Maternal-Fetal Medicine Practice Questions

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

Gestational diabetes. **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.

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

Nifedipine. **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).

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

Diamnionic monochorionic. 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.

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: Which antitubercular drug is contraindicated in pregnancy?

Streptomycin. **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.

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.

Question 1

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 2

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 3

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 4

A large baby is born with which complication in pregnancy?

Accepted Answer

Gestational diabetes

Answer

Gestational hypertension

Answer

Cardiac disease

Answer

Anemia

Question 5

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

Accepted Answer

Nifedipine

Answer

Labetalol

Answer

Ritodrine

Answer

Phenobarbitone

Question 6

Spalding sign is seen in which condition?

Accepted Answer

Intrauterine device (IUD)

Answer

Abortion

Answer

Still birth

Answer

Infanticide

Question 7

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

Accepted Answer

Diamnionic monochorionic

Answer

Diamnionic dichorionic

Answer

Monoamnionic monochorionic

Answer

Conjoined twins

Question 8

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 9

Which antitubercular drug is contraindicated in pregnancy?

Accepted Answer

Streptomycin

Answer

Rifampicin

Answer

Isoniazid

Answer

Ethambutol

Question 10

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

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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