Maternal-Fetal Medicine — MCQs

A 25-year-old primigravida delivered an infant with clubfoot. During her pregnancy, she was diagnosed with oligohydramnios and did not receive proper care. She was also taking certain medications during pregnancy. Which of the following medications is most likely to have caused oligohydramnios in this patient?

Q380Medium

What is a potential consequence for a child born to a mother with phenylketonuria?

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 371: Which of the following medications does NOT affect the fetus?

A. Lytic cocktail
B. Magnesium sulfate (Correct Answer)
C. Warfarin
D. Phenytoin

Explanation: **Explanation:** The correct answer is **Magnesium Sulfate (MgSO₄)**. In the context of obstetric pharmacology, MgSO₄ is the drug of choice for seizure prophylaxis in pre-eclampsia and management of eclampsia. It is considered safe for the fetus because it does not have teratogenic effects. While it crosses the placenta, it typically only causes minor, transient neonatal effects (such as decreased heart rate variability or mild hypotonia) at therapeutic levels. It is also used for **fetal neuroprotection** in preterm births <32 weeks. **Why the other options are incorrect:** * **Lytic Cocktail (Pethidine, Chlorpromazine, Promethazine):** Historically used for eclampsia, these drugs cross the placenta and cause significant **neonatal respiratory depression** and sedation. * **Warfarin:** A potent teratogen. Exposure during the first trimester (6–9 weeks) leads to **Fetal Warfarin Syndrome** (stippled epiphyses, nasal hypoplasia). In later trimesters, it can cause fetal intracranial hemorrhage. * **Phenytoin:** An anticonvulsant associated with **Fetal Hydantoin Syndrome**, characterized by craniofacial anomalies (cleft lip/palate), phalangeal hypoplasia, and growth retardation. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic range of MgSO₄:** 4–7 mEq/L. * **First sign of toxicity:** Loss of patellar reflex (8–10 mEq/L). * **Antidote:** 10% Calcium Gluconate (10 mL IV over 10 minutes). * **Safe Antihypertensives in Pregnancy:** Labetalol (1st line), Methyldopa, Nifedipine, and Hydralazine. * **Contraindicated Antihypertensives:** ACE inhibitors and ARBs (cause fetal renal dysgenesis and oligohydramnios).

Question 372: What is the easiest method for determining zygosity?

A. Blood grouping
B. Sex of fetus
C. Placental examination (Correct Answer)
D. Amniotic fluid examination

Explanation: **Explanation:** Determining zygosity in multiple gestations is crucial for risk stratification. **Placental examination** is considered the **easiest and most practical method** for determining zygosity, particularly in the clinical setting immediately following delivery. 1. **Why Placental Examination is Correct:** By examining the placenta and the intervening membranes, clinicians can determine chorionicity. If the twins are **Monochorionic**, they are definitively **Monozygotic** (identical). If they are **Dichorionic**, they can be either dizygotic or monozygotic (if cleavage occurred early). While DNA fingerprinting is the "gold standard" for accuracy, placental examination provides an immediate, non-invasive, and highly reliable clinical assessment of zygosity in most cases. 2. **Analysis of Incorrect Options:** * **Sex of Fetus (B):** While different-sex twins are always dizygotic, same-sex twins can be either monozygotic or dizygotic. Therefore, sex alone is insufficient for a definitive diagnosis. * **Blood Grouping (A):** Different blood groups confirm dizygosity, but identical blood groups do not guarantee monozygosity, as dizygotic twins can share the same blood type by chance. * **Amniotic Fluid Examination (D):** This is primarily used for genetic testing or lung maturity and does not provide a direct structural assessment of zygosity. **NEET-PG High-Yield Pearls:** * **Gold Standard:** DNA Fingerprinting (most accurate). * **Best Ultrasound Sign:** The **"Twin Peak" or "Lambda" (λ) sign** indicates Dichorionic twins; the **"T-sign"** indicates Monochorionic twins. * **Timing of Cleavage:** * 0–72 hours: Dichorionic Diamniotic (DCDA) * 4–8 days: Monochorionic Diamniotic (MCDA) — *Most common type of MZ twins.* * 8–13 days: Monochorionic Monoamniotic (MCMA) * >13 days: Conjoined twins

Question 373: Which of the following is NOT a feature of mild pre-eclampsia?

A. Diastolic BP < 100 mm Hg
B. Systolic BP < 160 mm Hg
C. Mild Intrauterine Growth Restriction (IUGR) (Correct Answer)
D. No premonitory symptoms

Explanation: **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 lakh, Elevated Liver Enzymes (ALT/AST), Serum Creatinine > 1.1 mg/dL, or Pulmonary Edema.

Question 374: Which cardiac lesion in pregnant women has the worst prognosis?

A. Mitral stenosis
B. Co-arctation of aorta
C. Eisenmenger syndrome (Correct Answer)
D. Tetralogy of Fallot's

Explanation: ### 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).

Question 375: All of the following are included as causes of maternal death except?

A. Following abortion
B. During the first month of lactation (puerperal)
C. During the eighth month of lactation (Correct Answer)
D. During the last trimester due to antepartum hemorrhage (APH)

Explanation: **Explanation:** The definition of **Maternal Death**, according to the World Health Organization (WHO) and ICD-10, is the death of a woman while pregnant or within **42 days (6 weeks)** of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. 1. **Why Option C is correct:** The eighth month of lactation falls well beyond the 42-day postpartum period (puerperium). Deaths occurring after 42 days but before one year are classified as "Late Maternal Deaths," which are tracked separately and not included in the standard Maternal Mortality Ratio (MMR). 2. **Why Options A, B, and D are incorrect:** * **Option A (Abortion):** Maternal death includes deaths resulting from complications of abortion (induced or spontaneous), as it occurs during or immediately after the termination of pregnancy. * **Option B (First month of lactation):** This falls within the 42-day puerperal period, making it a classic maternal death. * **Option D (Last trimester/APH):** Deaths occurring during pregnancy due to obstetric complications like Antepartum Hemorrhage are direct maternal deaths. **High-Yield Clinical Pearls for NEET-PG:** * **Maternal Mortality Ratio (MMR):** Number of maternal deaths per **1,00,000 live births**. * **Most Common Cause of Maternal Death (India & Global):** Hemorrhage (specifically Postpartum Hemorrhage/PPH). * **Most Common Indirect Cause:** Anemia (though some sources cite Heart Disease in developed regions). * **Timeframe:** Remember the "42-day rule." Any death after 42 days up to 1 year is a **Late Maternal Death**.

Question 376: A fetus is diagnosed with congenital heart block (CHB). What condition in the mother should be evaluated?

A. Systemic Lupus Erythematosus (SLE) (Correct Answer)
B. Antiphospholipid Antibody Syndrome (APLAS)
C. Diabetes Mellitus
D. Hemolytic Anemia

Explanation: **Explanation:** **1. Why SLE is the Correct Answer:** Congenital Heart Block (CHB) is most commonly associated with maternal autoimmune diseases, specifically **Systemic Lupus Erythematosus (SLE)** and **Sjögren’s Syndrome**. The underlying mechanism involves the transplacental passage of maternal IgG autoantibodies, specifically **anti-Ro (SS-A)** and **anti-La (SS-B)**. These antibodies cross the placenta (usually between 18–24 weeks) and cause inflammation and subsequent fibrosis of the fetal atrioventricular (AV) node. Once complete (third-degree) heart block occurs, it is generally irreversible and carries a high risk of fetal hydrops and mortality. **2. Why Incorrect Options are Wrong:** * **Antiphospholipid Antibody Syndrome (APLAS):** While APLAS is common in SLE patients, it is primarily associated with recurrent pregnancy loss, placental infarction, and preeclampsia due to its pro-thrombotic nature, rather than fetal conduction defects. * **Diabetes Mellitus:** Maternal diabetes is associated with structural cardiac defects (e.g., Transposition of the Great Arteries, VSD) and **Hypertrophic Cardiomyopathy** (septal hypertrophy), but not typically isolated heart block. * **Hemolytic Anemia:** This may lead to fetal anemia and hydrops (e.g., in Rh isoimmunization), but it does not affect the fetal cardiac conduction system. **3. NEET-PG High-Yield Pearls:** * **Antibody markers:** Anti-Ro (SS-A) is the most specific marker for neonatal lupus/CHB. * **Neonatal Lupus Syndrome:** Includes CHB, photosensitive skin rash (raccoon eyes), and cytopenias. The rash is transient, but the heart block is permanent. * **Management:** If early-stage block is detected, maternal **Dexamethasone** (which crosses the placenta) may be used to reduce inflammation. * **Recurrence Risk:** A mother with one affected child has a 15–20% risk of CHB in subsequent pregnancies.

Question 377: 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?

A. Brand-Andrews method
B. Crede's method
C. Macafee & Johnson's method (Correct Answer)
D. Lilley's regimen

Explanation: **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).

Question 378: Which of the following substances is present in a higher concentration in the mother compared to the fetus?

A. Zinc
B. Iron
C. Ascorbic acid
D. Human placental lactogen (HPL) (Correct Answer)

Explanation: **Explanation:** The correct answer is **Human placental lactogen (HPL)**. **1. Why HPL is the correct answer:** Human Placental Lactogen (also known as Human Chorionic Somatomammotropin) is synthesized by the **syncytiotrophoblast** of the placenta. It is primarily secreted into the **maternal circulation**, where its levels rise progressively throughout pregnancy, reaching a peak near term. Its main function is to induce maternal insulin resistance to ensure a steady supply of glucose for the fetus. Because it is secreted directly into maternal blood and has a large molecular weight, its concentration is significantly higher in the mother than in the fetus (maternal levels are roughly 100–1000 times higher). **2. Why the other options are incorrect:** * **Iron (B):** Iron is actively transported across the placenta via transferrin receptors. The fetus acts as a "parasite" for iron, maintaining higher serum ferritin and iron levels than the mother, even if the mother is anemic. * **Zinc (A) and Ascorbic acid (C):** Most water-soluble vitamins (like Vitamin C/Ascorbic acid) and essential minerals (like Zinc and Calcium) are transported via **active transport** against a concentration gradient. Consequently, their concentrations are higher in the fetal circulation than in the maternal circulation. **3. NEET-PG High-Yield Pearls:** * **Higher in Fetus:** Iron, Calcium, Amino acids, Water-soluble vitamins (B & C), and Glucose (though glucose moves by *facilitated diffusion*, fetal levels are high, but technically slightly lower than maternal levels; however, minerals and vitamins are strictly higher in the fetus). * **Higher in Mother:** HPL, HCG, Fat-soluble vitamins (A, D, E, K), and Free Fatty Acids. * **HPL Clinical Note:** HPL is the most potent "diabetogenic" hormone of pregnancy and is the primary reason for the increased insulin requirement in pregnant women.

Question 379: A 25-year-old primigravida delivered an infant with clubfoot. During her pregnancy, she was diagnosed with oligohydramnios and did not receive proper care. She was also taking certain medications during pregnancy. Which of the following medications is most likely to have caused oligohydramnios in this patient?

A. Insulin
B. Enalapril (Correct Answer)
C. Ciprofloxacin
D. None of the above

Explanation: **Explanation:** The correct answer is **Enalapril (Option B)**. Enalapril is an ACE (Angiotensin-Converting Enzyme) inhibitor, which is strictly contraindicated in the second and third trimesters of pregnancy (FDA Category D). **Mechanism of Action:** ACE inhibitors cross the placenta and interfere with the fetal renin-angiotensin system. This leads to **fetal hypotension** and **decreased renal perfusion**, resulting in fetal renal tubular dysgenesis and anuria/oliguria. Since fetal urine is the primary source of amniotic fluid in the second half of pregnancy, this causes **oligohydramnios**. Prolonged oligohydramnios leads to the **Potter sequence**, characterized by pulmonary hypoplasia, cranial deformities, and limb contractures like **clubfoot (talipes equinovarus)** due to uterine compression. **Analysis of Incorrect Options:** * **A. Insulin:** It is the drug of choice for managing diabetes in pregnancy. It does not cross the placenta and is not associated with oligohydramnios. In fact, uncontrolled maternal diabetes is more commonly associated with *polyhydramnios*. * **C. Ciprofloxacin:** This fluoroquinolone is generally avoided in pregnancy due to concerns regarding fetal cartilage damage (arthropathy), but it is not a known cause of oligohydramnios or renal failure. **High-Yield Clinical Pearls for NEET-PG:** * **ACE Inhibitor Fetopathy:** Includes oligohydramnios, hypocalvaria (hypoplasia of skull bones), renal failure, and IUGR. * **Drug of Choice for HTN in Pregnancy:** Labetalol (most common), Methyldopa, or Nifedipine. * **Oligohydramnios Definition:** Amniotic Fluid Index (AFI) < 5 cm or Single Deepest Pocket (SDP) < 2 cm. * **Other drugs causing Oligohydramnios:** NSAIDs (e.g., Indomethacin) due to constriction of the ductus arteriosus and reduced fetal renal blood flow.

Question 380: What is a potential consequence for a child born to a mother with phenylketonuria?

A. Microcephaly, mental retardation, congenital heart disease (Correct Answer)
B. Mental retardation, cataract, congenital heart disease
C. Hydrocephalus, cataract
D. Microcephaly, cataract, renal dysplasia

Explanation: **Explanation:** This question addresses **Maternal Phenylketonuria (PKU) Syndrome**, a condition where a mother with PKU has poorly controlled phenylalanine levels during pregnancy. Phenylalanine is a potent teratogen that crosses the placenta via active transport, leading to fetal levels significantly higher than maternal levels. **1. Why Option A is Correct:** High maternal phenylalanine levels disrupt fetal organogenesis and brain development. The classic triad of Maternal PKU Syndrome includes: * **Microcephaly:** Due to the neurotoxic effects of phenylalanine on the developing fetal brain. * **Mental Retardation (Intellectual Disability):** Even if the infant does not have the PKU genotype, the intrauterine exposure causes permanent cognitive impairment. * **Congenital Heart Disease (CHD):** Most commonly Fallot’s Tetralogy or VSD. * **Intrauterine Growth Restriction (IUGR):** Often seen alongside these features. **2. Why Other Options are Incorrect:** * **Cataracts (Options B, C, D):** Cataracts are characteristic of **Congenital Rubella Syndrome** or **Galactosemia**, not PKU. * **Hydrocephalus (Option C):** PKU causes a small brain (microcephaly), whereas hydrocephalus (enlarged ventricles) is more typical of infections like **Congenital Toxoplasmosis**. * **Renal Dysplasia (Option D):** This is not a recognized feature of Maternal PKU Syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Preconception Counseling:** The goal is to maintain maternal phenylalanine levels between **2–6 mg/dL** for at least 3 months before conception and throughout pregnancy. * **Dietary Management:** A strict low-phenylalanine diet (avoiding high-protein foods and aspartame) is the mainstay of treatment. * **Genetics:** The fetus is usually a heterozygote (carrier) and does not have the disease itself; the damage is purely due to the **teratogenic intrauterine environment**.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

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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

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Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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