Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 281: 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?

A. Stop antibiotics and start heparin
B. Continue antibiotics and start heparin (Correct Answer)
C. Surgical embolectomy
D. Hysterectomy

Explanation: **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.

Question 282: During pregnancy, there is a reduced risk of which of the following conditions?

A. Relapse of multiple sclerosis (Correct Answer)
B. Bell's palsy
C. Meningioma
D. Chorea

Explanation: **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).

Question 283: All of the following are true regarding Anti-phospholipid Syndrome EXCEPT:

A. It is associated with SLE.
B. It is associated with thrombosis of uteroplacental vessels.
C. It is associated with recurrent placental hemorrhage. (Correct Answer)
D. It can give false positive results in syphilis.

Explanation: **Explanation:** Antiphospholipid Syndrome (APS) is an autoimmune prothrombotic state characterized by the presence of antiphospholipid antibodies (aPL). **Why Option C is the correct answer (The Exception):** APS is fundamentally a **prothrombotic** condition, not a hemorrhagic one. The pathophysiology involves the activation of coagulation cascades and inhibition of fibrinolysis, leading to **thrombosis** of the uteroplacental vessels. This causes placental infarction, fetal growth restriction, and fetal loss. It is **not** associated with recurrent placental hemorrhage; rather, it causes "white infarcts" due to ischemia. **Analysis of other options:** * **Option A:** APS can be primary or secondary. Secondary APS is most commonly associated with **Systemic Lupus Erythematosus (SLE)**. Approximately 30-40% of SLE patients test positive for aPL. * **Option B:** The hallmark of obstetric APS is **thrombosis of the spiral arteries** and uteroplacental vessels, leading to placental insufficiency. * **Option C:** Anti-cardiolipin antibodies can cross-react with the cardiolipin antigen used in the **VDRL/RPR tests**, leading to a **Biological False Positive (BFP)** result for syphilis. **NEET-PG High-Yield Pearls:** * **Sapporo Criteria:** Diagnosis requires 1 Clinical (Vascular thrombosis or Pregnancy morbidity) + 1 Laboratory criterion (Lupus anticoagulant, Anti-cardiolipin IgG/IgM, or Anti-β2-glycoprotein I). * **Pregnancy Morbidity:** Defined as ≥3 unexplained abortions (<10 weeks), ≥1 fetal death (>10 weeks), or ≥1 preterm birth (<34 weeks) due to eclampsia/placental insufficiency. * **Management:** Low-dose Aspirin (LDA) + Low Molecular Weight Heparin (LMWH) is the gold standard during pregnancy. Warfarin is contraindicated (teratogenic).

Question 284: Which condition is associated with the highest maternal mortality?

A. Aortic Stenosis
B. Ventricular Septal Defect
C. Tetralogy of Fallot
D. Pulmonary Hypertension (Correct Answer)

Explanation: **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.

Question 285: 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?

A. Schedule an amniocentesis for amniotic fluid bilirubin at 16 weeks
B. Repeat titer in 4 weeks (Correct Answer)
C. Repeat titer in 28 weeks
D. Schedule PUBS to determine fetal hematocrit at 20 weeks

Explanation: **Explanation:** The management of an Rh-negative sensitized pregnancy (presence of anti-D antibodies) is determined by the **critical titer threshold**. In most laboratories, a titer of **1:16** (or 1:8 in some centers) is considered "critical," meaning it is the level below which the risk of severe fetal hydrops or intrauterine death is extremely low. 1. **Why Option B is Correct:** In this patient, the titer is **1:4**, which is well below the critical threshold. For non-critical titers, the standard protocol is to monitor the maternal antibody levels periodically to detect any significant rise. The recommended interval is to **repeat the titer every 4 weeks** until the critical threshold (1:16) is reached. If the titer remains low, the fetus is generally safe from severe hemolytic disease. 2. **Why Other Options are Incorrect:** * **Option A:** Amniocentesis for bilirubin (Liley Curve) is an outdated method for monitoring fetal anemia and is only considered after the critical titer is reached. * **Option C:** Waiting until 28 weeks is too long; a rapid rise in titers could occur earlier, leading to undetected fetal anemia. * **Option D:** Percutaneous Umbilical Blood Sampling (PUBS) is an invasive procedure with a high risk of feto-maternal hemorrhage (which can worsen sensitization). It is reserved for cases where fetal anemia is confirmed via non-invasive means (like MCA-PSV). **Clinical Pearls for NEET-PG:** * **Critical Titer:** 1:16 (Standard for most exams). * **Gold Standard for Monitoring:** Once the titer is ≥1:16, the next step is **Middle Cerebral Artery Peak Systolic Velocity (MCA-PSV)** doppler ultrasound to assess for fetal anemia. * **Kell Alloimmunization:** Unlike Rh-D, Kell antibodies do not correlate well with titers; even low titers can cause severe fetal anemia. * **Anti-D Prophylaxis:** Rh-immunoglobulin is **not** given to already sensitized women (those who already have anti-D antibodies).

Question 286: During pregnancy, HIV transmission from mother to child occurs mostly during which period?

A. First trimester
B. Second trimester
C. Third trimester
D. During labour and delivery (Correct Answer)

Explanation: **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 **<1%**. * **Breastfeeding:** Postnatal transmission via breast milk accounts for about 10–15% of cases. In India, the current recommendation is exclusive breastfeeding for 6 months followed by complementary feeding. * **Mode of Delivery:** Elective Cesarean Section (at 38 weeks) is indicated only if the maternal viral load is **>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 287: The risk of Down syndrome (mongolism) in a mother at 20 years of age is approximately 1 in 1000. What should be the approximate ratio when she is 45 years old?

A. 1 in 20
B. 1 in 50
C. 1 in 100
D. None of the above (Correct Answer)

Explanation: **Explanation:** The primary medical concept here is the **exponential relationship between advanced maternal age (AMA) and the risk of fetal chromosomal aneuploidies**, specifically Trisomy 21 (Down Syndrome). This occurs due to the aging of oocytes, which remain arrested in Prophase I (Meiosis I) from birth until ovulation, leading to an increased frequency of meiotic non-disjunction. **Why the correct answer is "None of the above":** The risk of Down syndrome increases significantly as a woman approaches the end of her reproductive years. According to standard obstetric data (Williams Obstetrics/ACOG): * At age **20**, the risk is approximately **1 in 1,500**. * At age **35**, the risk is **1 in 350**. * At age **40**, the risk is **1 in 100**. * At age **45**, the risk is approximately **1 in 30**. Since the actual risk at age 45 is **1 in 30**, none of the provided options (1 in 20, 1 in 50, or 1 in 100) accurately represent the standard clinical data. **Analysis of Incorrect Options:** * **Option A (1 in 20):** This overestimates the risk slightly (this risk is closer to age 47-48). * **Option B (1 in 50):** While closer than others, it still underestimates the 1 in 30 risk. * **Option C (1 in 100):** This is the specific risk for a **40-year-old** mother, not a 45-year-old. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Meiotic non-disjunction (95% of cases), most commonly occurring during Maternal Meiosis I. * **Screening:** All pregnant women, regardless of age, should be offered screening (Combined Test or NIPT). * **Cut-off:** Age **35** is traditionally considered the threshold for "Advanced Maternal Age" because, at this point, the risk of aneuploidy roughly equals the risk of pregnancy loss from invasive testing (amniocentesis).

Question 288: What is the drug of choice for the treatment of malaria due to P. Vivax in a 25-year-old pregnant female?

A. Chloroquine (Correct Answer)
B. Primaquine
C. Sulfadoxine-pyrimethamine
D. Quinine

Explanation: **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).

Question 289: Fetal scalp blood pH of less than what value is considered abnormal?

A. 7.4
B. 7.3
C. 7.2 (Correct Answer)
D. 7.35

Explanation: **Explanation:** Fetal scalp blood sampling (FBS) is a diagnostic tool used to assess fetal acid-base status when a cardiotocograph (CTG) shows a non-reassuring or pathological pattern. The pH of fetal blood is a direct indicator of fetal hypoxia and acidosis. **Why 7.2 is the Correct Answer:** In clinical practice, a fetal scalp pH of **< 7.20** is considered **abnormal (acidotic)** and indicates significant fetal distress. This value serves as a critical threshold for immediate intervention (usually delivery) to prevent hypoxic-ischemic encephalopathy or fetal demise. **Interpretation of Values:** * **Normal:** pH ≥ 7.25 * **Borderline (Pre-acidotic):** pH 7.21 – 7.24 (Sampling should be repeated in 30–60 minutes) * **Abnormal (Acidotic):** pH ≤ 7.20 (Indication for immediate delivery) **Analysis of Incorrect Options:** * **A (7.4) & D (7.35):** These are normal adult arterial blood pH ranges. Fetal blood is naturally more acidic than maternal blood due to the CO2 gradient required for gas exchange across the placenta. * **B (7.3):** A pH of 7.3 is considered well within the normal range for a fetus during labor. **High-Yield Clinical Pearls for NEET-PG:** * **Contraindications for FBS:** Maternal infections (HIV, Hepatitis B/C, Herpes Simplex), fetal bleeding disorders (e.g., Hemophilia), and prematurity (<34 weeks). * **Positioning:** FBS is performed with the mother in the left lateral or lithotomy position. * **Lactate vs. pH:** Recent guidelines suggest that measuring **fetal scalp lactate** is equally effective, requires less blood, and has a lower failure rate than pH. A lactate level **> 4.8 mmol/L** is considered abnormal.

Question 290: Define baseline variability in electronic fetal monitoring?

A. The mean FHR rounded to increments of 5bpm during a 10min segment
B. Fluctuations in the baseline FHR that are irregular in amplitude and frequency (Correct Answer)
C. A visually apparent abrupt increase in the FHR
D. Visually apparent symmetrical gradual decrease in the FHR

Explanation: ### Explanation **Baseline Fetal Heart Rate (FHR) Variability** is defined as fluctuations in the baseline FHR that are irregular in amplitude and frequency. These fluctuations are visually quantified as the amplitude of the peak-to-trough in beats per minute (bpm). It is considered the most important indicator of fetal oxygenation and an intact central nervous system. #### Why the Correct Answer is Right: Variability represents the "push-and-pull" interaction between the sympathetic and parasympathetic nervous systems. A healthy fetus with an oxygenated brainstem will show constant, irregular adjustments in heart rate. According to NICHD guidelines, variability is categorized as: * **Absent:** Undetectable. * **Minimal:** ≤ 5 bpm. * **Moderate:** 6–25 bpm (Normal/Reassuring). * **Marked:** > 25 bpm. #### Analysis of Incorrect Options: * **Option A:** This describes the **Baseline FHR** itself, not the variability. The baseline is the mean rate rounded to increments of 5 bpm during a 10-minute segment, excluding periodic changes. * **Option C:** This describes an **Acceleration**, defined as an abrupt increase (onset to peak < 30 sec) in FHR above the baseline. * **Option D:** This describes a **Early or Late Deceleration**, which are gradual decreases (onset to nadir ≥ 30 sec) in FHR. #### High-Yield Clinical Pearls for NEET-PG: * **Moderate variability** is the single best predictor of the absence of fetal acidemia. * **Sinusoidal Pattern:** A smooth, sine wave-like undulating pattern (frequency 3–5/min) persisting for ≥ 20 mins. It is a "Category III" tracing indicating severe fetal anemia (e.g., Rh isoimmunization) or acute hypoxia. * **Decreased variability** can be caused by fetal sleep cycles (usually lasts 20–40 mins), CNS depressants (opioids, MgSO4), or fetal acidemia.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

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Intrauterine Growth Restriction

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Multiple Gestation

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Rh Isoimmunization and Other Blood Group Incompatibilities

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Intrauterine Fetal Therapy

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Prenatal Diagnosis and Genetic Counseling

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Placental Abnormalities

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Preterm Labor and Delivery

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Management of Medical Disorders in Pregnancy

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