Maternal-Fetal Medicine Practice Questions

Q: What is the risk of subsequent preterm delivery in a woman with a history of two previous preterm deliveries before 34 weeks of gestation?

40%. The risk of recurrent preterm birth (PTB) is one of the most significant predictors in obstetric history. The risk increases progressively with each subsequent preterm delivery. ### **Explanation of the Correct Answer** The risk of preterm delivery in a primigravida is approximately **10-15%**. However, once a woman has a history of PTB, the risk for the next pregnancy rises sharply: * **After 1 previous PTB:** The risk increases to approximately **15–25%**. * **After 2 previous PTBs:** The risk escalates significantly to about **40%**. * **After 3 previous PTBs:** The risk can exceed **60%**. The risk is also inversely proportional to the gestational age of the previous delivery; the earlier the previous PTB (especially before 34 weeks), the higher the risk of recurrence. ### **Analysis of Incorrect Options** * **A (15%):** This is the baseline risk for a woman with no prior history or the risk after one prior term delivery followed by one preterm delivery. * **B (20%):** This represents the approximate risk after only **one** previous preterm delivery. * **C (30%):** While higher than the baseline, this underestimates the cumulative risk associated with two consecutive early preterm births. ### **High-Yield Clinical Pearls for NEET-PG** 1. **Best Predictor:** A history of previous spontaneous PTB is the strongest risk factor for future PTB. 2. **Prophylaxis:** For women with a history of spontaneous PTB, **Progesterone** (17-OHP caproate or vaginal progesterone) is indicated starting from 16–24 weeks to reduce recurrence. 3. **Cervical Length:** In women with a history of PTB, a cervical length of **<25 mm** on TVS (between 16–24 weeks) is a strong predictor and may warrant **Cervical Cerclage**. 4. **Inter-pregnancy Interval:** An interval of less than **6 months** significantly increases the risk of subsequent PTB.

Q: Which of the following types of ovarian tumors most frequently causes complications during pregnancy?

Teratoma. **Explanation:** **1. Why Teratoma is the Correct Answer:** Mature cystic teratoma (Dermoid cyst) is the most common germ cell tumor and the most frequent ovarian neoplasm encountered during pregnancy. Its high complication rate is primarily due to its **propensity for torsion**. Because teratomas contain heavy sebaceous material and hair, they are often buoyant and have a long pedicle, making them prone to twisting. Torsion most commonly occurs during the **first trimester** (as the uterus rises) or the **puerperium** (as the uterus rapidly involutes, creating space in the pelvis). Rupture, though rare, can lead to chemical peritonitis. **2. Analysis of Incorrect Options:** * **B. Mucinous cystadenoma:** While these can occur in pregnancy and grow to massive sizes, they are less common than teratomas and have a lower incidence of acute torsion. * **C. Serous cystadenocarcinoma:** Malignant ovarian tumors are rare during pregnancy (only 2–5% of cases). Serous cystadenocarcinoma is more common in postmenopausal women. * **D. Brenner’s tumor:** These are rare fibroepithelial tumors, usually asymptomatic and small, and are typically incidental findings in older women rather than pregnancy-related complications. **3. NEET-PG High-Yield Clinical Pearls:** * **Most common ovarian tumor in pregnancy:** Mature Cystic Teratoma. * **Most common complication:** Torsion (followed by rupture and labor obstruction). * **Management:** If an ovarian mass is >5–6 cm or symptomatic, the ideal time for surgical intervention (Laparoscopy/Laparotomy) is the **second trimester (16–20 weeks)** to minimize miscarriage risk and avoid the technical difficulty of a large third-trimester uterus. * **Emergency:** Acute torsion at any gestation requires immediate surgical intervention regardless of the trimester.

Q: A 10 cm ovarian cyst is detected incidentally in an 8-week pregnant woman. What is the appropriate management?

Second trimester surgery. **Explanation:** The management of an adnexal mass in pregnancy depends on the size of the cyst, gestational age, and ultrasound characteristics. **Why Option C is Correct:** The **second trimester (ideally 14–18 weeks)** is the "surgical window" for elective procedures in pregnancy. By this time, organogenesis is complete (reducing teratogenic risk), and the placenta has taken over progesterone production from the corpus luteum (reducing miscarriage risk). A 10 cm cyst is unlikely to resolve spontaneously and carries a high risk of **torsion, rupture, or labor obstruction**. Surgery is indicated for asymptomatic cysts >6–10 cm that persist into the second trimester. **Why Other Options are Incorrect:** * **Option A:** Surgery in the first trimester is avoided unless there is an emergency (e.g., acute torsion) because it increases the risk of miscarriage and may inadvertently remove a corpus luteum necessary for pregnancy maintenance. * **Option B:** CT scans are generally contraindicated in pregnancy due to ionizing radiation. MRI or Doppler Ultrasound are the preferred imaging modalities for assessing malignancy. * **Option D:** Waiting until a Cesarean section increases the risk of complications (torsion or rupture) during the second and third trimesters. Furthermore, most women with ovarian cysts can still have a vaginal delivery. **High-Yield Clinical Pearls for NEET-PG:** * **Most common ovarian mass in pregnancy:** Corpus luteum cyst (usually resolves by 14 weeks). * **Most common pathological cyst in pregnancy:** Mature cystic teratoma (Dermoid). * **Indications for surgery:** Size >10 cm, solid components/septations (suggesting malignancy), or acute complications (torsion). * **Laparoscopy** is safe in pregnancy but requires careful trocar placement and low intra-abdominal pressure (8–12 mmHg).

Q: Amniotic fluid alpha-fetoprotein levels are typically elevated in which of the following conditions?

Open neural tube defect. ### Explanation **Correct Answer: B. Open neural tube defect** **Mechanism:** Alpha-fetoprotein (AFP) is a glycoprotein synthesized by the fetal yolk sac and later by the fetal liver. In a healthy pregnancy, AFP is excreted into the fetal urine and subsequently into the amniotic fluid in controlled amounts. In cases of **Open Neural Tube Defects (ONTDs)**, such as anencephaly or open spina bifida, there is a lack of skin coverage over the neural tissue. This allows AFP to leak directly from the fetal serum and cerebrospinal fluid into the amniotic fluid, leading to significantly elevated levels. **Analysis of Options:** * **A. Traumatic amniocentesis:** While fetal blood contamination during amniocentesis can theoretically raise AFP levels (as fetal serum AFP is much higher than amniotic fluid levels), it is considered a **false positive** or an artifact of the procedure rather than a clinical "condition" where levels are typically elevated. * **C. Intrauterine fetal death (IUFD):** In IUFD, the fetal skin becomes macerated and permeable, which can lead to a rise in amniotic fluid AFP. However, the question asks for the condition where it is *typically* used as a diagnostic marker. ONTD is the classic, high-yield association for elevated AFP in maternal-fetal medicine exams. **High-Yield Clinical Pearls for NEET-PG:** * **Amniotic Acetylcholinesterase (AChE):** This is the most specific confirmatory test for an open NTD if the amniotic AFP is elevated. * **Low AFP Levels:** Associated with **Down Syndrome (Trisomy 21)**, Trisomy 18, and maternal obesity. * **Other causes of High AFP:** Omphalocele, Gastroschisis (ventral wall defects), Multiple gestations, and Renal anomalies (Finnish-type nephrosis). * **Screening Window:** Maternal Serum AFP (MSAFP) is typically screened between **15–20 weeks** of gestation.

Q: What is the most effective and safe drug to control eclampsia?

Magnesium sulfate. **Explanation:** **Magnesium Sulfate (MgSO₄)** is the drug of choice for both the prevention (prophylaxis) and treatment of seizures in eclampsia. It is superior to traditional anticonvulsants because it acts centrally by increasing the seizure threshold (via NMDA receptor antagonism) and peripherally by blocking neuromuscular transmission. Large-scale clinical trials, such as the **Collaborative Eclampsia Trial**, confirmed that MgSO₄ reduces the risk of recurrent seizures and maternal death more effectively than other agents. **Analysis of Incorrect Options:** * **Phenytoin (Option A):** While an effective anti-epileptic, it is less effective than MgSO₄ in preventing recurrent eclamptic seizures and is associated with a higher rate of maternal and neonatal complications. * **Diazepam (Option C):** Benzodiazepines can control acute seizures but are associated with a high risk of recurrence, maternal respiratory depression, and neonatal "Floppy Infant Syndrome." They are now only used if MgSO₄ is contraindicated or unavailable. **NEET-PG High-Yield Pearls:** * **Regimens:** The **Pritchard Regimen** (IM) and **Zuspan Regimen** (IV) are the standard protocols. * **Therapeutic Range:** 4–7 mEq/L. * **Toxicity Monitoring:** Always check for the presence of the **Patellar reflex** (first sign to disappear), Respiratory rate (>12/min), and Urine output (>30 ml/hr). * **Antidote:** **Calcium Gluconate** (10 ml of 10% solution given IV over 10 minutes). * **Mechanism:** It is also a potent vasodilator, which helps reduce cerebral vasospasm.

Q: A 150 cm tall pregnant woman with a hemoglobin of 11 gm%, blood pressure of 160/110 mm Hg, and a 12 kg weight gain during pregnancy delivered an intrauterine growth restriction (IUGR) baby. What are the causes of IUGR in this case?

Hypertension. **Explanation:** The primary cause of Intrauterine Growth Restriction (IUGR) in this patient is **Hypertension**. **1. Why Hypertension is the Correct Answer:** In this case, the patient presents with a blood pressure of 160/110 mm Hg, which signifies severe hypertension (likely Preeclampsia or Chronic Hypertension). Hypertension is the most common maternal cause of IUGR. The underlying pathophysiology involves **defective trophoblastic invasion** of the spiral arteries, leading to high-resistance blood flow and **uteroplacental insufficiency**. This reduces the supply of oxygen and nutrients to the fetus, resulting in asymmetric IUGR. **2. Analysis of Incorrect Options:** * **Maternal Infection (A):** While infections like TORCH can cause IUGR (typically symmetric), there is no clinical evidence (fever, rash, or lymphadenopathy) provided in the history to suggest this. * **Short Maternal Stature (B):** A height of 150 cm is generally considered the cutoff for "short stature" in some populations, but it usually correlates with a small-for-gestational-age (SGA) baby (constitutionally small) rather than pathological IUGR. * **Excessive Weight Gain (D):** The patient gained 12 kg, which is within the normal recommended range (11–16 kg). Poor maternal weight gain (malnutrition) is a risk factor for IUGR, not excessive gain. **Clinical Pearls for NEET-PG:** * **Most common cause of IUGR:** Maternal vascular disease (Hypertension). * **Asymmetric IUGR:** Most common type (80%); caused by placental insufficiency; "Head sparing" effect seen on USG. * **Symmetric IUGR:** Caused by early insults like chromosomal anomalies or early intrauterine infections. * **Ponderal Index:** Used to differentiate between symmetric and asymmetric IUGR (decreased in asymmetric).

Q: A 37-week pregnant lady presents with a BP of 150/100 mmHg and 3+ proteinuria. On pelvic examination, the cervix is soft with 50% effacement, station is '-2', the pelvis is adequate, and the cervical os is 1 cm dilated. What is the most appropriate next step?

Induction of labor. ### Explanation **1. Why Induction of Labor is Correct:** The patient presents with **Preeclampsia with severe features** (BP ≥140/90 mmHg with 3+ proteinuria) at **37 weeks gestation**. In cases of preeclampsia, the definitive treatment is delivery once the fetus reaches term (≥37 weeks). Since the pelvis is adequate and there are no contraindications to vaginal delivery (like fetal distress or malpresentation), **Induction of Labor (IOL)** is the management of choice. Even with a low Bishop score (implied by -2 station and 1 cm dilation), cervical ripening agents can be used to initiate labor. **2. Why Other Options are Incorrect:** * **A & B (Observation/Await Spontaneous Labor):** Expectant management is contraindicated at 37 weeks in preeclampsia. Delaying delivery increases the risk of maternal complications (eclampsia, HELLP syndrome, placental abruption) without providing further fetal benefit. * **D (Cesarean Section):** Preeclampsia itself is not an indication for a C-section. A trial of vaginal labor is preferred unless there are obstetric indications (e.g., cephalopelvic disproportion, fetal distress, or failed induction). **3. Clinical Pearls for NEET-PG:** * **Term Preeclampsia:** Always deliver at ≥37 weeks, regardless of severity. * **Pre-term Preeclampsia:** If <34 weeks and stable, manage expectantly with steroids; if ≥34 weeks with severe features, proceed to delivery. * **Magnesium Sulfate ($MgSO_4$):** Should be administered during labor for seizure prophylaxis in severe preeclampsia. * **Antihypertensives:** Indicated only if BP is ≥160/110 mmHg (Severe Hypertension) to prevent maternal stroke. Common choices: Labetalol, Hydralazine, or Nifedipine.

Q: After an initial pregnancy resulting in a spontaneous loss in the first trimester, a patient is concerned about the possibility of this recurring. What is the approximate chance of recurrence?

Is no different than it was prior to the miscarriage. ### Explanation **Correct Answer: B. Is no different than it was prior to the miscarriage** **Medical Concept:** Spontaneous abortion (miscarriage) is the most common complication of early pregnancy, occurring in approximately 10–15% of clinically recognized pregnancies. The vast majority (up to 50–70%) of sporadic first-trimester losses are due to **fetal chromosomal anomalies** (most commonly autosomal trisomies), which are typically random events. Statistically, after a **single** spontaneous loss, the risk of a subsequent miscarriage remains approximately **15%**, which is essentially the same as the baseline risk for the general population. **Analysis of Incorrect Options:** * **Option A:** While the genetic makeup explains *why* the first loss occurred, it does not dictate the *recurrence risk* for a subsequent pregnancy unless a parental balanced translocation is present (which is rare in sporadic cases). * **Option C:** A risk of 25% is typically seen only after **two** consecutive miscarriages. * **Option D:** A risk greater than 40–50% is generally reserved for patients with **three or more** consecutive losses (Recurrent Pregnancy Loss). **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of sporadic miscarriage:** Fetal Chromosomal Anomaly (Trisomy is the most common; **Trisomy 16** is the most frequent specific trisomy). * **Most common single chromosomal anomaly:** Monosomy X (Turner Syndrome, 45,X). * **Recurrence Risk Progression:** * After 1 loss: ~15% (Baseline) * After 2 losses: ~25% * After 3 losses: ~30–45% * **Management:** For a single first-trimester loss, no extensive workup is indicated. Reassurance is the primary management strategy. Investigation for Recurrent Pregnancy Loss (RPL) is traditionally initiated after 3 consecutive losses, though many clinicians start after 2.

Question 1

What is the risk of subsequent preterm delivery in a woman with a history of two previous preterm deliveries before 34 weeks of gestation?

Accepted Answer

40%

Answer

15%

Answer

20%

Answer

30%

Question 2

A 19-year-old primigravida presents with vaginal bleeding, an enlarged-for-dates uterus, and absent fetal heart sounds. Ultrasound findings are consistent with this presentation. What is the most likely diagnosis?

Accepted Answer

Hydatidiform mole

Answer

Sarcoma botryoides

Answer

Tuberculous endometritis

Answer

Adenocarcinoma of the uterus

Question 3

Which of the following types of ovarian tumors most frequently causes complications during pregnancy?

Accepted Answer

Teratoma

Answer

Mucinous cystadenoma

Answer

Serous cystadenocarcinoma

Answer

Brenner's tumor

Question 4

A 10 cm ovarian cyst is detected incidentally in an 8-week pregnant woman. What is the appropriate management?

Accepted Answer

Second trimester surgery

Answer

Immediate removal by laparotomy

Answer

CT scan to rule out malignancy and secondaries

Answer

Remove at the time of cesarean section

Question 5

Amniotic fluid alpha-fetoprotein levels are typically elevated in which of the following conditions?

Accepted Answer

Open neural tube defect

Answer

Traumatic amniocentesis

Answer

Intrauterine fetal death

Answer

None of the above

Question 6

A woman at 32 weeks of gestation presents with labor pains. On examination, her cervix is 2 cm dilated and one uterine contraction is felt every 20-30 seconds. What is the appropriate management?

Accepted Answer

Isoxsuprine hydrochloride

Answer

Wait and watch

Answer

Augmentation of labor

Answer

Emergency lower segment cesarean section

Question 7

What is the most effective and safe drug to control eclampsia?

Accepted Answer

Magnesium sulfate

Answer

Phenytoin

Answer

Diazepam

Answer

None of the above

Question 8

A 150 cm tall pregnant woman with a hemoglobin of 11 gm%, blood pressure of 160/110 mm Hg, and a 12 kg weight gain during pregnancy delivered an intrauterine growth restriction (IUGR) baby. What are the causes of IUGR in this case?

Accepted Answer

Hypertension

Answer

Maternal infection

Answer

Short maternal stature

Answer

Excessive weight gain during pregnancy

Question 9

A 37-week pregnant lady presents with a BP of 150/100 mmHg and 3+ proteinuria. On pelvic examination, the cervix is soft with 50% effacement, station is '-2', the pelvis is adequate, and the cervical os is 1 cm dilated. What is the most appropriate next step?

Accepted Answer

Induction of labor

Answer

Observation with monitoring of blood pressure

Answer

Antihypertensives and await spontaneous labor

Answer

Cesarean section

Question 10

After an initial pregnancy resulting in a spontaneous loss in the first trimester, a patient is concerned about the possibility of this recurring. What is the approximate chance of recurrence?

Accepted Answer

Is no different than it was prior to the miscarriage

Answer

Depends on the genetic makeup of the prior abortus

Answer

Is increased to approximately 25%

Answer

Is increased most likely to greater than 50%

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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