Maternal-Fetal Medicine — MCQs

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?

Q345Easy

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

Q346Medium

Alpha-fetoprotein levels are increased in all EXCEPT:

Q347Medium

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

Q348Medium

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

Q349Easy

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

Q350Medium

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

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 341: Elevated maternal serum alpha-fetoprotein (AFP) is seen in which of the following conditions?

A. Multiple pregnancy
B. Trisomy 21 (Down syndrome) (Correct Answer)
C. Open neural tube defect
D. Intrauterine fetal demise (IUD)

Explanation: **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.

Question 342: Which of the following statements is true regarding heart disease in pregnancy?

A. In Mitral Stenosis, surgery is better avoided during pregnancy. (Correct Answer)
B. Mitral Regurgitation has a definite indication for termination of pregnancy.
C. Aortic stenosis in old age is due to Bicuspid valve.
D. Termination of pregnancy is advised in NYHA class II.

Explanation: **Explanation:** **Correct Option (A):** In patients with Mitral Stenosis (MS), medical management is the primary approach. Surgery (such as Closed Mitral Valvotomy or Balloon Mitral Valvoplasty) is generally **avoided during pregnancy** unless the patient is refractory to medical therapy (NYHA Class III or IV). If necessary, it is ideally performed in the second trimester to minimize teratogenicity and the risk of preterm labor. **Incorrect Options:** * **Option B:** Mitral Regurgitation (MR) is generally **well-tolerated** during pregnancy because the physiological decrease in systemic vascular resistance (SVR) reduces the regurgitant fraction. It is never a routine indication for termination. * **Option C:** While a bicuspid aortic valve is the most common cause of Aortic Stenosis (AS) in younger patients, AS in **old age** is primarily due to **senile degenerative calcification**. * **Option D:** Termination is not advised for NYHA Class II. It is typically considered in high-risk conditions (WHO Class IV) such as Pulmonary Arterial Hypertension (Eisenmenger syndrome), severe symptomatic Aortic Stenosis, or Marfan syndrome with aortic root involvement. **High-Yield Clinical Pearls for NEET-PG:** * **Most common heart disease in pregnancy:** Rheumatic Heart Disease (RHD). * **Most common lesion in RHD:** Mitral Stenosis (MS). * **Most dangerous period:** Immediate postpartum (due to "autotransfusion" from the uterus, leading to fluid overload and pulmonary edema). * **Drug of choice for anticoagulation:** Low Molecular Weight Heparin (LMWH) is preferred; Warfarin is avoided in the first trimester (teratogenic) and near term (fetal hemorrhage). * **Antibiotic prophylaxis:** No longer routinely recommended for uncomplicated vaginal or cesarean deliveries unless there is active infection.

Question 343: Which of the following conditions can lead to blood loss of fetal origin?

A. Placenta previa
B. Vasa previa (Correct Answer)
C. Abruptio placenta
D. Circumvallate placenta

Explanation: **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.

Question 344: 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?

A. Beta-2 agonists are contraindicated during pregnancy.
B. Both beta-2 agonists and inhaled corticosteroids are contraindicated in pregnancy.
C. Both beta-2 agonists and inhaled corticosteroids are safe in pregnancy. (Correct Answer)
D. Beta-2 agonists and inhaled corticosteroids are both safe in pregnancy but only during the second and third trimesters.

Explanation: **Explanation:** The management of asthma in pregnancy follows the principle that **maintaining maternal oxygenation is paramount for fetal well-being.** Poorly controlled asthma increases the risk of preeclampsia, preterm birth, and low birth weight. **1. Why Option C is Correct:** The safety profile of standard asthma medications is well-established. **Short-acting beta-2 agonists (SABA)**, such as Albuterol, are the preferred rescue therapy. **Inhaled corticosteroids (ICS)**, such as Budesonide, are the preferred long-term controller medications. Extensive clinical data show no significant increase in congenital malformations or adverse pregnancy outcomes with these drugs. The risk to the fetus from maternal hypoxia during an asthma exacerbation far outweighs any theoretical risk from these medications. **2. Why Incorrect Options are Wrong:** * **Options A & B:** These are incorrect because withholding treatment leads to uncontrolled asthma, which is dangerous for both mother and fetus. Beta-2 agonists and ICS are considered first-line therapies. * **Option D:** This is incorrect because asthma must be managed throughout the **entire pregnancy**, including the first trimester. There is no evidence that these medications are teratogenic during organogenesis. **Clinical Pearls for NEET-PG:** * **The Rule of One-Thirds:** During pregnancy, asthma symptoms improve in 1/3 of patients, worsen in 1/3, and remain stable in 1/3. * **Drug of Choice:** **Budesonide** is the preferred ICS because it has the most safety data in pregnancy. * **Acute Exacerbation:** Management is similar to non-pregnant patients (Oxygen, SABA, and systemic steroids if needed). * **Labor Management:** Continue all maintenance medications. If systemic steroids were used recently, give "stress dose" steroids to prevent adrenal crisis. * **Avoid:** Prostaglandin F2-alpha (Carboprost/Hemabate) for postpartum hemorrhage in asthmatics, as it can cause bronchospasm. Use Oxytocin or Misoprostol instead.

Question 345: Which of the following is highly effective in preventing convulsions in a woman with severe preeclampsia?

A. Phenytoin
B. Magnesium sulfate (Correct Answer)
C. Diazepam
D. Levetiracetam

Explanation: **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.

Question 346: Alpha-fetoprotein levels are increased in all EXCEPT:

A. Open neural tube defects
B. Down syndrome (Correct Answer)
C. Twin pregnancy
D. Intrauterine death

Explanation: **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.

Question 347: Regarding appendicitis in pregnancy, which of the following statements is false?

A. It is the most common cause of acute abdomen in the first trimester.
B. Pregnancy does not increase the risk of appendicitis.
C. Conservative management with antibiotics should be attempted. (Correct Answer)
D. After rupture, fetal mortality is around 30-40%.

Explanation: **Explanation:** **1. Why Option C is False (The Correct Answer):** Appendicitis in pregnancy is a surgical emergency. Conservative management (antibiotics alone) is **not recommended** because the risk of perforation is significantly higher in pregnant women due to delayed diagnosis and the physical displacement of the omentum (which fails to wall off the infection). Early surgical intervention (Laparoscopic or Open Appendicectomy) is the gold standard to prevent rupture, which is the single most important factor in determining fetal and maternal outcomes. **2. Analysis of Other Options:** * **Option A:** Acute appendicitis is indeed the **most common non-obstetric surgical emergency** and the leading cause of acute abdomen across all trimesters of pregnancy. * **Option B:** Pregnancy **does not increase the incidence** of appendicitis; the frequency is the same as in non-pregnant women (approx. 1 in 1,000). However, pregnancy makes the *diagnosis* more challenging. * **Option D:** While maternal mortality is low, **fetal mortality** increases drastically if the appendix ruptures. In simple appendicitis, fetal loss is ~3-5%, but it surges to **20-35% following perforation** due to peritonitis and preterm labor. **Clinical Pearls for NEET-PG:** * **Anatomical Shift:** The appendix is displaced **upward and outward** by the enlarging uterus. By the 8th month, it may reach the level of the iliac crest, often causing RUQ pain instead of RLQ pain (Alder’s sign). * **Diagnosis:** Clinical diagnosis is paramount. **Graduated compression Ultrasonography** is the initial imaging of choice. MRI is the preferred second-line if USG is inconclusive. * **Surgery:** Laparoscopy is considered safe in all trimesters, though the second trimester is often cited as the ideal time for elective procedures.

Question 348: Which of the following is a known effect of dengue on fetuses if the mother is affected?

A. Abortion
B. Teratogenicity
C. Intrauterine growth restriction (IUGR)
D. None of the above (Correct Answer)

Explanation: **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.

Question 349: Fetal cells can be detected in maternal blood using which test?

A. DCT
B. LET
C. Kleihauer-Betke test (Correct Answer)
D. Bubble test

Explanation: ### Explanation **Correct Answer: C. Kleihauer-Betke (KB) test** The **Kleihauer-Betke (KB) test** is the standard method for quantifying the amount of fetal-maternal hemorrhage (FMH). It relies on the principle of **differential acid elution**. Fetal hemoglobin (HbF) is resistant to acid elution, whereas adult hemoglobin (HbA) is acid-labile. When a maternal blood smear is exposed to an acid buffer and then stained (usually with eosin), the adult RBCs lose their hemoglobin and appear as "ghost cells," while the fetal RBCs retain their hemoglobin and appear bright pink/red. This allows for the calculation of the volume of fetal blood in maternal circulation, which is crucial for determining the required dose of Anti-D immunoglobulin in Rh-negative mothers. **Analysis of Incorrect Options:** * **A. DCT (Direct Coombs Test):** Used to detect antibodies or complement proteins already bound to the surface of red blood cells. It is used to diagnose autoimmune hemolytic anemia or hemolytic disease of the newborn (HDN), not to quantify fetal cells. * **B. LET (Lecithin-to-Sphingomyelin Ratio):** A test performed on amniotic fluid to assess **fetal lung maturity**. A ratio >2:1 usually indicates mature lungs. * **C. Bubble Test (Shake Test):** Another bedside test for **fetal lung maturity**. It assesses the ability of pulmonary surfactant in amniotic fluid to form stable bubbles in the presence of ethanol. **High-Yield Clinical Pearls for NEET-PG:** * **Rosette Test:** This is a qualitative (screening) test used to detect FMH. If the Rosette test is positive, the **KB test** (quantitative) is performed to calculate the exact dose of Anti-D. * **Formula for Anti-D Dosage:** Volume of FMH (mL) = (Number of fetal cells / Total cells counted) × Maternal blood volume (approx. 5000 mL). * **Standard Dose:** 300 mcg of Anti-D neutralizes 30 mL of fetal whole blood (or 15 mL of fetal RBCs). * **Timing:** Anti-D should ideally be given within **72 hours** of the sensitizing event.

Question 350: Which of the following drugs are used for the medical treatment of ectopic pregnancy?

A. Methotrexate (MTX)
B. Actinomycin-D
C. Human Chorionic Gonadotropin (HCG)
D. Mifepristone (RU-486) (Correct Answer)

Explanation: **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 <3.5–4 cm, no fetal cardiac activity, and baseline β-hCG <5000 mIU/mL. * **Contraindications to MTX:** Breastfeeding, immunodeficiency, alcoholism, or chronic liver/renal disease. * **Monitoring:** Success is defined by a **>15% decline** in β-hCG levels between Day 4 and Day 7 after administration.

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

Practice Questions

Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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