Maternal-Fetal Medicine Practice Questions

Q: What is the most common type of twins following assisted reproductive technology?

Dizygotic twins. **Explanation:** The correct answer is **Dizygotic twins (C)**. **Why Dizygotic twins is correct:** Assisted Reproductive Technology (ART), specifically ovulation induction and In-Vitro Fertilization (IVF), significantly increases the rate of multiple gestations. The primary mechanism is the **transfer of multiple embryos** into the uterus during IVF or the **stimulation of multiple follicles** during ovulation induction (using drugs like Clomiphene citrate or Gonadotropins). Since these twins arise from two separate ova fertilized by two separate sperm, they are dizygotic (fraternal). While ART also slightly increases the risk of monozygotic twinning compared to natural conception, dizygotic twins remain overwhelmingly more common in this population. **Why the other options are incorrect:** * **Monozygotic twins (A):** These occur from the splitting of a single fertilized ovum. While the incidence is higher in IVF (approx. 2–5%) compared to natural conception (0.4%), they are still far less frequent than dizygotic twins in ART. * **Acardiac twin (B):** This is a rare, severe complication of Monochorionic Diamniotic (MCDA) twins known as Twin Reversed Arterial Perfusion (TRAP) sequence. It is a specific pathology, not a "type" of twinning common to ART. * **Conjoined twins (D):** These are a rare complication of monozygotic twinning where the embryo divides very late (after day 13). They are extremely rare and not the standard outcome of ART. **High-Yield Clinical Pearls for NEET-PG:** * **Natural Twinning Rate:** Approximately 1 in 80 pregnancies (Hellin’s Law). * **Most common type of Monozygotic twins:** Monochorionic Diamniotic (MCDA) — division occurs at 4–8 days (Blastocyst stage). * **Vanishing Twin Syndrome:** Frequent in ART, where one twin is resorbed in the first trimester. * **Risk Factor:** The single most important risk factor for dizygotic twinning is the use of ovulation-inducing drugs.

Q: All the conditions mentioned below are associated with decreased fetal heart rate except?

Fetal movement. **Explanation:** The fetal heart rate (FHR) is a dynamic indicator of fetal well-being, regulated by the autonomic nervous system. To answer this question, one must distinguish between factors that cause **accelerations** versus those that cause **decelerations** or bradycardia. **1. Why Fetal Movement is the Correct Answer:** Fetal movement is associated with a **transient increase** in fetal heart rate, known as an **acceleration**. An acceleration is defined as a rise in FHR of at least 15 beats per minute (bpm) above the baseline, lasting for at least 15 seconds. This is a reassuring sign indicating a functional fetal sympathetic nervous system and the absence of acidemia. Therefore, it does not decrease the heart rate. **2. Analysis of Incorrect Options:** * **Chronic Hypoxia (B):** Prolonged oxygen deprivation leads to myocardial depression and increased vagal tone, resulting in a decrease in baseline FHR or late decelerations. * **Cord Compression (C):** This causes umbilical vein/artery occlusion, triggering a baroreceptor-mediated reflex that results in **variable decelerations** (abrupt decreases in FHR). * **Head Compression (D):** During labor, pressure on the fetal head increases intracranial pressure, stimulating the vagus nerve. This results in **early decelerations**, which are symmetrical decreases in FHR mirroring uterine contractions. **NEET-PG High-Yield Pearls:** * **Reactive Non-Stress Test (NST):** Defined by $\geq$ 2 accelerations in 20 minutes. * **Early Decelerations:** "Mirror images" of contractions; caused by head compression (vagal reflex); clinically benign. * **Late Decelerations:** Occur after the peak of contraction; caused by **uteroplacental insufficiency**; always pathological. * **Variable Decelerations:** Most common type; caused by **cord compression**; managed by changing maternal position.

Q: Macrosomia is defined as a fetal weight greater than which of the following?

4.5 kg. **Explanation:** **Fetal Macrosomia** is defined by the American College of Obstetricians and Gynecologists (ACOG) as a birth weight of **more than 4,500 grams (4.5 kg)**, regardless of gestational age. This threshold is chosen because the risks of maternal and neonatal morbidity (such as shoulder dystocia and birth trauma) increase significantly above this weight. * **Option D (4.5 kg) is Correct:** While some older texts used 4 kg as a cutoff, current clinical guidelines (ACOG) strictly define macrosomia as >4.5 kg. In clinical practice, a weight >4 kg is often termed "Large for Gestational Age" (LGA), but "Macrosomia" is the specific diagnosis for the 4.5 kg threshold. * **Options A & B (3 kg and 3.5 kg):** These represent normal average birth weights. The average birth weight for a term neonate is approximately 3.2 kg to 3.5 kg. * **Option C (4 kg):** This is the threshold for LGA (weight >90th percentile for gestational age). While often used interchangeably in casual clinical settings, it is not the formal definition of macrosomia for boards. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Cause:** Maternal Diabetes Mellitus (Gestational or Pre-gestational). * **Complications:** Shoulder dystocia (most feared), Erb’s palsy, postpartum hemorrhage (due to uterine atony), and perineal tears. * **Management:** Elective Cesarean Section is recommended if the estimated fetal weight is **>5 kg** in non-diabetic women or **>4.5 kg** in diabetic women. * **Ponderal Index:** Used to differentiate between symmetrical and asymmetrical growth; macrosomic infants of diabetic mothers often show asymmetrical growth (increased fat deposition on shoulders/abdomen).

Q: Which of the following is NOT a complication of fibroid in pregnancy?

Malignant transformation. **Explanation:** The correct answer is **Malignant transformation**. While uterine fibroids (leiomyomas) are the most common benign tumors of the uterus, their transformation into leiomyosarcoma is extremely rare (incidence <0.3%). Crucially, there is no evidence that pregnancy increases this risk. In fact, most fibroids either remain stable or undergo "Red Degeneration" during pregnancy due to rapid growth and outstripping of blood supply, but they do not become malignant. **Why the other options are complications:** * **Abortion (C):** Fibroids, especially submucosal or large intramural ones, can distort the uterine cavity, interfere with implantation, or cause decidual irritation, leading to early pregnancy loss. * **Preterm labor (A):** Large fibroids act as space-occupying lesions, leading to uterine overdistension and increased uterine irritability, which triggers premature contractions. * **Postpartum hemorrhage (B):** Fibroids interfere with the effective contraction and retraction of the uterine myometrium after delivery (uterine atony), which is the most common cause of PPH in these patients. **High-Yield Clinical Pearls for NEET-PG:** * **Red Degeneration (Carneous Degeneration):** The most common complication of fibroid *during* pregnancy (usually 2nd trimester). It presents with acute abdominal pain, fever, and leukocytosis. Management is strictly **conservative** (analgesics and bed rest). * **Most common effect of pregnancy on fibroid:** Most fibroids (approx. 60-70%) show no significant change in size; however, if they do change, they usually enlarge during the first trimester. * **Myomectomy during pregnancy:** Generally contraindicated due to the risk of uncontrollable hemorrhage, except in cases of a pedunculated fibroid undergoing torsion.

Q: Fetal middle cerebral artery Doppler is most useful in the evaluation of which of the following conditions?

Fetal anemia. **Explanation:** The **Middle Cerebral Artery (MCA) Doppler** is the gold standard non-invasive screening tool for **fetal anemia** (most commonly due to Rh isoimmunization or Parvovirus B19 infection). **Why Fetal Anemia is Correct:** In anemic fetuses, the blood viscosity decreases and the cardiac output increases to maintain oxygen delivery. This results in an increased velocity of blood flow. The specific parameter measured is the **Peak Systolic Velocity (PSV)**. An MCA-PSV value **>1.5 Multiples of Median (MoM)** for the corresponding gestational age indicates a high risk of moderate-to-severe fetal anemia, necessitating further intervention like cordocentesis or intrauterine transfusion. **Analysis of Incorrect Options:** * **A & B (IUGR and Preeclampsia):** While Doppler is used here, the **Umbilical Artery (UA)** and **Uterine Artery** are the primary vessels evaluated. In IUGR, MCA Doppler is used to look for the "Brain Sparing Effect" (vasodilation leading to *decreased* resistance), but it is not the *most* specific use compared to its role in anemia. * **D (Fetal Metabolic Disorders):** These are typically diagnosed via genetic testing or biochemical analysis of amniotic fluid, not by Doppler flow studies. **High-Yield Clinical Pearls for NEET-PG:** * **Brain Sparing Effect:** In hypoxia (IUGR), blood is shunted to the brain, leading to **decreased Pulsatility Index (PI)** in the MCA. * **Cerebroplacental Ratio (CPR):** Calculated as MCA-PI / UA-PI. A low CPR (<1.0) is a sensitive marker for adverse perinatal outcomes in IUGR. * **Ductus Venosus:** The best vessel to assess for immediate fetal cardiac failure or impending demise (look for reversed 'a' wave).

Q: Which umbilical artery Doppler finding most significantly predicts intrauterine fetal death?

Reversal of diastolic flow. **Explanation:** Umbilical artery (UA) Doppler is a vital tool for monitoring fetuses with Fetal Growth Restriction (FGR). It reflects placental vascular resistance; as resistance increases, the diastolic flow progressively decreases. **1. Why "Reversal of Diastolic Flow" is correct:** Reversed End-Diastolic Velocity (REVDV) represents the most advanced stage of placental insufficiency. It occurs when more than 70% of the placental vascular bed is obliterated. During diastole, the high resistance in the placenta causes blood to actually flow backward toward the fetal heart. This finding is a critical "pre-terminal" sign, indicating extreme fetal hypoxia and acidosis, and is the strongest predictor of impending intrauterine fetal death (IUFD). **2. Analysis of Incorrect Options:** * **Absent Diastolic Flow (AEDV):** This occurs when approximately 60-70% of the placental bed is damaged. While a serious sign of fetal compromise, it precedes reversal and carries a lower immediate risk of IUFD compared to REVDV. * **Absent Systolic Flow:** This is not a recognized clinical stage in UA Doppler. If systolic flow were absent, it would imply a complete lack of cardiac output, which is incompatible with life. * **Presence of Diastolic Notch:** This is a characteristic finding in **Uterine Artery** Doppler (maternal side), indicating a failure of trophoblastic invasion and a risk for pre-eclampsia/FGR, but it does not predict immediate fetal death. **Clinical Pearls for NEET-PG:** * **Sequence of Deterioration:** Reduced Diastolic Flow → Absent Diastolic Flow (AEDV) → Reversed Diastolic Flow (REVDV). * **Management:** REVDV in a viable fetus (>32 weeks) is usually an indication for immediate delivery via Cesarean section. * **Ductus Venosus:** If UA Doppler shows REVDV, the next step is often checking the Ductus Venosus; reversal of the 'a' wave here is the final sign before fetal demise.

Q: A primigravida at 36 weeks of gestation presents with generalized pruritus, which is more intense on the soles. What is the most likely diagnosis?

Intrahepatic cholestasis of pregnancy. ### Explanation **1. Why Intrahepatic Cholestasis of Pregnancy (ICP) is Correct:** ICP is the most common pregnancy-specific liver disorder, typically occurring in the **third trimester**. It is characterized by **generalized pruritus** that classically starts or is most intense on the **palms and soles**, worsening at night. Pathophysiologically, it involves the failure of bile acid excretion, leading to elevated serum bile acids. Crucially, there is **no primary skin rash** (only secondary excoriations) and no jaundice in most cases. **2. Why the Other Options are Incorrect:** * **HELLP Syndrome:** Presents with Hemolysis, Elevated Liver enzymes, and Low Platelets. It is usually associated with preeclampsia (hypertension/proteinuria) and presents with epigastric pain, not isolated pruritus. * **Viral Hepatitis:** The most common cause of jaundice in pregnancy. It presents with prodromal symptoms like fever, nausea, vomiting, and significantly elevated transaminases, rather than isolated pruritus of the soles. * **Acute Fatty Liver of Pregnancy (AFLP):** A medical emergency occurring in the late third trimester. It presents with acute liver failure symptoms (hypoglycemia, jaundice, encephalopathy, and DIC). Pruritus is not a hallmark feature. **3. High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Elevated **Serum Bile Acids** (>10 µmol/L) is the most sensitive biochemical marker. * **Treatment:** **Ursodeoxycholic acid (UDCA)** is the drug of choice (improves pruritus and liver functions). * **Fetal Risk:** ICP is associated with increased risks of **meconium-stained amniotic fluid**, preterm labor, and **sudden intrauterine fetal death (IUFD)**. * **Management:** Delivery is usually recommended by **37 weeks** to prevent late-term fetal complications.

Question 1

What is the most common type of twins following assisted reproductive technology?

Accepted Answer

Dizygotic twins

Answer

Monozygotic twins

Answer

Acardiac twin

Answer

Conjoined twins

Question 2

Fetal growth restriction is defined as estimated fetal weight is below the ______ for their gestational age?

Accepted Answer

10th percentile

Answer

3rd percentile

Answer

5th percentile

Answer

15th percentile

Question 3

All the conditions mentioned below are associated with decreased fetal heart rate except?

Accepted Answer

Fetal movement

Answer

Chronic hypoxia

Answer

Cord compression

Answer

Head compression

Question 4

Macrosomia is defined as a fetal weight greater than which of the following?

Accepted Answer

4.5 kg

Answer

3 kg

Answer

3.5 kg

Answer

4 kg

Question 5

Which of the following is NOT a complication of fibroid in pregnancy?

Accepted Answer

Malignant transformation

Answer

Preterm labor

Answer

Postpartum hemorrhage

Answer

Abortion

Question 6

At which gestational age is the Shirodkar stitch typically performed during pregnancy?

Accepted Answer

14-16 weeks

Answer

6 weeks

Answer

12 weeks

Answer

20-24 weeks

Question 7

Fetal middle cerebral artery Doppler is most useful in the evaluation of which of the following conditions?

Accepted Answer

Fetal anemia

Answer

Intrauterine growth restriction

Answer

Preeclampsia

Answer

Fetal metabolic disorders

Question 8

Which umbilical artery Doppler finding most significantly predicts intrauterine fetal death?

Accepted Answer

Reversal of diastolic flow

Answer

Absent diastolic flow

Answer

Absent systolic flow

Answer

Presence of diastolic notch

Question 9

A 20-year-old primigravida at 30 weeks of gestation has polyhydramnios. What advice should be given?

Accepted Answer

Oral indomethacin

Answer

Bed rest

Answer

Artificial rupture of membranes

Answer

Restriction of oral fluids

Question 10

A primigravida at 36 weeks of gestation presents with generalized pruritus, which is more intense on the soles. What is the most likely diagnosis?

Accepted Answer

Intrahepatic cholestasis of pregnancy

Answer

HELLP syndrome

Answer

Viral hepatitis

Answer

Acute fatty liver of pregnancy

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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