Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 301: Which of the following conditions typically improves during pregnancy?

A. Multiple sclerosis
B. Systemic lupus erythematosus (SLE)
C. Myasthenia gravis
D. Rheumatoid arthritis (Correct Answer)

Explanation: **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.

Question 302: Congenital heart block develops in fetuses of women suffering from which of the following conditions?

A. Systemic Lupus Erythematosus (SLE) (Correct Answer)
B. Epilepsy
C. Rheumatoid arthritis
D. Ankylosing spondylitis

Explanation: **Explanation:** **Correct Answer: A. Systemic Lupus Erythematosus (SLE)** The association between maternal SLE and **Congenital Complete Heart Block (CCHB)** is a classic high-yield topic in Maternal-Fetal Medicine. The underlying mechanism involves the transplacental passage of maternal IgG autoantibodies, specifically **Anti-Ro (SS-A)** and **Anti-La (SS-B)**. These antibodies cross the placenta (usually between 18–24 weeks of gestation) and cause an inflammatory reaction in the fetal heart, leading to fibrosis and permanent damage to the Atrioventricular (AV) node. Once complete heart block develops, it is typically irreversible and carries a high risk of fetal hydrops and neonatal mortality. **Why other options are incorrect:** * **B. Epilepsy:** Maternal epilepsy is primarily associated with risks related to **Anti-Epileptic Drugs (AEDs)**, such as Valproate, which can cause Neural Tube Defects (NTDs) or orofacial clefts, but not congenital heart block. * **C. Rheumatoid Arthritis (RA):** While RA is an autoimmune condition, it is rarely associated with Anti-Ro/La antibodies. It generally does not adversely affect the fetal heart. * **D. Ankylosing Spondylitis:** This is a seronegative spondyloarthropathy (HLA-B27 associated) and does not involve the autoantibodies responsible for fetal conduction defects. **NEET-PG High-Yield Pearls:** * **Neonatal Lupus Syndrome:** Characterized by CCHB, photosensitive skin rashes, and cytopenias. While the rash and cytopenia resolve as maternal antibodies wane, the **heart block is permanent**. * **Screening:** Pregnant women with known SLE/Anti-Ro antibodies should undergo weekly or bi-weekly **fetal echocardiography** from 18 to 26 weeks to monitor the PR interval. * **Treatment:** If early-stage (incomplete) block is detected, maternal **fluorinated corticosteroids** (Dexamethasone or Betamethasone) are used as they cross the placenta and reduce inflammation.

Question 303: As per WHO, anemia is considered to exist in pregnancy if the hemoglobin level is below what value?

A. 11 gm% (Correct Answer)
B. 14 gm%
C. 12 gm%
D. 13 gm%

Explanation: **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.

Question 304: In asymmetrical Intrauterine Growth Restriction (IUGR), which organ is typically spared from significant growth restriction?

A. Subcutaneous fat
B. Muscle
C. Liver
D. Brain (Correct Answer)

Explanation: **Explanation:** In **Asymmetrical Intrauterine Growth Restriction (IUGR)**, the correct answer is the **Brain**. This phenomenon is known as the **"Brain-Sparing Effect."** **1. Why the Brain is spared:** Asymmetrical IUGR typically occurs in the late second or third trimester, often due to placental insufficiency (e.g., maternal hypertension or pre-eclampsia). When the fetus faces a chronic shortage of nutrients and oxygen, it undergoes a hemodynamic redistribution. Blood flow is preferentially shunted toward vital organs—the **brain, heart, and adrenal glands**—at the expense of peripheral and abdominal organs. This ensures that neurological development is prioritized despite the growth restriction. **2. Why other options are incorrect:** * **Liver:** This is the most significantly affected organ. The liver size decreases due to depleted glycogen stores and reduced venous return from the umbilical vein. This leads to a reduced abdominal circumference (AC), which is the earliest sign of asymmetrical IUGR. * **Subcutaneous Fat and Muscle:** These are non-essential tissues during fetal stress. The body mobilizes these energy stores to support vital organ function, leading to the characteristic "scrawny" appearance of the newborn with wasted extremities. **High-Yield Clinical Pearls for NEET-PG:** * **Ponderal Index:** It is **low** in asymmetrical IUGR (the baby is "thin") but normal in symmetrical IUGR. * **HC/AC Ratio:** In asymmetrical IUGR, the Head Circumference (HC) to Abdominal Circumference (AC) ratio is **increased** (>1.0). * **Symmetrical IUGR:** Usually occurs early in pregnancy due to intrinsic factors (chromosomal anomalies, TORCH infections). Here, all organs, including the brain, are proportionately small. * **Diagnosis:** The single most sensitive parameter for diagnosing asymmetrical IUGR is a **lagging Abdominal Circumference (AC)** on ultrasound.

Question 305: The clinical diagnosis of threatened abortion is presumed when a bloody vaginal discharge appears through a closed cervical os during which period of pregnancy?

A. First half of pregnancy (Correct Answer)
B. Second half of pregnancy
C. Third trimester
D. All

Explanation: **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 306: Which of the following statements regarding the transmission of HIV to an infant from an infected mother are true?

A. Start zidovudine during labor, 25% chance of vertical transmission, and avoid breastfeeding. (Correct Answer)
B. Start zidovudine during labor, 25% chance of vertical transmission, and vaccinate infant with OPV and MMR.
C. Start zidovudine during labor, avoid breastfeeding, and Cesarean section causes less transmission.
D. Start zidovudine during labor, vaccinate infant with OPV and MMR, and Cesarean section causes less transmission.

Explanation: **Explanation:** The risk of vertical transmission of HIV from an untreated mother to her infant is approximately **25-30%**. This transmission can occur in utero (5-10%), during labor and delivery (15%), or through breastfeeding (5-15%). 1. **Why Option A is correct:** In the absence of modern Highly Active Antiretroviral Therapy (HAART), the standard protocol (based on the landmark PACTG 076 trial) involved administering **Zidovudine (AZT)** during labor and to the neonate to reduce transmission risk. Furthermore, because breast milk contains the virus, **avoiding breastfeeding** is a critical intervention to prevent postnatal transmission in settings where safe alternatives are available. 2. **Why other options are incorrect:** * **Options B & D:** These are incorrect because of the vaccination protocol. In HIV-exposed or infected infants, **live vaccines** like **OPV** (Oral Polio Vaccine) and **MMR** are generally contraindicated or deferred if the infant is symptomatic or severely immunosuppressed. In many protocols, IPV (Inactivated Polio Vaccine) is preferred over OPV. * **Option C:** While Elective Cesarean Section (before labor/ROM) does reduce transmission compared to vaginal delivery, the specific statistical "25% chance" mentioned in Option A is a more classic academic descriptor for the overall risk profile in untreated cases. **High-Yield Clinical Pearls for NEET-PG:** * **Most common timing:** Most vertical transmission occurs **intranatally** (during labor). * **Current Protocol (WHO/India):** All pregnant women testing HIV positive are started on **Lifelong ART** (usually TLE regimen: Tenofovir + Lamivudine + Efavirenz) regardless of CD4 count. * **Infant Prophylaxis:** Nevirapine syrup is given to the infant for at least 6 weeks. * **Breastfeeding:** In India, "Exclusive Breastfeeding" for 6 months is recommended if replacement feeding is not "Acceptable, Feasible, Affordable, Sustainable, and Safe" (AFASS). Mixed feeding is strictly contraindicated.

Question 307: A primigravida at full term complains of faintness when lying supine, which resolves when she turns to her side or sits up. What is the most likely cause of this symptom?

A. Increased abdominal pressure
B. Inferior vena cava (IVC) compression (Correct Answer)
C. Increased intracranial pressure
D. Orthostatic hypotension after a meal

Explanation: **Explanation:** The clinical presentation described is a classic case of **Supine Hypotension Syndrome** (also known as Aortocaval Compression). **1. Why the correct answer is right:** In a term pregnancy, the gravid uterus is heavy and bulky. When the patient lies in the supine position, the uterus gravitates backward, compressing the **Inferior Vena Cava (IVC)** against the vertebral column. This leads to: * Decreased venous return to the heart (reduced preload). * A subsequent fall in cardiac output. * Systemic hypotension, leading to symptoms of faintness, dizziness, or nausea. Turning to the **left lateral position** relieves the compression, restores venous return, and resolves the symptoms. **2. Why the incorrect options are wrong:** * **A. Increased abdominal pressure:** While intra-abdominal pressure does increase in pregnancy, it causes symptoms like GERD or breathlessness, not acute postural syncope. * **C. Increased intracranial pressure:** This would typically present with headaches, projectile vomiting, or papilledema, and is not relieved by simple postural changes. * **D. Orthostatic hypotension after a meal:** Orthostatic hypotension occurs upon standing, not lying down. Post-prandial symptoms are unrelated to the mechanical compression seen in late pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **The "Poseiro Effect":** This refers to the compression of the abdominal aorta (rather than the IVC) by the uterus, which can lead to fetal distress without maternal hypotension. * **Management:** Always advise pregnant women in the third trimester to sleep in the **left lateral position** to maximize uterine blood flow. * **Clinical Significance:** During CPR in a pregnant woman, manual left uterine displacement (LUD) is a critical step to relieve IVC compression and improve the efficacy of chest compressions.

Question 308: Which of the following is NOT a risk factor for preeclampsia?

A. Diabetes in pregnancy (Correct Answer)
B. Hydatidiform mole
C. Primipara
D. Previous history of preeclampsia

Explanation: **Explanation:** The correct answer is **A. Diabetes in pregnancy**. In the context of NEET-PG, it is crucial to distinguish between **Pre-gestational Diabetes** (Type 1 or Type 2) and **Gestational Diabetes (GDM)**. While pre-gestational diabetes is a well-established major risk factor for preeclampsia due to underlying vasculopathy, simple "Diabetes in pregnancy" (often implying GDM) is generally considered a *consequence* of shared metabolic risk factors rather than a primary independent trigger, making it the "least" correct risk factor among the options provided in classic MCQ patterns. **Analysis of Options:** * **B. Hydatidiform Mole:** This is a high-yield risk factor. The hyperplacentosis (excessive trophoblastic tissue) leads to high levels of sFlt-1 and other anti-angiogenic factors. Preeclampsia occurring before 20 weeks is highly suggestive of a molar pregnancy. * **C. Primipara:** Nulliparity or being a primigravida is a classic risk factor. The "first exposure" to paternal antigens and the lack of previous uterine vascular remodeling increase the risk. * **D. Previous history of preeclampsia:** This is the strongest predictor for the development of preeclampsia in a subsequent pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Major Risk Factors:** Previous preeclampsia, chronic hypertension, pre-gestational diabetes, multifetal gestation, and autoimmune diseases (SLE, APS). * **Moderate Risk Factors:** Nulliparity, obesity (BMI >30), family history, and advanced maternal age (≥35). * **Prophylaxis:** Low-dose Aspirin (75–150 mg) started before 16 weeks is recommended for women with high-risk factors. * **Protective Factor:** Interestingly, **smoking** is associated with a *decreased* risk of preeclampsia (though not recommended due to other fetal risks).

Question 309: 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?

A. Sarcoma botryoides
B. Tuberculous endometritis
C. Adenocarcinoma of the uterus
D. Hydatidiform mole (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Hydatidiform mole** The clinical triad of **vaginal bleeding**, a **uterus larger than the period of gestation (LMP)**, and **absent fetal heart sounds** in a young primigravida is a classic presentation of a Hydatidiform Mole (Molar Pregnancy). In a complete mole, the proliferation of chorionic villi leads to hydropic degeneration (fluid-filled vesicles), which causes the uterus to expand rapidly beyond expected dates. Because there is no functional fetal tissue or circulation in a complete mole, fetal heart sounds are absent. Ultrasound typically reveals a "snowstorm appearance" due to the multiple hydropic villi. **Why the other options are incorrect:** * **A. Sarcoma botryoides:** This is a rare, highly malignant vaginal tumor (Rhabdomyosarcoma) usually seen in children under age 5. It presents as "grape-like" masses protruding from the vagina, not as an enlarged pregnant uterus. * **B. Tuberculous endometritis:** This typically presents with infertility, menstrual irregularities (often amenorrhea or oligomenorrhea), and pelvic pain. It does not cause an acutely enlarged uterus or mimic pregnancy symptoms. * **C. Adenocarcinoma of the uterus:** This is primarily a disease of postmenopausal women. While it causes uterine enlargement and bleeding, it is extremely rare in a 19-year-old and would not present with pregnancy-like symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom:** Vaginal bleeding (often described as "prune juice" discharge). * **Hyperemesis Gravidarum:** Common due to excessively high levels of hCG. * **Theca Lutein Cysts:** Often seen bilaterally on ovaries due to hCG stimulation. * **Early-onset Preeclampsia:** If a patient develops hypertension before 20 weeks of gestation, always suspect a molar pregnancy. * **Gold Standard Investigation:** Pelvic Ultrasound (Snowstorm appearance). * **Management:** Suction and Evacuation (S&E) is the treatment of choice.

Question 310: Which of the following statements is NOT true regarding the use of Nifedipine in pregnant women with hypertension?

A. Can cause myocardial infarction and pulmonary edema in patients with severe gestational hypertension.
B. Also used for tocolysis in preterm labor.
C. Can potentiate the action of magnesium sulfate given for eclampsia neuroprophylaxis.
D. None of the above. (Correct Answer)

Explanation: **Explanation:** The correct answer is **D (None of the above)** because all the statements (A, B, and C) are clinically accurate regarding the use of Nifedipine in pregnancy. * **Option A (True):** While Nifedipine is a first-line agent for managing severe hypertension in pregnancy, its rapid-acting oral formulation can occasionally cause a precipitous drop in blood pressure. This may lead to reflex tachycardia and decreased coronary perfusion, potentially triggering **myocardial infarction**. Additionally, excessive fluid resuscitation combined with peripheral vasodilation can lead to **pulmonary edema**. * **Option B (True):** Nifedipine is a Calcium Channel Blocker (CCB) that inhibits the influx of calcium into the myometrium, leading to smooth muscle relaxation. It is widely used as a **first-line tocolytic agent** for preterm labor due to its efficacy and favorable side-effect profile compared to beta-mimetics. * **Option C (True):** Both Nifedipine and Magnesium Sulfate ($MgSO_4$) inhibit calcium entry into cells. When used concurrently, Nifedipine can **potentiate the neuromuscular blocking effect** of $MgSO_4$, theoretically increasing the risk of muscular paralysis or respiratory depression, though this is rare in clinical practice. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Blocks L-type calcium channels. * **Dosage:** For acute hypertensive crisis, 10–20 mg orally (not sublingually, as sublingual use is associated with unpredictable absorption and sudden hypotension). * **Side Effects:** Headache, flushing, and peripheral edema are common. * **Contraindication:** Avoid in women with known hypersensitivity to CCBs or specific cardiac conditions like aortic stenosis.

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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