Maternal-Fetal Medicine Practice Questions

Q: Antepartum bleeding of fetal origin is:

Vasa previa. **Explanation:** In **Vasa Previa**, fetal blood vessels (unprotected by Wharton’s jelly or placental tissue) run across the internal os of the cervix, usually due to a velamentous insertion of the umbilical cord or a succenturiate placental lobe. When the membranes rupture (spontaneous or artificial), these vessels are lacerated. Because the blood originates from the umbilical-placental circulation, the hemorrhage is of **fetal origin**. This is a critical emergency because the total fetal blood volume is small (~80-100 mL/kg); even minor bleeding can lead to rapid fetal exsanguination and death, while the mother remains hemodynamically stable. **Analysis of Incorrect Options:** * **Abruptio Placenta:** Bleeding occurs due to the premature separation of a normally situated placenta. The hemorrhage is **maternal** in origin, arising from the spiral arteries in the decidua basalis. * **Placenta Previa:** Bleeding occurs when the placenta is implanted in the lower uterine segment. The bleeding is **maternal**, resulting from the stretching of the lower segment and tearing of the placental attachments. * **Circumvallate Placenta:** This is a morphological variation where the chorionic plate is smaller than the basal plate. While it increases the risk of abruption or preterm labor, any associated bleeding is typically **maternal**. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Rupture of membranes + Painless vaginal bleeding + Fetal bradycardia/distress. * **Diagnostic Test:** The **Apt test** or **Ogita test** can differentiate fetal hemoglobin (HbF) from maternal hemoglobin (HbA) based on alkali resistance. * **Management:** If diagnosed prenatally via Color Doppler, a planned Cesarean section is performed at 34–36 weeks. If diagnosed during labor, immediate emergency Cesarean is mandatory.

Q: What is the most common congenital anomaly observed in pregnancies complicated by diabetes mellitus?

Neural tube defect. **Explanation:** In pregnancies complicated by pre-gestational diabetes mellitus (Type 1 or Type 2), the risk of congenital malformations is 3–4 times higher than in the general population, primarily due to the teratogenic effects of hyperglycemia during organogenesis. **Why Neural Tube Defects (NTDs) are correct:** While **Sacral Agenesis (Caudal Regression Syndrome)** is the most *specific* anomaly associated with diabetic embryopathy, it is rare. In terms of absolute frequency, **Neural Tube Defects** (such as anencephaly and spina bifida) are the **most common** major malformations seen in these patients. The risk of NTDs in diabetic pregnancies is increased nearly 10-fold compared to the non-diabetic population. **Analysis of Incorrect Options:** * **A. Multicystic kidneys:** While renal anomalies (like renal agenesis or ureteral duplication) occur more frequently in diabetic pregnancies, they are less common than CNS malformations. * **B & D. Oesophageal and Duodenal atresia:** Gastrointestinal atresias are associated with diabetic embryopathy, but their prevalence is significantly lower than that of NTDs and Cardiac defects. **High-Yield NEET-PG Pearls:** 1. **Most Common Overall:** Neural Tube Defects (specifically Anencephaly and Spina Bifida). 2. **Most Specific/Pathognomonic:** Caudal Regression Syndrome (Sacral Agenesis). 3. **Most Common Cardiac Anomaly:** Ventricular Septal Defect (VSD) and Transposition of the Great Arteries (TGA). 4. **Screening:** Maternal HbA1c levels >8.5% at conception are associated with a significantly higher risk of these anomalies. 5. **Prevention:** Strict glycemic control and high-dose Folic Acid (5 mg) pre-conceptionally are essential.

Q: Which of the following is NOT a risk factor for placenta previa?

Young maternal age. **Explanation:** Placenta previa occurs when the placenta implants in the lower uterine segment, partially or completely covering the internal cervical os. The underlying pathophysiology is often related to **endometrial scarring** or a **large placental surface area**, necessitating a lower implantation site for adequate nutrition. **1. Why "Young maternal age" is the correct answer:** Advanced maternal age (typically >35 years) is a well-established risk factor for placenta previa. Conversely, **young maternal age is not a risk factor**. As women age, there is a higher likelihood of subclinical endometrial damage and atherosclerotic changes in the uterine vessels, which may predispose to low implantation. **2. Why the other options are incorrect (Risk Factors):** * **Multifetal gestation:** A larger placental surface area is required to support multiple fetuses, increasing the probability that the placenta will extend into the lower uterine segment. * **Cigarette smoking:** Carbon monoxide-induced hypoxemia leads to compensatory **placental hypertrophy** (increased surface area) to maximize oxygen transport, raising the risk of previa. * **Multiparity:** Repeated pregnancies can cause permanent changes in the endometrium and uterine vasculature, favoring lower implantation in subsequent gestations. **High-Yield Clinical Pearls for NEET-PG:** * **Most significant risk factor:** Previous Cesarean Section (risk increases linearly with the number of prior C-sections). * **Classic Presentation:** Painless, bright red, causative-less, recurrent vaginal bleeding in the third trimester. * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) is safer and more accurate than transabdominal ultrasound. * **Management Contraindication:** Digital vaginal examination is strictly contraindicated (can trigger torrential hemorrhage). Always perform a speculum exam only after placental location is confirmed.

Q: A 25-year-old woman, G2P1L1, at 8 weeks gestation, with RhD negative status and a non-sensitized pregnancy, has had a spontaneous complete miscarriage. What is the dose of Anti-D immunoglobulin to be given?

Anti-D not required. ### Explanation **1. Why the correct answer is right:** The primary objective of Anti-D administration is to prevent Rh-isoimmunization. In a **spontaneous complete miscarriage occurring before 12 weeks of gestation**, the risk of significant fetomaternal hemorrhage (FMH) is negligible because the fetal erythropoiesis and circulation are not sufficiently developed to cause maternal sensitization. According to standard guidelines (including RCOG and many national protocols), Anti-D prophylaxis is **not required** for spontaneous complete miscarriages before 12 weeks, provided there is no surgical intervention (like D&C) or heavy bleeding. **2. Why the incorrect options are wrong:** * **Option B (250 IU) & C (500 IU):** These doses are indicated for "sensitizing events" occurring before 20 weeks (e.g., threatened miscarriage, ectopic pregnancy, or surgical evacuation). Since a spontaneous complete miscarriage at 8 weeks is not considered a sensitizing event, these doses are unnecessary. * **Option D (Testing FMH):** Testing for the quantity of fetomaternal bleed (e.g., Kleihauer-Betke test) is typically indicated only after **20 weeks** of gestation to calculate the required dose of Anti-D. It is not performed in the first trimester. **3. Clinical Pearls for NEET-PG:** * **The "12-Week Rule":** Anti-D is generally indicated for all Rh-negative non-sensitized women after any miscarriage/abortion **after 12 weeks**. * **Exceptions before 12 weeks:** Anti-D **must** be given if there is: 1. Ectopic pregnancy. 2. Molar pregnancy. 3. Therapeutic termination of pregnancy (Medical or Surgical). 4. Heavy vaginal bleeding in a threatened miscarriage. * **Standard Doses:** * 20 weeks: 1500 IU (or 300 mcg). * **Timeframe:** Anti-D should ideally be given within **72 hours** of the event, but it still provides some benefit if given up to 10 days later.

Q: Which of the following conditions typically improves during pregnancy?

Rheumatoid arthritis. **Explanation:** **Rheumatoid Arthritis (RA)** is the correct answer because approximately **75–90% of patients** experience significant clinical improvement or even complete remission during pregnancy. This improvement is primarily attributed to the **shift from a Th1 (pro-inflammatory) to a Th2 (anti-inflammatory) cytokine profile**, increased levels of circulating progesterone, and the presence of fetal-maternal HLA disparity, which induces a state of maternal immune tolerance. However, it is important to note that up to 90% of these patients will experience a **flare-up in the postpartum period**. **Analysis of Incorrect Options:** * **Multiple Sclerosis (MS):** While the relapse rate often decreases during the second and third trimesters, MS does not "typically improve" in the same predictable manner as RA. Furthermore, there is a significantly high risk of relapse in the first 3 months postpartum. * **Systemic Lupus Erythematosus (SLE):** Pregnancy is generally a period of **exacerbation** for SLE. It can trigger new flares (especially lupus nephritis) and is associated with increased risks of preeclampsia, fetal loss, and Neonatal Lupus (due to Anti-Ro/SSA and Anti-La/SSB antibodies). * **Myasthenia Gravis:** The course is highly unpredictable. One-third improve, one-third worsen, and one-third remain stable. It is not characterized by typical improvement. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice for RA in pregnancy:** Sulfasalazine and Hydroxychloroquine are considered safe. **Methotrexate and Leflunomide are strictly contraindicated** (teratogenic). * **Postpartum Flare:** RA is notorious for flaring up 6–12 weeks after delivery. * **SLE & Pregnancy:** Patients should ideally be in remission for at least 6 months before conceiving to ensure the best maternal and fetal outcomes.

Q: True about intrauterine fetal death (IUD)?

Overlapping of skull bones. **Explanation:** Intrauterine Fetal Death (IUFD) is characterized by specific radiological signs that occur due to the cessation of circulation and subsequent degenerative changes in the fetus. **1. Why Option C is Correct:** **Spalding’s Sign** refers to the **overlapping of fetal skull bones**. It occurs due to the liquefaction of the brain matter and loss of intracranial pressure following fetal death. This sign typically appears 4–7 days after death. It is a classic radiological marker for IUFD, provided the mother is not in labor (as molding during labor can also cause overlapping). **2. Analysis of Incorrect Options:** * **Option A (Gas bubbles in great vessels):** This is known as **Robert’s Sign**. While it is a sign of IUFD, it is caused by the liberation of gas (CO2) from blood decomposition. However, it is an early sign (appearing within 12 hours) and is less commonly tested or specific compared to Spalding's sign in clinical scenarios. * **Option B (Halo’s Sign):** This refers to the elevation of the scalp fat layer due to edema, creating a "halo" appearance. While associated with IUFD (Deuel’s halo sign), it is non-specific and can also be seen in cases of fetal hydrops or maternal diabetes. * **Option D (Decreased amniotic fluid):** While oligohydramnios may be associated with the cause of death (e.g., renal agenesis or placental insufficiency), it is not a diagnostic radiological sign of the death itself. **Clinical Pearls for NEET-PG:** * **Earliest Sign of IUFD:** Robert’s Sign (Gas in the heart/great vessels). * **Most Common Sign:** Spalding’s Sign. * **Confirmatory Test of Choice:** Real-time Ultrasound showing absence of fetal cardiac activity. * **Spalding’s Sign Mimic:** Can be false-positive in a live fetus during active labor due to molding or in cases of severe dehydration.

Q: As per WHO, anemia is considered to exist in pregnancy if the hemoglobin level is below what value?

11 gm%. **Explanation:** The correct answer is **11 gm%**. According to the **World Health Organization (WHO)**, anemia in pregnancy is defined as a hemoglobin (Hb) concentration of **< 11 g/dL** (or a hematocrit < 33%). This threshold is lower than that for non-pregnant women (12 g/dL) due to the physiological changes of pregnancy. During gestation, there is a disproportionate increase in plasma volume (approx. 50%) compared to red cell mass (approx. 20-30%), leading to **hemodilution**, often referred to as "physiological anemia of pregnancy." **Analysis of Options:** * **11 gm% (Correct):** The WHO standard for anemia throughout pregnancy. However, note that the CDC and some guidelines suggest < 10.5 g/dL specifically during the second trimester. * **12 gm% (Incorrect):** This is the WHO cutoff for anemia in **non-pregnant, non-lactating adult women**. * **13 gm% (Incorrect):** This is the WHO cutoff for anemia in **adult men**. * **14 gm% (Incorrect):** This represents a normal, healthy hemoglobin level and is never used as a diagnostic cutoff for anemia. **High-Yield Clinical Pearls for NEET-PG:** 1. **ICMR/Government of India Classification:** While WHO uses < 11 g/dL, the National Iron Plus Initiative (NIPI) in India classifies severity as: * **Mild:** 10 – 10.9 g/dL * **Moderate:** 7 – 9.9 g/dL * **Severe:** < 7 g/dL * **Very Severe:** < 4 g/dL 2. **Most Common Cause:** Iron deficiency anemia (IDA) is the most common cause of anemia in pregnancy worldwide. 3. **Prophylaxis:** Under the *Anemia Mukt Bharat* strategy, pregnant women should receive **60 mg elemental iron and 500 mcg folic acid** daily for 180 days, starting from the second trimester.

Q: A pregnant female at 16 weeks of gestation presents with bleeding. Ultrasound reveals a fibroid. What is the most appropriate management?

Conservative management. **Explanation:** The correct management for a fibroid diagnosed during pregnancy is **Conservative Management (Option A)**. **Why it is correct:** Most fibroids are asymptomatic during pregnancy and do not require intervention. Surgical removal of a fibroid (myomectomy) during pregnancy is strictly contraindicated due to the high risk of profuse hemorrhage from the increased pelvic vascularity and the significant risk of miscarriage or preterm labor. If a patient experiences pain (often due to **Red Degeneration**), the standard of care is bed rest, hydration, and analgesics (NSAIDs like Ibuprofen, though avoided near term). **Why other options are incorrect:** * **Laparoscopic myomectomy (Option B):** Myomectomy is generally deferred until 3–6 months postpartum. Surgery during pregnancy is only considered in extreme, rare cases of pedunculated fibroid torsion that fails to respond to conservative treatment. * **Curettage (Option C):** This is a procedure to remove the uterine lining or products of conception; it has no role in the management of a fibroid and would lead to pregnancy loss. * **Hysterectomy (Option D):** This is an invasive, definitive surgery that results in the loss of the fetus and future fertility. It is only a last resort for life-threatening postpartum hemorrhage. **NEET-PG High-Yield Pearls:** * **Most common change** in fibroid during pregnancy: No change in size (though 20-30% may increase). * **Most common complication:** Red Degeneration (Necrobiosis), typically occurring in the 2nd trimester. * **Red Degeneration Diagnosis:** Clinical (pain, fever, tenderness); MRI shows a characteristic peripheral rim of high signal intensity on T1-weighted images. * **Mode of delivery:** Fibroids are not an absolute indication for C-section unless they are large, lower-segment fibroids obstructing the birth canal (Previa fibroid).

Q: The clinical diagnosis of threatened abortion is presumed when a bloody vaginal discharge appears through a closed cervical os during which period of pregnancy?

First half of pregnancy. **Explanation:** **1. Why Option A is Correct:** The definition of **Threatened Abortion** is clinically specific: it refers to vaginal bleeding occurring before the **20th week of gestation** (the first half of pregnancy) in the presence of a **closed cervical os**. At this stage, the fetus is still viable, and the pregnancy may continue. The "first half of pregnancy" is the standard medical threshold because, after 20 weeks (or 24 weeks in some jurisdictions), the fetus reaches the age of viability, and any bleeding or complications are categorized under different clinical entities like antepartum hemorrhage or preterm labor. **2. Why Other Options are Incorrect:** * **Option B & C:** Bleeding in the second half of pregnancy or the third trimester is classified as **Antepartum Hemorrhage (APH)**. Common causes include Abruptio Placentae or Placenta Previa. The term "abortion" is never used for complications occurring after the point of viability. * **Option D:** Since the terminology changes based on gestational age, "All" is incorrect. **3. NEET-PG High-Yield Pearls:** * **Cervical Os Status:** In Threatened Abortion, the internal os is always **closed**. If the os is open with bleeding, it is classified as an Inevitable or Incomplete abortion. * **Prognosis:** Approximately 50% of threatened abortions proceed to actual miscarriage. However, if fetal heart activity is documented on ultrasound, the chance of pregnancy continuation is >90%. * **Management:** The mainstay of treatment is **expectant management** and bed rest (though evidence for bed rest is limited). Progesterone supplementation is often used if a corpus luteum deficiency is suspected. * **Differential Diagnosis:** Always rule out ectopic pregnancy and molar pregnancy in any patient presenting with first-trimester bleeding.

Question 1

Antepartum bleeding of fetal origin is:

Accepted Answer

Vasa previa

Answer

Circumvallate placenta

Answer

Abruptio placenta

Answer

Placenta previa

Question 2

What is the most common congenital anomaly observed in pregnancies complicated by diabetes mellitus?

Accepted Answer

Neural tube defect

Answer

Multicystic kidneys

Answer

Oesophageal atresia

Answer

Duodenal atresia

Question 3

Which of the following is NOT a risk factor for placenta previa?

Accepted Answer

Young maternal age

Answer

Multifetal gestation

Answer

Cigarette smoking

Answer

Multiparity

Question 4

A 25-year-old woman, G2P1L1, at 8 weeks gestation, with RhD negative status and a non-sensitized pregnancy, has had a spontaneous complete miscarriage. What is the dose of Anti-D immunoglobulin to be given?

Accepted Answer

Anti-D not required

Answer

250 IU

Answer

500 IU

Answer

Quantity of fetomaternal bleed should be tested before giving Anti-D

Question 5

Which of the following conditions typically improves during pregnancy?

Accepted Answer

Rheumatoid arthritis

Answer

Multiple sclerosis

Answer

Systemic lupus erythematosus (SLE)

Answer

Myasthenia gravis

Question 6

True about intrauterine fetal death (IUD)?

Accepted Answer

Overlapping of skull bones

Answer

Gas bubbles in great vessels

Answer

Halo's sign +ve

Answer

Decreased amniotic fluid volume

Question 7

As per WHO, anemia is considered to exist in pregnancy if the hemoglobin level is below what value?

Accepted Answer

11 gm%

Answer

14 gm%

Answer

12 gm%

Answer

13 gm%

Question 8

A pregnant female at 16 weeks of gestation presents with bleeding. Ultrasound reveals a fibroid. What is the most appropriate management?

Accepted Answer

Conservative management

Answer

Laparoscopic myomectomy

Answer

Curettage

Answer

Hysterectomy

Question 9

The clinical diagnosis of threatened abortion is presumed when a bloody vaginal discharge appears through a closed cervical os during which period of pregnancy?

Accepted Answer

First half of pregnancy

Answer

Second half of pregnancy

Answer

Third trimester

Answer

All

Question 10

Which of the following statements regarding the transmission of HIV to an infant from an infected mother are true?

Accepted Answer

Start zidovudine during labor, 25% chance of vertical transmission, and avoid breastfeeding.

Answer

Start zidovudine during labor, 25% chance of vertical transmission, and vaccinate infant with OPV and MMR.

Answer

Start zidovudine during labor, avoid breastfeeding, and Cesarean section causes less transmission.

Answer

Start zidovudine during labor, vaccinate infant with OPV and MMR, and Cesarean section causes less transmission.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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