Maternal-Fetal Medicine — MCQs

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?

Q334Easy

A large baby is born with which complication in pregnancy?

Q335Medium

Which drug is not useful in an emergency condition during pregnancy?

Q336Easy

Spalding sign is seen in which condition?

Q337Medium

If division of a fertilized egg occurs at 4-8 days, what kind of monozygotic twin pregnancy will it give rise to?

Q338Medium

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?

Q339Easy

Which antitubercular drug is contraindicated in pregnancy?

Q340Easy

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

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 331: Increased acidosis and hypoxemia in a fetus is associated with which of the following findings?

A. Normal Doppler waveform
B. Increased fetal diastolic flow in the middle cerebral artery with absent diastolic flow in the aorta (Correct Answer)
C. Presence of the 'notch' in the uterine artery
D. Absent umbilical artery

Explanation: **Explanation:** The correct answer is **B**. This finding represents the physiological response to fetal hypoxia known as the **"Brain Sparing Effect."** 1. **Why Option B is correct:** When a fetus experiences chronic hypoxia and acidosis (often due to placental insufficiency), it redistributes its cardiac output to protect vital organs (brain, heart, and adrenals). * **Middle Cerebral Artery (MCA):** Vasodilation occurs to increase blood flow to the brain, resulting in **increased diastolic flow** (decreased Pulsatility Index). * **Aorta/Umbilical Artery:** Vasoconstriction occurs in peripheral and visceral vessels to shunt blood away. This leads to increased resistance, progressing from reduced diastolic flow to **Absent End-Diastolic Velocity (AEDV)** or even Reversed End-Diastolic Velocity (REDV). The combination of MCA vasodilation and Aortic/Umbilical vasoconstriction is a hallmark of significant fetal compromise. 2. **Why other options are incorrect:** * **A. Normal Doppler waveform:** Indicates adequate placental perfusion and fetal oxygenation. * **C. Presence of the 'notch' in the uterine artery:** This is a marker of **high maternal vascular resistance** and an increased risk for pre-eclampsia or IUGR, but it reflects maternal uterine circulation rather than the immediate acidotic state of the fetus. * **D. Absent umbilical artery:** This refers to a structural anomaly (Single Umbilical Artery), which is associated with chromosomal issues but is not a dynamic Doppler finding of acute acidosis. **High-Yield Clinical Pearls for NEET-PG:** * **Sequence of Doppler deterioration:** Umbilical Artery (AEDV/REDV) → MCA (Brain Sparing) → **Ductus Venosus (A-wave inversion)**. * **Ductus Venosus (DV):** Inversion of the 'a' wave in the DV is the most ominous sign, indicating imminent fetal heart failure and a high risk of stillbirth. * **Cerebro-Placental Ratio (CPR):** Calculated as MCA PI / Umbilical Artery PI. A ratio **<1.08** is an early sign of brain sparing and adverse perinatal outcome.

Question 332: A woman presents with chickenpox at 8 weeks of gestation. What is the best method to exclude fetal varicella syndrome?

A. Perform amniocentesis at 15 weeks and test for VZV DNA in the amniotic fluid.
B. Perform an ultrasound scan at 20 weeks. (Correct Answer)
C. Perform an ultrasound scan immediately.
D. Perform chorionic villus sampling and test for VZV DNA.

Explanation: **Explanation:** The primary goal in managing a pregnant woman with chickenpox is to identify **Fetal Varicella Syndrome (FVS)**, which occurs in approximately 1–2% of cases when infection happens before 20 weeks of gestation. **Why Option B is Correct:** The diagnosis of FVS is clinical and based on structural abnormalities rather than the mere presence of the virus. A detailed **anomaly scan at 20 weeks** (or 5 weeks after the initial infection) is the gold standard for screening. It looks for characteristic markers such as limb hypoplasia, microcephaly, hydrocephalus, soft tissue calcifications, and intrauterine growth restriction (IUGR). The absence of these structural defects on a high-quality ultrasound is highly reassuring. **Why Other Options are Incorrect:** * **Option A & D:** While amniocentesis or CVS can detect **VZV DNA** via PCR, the presence of the virus in the amniotic fluid or placenta does not equate to fetal damage. Many fetuses are infected but do not develop the syndrome; thus, these tests have a low positive predictive value for FVS and carry a risk of miscarriage. * **Option C:** Performing an ultrasound immediately at 8 weeks is useless for detecting FVS, as the structural sequelae take several weeks to manifest and the fetus is not yet anatomically developed enough to visualize these defects. **Clinical Pearls for NEET-PG:** * **Risk Period:** Highest risk for FVS is between **13–20 weeks** (2%), though it can occur as early as 8 weeks. * **VZIG:** Should be administered to non-immune pregnant women within **10 days** of exposure to prevent/attenuate maternal disease, but it does *not* prevent fetal infection. * **Oral Acyclovir:** Indicated if the pregnant woman presents within 24 hours of rash onset and is >20 weeks gestation (use with caution <20 weeks). * **Neonatal Varicella:** If maternal rash appears 5 days before to 2 days after delivery, the neonate is at risk of severe disseminated varicella due to lack of maternal antibodies.

Question 333: 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?

A. Appendicitis
B. Ectopic pregnancy (Correct Answer)
C. Ovarian cancer
D. Pelvic inflammatory disease

Explanation: **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).

Question 334: A large baby is born with which complication in pregnancy?

A. Gestational diabetes (Correct Answer)
B. Gestational hypertension
C. Cardiac disease
D. Anemia

Explanation: **Explanation:** The correct answer is **Gestational Diabetes Mellitus (GDM)**. The underlying pathophysiology is the **Pedersen Hypothesis**: maternal hyperglycemia leads to fetal hyperglycemia. Since insulin does not cross the placenta but glucose does, the fetal pancreas responds by secreting excess insulin. **Fetal hyperinsulinemia** acts as a potent growth hormone, leading to increased fat deposition and organomegaly, resulting in a large-for-gestational-age (LGA) baby or **macrosomia** (birth weight >4 kg). **Analysis of Incorrect Options:** * **Gestational Hypertension:** Hypertensive disorders of pregnancy typically cause **Uteroplacental Insufficiency**, leading to Fetal Growth Restriction (FGR) and small-for-gestational-age (SGA) babies, rather than large babies. * **Cardiac Disease:** Maternal cardiac compromise often results in chronic fetal hypoxia and reduced nutrient delivery, commonly leading to **low birth weight** and preterm delivery. * **Anemia:** Severe maternal anemia is associated with increased risks of preterm birth and **Fetal Growth Restriction** due to decreased oxygen-carrying capacity to the fetus. **High-Yield Clinical Pearls for NEET-PG:** * **Macrosomia Definition:** Birth weight >4000g or >4500g (regardless of gestational age). * **Most Common Complication of GDM:** Fetal macrosomia. * **Shoulder Dystocia:** Macrosomic babies of diabetic mothers have a disproportionately increased chest-to-head ratio, significantly increasing the risk of shoulder dystocia. * **Neonatal Complications of GDM:** Hypoglycemia (most common), hypocalcemia, hyperbilirubinemia, and Polycythemia. * **Congenital Anomaly:** While Sacral Agenesis is the most specific, **Ventricular Septal Defect (VSD)** is the most common cardiac anomaly in infants of diabetic mothers.

Question 335: Which drug is not useful in an emergency condition during pregnancy?

A. Nifedipine (Correct Answer)
B. Labetalol
C. Ritodrine
D. Phenobarbitone

Explanation: **Explanation:** The question focuses on the management of obstetric emergencies, specifically hypertensive crises and preterm labor. **Why Nifedipine is the correct answer:** While **Nifedipine** is a first-line agent for the management of chronic hypertension in pregnancy and is used as an oral tocolytic, it is **not** the drug of choice in an acute hypertensive emergency (e.g., severe pre-eclampsia or eclampsia). In emergency settings, rapid-acting intravenous agents are preferred to ensure controlled and predictable reduction of blood pressure. Furthermore, sublingual nifedipine is strictly contraindicated due to the risk of sudden, uncontrolled hypotension which can lead to placental hypoperfusion and fetal distress. **Analysis of other options:** * **Labetalol:** This is a gold-standard drug for **hypertensive emergencies** in pregnancy. It is a combined alpha and beta-blocker administered intravenously to rapidly lower blood pressure without causing reflex tachycardia. * **Ritodrine:** A beta-2 agonist used as a tocolytic in the emergency management of **preterm labor** to suppress uterine contractions. Although its use is declining due to side effects, it remains a classic "emergency" tocolytic in textbooks. * **Phenobarbitone:** Historically used in the management of **eclampsia** (seizure control) and fetal lung maturity induction, though Magnesium Sulfate is now the drug of choice for seizures. **Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC) for Hypertensive Emergency in Pregnancy:** IV Labetalol (Hydralazine is an alternative). * **DOC for Eclampsia:** Magnesium Sulfate (Pritchard Regimen). * **Nifedipine** is the DOC for **maintenance tocolysis** but should be avoided in patients with cardiac disease or those concurrently using $MgSO_4$ (risk of neuromuscular blockade).

Question 336: Spalding sign is seen in which condition?

A. Abortion
B. Still birth
C. Intrauterine device (IUD) (Correct Answer)
D. Infanticide

Explanation: **Explanation:** **Spalding’s Sign** is a classic radiological indicator of **Intrauterine Fetal Death (IUFD)**. It refers to the **overlapping of the fetal skull bones** caused by the liquefaction of the brain matter and the loss of alignment of the cranial sutures following fetal demise. 1. **Why the correct answer is right:** In the context of this question, "Intrauterine device" is a common (though technically imprecise) synonym used in some Indian medical examinations to refer to **Intrauterine Death (IUD)**. When a fetus dies in utero, the intracranial pressure drops due to brain tissue necrosis. The resulting collapse causes the parietal bones to overlap. This sign typically appears **4 to 7 days** after fetal death. 2. **Why the incorrect options are wrong:** * **Abortion:** While this involves fetal loss, Spalding’s sign is specifically a radiological finding of a more advanced fetus (usually second or third trimester) where the skull bones are sufficiently mineralized to be seen on X-ray or Ultrasound. * **Stillbirth:** This is the birth of a dead fetus. While Spalding's sign may have been present *before* delivery, the sign itself is a diagnostic tool used to confirm death *in utero*. * **Infanticide:** This refers to the killing of a live-born infant. Spalding’s sign is a decomposition change that occurs only within the uterine environment. **High-Yield Clinical Pearls for NEET-PG:** * **Robert’s Sign:** The presence of gas in the fetal heart and large vessels (earliest sign of IUFD, seen within 12 hours). * **Deuel’s Halo Sign:** Edema of the fetal scalp causing a "halo" appearance (due to fluid accumulation in subcutaneous tissues). * **Curvature of the Spine:** Excessive angulation or collapse of the fetal vertebral column due to loss of muscle tone. * **Confirmatory Test:** Today, the gold standard for diagnosing IUFD is the **real-time Ultrasound** showing absence of fetal cardiac activity.

Question 337: If division of a fertilized egg occurs at 4-8 days, what kind of monozygotic twin pregnancy will it give rise to?

A. Diamnionic dichorionic
B. Diamnionic monochorionic (Correct Answer)
C. Monoamnionic monochorionic
D. Conjoined twins

Explanation: The type of monozygotic (MZ) twinning depends entirely on the **timing of the division** of the fertilized ovum. The rule of thumb for NEET-PG is the "0-4, 4-8, 8-12" day rule. ### **Explanation of the Correct Answer** **B. Diamnionic Monochorionic (MCDA):** This occurs when division happens between **4 to 8 days** post-fertilization, at the **blastocyst stage**. At this point, the outer layer (trophoblast), which forms the chorion, has already differentiated, but the inner cell mass (which forms the amnion) has not. Therefore, the twins share a single placenta and chorionic sac but develop within two separate amniotic sacs. This is the most common type of monozygotic twinning (~70-75%). ### **Why Other Options are Incorrect** * **A. Diamnionic Dichorionic (DCDA):** Division occurs early, within **0-4 days** (morula stage), before the differentiation of the trophoblast. Each twin develops its own placenta and sac. * **C. Monoamnionic Monochorionic (MCMA):** Division occurs late, between **8-12 days** (implanted blastocyst stage), after both the chorion and amnion have differentiated. They share everything, leading to risks like cord entanglement. * **D. Conjoined Twins:** Division occurs very late, **after 13 days** (embryonic disc stage). The cleavage is incomplete, resulting in fused fetuses. ### **High-Yield Clinical Pearls for NEET-PG** * **Most common MZ twin:** Monochorionic Diamnionic (MCDA). * **T-sign vs. Lambda (λ) sign:** On ultrasound, MCDA twins show a **"T-sign"** (thin membrane), while DCDA twins show a **"Lambda/Twin-peak sign"** (thick membrane). * **Complications:** Monochorionic twins are at unique risk for **Twin-to-Twin Transfusion Syndrome (TTTS)** due to vascular anastomoses in the single placenta. * **Dizygotic twins** are always Diamnionic Dichorionic.

Question 338: 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?

A. Dexamethasone and nifedipine
B. Bed rest and sedation
C. Wait and watch
D. Emergency LSCS (Correct Answer)

Explanation: **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.

Question 339: Which antitubercular drug is contraindicated in pregnancy?

A. Streptomycin (Correct Answer)
B. Rifampicin
C. Isoniazid
D. Ethambutol

Explanation: **Explanation:** **Streptomycin (Option A)** is the correct answer because it is an aminoglycoside that is strictly contraindicated in pregnancy. It crosses the placenta and is known to be **ototoxic** to the developing fetus. Exposure can lead to permanent **congenital deafness** (damage to the 8th cranial nerve) and vestibular dysfunction. In the FDA pregnancy categories, it is classified as Category D. **Why the other options are incorrect:** * **Isoniazid (INH) (Option C):** Considered safe in pregnancy. It is the drug of choice for latent TB in pregnant women. However, it is usually co-administered with **Pyridoxine (Vitamin B6)** to prevent peripheral neuropathy in the mother and fetus. * **Rifampicin (Option B):** Considered safe and is a core component of the RNTCP/NTEP regimen for pregnant women. While there is a theoretical risk of neonatal hemorrhage due to vitamin K deficiency, this is rare and manageable. * **Ethambutol (Option D):** Considered the safest of the first-line drugs. It has not been associated with teratogenicity or fetal visual impairment (optic neuritis) at standard doses. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Regimen:** The WHO and NTEP recommend the same 6-month regimen (2HRE/4HR) for pregnant women as for non-pregnant adults. * **Pyrazinamide:** Though previously controversial, it is now considered safe and included in standard protocols for pregnant women in India. * **Avoid:** Streptomycin, Kanamycin, and Ethionamide are generally avoided due to teratogenic or toxic risks. * **Breastfeeding:** All first-line ATT drugs are compatible with breastfeeding as they are excreted in negligible amounts in breast milk.

Question 340: The risk factors for placental abruption include the following, except:

A. History of placental abruption in previous pregnancy
B. Hypertension
C. Diabetes mellitus (Correct Answer)
D. Preterm rupture of membranes

Explanation: **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.

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

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Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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