Maternal-Fetal Medicine Practice Questions

Q: Medical treatment of ectopic pregnancy should be offered to which of the following patient profiles?

hCG level < 10,000 IU/L and mass size < 4 cm. **Explanation:** The medical management of ectopic pregnancy primarily involves the administration of **Methotrexate**, a folic acid antagonist that inhibits DNA synthesis in rapidly dividing trophoblastic cells. The success of medical therapy is highly dependent on the initial serum β-hCG levels and the size of the ectopic mass. **Why Option A is Correct:** According to standard clinical guidelines (including ACOG and RCOG), medical management is most effective and should be considered when the **serum β-hCG is < 5,000–10,000 IU/L** and the **ectopic mass size is < 4 cm**. While a lower hCG (< 5,000) is preferred for higher success rates, the threshold of < 10,000 IU/L with a mass < 4 cm represents the upper limit of acceptable criteria for offering medical treatment in a hemodynamically stable patient without fetal cardiac activity. **Analysis of Incorrect Options:** * **Option B:** While an hCG < 5,000 is a very strong indication, a mass size of < 5 cm is generally considered too large, increasing the risk of rupture and treatment failure. * **Option C:** An hCG of 7,500 is acceptable, but a mass size of 7.5 cm is a contraindication for medical management; surgical intervention is required. * **Option D:** These values are very safe for medical management, but they are overly restrictive. Patients with higher values (up to 4 cm and 10,000 IU/L) are still eligible for treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications for Methotrexate:** Hemodynamic instability (ruptured ectopic), intrauterine pregnancy, breastfeeding, and hepatic/renal/hematologic dysfunction. * **Relative Contraindications:** Fetal cardiac activity and hCG > 5,000 IU/L (increased failure rate). * **Monitoring:** hCG levels are measured on Day 4 and Day 7. A drop of **≥ 15%** between Day 4 and Day 7 indicates successful treatment. * **Dose:** Single-dose regimen is 50 mg/m² BSA.

Q: What condition is characterized by painless, heavy, recurrent bleeding of sudden onset?

Placenta previa. **Explanation:** The clinical presentation of **painless, bright red, recurrent, and sudden-onset vaginal bleeding** in the second half of pregnancy is the classic hallmark of **Placenta Previa**. This occurs because the placenta is implanted in the lower uterine segment. As the lower segment stretches and thins out in the third trimester, the placental attachments are disrupted, leading to unavoidable bleeding. Since the bleeding is primarily maternal in origin and not associated with uterine contractions or placental separation from the fundus, it remains painless. **Analysis of Incorrect Options:** * **Abruptio Placentae:** Characterized by **painful** vaginal bleeding (dark red), uterine tenderness, and often associated with hypertension. The pain is due to retroplacental hemorrhage and uterine spasm. * **Cervical Carcinoma:** While it can cause bleeding, it is usually associated with contact bleeding (post-coital) or foul-smelling discharge, rather than sudden, heavy obstetric hemorrhage. * **Circumvallate Placenta:** This is a morphological variation where the chorionic plate is smaller than the basal plate. It may cause mild antepartum hemorrhage or preterm labor, but it does not typically present with the "sudden, heavy, and recurrent" pattern seen in previa. **NEET-PG High-Yield Pearls:** * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pressed into the pelvis, suggesting a posterior placenta previa. * **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the gold standard (safer and more accurate than transabdominal). * **Contraindication:** **Never** perform a digital vaginal examination (PV) in a suspected case of placenta previa until it is ruled out by USG, as it can provoke torrential hemorrhage. * **Management:** If the patient is stable and <37 weeks, follow **Macafee’s expectant management regime**.

Q: A 21-year-old primigravida at 39 weeks gestation presents with painless antepartum hemorrhage. On examination, the uterus is soft and non-tender, with the fetal head engaged. What is the appropriate management?

Pelvic examination in the operating theatre. ### Explanation The clinical presentation of **painless, bright red antepartum hemorrhage (APH)** in a stable patient with a soft, non-tender uterus and an engaged fetal head is highly suggestive of **Placenta Previa**. **Why Option C is Correct:** In cases of suspected placenta previa, a digital vaginal examination is strictly contraindicated in the labor room because it can provoke massive, life-threatening hemorrhage by dislodging a clot or tearing the placenta. The definitive management is a **Double Set-up Examination** (pelvic examination performed in an operating theatre prepared for an immediate Cesarean section). This allows the clinician to confirm the degree of placenta previa and proceed immediately to delivery if torrential bleeding occurs. **Why Other Options are Incorrect:** * **Option A:** While resuscitation is vital, blood transfusion alone does not address the underlying cause or determine the mode of delivery. * **Option B:** A speculum examination may be used to rule out local causes (like cervical polyps), but it must be done with extreme caution and only after ultrasound has localized the placenta. It is not the definitive "management" step for delivery planning. * **Option D:** Tocolysis is used in expectant management (Macafee regime) for preterm cases (<37 weeks) to gain time for steroid administration. This patient is at **39 weeks (term)**; therefore, delivery is indicated, not prolongation of pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pushed into the pelvis, commonly seen in posterior placenta previa. * **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the gold standard for placental localization (safer and more accurate than transabdominal). * **Engagement Rule:** If the fetal head is engaged, it usually rules out major degrees (Type III or IV) of placenta previa.

Q: Malformations of which of the following fetal organ systems are most commonly associated with a single umbilical artery?

Genitourinary. **Explanation:** **Single Umbilical Artery (SUA)**, also known as a 2-vessel cord, occurs when one of the two umbilical arteries is absent (usually the left). While most cases are isolated, approximately 20–30% are associated with structural anomalies or chromosomal trisomies (especially Trisomy 18 and 13). **Why Genitourinary is correct:** Among the associated structural malformations, **Genitourinary (GU) anomalies** are the most frequently documented. The common embryological origin and proximity of the umbilical arteries to the developing urogenital system explain this link. Common GU findings include renal agenesis, multicystic dysplastic kidney, and hydronephrosis. **Analysis of Incorrect Options:** * **Cardiovascular (B):** These are the second most common anomalies associated with SUA (e.g., VSD). While highly significant, they statistically follow GU anomalies in frequency in most large-scale screening studies. * **Central Nervous System (A) & Skeletal (D):** While anomalies like holoprosencephaly or limb defects can occur with SUA (particularly in the context of aneuploidy), they are significantly less common than GU or cardiac defects. **High-Yield Clinical Pearls for NEET-PG:** * **Incidence:** ~1% of singleton pregnancies; higher in twin gestations and diabetic mothers. * **Management:** If SUA is detected on a mid-trimester scan, a **detailed targeted anomaly scan (Level II)** and **fetal echocardiography** are mandatory. * **Prognosis:** If the SUA is an isolated finding (no other anomalies), the prognosis is generally excellent, though there is a slightly increased risk of **Intrauterine Growth Restriction (IUGR)**. * **Vessel Anatomy:** The normal cord contains **two arteries** (carrying deoxygenated blood from fetus to placenta) and **one vein** (carrying oxygenated blood to the fetus).

Q: Which of the following is not used in the management of DIC in pregnancy?

Epsilon-aminocaproic acid and heparin. **Explanation:** Disseminated Intravascular Coagulation (DIC) in pregnancy is a secondary pathological process characterized by widespread activation of the coagulation cascade, leading to the consumption of clotting factors and platelets. **1. Why Option A is the Correct Answer:** * **Epsilon-aminocaproic acid (EACA):** This is an antifibrinolytic agent. In DIC, while there is excessive fibrinolysis, it is a secondary response to widespread clotting. Inhibiting fibrinolysis with EACA can lead to catastrophic, irreversible widespread thrombosis and organ failure. It is generally **contraindicated** in DIC. * **Heparin:** While heparin is used in some chronic DIC cases (like retained dead fetus), it is **avoided** in acute obstetric DIC (e.g., Abruptio Placentae, Postpartum Hemorrhage) because it can aggravate active life-threatening bleeding. **2. Why the other options are incorrect:** * **Option B (Blood Transfusion):** This is a cornerstone of management. DIC involves the consumption of RBCs and clotting factors; therefore, Whole Blood, Packed RBCs, Fresh Frozen Plasma (FFP), and Cryoprecipitate are essential to replace what is lost. * **Option C (Intravenous Fluids):** Maintaining hemodynamic stability and renal perfusion is critical in DIC to prevent Acute Tubular Necrosis (ATN). Crystalloids are the first line of resuscitation. **Clinical Pearls for NEET-PG:** * **Definitive Treatment:** The most important step in managing obstetric DIC is the **removal of the underlying cause** (e.g., delivery of the fetus/placenta). * **Most Common Cause:** Abruptio placentae is the most common cause of DIC in pregnancy. * **Diagnosis:** Look for low Fibrinogen (<150 mg/dL), elevated D-dimer/FDPs, and prolonged PT/APTT. * **Rule of Thumb:** In obstetric DIC, "Replace what is lost and empty the uterus." Avoid anticoagulants and antifibrinolytics unless specifically indicated in rare, non-bleeding scenarios.

Q: Which of the following laboratory findings is known as a biochemical marker of pre-eclampsia?

Serum uric acid. **Explanation:** **Serum uric acid** is considered a classic biochemical marker for pre-eclampsia. The underlying pathophysiology involves reduced renal perfusion and a decrease in the glomerular filtration rate (GFR). Specifically, pre-eclampsia causes functional changes in the renal tubules, leading to **decreased clearance and increased reabsorption of uric acid**. Hyperuricemia often precedes the clinical onset of hypertension and proteinuria, and its levels correlate significantly with the severity of the disease and adverse perinatal outcomes. **Analysis of Incorrect Options:** * **A & C (Low platelets & Elevated liver enzymes):** While these are critical components of the **HELLP syndrome** (a severe complication of pre-eclampsia), they are considered diagnostic criteria for "pre-eclampsia with severe features" rather than primary biochemical markers used for early identification or screening of the disease process itself. * **B (Raised serum Na):** Sodium levels are generally not used as markers for pre-eclampsia. In fact, due to the activation of the Renin-Angiotensin-Aldosterone System (RAAS) and subsequent edema, there is often water retention, but serum sodium typically remains within the normal range. **High-Yield Clinical Pearls for NEET-PG:** * **Hyperuricemia (>4.5 mg/dL)** is one of the earliest laboratory signs of pre-eclampsia. * **Soluble fms-like tyrosine kinase-1 (sFlt-1)** and **Placental Growth Factor (PlGF)** ratio is the modern "gold standard" biochemical marker for predicting pre-eclampsia. * The most common cause of death in pre-eclampsia is **Cerebral Hemorrhage**, while the most common cause of death in HELLP syndrome is **Hepatic Rupture**.

Q: Which of the following is seen in intrauterine fetal demise?

Disseminated intravascular coagulation (DIC). **Explanation:** Intrauterine Fetal Demise (IUFD) refers to fetal death occurring after 20 weeks of gestation but before birth. **Why B is Correct:** The primary complication associated with a retained dead fetus is **Disseminated Intravascular Coagulation (DIC)**. When a fetus dies and is retained in the uterus for more than 3–4 weeks, thromboplastin-like substances are released from the degenerating fetal tissues and placenta into the maternal circulation. This triggers the extrinsic coagulation pathway, leading to the consumption of clotting factors (especially fibrinogen) and platelets, ultimately resulting in a consumptive coagulopathy. **Why Incorrect Options are Wrong:** * **A. Hypertension:** IUFD does not cause hypertension. While Preeclampsia is a common *cause* of IUFD, the death of the fetus itself often leads to a decrease in blood pressure as the placental hormonal influence diminishes. * **C. Increase in fundal height:** In IUFD, the fundal height **decreases** or remains stationary. This is due to the cessation of fetal growth, the absorption of amniotic fluid (liquor), and the collapse of the fetal skull bones (Spalding’s sign). * **D. Increased uterine tone:** IUFD is typically associated with a "silent" or flaccid uterus. Increased uterine tone (hypertonicity) is more characteristic of Abruptio Placentae. **High-Yield Clinical Pearls for NEET-PG:** * **Spalding’s Sign:** Overlapping of fetal skull bones (seen on X-ray/USG 4–7 days after death). * **Robert’s Sign:** Appearance of gas in the fetal large vessels or heart (earliest radiological sign, seen within 12 hours). * **Investigation of Choice:** Ultrasound (demonstrates absence of fetal heart activity). * **Management:** If fibrinogen levels drop below 150 mg/dL, it indicates impending DIC, and the uterus must be evacuated immediately after stabilizing the patient.

Q: What is the single most sensitive marker of intrauterine growth restriction on ultrasonography?

Abdominal Circumference (AC). **Explanation:** **Abdominal Circumference (AC)** is the single most sensitive ultrasound parameter for diagnosing Intrauterine Growth Restriction (IUGR). The physiological basis lies in the fact that the fetal liver is the first organ to be affected by chronic placental insufficiency. IUGR leads to a depletion of fetal glycogen stores in the liver and a reduction in subcutaneous fat. Since the AC measurement primarily reflects the size of the liver and the thickness of the abdominal wall fat, it decreases significantly before other skeletal parameters are affected. **Analysis of Options:** * **Amniotic Fluid Index (AFI):** While oligohydramnios (low AFI) is a common association and a sign of fetal distress in IUGR, it is a non-specific marker and can occur due to various other causes (e.g., PROM, renal anomalies). * **Femur Length (FL) & Biparietal Diameter (BPD):** These are markers of skeletal growth. In "Asymmetrical IUGR" (the most common type), the fetus exhibits "brain-sparing," meaning the head and long bones continue to grow while the body remains small. Therefore, BPD and FL remain relatively preserved until the late stages of growth restriction. **Clinical Pearls for NEET-PG:** * **Most sensitive single parameter:** Abdominal Circumference (AC). * **Most sensitive ratio:** HC/AC ratio (Head Circumference/Abdominal Circumference). This ratio is elevated in asymmetrical IUGR. * **Earliest sign of IUGR on Doppler:** Increased resistance/pulsatility index in the **Umbilical Artery**. * **Gold Standard for Monitoring:** Umbilical Artery Doppler is the best tool for managing IUGR and deciding the timing of delivery.

Question 1

Which of the following is FALSE regarding maternal adaptations in multiple pregnancy compared to singleton pregnancy?

Accepted Answer

Proportionately more red cell mass increase along with fluid increase, resulting in a similar Hemoglobin pattern as singleton pregnancy

Answer

Greater maternal blood volume expansion

Answer

Higher incidence of hyperemesis in twins

Answer

Higher blood volume expansion in twins

Question 2

Medical treatment of ectopic pregnancy should be offered to which of the following patient profiles?

Accepted Answer

hCG level < 10,000 IU/L and mass size < 4 cm

Answer

hCG level < 5,000 IU/L and mass size < 5 cm

Answer

hCG level < 7,500 IU/L and mass size < 7.5 cm

Answer

hCG level < 2,000 IU/L and mass size < 3 cm

Question 3

What condition is characterized by painless, heavy, recurrent bleeding of sudden onset?

Accepted Answer

Placenta previa

Answer

Cervical carcinoma

Answer

Circumvallate placenta

Answer

Abruptio placentae

Question 4

A 21-year-old primigravida at 39 weeks gestation presents with painless antepartum hemorrhage. On examination, the uterus is soft and non-tender, with the fetal head engaged. What is the appropriate management?

Accepted Answer

Pelvic examination in the operating theatre

Answer

Blood transfusion and sedatives

Answer

A speculum examination

Answer

Tocolysis and sedatives

Question 5

What is true regarding the delivery of an HIV-positive woman?

Accepted Answer

Vaginal delivery has a higher risk of HIV transmission to the child compared to Cesarean section.

Answer

Vaginal delivery has a lower risk of HIV transmission to the child compared to Cesarean section.

Answer

The use of instrumentation during delivery has no risk of increased HIV infection transmission.

Answer

Vertical transmission of HIV is less likely in cases of preterm birth.

Question 6

Malformations of which of the following fetal organ systems are most commonly associated with a single umbilical artery?

Accepted Answer

Genitourinary

Answer

Central nervous system

Answer

Cardiovascular

Answer

Skeletal

Question 7

Which of the following is not used in the management of DIC in pregnancy?

Accepted Answer

Epsilon-aminocaproic acid and heparin

Answer

Blood transfusion

Answer

Intravenous fluids

Answer

None of the above

Question 8

Which of the following laboratory findings is known as a biochemical marker of pre-eclampsia?

Accepted Answer

Serum uric acid

Answer

Low platelets

Answer

Raised serum Na

Answer

Elevated liver enzymes

Question 9

Which of the following is seen in intrauterine fetal demise?

Accepted Answer

Disseminated intravascular coagulation (DIC)

Answer

Hypertension

Answer

Increase in fundal height of uterus

Answer

Increased uterine tone

Question 10

What is the single most sensitive marker of intrauterine growth restriction on ultrasonography?

Accepted Answer

Abdominal Circumference (AC)

Answer

Amniotic Fluid Index (AFI)

Answer

Femur Length (FL)

Answer

Biparietal Diameter (BPD)

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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