Maternal-Fetal Medicine Practice Questions

Q: Which is the earliest ectopic pregnancy location to undergo rupture?

Isthmic. **Explanation:** The timing of rupture in an ectopic pregnancy is primarily determined by the **distensibility and diameter** of the anatomical site where the blastocyst implants. **Why Isthmic is the correct answer:** The **isthmus** is the narrowest part of the fallopian tube with a very thin muscular wall and minimal distensibility. Because the lumen is so constricted, the growing embryo quickly outgrows the available space and erodes through the wall. Consequently, isthmic pregnancies undergo the **earliest rupture**, typically between **6 to 8 weeks** of gestation. **Analysis of Incorrect Options:** * **Ampullary:** This is the most common site of ectopic pregnancy (70-80%). The ampulla is wider and more distensible than the isthmus, allowing the pregnancy to progress further. Rupture usually occurs later, around **8 to 12 weeks**. * **Interstitial:** This is the portion of the tube that traverses the thick myometrium of the uterus. Due to the surrounding muscular support and rich blood supply, it can expand significantly. Rupture occurs **latest (12–16 weeks)** but is the most life-threatening due to massive hemorrhage from the uterine arteries. * **Ovarian:** These are rare and do not follow a fixed timeline for rupture as strictly as tubal pregnancies, though they generally occur earlier than interstitial ones. **NEET-PG High-Yield Pearls:** * **Most common site of ectopic:** Ampulla. * **Earliest rupture:** Isthmus (6-8 weeks). * **Latest rupture/Most dangerous:** Interstitial (12-16 weeks). * **Most common site for Ectopic following IVF:** Interstitial. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases).

Q: A 35 weeks pregnant woman has ultrasound parameters corresponding to gestational age. Doppler shows absent end diastolic flow. What is the recommended management?

Plan for termination. **Explanation:** The core issue in this scenario is **Absent End Diastolic Flow (AEDF)** in the umbilical artery, which signifies high placental resistance and impending fetal compromise. **1. Why "Plan for termination" is correct:** According to standard management protocols for Fetal Growth Restriction (FGR) and placental insufficiency, the presence of AEDF at **≥34 weeks** of gestation is a definitive indication for delivery. At 35 weeks, the risks of intrauterine fetal demise (IUFD) due to chronic hypoxia outweigh the risks of prematurity. Therefore, the pregnancy should be terminated (delivered), usually via Cesarean section if the Bishop score is unfavorable or fetal distress is evident. **2. Why the other options are incorrect:** * **Options A & B:** Monitoring until 37 weeks or until the flow reverses is dangerous. AEDF is a late-stage marker; waiting further increases the risk of acidosis and stillbirth. Expectant management is only considered if the fetus is <34 weeks to gain maturity, but even then, it requires intensive monitoring. * **Option C:** While steroids (Betamethasone/Dexamethasone) are administered for fetal lung maturity if delivery is planned between 24 and 36+6 weeks, the question asks for the "management" of the pregnancy. "Waiting for 48 hours" is secondary to the primary decision to terminate. In practice, steroids are given *while* preparing for delivery, but the definitive management plan is termination. **Clinical Pearls for NEET-PG:** * **S/D Ratio:** The first Doppler sign of placental insufficiency is an increased Systolic/Diastolic ratio. * **AEDF:** Delivery is indicated at **≥34 weeks**. * **REDF (Reversed End Diastolic Flow):** This is a critical emergency. Delivery is indicated at **≥30-32 weeks**. * **Ductus Venosus:** Abnormal flow (absent/reversed a-wave) in the ductus venosus is the most sensitive predictor of imminent fetal death.

Q: Among the following, which is the most sensitive ultrasonographic finding of Trisomy 21?

Thickened nuchal fold. **Explanation:** The detection of Trisomy 21 (Down Syndrome) via ultrasonography relies on identifying specific "soft markers." Among the options provided, **Thickened Nuchal Fold (NF)** is the most sensitive and specific second-trimester marker. 1. **Why Thickened Nuchal Fold is Correct:** Measured between 15 and 20 weeks of gestation, a nuchal fold thickness of **≥6 mm** is considered abnormal. It has the highest positive likelihood ratio (LR) for Trisomy 21 in the second trimester. Unlike the nuchal translucency (NT) seen in the first trimester, the nuchal fold persists longer and is a highly reliable indicator of lymphatic obstruction or cardiovascular congestion associated with Down Syndrome. 2. **Analysis of Incorrect Options:** * **Absent Nasal Bone:** While a very strong marker (high specificity), it is less sensitive than the nuchal fold in the second trimester because the nasal bone may simply be late to ossify or difficult to visualize depending on fetal position. * **Short Femur:** This is a common finding in many skeletal dysplasias and growth restrictions; its sensitivity for Trisomy 21 is lower compared to nuchal thickening. * **Echogenic Bowel:** While associated with Trisomy 21, it is also frequently seen in cystic fibrosis, intra-amniotic hemorrhage, and congenital infections (CMV), making it less specific and sensitive for Down Syndrome alone. **High-Yield Clinical Pearls for NEET-PG:** * **First Trimester Screen:** Increased **Nuchal Translucency (NT)** + Low PAPP-A + High β-hCG. * **Second Trimester Screen (Quadruple Test):** Low AFP, Low Estriol (uE3), High hCG, and High Inhibin-A. * **Most common cardiac defect:** Endocardial cushion defect (Atrioventricular Septal Defect). * **Most sensitive 2nd-trimester USG marker:** Nuchal Fold thickness (≥6 mm).

Q: Which of the following is NOT an explanation for decreased variability of the fetal heart rate tracing?

Fetal stimulation. **Explanation:** Fetal heart rate (FHR) variability represents the fine-tuning of the fetal cardiac output by the interplay between the sympathetic and parasympathetic nervous systems. It is the single most important indicator of an intact neurological pathway and fetal oxygenation. **Why Fetal Stimulation is the correct answer:** Fetal stimulation (e.g., scalp stimulation or vibroacoustic stimulation) is used to provoke a response in a fetus with a non-reactive or quiet trace. It typically causes **increased variability** and **accelerations**, confirming fetal well-being and the absence of acidosis. Therefore, it does not cause decreased variability. **Why the other options are incorrect:** * **Fetal sleep state:** This is the most common cause of transiently decreased variability. Fetal "quiet sleep" cycles usually last 20–40 minutes; if variability is low, the clinician should wait or stimulate the fetus to rule out sleep. * **Prematurity:** Variability is dependent on the maturation of the autonomic nervous system. In very preterm fetuses (especially <28 weeks), the parasympathetic system is underdeveloped, leading to naturally lower baseline variability. * **Barbiturate ingestion:** Central nervous system (CNS) depressants, including barbiturates, benzodiazepines, and opioids (like pethidine), cross the placenta and suppress fetal brain activity, leading to a "flat" or diminished variability trace. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Normal variability is **6–25 bpm**. * **Minimal variability:** ≤5 bpm; **Absent:** Undetectable; **Marked:** >25 bpm. * **Sinusoidal Pattern:** A specific type of absent variability indicating severe fetal anemia (e.g., Rh isoimmunization) or acute hypoxia. * **Management:** If decreased variability persists >40 minutes despite stimulation, consider fetal hypoxia, acidosis, or drug effects.

Q: Which maternal condition is associated with the following fetal anomaly?

Diabetes Mellitus (DM). ***Diabetes Mellitus (DM)*** - **Caudal regression syndrome** (sacral agenesis) is the pathognomonic fetal anomaly associated with **pre-gestational diabetes mellitus** (Type 1 or Type 2 DM). - **Pre-conception hyperglycemia** during organogenesis leads to **neural crest cell disruption**, affecting sacral and lower lumbar vertebrae development. *Gestational Diabetes Mellitus (GDM)* - GDM typically causes **fetal macrosomia** and **metabolic complications** rather than structural anomalies like caudal regression syndrome. - Onset occurs after **20 weeks gestation**, well after the critical period for **organogenesis** when structural defects develop. *Intake of ACE inhibitors* - ACE inhibitors cause **renal tubular dysgenesis** and **oligohydramnios**, leading to **Potter sequence** with facial deformities. - Associated with **intrauterine growth restriction (IUGR)** and **renal failure**, not spinal defects like sacral agenesis. *Intake of sodium valproate* - Sodium valproate is associated with **neural tube defects** such as **spina bifida** and **anencephaly**. - Also causes **valproate syndrome** with characteristic facial dysmorphism and **cognitive impairment**, distinct from caudal regression syndrome.

Q: On a routine first-trimester ultrasound at 6 weeks, the gestational sac is seen separate from the endometrium and more than 1 cm away from the most lateral edge of the uterine cavity. The "interstitial line sign" is observed. What is your diagnosis?

Interstitial pregnancy. **Explanation:** The correct diagnosis is **Interstitial pregnancy**, a specific type of ectopic pregnancy where the blastocyst implants within the proximal, intramural portion of the fallopian tube as it traverses the muscular uterine wall. **Why it is correct:** The diagnosis is confirmed by three classic sonographic criteria: 1. **Empty uterine cavity:** The gestational sac is seen separate from the endometrium. 2. **Eccentric location:** The sac is located more than 1 cm from the most lateral edge of the uterine cavity. 3. **Interstitial line sign:** This is a highly specific high-yield finding where a thin echogenic line extends from the endometrial canal to the center of the ectopic gestational sac, representing the interstitial portion of the fallopian tube. **Why the other options are incorrect:** * **Angular pregnancy:** The embryo implants in the lateral angle of the uterine cavity, *medial* to the uterotubal junction. Unlike interstitial pregnancy, it is surrounded by myometrium and can potentially progress to a viable term delivery, though with higher risks. * **Cornual pregnancy:** This term is often used interchangeably but strictly refers to a pregnancy in the horn of a **bicornuate or unicornuate uterus**. * **Isthmic pregnancy:** This refers to an ectopic pregnancy in the narrow, extra-uterine portion of the fallopian tube (isthmus), not within the uterine wall. **Clinical Pearls for NEET-PG:** * **Risk of Rupture:** Interstitial pregnancies often rupture later (12–14 weeks) than other tubal pregnancies because the myometrium allows for more expansion. * **Hemorrhage:** Rupture can lead to catastrophic, life-threatening hemorrhage due to the proximity of the **uterine and ovarian artery anastomosis** (Sampson’s artery). * **Management:** While methotrexate can be used in stable cases, surgical management often requires cornual resection or hysterectomy.

Q: Placental villi invading through the serosa of the uterus falls under which category?

Placenta percreta. **Explanation:** The question describes a spectrum of **Morbidly Adherent Placenta (MAP)**, where there is an abnormal attachment of the placenta to the uterine wall due to the absence or deficiency of the **Nitabuch’s layer** (decidua basalis). **Why Option D is Correct:** * **Placenta Percreta:** This is the most severe form. The chorionic villi penetrate through the entire thickness of the myometrium and breach the **uterine serosa**. In some cases, it may even invade adjacent organs, most commonly the urinary bladder. **Why Other Options are Incorrect:** * **A. Placenta Previa:** This refers to the abnormal *location* of the placenta (implanted in the lower uterine segment), not the depth of invasion. * **B. Placenta Accreta:** The villi are attached directly to the myometrium but do not invade it. This is the most common type (approx. 75-80%). * **C. Placenta Increta:** The villi invade deep **into** the myometrium but do not reach or pass through the serosa. **NEET-PG High-Yield Pearls:** 1. **Risk Factors:** The single most important risk factor is a **previous Cesarean Section** combined with **Placenta Previa**. The risk increases linearly with the number of prior C-sections. 2. **Diagnosis:** Antenatal diagnosis is primarily via **Ultrasound/Color Doppler**. Look for "placental lacunae" (Swiss cheese appearance) and loss of the retroplacental clear zone. 3. **Management:** The gold standard management for confirmed percreta is a **planned Cesarean Hysterectomy**. 4. **Complication:** The most common and life-threatening complication is massive postpartum hemorrhage (PPH).

Q: The McAfee and Johnson regimen is used for which of the following conditions?

Placenta previa. **Explanation:** The **McAfee and Johnson regimen** (also known as the expectant management of placenta previa) is the gold standard for managing asymptomatic or hemodynamically stable patients with placenta previa before 37 weeks of gestation. **Why it is correct:** The primary goal of this regimen is to prolong pregnancy to achieve fetal lung maturity while ensuring maternal safety. It is indicated when the fetus is preterm ( 10 g/dL. * Rh-immunoglobulin if the mother is Rh-negative. **Why other options are incorrect:** * **Eclampsia:** Managed using the **Pritchard regimen** or **Zuspan regimen** (Magnesium Sulfate) to control seizures. * **Placental Abruption:** Usually requires definitive management (delivery) rather than expectant management, as it poses an immediate risk of DIC and fetal distress. * **Placenta Accreta:** This is a surgical emergency typically managed by planned cesarean hysterectomy; expectant management is not the standard "McAfee" protocol. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisite:** The first step in suspected placenta previa is a **Transvaginal Ultrasound (TVS)**; per-vaginal examination is strictly contraindicated (can cause torrential hemorrhage). * **Termination:** Expectant management is terminated at **37 weeks** or if heavy bleeding/fetal distress occurs. * **Stallworthy’s Sign:** A clinical sign where the fetal head is displaced anteriorly or posteriorly due to a low-lying placenta.

Q: A non-stress test (NST) performed on a 36-week pregnant diabetic female is non-reactive. What is the recommended next step?

Proceed to biophysical profile assessment. **Explanation:** The **Non-Stress Test (NST)** is a screening tool used to assess fetal well-being by observing the fetal heart rate (FHR) response to fetal movement. A **non-reactive NST** (defined as fewer than two accelerations of at least 15 bpm lasting 15 seconds over a 20-minute period) is a sensitive but non-specific finding. It may indicate fetal hypoxia, but it is frequently caused by a **fetal sleep cycle** (which can last up to 40 minutes) or maternal drug use. **Why Option D is correct:** Because a non-reactive NST has a high false-positive rate, it must be followed by a more specific backup test to confirm fetal compromise. The **Biophysical Profile (BPP)** or a **Contraction Stress Test (CST)** are the standard next steps. The BPP evaluates acute (NST, breathing, movement, tone) and chronic (amniotic fluid volume) markers of fetal health, providing a more accurate assessment of whether the fetus is truly in distress. **Why incorrect options are wrong:** * **Options A & B:** Immediate delivery (Induction or LSCS) is premature without confirming fetal distress. Delivering a 36-week fetus unnecessarily increases the risk of respiratory distress syndrome and prematurity-related complications. * **Option C:** While acoustic stimulation can be used to "wake" a fetus, the standard protocol after a confirmed non-reactive 40-minute NST is to proceed to a BPP or CST rather than simply repeating the same test an hour later. **Clinical Pearls for NEET-PG:** * **Most common cause of a non-reactive NST:** Fetal sleep cycle. * **BPP Components:** Tone, Movement, Breathing, NST, and Amniotic Fluid (Mnemonic: **T**he **M**any **B**abies **N**eed **A**ir). * **Modified BPP:** Consists of NST + Amniotic Fluid Index (AFI). * **High-yield:** A BPP score of 8-10 is normal; 4 or less is an indication for delivery.

Question 1

A couple with an Rh-positive female and an Rh-negative male seeks counseling regarding pregnancy. What is the recommended course of action?

Accepted Answer

No treatment is needed.

Answer

Administer vaccine to the mother after the birth of the first baby.

Answer

Administer vaccine to the first baby.

Answer

Administer vaccine to the father.

Question 2

Which is the earliest ectopic pregnancy location to undergo rupture?

Accepted Answer

Isthmic

Answer

Interstitial

Answer

Ampullary

Answer

Ovarian

Question 3

A 35 weeks pregnant woman has ultrasound parameters corresponding to gestational age. Doppler shows absent end diastolic flow. What is the recommended management?

Accepted Answer

Plan for termination

Answer

Monitor until end diastolic flow becomes reversed or until 37 weeks gestation

Answer

Monitor until 37 weeks gestation

Answer

Administer steroids and wait for 48 hours

Question 4

Among the following, which is the most sensitive ultrasonographic finding of Trisomy 21?

Accepted Answer

Thickened nuchal fold

Answer

Absent nasal bone

Answer

Short femur

Answer

Echogenic bowel

Question 5

Which of the following is NOT an explanation for decreased variability of the fetal heart rate tracing?

Accepted Answer

Fetal stimulation

Answer

Fetal sleep state

Answer

Prematurity

Answer

Barbiturate ingestion

Question 6

Which maternal condition is associated with the following fetal anomaly?

Accepted Answer

Diabetes Mellitus (DM)

Answer

Gestational Diabetes Mellitus (GDM)

Answer

Intake of ACE inhibitors

Answer

Intake of sodium valproate

Question 7

On a routine first-trimester ultrasound at 6 weeks, the gestational sac is seen separate from the endometrium and more than 1 cm away from the most lateral edge of the uterine cavity. The "interstitial line sign" is observed. What is your diagnosis?

Accepted Answer

Interstitial pregnancy

Answer

Angular pregnancy

Answer

Cornual pregnancy

Answer

Isthmic pregnancy

Question 8

Placental villi invading through the serosa of the uterus falls under which category?

Accepted Answer

Placenta percreta

Answer

Placenta previa

Answer

Placenta accreta

Answer

Placenta increta

Question 9

The McAfee and Johnson regimen is used for which of the following conditions?

Accepted Answer

Placenta previa

Answer

Eclampsia

Answer

Placental abruption

Answer

Placenta accreta

Question 10

A non-stress test (NST) performed on a 36-week pregnant diabetic female is non-reactive. What is the recommended next step?

Accepted Answer

Proceed to biophysical profile assessment

Answer

Induction of labor

Answer

Lower segment cesarean section (LSCS)

Answer

Repeat non-stress test (NST) after 1 hour

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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