infants of diabetic mothers?

A. Cardiac defect (Correct Answer)
B. Renal defect
C. Liver defect
D. Lung defect

Explanation: **Explanation:** Infants of diabetic mothers (IDM) are at a 3–4 fold increased risk of congenital malformations due to the teratogenic effects of maternal hyperglycemia during organogenesis. **1. Why Cardiac Defects are Correct:** Congenital Heart Diseases (CHDs) are the **most common** malformations seen in IDMs. Among these, **Ventricular Septal Defect (VSD)** and **Transposition of the Great Arteries (TGA)** are the most frequent. It is important to distinguish this from the *most specific* malformation (Caudal Regression Syndrome). Hyperglycemia leads to oxidative stress and altered gene expression during the critical period of heart development (3rd to 8th week). **2. Why other options are incorrect:** * **Renal defects:** While renal anomalies (like renal agenesis or hydronephrosis) occur more frequently in IDMs than in the general population, they are statistically less common than cardiac defects. * **Liver and Lung defects:** These are not primary structural malformations associated with diabetic embryopathy. However, IDMs often face functional lung issues, such as **Respiratory Distress Syndrome (RDS)**, due to hyperinsulinemia delaying surfactant production, but this is a developmental delay rather than a structural malformation. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Malformation:** Cardiac defects (VSD > TGA). * **Most Specific Malformation:** Caudal Regression Syndrome (Sacral Agenesis). * **Most Common Echo finding:** Asymmetric Septal Hypertrophy (usually transient/resolves after birth). * **Neural Tube Defects (NTDs):** These are the second most common malformations in IDMs. * **HbA1c Correlation:** The risk of malformations is directly proportional to the maternal HbA1c levels during the first trimester.

Question 278: A pregnant patient in her first trimester presents with an amoebic liver abscess. What is the preferred treatment?

A. Metronidazole
B. Diloxanide furoate
C. Chloroquine
D. Aspiration (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Aspiration** **1. Why Aspiration is the Correct Choice:** In the first trimester of pregnancy, the primary goal is to avoid potential teratogens during organogenesis. **Metronidazole**, the standard treatment for amoebic liver abscess, is generally avoided in the first trimester as it crosses the placenta and has shown mutagenic potential in some animal studies (though human data is inconclusive). Therefore, for a pregnant patient in her first trimester, **needle aspiration** is the preferred initial management to provide symptomatic relief and reduce the abscess size without pharmacological risk to the fetus. Medical therapy is typically deferred until the second trimester unless the situation is life-threatening. **2. Analysis of Incorrect Options:** * **A. Metronidazole:** While it is the drug of choice for non-pregnant adults, it is contraindicated/avoided in the **first trimester** due to theoretical teratogenic risks. It can be used cautiously in the second and third trimesters. * **B. Diloxanide furoate:** This is a luminal amoebicide used to eradicate the carrier state after treating the systemic infection. It is generally avoided in pregnancy. * **C. Chloroquine:** While it can be used for amoebic liver abscesses that do not respond to metronidazole, it is not the first-line treatment and is not preferred over aspiration in the first trimester. **3. NEET-PG High-Yield Pearls:** * **Amoebic Liver Abscess vs. Pyogenic:** Amoebic abscesses are usually solitary and located in the right lobe (superior-posterior aspect). The classic "anchovy sauce" pus is a diagnostic hallmark. * **Drug of Choice (General):** Metronidazole (Tinidazole is an alternative). * **Indications for Aspiration (Non-pregnant):** Large abscess (>5–10 cm), risk of imminent rupture, left lobe abscess (high risk of pericardial rupture), or failure to respond to medical therapy within 48–72 hours. * **Pregnancy Rule:** Always prioritize non-pharmacological interventions or Category B drugs in the first trimester whenever clinically feasible.

Question 279: Which of the following is NOT associated with an increased risk of thromboembolism in pregnancy?

A. Anemia
B. Blood group O (Correct Answer)
C. Increased risk with rising parity
D. Antithrombin deficiency

Explanation: **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.

Question 280: What is the indication for amnioinfusion?

A. Oligohydramnios (Correct Answer)
B. Suspected renal anomalies
C. To facilitate labor
D. Fetal distress

Explanation: **Explanation:** **Amnioinfusion** is the technique of infusing a liquid (usually normal saline or Ringer’s lactate) into the amniotic cavity. **Why Option A is Correct:** The primary indication for amnioinfusion is **Oligohydramnios**, particularly when it leads to **variable decelerations** during labor. In oligohydramnios, the lack of cushioning fluid causes the umbilical cord to be compressed by fetal parts or the uterine wall. Amnioinfusion restores the fluid volume, relieves cord compression, and improves fetal oxygenation. It is also used prophylactically in cases of Preterm Premature Rupture of Membranes (PPROM) to prevent pulmonary hypoplasia. **Why Other Options are Incorrect:** * **B. Suspected renal anomalies:** While renal anomalies (like Potter’s syndrome) cause oligohydramnios, amnioinfusion is not a treatment for the anomaly itself. It may be used as a diagnostic tool (diagnostic amnioinfusion) to improve ultrasound visualization, but it is not the primary therapeutic indication. * **C. To facilitate labor:** Amnioinfusion does not shorten the duration of labor or improve uterine contractions; its role is strictly fetal protection. * **D. Fetal distress:** While it treats fetal distress caused specifically by *cord compression* (variable decelerations), it is contraindicated in cases of acute fetal distress due to other causes (like placental abruption) where immediate delivery is required. **High-Yield NEET-PG Pearls:** 1. **Indications:** Relief of variable decelerations (most common), dilution of thick meconium (though controversial now), and diagnostic visualization. 2. **Route:** Transvaginal (via IUPC) during labor or Transabdominal (ultrasound-guided). 3. **Fluid used:** Room temperature Normal Saline or Ringer's Lactate. 4. **Contraindications:** Amnionitis, Polyhydramnios, Placental Abruption, and Uterine Hypertonicity.

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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