Maternal-Fetal Medicine Practice Questions

Q: In a patient with preeclampsia, all of the following drugs can be used in treatment EXCEPT?

Enalapril. **Explanation:** The management of hypertension in pregnancy requires drugs that are effective for the mother while being safe for the developing fetus. **Why Enalapril is the Correct Answer:** Enalapril is an **ACE Inhibitor (ACEI)**. ACE inhibitors and Angiotensin Receptor Blockers (ARBs) are strictly **contraindicated** in pregnancy (FDA Category D). Their use, especially in the second and third trimesters, is associated with **fetal renal dysgenesis**, oligohydramnios (due to decreased fetal urine production), pulmonary hypoplasia, intrauterine growth restriction (IUGR), and calvarial hypoplasia. **Analysis of Incorrect Options:** * **Labetalol (Option A):** A combined alpha and beta-blocker. It is currently considered the **first-line** drug for both chronic hypertension and acute hypertensive emergencies in pregnancy due to its rapid onset and safety profile. * **Methyldopa (Option B):** A centrally acting alpha-2 agonist. It has the longest track record of safety in pregnancy and is often the preferred drug for long-term management of **chronic hypertension** in pregnant patients. * **Hydralazine (Option C):** A direct vasodilator. It is traditionally used intravenously for the management of **acute hypertensive crises** (Severe Preeclampsia/Eclampsia) when rapid blood pressure reduction is required. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC) for Acute Hypertensive Crisis in Pregnancy:** IV Labetalol (Hydralazine is an alternative). * **DOC for Chronic Hypertension in Pregnancy:** Oral Methyldopa. * **Target BP in Preeclampsia:** Aim to maintain Systolic BP between 140–150 mmHg and Diastolic BP between 90–100 mmHg. * **Other Contraindicated Drugs:** Diuretics (may compromise placental perfusion), Nitroprusside (risk of fetal cyanide poisoning), and Atenolol (associated with fetal bradycardia and IUGR).

Q: Which is the commonest type of ectopic pregnancy presenting with rupture?

Isthmic. **Explanation:** The correct answer is **Isthmic (Option A)**. The site of ectopic pregnancy significantly influences the timing and likelihood of rupture based on the anatomical diameter and distensibility of the Fallopian tube. 1. **Why Isthmic is correct:** The **isthmus** is the narrowest part of the Fallopian tube with a thick, muscular wall and minimal distensibility. Because the lumen is so small, the growing embryo quickly outgrows the space, leading to **early rupture**, typically between 6 to 8 weeks of gestation. While the ampulla is the most common site for ectopic pregnancy overall, the isthmus is the site most likely to present with an acute rupture. 2. **Why other options are incorrect:** * **Ampulla (B):** This is the most common site for ectopic pregnancy (approx. 70%). However, because the ampulla is wider and more distensible, it often results in a "tubal abortion" or a delayed rupture (8–12 weeks) rather than an early, acute rupture. * **Interstitial (C):** This is the most dangerous site. Because it is surrounded by thick myometrium, it can distend significantly, rupturing late (12–16 weeks). When it does rupture, it causes massive, life-threatening hemorrhage. * **Infundibular (D):** This is the least common site and usually results in tubal abortion into the peritoneal cavity. **High-Yield NEET-PG Pearls:** * **Most common site of Ectopic Pregnancy:** Ampulla. * **Most common site of Ruptured Ectopic:** Isthmus. * **Most common site of Tubal Abortion:** Ampulla. * **Site with highest mortality/most severe hemorrhage:** Interstitial (Cornual). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases).

Q: What is the safe drug for antihypertensive crisis during pregnancy?

Hydralazine. **Explanation:** The management of hypertension in pregnancy is categorized into chronic management and the management of an **acute hypertensive crisis** (defined as BP ≥160/110 mmHg). **Why Hydralazine is correct:** Hydralazine is a potent direct-acting peripheral vasodilator. It is considered a first-line agent for **hypertensive emergencies** in pregnancy because of its rapid onset of action (5–20 minutes) when administered intravenously. It effectively reduces systemic vascular resistance, ensuring rapid stabilization of blood pressure to prevent maternal intracranial hemorrhage. **Analysis of Incorrect Options:** * **Enalapril (Option A):** ACE inhibitors are strictly **contraindicated** in pregnancy (Category X). They are teratogenic and can cause fetal renal dysgenesis, oligohydramnios, and skull hypoplasia. * **Methyldopa (Option C):** While Methyldopa is the **drug of choice for chronic hypertension** in pregnancy, it is unsuitable for a crisis. It has a slow onset of action (4–6 hours) and works via a central mechanism, making it ineffective for immediate BP reduction. * **Option D:** Incorrect because Methyldopa cannot be used for an acute crisis. **High-Yield Clinical Pearls for NEET-PG:** 1. **First-line drugs for Hypertensive Crisis:** IV Labetalol (most common/preferred), IV Hydralazine, and Oral Nifedipine (rapid release). 2. **Drug of Choice (DOC) for Chronic Hypertension:** Methyldopa (safest long-term profile). 3. **DOC for Eclampsia/Preeclampsia Seizures:** Magnesium Sulfate ($MgSO_4$). 4. **Avoid in Pregnancy:** ACE inhibitors, ARBs, Sodium Nitroprusside (risk of fetal cyanide poisoning), and Diuretics (may compromise placental perfusion).

Q: What is the cut-off value of cervical length at 24 weeks of gestation for the prediction of preterm delivery?

2.5 cm. **Explanation:** The assessment of cervical length via **Transvaginal Sonography (TVS)** is a critical screening tool for predicting spontaneous preterm birth (PTB). **1. Why 2.5 cm is the Correct Answer:** In clinical practice and major guidelines (such as ACOG and Fetal Medicine Foundation), a cervical length of **<25 mm (2.5 cm)** before 24 weeks of gestation is the standard threshold used to identify women at high risk for preterm delivery. This value corresponds to the 10th percentile for cervical length at this gestational age. A cervix shorter than this indicates "cervical effacement" or insufficiency, necessitating interventions like vaginal progesterone or cervical cerclage to reduce the risk of prematurity. **2. Analysis of Incorrect Options:** * **0.5 cm (Option A):** This represents extreme shortening or near-complete effacement, usually seen in imminent labor or advanced cervical incompetence, rather than a screening cut-off. * **1.5 cm (Option B):** While 1.5 cm is a "high-risk" threshold (often used to decide on cerclage in twin pregnancies or specific high-risk scenarios), it is not the standard screening cut-off for the general population. * **3.5 cm (Option D):** This is considered a normal, healthy cervical length. A length >30 mm has a high negative predictive value, meaning preterm birth is highly unlikely. **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Transvaginal Ultrasound (TVS) is superior to transabdominal ultrasound for measuring cervical length. * **Funneling:** The protrusion of the amniotic sac into the internal os (forming a U or V shape) is an additional sign of cervical incompetence. * **Management:** If cervical length is <25 mm in a singleton pregnancy, the first-line management is typically **Vaginal Progesterone**. * **Timing:** Screening is most effective when performed between **18 and 24 weeks** of gestation.

Q: A 31-year-old woman presents with abdominal pain and vaginal spotting. The pain started 2 days ago and has been worsening, with spotting occurring this morning. Her last menstrual period was 6 weeks ago. Vital signs show a temperature of 37°C, blood pressure of 90/50 mm Hg, pulse of 110/minute, and respirations of 14/minute. Physical examination reveals significant lower abdominal tenderness, scant blood in the vagina with a closed cervical os, and significant left adnexal tenderness on bimanual examination. Urine hCG is positive, and serum hCG is 5,000 mIU/mL. Pelvic ultrasound shows a normal uterus with a left adnexal mass surrounded by free fluid. Which of the following is the most likely diagnosis?

Ectopic pregnancy. **Explanation:** The clinical presentation of **amenorrhea (6 weeks), abdominal pain, and vaginal spotting** in a woman of reproductive age is a classic triad for **Ectopic Pregnancy**. The diagnosis is confirmed by the following findings: 1. **Hemodynamic Instability:** Hypotension (90/50 mmHg) and tachycardia (110 bpm) suggest a **ruptured ectopic pregnancy** leading to hemoperitoneum. 2. **Biochemical Markers:** A positive urine hCG and a serum hCG of 5,000 mIU/mL indicate pregnancy. 3. **Imaging:** Ultrasound reveals an empty uterus (despite hCG being well above the discriminatory zone of 1,500–2,000 mIU/mL) and a left adnexal mass with free fluid (blood), localized to the site of tenderness. **Incorrect Options:** * **Appendicitis:** While it causes RLQ pain, it does not explain the positive hCG, vaginal spotting, or adnexal mass. * **Ovarian Cancer:** Usually presents in older women with chronic symptoms (bloating, weight loss) rather than acute pain and a positive pregnancy test. * **Pelvic Inflammatory Disease (PID):** Can cause adnexal tenderness and pain, but it typically presents with fever, purulent cervical discharge, and a negative pregnancy test. **NEET-PG High-Yield Pearls:** * **Discriminatory Zone:** The serum hCG level at which an intrauterine gestational sac should be visible on TVS (usually 1,500–2,000 mIU/mL). If the uterus is empty above this level, suspect ectopic pregnancy. * **Most Common Site:** The **Ampulla** of the fallopian tube. * **Management:** Hemodynamically unstable patients (like this one) require **emergency laparotomy**, not medical management with Methotrexate. * **Arias-Stella Reaction:** Hypersecretory endometrium seen on biopsy in ectopic pregnancy (due to hormonal stimulation without an intrauterine sac).

Q: What is the best diagnostic modality for unruptured tubal pregnancy?

Vaginal ultrasound. **Explanation:** The diagnosis of an unruptured tubal pregnancy relies on the visualization of an extrauterine gestational sac. **Transvaginal Ultrasound (TVS)** is the gold standard and the best diagnostic modality because it offers high resolution and can detect an intrauterine pregnancy as early as 4.5 to 5 weeks. The characteristic findings on TVS include an empty uterus, a "tubal ring" sign (hyperechoic ring around the extrauterine sac), or a complex adnexal mass. **Analysis of Options:** * **Serum hCG estimation (Option B):** While essential for confirming pregnancy and interpreting ultrasound findings (via the "Discriminatory Zone"), a single hCG value cannot localize the pregnancy. It is a biochemical marker, not a definitive diagnostic modality for tubal location. * **Serum Progesterone estimation (Option C):** Low progesterone (<5 ng/mL) suggests a non-viable pregnancy but does not differentiate between a miscarriage and an ectopic pregnancy. * **Culdocentesis (Option D):** This involves aspirating fluid from the Pouch of Douglas. It is used to detect hemoperitoneum in **ruptured** ectopic pregnancies. It has largely been replaced by TVS and is not the investigation of choice for unruptured cases. **High-Yield Clinical Pearls for NEET-PG:** * **Discriminatory Zone:** The level of β-hCG at which an intrauterine gestational sac should be visible on TVS is **1500–2000 mIU/mL**. If hCG is above this and the uterus is empty, ectopic pregnancy is highly suspected. * **Gold Standard for Diagnosis:** While TVS is the best initial/diagnostic modality, **Laparoscopy** remains the "Gold Standard" for definitive confirmation. * **Most common site:** The **Ampulla** is the most common site for tubal pregnancy. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases).

Question 1

In a patient with preeclampsia, all of the following drugs can be used in treatment EXCEPT?

Accepted Answer

Enalapril

Answer

Labetalol

Answer

Methyldopa

Answer

Hydralazine

Question 2

A pregnant female with a past history of embolism in puerperium requires medical management in her next pregnancy to avoid recurrence. What is the recommended management?

Accepted Answer

Anticoagulation therapy with warfarin initiated after delivery.

Answer

Prophylaxis with warfarin starting at 10 weeks gestation.

Answer

The risk of thromboembolism increases by 12% in the next pregnancy.

Answer

No specific medical management is required.

Question 3

A young lady presents with 6 weeks of amenorrhea, nausea, vomiting, and severe abdominal pain. Her BP is 100/80 mm Hg. Examination reveals a 5 x 5 cm adnexal mass. What is the plan of management?

Accepted Answer

Immediate laparoscopic surgery

Answer

Send beta-hCG

Answer

Methotrexate

Answer

IV fluids, NPO, and observation for 4-5 days

Question 4

Which is the commonest type of ectopic pregnancy presenting with rupture?

Accepted Answer

Isthmic

Answer

Ampulla

Answer

Interstitial

Answer

Infundibular

Question 5

What is the safe drug for antihypertensive crisis during pregnancy?

Accepted Answer

Hydralazine

Answer

Enalapril

Answer

Methyldopa

Answer

Both Hydralazine and Methyldopa

Question 6

Increased acidosis and hypoxemia in a fetus is associated with which of the following findings?

Accepted Answer

Increased fetal diastolic flow in the middle cerebral artery with absent diastolic flow in the aorta

Answer

Normal Doppler waveform

Answer

Presence of the 'notch' in the uterine artery

Answer

Absent umbilical artery

Question 7

A woman presents with chickenpox at 8 weeks of gestation. What is the best method to exclude fetal varicella syndrome?

Accepted Answer

Perform an ultrasound scan at 20 weeks.

Answer

Perform amniocentesis at 15 weeks and test for VZV DNA in the amniotic fluid.

Answer

Perform an ultrasound scan immediately.

Answer

Perform chorionic villus sampling and test for VZV DNA.

Question 8

What is the cut-off value of cervical length at 24 weeks of gestation for the prediction of preterm delivery?

Accepted Answer

2.5 cm

Answer

0.5 cm

Answer

1.5 cm

Answer

3.5 cm

Question 9

A 31-year-old woman presents with abdominal pain and vaginal spotting. The pain started 2 days ago and has been worsening, with spotting occurring this morning. Her last menstrual period was 6 weeks ago. Vital signs show a temperature of 37°C, blood pressure of 90/50 mm Hg, pulse of 110/minute, and respirations of 14/minute. Physical examination reveals significant lower abdominal tenderness, scant blood in the vagina with a closed cervical os, and significant left adnexal tenderness on bimanual examination. Urine hCG is positive, and serum hCG is 5,000 mIU/mL. Pelvic ultrasound shows a normal uterus with a left adnexal mass surrounded by free fluid. Which of the following is the most likely diagnosis?

Accepted Answer

Ectopic pregnancy

Answer

Appendicitis

Answer

Ovarian cancer

Answer

Pelvic inflammatory disease

Question 10

What is the best diagnostic modality for unruptured tubal pregnancy?

Accepted Answer

Vaginal ultrasound

Answer

Serum hCG estimation

Answer

Serum Progesterone estimation

Answer

Culdocentesis

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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