Maternal-Fetal Medicine Practice Questions

Q: All are complications of fibroid in pregnancy except:

Placenta previa. **Explanation:** The correct answer is **Placenta previa**. In medical entrance exams like NEET-PG, it is crucial to distinguish between conditions *caused* by a fibroid and conditions that are merely coincidental. While fibroids are associated with an increased risk of placental abruption (due to impaired implantation over a submucosal fibroid), they do not cause placenta previa. Placenta previa is primarily related to factors like previous scarring (C-sections) or multiparity. **Analysis of Options:** * **Red Degeneration (Option A):** This is the most common complication of fibroids during the **second trimester**. It occurs due to rapid growth leading to venous obstruction and infarction. It presents with acute pain, fever, and localized tenderness. * **Obstructed Labor (Option B):** Large subserosal or intramural fibroids located in the lower uterine segment or cervix can physically block the birth canal, preventing the descent of the fetal head and necessitating a Cesarean section. * **PPH (Option C):** Fibroids interfere with the effective contraction and retraction of uterine muscle fibers after delivery (uterine atony), which is a major cause of Postpartum Hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **Most common change** in fibroid during pregnancy: No change (though 20-30% increase in size). * **Most common degeneration** in pregnancy: Red degeneration (Necrobiosis). * **Management of Red Degeneration:** Always conservative (bed rest, analgesics like NSAIDs). Surgery (Myomectomy) is contraindicated during pregnancy due to high risk of hemorrhage. * **Malpresentations:** Fibroids increase the risk of breech or transverse lie due to distortion of the uterine cavity.

Q: Stillbirth is defined as the birth of a dead newborn child after how many completed weeks of gestation?

28. **Explanation:** The definition of **Stillbirth** varies globally based on the criteria used (WHO vs. National guidelines). In the context of the Indian healthcare system and the National Health Mission (NHM), stillbirth is defined as a baby born with no signs of life at or after **28 completed weeks of gestation**. **1. Why 28 weeks is correct:** In India, the legal and clinical threshold for "viability" (the ability of the fetus to survive outside the womb) is traditionally considered 28 weeks. Any fetal death occurring after this period but before birth is classified as a stillbirth. This aligns with the International Classification of Diseases (ICD-10) recommendation for international reporting. **2. Analysis of Incorrect Options:** * **20 weeks (Option A):** This is the threshold used in many developed countries (like the USA) where neonatal intensive care is more advanced. In India, fetal loss before 20–22 weeks is generally classified as an **Abortion (Miscarriage)**. * **37 weeks (Option B):** This marks the beginning of **Term** pregnancy. A fetal death between 28 and 37 weeks is a preterm stillbirth, while after 37 weeks, it is a term stillbirth. * **40 weeks (Option D):** This is the expected date of delivery (EDD). Death at this stage is a post-term or term stillbirth. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Definition:** For international comparison, WHO defines stillbirth as fetal death at **≥28 weeks** or birth weight **≥1000g**. * **Fresh vs. Macerated:** A "Fresh Stillbirth" (death <24 hours before delivery) suggests intrapartum complications, while a "Macerated Stillbirth" (peeling skin, skull collapse) suggests the fetus died in utero days before delivery. * **Spalding’s Sign:** Overlapping of skull bones on X-ray, a classic sign of fetal death (usually appears 4–7 days after death).

Q: The theorized function of the Hyl anastomosis is equalization of which of the following pressure gradients?

Pressure gradient between umbilical arteries. **Explanation:** The **Hyrtl anastomosis** (often referred to as the Hyl anastomosis in some texts) is a unique vascular shunt located on the fetal surface of the placenta, typically within 1–2 cm of the umbilical cord insertion. It represents a transverse connection between the two umbilical arteries. **Why the correct answer is right:** The primary physiological function of the Hyrtl anastomosis is to act as a **pressure-equalizing valve** between the two umbilical arteries. This ensures that blood flow is distributed evenly to all lobes of the placenta, even if one umbilical artery is partially compressed or if there is asymmetrical resistance in the placental vascular beds. It prevents "backflow" and maintains a stable hemodynamic environment for fetal-maternal exchange. **Analysis of Incorrect Options:** * **Option A:** Oxygen diffusion occurs at the level of the terminal villi in the intervillous space, governed by Fick’s law, not by macro-vascular shunts like the Hyrtl anastomosis. * **Option B:** Osmotic gradients across membranes regulate amniotic fluid volume and electrolyte balance; they are unrelated to the arterial shunts of the umbilical cord. * **Option C:** Spiral arteries are maternal vessels located in the decidua basalis. The Hyrtl anastomosis is a fetal structure located on the chorionic plate. **Clinical Pearls for NEET-PG:** * **Location:** It is the only connection between the two umbilical arteries before they branch into the chorionic villi. * **Safety Mechanism:** In cases of a **Single Umbilical Artery (SUA)**, this anastomosis is absent, which is associated with an increased risk of IUGR and congenital anomalies. * **Flow Direction:** Blood usually flows from the artery with higher pressure to the one with lower pressure, ensuring the entire placenta is perfused even during uterine contractions.

Q: A gravida 3 female with a history of two prior second-trimester abortions associated with painless cervical dilatation presents with Level II ultrasound findings. What is the most appropriate management?

Apply McDonald suture. ***Apply McDonald suture*** - History of two prior **second-trimester abortions** with **painless cervical dilatation** indicates **cervical incompetence**, requiring **cervical cerclage**. - **McDonald cerclage** is the standard procedure for cervical incompetence, using a **purse-string suture** around the cervix to provide mechanical support. *Administer progesterone* - **Progesterone** is used as adjunctive therapy for **short cervix** but is not the definitive treatment for **cervical incompetence**. - It may help maintain pregnancy but cannot provide the **mechanical support** needed to prevent cervical dilatation. *Apply Fothergill suture* - **Fothergill suture** refers to the **Manchester operation** for **uterovaginal prolapse**, not cervical incompetence. - This procedure involves **amputation of the cervix** and **cardinal ligament shortening**, which is inappropriate for pregnancy management. *Wait and watch* - **Expectant management** is inappropriate given the clear history of **recurrent second-trimester losses** due to cervical incompetence. - **Level II ultrasound** likely shows **cervical funneling** or **short cervix**, indicating active cervical changes requiring immediate intervention.

Q: Which of the following is a side effect of magnesium sulfate?

Hypotonia. **Explanation:** Magnesium sulfate ($MgSO_4$) is the drug of choice for seizure prophylaxis in pre-eclampsia and control in eclampsia. Its primary mechanism involves blocking neuromuscular transmission by decreasing the amount of acetylcholine released at the motor endplate. **Why Hypotonia is correct:** As a neuromuscular blocker and CNS depressant, magnesium causes generalized muscle relaxation. In the mother, this manifests as a loss of deep tendon reflexes (the first sign of toxicity). If it crosses the placenta, it can cause **neonatal hypotonia** (floppy baby syndrome) and respiratory depression, especially if administered shortly before delivery. **Analysis of Incorrect Options:** * **Anuria:** $MgSO_4$ is excreted almost exclusively by the kidneys. While renal failure leads to magnesium toxicity, the drug itself does not cause anuria. In fact, monitoring urine output ($>30$ ml/hr) is mandatory to prevent toxicity. * **Coma:** While severe toxicity can lead to CNS depression and somnolence, "Coma" is an extreme end-stage manifestation. Hypotonia and loss of reflexes are much more characteristic and common side effects. * **Pulmonary Edema:** This is a known complication of pre-eclampsia and can be exacerbated by fluid overload during $MgSO_4$ administration, but it is not a direct pharmacological side effect of the magnesium ion itself. **NEET-PG High-Yield Pearls:** * **Monitoring Parameters:** 1. Patellar reflex (earliest sign of toxicity: loss of reflex at 7–10 mEq/L); 2. Respiratory rate ($>12$/min); 3. Urine output ($>100$ ml/4 hours). * **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (administered over 10 minutes). * **Therapeutic Range:** 4–7 mEq/L. Respiratory paralysis occurs at $>12$ mEq/L and cardiac arrest at $>25$ mEq/L.

Q: Which of the following is NOT an unequivocal evidence of heart disease in pregnancy?

Systolic murmur. **Explanation:** In pregnancy, physiological changes such as increased blood volume, decreased blood viscosity, and a hyperdynamic circulation often lead to the development of **functional (innocent) murmurs**. **1. Why Systolic Murmur is the Correct Answer:** A **systolic murmur** (specifically a soft, mid-systolic ejection murmur) is found in up to 90% of healthy pregnant women. It is caused by increased flow across the pulmonary and aortic valves. Because it is a common physiological finding, it is **not** unequivocal evidence of organic heart disease. **2. Why the other options are wrong (Evidence of Organic Disease):** * **Diastolic Murmur (Option B):** Diastolic murmurs are **always pathological** in pregnancy. They usually indicate underlying conditions like Mitral Stenosis (the most common rheumatic heart lesion in pregnancy) or Aortic Regurgitation. * **Diastolic/Systolic Thrills (Options C & D):** The presence of a **thrill** (a palpable murmur) signifies a high-grade turbulence that is never physiological. A systolic thrill usually indicates severe valvular stenosis or a Ventricular Septal Defect (VSD). **High-Yield Clinical Pearls for NEET-PG:** * **Burwell’s Criteria:** Organic heart disease is diagnosed if any of the following are present: 1. Diastolic, presystolic, or continuous murmur. 2. Cardiac enlargement (clinically or via X-ray). 3. Loud systolic murmur associated with a **thrill**. 4. Severe arrhythmia (e.g., Atrial Fibrillation). * **Most common heart disease in pregnancy (India):** Rheumatic Heart Disease (Mitral Stenosis is the most common lesion). * **Most common congenital heart disease:** ASD (Atrial Septal Defect). * **Dangerous Period:** The risk of heart failure is highest at **28–32 weeks** (peak blood volume), during **labor**, and immediately **postpartum** (due to autotransfusion from the uterus).

Q: Which of the following tests is not used for the detection of specific aneuploidy?

Microarray. **Explanation:** The core of this question lies in distinguishing between **numerical** chromosomal abnormalities (aneuploidy) and **structural** sub-microscopic abnormalities (copy number variants). **Why Microarray is the correct answer:** Chromosomal Microarray (CMA) is designed to detect **microdeletions and microduplications** (Copy Number Variations - CNVs) that are too small to be seen under a microscope. While it can detect unbalanced rearrangements, it is **not** the primary tool for specific aneuploidy detection because it cannot detect balanced translocations or triploidy effectively. In clinical practice, if a specific aneuploidy (like Trisomy 21) is suspected, rapid molecular tests or karyotyping are preferred. **Why the other options are incorrect:** * **FISH (Fluorescent In Situ Hybridization):** Uses fluorescent probes to bind to specific chromosomes (13, 18, 21, X, Y). It is a rapid gold-standard test for detecting specific aneuploidies in interphase nuclei. * **QF-PCR (Quantitative Fluorescent PCR):** Amplifies polymorphic microsatellite markers. It is the fastest method (24–48 hours) specifically used to diagnose common autosomal and sex chromosome aneuploidies. * **Karyotyping:** The traditional "gold standard" that provides a visual representation of all chromosomes. It identifies both numerical (aneuploidy) and large structural abnormalities (>5-10 Mb). **Clinical Pearls for NEET-PG:** * **Rapid Aneuploidy Testing:** FISH and QF-PCR are the preferred methods for quick results (e.g., following an abnormal prenatal screen). * **Microarray Indication:** It is the **first-line investigation** for a fetus with one or more structural ultrasound abnormalities but a normal karyotype. * **Karyotyping Limitation:** It requires cell culture (takes 2–3 weeks), whereas molecular methods (QF-PCR/FISH) do not. * **Triploidy:** QF-PCR is superior to Microarray in detecting triploidy.

Q: A pregnant woman presents with a major degree placenta previa and a malformed fetus. What is the best management approach?

Cesarean section. **Explanation:** The management of placenta previa is primarily dictated by the degree of the previa and the maternal hemodynamic status, rather than the condition of the fetus. **1. Why Cesarean Section is Correct:** In cases of **major degree placenta previa** (Grade III and IV), the placenta completely or partially covers the internal os. This creates a physical barrier to vaginal delivery and, more importantly, poses a massive risk of life-threatening maternal hemorrhage if the cervix begins to dilate or if any attempt at vaginal delivery is made. Even if the fetus is malformed or dead, the **maternal safety** takes precedence. A Cesarean section is mandatory to bypass the obstruction and control bleeding, regardless of fetal viability or anomalies. **2. Why Incorrect Options are Wrong:** * **Oxytocin drip & Rupture of membranes (ARM):** These are methods to induce or augment labor. In major placenta previa, uterine contractions and cervical dilatation will cause placental separation from the lower uterine segment, leading to torrential, uncontrollable bleeding. ARM is only considered in minor degrees (Grade I or II-anterior). * **Instillation of Prostaglandin E2:** This is used for cervical ripening and induction. Similar to oxytocin, inducing labor in a major previa is contraindicated due to the risk of maternal exsanguination. **Clinical Pearls for NEET-PG:** * **Macafee’s Regimen:** Expectant management used to gain fetal maturity, but only if the mother is stable and bleeding has stopped. * **Double Set-up Examination:** Only performed in the OT (ready for immediate CS) for cases of minor/doubtful placenta previa to decide the mode of delivery. * **Rule of Thumb:** In placenta previa, "The life of the mother is always more important than the condition of the fetus." Major degree = Mandatory CS.

Q: A 25-year-old pregnant woman diagnosed with Rheumatic Heart Disease and Mitral Stenosis at 16 years of age presents at 6 weeks of gestation with a mitral valve area of 1.4 sq cm. She is currently in NYHA class 2 and on antiarrhythmic drugs. What is the risk of maternal mortality?

1.5 cm²) or **moderate** (Valve area 1.0–1.5 cm²) and the patient is asymptomatic or mildly symptomatic (NYHA Class I or II). * For mWHO Class II, the risk of maternal mortality is extremely low, typically **<1%**. Although she is on antiarrhythmics, her valve area (1.4 cm²) and functional status (NYHA II) do not place her in a high-risk category. 2. **Why incorrect options are wrong:** * **Options B, C, and D (5% to 50%):** These high mortality rates are associated with **mWHO Class IV** conditions. These include Severe Mitral Stenosis (Valve area <1.0 cm²), Pulmonary Arterial Hypertension (Eisenmenger syndrome), and severe systemic ventricular dysfunction (EF <30%). In such cases, mortality can range from 10% to 50%, and pregnancy is generally contraindicated. **High-Yield Clinical Pearls for NEET-PG:** * **Most common heart disease in pregnancy (India):** Rheumatic Heart Disease (RHD). * **Most common lesion in RHD:** Mitral Stenosis. * **Critical MS:** Valve area **<1.0 cm²**. This is mWHO Class IV and carries a high risk of pulmonary edema and mortality. * **Most dangerous period:** The immediate postpartum period (first 24–48 hours) due to "autotransfusion" from the involuting uterus and relief of IVC compression, leading to sudden fluid overload. * **Management:** Beta-blockers are the mainstay for rate control in MS to allow adequate diastolic filling.

Question 1

All are complications of fibroid in pregnancy except:

Accepted Answer

Placenta previa

Answer

Red degeneration

Answer

Obstructed labor

Answer

PPH

Question 2

Stillbirth is defined as the birth of a dead newborn child after how many completed weeks of gestation?

Accepted Answer

28

Answer

20

Answer

37

Answer

40

Question 3

The theorized function of the Hyl anastomosis is equalization of which of the following pressure gradients?

Accepted Answer

Pressure gradient between umbilical arteries

Answer

Oxygen diffusion across villi

Answer

Osmotic gradient across fetal membranes

Answer

Pressure gradient between spiral arteries

Question 4

A gravida 3 female with a history of two prior second-trimester abortions associated with painless cervical dilatation presents with Level II ultrasound findings. What is the most appropriate management?

Accepted Answer

Apply McDonald suture

Answer

Administer progesterone

Answer

Apply Fothergill suture

Answer

Wait and watch

Question 5

A G2P1L1 woman with a previous lower segment cesarean section (LSCS) presents at 37 weeks gestation with a blood pressure of 150/100 mm Hg. The cardiotocography (CTG) is reactive, and her per vaginum (P/V) findings are: os closed, cervix partially effaced, soft, midline, vertex at -2 station, and the pelvis is adequate. Urine protein by dipstick is 1+. What is the management?

Accepted Answer

Induction of labor.

Answer

Start antihypertensives and follow up after 1 week.

Answer

Cesarean section.

Answer

Do not start antihypertensives but follow up after 1 week.

Question 6

Which of the following is a side effect of magnesium sulfate?

Accepted Answer

Hypotonia

Answer

Anuria

Answer

Coma

Answer

Pulmonary edema

Question 7

Which of the following is NOT an unequivocal evidence of heart disease in pregnancy?

Accepted Answer

Systolic murmur

Answer

Diastolic murmur

Answer

Diastolic thrill and murmur

Answer

Systolic thrill and murmur

Question 8

Which of the following tests is not used for the detection of specific aneuploidy?

Accepted Answer

Microarray

Answer

FISH

Answer

Karyotyping

Answer

QF-PCR

Question 9

A pregnant woman presents with a major degree placenta previa and a malformed fetus. What is the best management approach?

Accepted Answer

Cesarean section

Answer

Oxytocin drip

Answer

Rupture of membranes

Answer

Instillation of Prostaglandin E2

Question 10

A 25-year-old pregnant woman diagnosed with Rheumatic Heart Disease and Mitral Stenosis at 16 years of age presents at 6 weeks of gestation with a mitral valve area of 1.4 sq cm. She is currently in NYHA class 2 and on antiarrhythmic drugs. What is the risk of maternal mortality?

Accepted Answer

<1%

Answer

50%

Answer

15%

Answer

5%

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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