Maternal-Fetal Medicine Practice Questions

Q: All are prognostic indicators of pre-eclampsia, except:

High serum Sodium. In pre-eclampsia, the pathophysiology involves widespread endothelial dysfunction and vasospasm, leading to multi-organ involvement. Prognostic indicators are markers that reflect the severity of this systemic damage. **Why High Serum Sodium is the Correct Answer:** Serum sodium levels are typically **not** used as a prognostic marker for pre-eclampsia. In fact, sodium levels in pre-eclampsia are usually normal or slightly decreased (hyponatremia) due to the activation of the renin-angiotensin-aldosterone system and fluid shifts into the extravascular space (edema). Hypernatremia is not a characteristic feature or a marker of severity in this condition. **Analysis of Incorrect Options:** * **Low Platelets (Thrombocytopenia):** A hallmark of severe pre-eclampsia and HELLP syndrome. A platelet count <100,000/mm³ indicates significant endothelial damage and consumption, signaling a poor prognosis. * **Elevated Liver Enzymes:** Reflects hepatic ischemia or periportal hemorrhage (as seen in HELLP syndrome). Elevated ALT/AST levels are "red flags" for impending complications like hepatic rupture or eclampsia. * **High Serum Uric Acid:** Hyperuricemia is one of the earliest and most reliable indicators of pre-eclampsia severity. It results from decreased renal clearance (due to reduced GFR) and increased tubular reabsorption, correlating strongly with poor fetal outcomes. **NEET-PG High-Yield Pearls:** * **Most specific biochemical marker:** Serum Uric Acid (>6 mg/dL is significant). * **HELLP Syndrome:** Hemolysis, Elevated Liver enzymes, Low Platelets. * **Proteinuria:** While used for diagnosis (≥300 mg/24h), the *degree* of proteinuria is no longer used to classify "severe" features in modern ACOG guidelines, though it remains a classic prognostic sign. * **Definitive Treatment:** Delivery of the fetus and placenta.

Q: All the following are indications for delivery in women <34 weeks' gestation managed expectantly with severe preeclampsia, EXCEPT:

Raised umbilical artery Doppler indices. **Explanation:** In the management of severe preeclampsia before 34 weeks, the goal of expectant management is to improve neonatal outcomes by increasing gestational age. However, delivery is indicated when maternal or fetal risks outweigh the benefits of prolongation. **1. Why "Raised Umbilical Artery Doppler Indices" is the correct answer:** Isolated raised umbilical artery (UA) Doppler indices (like an increased S/D ratio or Pulsatility Index) indicate increased placental resistance but are **not** an absolute indication for immediate delivery in severe preeclampsia. In such cases, expectant management can continue with intensive monitoring. Delivery is only mandated if there is **absent or reversed end-diastolic flow (AEDF/REDF)**, or if other fetal testing (like a non-reactive NST or low Biophysical Profile) becomes abnormal. **2. Why the other options are wrong (Indications for Delivery):** * **Eclampsia (B):** The onset of seizures is a maternal emergency. Once the mother is stabilized, delivery must be initiated regardless of gestational age. * **Pulmonary Edema (C):** This indicates severe end-organ decompensation. Continued pregnancy poses a life-threatening risk to the mother. * **Placental Abruption (D):** This is an obstetric emergency that can lead to maternal hemorrhage and fetal demise, necessitating immediate delivery. **Clinical Pearls for NEET-PG:** * **Maternal Indications for Delivery:** Uncontrolled severe hypertension, eclampsia, pulmonary edema, placental abruption, DIC, or persistent neurological symptoms. * **Fetal Indications for Delivery:** Abnormal BPP (<4), REDF on UA Doppler, or fetal death. * **HELLP Syndrome:** While often an indication for delivery, some guidelines allow for a 48-hour delay for steroid administration if the mother is stable and <34 weeks. * **Magnesium Sulfate:** Always the drug of choice for seizure prophylaxis in severe preeclampsia.

Q: Ultrasonography of the umbilical artery is performed to assess which parameter?

Fetal heart rate. **Explanation:** The correct answer is **A. Fetal heart rate.** In the context of basic obstetric ultrasonography, the umbilical artery is a primary site for assessing the fetal cardiovascular system. The pulsatile flow within the umbilical artery directly reflects the fetal cardiac cycle. By placing a Doppler gate over the umbilical artery, clinicians can visualize the systolic and diastolic peaks, allowing for an accurate calculation of the **Fetal Heart Rate (FHR)**. This is particularly useful in early pregnancy or when the fetal heart itself is difficult to visualize clearly. **Why other options are incorrect:** * **B. Gestational age:** This is assessed using biometric parameters such as Crown-Rump Length (CRL) in the first trimester, or Biparietal Diameter (BPD), Head Circumference (HC), and Femur Length (FL) in the second and third trimesters. * **C. Fetal weight:** Estimated Fetal Weight (EFW) is calculated using Hadlock’s formula, which incorporates BPD, HC, Abdominal Circumference (AC), and FL. * **D. Fetal maturity:** This refers to functional readiness (e.g., lung maturity), traditionally assessed via amniocentesis (L/S ratio) or clinical dating, rather than umbilical artery Doppler. **Clinical Pearls for NEET-PG:** * **Umbilical Artery Doppler:** Beyond FHR, it is primarily used to monitor **placental insufficiency**. * **Abnormal Waveforms:** The progression of placental resistance is marked by: Reduced End-Diastolic Velocity (EDV) → **Absent End-Diastolic Velocity (AEDV)** → **Reversed End-Diastolic Velocity (REDV)**. * **High-Yield Fact:** AEDV and REDV are critical markers of fetal compromise in Intrauterine Growth Restriction (IUGR) and often indicate the need for urgent delivery.

Q: A 24-year-old patient presents at 18 weeks of pregnancy with a previous history of a child with Down syndrome. What is the most appropriate next step?

Amniocentesis. ### Explanation **1. Why Amniocentesis is the Correct Answer:** The patient is currently at **18 weeks of gestation**, which falls within the ideal window for **Amniocentesis (typically performed between 15–20 weeks)**. Since she has a high-risk history (a previous child with Down syndrome), she requires a **diagnostic test** rather than a screening test to confirm the fetal karyotype. Amniocentesis is the gold-standard diagnostic procedure for chromosomal analysis at this gestational age. **2. Why Other Options are Incorrect:** * **A. Triple Test:** This is a screening test (measuring AFP, hCG, and uE3). In a patient with a prior history of aneuploidy, diagnostic testing is preferred over screening because screening only provides a probability, not a definitive diagnosis. * **B. Chorionic Villous Biopsy (CVS):** While CVS is a diagnostic test, it is performed between **10–13 weeks**. At 18 weeks, the placenta is more developed, and the procedure is no longer the standard of care compared to the safer amniocentesis. * **D. Cordocentesis:** Also known as Percutaneous Umbilical Blood Sampling (PUBS), this is usually performed **after 18–20 weeks**. However, it carries a higher risk of fetal loss (1–2%) and is generally reserved for cases where rapid karyotyping is needed or when amniocentesis results are inconclusive. **3. Clinical Pearls for NEET-PG:** * **Diagnostic vs. Screening:** Always check the gestational age first. * **10–13 weeks:** CVS (Diagnostic) or Combined Test (Screening). * **15–20 weeks:** Amniocentesis (Diagnostic) or Quadruple Test (Screening). * **Risk of Fetal Loss:** Amniocentesis has a lower procedure-related risk (~0.5%) compared to CVS (~1%). * **Most Common Aneuploidy:** Down Syndrome (Trisomy 21). The recurrence risk after one affected child is approximately 1% or the age-specific risk, whichever is higher.

Q: A 32-year-old female presents with 8 weeks of amenorrhea, signs of shock, and a past medical history of tuberculosis. What is the most likely diagnosis?

Ruptured ectopic pregnancy. **Explanation:** The clinical presentation of **amenorrhea (8 weeks)** followed by **signs of shock** (hypotension, tachycardia, pallor) in a reproductive-age woman is a classic "spotter" for a **ruptured ectopic pregnancy** until proven otherwise. **Why Option A is correct:** The key diagnostic clue here is the **history of tuberculosis (TB)**. In endemic regions like India, pelvic tuberculosis is a leading cause of chronic salpingitis. This leads to tubal scarring, distorted anatomy, and ciliary dysfunction. When the fallopian tube is damaged but not completely occluded, it allows sperm to pass but traps the larger blastocyst, leading to an ectopic implantation. Rupture typically occurs between 6–10 weeks, causing massive intraperitoneal hemorrhage and hemorrhagic shock. **Why other options are incorrect:** * **Option B (Septic Shock):** While shock is present, septic shock usually follows an infected abortion or pelvic inflammatory disease and is characterized by high-grade fever, foul-smelling vaginal discharge, and leukocytosis, rather than sudden collapse following amenorrhea. * **Option C (DIC):** DIC is a secondary consumptive coagulopathy. While it can occur as a complication of severe hemorrhage or abruptio placentae, it is not a primary diagnosis for sudden shock at 8 weeks of gestation. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of ectopic pregnancy:** Ampulla of the fallopian tube. * **Most common site of rupture:** Isthmus (occurs earlier, around 6–8 weeks, due to narrow lumen). * **Risk Factors:** History of PID/Tubal TB (strongest in India), previous ectopic pregnancy, tubal surgery, and IUCD use. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Gold Standard Investigation:** Transvaginal Ultrasound (TVUS) + Serum β-hCG (Correlation of the "Discriminatory Zone").

Q: Which of the following are causes of polyhydramnios?

Diabetes mellitus, esophageal atresia, anencephaly. **Explanation:** Polyhydramnios is defined as an excess of amniotic fluid (Amniotic Fluid Index >25 cm or Single Deepest Pocket >8 cm). The volume of amniotic fluid is a balance between production (primarily fetal urine) and removal (primarily fetal swallowing). **Why Option D is Correct:** * **Diabetes Mellitus:** Maternal hyperglycemia leads to fetal hyperglycemia, causing **osmotic diuresis** and fetal polyuria. * **Esophageal Atresia:** This creates a mechanical GI obstruction, preventing the fetus from **swallowing** and absorbing amniotic fluid. * **Anencephaly:** This causes polyhydramnios via two mechanisms: the absence of the swallowing reflex and **transudation** of fluid from the exposed meninges into the amniotic cavity. **Why Other Options are Incorrect:** * **Renal Agenesis (Options A, B, C):** This is a classic cause of **oligohydramnios**. Since fetal urine is the primary source of amniotic fluid in the second and third trimesters, the absence of kidneys leads to a severe fluid deficiency (Potter’s sequence). * **Preeclampsia (Option B):** This is typically associated with placental insufficiency and fetal growth restriction, which leads to redirection of blood flow away from the fetal kidneys, resulting in **oligohydramnios**. **NEET-PG High-Yield Pearls:** * **Most common cause:** Idiopathic (approx. 50-60%). * **Most common maternal cause:** Diabetes Mellitus. * **Congenital anomalies:** Neural tube defects (anencephaly) and GI obstructions (duodenal atresia - "double bubble" sign) are high-yield associations. * **Complications:** Preterm labor (due to uterine overdistension), cord prolapse (upon ROM), and postpartum hemorrhage (uterine atony).

Question 1

All are prognostic indicators of pre-eclampsia, except:

Accepted Answer

High serum Sodium

Answer

Low platelets

Answer

Elevated liver enzymes

Answer

High serum Uric acid

Question 2

All the following are indications for delivery in women <34 weeks' gestation managed expectantly with severe preeclampsia, EXCEPT:

Accepted Answer

Raised umbilical artery Doppler indices

Answer

Eclampsia

Answer

Pulmonary edema

Answer

Placental abruption

Question 3

Selective reduction of multi-chorionic, multi-fetal gestation is performed around which gestational age?

Accepted Answer

10 to 13 weeks

Answer

4 to 6 weeks

Answer

8 to 10 weeks

Answer

16 to 20 weeks

Question 4

Ultrasonography of the umbilical artery is performed to assess which parameter?

Accepted Answer

Fetal heart rate

Answer

Gestational age

Answer

Fetal weight

Answer

Fetal maturity

Question 5

A 24-year-old patient presents at 18 weeks of pregnancy with a previous history of a child with Down syndrome. What is the most appropriate next step?

Accepted Answer

Amniocentesis

Answer

Triple test

Answer

Chorionic villous biopsy

Answer

Cordocentesis

Question 6

Which of the following is a potential candidate for a high risk of Gestational Diabetes Mellitus (GDM)?

Accepted Answer

Unexplained perinatal loss

Answer

Young primigravida

Answer

Presence of oligohydramnios

Answer

Previous low birth weight baby

Question 7

A 32-year-old female presents with 8 weeks of amenorrhea, signs of shock, and a past medical history of tuberculosis. What is the most likely diagnosis?

Accepted Answer

Ruptured ectopic pregnancy

Answer

Septic shock

Answer

Disseminated intravascular coagulation (DIC)

Answer

None of the above

Question 8

Which of the following are causes of polyhydramnios?

Accepted Answer

Diabetes mellitus, esophageal atresia, anencephaly

Answer

Diabetes mellitus, renal agenesis, anencephaly

Answer

Preeclampsia, renal agenesis, anencephaly

Answer

Esophageal atresia, renal agenesis, anencephaly

Question 9

Cervical pregnancy is confirmed by the presence of?

Accepted Answer

Histology showing the presence of villi inside the cervical stroma

Answer

Gestational sac below the internal os

Answer

Intractable bleeding following evacuation or expulsion of products

Answer

Painless bleeding

Question 10

A 22-year-old woman presents with a 2-hour history of acute abdominal pain and vaginal bleeding. Her vital signs are normal. Physical examination reveals blood oozing from the vaginal opening. Laparotomy shows an enlarged right fallopian tube with hemorrhage and rupture. What is the most likely cause of hemorrhage in this patient?

Accepted Answer

Ectopic pregnancy

Answer

Choriocarcinoma

Answer

Infarcted tubal polyp

Answer

Intramural leiomyoma

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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