Maternal-Fetal Medicine Practice Questions

Q: What is the approximate percentage decrease in the chance of transmission of HIV to a fetus during pregnancy with the use of antiretroviral prophylaxis?

65%. The correct answer is **D. 65%**. ### **Explanation** The risk of vertical transmission of HIV from mother to child without any intervention is approximately **25–30%**. The landmark **PACTG 076 trial** established that the administration of Zidovudine (AZT) monotherapy during pregnancy, labor, and to the newborn reduces this risk by approximately **two-thirds (66-67%)**, bringing the transmission rate down to about 8%. In modern clinical practice, with Highly Active Antiretroviral Therapy (HAART) and viral load suppression to undetectable levels, the risk can be further reduced to **less than 1%**. However, in the context of standard prophylaxis (as often tested in exams based on classic trials), the 65% reduction is the benchmark figure. ### **Analysis of Incorrect Options** * **A, B, and C:** These percentages (35%, 45%, 50%) underestimate the efficacy of antiretroviral prophylaxis. While any ART provides some benefit, the established clinical standard for the *decrease in risk* is significantly higher than 50%. ### **High-Yield Clinical Pearls for NEET-PG** * **Most common route of transmission:** Intrapartum (during labor and delivery) is the period of highest risk. * **Preferred Regimen (India/WHO):** TLE regimen (Tenofovir + Lamivudine + Efavirenz) was the standard; however, newer guidelines favor **Dolutegravir (DTG)** based regimens. * **Breastfeeding:** In resource-limited settings (like India), exclusive breastfeeding for the first 6 months is recommended if the mother is on ART, as the benefits of nutrition/immunity outweigh the risk of HIV transmission. * **Mode of Delivery:** Elective Cesarean Section (at 38 weeks) is indicated if the maternal viral load is **>1000 copies/mL** near term to further reduce transmission. * **Neonatal Prophylaxis:** Nevirapine syrup is typically given to the infant for 6 weeks (extendable to 12 weeks in high-risk cases).

Q: In which period of pregnancy is cordiocentesis typically performed?

18-20 weeks. **Explanation:** **Cordocentesis**, also known as Percutaneous Umbilical Blood Sampling (PUBS), is an invasive prenatal diagnostic procedure used to obtain fetal blood directly from the umbilical vein. **Why 18-20 weeks is the correct answer:** The procedure is typically performed after **18 weeks** of gestation. Before this period, the umbilical vein is technically too small and fragile to puncture safely, and the risk of procedure-related pregnancy loss is significantly higher. By 18–20 weeks, the vessel diameter is sufficient to allow for ultrasound-guided needle insertion (usually at the placental insertion site of the cord) with a higher success rate and lower risk of fetal bradycardia or hemorrhage. **Analysis of Incorrect Options:** * **A. 11-14 weeks:** This is the window for Chorionic Villus Sampling (CVS) and Nuchal Translucency (NT) scans. Cordocentesis is not feasible here due to the minute size of the umbilical cord. * **C & D. 22-30 weeks:** While cordocentesis *can* be performed later in pregnancy (e.g., for fetal anemia or late-onset growth restriction), it is not the "typical" or earliest recommended window for primary diagnostic purposes. Non-invasive methods or amniocentesis are often preferred if possible during these stages. **High-Yield Clinical Pearls for NEET-PG:** * **Indications:** Rapid karyotyping (results in 48–72 hours), diagnosis of fetal infections (e.g., Toxoplasmosis, CMV), and management of Rh-isoimmunization (fetal hemoglobin/hematocrit assessment and intrauterine transfusion). * **Complication:** The most common complication is **fetal bleeding** from the puncture site. * **Comparison:** Amniocentesis is typically done at 15–20 weeks; CVS at 10–13 weeks. Cordocentesis has the highest procedure-related loss rate (~1-2%) among the three.

Q: What does the CTG graph shown in the image indicate regarding fetal heart rate patterns?

A deceleration in the cardiotocography trace. ***A deceleration in the cardiotocography trace*** - A **deceleration** represents a transient fall in **fetal heart rate (FHR)** below the baseline, indicating potential **fetal hypoxia** or **uteroplacental insufficiency**. - Decelerations are classified as **early**, **late**, or **variable** based on their timing relative to **uterine contractions** and require immediate evaluation. *An acceleration in the cardiotocography trace* - **Accelerations** are transient increases in FHR above baseline, typically indicating **fetal well-being** and adequate **oxygenation**. - They are considered **reassuring signs** on CTG monitoring, not concerning patterns requiring intervention. *Insufficient information to determine fetal well-being* - CTG provides continuous monitoring of **fetal heart rate** and **uterine activity**, offering valuable information about fetal status. - Modern CTG technology provides sufficient data to assess **fetal well-being** through pattern recognition and trend analysis. *A normal cardiotocography tracing* - A **normal CTG** shows baseline FHR between **110-160 bpm** with moderate **variability** and **accelerations** present. - Normal tracings are **reassuring** and do not indicate pathological fetal heart rate patterns requiring intervention.

Q: A pregnant woman presents at 22 weeks gestation for a routine prenatal visit. Physical examination demonstrates ankle edema and new onset hypertension. Urinalysis reveals marked proteinuria. Development of which of the following would justify a diagnosis of eclampsia?

Seizures. ### Explanation **Correct Answer: C. Seizures** The clinical presentation of new-onset hypertension and marked proteinuria after 20 weeks of gestation defines **Preeclampsia**. The progression from preeclampsia to **Eclampsia** is defined specifically by the occurrence of **generalized tonic-clonic seizures** that cannot be attributed to other neuropsychiatric causes (e.g., epilepsy or brain tumors). In this patient at 22 weeks, the presence of the "classic triad" (hypertension, proteinuria, and edema) points toward preeclampsia. The development of seizures is the pathognomonic feature that justifies the diagnosis of eclampsia. **Why other options are incorrect:** * **A. Diabetes mellitus:** While a risk factor for developing preeclampsia, it is a metabolic disorder and not a diagnostic criterion for eclampsia. * **B. Hyperuricemia:** Elevated serum uric acid is a common finding in preeclampsia due to decreased renal clearance and is often used as a marker of disease severity, but it does not define eclampsia. * **D. Systemic lupus erythematosus (SLE):** SLE can mimic preeclampsia (lupus nephritis) or coexist with it, but it is an autoimmune pathology, not a diagnostic stage of hypertensive disorders of pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Eclampsia = Preeclampsia + Seizures. * **Drug of Choice (DOC):** **Magnesium Sulfate ($MgSO_4$)** is the DOC for both the prophylaxis and control of eclamptic seizures (Pritchard Regimen). * **Antidote:** Always keep **Calcium Gluconate** (10 ml of 10% solution) ready at the bedside to treat $MgSO_4$ toxicity. * **Timing:** Eclampsia can occur antepartum (50%), intrapartum (25%), or postpartum (25%). * **Management:** The definitive treatment for eclampsia, regardless of gestational age, is the **stabilization of the mother followed by delivery.**

Q: What is the most common tumor of the ovary found in pregnancy?

Dermoid cyst. **Explanation:** The most common ovarian tumor encountered during pregnancy is the **Dermoid cyst (Mature Cystic Teratoma)**. This is a germ cell tumor that typically occurs during the reproductive years, coinciding with the peak age of pregnancy. While most are asymptomatic and discovered incidentally during routine prenatal ultrasound, they carry a risk of complications like **ovarian torsion** (most common in the second trimester) or rupture. **Analysis of Options:** * **Dermoid Cyst (Correct):** It accounts for approximately 25–40% of all ovarian masses identified during pregnancy. They are usually benign and unilateral. * **Epithelial Tumors:** While common in the general population, they are less frequent than dermoids in pregnant women. Serous cystadenomas are the second most common benign tumors after dermoids. * **Dysgerminoma:** This is the most common **malignant** germ cell tumor found in pregnancy, but it is far less common than the benign dermoid cyst. * **Sex Cord Tumors:** These (e.g., Granulosa cell tumors) are rare during pregnancy. **NEET-PG High-Yield Pearls:** * **Most common ovarian mass in pregnancy:** Corpus Luteum Cyst (Functional). * **Most common benign neoplasm in pregnancy:** Dermoid Cyst. * **Most common malignancy in pregnancy:** Dysgerminoma. * **Management:** If an ovarian mass is >5–6 cm or symptomatic, the ideal time for surgical intervention (Laparoscopy/Laparotomy) is the **early second trimester (14–18 weeks)** to minimize miscarriage risk and avoid technical difficulties of a large uterus. * **Complication:** Torsion is the most frequent complication of ovarian cysts during pregnancy.

Q: Which of the following is a risk factor for pre-eclampsia?

Primigravida. **Explanation:** Pre-eclampsia is a multisystem disorder characterized by new-onset hypertension (≥140/90 mmHg) and proteinuria (or end-organ dysfunction) after 20 weeks of gestation. **Why Primigravida is Correct:** Primigravida (nulliparity) is a well-established major risk factor for pre-eclampsia. The underlying pathophysiology involves **defective trophoblastic invasion** of the spiral arteries. In a first pregnancy, the maternal immune system has not been previously exposed to paternal antigens, leading to an altered immune response that contributes to placental ischemia and subsequent endothelial dysfunction. **Analysis of Incorrect Options:** * **Thin build:** Obesity (BMI >30) is a significant risk factor, not a thin build. Adiposity promotes a pro-inflammatory state and insulin resistance, both of which exacerbate endothelial damage. * **Smoking:** Paradoxically, smoking is associated with a **reduced risk** of pre-eclampsia. It is hypothesized that nicotine or carbon monoxide may inhibit the release of anti-angiogenic factors (like sFlt-1), though smoking is still discouraged due to risks of IUGR and abruption. * **Placenta previa:** There is no direct causal link between placenta previa and pre-eclampsia. However, **Placental Abruption** is a known complication of pre-eclampsia. **High-Yield Clinical Pearls for NEET-PG:** * **Highest Risk Factor:** A prior history of pre-eclampsia is the strongest predictor for recurrence. * **Other Risk Factors:** Multiple pregnancy (increased placental mass), Maternal age (>40 or <18), Chronic hypertension, Diabetes Mellitus, and Antiphospholipid Syndrome (APLA). * **Prophylaxis:** Low-dose Aspirin (75–150 mg) started before 16 weeks of gestation is recommended for high-risk women. * **Definitive Treatment:** Delivery of the fetus and placenta.

Q: A 32-year-old G5P1 presents for her first prenatal visit. Classically, cervical incompetence is characterized by delivery in the second trimester preceded by which of the following?

Painless dilatation. ### Explanation **Correct Answer: C. Painless dilatation** **Medical Concept:** Cervical incompetence (now often termed **Cervical Insufficiency**) is defined as the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions, labor, or both. The hallmark of this condition is the **painless, progressive dilatation and effacement** of the cervix. This occurs because the structural integrity of the cervical tissue is compromised, leading to the "silent" prolapse of fetal membranes into the vagina, followed by premature rupture of membranes (PROM) and expulsion of a premature fetus. **Analysis of Incorrect Options:** * **A. Fever:** Fever is suggestive of **Chorioamnionitis** or systemic infection. While infection can be a consequence of cervical incompetence (due to exposed membranes), it is not the preceding characteristic. * **B. Heavy bleeding:** This is more characteristic of **Abruptio Placentae** or **Placenta Previa**. Cervical incompetence may involve "show" or light spotting, but heavy hemorrhage is not typical. * **D. Painful contractions:** This is the defining feature of **Preterm Labor**. In cervical incompetence, the cervix fails *without* the presence of uterine contractions. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Usually clinical, based on a history of repeated mid-trimester losses. * **Ultrasonography (TVS):** A cervical length **<25 mm** or the presence of **"funneling"** (beaking of the internal os) before 24 weeks is a significant marker. * **Treatment:** The primary intervention is **Cervical Cerclage** (e.g., McDonald or Shirodkar techniques), typically performed between **12–14 weeks** of gestation. * **Classic History:** A patient describing a "sudden pressure" followed by the rapid, relatively painless delivery of a normal-appearing fetus in the second trimester.

Q: What is the earliest sign of uteroplacental insufficiency detected by Doppler ultrasound?

Diastolic notch. ### Explanation **1. Why "Diastolic Notch" is correct:** The earliest sign of uteroplacental insufficiency is the persistence of the **diastolic notch** in the uterine artery waveform. In a normal pregnancy, the physiological remodeling of spiral arteries by trophoblasts (low-resistance, high-flow system) causes the diastolic notch to disappear by **20–24 weeks** of gestation. If this remodeling fails, high resistance persists, resulting in a sharp drop in blood flow at the beginning of diastole (the notch). This serves as a predictive marker for pre-eclampsia and Intrauterine Growth Restriction (IUGR). **2. Why other options are incorrect:** * **Reversal of diastolic flow (B):** This is a **late and critical sign** of fetal compromise, typically seen in the umbilical artery. It indicates severe placental resistance and impending fetal demise. * **Blunting of systolic flow (C):** This is not a standard Doppler descriptor for early insufficiency. Doppler indices focus on the relationship between systolic and diastolic velocities (like the S/D ratio). * **Absent mid-diastolic flow (D):** While "Absent End Diastolic Velocity" (AEDV) is a significant marker of worsening insufficiency, it occurs much later in the disease spectrum than the appearance of a notch. **3. Clinical Pearls for NEET-PG:** * **Uterine Artery Doppler:** Best used for **screening** high-risk pregnancies (at 20–24 weeks). * **Umbilical Artery Doppler:** Best for **monitoring** a growth-restricted fetus. * **Sequence of deterioration:** Increased S/D ratio → Absent End Diastolic Velocity (AEDV) → Reversed End Diastolic Velocity (REDV). * **Ductus Venosus:** Reversal of the 'a' wave is the most ominous sign, indicating fetal heart failure.

Question 1

What is the approximate percentage decrease in the chance of transmission of HIV to a fetus during pregnancy with the use of antiretroviral prophylaxis?

Accepted Answer

65%

Answer

35%

Answer

45%

Answer

50%

Question 2

In which period of pregnancy is cordiocentesis typically performed?

Accepted Answer

18-20 weeks

Answer

11-14 weeks

Answer

22-26 weeks

Answer

28-30 weeks

Question 3

What does the CTG graph shown in the image indicate regarding fetal heart rate patterns?

Accepted Answer

A deceleration in the cardiotocography trace

Answer

An acceleration in the cardiotocography trace

Answer

Insufficient information to determine fetal well-being

Answer

A normal cardiotocography tracing

Question 4

Which of the following is seen in pregnancy with heart disease, which is not seen in normal pregnancy?

Accepted Answer

Distended neck veins

Answer

Exertional dyspnea

Answer

Pedal edema

Answer

Supine hypotension

Question 5

A pregnant woman presents at 22 weeks gestation for a routine prenatal visit. Physical examination demonstrates ankle edema and new onset hypertension. Urinalysis reveals marked proteinuria. Development of which of the following would justify a diagnosis of eclampsia?

Accepted Answer

Seizures

Answer

Diabetes mellitus

Answer

Hyperuricemia

Answer

Systemic lupus erythematosus

Question 6

What is the most common tumor of the ovary found in pregnancy?

Accepted Answer

Dermoid cyst

Answer

Sex cord tumor

Answer

Epithelial tumor

Answer

Dysgerminoma

Question 7

Which of the following is a risk factor for pre-eclampsia?

Accepted Answer

Primigravida

Answer

Thin build

Answer

Smoking

Answer

Placenta previa

Question 8

A 25-year-old woman is G5, P0, Ab4. All of her previous pregnancies ended in spontaneous abortion in the first or second trimester. She is now in the 16th week of her fifth pregnancy and has had no prenatal problems. Laboratory findings include maternal blood type of A positive, negative serologic test for syphilis, and immunity to rubella. Which of the following laboratory studies would be most useful for determining a potential cause of recurrent fetal loss in this patient?

Accepted Answer

Amniocentesis with chromosomal analysis

Answer

Genetic analysis of the CFTR gene

Answer

Maternal serum antibody screening

Answer

Maternal serum a-fetoprotein determination

Question 9

A 32-year-old G5P1 presents for her first prenatal visit. Classically, cervical incompetence is characterized by delivery in the second trimester preceded by which of the following?

Accepted Answer

Painless dilatation

Answer

Fever

Answer

Heavy bleeding

Answer

Painful contractions

Question 10

What is the earliest sign of uteroplacental insufficiency detected by Doppler ultrasound?

Accepted Answer

Diastolic notch

Answer

Reversal of diastolic flow

Answer

Blunting of systolic flow

Answer

Absent mid-diastolic flow

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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