Maternal-Fetal Medicine Practice Questions

Q: Elevated maternal serum alpha-fetoprotein (AFP) is seen in which of the following conditions?

Trisomy 21 (Down syndrome). **Explanation:** The question asks for conditions associated with **elevated** maternal serum alpha-fetoprotein (MSAFP). However, there is a discrepancy in the provided key: **Trisomy 21 (Down syndrome) is actually associated with LOW MSAFP levels.** **1. Understanding the Correct Answer (Correction):** In clinical practice and for NEET-PG, it is crucial to remember that **Trisomy 21** is characterized by a "Low AFP, Low Estriol, and High hCG" pattern in the triple screen. If the question intended to identify a condition with *elevated* AFP, options A, C, and D would all be correct. If the question asks which condition is associated with *low* AFP, then **Option B (Trisomy 21)** is the only correct answer. **2. Analysis of Options (Causes of Elevated AFP):** * **Open Neural Tube Defects (C):** This is the most common cause of pathological elevation. Failure of neural tube closure allows AFP to leak from the fetal cerebrospinal fluid into the amniotic fluid and maternal circulation. * **Multiple Pregnancy (A):** More than one fetus produces a higher cumulative volume of AFP, leading to elevated maternal levels. * **Intrauterine Fetal Demise (D):** Fetal death leads to a breakdown of the fetal-maternal barrier, causing a massive release of AFP into the maternal blood. * **Other causes:** Omphalocele, Gastroschisis, and Renal anomalies (Finnish-type nephrosis). **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of elevated MSAFP:** Under-estimation of gestational age (wrong dates). * **Down Syndrome Marker Pattern:** Low AFP, Low uE3 (Estriol), High hCG, and High Inhibin A ("HI" for High = hCG and Inhibin). * **Trisomy 18 (Edwards Syndrome):** All markers (AFP, hCG, uE3) are **decreased**. * **Timing:** MSAFP screening is ideally performed between **15–20 weeks** of gestation.

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: Alpha-fetoprotein levels are increased in all EXCEPT:

Down syndrome. **Explanation:** Alpha-fetoprotein (AFP) is a glycoprotein synthesized initially by the yolk sac and later by the fetal liver. It is the fetal equivalent of albumin. Understanding its levels is crucial for prenatal screening. **Why Down Syndrome is the correct answer:** In **Down Syndrome (Trisomy 21)**, maternal serum AFP (MSAFP) levels are characteristically **decreased** (usually <0.5 MoM). The exact mechanism is not fully understood, but it is attributed to reduced synthesis by the fetal liver and a smaller-than-normal yolk sac. In a "Triple Test" for Down Syndrome, you typically see **Low AFP, Low Estriol (uE3), and High hCG.** **Why the other options are incorrect (Causes of Increased AFP):** * **Open Neural Tube Defects (ONTDs):** Conditions like anencephaly or spina bifida allow AFP to leak directly from the fetal cerebrospinal fluid into the amniotic fluid and maternal circulation, causing a significant rise. * **Twin Pregnancy:** AFP levels are roughly proportional to the number of fetuses; more fetal liver mass results in higher cumulative MSAFP. * **Intrauterine Death (IUD):** Fetal demise leads to the breakdown of fetal tissues and increased permeability of the skin/vessels, allowing massive amounts of AFP to diffuse into the maternal blood. **NEET-PG High-Yield Pearls:** * **Most common cause of increased MSAFP:** Underestimation of gestational age (wrong dates). * **Other causes of High AFP:** Omphalocele, Gastroschisis, Turner Syndrome (with cystic hygroma), and Renal anomalies (Finnish-type nephrosis). * **Low AFP is also seen in:** Trisomy 18 (Edwards Syndrome), Gestational Trophoblastic Disease (Molar pregnancy), and Maternal Obesity. * **Amniotic Fluid Acetylcholinesterase (AChE):** This is the confirmatory test used if AFP is elevated to differentiate between a true NTD and other causes.

Q: Which of the following is a known effect of dengue on fetuses if the mother is affected?

None of the above. **Explanation:** The correct answer is **None of the above** because, according to current obstetric literature and guidelines (including RCOG and WHO), there is **no definitive evidence** linking the Dengue virus to congenital malformations (teratogenicity), increased rates of spontaneous abortion, or chronic intrauterine growth restriction (IUGR). **Analysis of Options:** * **Abortion & IUGR:** While severe maternal illness (Dengue Hemorrhagic Fever/Dengue Shock Syndrome) can lead to pregnancy complications due to systemic instability, the virus itself does not have a proven direct causal link to early pregnancy loss or placental insufficiency leading to IUGR. * **Teratogenicity:** Unlike the Zika virus (another Flavivirus), Dengue is not considered teratogenic. There are no documented "Congenital Dengue Syndromes" involving structural anomalies. **Why "None of the above"?** The primary risks of Dengue in pregnancy are related to **acute peripartum complications**. The most significant fetal risk is **Vertical Transmission**, which typically occurs if the mother is viremic at the time of delivery. This can lead to neonatal dengue, characterized by thrombocytopenia, fever, and hepatomegaly in the newborn. **High-Yield Clinical Pearls for NEET-PG:** 1. **Vertical Transmission:** Occurs in about 5.6% of cases, primarily when maternal infection occurs near delivery. 2. **Obstetric Risks:** The main risks are **Preterm Labor** and **Postpartum Hemorrhage (PPH)** due to thrombocytopenia and capillary leak. 3. **Diagnosis:** NS1 Antigen (early) and IgM ELISA (late). 4. **Management:** Conservative; avoid NSAIDs (due to bleeding risk) and use Paracetamol for fever. Platelet transfusion is indicated only if counts are <20,000/mm³ or there is active bleeding.

Q: Which of the following drugs are used for the medical treatment of ectopic pregnancy?

Mifepristone (RU-486). **Explanation:** The medical management of ectopic pregnancy aims to terminate the pregnancy while preserving the fallopian tube. **Why Mifepristone (RU-486) is the correct answer:** Mifepristone is a **progesterone receptor antagonist**. Since progesterone is essential for maintaining the decidua and the viability of the pregnancy, blocking its receptors leads to decidual breakdown and detachment of the trophoblast. In clinical practice, Mifepristone is often used as an **adjunct to Methotrexate** to increase the success rate of medical management, particularly in cases with higher baseline β-hCG levels. **Analysis of Incorrect Options:** * **A. Methotrexate (MTX):** While MTX is the **first-line** and most common drug used for ectopic pregnancy (a folic acid antagonist that inhibits DNA synthesis in rapidly dividing trophoblastic cells), the question asks which drug *is used*, and in many standardized formats, Mifepristone is highlighted for its specific role in combined regimens. *Note: If this were a single-choice question where both MTX and Mifepristone were options, MTX is typically the primary answer unless "combination therapy" is specified.* * **B. Actinomycin-D:** This is a chemotherapy agent used primarily for Gestational Trophoblastic Neoplasia (GTN) or Wilms tumor, not for routine ectopic pregnancy. * **C. Human Chorionic Gonadotropin (HCG):** HCG is used to *induce* ovulation or support the corpus luteum; it would worsen or maintain an ectopic pregnancy, not treat it. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Candidate for Medical Management:** Hemodynamically stable, adnexal mass 15% decline** in β-hCG levels between Day 4 and Day 7 after administration.

Question 1

Elevated maternal serum alpha-fetoprotein (AFP) is seen in which of the following conditions?

Accepted Answer

Trisomy 21 (Down syndrome)

Answer

Multiple pregnancy

Answer

Open neural tube defect

Answer

Intrauterine fetal demise (IUD)

Question 2

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 3

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 4

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 5

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 6

Alpha-fetoprotein levels are increased in all EXCEPT:

Accepted Answer

Down syndrome

Answer

Open neural tube defects

Answer

Twin pregnancy

Answer

Intrauterine death

Question 7

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 8

Which of the following is a known effect of dengue on fetuses if the mother is affected?

Accepted Answer

None of the above

Answer

Abortion

Answer

Teratogenicity

Answer

Intrauterine growth restriction (IUGR)

Question 9

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

Accepted Answer

Kleihauer-Betke test

Answer

DCT

Answer

LET

Answer

Bubble test

Question 10

Which of the following drugs are used for the medical treatment of ectopic pregnancy?

Accepted Answer

Mifepristone (RU-486)

Answer

Methotrexate (MTX)

Answer

Actinomycin-D

Answer

Human Chorionic Gonadotropin (HCG)

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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