Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 411: A 26-year-old woman, who underwent mitral valve replacement two years ago for severe mitral stenosis and is currently on therapeutic anticoagulation with 5mg of Warfarin daily, seeks preconception counseling. Which of the following statements is FALSE?

A. The risk of warfarin embryopathy is approximately 6%.
B. Warfarin should be stopped periconceptionally and switched to heparin. (Correct Answer)
C. Anticoagulation must continue throughout pregnancy.
D. The prognosis for her pregnancy is influenced by her NYHA functional class.

Explanation: This question tests the management of mechanical heart valves during pregnancy, a high-yield topic in Maternal-Fetal Medicine. ### **Explanation of the Correct Answer (Option B)** Option B is **FALSE** because current guidelines (AHA/ACC and ESC) recommend that for women on a stable dose of **Warfarin ≤ 5mg/day**, the drug can be continued until the **end of the first trimester** (specifically until 6 weeks gestation). The risk of warfarin embryopathy is dose-dependent and is significantly lower (<3%) when the daily dose is ≤ 5mg. Switching to Heparin (UFH or LMWH) periconceptionally is often avoided because Heparin carries a higher risk of valve thrombosis compared to Warfarin. The switch to Heparin is typically only mandatory between 6–12 weeks of gestation if the dose exceeds 5mg/day, or just before delivery (36 weeks) to prevent fetal intracranial hemorrhage during labor. ### **Analysis of Other Options** * **Option A:** True. The overall risk of warfarin embryopathy (nasal hypoplasia, stippled epiphyses) is cited around 6% in general populations, though it is lower with low-dose regimens. * **Option C:** True. Mechanical valves are highly thrombogenic; stopping anticoagulation at any point during pregnancy poses a life-threatening risk of valve thrombosis. * **Option D:** True. Pre-pregnancy NYHA functional class is a major predictor of maternal cardiovascular outcomes (modified WHO classification). ### **NEET-PG Clinical Pearls** * **Warfarin Embryopathy Window:** Occurs primarily between **6 to 9 weeks** of gestation. * **Drug of Choice for Valve Protection:** Warfarin is superior to Heparin for preventing maternal valve thrombosis but crosses the placenta. * **Delivery Protocol:** Always switch Warfarin to IV Unfractionated Heparin at **36 weeks** because Warfarin crosses the placenta and can cause fetal hemorrhage during the trauma of birth; Heparin does not. * **Breastfeeding:** Warfarin is **safe** during breastfeeding as it is not excreted in breast milk.

Question 412: What does a Cardiotocography (CTG) typically depict?

A. Fetal heart rate monitoring (Correct Answer)
B. Fetal growth monitoring
C. Fetal size monitoring
D. Amniotic fluid index monitoring

Explanation: **Explanation:** **Cardiotocography (CTG)** is a technical means of recording the **fetal heart rate (FHR)** and the **uterine contractions** during pregnancy. The term is derived from Greek: *Kardio* (heart), *Toco* (labor/contraction), and *Graph* (writing). It is the primary tool used in the third trimester and during labor to assess fetal well-being and identify signs of fetal distress (hypoxia). **Why Option A is Correct:** CTG uses two transducers placed on the maternal abdomen: an ultrasound transducer to monitor the fetal heart rate and a pressure-sensitive tocodynamometer to record the frequency and duration of uterine contractions. The resulting trace allows clinicians to analyze the baseline heart rate, variability, accelerations, and decelerations. **Why Other Options are Incorrect:** * **B & C (Fetal Growth/Size):** These are assessed via **Symphysio-fundal height (SFH)** measurement clinically or through **Obstetric Ultrasonography (USG)** using parameters like Biparietal Diameter (BPD), Abdominal Circumference (AC), and Femur Length (FL). * **D (Amniotic Fluid Index):** AFI is calculated using **Ultrasonography** by measuring the deepest vertical pockets in four quadrants of the uterus. **High-Yield Clinical Pearls for NEET-PG:** * **Normal Baseline FHR:** 110–160 bpm. * **Reassuring Feature:** Presence of **accelerations** (increase of >15 bpm for >15 seconds) and **good variability** (5–25 bpm). * **Early Decelerations:** Usually benign; caused by fetal head compression. * **Late Decelerations:** Pathological; indicates **uteroplacental insufficiency**. * **Variable Decelerations:** Most common; indicates **cord compression**.

Question 413: What is the most common cause of first-trimester abortion?

A. Chromosomal defect (Correct Answer)
B. Endocrine disturbances
C. Anatomic abnormality of the uterus
D. Infections

Explanation: **Explanation:** **1. Why Chromosomal Defect is Correct:** Chromosomal abnormalities are the single most common cause of spontaneous abortion in the first trimester, accounting for **50–70% of all cases**. These are usually sporadic (de novo) events resulting from errors in gametogenesis, such as non-disjunction. Among these, **Autosomal Trisomy** is the most frequent specific abnormality (Trisomy 16 being the most common), followed by Monosomy X (Turner Syndrome) and Triploidy. **2. Analysis of Incorrect Options:** * **Endocrine disturbances:** Conditions like Luteal Phase Defect (Progesterone deficiency), uncontrolled Diabetes Mellitus, and Thyroid disorders are significant causes but are statistically less frequent than genetic factors. * **Anatomic abnormality of the uterus:** Factors such as septate uterus, submucosal fibroids, or cervical incompetence more commonly lead to **second-trimester** losses rather than first-trimester abortions. * **Infections:** While TORCH infections, *Listeria*, and *Mycoplasma* can cause pregnancy loss, they are rare causes of early sporadic abortion in modern clinical practice. **3. NEET-PG High-Yield Pearls:** * **Most common Trisomy in abortus:** Trisomy 16 (Note: Trisomy 21 is the most common trisomy in live births). * **Most common single chromosomal anomaly:** Monosomy X (45,X). * **Second-trimester abortions:** Most commonly due to maternal factors (anatomic defects, systemic diseases) rather than fetal factors. * **Recurrent Pregnancy Loss (RPL):** Defined as ≥2 consecutive spontaneous abortions; the most common treatable cause is Antiphospholipid Antibody Syndrome (APS).

Question 414: A diabetic mother may have the following complications in the fetus EXCEPT:

A. Hydramnios
B. Macrosomia
C. Cardiac anomaly
D. Dimorphic anemia (Correct Answer)

Explanation: **Explanation:** The correct answer is **Dimorphic anemia**. In diabetic pregnancies, the primary hematological complication in the fetus is **polycythemia** (not anemia). This occurs because fetal hyperglycemia leads to hyperinsulinemia, which increases the metabolic rate and oxygen consumption. The resulting fetal hypoxia stimulates erythropoietin production, leading to an excess of red blood cells. **Analysis of Options:** * **Hydramnios (Polyhydramnios):** This is a common complication. Fetal hyperglycemia causes osmotic diuresis, leading to **fetal polyuria**, which increases the volume of amniotic fluid. * **Macrosomia:** Maternal hyperglycemia results in fetal hyperinsulinemia. Since insulin is a potent growth-promoting hormone, it leads to excessive fat deposition and organomegaly, typically resulting in a birth weight >4000g. * **Cardiac Anomaly:** Pre-gestational diabetes is teratogenic. The most common cardiac defect is a **Ventricular Septal Defect (VSD)**, though **Transposition of the Great Arteries (TGA)** and Hypertrophic Cardiomyopathy (septal hypertrophy) are also highly associated. **NEET-PG High-Yield Pearls:** 1. **Most common malformation:** Cardiovascular anomalies. 2. **Most specific malformation:** **Caudal Regression Syndrome** (Sacral agenesis). 3. **Metabolic triad in neonate:** Hypoglycemia, Hypocalcemia, and Hypomagnesemia. 4. **Respiratory risk:** Delayed surfactant production leads to an increased risk of **Respiratory Distress Syndrome (RDS)**, even in near-term infants.

Question 415: In which of the following conditions can normal pregnancy be continued?

A. Primary pulmonary hypertension
B. Wolf-Parkinson-White syndrome (Correct Answer)
C. Eisenmenger syndrome
D. Marfan syndrome with dilated aortic root

Explanation: **Explanation:** In obstetric medicine, cardiac conditions are categorized by risk. The correct answer is **Wolf-Parkinson-White (WPW) syndrome** because it is generally considered a low-risk condition that does not contraindicate pregnancy. **1. Why WPW Syndrome is the Correct Answer:** WPW is a pre-excitation syndrome involving an accessory pathway (Bundle of Kent). While pregnancy can increase the frequency of paroxysmal supraventricular tachycardia (PSVT) due to hemodynamic changes, the condition itself does not carry a high risk of maternal mortality. Most patients remain asymptomatic or can be managed safely with medical therapy (like Adenosine or Beta-blockers) or DC cardioversion if hemodynamically unstable. It is not an indication for termination of pregnancy. **2. Why the Other Options are Incorrect:** The other three options represent **WHO Class IV Cardiac Conditions**, which carry a maternal mortality risk of 25–50%. In these cases, pregnancy is strictly contraindicated, and early termination is advised: * **Primary Pulmonary Hypertension (PPH):** Carries the highest risk of maternal mortality (up to 50%), usually occurring in the last trimester or early puerperium due to right heart failure. * **Eisenmenger Syndrome:** The reversal of a left-to-right shunt due to pulmonary hypertension leads to severe hypoxemia. Mortality is extremely high (30–50%). * **Marfan Syndrome with Dilated Aortic Root (>4cm):** Pregnancy increases the risk of aortic dissection or rupture due to hypervolemia and hormonal changes (estrogen) affecting the vascular media. **High-Yield NEET-PG Pearls:** * **Absolute Contraindications to Pregnancy:** Eisenmenger syndrome, Severe Pulmonary Hypertension, Marfan with Aortic Root >4cm, and Severe Mitral Stenosis/Aortic Stenosis. * **Most common cause of heart disease in pregnancy (India):** Rheumatic Heart Disease (Mitral Stenosis is the most common lesion). * **Safest time for cardiac surgery during pregnancy:** 13–28 weeks (Second trimester).

Question 416: A 32-year-old female, unable to conceive for 6 years, presents with a missed period of three weeks, left-sided lower abdominal pain, and nausea. B subunit human chorionic gonadotropin (HCG) and pelvic ultrasound confirm an ectopic pregnancy. What is the appropriate management?

A. Immediate laparotomy and salpingectomy
B. If unruptured, the fallopian tube should be spared (Correct Answer)
C. Avoid incidental appendectomy
D. If the patient is hemodynamically stable, surgery should be avoided

Explanation: **Explanation:** The clinical presentation of secondary infertility (6 years), missed periods, abdominal pain, and positive hCG/ultrasound confirms an **ectopic pregnancy**. **1. Why Option B is Correct:** In a patient with a history of infertility (6 years), preserving reproductive potential is a priority. If the ectopic pregnancy is **unruptured**, a **salpingostomy** (opening the tube to remove the products of conception) is preferred over a salpingectomy (removing the tube). This "tube-sparing" approach is the standard of care to maintain future fertility, provided the contralateral tube is damaged or the patient desires future pregnancy. **2. Why Other Options are Incorrect:** * **Option A:** Immediate laparotomy is reserved for hemodynamically unstable patients (ruptured ectopic). In stable cases, laparoscopy is the gold standard as it offers faster recovery and less adhesion formation. * **Option C:** While not the primary focus, incidental appendectomy is generally avoided during ectopic surgery to prevent contamination and increased operative time; however, this is a general surgical principle and not the specific management goal for ectopic pregnancy. * **Option D:** Hemodynamic stability does not mean surgery should be "avoided." While medical management (Methotrexate) is an option for stable patients with low hCG levels and no fetal heart rate, surgical intervention (laparoscopic salpingostomy) remains a definitive and appropriate management route. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of ectopic:** Ampulla of the Fallopian tube. * **Most common site for rupture:** Isthmus (occurs early, around 6–8 weeks). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) + Serum β-hCG (Discriminatory zone: 1500–2000 mIU/mL). * **Drug of Choice (Medical Management):** Methotrexate (folate antagonist). * **Surgical Choice:** Laparoscopy is preferred over Laparotomy in stable patients.

Question 417: Treatment of cholestasis during pregnancy is all except-

A. Vitamin K
B. Ursodeoxycholic acid
C. Oral contraceptive pills (Correct Answer)
D. Cholestyramine

Explanation: **Explanation:** Intrahepatic Cholestasis of Pregnancy (ICP) is a reversible type of hormone-induced cholestasis occurring in the third trimester, characterized by intense pruritus and elevated serum bile acids. **Why Oral Contraceptive Pills (OCPs) are the correct answer:** OCPs are **contraindicated** in patients with a history of ICP. The pathogenesis of cholestasis is linked to high levels of estrogen and progesterone, which interfere with bile acid transport. Since OCPs contain synthetic estrogens and progestogens, they can trigger or worsen cholestasis. In fact, a history of ICP is a relative contraindication for combined hormonal contraception postpartum. **Analysis of other options:** * **Ursodeoxycholic acid (UDCA):** This is the **drug of choice** for ICP. It improves bile flow, reduces pruritus, and lowers serum bile acid levels, potentially improving fetal outcomes. * **Vitamin K:** Cholestasis leads to malabsorption of fat-soluble vitamins (A, D, E, K) due to decreased bile salts in the gut. Supplementation of Vitamin K is essential to prevent maternal postpartum hemorrhage and fetal intracranial hemorrhage. * **Cholestyramine:** This is a bile acid sequestrant used as a second-line agent to relieve itching. However, it can further deplete Vitamin K levels, so it must be used cautiously. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Symptom:** Pruritus, typically starting on the palms and soles, worsening at night. There is **no primary rash** (only excoriations). * **Diagnostic Gold Standard:** Elevated Total Serum Bile Acids (TSBA) >10 µmol/L. * **Fetal Risks:** Increased risk of meconium-stained amniotic fluid, preterm labor, and **sudden intrauterine fetal death (IUFD)**, especially if bile acids exceed 40–100 µmol/L. * **Management:** Delivery is usually recommended between 36 0/7 and 39 0/7 weeks, depending on bile acid levels.

Question 418: Highest maternal mortality is seen in which congenital heart disease?

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

Explanation: ### Explanation **Correct Answer: A. Eisenmenger's syndrome** **Why it is correct:** Eisenmenger’s syndrome carries the highest risk of maternal mortality (estimated at **30–50%**). It occurs when a long-standing left-to-right shunt (like a VSD or PDA) causes irreversible pulmonary hypertension, leading to a reversal of the shunt (right-to-left) and systemic cyanosis. During pregnancy, the normal physiological **decrease in systemic vascular resistance (SVR)** exacerbates the right-to-left shunt, worsening hypoxia. Furthermore, the fixed pulmonary hypertension prevents the heart from increasing cardiac output to meet pregnancy demands. The most critical period is the immediate postpartum stage, where fluid shifts and sudden changes in SVR can lead to fatal cardiovascular collapse. **Why the other options are incorrect:** * **B. Pulmonary stenosis:** Generally well-tolerated in pregnancy unless the stenosis is severe. It is classified under WHO Risk Category II or III, whereas Eisenmenger is Category IV (pregnancy contraindicated). * **C. Coarctation of aorta:** While it carries risks like aortic dissection or rupture, the mortality rate is significantly lower (approx. 3-9%) compared to Eisenmenger’s, especially if the coarctation has been surgically corrected. * **D. Ventricular septal defect (VSD):** Small to moderate VSDs without pulmonary hypertension are low-risk (WHO Category I or II) and are usually asymptomatic during pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Class IV Heart Diseases:** Pregnancy is **contraindicated** in Eisenmenger’s syndrome, severe Pulmonary Arterial Hypertension (PAH), severe mitral stenosis, and Marfan syndrome with aortic root >40mm. * **Termination:** If a patient with Eisenmenger’s presents in the first trimester, therapeutic abortion is strongly advised. * **Most common cause of maternal death in heart disease:** Heart failure. * **Most common heart disease in pregnancy (India):** Rheumatic Heart Disease (Mitral Stenosis). * **Most common congenital heart disease in pregnancy:** Atrial Septal Defect (ASD).

Question 419: What is the best prenatal treatment for Congenital Adrenal Hyperplasia (CAH)?

A. Betamethasone
B. Prednisolone
C. Hydrocortisone
D. Dexamethasone (Correct Answer)

Explanation: **Explanation:** The primary goal of prenatal treatment for **Congenital Adrenal Hyperplasia (CAH)**, specifically the 21-hydroxylase deficiency variant, is to prevent the **virilization (masculinization)** of a female fetus by suppressing the fetal pituitary-adrenal axis. **Why Dexamethasone is the Correct Answer:** Dexamethasone is a potent glucocorticoid that **crosses the placenta** without being inactivated by the placental enzyme **11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2)**. By reaching the fetal circulation, it suppresses fetal ACTH secretion, thereby reducing the production of adrenal androgens that cause ambiguous genitalia in female fetuses. Treatment must be started early (before the 9th week of gestation) to be effective. **Why Other Options are Incorrect:** * **Prednisolone & Hydrocortisone:** These steroids are largely **inactivated** by the placental enzyme 11β-HSD2. Consequently, they do not reach the fetus in therapeutic concentrations and are ineffective for prenatal fetal treatment (though they are used to treat the mother). * **Betamethasone:** While betamethasone also crosses the placenta, it is primarily used for **fetal lung maturity** in cases of preterm labor. Clinical protocols for CAH specifically standardize the use of Dexamethasone (0.02 mg/kg/day). **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Treatment must begin **empirically** as soon as pregnancy is confirmed (ideally by 6–7 weeks), before the sex of the fetus or the genetic status is known. * **Target:** Treatment is only necessary for **female fetuses** affected by CAH. If the fetus is male or an unaffected female (determined via CVS or NIPT), Dexamethasone is discontinued. * **Mechanism:** It works by providing negative feedback to the fetal hypothalamus/pituitary, preventing the "androgen shower" that occurs during the critical period of genital differentiation.

Question 420: Highest rate of transmission of toxoplasmosis to the fetus during pregnancy is seen in which trimester?

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

Explanation: **Explanation:** The risk of vertical transmission of *Toxoplasma gondii* is directly proportional to the gestational age at the time of maternal infection. **1. Why the Third Trimester is Correct:** The rate of transmission is highest in the **third trimester (60–80%)**. This is primarily due to the increased permeability and surface area of the placenta, along with enhanced uterine blood flow as pregnancy progresses, which facilitates the passage of tachyzoites from the mother to the fetus. **2. Why Other Options are Incorrect:** * **First Trimester:** While the risk of transmission is lowest here (approx. 10–15%), the **severity** of fetal damage is highest (e.g., miscarriage, severe neurological deficits). * **Second Trimester:** The transmission rate is intermediate (approx. 25–30%). * **Puerperium:** This refers to the period after delivery. Congenital toxoplasmosis occurs due to *in utero* infection, not during the postpartum period. **3. High-Yield Clinical Pearls for NEET-PG:** * **Inverse Relationship:** Remember the "Rule of Inverses"—as gestational age increases, the **risk of transmission increases**, but the **severity of fetal disease decreases**. * **Classic Triad (Sabin’s Triad):** Chorioretinitis, Hydrocephalus, and Intracranial calcifications (usually diffuse). * **Diagnosis:** Maternal screening is done via IgM/IgG titers. Fetal diagnosis is best confirmed via **PCR of Amniotic fluid** (Gold Standard). * **Treatment:** * If maternal infection is suspected but fetal infection is not confirmed: **Spiramycin** (to prevent transmission). * If fetal infection is confirmed: **Pyrimethamine, Sulfadiazine, and Folinic acid**.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

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Multiple Gestation

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Rh Isoimmunization and Other Blood Group Incompatibilities

Practice Questions

Intrauterine Fetal Therapy

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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

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