Maternal-Fetal Medicine Practice Questions

Q: A 30-year-old woman presents with amenorrhoea of 6 weeks duration and a lump in the right iliac fossa. What is the investigation of choice?

Ultrasound abdomen. **Explanation:** The clinical presentation of **amenorrhoea (6 weeks)** combined with a **lump in the right iliac fossa** in a woman of reproductive age is highly suspicious for an **Ectopic Pregnancy** or a **Corpus Luteum cyst**. **Why Ultrasound (USG) is the Investigation of Choice:** Ultrasound (specifically Transvaginal Sonography/TVS) is the gold standard first-line investigation for early pregnancy complications. It is non-invasive, cost-effective, and lacks ionizing radiation, making it safe for the fetus. It can accurately confirm intrauterine pregnancy, identify an adnexal mass (like a tubal pregnancy), and detect free fluid in the Pouch of Douglas (suggestive of rupture). **Analysis of Incorrect Options:** * **Laparoscopy (Option B):** While it is the **Gold Standard for diagnosis** and treatment of ectopic pregnancy, it is an invasive surgical procedure. It is reserved for cases where USG is inconclusive or the patient is hemodynamically unstable. * **Shielded CT scan (Option C):** CT involves high doses of ionizing radiation. Even with shielding, it is contraindicated in early pregnancy due to the risk of teratogenicity and is less sensitive than USG for pelvic structures. * **X-ray (Option D):** X-rays have no role in diagnosing early pregnancy or soft tissue pelvic masses and pose a radiation risk. **High-Yield Clinical Pearls for NEET-PG:** * **Discriminatory Zone:** The level of serum β-hCG at which an intrauterine gestational sac should be visible on USG (TVS: 1500–2000 mIU/ml; TAS: 6500 mIU/ml). * **Classic Triad of Ectopic Pregnancy:** Amenorrhoea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Most common site of Ectopic Pregnancy:** Ampulla of the Fallopian tube.

Q: A woman in her first pregnancy reports that she smokes one pack of cigarettes a day. An ultrasound is ordered in the thirty-second week of the pregnancy to evaluate for which of the following?

Fetal size. **Explanation:** **1. Why "Fetal size" is the correct answer:** Cigarette smoking during pregnancy is a well-established risk factor for **Fetal Growth Restriction (FGR)**. Nicotine and carbon monoxide in tobacco smoke cause systemic vasoconstriction and increase carboxyhemoglobin levels, leading to chronic placental insufficiency and reduced oxygen delivery to the fetus. This typically results in "asymmetric" growth restriction. Since the risk of FGR increases as the pregnancy progresses, a 32-week ultrasound is specifically indicated to assess fetal biometry (size) and estimated fetal weight to ensure the fetus is growing appropriately for its gestational age. **2. Why the other options are incorrect:** * **Amniotic fluid volume:** While oligohydramnios can be associated with placental insufficiency, it is usually a secondary finding. The primary concern with smoking is the direct impact on fetal weight and size. * **Fetal abnormalities:** Smoking is not a major teratogen associated with structural malformations detectable at 32 weeks. Screening for structural anomalies is ideally performed during the "Level II" anomaly scan at 18–20 weeks. * **Fetal motion:** Fetal movement is a marker of acute fetal well-being (biophysical profile). While important, it is not the specific pathology linked to the chronic vascular effects of smoking. **Clinical Pearls for NEET-PG:** * **Dose-Response Relationship:** The reduction in birth weight is directly proportional to the number of cigarettes smoked (approx. 15–20g reduction per cigarette per day). * **Smoking & Placenta:** Smoking increases the risk of **Placenta Previa** and **Abruptio Placentae**. * **Postnatal Risks:** Maternal smoking is a significant risk factor for **Sudden Infant Death Syndrome (SIDS)** and childhood respiratory infections.

Q: Which of the following tests is used to estimate the amount of feto-maternal hemorrhage?

Kleihauer Betke test. **Explanation:** The **Kleihauer-Betke (KB) test** is the gold standard for quantifying the volume of feto-maternal hemorrhage (FMH). It is based on the principle of **acid elution**. Fetal hemoglobin (HbF) is resistant to acid elution, whereas adult hemoglobin (HbA) is sensitive. When a maternal blood smear is treated with acid and stained, adult RBCs appear as pale "ghost cells," while fetal RBCs remain dark pink. By counting the ratio of fetal to maternal cells, the volume of FMH can be calculated using the formula: *Volume of FMH (mL) = (% of fetal cells × 50).* This is clinically vital for calculating the required dose of Anti-D immunoglobulin in Rh-negative mothers. **Analysis of Incorrect Options:** * **Coombs' test:** Used to detect antibodies against RBCs. The Indirect Coombs' Test (ICT) screens for maternal sensitization, while the Direct Coombs' Test (DCT) detects antibodies on the newborn's RBCs (e.g., in Hemolytic Disease of the Newborn). * **Liley’s Spectrophotometry:** Historically used to assess the severity of fetal hemolysis by measuring **bilirubin levels** in amniotic fluid (at 450 nm) and plotting them on a Liley chart. * **Schrill's test:** This is a distractor; it is not a standard test in OBGYN. (Note: It is often confused with the *Schilling test* used for Vitamin B12 absorption). **High-Yield Clinical Pearls for NEET-PG:** * **Screening vs. Quantification:** The **Rosette test** is the initial qualitative screening test for FMH. If positive, the **KB test** is performed for quantification. * **Anti-D Dosing:** One 300 mcg vial of Anti-D neutralizes **30 mL** of fetal whole blood (or 15 mL of packed RBCs). * **Alternative:** Flow cytometry is increasingly replacing the KB test due to better precision and less inter-observer variability.

Q: Which of the following statements regarding epilepsy in pregnancy is true?

Monotherapy is preferred over polydrug therapy.. **Explanation:** **1. Why Monotherapy is Preferred:** The primary goal in managing epilepsy during pregnancy is to achieve seizure control using the lowest effective dose of a single drug. **Monotherapy** is preferred because the risk of major congenital malformations (MCMs) increases significantly with **polytherapy** (the use of multiple anti-epileptic drugs). For example, combining Valproate with other drugs exponentially increases the risk of neural tube defects and cognitive impairment compared to using a single agent. **2. Analysis of Incorrect Options:** * **Option A:** In reality, seizure frequency remains **unchanged in about 50-60%** of patients. It increases in approximately 20-30% of cases, often due to physiological changes (increased volume of distribution, increased renal clearance, or sleep deprivation). * **Option C:** There is a **genetic predisposition**; the incidence of epilepsy in offspring is higher (approx. 2-5%) compared to the general population (approx. 1%). * **Option D:** Breastfeeding is **not contraindicated**. While AEDs are secreted in breast milk, the benefits of breastfeeding generally outweigh the risks. Infants should simply be monitored for sedation or poor feeding. **3. Clinical Pearls for NEET-PG:** * **Pre-conception:** Start **Folic acid (5 mg/day)** at least 3 months prior to conception to reduce NTD risks. * **Drug of Choice:** **Lamotrigine** and **Levetiracetam** are generally considered the safest options. **Valproate** is the most teratogenic and should be avoided if possible. * **Vitamin K:** To prevent hemorrhagic disease of the newborn, 1 mg of Vitamin K is administered to the neonate at birth (especially if the mother is on enzyme-inducing drugs like Phenytoin or Phenobarbital).

Q: Anti-phospholipid antibodies are not typically tested in which of the following conditions?

Polyhydramnios. **Explanation:** The core pathophysiology of **Antiphospholipid Antibody Syndrome (APS)** in pregnancy involves a prothrombotic state and placental insufficiency. Antibodies (Lupus anticoagulant, Anti-cardiolipin, and Anti-β2-glycoprotein I) cause thrombosis in the placental vasculature and inhibit trophoblast invasion, leading to decreased placental perfusion. **Why Polyhydramnios is the Correct Answer:** Polyhydramnios (excess amniotic fluid) is typically associated with fetal anomalies (e.g., esophageal atresia), maternal diabetes, or multiple gestations. It is **not** a manifestation of placental vascular compromise. In contrast, APS is characteristically associated with **Oligohydramnios** due to placental insufficiency and reduced fetal renal perfusion. **Analysis of Incorrect Options:** * **Recurrent Abortion:** This is a hallmark of APS. The clinical criteria for APS include ≥3 consecutive spontaneous abortions before 10 weeks, or ≥1 unexplained death of a morphologically normal fetus at ≥10 weeks. * **IUGR:** Placental infarction and reduced nutrient transfer caused by APS lead to fetal growth restriction. * **Mild Preeclampsia:** APS is a significant risk factor for placental-mediated hypertensive disorders. Testing is indicated if a patient develops severe preeclampsia or eclampsia before 34 weeks of gestation. **NEET-PG High-Yield Pearls:** * **Sapporo Criteria:** Diagnosis requires at least one clinical (vascular thrombosis or pregnancy morbidity) and one laboratory criterion (positive tests 12 weeks apart). * **Treatment:** The standard of care for APS in pregnancy is **Low Dose Aspirin (LDA)** and **Low Molecular Weight Heparin (LMWH)**. * **Most Specific Test:** Anti-β2-glycoprotein I is the most specific, while Lupus Anticoagulant is the strongest predictor of pregnancy complications.

Q: What is the least common site of ectopic pregnancy?

Interstitial part. **Explanation:** The site of an ectopic pregnancy is determined by where the blastocyst implants outside the uterine cavity. Over 95% of ectopic pregnancies occur in the Fallopian tube. **1. Why the Interstitial part is the correct answer:** The **interstitial (intramural) part** is the segment of the Fallopian tube that traverses the muscular wall of the uterus. It is the **least common tubal site**, accounting for only about **2–3%** of cases. Because this area is surrounded by thick myometrium, it can accommodate a larger gestational sac before rupturing (usually between 12–16 weeks), often leading to life-threatening hemorrhage due to its proximity to the uterine and ovarian vessels. **2. Why the other options are incorrect:** * **Ampulla (Option C):** This is the **most common** site of ectopic pregnancy (approx. 70–80%). It is the widest part of the tube where fertilization typically occurs. * **Isthmus (Option B):** This is the second most common site (approx. 12%). Rupture occurs early here (6–8 weeks) because the lumen is narrow and non-distensible. * **Fimbrial end (Option D):** This accounts for about 5% of cases. It is more common than the interstitial part but less common than the ampulla or isthmus. **Clinical Pearls for NEET-PG:** * **Most common overall site:** Ampulla (70-80%). * **Least common tubal site:** Interstitial (2-3%). * **Most common non-tubal site:** Ovary (followed by abdominal and cervical). * **Highest risk of mortality:** Interstitial pregnancy (due to delayed rupture and massive bleeding). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases).

Q: Of the following potential clinical outcomes of tubal pregnancy, which one is the commonest?

Vascular insufficiency degenerating the embryo. **Explanation:** In a tubal ectopic pregnancy, the fallopian tube lacks a well-developed decidua and sufficient space for growth. The **most common clinical outcome** is that the embryo fails to thrive due to **vascular insufficiency**, leading to early degeneration and resorption. This often occurs before the patient even realizes they are pregnant or before clinical symptoms manifest. * **Option C (Correct):** The trophoblast fails to establish a robust blood supply in the thin tubal wall. This leads to early embryonic death, followed by the formation of a tubal mole or complete resorption. * **Option A (Incorrect):** Tubal rupture is a dramatic and life-threatening complication, but it is statistically less common than early degeneration. It typically occurs when the trophoblast invades the muscularis or when the distension exceeds the tube's capacity (common in isthmic pregnancies). * **Option B (Incorrect):** Tubal abortion occurs when the products of conception are expelled through the fimbrial end into the peritoneal cavity. While common in ampullary pregnancies, it ranks second to early degeneration/resorption. * **Option D (Incorrect):** Cornual (interstitial) pregnancies are dangerous because they can grow larger due to the distensibility of the myometrium, but reaching term is extremely rare and carries a high risk of catastrophic rupture. **NEET-PG High-Yield Pearls:** * **Most common site of Ectopic Pregnancy:** Ampulla (70%). * **Most common site for Tubal Rupture:** Isthmus (due to narrow lumen). * **Most common site for Tubal Abortion:** Ampulla. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serum $\beta$-hCG (Discriminatory zone: 1500–2000 mIU/mL).

Question 1

A 35-week pregnant female presents to the emergency department with complaints of headache and blurred vision. Her blood pressure is 170/110 mm Hg. How should this patient be managed?

Accepted Answer

Admit, start magnesium sulfate and antihypertensives, and terminate the pregnancy

Answer

Admit and observe

Answer

Admit, control blood pressure, and continue pregnancy until term

Answer

Start antihypertensives and follow up in the outpatient department

Question 2

A pregnant woman at 32 weeks gestation presents for routine antenatal checkup. Examination reveals pedal edema and her blood pressure on repeated recordings is 150/100 mm Hg. Her urine protein is 2+. Which of the following will be the first-line drug of choice in this patient?

Accepted Answer

Nifedipine

Answer

Metoprolol

Answer

Methyldopa

Answer

Losartan

Question 3

A 30-year-old woman presents with amenorrhoea of 6 weeks duration and a lump in the right iliac fossa. What is the investigation of choice?

Accepted Answer

Ultrasound abdomen

Answer

Laparoscopy

Answer

Shielded CT scan

Answer

X-ray

Question 4

A woman in her first pregnancy reports that she smokes one pack of cigarettes a day. An ultrasound is ordered in the thirty-second week of the pregnancy to evaluate for which of the following?

Accepted Answer

Fetal size

Answer

Amniotic fluid volume

Answer

Fetal abnormalities

Answer

Fetal motion

Question 5

A pathologist is examining placentas from five different patients. He notes the following characteristics in the placentas: Patient A: fused dichorionic diamniotic; Patient B: dichorionic diamniotic; Patient C: circumvallate placenta; Patient D: monochorionic diamniotic. Which of the patients unquestionably gave birth to identical twins?

Accepted Answer

Patient D

Answer

Patient A

Answer

Patient B

Answer

Patient C

Question 6

Which of the following tests is used to estimate the amount of feto-maternal hemorrhage?

Accepted Answer

Kleihauer Betke test

Answer

Coombs' test

Answer

Lily's spectrophotometer

Answer

Schrill's test

Question 7

Which of the following statements regarding epilepsy in pregnancy is true?

Accepted Answer

Monotherapy is preferred over polydrug therapy.

Answer

Seizure frequency decreases in the majority of patients.

Answer

There is no increased incidence of epilepsy in the offspring.

Answer

Breastfeeding is contraindicated.

Question 8

Anti-phospholipid antibodies are not typically tested in which of the following conditions?

Accepted Answer

Polyhydramnios

Answer

Intrauterine Growth Restriction (IUGR)

Answer

Mild Preeclampsia

Answer

Recurrent Abortion

Question 9

What is the least common site of ectopic pregnancy?

Accepted Answer

Interstitial part

Answer

Isthmus

Answer

Ampulla

Answer

Fimbrial end

Question 10

Of the following potential clinical outcomes of tubal pregnancy, which one is the commonest?

Accepted Answer

Vascular insufficiency degenerating the embryo

Answer

Tubal rupture

Answer

Tubal abortion

Answer

Cornual pregnancy reaching term duration

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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