Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 431: Antiphospholipid antibody detection is indicated in all of the following conditions except:

A. Three or more consecutive first trimester pregnancy losses
B. Unexplained cerebrovascular accidents
C. Early onset severe pre-eclampsia
D. Gestational Diabetes (Correct Answer)

Explanation: **Explanation:** Antiphospholipid Syndrome (APS) is an autoimmune condition characterized by the presence of antiphospholipid antibodies (aPL) leading to a hypercoagulable state. The diagnosis requires at least one clinical criterion (vascular thrombosis or pregnancy morbidity) and one laboratory criterion (positive Lupus Anticoagulant, Anticardiolipin, or Anti-β2-glycoprotein I antibodies). **Why Gestational Diabetes (GDM) is the correct answer:** Gestational Diabetes is a metabolic disorder characterized by glucose intolerance with onset or first recognition during pregnancy. It is primarily driven by insulin resistance caused by placental hormones (e.g., hPL). It has **no pathophysiological association** with autoimmune-mediated thrombosis or antiphospholipid antibodies. Therefore, screening for aPL is not indicated in GDM. **Analysis of other options (Indications for aPL testing):** * **Three or more consecutive first-trimester losses:** This is a classic clinical criterion for APS. Recurrent pregnancy loss (RPL) in APS is often due to defective placentation and placental infarction. * **Unexplained cerebrovascular accidents (CVA):** APS is a leading cause of "cryptogenic" stroke in young patients due to arterial thrombosis. * **Early-onset severe pre-eclampsia:** Delivery before 34 weeks due to severe pre-eclampsia or placental insufficiency is a recognized clinical criterion for APS, reflecting the underlying vasculopathy. **High-Yield Clinical Pearls for NEET-PG:** * **Sapporo Criteria:** Used for APS diagnosis. Clinical criteria include: 1) Vascular thrombosis, 2) $\geq$3 first-trimester losses, 3) $\geq$1 loss after 10 weeks (morphologically normal fetus), or 4) $\geq$1 preterm birth before 34 weeks due to eclampsia/pre-eclampsia/placental insufficiency. * **Laboratory Timing:** Antibodies must be positive on two or more occasions, at least **12 weeks apart**. * **Treatment in Pregnancy:** Combined **Low Dose Aspirin (LDA) and Low Molecular Weight Heparin (LMWH)** is the gold standard to improve live birth rates. Warfarin is contraindicated in pregnancy due to embryopathy.

Question 432: Regarding Listeriosis in pregnancy, which of the following statements is false?

A. It can cause second-trimester loss.
B. It is often acquired by drinking raw milk.
C. Symptoms typically occur within 3 days of exposure. (Correct Answer)
D. It can lead to granulomatosis infantiseptica.

Explanation: **Explanation:** Listeriosis, caused by the Gram-positive motile bacillus *Listeria monocytogenes*, is a significant foodborne illness in pregnancy due to the pathogen’s predilection for the placenta. **Why Option C is False (The Correct Answer):** The incubation period for *Listeria* is notably long and variable, typically ranging from **1 to 4 weeks** (average ~3 weeks), though it can extend up to 70 days. The statement that symptoms occur within 3 days is incorrect, as this is much shorter than the typical clinical course for listeriosis. **Analysis of Other Options:** * **Option A:** Listeriosis is a known cause of adverse pregnancy outcomes, including **second-trimester spontaneous abortion**, preterm labor, and stillbirth. * **Option B:** Infection is primarily foodborne. High-risk sources include **unpasteurized (raw) milk**, soft cheeses (feta, brie), deli meats, and contaminated sprouts. * **Option D:** **Granulomatosis infantiseptica** is the classic, severe neonatal manifestation of *in utero* infection. It is characterized by disseminated abscesses and granulomas in multiple organs (liver, spleen, lungs) and carries a high mortality rate. **Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Often presents as a non-specific **flu-like illness** (fever, myalgia, arthralgia) in the mother. * **Diagnosis:** The gold standard is a **blood culture**. * **Treatment of Choice:** **IV Ampicillin** (or Penicillin G). For penicillin-allergic patients, Trimethoprim-Sulfamethoxazole (TMP-SMX) is used. * **Microscopy:** Look for "tumbling motility" on wet mount at 25°C.

Question 433: An ectopic pregnancy implanted in the ovary clinically may most closely mimic which of the following conditions?

A. Ovarian torsion
B. Corpus luteum cyst rupture (Correct Answer)
C. Uterine horn pregnancy rupture
D. Interstitial ectopic pregnancy rupture

Explanation: **Explanation:** The clinical presentation of an **ovarian ectopic pregnancy** is often indistinguishable from a **ruptured corpus luteum cyst**. Both conditions typically occur in women of reproductive age, presenting with sudden-onset unilateral pelvic pain and signs of hemoperitoneum (tachycardia, hypotension, and peritoneal irritation). **Why Corpus Luteum Cyst Rupture is the correct answer:** The primary reason for the clinical mimicry is the **anatomical location** and the **vascularity** of the ovary. A corpus luteum is physiologically present in early pregnancy to support the gestation; if an ectopic pregnancy implants on the ovary, it often develops within or near the corpus luteum. When either the ectopic pregnancy or the cyst ruptures, it leads to significant intra-abdominal bleeding. Since both conditions involve the same organ and occur during the luteal phase or early pregnancy, they share identical clinical signs and symptoms. **Analysis of Incorrect Options:** * **Ovarian Torsion:** While it causes acute pelvic pain, it usually presents with an adnexal mass and intermittent pain without the significant hemoperitoneum or positive pregnancy test associated with ectopic pregnancy. * **Uterine Horn/Interstitial Pregnancy Rupture:** These are types of tubal/uterine ectopics. While they cause severe hemorrhage, the pain is usually more midline or localized to the cornua, and the bleeding is often more catastrophic (occurring at 8–12 weeks) compared to ovarian ectopics. **High-Yield Clinical Pearls for NEET-PG:** * **Spiegelberg Criteria:** Used to diagnose ovarian pregnancy (1. Tube on the affected side is intact; 2. Gestational sac occupies the position of the ovary; 3. Ovary is connected to the uterus by the ovarian ligament; 4. Ovarian tissue is found in the sac wall). * **Primary Risk Factor:** Unlike tubal ectopics (linked to PID), ovarian ectopics are strongly associated with **IUD use**. * **Management:** Usually surgical (wedge resection or cystectomy) to preserve ovarian tissue.

Question 434: What is a complication specific to monoamniotic twins?

A. Twin-to-twin transfusion syndrome (TTTS)
B. Cord entanglement (Correct Answer)
C. Twin reversed arterial perfusion (TRAP) sequence
D. Acardiac twin

Explanation: **Explanation:** Monoamniotic-monochorionic (MoMo) twins occur when the zygote divides between days 8 and 13 post-fertilization. Because these twins share a single amniotic sac without an intervening membrane, **cord entanglement** is a unique and life-threatening complication specific to this subtype. As the fetuses move within the same cavity, their umbilical cords frequently twist around each other, leading to occlusion of blood flow and sudden fetal demise. This necessitates intensive monitoring and elective delivery, typically between 32 and 34 weeks. **Analysis of Incorrect Options:** * **Twin-to-twin transfusion syndrome (TTTS):** While TTTS occurs in monochorionic twins, it requires two separate amniotic sacs (Diamniotic) to manifest clinically (e.g., polyhydramnios/oligohydramnios sequence). It is not *specific* to monoamniotic twins. * **Twin reversed arterial perfusion (TRAP) sequence / Acardiac twin:** These are the same clinical entity. While they occur in monochorionic pregnancies due to large artery-to-artery anastomoses, they can occur in both diamniotic and monoamniotic gestations; they are not unique to the monoamniotic state. **High-Yield Facts for NEET-PG:** * **Timing of Division:** * 0–72 hours: Dichorionic Diamniotic (Didi) * 4–8 days: Monochorionic Diamniotic (Modi) * **8–13 days: Monochorionic Monoamniotic (Momo)** * >13 days: Conjoined twins * **Management:** MoMo twins are often managed with inpatient surveillance starting at 24–28 weeks and mandatory Cesarean section to avoid cord accidents during labor. * **Most common type of MZ twins:** Monochorionic Diamniotic (~75%).

Question 435: Which of the following is NOT a fetal affection caused by Rh antibodies?

A. Nonimmune hydrops fetalis (Correct Answer)
B. Icterus gravis neonatorum
C. Congenital anemia of the newborn
D. Fetal death

Explanation: **Explanation:** The core concept in Rh isoimmunization is **immune-mediated hemolysis**. When maternal Rh antibodies (IgG) cross the placenta, they attack fetal Rh-positive red blood cells, leading to a spectrum of conditions collectively known as **Erythroblastosis Fetalis**. **1. Why "Nonimmune hydrops fetalis" is the correct answer:** Hydrops fetalis is characterized by generalized fetal edema and fluid accumulation in at least two serous cavities (e.g., ascites, pleural effusion). While Rh isoimmunization is a classic cause of **Immune Hydrops**, it cannot cause *Nonimmune* hydrops by definition. Nonimmune hydrops (NIHF) accounts for 90% of cases today and is caused by factors unrelated to red cell antibodies, such as chromosomal abnormalities (Turner syndrome), cardiac anomalies, or infections (Parvovirus B19). **2. Analysis of incorrect options (Features of Rh affection):** * **Icterus gravis neonatorum:** This refers to severe jaundice in the newborn. Rapid hemolysis leads to excessive indirect bilirubin. If untreated, this can cross the blood-brain barrier causing **Kernicterus**. * **Congenital anemia of the newborn:** This is the mildest form of the disease where hemolysis is slowly compensated by the bone marrow, resulting in anemia without significant edema or jaundice at birth. * **Fetal death:** In severe cases, profound anemia leads to high-output cardiac failure, hepatic dysfunction (hypoalbuminemia), and ultimately intrauterine fetal death (IUFD). **Clinical Pearls for NEET-PG:** * **Most common cause of NIHF:** Cardiac anomalies. * **Liley’s Chart:** Used to predict the severity of fetal hemolysis by measuring bilirubin in amniotic fluid ($\Delta OD_{450}$). * **MCA-PSV (Middle Cerebral Artery Peak Systolic Velocity):** The current gold standard non-invasive investigation to detect fetal anemia. * **Standard Dose of Anti-D:** 300 $\mu$g (protects against 15 mL of fetal RBCs or 30 mL of fetal whole blood).

Question 436: Which of the following cardiac lesions is associated with the least maternal mortality?

A. Previous myocardial infarction
B. Aortic stenosis
C. Pulmonary hypertension
D. Patent ductus arteriosus (Correct Answer)

Explanation: **Explanation:** The maternal mortality risk in cardiac disease is categorized using the **Modified WHO (mWHO) Classification**. The correct answer, **Patent Ductus Arteriosus (PDA)**, is generally considered a low-risk lesion (mWHO Class I or II) if it is uncomplicated and the shunt is left-to-right. **1. Why PDA is the correct answer:** In an uncomplicated PDA, the pressure in the aorta is higher than in the pulmonary artery, leading to a left-to-right shunt. While pregnancy increases cardiac output, these patients usually tolerate the volume overload well. Unless pulmonary hypertension (Eisenmenger syndrome) develops, the mortality rate is **less than 1%**. **2. Why the other options are incorrect:** * **Pulmonary Hypertension (Option C):** This is the most dangerous cardiac condition in pregnancy (mWHO Class IV). Mortality rates are extremely high (**25–50%**) due to the inability of the right ventricle to adapt to increased blood volume and the risk of sudden cardiovascular collapse postpartum. * **Aortic Stenosis (Option B):** Severe symptomatic aortic stenosis is mWHO Class IV. The fixed cardiac output cannot meet the increased demands of pregnancy, leading to heart failure or sudden death (mortality **~10–15%**). * **Previous Myocardial Infarction (Option A):** Ischemic heart disease carries a significant risk (mWHO Class III or IV depending on ventricular function). Pregnancy increases myocardial oxygen demand, which can trigger heart failure or re-infarction. **Clinical Pearls for NEET-PG:** * **Highest Risk (Contraindications to pregnancy):** Pulmonary hypertension (Eisenmenger), Marfan syndrome with aortic root >40mm, and severe Mitral Stenosis. * **Most common heart disease in pregnancy (India):** Rheumatic Heart Disease (Mitral Stenosis is the most common lesion). * **Most common congenital heart disease in pregnancy:** Atrial Septal Defect (ASD). * **Safe delivery:** Vaginal delivery with shortened second stage (instrumental delivery) is preferred over C-section for most cardiac patients.

Question 437: In a case of intrauterine growth retardation, what is the most dependable method for determining fetal well-being?

A. Ultrasonic fetal cephalometry
B. Contraction stress test (oxytocin challenge test) (Correct Answer)
C. Amniotic fluid triglyceride
D. Uteroplacental blood flow

Explanation: **Explanation:** In Intrauterine Growth Restriction (IUGR), the primary concern is placental insufficiency, which leads to chronic fetal hypoxia. The **Contraction Stress Test (CST)**, also known as the Oxytocin Challenge Test, is considered the most dependable method among the given options for assessing fetal respiratory reserve. **Why CST is the Correct Answer:** The CST evaluates the fetal heart rate (FHR) response to uterine contractions, which transiently reduce uteroplacental blood flow. A fetus with borderline oxygenation (due to IUGR) will exhibit **late decelerations** during these contractions. A "negative" CST (no late decelerations) is highly predictive of fetal well-being for at least one week, making it a gold standard for assessing whether the fetus can tolerate the stress of labor. **Analysis of Incorrect Options:** * **A. Ultrasonic fetal cephalometry:** This measures the Biparietal Diameter (BPD). While useful for *diagnosing* growth restriction, it assesses growth, not acute fetal well-being or hypoxia. * **C. Amniotic fluid triglyceride:** This is a marker used to assess fetal **lung maturity**, not fetal well-being or placental function. * **D. Uteroplacental blood flow:** While Doppler studies (e.g., Umbilical Artery) are modern mainstays for monitoring IUGR, "uteroplacental blood flow" is a physiological parameter rather than a standardized clinical test for immediate well-being compared to the CST. **High-Yield Clinical Pearls for NEET-PG:** * **CST Contraindications:** Preterm Rupture of Membranes (PROM), previous classical C-section, and Placenta Previa. * **Modern Practice:** In current clinical practice, the **Biophysical Profile (BPP)** and **Doppler Velocimetry** have largely replaced CST due to being non-invasive; however, in the context of classic exam questions, CST remains the "most dependable" for respiratory reserve. * **Late Decelerations:** Always signify uteroplacental insufficiency.

Question 438: Smoking in pregnancy causes all of the following except:

A. Intrauterine Growth Restriction (IUGR)
B. Pregnancy-Induced Hypertension (PIH)
C. Antepartum Hemorrhage (APH)
D. Postpartum Hemorrhage (PPH) (Correct Answer)

Explanation: **Explanation:** Smoking during pregnancy is a significant risk factor for various adverse obstetric outcomes, primarily due to the effects of **nicotine** (a potent vasoconstrictor) and **carbon monoxide** (which increases carboxyhemoglobin levels, leading to fetal hypoxia). **Why Postpartum Hemorrhage (PPH) is the correct answer:** While smoking is associated with numerous placental and fetal complications, it is **not** a direct cause of Postpartum Hemorrhage. PPH is primarily caused by the "4 Ts": Tone (Atony), Tissue (Retained products), Trauma, and Thrombin (Coagulopathy). Interestingly, some epidemiological studies have even suggested a slightly lower risk of PPH in smokers, though it is not considered a protective factor. **Analysis of Incorrect Options:** * **IUGR (Option A):** Nicotine causes vasoconstriction of uteroplacental vessels, while carbon monoxide reduces oxygen delivery to the fetus. This leads to chronic fetal hypoxia and is a classic cause of **asymmetrical IUGR**. * **PIH (Option B):** This is a controversial but high-yield point. While some studies suggest smoking might paradoxically lower the risk of preeclampsia, standard medical teaching and exams often link smoking to **Pregnancy-Induced Hypertension** and vascular damage due to oxidative stress and endothelial dysfunction. * **APH (Option C):** Smoking is a major risk factor for **Abruptio Placentae** and **Placenta Previa**. Decidual necrosis and vascular changes in the placenta increase the risk of premature separation and abnormal implantation. **Clinical Pearls for NEET-PG:** * **Sudden Infant Death Syndrome (SIDS):** Maternal smoking is the most important modifiable risk factor for SIDS. * **Congenital Anomalies:** Smoking is specifically linked to an increased risk of **Orofacial clefts** (Cleft lip/palate). * **Spontaneous Abortion:** Smoking increases the risk of miscarriage by approximately 25%.

Question 439: What is the rate of transmission of HIV from an infected mother to her infant?

A. 100%
B. 66%
C. 30% (Correct Answer)
D. 5-10%

Explanation: **Explanation:** The transmission of HIV from an mother to her infant is known as **Vertical Transmission** or Mother-to-Child Transmission (MTCT). In the absence of any medical intervention (antiretroviral therapy, elective cesarean section, or avoidance of breastfeeding), the overall risk of transmission is approximately **25–30%**. **Breakdown of Transmission Timing:** * **In-utero (Antenatal):** ~5–10% * **During Labor/Delivery (Intrapartum):** ~15% (This is the period of highest risk due to exposure to infected maternal blood and vaginal secretions). * **Breastfeeding (Postpartum):** ~5–10% **Analysis of Options:** * **Option A (100%) & B (66%):** These are incorrectly high. HIV is not transmitted to every fetus because the placenta acts as a partial barrier and viral load varies. * **Option C (30%):** **Correct.** This represents the global average risk in a non-intervention scenario. * **Option D (5–10%):** This represents the risk if only one phase (like breastfeeding or antenatal) is considered, or the risk achieved with partial medical intervention. **High-Yield Clinical Pearls for NEET-PG:** 1. **With Intervention:** With modern HAART (Highly Active Antiretroviral Therapy), elective LSCS, and formula feeding, the transmission risk can be reduced to **<2%**. 2. **Most Common Route:** Intrapartum (during labor) is the most common time for transmission. 3. **Zidovudine:** Historically the drug of choice for prophylaxis; however, current WHO/National guidelines (NACO) recommend **Tenofovir + Lamivudine + Efavirenz (TLE)** or Dolutegravir-based regimens for all pregnant women regardless of CD4 count. 4. **Breastfeeding:** In India, exclusive breastfeeding is recommended for the first 6 months if replacement feeding is not "Acceptable, Feasible, Affordable, Sustainable, and Safe" (AFASS).

Question 440: A small-sized placenta is typically seen in which of the following conditions?

A. Peripheral vascular disease in the mother
B. Pre-eclampsia (Correct Answer)
C. Maternal weight less than 50 kg
D. Multiple pregnancy

Explanation: **Explanation:** The size and weight of the placenta are directly related to the surface area available for nutrient and oxygen exchange. A **small-sized placenta** (placental hypoplasia) occurs when there is impaired trophoblastic invasion or chronic uteroplacental insufficiency. **Why Pre-eclampsia is correct:** In pre-eclampsia, there is a failure of the secondary wave of trophoblastic invasion (at 16–20 weeks). This results in the spiral arteries remaining narrow and high-resistance, leading to reduced blood flow to the placental bed. The chronic ischemia causes placental infarcts, cytotrophoblastic proliferation, and villous hypoplasia, ultimately resulting in a small, underweight placenta. This is a classic cause of Fetal Growth Restriction (FGR). **Analysis of Incorrect Options:** * **Peripheral vascular disease:** While systemic, it does not specifically target the uterine spiral arteries like the localized pathology of pre-eclampsia. * **Maternal weight < 50 kg:** While maternal nutrition affects birth weight, a low BMI alone does not pathologically restrict placental growth unless associated with severe malnutrition or anemia. * **Multiple pregnancy:** This is a cause of a **large/heavy placenta** (or multiple placentas), as the increased fetal demand requires a larger surface area for exchange. **High-Yield Clinical Pearls for NEET-PG:** * **Large Placenta (Placentomegaly):** Seen in Diabetes Mellitus, Rh-isoimmunization, Syphilis, and Multiple pregnancy. * **Placental Weight:** The average weight at term is ~500g (Ratio of placental weight to fetal weight is 1:6). * **Microscopic hallmark of Pre-eclampsia:** Tenney-Parker changes (increased syncytial knots).

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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