Maternal-Fetal Medicine Practice Questions

Q: When shoulder pain develops in a case of tubal pregnancy, what does it indicate?

Severe internal bleeding. **Explanation:** The correct answer is **D. Severe internal bleeding.** In the context of a ruptured ectopic pregnancy, shoulder tip pain is a classic clinical sign known as **Danforth’s Sign**. This occurs due to massive intraperitoneal hemorrhage (hemoperitoneum). The blood accumulates in the subdiaphragmatic space, causing irritation of the **phrenic nerve** (C3, C4, C5). Because the phrenic nerve shares the same spinal cord segments as the supraclavicular nerves, the pain is referred to the shoulder (dermatomes C3-C4). This indicates a surgical emergency and significant blood loss. **Analysis of Incorrect Options:** * **A. Tubal abortion:** While this involves the expulsion of the products of conception through the fimbrial end and can cause bleeding, it is often gradual and may form a pelvic hematocele rather than the massive, rapid bleeding required to reach the diaphragm. * **B. Tubal mole:** This occurs when the ovum dies but remains in the tube, surrounded by layers of blood clot. It is usually a contained process and does not typically cause massive intraperitoneal hemorrhage. * **C. Broad ligament hematoma:** This occurs in an extraperitoneal rupture (between the leaves of the broad ligament). Since the blood is contained within the ligament and does not enter the general peritoneal cavity to touch the diaphragm, it will not cause shoulder pain. **High-Yield Clinical Pearls for NEET-PG:** * **Kehr’s Sign:** Similar referred shoulder pain, but classically associated with a **ruptured spleen**. * **Cullen’s Sign:** Periumbilical ecchymosis (bluish discoloration) indicating intraperitoneal hemorrhage; seen in ruptured ectopic pregnancy or acute pancreatitis. * **Golden Rule:** Any woman of reproductive age presenting with amenorrhea, abdominal pain, and fainting/syncope should be evaluated for ruptured ectopic pregnancy until proven otherwise.

Q: Maternal Alpha-fetoprotein is increased in which of the following conditions?

Neural tube defects. **Explanation:** **Alpha-fetoprotein (AFP)** is a glycoprotein synthesized by the fetal yolk sac and later by the fetal liver. It is the fetal equivalent of albumin. In a normal pregnancy, small amounts of AFP leak into the maternal circulation through the placenta. **Why Neural Tube Defects (NTDs) cause increased AFP:** In conditions like **Anencephaly** and **Open Spina Bifida**, there is a defect in the fetal skin or neural coverings. This allows AFP to leak directly from the fetal cerebrospinal fluid or exposed capillaries into the amniotic fluid, and subsequently into the maternal serum. Therefore, Maternal Serum AFP (MSAFP) is a primary screening tool for open NTDs. **Analysis of Incorrect Options:** * **Diabetes Mellitus:** Maternal diabetes is actually associated with **decreased** levels of MSAFP. The exact mechanism is unclear but may relate to delayed fetal growth or placental factors. * **Fetal Cardiac Defects:** These do not typically cause a breach in fetal integument; hence, AFP levels remain normal. * **Rubella Infection:** While intrauterine infections can cause various anomalies, they are not classically associated with elevated AFP. **High-Yield Clinical Pearls for NEET-PG:** * **Causes of Increased MSAFP:** Open NTDs, Multiple pregnancy (most common cause of "unexplained" elevation), Omphalocele, Gastroschisis, Renal anomalies (Finnish-type nephrosis), and Fetal demise. * **Causes of Decreased MSAFP:** Down Syndrome (Trisomy 21), Trisomy 18, Maternal Obesity, and Gestational Trophoblastic Disease. * **Screening Window:** MSAFP is ideally measured between **15–20 weeks** (Second Trimester). * **Next Step:** If MSAFP is elevated, the first step is a **Targeted Ultrasound** to confirm gestational age and rule out multiple pregnancies or visible defects.

Q: Placenta succenturiata may lead to all of the following except?

Preterm delivery. **Explanation:** **Placenta Succenturiata** is a morphological variation where one or more small accessory lobes of placental tissue are located in the membranes at a distance from the main placental mass. These lobes are connected to the main placenta by fetal vessels (vasa previa risk). **Why Option A is the correct answer:** Preterm delivery is **not** typically caused by a succenturiate lobe. Preterm labor is generally associated with conditions like uterine overdistension (polyhydramnios, twins), infections, or cervical insufficiency. While placental abnormalities like placenta previa or abruption can lead to preterm birth, a succenturiate lobe itself does not trigger early labor. **Analysis of Incorrect Options:** * **B. Postpartum Hemorrhage (PPH):** If the accessory lobe is retained in the uterus after the main placenta is delivered, it prevents effective uterine contraction, leading to atonic PPH. * **C. Missing Lobe:** Upon inspection of the delivered placenta, a "gap" in the membranes with torn vessels extending from the main mass suggests a missing succenturiate lobe remains inside the uterus. * **D. Sepsis and Subinvolution:** A retained accessory lobe acts as a nidus for infection (**Sepsis/Endometritis**) and prevents the uterus from returning to its non-pregnant size (**Subinvolution**). **High-Yield NEET-PG Pearls:** 1. **Vasa Previa:** The most dangerous complication occurs when the connecting vessels run across the internal os. Rupture of these vessels leads to fetal exsanguination (Benckiser’s hemorrhage). 2. **Management:** Always inspect the membranes for torn vessels; if a lobe is suspected to be missing, manual exploration of the uterus is mandatory. 3. **Diagnosis:** Often made via antenatal color Doppler ultrasound.

Q: A 38-week pregnant woman delivered a baby without upper limbs. What is a possible cause?

Amniotic band. **Explanation:** The correct answer is **Amniotic Band Syndrome (ABS)**. This condition occurs due to the premature rupture of the amnion, leading to the formation of fibrous, sticky bands. These bands can entangle, constrict, or amputate developing fetal parts, most commonly the distal limbs and digits. When these bands encircle a limb early in gestation, they can lead to complete **congenital amputation** or transverse limb defects, explaining the absence of upper limbs in this neonate. **Analysis of Incorrect Options:** * **B. True knot of umbilical cord:** While a true knot can lead to fetal distress or intrauterine fetal death (IUFD) due to compromised blood flow, it does not cause structural limb defects or amputations. * **C. Genetic abnormality:** While certain genetic syndromes (like Roberts syndrome) can cause limb reduction defects (phocomelia), they are usually symmetrical and associated with other dysmorphic features. Amniotic band syndrome is typically **asymmetrical and sporadic**, making it a more classic cause for isolated limb absence in a non-syndromic presentation. **High-Yield Clinical Pearls for NEET-PG:** * **Pathogenesis:** The most widely accepted theory is the **Torpin Theory** (Exogenous theory), which suggests that amnion rupture leads to "entrapment" by fibrous bands. * **Clinical Presentation:** Look for "constriction rings" on limbs, pseudo-syndactyly (fused fingers), or asymmetric amputations. * **Associated Defects:** ABS is also linked to craniofacial clefts and body wall defects (e.g., gastroschisis) if the bands involve the head or abdomen. * **Risk Factors:** It is generally a **sporadic event** with a very low recurrence risk in subsequent pregnancies.

Q: An **AG2 P1L1** (gravida 2, para 1, living 1) female, with a previous history of lower segment cesarean section (LSCs), presents at 36 weeks of gestation with breech presentation. What is the next step in management?

External cephalic version (ECV) at 37 weeks. ### Explanation **Correct Option: A. External cephalic version (ECV) at 37 weeks** The primary goal in managing a breech presentation is to achieve a cephalic presentation to allow for a trial of labor. According to RCOG and ACOG guidelines, a **previous lower segment cesarean section (LSCS) is NOT a contraindication to ECV**. The success rate of ECV in women with a prior scar is similar to those without one, and the risk of uterine rupture is extremely low (<0.5%). ECV is ideally performed at **37 weeks** in multiparous women to minimize the risk of preterm labor while ensuring the fetus is mature enough if an emergency delivery is required. **Why other options are incorrect:** * **B. Planned cesarean section at 38 weeks:** While a repeat CS is an option, it is not the *next* step. Guidelines recommend offering ECV first to provide the patient the opportunity for a Vaginal Birth After Cesarean (VBAC). * **C. Immediate cesarean section:** There is no evidence of fetal distress or active labor. At 36 weeks, the fetus is late-preterm; immediate delivery without indication increases neonatal morbidity. * **D. Induction of labor:** Inducing labor in a breech presentation, especially with a scarred uterus, is contraindicated due to the high risk of cord prolapse and difficult after-coming head delivery. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisites for ECV:** Reactive NST, adequate liquor (AFI >5), and no uterine anomalies. * **Contraindications to ECV:** Placenta previa, multifetal gestation, ruptured membranes, or any indication for a CS regardless of presentation. * **Success Rate:** Approximately 50% in nulliparous and 60% in multiparous women. * **Tocolysis:** Use of beta-mimetics (e.g., Ritodrine or Terbutaline) during ECV increases the success rate by relaxing the myometrium.

Q: A 24-year-old woman presents with primary infertility and acute abdominal pain. Her vital signs are: blood pressure 90/60 mm Hg, pulse rate 102 bpm. Her hematocrit is 28%. Which of the following is a feature of ectopic pregnancy?

Pain referred to the supraclavicular region. ### Explanation The clinical presentation of acute abdominal pain, hypotension (90/60 mm Hg), tachycardia (102 bpm), and a low hematocrit (28%) in a woman of reproductive age strongly suggests a **ruptured ectopic pregnancy** with resulting hemoperitoneum and hypovolemic shock. **Why Option D is Correct:** The correct answer is **pain referred to the supraclavicular region (Laffon’s sign)**. When an ectopic pregnancy ruptures, blood accumulates in the peritoneal cavity. As the patient lies down, this blood tracks up to the subdiaphragmatic space, irritating the **phrenic nerve (C3-C5)**. Since the supraclavicular nerves share the same spinal origin (C3-C4), the brain perceives this irritation as pain in the shoulder/neck area. This is a classic example of **referred pain**. **Analysis of Incorrect Options:** * **Option A:** In hypovolemic shock, blood pressure **decreases** (orthostatic hypotension) rather than elevates when assuming an erect position. * **Option B:** **Pulsus paradoxus** (an exaggerated drop in systolic BP >10 mmHg during inspiration) is characteristic of cardiac tamponade or severe asthma, not ectopic pregnancy. * **Option C:** **Murphy’s sign** is indicative of acute cholecystitis. While right upper quadrant pain can occur in Fitz-Hugh-Curtis syndrome (PID), it is not a classic feature of ruptured ectopic pregnancy. **NEET-PG High-Yield Pearls:** * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serum β-hCG (Correlation with the "Discriminatory Zone" of 1500–2000 mIU/mL). * **Cullen’s Sign:** Periumbilical bluish discoloration indicating hemoperitoneum (rare but high-yield). * **Management:** Hemodynamically unstable patients (like the one in this vignette) require **immediate laparotomy**, not laparoscopy or medical management.

Question 1

When shoulder pain develops in a case of tubal pregnancy, what does it indicate?

Accepted Answer

Severe internal bleeding

Answer

Tubal abortion

Answer

Development of a tubal mole

Answer

Development of a broad ligament hematoma

Question 2

Maternal Alpha-fetoprotein is increased in which of the following conditions?

Accepted Answer

Neural tube defects

Answer

Diabetes mellitus

Answer

Fetal cardiac defects

Answer

Rubella infection

Question 3

Which of the following is the most appropriate imaging modality to detect an abnormally located placenta?

Accepted Answer

Transvaginal Ultrasound (TVS)

Answer

Magnetic Resonance Imaging (MRI)

Answer

Doppler Ultrasound

Answer

Transabdominal Ultrasound (TAS)

Question 4

Placenta succenturiata may lead to all of the following except?

Accepted Answer

Preterm delivery

Answer

Postpartum hemorrhage

Answer

Missing lobe

Answer

Sepsis and subinvolution

Question 5

A pregnant woman at 34 weeks gestation presents with antepartum hemorrhage and a blood pressure of 80/something. What is the initial management?

Accepted Answer

Blood transfusion

Answer

Examination in OT and termination of pregnancy

Answer

Observation

Answer

Lower segment caesarean section

Question 6

A 38-week pregnant woman delivered a baby without upper limbs. What is a possible cause?

Accepted Answer

Amniotic band

Answer

True knot of umbilical cord

Answer

Genetic abnormality

Answer

None of the above

Question 7

Increased gestational period is associated with which congenital anomaly?

Accepted Answer

Anencephaly

Answer

Spina bifida

Answer

Meningomyelocele

Answer

Omphalocele

Question 8

An **AG2 P1L1** (gravida 2, para 1, living 1) female, with a previous history of lower segment cesarean section (LSCs), presents at 36 weeks of gestation with breech presentation. What is the next step in management?

Accepted Answer

External cephalic version (ECV) at 37 weeks

Answer

Planned cesarean section at 38 weeks

Answer

Immediate cesarean section

Answer

Induction of labor

Question 9

A 24-year-old woman presents with primary infertility and acute abdominal pain. Her vital signs are: blood pressure 90/60 mm Hg, pulse rate 102 bpm. Her hematocrit is 28%. Which of the following is a feature of ectopic pregnancy?

Accepted Answer

Pain referred to the supraclavicular region

Answer

Elevated blood pressure on assuming an erect position

Answer

Pulsus paradoxus

Answer

Tenderness below the right subcostal margin (Murphy's sign)

Question 10

A 32-year-old G2P1001 at 20 weeks gestational age presents to the emergency room complaining of constipation and abdominal pain for the past 24 hours. The patient also admits to bouts of nausea and emesis since eating a very spicy meal the evening before. She denies a history of any medical problems. During her last pregnancy, the patient underwent an elective cesarean section at term to deliver a fetus in the breech presentation. The emergency room doctor reports that the patient has a low-grade fever of 100°F, with a normal pulse and blood pressure. She is minimally tender to deep palpation with hypoactive bowel sounds and no rebound tenderness. Her WBC is 13,000, and electrolytes are normal. What is the appropriate next step in the management of this patient?

Accepted Answer

The patient should be sent to radiology for an upright abdominal x-ray.

Answer

The patient should be discharged with reassurance and instructions to give herself a soapsuds enema and follow a high-fiber diet with laxative use as needed.

Answer

The patient should be prepped for the operating room immediately to have an emergent appendectomy.

Answer

The patient should be reassured that her symptoms are due to the spicy meal consumed the evening before and should be given Pepto-Bismol to alleviate the symptoms.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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