Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 361: Which of the following is a delayed complication of massive bleeding secondary to placenta previa?

A. Menorrhagia
B. Galactorrhea
C. Diabetes insipidus (Correct Answer)
D. Cushing disease

Explanation: **Explanation:** The correct answer is **Diabetes insipidus**. This question tests your understanding of **Sheehan Syndrome** (Postpartum Pituitary Necrosis), a classic complication of massive obstetric hemorrhage. **Why Diabetes Insipidus is correct:** Massive bleeding secondary to placenta previa can lead to severe hypotension and hypovolemic shock. During pregnancy, the pituitary gland enlarges (hypertrophies), making it highly susceptible to ischemia if blood pressure drops significantly. While Sheehan syndrome most commonly affects the **anterior pituitary** (causing deficiencies in GH, LH/FSH, ACTH, and TSH), severe cases can involve the **posterior pituitary** or the hypothalamus, leading to a deficiency in Antidiuretic Hormone (ADH). This results in **Central Diabetes Insipidus**, characterized by polyuria and polydipsia. **Why the other options are incorrect:** * **Menorrhagia:** Sheehan syndrome typically causes **amenorrhea** or oligomenorrhea due to the loss of gonadotropins (FSH/LH), not heavy bleeding. * **Galactorrhea:** The most common initial sign of Sheehan syndrome is **failure to lactate** (agalactia) due to prolactin deficiency. Galactorrhea (excessive milk production) is not associated with pituitary necrosis. * **Cushing Disease:** This is caused by an ACTH-secreting pituitary adenoma (excess). Sheehan syndrome causes **secondary adrenal insufficiency** (deficiency) due to the destruction of ACTH-producing cells. **Clinical Pearls for NEET-PG:** * **Earliest sign of Sheehan Syndrome:** Failure to lactate/breastfeed in the immediate postpartum period. * **Most common long-term sign:** Secondary amenorrhea and loss of pubic/axillary hair. * **Diagnosis:** Growth Hormone (GH) deficiency is often the earliest hormonal loss, but the clinical diagnosis is confirmed via MRI (showing an "Empty Sella" in late stages) and dynamic hormonal testing.

Question 362: Highest maternal mortality is seen in which of the following congenital heart diseases?

A. Eisenmenger's syndrome (Correct Answer)
B. Pulmonary stenosis
C. Coarctation of aorta
D. Ventricular septal defect (VSD)

Explanation: **Explanation:** **Eisenmenger’s Syndrome** is associated with the highest maternal mortality rate among congenital heart diseases (CHD), ranging from **30% to 50%**. 1. **Why it is the correct answer:** Eisenmenger’s syndrome involves a long-standing left-to-right shunt that leads to severe pulmonary hypertension and eventual shunt reversal (right-to-left). During pregnancy, the normal physiological decrease in systemic vascular resistance (SVR) exacerbates the right-to-left shunt, leading to profound hypoxemia, cyanosis, and heart failure. The most critical period is the **immediate postpartum phase**, where sudden hemodynamic shifts often lead to cardiovascular collapse. 2. **Why the other options are incorrect:** * **Pulmonary Stenosis (B):** Generally well-tolerated in pregnancy unless the stenosis is severe. Mortality is low. * **Coarctation of Aorta (C):** While it carries risks like aortic dissection or rupture, the mortality rate (approx. 3-9%) is significantly lower than Eisenmenger’s. * **Ventricular Septal Defect (D):** Small to moderate VSDs are usually well-tolerated. It only becomes high-risk if it progresses to Eisenmenger’s syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Class IV (Pregnancy Contraindicated):** Includes Eisenmenger’s syndrome, severe Pulmonary Arterial Hypertension (PAH), severe systemic ventricular dysfunction (EF <30%), and severe symptomatic mitral/aortic stenosis. * **Most common CHD in pregnancy:** Atrial Septal Defect (ASD). * **Most common heart disease in pregnancy (India):** Rheumatic Heart Disease (Mitral Stenosis is the most common lesion). * **Management:** Termination of pregnancy is usually advised in the first trimester for Eisenmenger's patients due to the extreme mortality risk.

Question 363: What is the risk of neural tube defect in a child if either parent was born with spina bifida?

A. 3%
B. 5% (Correct Answer)
C. 10%
D. 15%

Explanation: **Explanation:** **1. Why Option B (5%) is correct:** Neural Tube Defects (NTDs) follow a **multifactorial inheritance** pattern, meaning they result from a combination of multiple genetic predispositions and environmental factors (like folic acid deficiency) [1]. In multifactorial inheritance, the recurrence risk is directly related to the degree of kinship [1]. If a **first-degree relative** (a parent or a previous sibling) is affected by an NTD, the risk for the offspring increases significantly from the general population risk (0.1%) to approximately **3–5%**. Standard textbooks and clinical guidelines for PG entrance exams cite 4–5% as the specific risk when one parent is affected. **2. Why other options are incorrect:** * **Option A (3%):** While 3% is sometimes cited as the lower end of the range for a previous sibling, 5% is the more definitive "high-yield" figure used in examinations for a parent or one sibling. * **Option C (10%):** This risk level is typically seen if **two** previous siblings are affected, or if one parent and one sibling are affected. * **Option D (15%):** This is an overestimation for a single first-degree relative. Risks this high are generally not seen in multifactorial inheritance unless there is a very strong family clustering (three or more affected first-degree relatives). **3. Clinical Pearls for NEET-PG:** * **Folic Acid Prophylaxis:** For the general population, the dose is **400 mcg (0.4 mg)** daily [2]. * **High-Risk Dose:** For women with a previous child with NTD or if either parent has an NTD, the dose is increased to **4 mg (4000 mcg)** daily, started at least 1 month (ideally 3 months) before conception through the first trimester. * **Screening:** Maternal Serum Alpha-Fetoprotein (MSAFP) is measured at **15–20 weeks**; elevated levels (>2.5 MoM) suggest an open NTD [3].

Question 364: Of all the risk factors for ectopic pregnancy, which one is the commonest?

A. Intrauterine contraceptive device (IUCD)
B. Previous surgery for ectopic pregnancy (Correct Answer)
C. Infertility
D. Pelvic inflammatory disease

Explanation: **Explanation:** The risk factors for ectopic pregnancy are categorized into high, moderate, and low risk. Understanding the distinction between the **highest risk** (odds ratio) and the **most common** risk factor is crucial for NEET-PG. **1. Why "Previous surgery for ectopic pregnancy" is correct:** A history of ectopic pregnancy is the strongest predictor for a recurrence. Once a woman has had one ectopic pregnancy, the risk of a repeat event increases significantly (approximately 10-fold). If a patient has had two or more previous ectopic pregnancies, the risk rises to over 25%. This is due to underlying tubal damage or permanent alterations in ciliary function and tubal motility. **2. Analysis of Incorrect Options:** * **Pelvic Inflammatory Disease (PID):** While PID is the most common **preceding infection** associated with ectopic pregnancy (due to salpingitis and tubal scarring), statistically, a prior history of ectopic pregnancy carries a higher relative risk. * **Intrauterine Contraceptive Device (IUCD):** IUCDs do not *cause* ectopic pregnancy; they are highly effective at preventing all pregnancies. However, if a woman becomes pregnant with an IUCD in situ, the *proportion* of those pregnancies being ectopic is higher. * **Infertility:** Infertility and its treatments (like IVF) are moderate risk factors. While IVF increases the risk of heterotopic pregnancy, it is not the commonest risk factor compared to prior tubal pathology. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Ampulla (70%). * **Most common site for rupture:** Isthmus (due to narrow lumen). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serial β-hCG (Discriminatory zone: 1500–2000 mIU/mL). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on biopsy, which is suggestive but not diagnostic of ectopic pregnancy.

Question 365: Which of the following is true regarding placenta previa?

A. Incidence increases twofold after LSCS. (Correct Answer)
B. It is more common in primipara.
C. It is most common in developed countries.
D. The incidence is 1 per 1000 pregnancies.

Explanation: **Explanation:** **1. Why Option A is Correct:** The single most significant risk factor for placenta previa is a **previous Cesarean Section (LSCS)**. The presence of a uterine scar interferes with the normal upward migration of the placenta as the lower uterine segment develops. Studies indicate that the risk of placenta previa increases approximately **twofold** after one LSCS (incidence ~1%) and continues to rise linearly with each subsequent surgery. **2. Why the Other Options are Incorrect:** * **Option B:** Placenta previa is more common in **multipara** (especially grand multipara) than in primipara. Increasing parity is a well-documented risk factor due to cumulative endometrial changes. * **Option C:** There is no significant geographical predilection for developed countries. Risk is primarily driven by clinical factors like advanced maternal age, smoking, and surgical history, which are global issues. * **Option D:** The incidence of placenta previa is approximately **1 in 200 (0.5%)** pregnancies, not 1 in 1000. **3. High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** Painless, causeless, recurrent, bright red vaginal bleeding in the third trimester. * **Stallworthy’s Sign:** A dip in the fetal heart rate when the head is pressed into the pelvic inlet, suggestive of posterior placenta previa. * **Diagnosis:** **Transvaginal Ultrasound (TVS)** is the gold standard (more accurate than transabdominal). * **Contraindication:** **Digital vaginal examination** is strictly contraindicated unless the patient is in the operation theater prepared for an immediate Cesarean (Double Setup Examination), as it can provoke torrential hemorrhage. * **Associated Condition:** Always screen for **Placenta Accreta Spectrum** in patients with a previous LSCS and an overlying placenta previa.

Question 366: Which of the following is NOT a risk factor for preeclampsia?

A. Antiphospholipid syndrome
B. Obesity
C. Previous history of preeclampsia
D. Multigravida (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Multigravida** **1. Why Multigravida is the Correct Answer:** Preeclampsia is classically a disease of **primigravidae** (first-time mothers). The underlying pathophysiology involves an immune maladaptation to paternal antigens during the first exposure. Being a **multigravida** (especially with the same partner) is actually a **protective factor**, as the maternal immune system has been previously "sensitized" to fetal/placental antigens, reducing the risk of placental dysfunction. **2. Why the Other Options are Wrong (Risk Factors):** * **A. Antiphospholipid Syndrome (APS):** This is one of the strongest high-risk factors. It causes a prothrombotic state and defective trophoblastic invasion, leading to placental ischemia. * **B. Obesity:** A BMI >30 kg/m² is a significant risk factor. Obesity is associated with chronic inflammation and insulin resistance, which trigger endothelial dysfunction—the hallmark of preeclampsia. * **C. Previous History of Preeclampsia:** This is the single most important predictor. A woman with a history of preeclampsia has a 7-10x higher risk of recurrence in subsequent pregnancies. **3. High-Yield Clinical Pearls for NEET-PG:** * **The "New Partner" Rule:** If a multigravida has a child with a **new partner**, her risk resets to that of a primigravida (due to new paternal antigens). * **High-Risk Factors (Aspirin Indicated):** History of preeclampsia, Chronic Hypertension, Type 1 or 2 Diabetes, Renal disease, and Autoimmune diseases (SLE/APS). * **Moderate Risk Factors:** Nulliparity, Obesity, Family history (mother/sister), Age ≥35, and Multifetal gestation. * **Prophylaxis:** Low-dose Aspirin (75–150 mg) started before 16 weeks of gestation is recommended for women with high-risk factors.

Question 367: Maternal mortality is maximum in which period?

A. Antenatal period
B. Perinatal period (Correct Answer)
C. Postnatal period
D. None of the above

Explanation: **Explanation:** The **Perinatal period** (specifically the time around labor and the first 24 hours postpartum) is the most critical window for maternal survival. This is because the physiological stress of labor, sudden hemodynamic shifts, and the risk of acute complications like Postpartum Hemorrhage (PPH), eclampsia, and amniotic fluid embolism are at their peak during this timeframe. Statistically, the majority of maternal deaths occur within 24 to 48 hours of delivery. * **Antenatal period (Option A):** While complications like ectopic pregnancy or pre-eclampsia can occur, they are generally less acutely fatal than the events surrounding delivery. * **Postnatal period (Option C):** Although the postpartum period (up to 42 days) accounts for a significant portion of maternal mortality, the risk is highest in the immediate 24 hours (the perinatal/intranatal window) and tapers off significantly as the weeks progress. * **Perinatal period (Option B):** This is the correct choice as it encompasses the most hazardous hours of a woman's life—labor and the immediate aftermath of birth. **High-Yield Facts for NEET-PG:** * **Most common cause of Maternal Mortality (India & Global):** Postpartum Hemorrhage (PPH). * **Most common cause of Indirect Maternal Mortality:** Anemia (followed by Heart Disease). * **Maternal Mortality Ratio (MMR):** Calculated per 100,000 live births. * **The "4th Stage of Labor":** The first hour after delivery is the most critical for monitoring PPH.

Question 368: All of the following are obstetric clinical criteria for the diagnosis of Antiphospholipid Antibody Syndrome except:

A. One or more unexplained deaths of a morphologically normal fetus at or beyond 10 weeks gestation.
B. Severe preeclampsia or placental insufficiency necessitating delivery before 34 weeks.
C. Three or more unexplained consecutive abortions before 10 weeks gestation.
D. One or more episodes of arterial, venous, or small vessel thrombosis in any tissue or organ. (Correct Answer)

Explanation: To diagnose **Antiphospholipid Antibody Syndrome (APS)**, clinicians use the **Revised Sapporo Criteria**, which require at least one clinical criterion and one laboratory criterion (presence of Lupus anticoagulant, Anticardiolipin, or Anti-β2-glycoprotein I antibodies). ### Why Option D is the Correct Answer The question asks for the **obstetric** clinical criteria. While "one or more episodes of arterial, venous, or small vessel thrombosis" is indeed a clinical criterion for APS, it is classified as a **Vascular criterion**, not an obstetric one. In the context of a NEET-PG question focusing specifically on obstetric criteria, this distinction is vital. ### Analysis of Obstetric Criteria (Incorrect Options) The following are the three specific obstetric criteria; if any are present, the clinical arm of the diagnosis is met: * **Option A:** One or more unexplained deaths of a morphologically normal fetus at or beyond **10 weeks** gestation. * **Option B:** One or more premature births of a morphologically normal neonate before **34 weeks** gestation due to severe preeclampsia, eclampsia, or placental insufficiency. * **Option C:** Three or more unexplained consecutive spontaneous abortions before **10 weeks** gestation (excluding maternal anatomic/hormonal or paternal/maternal chromosomal causes). ### High-Yield Clinical Pearls for NEET-PG * **Laboratory Timing:** Antibodies must be present on two or more occasions, at least **12 weeks apart**. * **Treatment in Pregnancy:** The standard of care is **Low-Dose Aspirin (LDA) + Prophylactic Low Molecular Weight Heparin (LMWH)**. Warfarin is contraindicated in pregnancy due to teratogenicity (except in some cases of mechanical heart valves). * **Most Specific Test:** Lupus Anticoagulant is the strongest predictor of pregnancy loss among the three antibodies.

Question 369: Intrahepatic cholestasis of pregnancy typically occurs in which trimester?

A. First trimester
B. Second trimester
C. Third trimester (Correct Answer)
D. Postpartum period

Explanation: **Explanation:** **Intrahepatic Cholestasis of Pregnancy (ICP)** is a reversible type of hormone-influenced cholestasis. The correct answer is the **Third Trimester** because this is when serum estrogen and progesterone levels reach their peak. High levels of estrogen (specifically estriol) and progesterone metabolites interfere with the transport of bile acids across the canalicular membrane, leading to their accumulation in the systemic circulation. * **Why Third Trimester is Correct:** Approximately 80% of cases occur after 30 weeks of gestation. The increasing hormonal load and the stretching of the gallbladder lead to decreased bile flow (cholestasis). * **Why other options are incorrect:** * **First Trimester:** Hormonal levels are not yet high enough to cause significant cholestasis. * **Second Trimester:** While possible in late second trimester, it is statistically much less common than the third. * **Postpartum:** ICP is characterized by the **rapid resolution** of symptoms (usually within 48 hours) after delivery as hormone levels plummet. **Clinical Pearls for NEET-PG:** 1. **Hallmark Symptom:** Pruritus, which is typically worse at night and characteristically involves the **palms and soles**. There is **no primary rash**. 2. **Diagnostic Gold Standard:** Elevated **Total Serum Bile Acids (TSBA)** >10 µmol/L. 3. **Fetal Risk:** Increased risk of sudden intrauterine fetal death (IUFD), meconium-stained liquor, and preterm labor. 4. **Management:** **Ursodeoxycholic Acid (UDCA)** is the drug of choice to reduce pruritus and improve biochemical parameters. Delivery is usually recommended by 37–38 weeks to prevent stillbirth.

Question 370: IUGR is defined when:

A. Birth weight is below the tenth percentile for the gestational age (Correct Answer)
B. Birth weight is below the 20th percentile for the gestational age
C. Birth weight is below the 30th percentile for the gestational age
D. Weight of baby is less than 1000 gm

Explanation: **Explanation:** Intrauterine Growth Restriction (IUGR), often used interchangeably with Small for Gestational Age (SGA) in clinical practice, is defined as a **birth weight below the 10th percentile** for a specific gestational age. This definition is based on standardized growth curves (like the Hadlock or Fenton charts) that account for the baby's maturity at birth. **Why the correct answer is right:** * **Option A:** The 10th percentile is the globally accepted statistical cutoff. It identifies neonates who have failed to achieve their biological growth potential due to maternal, placental, or fetal factors. These infants are at a significantly higher risk for perinatal morbidity (hypoglycemia, hypothermia, polycythemia) and mortality. **Why the incorrect options are wrong:** * **Options B & C:** The 20th and 30th percentiles are too broad. Using these cutoffs would over-diagnose IUGR, including many constitutionally small but otherwise healthy babies, leading to unnecessary medical interventions. * **Option D:** A weight of less than 1000g defines an **Extremely Low Birth Weight (ELBW)** infant, regardless of gestational age. While an ELBW baby may be growth-restricted, the definition of IUGR is relative to gestational age, not an absolute weight. **High-Yield Clinical Pearls for NEET-PG:** * **Symmetry:** IUGR is classified into **Type I (Symmetrical)**, caused by early insults like chromosomal anomalies or TORCH infections, and **Type II (Asymmetrical)**, usually caused by placental insufficiency (e.g., Preeclampsia) where "head-sparing" occurs. * **Diagnosis:** The most sensitive clinical parameter is **Symphysio-fundal height (SFH)**; a lag of >3 cm suggests IUGR. * **Gold Standard Monitoring:** **Umbilical Artery Doppler** is the best tool to monitor fetal well-being in IUGR. Absent or reversed end-diastolic flow (AREDF/REDF) indicates critical fetal distress.

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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