Maternal-Fetal Medicine Practice Questions

Q: A 37-week pregnant female presents with grade 3 placenta previa, bleeding per vaginum, and uterine contractions. What is the most appropriate management for this patient?

Emergency LSCS. **Explanation:** The management of placenta previa is primarily determined by the **gestational age**, the **severity of bleeding**, and the **stability of the mother and fetus**. 1. **Why Emergency LSCS is correct:** This patient is at **37 weeks (term)** and is presenting with **active bleeding** and **uterine contractions**. In placenta previa, contractions cause further cervical effacement and dilatation, leading to massive, life-threatening hemorrhage due to the separation of the placenta from the lower uterine segment. Since the pregnancy has reached term and there is active bleeding, immediate delivery via **Emergency Lower Segment Cesarean Section (LSCS)** is the definitive management to ensure maternal and fetal safety. Grade 3 (totalis/partial) placenta previa is a contraindication for vaginal delivery. 2. **Why other options are incorrect:** * **A. Dexamethasone and nifedipine:** These are components of "Expectant Management" (Macafee-Johnson protocol). Dexamethasone is used for fetal lung maturity (usually <34 weeks), and nifedipine is a tocolytic. They are contraindicated here because the patient is at term and actively bleeding. * **B & C. Bed rest, sedation, and Wait and watch:** These are passive approaches. Waiting in the presence of active bleeding and contractions at 37 weeks risks maternal shock and fetal demise. **High-Yield Clinical Pearls for NEET-PG:** * **Macafee-Johnson Protocol:** Indicated only if the fetus is preterm (<37 weeks), bleeding is not life-threatening, and the mother is hemodynamically stable. * **Double Setup Examination:** Historically used to diagnose previa in the OT; however, it is now largely replaced by **Transvaginal Sonography (TVS)**, which is the gold standard for diagnosis. * **Vaginal Examination:** Strictly contraindicated in suspected placenta previa (can cause torrential hemorrhage) until previa is ruled out by ultrasound.

Q: The risk factors for placental abruption include the following, except:

Diabetes mellitus. **Explanation:** Placental abruption (abruptio placentae) is the premature separation of a normally situated placenta from the uterine wall. The primary pathophysiology involves **rupture of maternal spiral arteries** in the decidua basalis, leading to retroplacental hemorrhage. **Why Diabetes Mellitus is the correct answer:** Diabetes mellitus (both pre-gestational and gestational) is **not** a direct risk factor for placental abruption. While diabetes is associated with other placental complications like placentomegaly and placental insufficiency, it does not predispose the patient to premature separation. In fact, the risk of abruption is primarily linked to conditions causing vascular damage or sudden uterine decompression. **Analysis of Incorrect Options:** * **History of previous abruption:** This is the **strongest risk factor**. A woman with a history of abruption has a 10–15 fold increased risk in subsequent pregnancies. * **Hypertension:** This is the **most common cause** of abruption. Both chronic hypertension and preeclampsia cause vascular vasospasm and endothelial damage, leading to hemorrhage. * **Preterm Rupture of Membranes (PROM):** Sudden decompression of the uterus (also seen in polyhydramnios) causes a rapid decrease in intrauterine pressure, which can shear the placenta away from the uterine wall. **Clinical Pearls for NEET-PG:** * **Most common cause:** Hypertension (Preeclampsia). * **Strongest risk factor:** Previous history of abruption. * **Other high-yield risk factors:** Smoking, Cocaine use (causes acute vasospasm), Trauma, and Short umbilical cord. * **Classic Triad:** Painful vaginal bleeding, uterine tenderness (woody hard uterus), and fetal distress. * **Couvelaire Uterus:** A complication where blood extravasates into the myometrium, seen during C-section.

Q: Which of the following conditions can lead to blood loss of fetal origin?

Vasa previa. **Explanation:** In obstetric hemorrhage, it is crucial to distinguish between maternal and fetal sources of bleeding. **Why Vasa Previa is correct:** In **Vasa previa**, fetal vessels (unprotected by Wharton’s jelly or placental tissue) run across the internal os, usually due to a velamentous cord insertion or a succenturiate lobe. When the membranes rupture (ROM), these vessels are easily lacerated. Since the blood contained within these vessels belongs to the fetus, the resulting hemorrhage is of **fetal origin**. Because the total fetal blood volume is small (~80-100 mL/kg), even a minor bleed can rapidly lead to fetal exsanguination, distress, and demise, while the mother remains hemodynamically stable. **Why other options are incorrect:** * **Placenta Previa:** The bleeding occurs from the premature separation of the placenta from the lower uterine segment. This blood is primarily **maternal** in origin (from the uterine sinuses). * **Abruptio Placenta:** This involves the premature separation of a normally situated placenta. The hemorrhage occurs into the decidua basalis and is **maternal** blood. * **Circumvallate Placenta:** This is a morphological variation where the chorionic plate is smaller than the basal plate. While it increases the risk of abruption or preterm labor, any associated bleeding is **maternal**. **High-Yield Clinical Pearls for NEET-PG:** * **Apt Test / Ogita Test / Loendersloot Test:** These tests are used to differentiate fetal hemoglobin (HbF) from maternal hemoglobin (HbA) based on alkali resistance. * **Classic Triad of Vasa Previa:** (1) Rupture of membranes, (2) Painless vaginal bleeding, and (3) Fetal bradycardia/distress. * **Diagnosis:** Best diagnosed via **Color Doppler Ultrasound** showing vessels crossing the internal os.

Q: Which of the following is highly effective in preventing convulsions in a woman with severe preeclampsia?

Magnesium sulfate. **Explanation:** **Magnesium Sulfate (MgSO₄)** is the drug of choice for both the prevention of seizures in severe preeclampsia (prophylaxis) and the control of seizures in eclampsia. Its efficacy was definitively established by the **MAGPIE trial**, which demonstrated that MgSO₄ reduces the risk of eclampsia by more than 50% compared to placebo. **Mechanism of Action:** It acts primarily as a **NMDA receptor antagonist** in the brain, raising the seizure threshold. It also causes cerebral vasodilation, reducing ischemia, and acts as a calcium channel blocker at the neuromuscular junction, which provides a mild sedative effect on the central nervous system. **Why other options are incorrect:** * **Phenytoin (A):** While an effective anti-epileptic, clinical trials (e.g., Lucas et al.) showed it is significantly less effective than MgSO₄ in preventing eclamptic seizures and carries a higher risk of toxicity. * **Diazepam (C):** Benzodiazepines are associated with a higher rate of recurrent seizures and increased maternal/neonatal respiratory depression compared to MgSO₄. * **Levetiracetam (D):** Although used in general epilepsy, there is insufficient evidence to support its use as a first-line agent in preeclampsia/eclampsia over MgSO₄. **High-Yield Clinical Pearls for NEET-PG:** * **Regimen:** The **Pritchard Regimen** (IM) and **Zuspan Regimen** (IV) are the standard protocols. * **Monitoring:** Always monitor the **Patellar reflex** (first sign of toxicity to disappear), **Respiratory rate** (>12/min), and **Urine output** (>30ml/hr or 100ml/4hr) as MgSO₄ is excreted renally. * **Antidote:** **10% Calcium Gluconate** (10ml IV over 10 minutes) must be kept at the bedside. * **Therapeutic Range:** 4–7 mEq/L. Loss of patellar reflex occurs at 8–10 mEq/L; respiratory paralysis at >12 mEq/L.

Q: All the following are advised in an epileptic woman preconceptionally except?

Supplement folic acid with a dose of 1mg/day.. **Explanation:** The management of epilepsy in pregnancy focuses on balancing seizure control with minimizing teratogenic risks. **Why Option B is the correct answer (The "Except"):** Women taking Anti-Epileptic Drugs (AEDs) are at a significantly higher risk of having a child with Neural Tube Defects (NTDs) because many AEDs (especially Valproate and Carbamazepine) interfere with folate metabolism. To counteract this, the recommended preconception dose of **Folic Acid is 4–5 mg/day**, starting at least one month before conception and continuing through the first trimester. The standard dose of 0.4 mg or 1 mg is insufficient for this high-risk group. **Analysis of Incorrect Options:** * **Option A:** Monotherapy is the gold standard. Polytherapy significantly increases the risk of congenital malformations compared to a single agent. * **Option C:** If a patient has been seizure-free for **>2 years**, a supervised trial of tapering and withdrawing medication may be attempted before pregnancy to eliminate fetal drug exposure. * **Option D:** Teratogenicity is dose-dependent and drug-specific. For example, Valproate carries the highest risk (up to 10%), while Levetiracetam and Lamotrigine are considered safer alternatives. **NEET-PG High-Yield Pearls:** * **Drug of Choice:** Lamotrigine or Levetiracetam are preferred in pregnancy. * **Avoid:** Valproate (highest risk of NTDs and cognitive impairment). * **Vitamin K:** If the mother is on enzyme-inducing AEDs (e.g., Phenytoin, Phenobarbital), 10 mg of Vitamin K is given to the mother in the last month of pregnancy, and 1 mg is given to the neonate at birth to prevent Hemorrhagic Disease of the Newborn. * **Breastfeeding:** Generally encouraged as the benefits outweigh the risks of drug excretion in milk.

Question 1

A 37-week pregnant female presents with grade 3 placenta previa, bleeding per vaginum, and uterine contractions. What is the most appropriate management for this patient?

Accepted Answer

Emergency LSCS

Answer

Dexamethasone and nifedipine

Answer

Bed rest and sedation

Answer

Wait and watch

Question 2

The risk factors for placental abruption include the following, except:

Accepted Answer

Diabetes mellitus

Answer

History of placental abruption in previous pregnancy

Answer

Hypertension

Answer

Preterm rupture of membranes

Question 3

Which of the following statements is true regarding heart disease in pregnancy?

Accepted Answer

In Mitral Stenosis, surgery is better avoided during pregnancy.

Answer

Mitral Regurgitation has a definite indication for termination of pregnancy.

Answer

Aortic stenosis in old age is due to Bicuspid valve.

Answer

Termination of pregnancy is advised in NYHA class II.

Question 4

Which of the following findings are highly predictive of placenta accreta?

Accepted Answer

Less than 1 mm between uterine serosa - bladder interface and retroplacental vessels; large placental lakes.

Answer

Large intraplacental lakes; fundal placenta.

Answer

Less than 1 mm between uterine serosa - bladder interface and retroplacental vessels; lateral placenta.

Answer

None of the above.

Question 5

Which of the following conditions can lead to blood loss of fetal origin?

Accepted Answer

Vasa previa

Answer

Placenta previa

Answer

Abruptio placenta

Answer

Circumvallate placenta

Question 6

A 23-year-old G1P0 woman at 10 weeks' gestation presents for her initial evaluation. She reports several hospitalizations for asthma exacerbations, but has never required intubation or ICU admission. She is controlled on daily inhaled corticosteroids and albuterol with adequate symptom relief. She is concerned about taking these medications during pregnancy. Which of the following is true regarding asthma medications in pregnancy?

Accepted Answer

Both beta-2 agonists and inhaled corticosteroids are safe in pregnancy.

Answer

Beta-2 agonists are contraindicated during pregnancy.

Answer

Both beta-2 agonists and inhaled corticosteroids are contraindicated in pregnancy.

Answer

Beta-2 agonists and inhaled corticosteroids are both safe in pregnancy but only during the second and third trimesters.

Question 7

Which of the following is highly effective in preventing convulsions in a woman with severe preeclampsia?

Accepted Answer

Magnesium sulfate

Answer

Phenytoin

Answer

Diazepam

Answer

Levetiracetam

Question 8

Regarding appendicitis in pregnancy, which of the following statements is false?

Accepted Answer

Conservative management with antibiotics should be attempted.

Answer

It is the most common cause of acute abdomen in the first trimester.

Answer

Pregnancy does not increase the risk of appendicitis.

Answer

After rupture, fetal mortality is around 30-40%.

Question 9

All the following are advised in an epileptic woman preconceptionally except?

Accepted Answer

Supplement folic acid with a dose of 1mg/day.

Answer

Attempt to achieve seizure control with monotherapy.

Answer

Medication withdrawal is considered if a woman is seizure-free for 2 years or more.

Answer

Risk of congenital abnormalities in the fetus is dependent on the type, number, and dose of antiepileptic drugs.

Question 10

Fetal cells can be detected in maternal blood using which test?

Accepted Answer

Kleihauer-Betke test

Answer

DCT

Answer

LET

Answer

Bubble test

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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