Maternal-Fetal Medicine Practice Questions

Q: Which of the following is NOT a feature of mild pre-eclampsia?

Mild Intrauterine Growth Restriction (IUGR). **Explanation:** In modern obstetric practice (based on ACOG and NHBPEP guidelines), pre-eclampsia is classified into two categories: **Pre-eclampsia without severe features** (formerly "Mild") and **Pre-eclampsia with severe features**. **Why Option C is the Correct Answer:** Intrauterine Growth Restriction (IUGR) is considered a sign of placental insufficiency and significant fetal compromise. According to standard diagnostic criteria, the presence of **fetal growth restriction** automatically upgrades the diagnosis to **Severe Pre-eclampsia**. Therefore, IUGR is never a feature of "mild" pre-eclampsia; its presence indicates a more advanced disease state requiring closer monitoring and potential delivery. **Analysis of Incorrect Options:** * **Options A & B:** Mild pre-eclampsia is defined by a Blood Pressure $\geq$ 140/90 mm Hg but **$<$ 160/110 mm Hg**. Thus, a Diastolic BP < 100 mm Hg and a Systolic BP < 160 mm Hg are consistent with the mild category. * **Option D:** "Premonitory symptoms" include headache, visual disturbances, epigastric pain, and oliguria. These are markers of end-organ damage. Their **absence** is a hallmark of mild pre-eclampsia; if these symptoms appear, it is classified as severe. **High-Yield Clinical Pearls for NEET-PG:** * **Proteinuria:** In mild cases, it is $\geq$ 300 mg/24 hours or 1+ on dipstick. Massive proteinuria (> 5g) is no longer used to define severity in current ACOG guidelines, but is still frequently tested in exams. * **Edema:** Pedal edema is common in normal pregnancy and is **no longer** a diagnostic criterion for pre-eclampsia. * **The "Severe" Checklist:** BP $\geq$ 160/110, Platelets 1.1 mg/dL, or Pulmonary Edema.

Q: Which cardiac lesion in pregnant women has the worst prognosis?

Eisenmenger syndrome. ### Explanation **Eisenmenger Syndrome** is associated with the highest maternal mortality rate (30–50%), making it the cardiac lesion with the worst prognosis in pregnancy. **1. Why Eisenmenger Syndrome is the Correct Answer:** Eisenmenger syndrome involves a reversed (right-to-left) shunt due to severe pulmonary hypertension. During pregnancy, the systemic vascular resistance (SVR) naturally decreases. This drop in SVR exacerbates the right-to-left shunt, leading to profound hypoxemia, cyanosis, and sudden cardiovascular collapse. The most critical period is the **immediate postpartum phase**, where shifts in fluid and pressure can lead to fatal right-sided heart failure. **2. Why the Other Options are Incorrect:** * **Mitral Stenosis (A):** This is the most common rheumatic heart lesion in pregnancy. While it carries significant risk (especially of pulmonary edema due to tachycardia), the mortality rate is much lower (approx. 1–5% in NYHA Class I/II) compared to Eisenmenger. * **Coarctation of the Aorta (B):** While it poses risks like aortic dissection or rupture, it is generally manageable with strict blood pressure control. * **Tetralogy of Fallot (D):** If uncorrected, it carries risk, but if surgically corrected prior to pregnancy, women usually tolerate pregnancy well. Even uncorrected, the mortality is lower than in pulmonary hypertensive conditions. **3. NEET-PG High-Yield Pearls:** * **Absolute Contraindications to Pregnancy:** Eisenmenger syndrome, severe Pulmonary Arterial Hypertension (PAH), Marfan syndrome with aortic root dilation (>4cm), and severe symptomatic Aortic Stenosis. * **Most Common Heart Disease in Pregnancy:** Mitral Stenosis (Rheumatic). * **Most Common Congenital Heart Disease in Pregnancy:** ASD (Atrial Septal Defect). * **Highest Risk Period:** The third stage of labor and the first 48 hours postpartum (due to "autotransfusion" from the uterus).

Q: A 32-week pregnant female presents with sudden onset of painless vaginal bleeding. Ultrasonography reveals placenta previa. What is the expectant method of management for this patient?

Macafee & Johnson's method. **Explanation:** The correct answer is **C. Macafee & Johnson’s method.** In cases of placenta previa, the primary goal of management is to prolong the pregnancy until fetal lung maturity is achieved (ideally 37 weeks), provided the mother and fetus remain stable. This conservative approach is known as **Macafee & Johnson’s regimen**. It is indicated when the pregnancy is <37 weeks, bleeding is not life-threatening, and the fetus is alive and stable. The patient is kept on bed rest, monitored for further bleeding, and administered corticosteroids (e.g., Dexamethasone) to accelerate fetal lung maturity. **Analysis of Incorrect Options:** * **A. Brandt-Andrews method:** This is a technique used for the active management of the third stage of labor to deliver the placenta by applying controlled cord traction while guarding the uterus. * **B. Crede’s method:** An obsolete and potentially dangerous technique of delivering the placenta by squeezing the uterine fundus. It is no longer recommended due to the risk of uterine inversion. * **D. Liley’s regimen:** This refers to the **Liley Chart**, which was historically used to manage Rh-isoimmunization by plotting bilirubin levels in amniotic fluid (measured by $\Delta OD_{450}$) against gestational age. **Clinical Pearls for NEET-PG:** * **Cardinal Sign:** Painless, causeless, and recurrent vaginal bleeding is the hallmark of placenta previa. * **Contraindication:** A **digital vaginal examination (PV)** is strictly contraindicated in suspected placenta previa until the diagnosis is ruled out by USG, as it can provoke torrential hemorrhage (the "Stallworthy's sign"). * **Termination:** If the patient is >37 weeks or in active labor/distress, the Macafee regimen is abandoned in favor of delivery (usually Cesarean section).

Q: Clinical signs of hydramnios can be demonstrated when amniotic fluid collection is more than:

2 liters. **Explanation:** **1. Understanding the Correct Answer (B):** Hydramnios (Polyhydramnios) is defined pathologically as an amniotic fluid volume exceeding **2,000 ml (2 liters)**. While the normal volume at term is approximately 600–800 ml, clinical signs such as an overdistended abdomen, "fluid thrill," and difficulty palpating fetal parts typically manifest only when the volume crosses the **2-liter threshold**. In clinical practice, this is often diagnosed via ultrasound using an Amniotic Fluid Index (AFI) ≥ 25 cm or a Single Deepest Pocket (SDP) ≥ 8 cm. **2. Analysis of Incorrect Options:** * **A (1 liter):** While 1 liter is above the average volume at term, it is still within the physiological upper limit (up to 1.5 liters can be normal in some pregnancies). It does not meet the diagnostic criteria for polyhydramnios. * **C & D (3 and 4 liters):** These volumes represent severe polyhydramnios. While clinical signs are certainly present at these levels, the question asks for the minimum threshold at which hydramnios can be demonstrated, which is 2 liters. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Cause:** Idiopathic (approx. 50–60%). * **Maternal Cause:** Diabetes Mellitus is the most common maternal association. * **Fetal Causes:** Tracheoesophageal fistula, anencephaly (lack of swallowing/antidiuretic hormone), and fetal hydrops. * **Complications:** Preterm labor (due to uterine overdistension), Cord Prolapse (due to sudden rupture of membranes), and Postpartum Hemorrhage (PPH) due to uterine atony. * **Management:** Therapeutic amniocentesis (amnionreduction) or Indomethacin (decreases fetal urine output, but used with caution due to risk of premature closure of ductus arteriosus).

Q: Which of the following is true regarding accidental hemorrhage?

Uterus is tender. **Explanation:** **Accidental hemorrhage** is the clinical term for **Abruptio Placentae**, which refers to the premature separation of a normally situated placenta. **1. Why the correct answer is right:** In Abruptio Placentae, bleeding occurs between the uterine wall and the placenta. This leads to the formation of a retroplacental clot. The blood often infiltrates the myometrium (Couvelaire uterus), causing irritation and increased intrauterine pressure. This manifests clinically as **uterine tenderness** and a "woody hard" or board-like rigidity of the uterus on palpation. **2. Why the incorrect options are wrong:** * **Option A:** Bleeding in Abruptio Placentae is characteristically **painful**. Painless, causeless, and recurrent bleeding is the hallmark of *Placenta Previa*. * **Option C:** In the "concealed" or "mixed" variety of abruption, the retroplacental clot causes the **uterine size to be greater than the period of gestation**. * **Option D:** While fetal distress is common, fetal heart sounds (FHS) are **not always absent**. They may be present, irregular, or absent depending on the severity of the separation. FHS are typically absent only in severe (Grade 3) abruption. **Clinical Pearls for NEET-PG:** * **Risk Factors:** Pregnancy-induced hypertension (most common), trauma, sudden uterine decompression, and cocaine use. * **Classic Triad:** Painful vaginal bleeding + Uterine tenderness + Increased uterine tone. * **Complications:** DIC (Disseminated Intravascular Coagulation) is more common in abruption than in any other obstetric condition. * **Diagnosis:** Primarily clinical; Ultrasound is unreliable for ruling out abruption as it only detects about 25-50% of cases.

Q: Which of the following complications is NOT caused by malaria in pregnancy?

HELLP syndrome. **Explanation:** Malaria in pregnancy, particularly when caused by *Plasmodium falciparum*, leads to significant maternal and fetal morbidity due to **placental sequestration**. In this process, parasitized erythrocytes express ligands (like VAR2CSA) that bind to chondroitin sulfate A in the placenta. This triggers an inflammatory response, leading to placental insufficiency and vascular damage. **Why HELLP Syndrome is the Correct Answer:** HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe manifestation of the **preeclampsia spectrum**, primarily driven by abnormal trophoblastic invasion and generalized endothelial dysfunction. While malaria can cause hemolysis and thrombocytopenia, it does not etiologically cause the specific multi-organ triad of HELLP syndrome. **Why the other options are incorrect:** * **IUGR (Option B):** Placental sequestration of parasites leads to chronic placental insufficiency and nutrient deprivation, making IUGR one of the most common complications of malaria in pregnancy. * **IUD (Option C):** Severe maternal anemia, high-grade fever (hyperpyrexia), and acute placental damage can lead to fetal hypoxia and subsequent intrauterine death. * **Preterm Delivery (Option D):** The systemic inflammatory cytokine response (TNF-α, IL-1) triggered by malaria can stimulate uterine contractions, leading to spontaneous preterm labor. **High-Yield Clinical Pearls for NEET-PG:** * **Most common complication:** Maternal anemia and Low Birth Weight (LBW). * **Drug of Choice:** According to WHO/National guidelines, **Artesunate-based Combination Therapy (ACT)** is now recommended for uncomplicated malaria in all trimesters. **Quinine** is an alternative in the first trimester if ACT is unavailable. * **Prophylaxis:** Intermittent Preventive Treatment (IPTp) with Sulfadoxine-Pyrimethamine is recommended in endemic areas.

Q: What is the best time for detecting chorionicity in a twin pregnancy on ultrasound?

10-14 weeks. **Explanation:** Determining chorionicity is the most critical step in managing twin pregnancies, as monochorionic twins carry significantly higher risks (e.g., TTTS). The **best time for detecting chorionicity is 10–14 weeks** (late first trimester). **Why 10–14 weeks is the Correct Answer:** During this window, the ultrasound signs are most distinct. The presence of the **'Lambda' (λ) sign** (or twin-peak sign) indicates a dichorionic pregnancy, where the thick chorion projects into the base of the inter-twin membrane. Conversely, the **'T' sign** indicates a monochorionic pregnancy, where a thin amnion meets the placenta without intervening chorionic tissue. After 14 weeks, the chorion frondosum regresses, and the layers of the inter-twin membrane fuse, making these signs difficult to visualize. **Analysis of Incorrect Options:** * **A (8–12 weeks):** While chorionicity can be seen as early as 7–8 weeks by counting the number of gestational sacs, the definitive membrane signs (Lambda vs. T) are best visualized after 10 weeks when the amniotic sac has expanded. * **C & D (14–24 weeks):** Beyond 14 weeks, the "Lambda sign" often disappears (the "vanishing" Lambda sign) as the chorion laeve regresses. Accuracy drops significantly in the second trimester, often requiring less reliable methods like fetal sex or placental location. **High-Yield Clinical Pearls for NEET-PG:** * **Lambda Sign:** Dichorionic Diamniotic (DCDA). * **T Sign:** Monochorionic Diamniotic (MCDA). * **Gold Standard:** Ultrasound in the first trimester is the gold standard for chorionicity. * **Membrane Thickness:** A membrane >2 mm usually suggests DCDA; 13 days: Conjoined twins

Question 1

Which of the following is NOT a feature of mild pre-eclampsia?

Accepted Answer

Mild Intrauterine Growth Restriction (IUGR)

Answer

Diastolic BP < 100 mm Hg

Answer

Systolic BP < 160 mm Hg

Answer

No premonitory symptoms

Question 2

Which cardiac lesion in pregnant women has the worst prognosis?

Accepted Answer

Eisenmenger syndrome

Answer

Mitral stenosis

Answer

Co-arctation of aorta

Answer

Tetralogy of Fallot's

Question 3

A woman at 32 weeks of gestation presents with labor pains. On examination, her cervix is dilated and uterine contractions are palpable. What is the appropriate management?

Accepted Answer

Isoxsuprine hydrochloride

Answer

Dilatation and Evacuation

Answer

Termination of pregnancy

Answer

Wait and watch

Question 4

A 32-week pregnant female presents with sudden onset of painless vaginal bleeding. Ultrasonography reveals placenta previa. What is the expectant method of management for this patient?

Accepted Answer

Macafee & Johnson's method

Answer

Brand-Andrews method

Answer

Crede's method

Answer

Lilley's regimen

Question 5

In a nulliparous woman, what is the treatment of choice for a ruptured ectopic pregnancy?

Accepted Answer

Linear salpingostomy

Answer

Salpingectomy and end-to-end anastomosis

Answer

Salpingo-oophorectomy

Answer

Expectant management (Wait and watch)

Question 6

A 32-week-pregnant woman with a history of two previous mid-trimester abortions presents with regular uterine contractions. The cervix is 2 cm dilated. All the following are done except?

Accepted Answer

Emergency encirclage

Answer

Tocolytics

Answer

Dexamethasone

Answer

Antibiotics

Question 7

Clinical signs of hydramnios can be demonstrated when amniotic fluid collection is more than:

Accepted Answer

2 liters

Answer

1 liter

Answer

3 liters

Answer

4 liters

Question 8

Which of the following is true regarding accidental hemorrhage?

Accepted Answer

Uterus is tender

Answer

Painless bleeding per vagina

Answer

Uterine size is less than period of gestation

Answer

Fetal heart sounds are always absent

Question 9

Which of the following complications is NOT caused by malaria in pregnancy?

Accepted Answer

HELLP syndrome

Answer

Intrauterine growth restriction (IUGR)

Answer

Intrauterine death (IUD)

Answer

Preterm delivery

Question 10

What is the best time for detecting chorionicity in a twin pregnancy on ultrasound?

Accepted Answer

10-14 weeks

Answer

8-12 weeks

Answer

14-18 weeks

Answer

16-24 weeks

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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