Maternal-Fetal Medicine Practice Questions

Q: A woman treated for infertility presents with 6 weeks of amenorrhea and urinary retention. What is the most likely etiology?

Impacted cervical fibroid. **Explanation:** The clinical presentation of **6 weeks of amenorrhea** (suggestive of early pregnancy) combined with **acute urinary retention** is a classic triad seen when a pelvic mass becomes "impacted" in the pouch of Douglas, displacing the cervix anteriorly. **1. Why "Impacted Cervical Fibroid" is correct:** In a woman being treated for infertility, a pre-existing cervical or low-lying posterior wall fibroid is common. As the uterus enlarges during early pregnancy (around 6–10 weeks), the fibroid can become incarcerated in the hollow of the sacrum. This pushes the cervix upward and forward against the symphysis pubis, stretching the urethra and compressing the bladder neck, leading to acute urinary retention. **2. Analysis of Incorrect Options:** * **Retroverted Uterus:** While an incarcerated gravid retroverted uterus is a classic cause of urinary retention at 12–14 weeks, it is less likely at only 6 weeks, as the uterus is not yet large enough to fill the pelvic cavity and cause impaction. * **Pelvic Hematocoele:** Usually associated with a ruptured ectopic pregnancy. While it causes pelvic pain and shock, it rarely presents with acute urinary retention as the primary symptom. * **Carcinoma Cervix:** While it can cause urinary symptoms through direct invasion (ureteric obstruction), it typically presents with post-coital bleeding or discharge in older women, not acute retention and amenorrhea in an infertility patient. **Clinical Pearls for NEET-PG:** * **The "12-week rule":** Retroverted gravid uterus typically causes retention at **12–14 weeks** when the fundus gets stuck under the sacral promontory. * **Mechanism:** Retention is due to the **elongation of the urethra** and compression of the bladder neck, not direct pressure on the bladder itself. * **Management:** Immediate catheterization followed by manual correction of the uterine position (if retroverted).

Q: Theca-lutein cysts are characteristic of which condition?

Molar pregnancy. **Explanation:** **Theca-lutein cysts** are functional ovarian cysts that occur due to supraphysiological stimulation of the ovaries by high levels of **human chorionic gonadotropin (hCG)**. 1. **Why Molar Pregnancy is Correct:** In Hydatidiform mole (molar pregnancy) and Choriocarcinoma, there is a massive proliferation of trophoblastic tissue leading to extremely high serum hCG levels. hCG shares a common alpha-subunit with LH; at high concentrations, it mimics LH action, causing luteinization and cystic enlargement of the theca interna cells. These cysts are typically bilateral, multiloculated, and regress spontaneously once the source of hCG is removed (e.g., suction evacuation). 2. **Why Other Options are Incorrect:** * **Ectopic Pregnancy:** While hCG is present, the levels are usually lower than in a normal intrauterine pregnancy, making theca-lutein cysts highly unlikely. * **Missed Abortion:** In this condition, the products of conception have died, and hCG levels are rapidly declining, which would not provide the stimulus needed for cyst formation. * **Preeclampsia:** This is a hypertensive disorder of pregnancy. While it can be associated with large placentas (like in twins or moles), it is not the primary cause of theca-lutein cysts. **High-Yield NEET-PG Pearls:** * **Hyperreactio Luteinalis:** This is the term used when theca-lutein cysts occur in a normal singleton pregnancy (rare). * **Associations:** Apart from molar pregnancy, these cysts are seen in **Multiple gestations**, **Rh-isoimmunization**, and **Ovulation induction** (Ovarian Hyperstimulation Syndrome). * **Management:** They are benign and usually managed **conservatively**. Surgery is only indicated in cases of torsion or rupture with hemorrhage.

Q: An obstetrician sees a pregnant patient who was exposed to rubella virus at eighteen weeks of pregnancy. She does not remember getting a rubella vaccination. What is the best immediate course of action?

Order a rubella antibody titer to determine immune status. **Explanation:** The management of rubella exposure in pregnancy depends on the mother’s immune status and the gestational age at exposure. **Why Option B is Correct:** The immediate priority is to determine if the mother is already immune. A **Rubella IgG antibody titer** should be ordered. If the patient is IgG positive, she is immune, and the fetus is at no risk. If she is IgG negative (susceptible), a second sample is taken 2–3 weeks later to check for seroconversion (IgM or rising IgG), which would indicate an acute infection. **Why Other Options are Incorrect:** * **Option A:** Termination is not indicated without confirming maternal infection and assessing fetal risk. Furthermore, the risk of **Congenital Rubella Syndrome (CRS)** decreases significantly after 16 weeks; exposure at 18 weeks carries a much lower risk (approx. 10–15%) compared to the first trimester. * **Option C:** This is factually incorrect. Rubella is most dangerous in the **first trimester** (up to 85% risk of CRS). While the risk decreases after 16 weeks, it does not become "not a problem" specifically after 30 weeks. * **Option D:** The rubella vaccine is a **Live Attenuated Vaccine (RA 27/3 strain)** and is strictly **contraindicated during pregnancy** due to the theoretical risk of fetal infection. **High-Yield Clinical Pearls for NEET-PG:** * **Gregg’s Triad (CRS):** Cataracts, Sensorineural hearing loss (most common), and Cardiac defects (PDA/Peripheral Pulmonary Artery Stenosis). * **Vaccination Timing:** If a woman is found to be non-immune during pregnancy, she should be vaccinated in the **immediate postpartum period**. She must avoid pregnancy for **28 days (1 month)** after vaccination. * **Diagnosis:** The presence of **Rubella IgM** in a newborn is diagnostic of congenital infection, as IgM does not cross the placenta.

Q: Which one of the following is categorized as a high-risk pregnancy?

Twins pregnancy. **Explanation:** A **high-risk pregnancy** is defined as one in which the mother, the fetus, or the newborn is at an increased risk of morbidity or mortality due to factors complicating the pregnancy. **Why "Twins Pregnancy" is Correct:** Multiple gestations (twins, triplets, etc.) are inherently high-risk because they significantly increase the risk of both maternal and fetal complications. * **Maternal risks:** Preeclampsia (3x higher risk), gestational diabetes, anemia, and postpartum hemorrhage (due to uterine overdistension). * **Fetal risks:** Preterm birth (the most common complication), intrauterine growth restriction (IUGR), malpresentation, and specific risks like Twin-to-Twin Transfusion Syndrome (TTTS) in monochorionic twins. **Analysis of Incorrect Options:** * **Birth order 3:** Generally, the "Grand Multipara" (Para 4 or more) is considered high-risk due to risks of placenta previa, malpresentation, and atonic PPH. A third pregnancy is typically considered a "safe" parity. * **Maternal height 150 cm:** In the Indian context, a "short-statured" mother is defined as having a height **<145 cm** (or 140 cm in some guidelines). 150 cm is above the threshold for increased risk of Cephalopelvic Disproportion (CPD). * **Blood group AB positive:** This is the "universal recipient" and does not pose an immunological risk. High-risk blood groups include **Rh-negative** (risk of isoimmunization) or rare blood groups where cross-matching may be difficult during emergencies. **NEET-PG High-Yield Pearls:** * **Primi-elderly:** Age >30 years (some texts say >35). * **Short Stature:** Height <145 cm (associated with contracted pelvis). * **Anemia in Pregnancy:** Hb <11 g/dL (WHO). * **Previous LSCS:** Always categorized as high-risk due to the risk of scar dehiscence or morbidly adherent placenta.

Q: An Rh-negative woman married to a heterozygous Rh-positive man has three children. What is the probability that all three of their children are Rh-positive?

1:8. ### Explanation **1. Why the Correct Answer (C) is Right:** The inheritance of the Rh factor follows Mendelian genetics. In this scenario: * **Mother:** Rh-negative (Genotype: **dd**) * **Father:** Heterozygous Rh-positive (Genotype: **Dd**) Using a Punnett square for each pregnancy: * Possible offspring genotypes: **Dd** (Rh-positive) or **dd** (Rh-negative). * The probability of having an Rh-positive child in **each** pregnancy is **1/2 (50%)**. Since each pregnancy is an independent event, the probability of all three children being Rh-positive is calculated using the multiplication rule: **1/2 (1st child) × 1/2 (2nd child) × 1/2 (3rd child) = 1/8.** **2. Why Other Options are Wrong:** * **Option A (1:2):** This is the probability for a *single* child to be Rh-positive, not all three. * **Option B (1:4):** This would be the probability if only *two* children were Rh-positive. * **Option D (Zero):** This would only be possible if the father were also Rh-negative (dd). **3. Clinical Pearls for NEET-PG:** * **Rh Incompatibility:** Occurs only when the mother is Rh-negative and the fetus is Rh-positive. * **Homozygous Father:** If the father were homozygous Rh-positive (DD), **100%** of the children would be Rh-positive. * **Anti-D Prophylaxis:** Administered at 28 weeks of gestation and within 72 hours of delivery to prevent sensitization. * **Kleihauer-Betke Test:** Used to quantify fetal-maternal hemorrhage to determine the required dose of Rh-immunoglobulin. * **Critical Titer:** An Indirect Coombs Test (ICT) titer of **1:16** is generally considered the critical threshold requiring further fetal surveillance (e.g., MCA-PSV Doppler).

Q: A pregnant woman at 18 weeks gestation is found to have an abdominal pregnancy with the fetus and placenta attached to the omentum. What is the best course of action?

Removal of the fetus only. **Explanation:** In abdominal pregnancy, the management of the placenta is the most critical decision. Unlike an intrauterine pregnancy, there is no uterine contraction to constrict blood vessels after placental separation. **Why "Removal of the fetus only" is correct:** When the placenta is attached to a highly vascular or vital organ (like the omentum, bowel, or large vessels), attempting to remove it can lead to **uncontrollable, life-threatening hemorrhage**. The standard surgical recommendation is to ligate the umbilical cord close to the placenta and leave the placenta *in situ*. The placenta will eventually undergo spontaneous resorption, a process that can be monitored using serial β-hCG levels and ultrasound. **Analysis of Incorrect Options:** * **Option A:** Removing the placenta carries a high risk of massive bleeding because the site lacks the "living ligatures" (myometrial fibers) found in the uterus. * **Option B:** While the cord is ligated, the fetus must be removed to prevent infection, lithopedion formation, or maternal inflammatory response. Ligation alone is insufficient. * **Option C:** Waiting for viability is extremely dangerous. Abdominal pregnancies are associated with high maternal mortality (up to 7-8 times higher than tubal ectopic) and a high risk of sudden placental abruption or organ rupture. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Suggested by "painful fetal movements," easily palpable fetal parts, and an empty uterus on ultrasound. * **Placental Management:** If the placenta is left behind, **Methotrexate** is generally **avoided** as it causes rapid placental necrosis, leading to infection and abscess formation. * **Classification:** Primary abdominal pregnancy (rare) vs. Secondary (more common, usually following tubal abortion/rupture). * **Criteria:** Studdiford’s Criteria are used to diagnose primary abdominal pregnancy.

Q: A primigravida at 37 weeks of gestation presents with central placenta previa and heavy vaginal bleeding. The fetal heart rate is normal. What is the best management option for this patient?

Cesarean section. **Explanation:** The management of placenta previa is guided by the degree of placenta encroachment on the internal os and the clinical stability of the mother and fetus. **Why Option B is Correct:** In **central (Type IV/Total) placenta previa**, the placenta completely covers the internal cervical os. Vaginal delivery is physically impossible because the placenta precedes the fetus; any cervical dilation will cause massive, life-threatening maternal hemorrhage. Furthermore, the patient is at **37 weeks (term)** and presenting with **heavy bleeding**. At term, the goal is delivery. Even if the fetal heart rate is currently normal, the severity of the bleeding in a central previa necessitates an immediate **Cesarean section** to save the mother and the fetus. **Why Other Options are Incorrect:** * **Option A:** Expectant management (Macafee-Johnson protocol) is only indicated if the fetus is preterm (<37 weeks), the bleeding is mild/settled, and there is no fetal distress. This patient is at term with heavy bleeding. * **Options C & D:** Induction of labor and vaginal delivery are contraindicated in central placenta previa. Attempting vaginal delivery would lead to catastrophic hemorrhage. Vaginal delivery is only considered in low-lying placenta (Type I) or some cases of marginal previa (Type II anterior) where the head can compress the placental edge. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) is safer and more accurate than transabdominal ultrasound for locating the placenta. * **Vaginal Examination:** A "per-vaginal" (PV) examination is **strictly contraindicated** in suspected placenta previa (can cause torrential hemorrhage) unless performed as a "Double Setup Examination" in the OT. * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pressed into the pelvis, seen in posterior placenta previa.

Question 1

What is the most common type of heart disease encountered in pregnancy?

Accepted Answer

Mitral Stenosis (MS)

Answer

Atrial Septal Defect (ASD)

Answer

Ventricular Septal Defect (VSD)

Answer

Mitral Regurgitation (MR)

Question 2

A woman treated for infertility presents with 6 weeks of amenorrhea and urinary retention. What is the most likely etiology?

Accepted Answer

Impacted cervical fibroid

Answer

Retroverted uterus

Answer

Pelvic hematocoele

Answer

Carcinoma cervix

Question 3

In the Manning scoring system of biophysical profile for fetal monitoring, which parameter is not included?

Accepted Answer

Oxytocin challenge test

Answer

Fetal tone

Answer

Fetal gross body movements

Answer

Non-stress test

Question 4

Congenital anomalies are most severe in which of the following infections?

Accepted Answer

Rubella infection

Answer

Mumps

Answer

Cytomegalovirus (CMV)

Answer

Toxoplasma

Question 5

Theca-lutein cysts are characteristic of which condition?

Accepted Answer

Molar pregnancy

Answer

Ectopic pregnancy

Answer

Missed abortion

Answer

Preeclampsia

Question 6

An obstetrician sees a pregnant patient who was exposed to rubella virus at eighteen weeks of pregnancy. She does not remember getting a rubella vaccination. What is the best immediate course of action?

Accepted Answer

Order a rubella antibody titer to determine immune status

Answer

Terminate the pregnancy

Answer

Reassure the patient because rubella is not a problem until after the thirtieth week

Answer

Administer rubella vaccine

Question 7

Which one of the following is categorized as a high-risk pregnancy?

Accepted Answer

Twins pregnancy

Answer

Birth order 3

Answer

Maternal height 150 cm

Answer

Blood group AB positive

Question 8

An Rh-negative woman married to a heterozygous Rh-positive man has three children. What is the probability that all three of their children are Rh-positive?

Accepted Answer

1:8

Answer

1:2

Answer

1:4

Answer

Zero

Question 9

A pregnant woman at 18 weeks gestation is found to have an abdominal pregnancy with the fetus and placenta attached to the omentum. What is the best course of action?

Accepted Answer

Removal of the fetus only

Answer

Removal of both fetus and placenta

Answer

Laparoscopic ligation of umbilical cord

Answer

Close follow-up until viability and then delivery by laparotomy

Question 10

A primigravida at 37 weeks of gestation presents with central placenta previa and heavy vaginal bleeding. The fetal heart rate is normal. What is the best management option for this patient?

Accepted Answer

Cesarean section

Answer

Expectant management

Answer

Induction and vaginal delivery

Answer

Induction and forceps delivery

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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