Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 561: Which of the following is NOT a cause of Disseminated Intravascular Coagulation (DIC)?

A. Abruption placentae
B. Fat emboli (Correct Answer)
C. Amniotic fluid embolism
D. Intrauterine fetal demise (IUD)

Explanation: **Explanation:** Disseminated Intravascular Coagulation (DIC) in obstetrics is primarily triggered by the release of **thromboplastin** (tissue factor) into the maternal circulation, leading to widespread activation of the coagulation cascade and subsequent consumption of clotting factors. **Why Fat Emboli is the Correct Answer:** While **Fat Embolism Syndrome (FES)** is a life-threatening condition typically associated with long bone fractures or orthopedic trauma, it is **not** a recognized cause of DIC in the obstetric context. FES primarily causes respiratory distress, petechial rashes, and neurological symptoms due to mechanical obstruction of capillaries and free fatty acid toxicity, rather than a systemic consumptive coagulopathy. **Analysis of Incorrect Options:** * **Abruption Placentae:** This is the **most common** cause of DIC in pregnancy. The retroplacental clot releases massive amounts of tissue thromboplastin into the maternal bloodstream. * **Amniotic Fluid Embolism (AFE):** This is the **most severe** cause. Amniotic fluid contains high concentrations of procoagulant factors and tissue factor, triggering an "anaphylactoid syndrome" and sudden, profound DIC. * **Intrauterine Fetal Demise (IUD):** If a dead fetus is retained for more than 3–4 weeks ("Dead Fetus Syndrome"), the gradual release of degenerating fetal tissue products into the maternal circulation leads to chronic DIC. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of DIC in pregnancy:** Abruptio Placentae. * **Earliest lab finding in DIC:** Decreased platelet count and presence of Schistocytes (fragmented RBCs) on peripheral smear. * **Best screening test:** FDPs (Fibrin Degradation Products) or D-dimer (elevated). * **Confirmatory/Most specific finding:** Low Fibrinogen levels (<150 mg/dL). * **Management:** Always treat the underlying cause (e.g., delivery) and replace blood products (FFP, Cryoprecipitate).

Question 562: The 'banana sign' and 'lemon sign' on fetal ultrasound are characteristic findings associated with which of the following fetal anomalies?

A. Neural tube defects (Correct Answer)
B. Hydrops fetalis
C. Multiple gestations (twins)
D. Intrauterine demise (IUD)

Explanation: The 'banana' and 'lemon' signs are classic sonographic markers of **Open Neural Tube Defects (ONTDs)**, specifically **Spina Bifida**. These findings are part of the **Arnold-Chiari Malformation Type II** complex. **1. Why Neural Tube Defects is correct:** * **Lemon Sign:** This refers to the inward scalloping of the frontal bones, giving the fetal skull a lemon-like shape. It occurs due to decreased intraspinal pressure, which causes a downward shift of the brain and a subsequent decrease in intracranial pressure. * **Banana Sign:** This refers to the cerebellum being pulled downward into the foramen magnum. This traction causes the cerebellum to lose its typical "dumbbell" shape and appear curved/oblong, resembling a banana. This is often associated with obliteration of the cisterna magna. **2. Why other options are incorrect:** * **Hydrops Fetalis:** Characterized by abnormal fluid accumulation in two or more fetal compartments (e.g., ascites, pleural effusion, skin edema). * **Multiple Gestations:** Associated with signs like the 'Twin-peak' (lambda) or 'T-sign' to determine chorionicity, not cranial shape changes. * **Intrauterine Demise (IUD):** Associated with **Spalding’s sign** (overlapping of skull bones due to liquefaction of the brain) and **Robert’s sign** (gas in the fetal heart/vessels). **High-Yield Clinical Pearls for NEET-PG:** * **Sensitivity:** The lemon sign is most reliable in the second trimester (disappears by the third). The banana sign is more specific for spina bifida. * **Ventriculomegaly:** Often accompanies these signs due to CSF flow obstruction. * **Screening:** Maternal Serum Alpha-Fetoprotein (MSAFP) is elevated in open NTDs. * **Prevention:** 400 mcg/day of Folic Acid (4 mg/day for high-risk) pre-conceptionally reduces NTD risk.

Question 563: Which among the following is decreased in twin pregnancy compared to singleton pregnancy?

A. Blood loss at delivery
B. Blood pressure at term
C. Blood volume expansion
D. Systemic vascular resistance (Correct Answer)

Explanation: In a twin pregnancy, the maternal body undergoes exaggerated physiological adaptations compared to a singleton pregnancy to meet the increased metabolic demands of two fetuses. **Explanation of the Correct Answer:** **Systemic Vascular Resistance (SVR)** is significantly **decreased** in twin pregnancies. This is due to the high-flow, low-resistance circuit of the dual placentae and the profound vasodilatory effects of increased progesterone and nitric oxide. While SVR drops in all pregnancies, the decline is more pronounced in multifetal gestations to accommodate a much higher cardiac output (which increases by an additional 20% over singleton levels). **Why the other options are incorrect:** * **Blood loss at delivery:** This is **increased**. The larger placental site and the risk of uterine atony due to overdistension of the uterus make postpartum hemorrhage (PPH) much more common in twins. * **Blood pressure at term:** This is typically **increased** or remains similar. Twin pregnancies carry a significantly higher risk (3–4 times) of developing gestational hypertension and preeclampsia compared to singletons. * **Blood volume expansion:** This is **increased**. While singleton pregnancies see a 40–50% increase, twin pregnancies experience a 50–60% increase in plasma volume to support dual uteroplacental perfusion. **High-Yield Clinical Pearls for NEET-PG:** * **Anemia:** Because plasma volume expansion exceeds the rise in red cell mass more severely in twins, **physiologic anemia** is more profound. * **Cardiac Output:** Reaches its peak earlier and is higher in twins. * **Uterine Volume:** Can reach up to 10 liters or more, leading to increased diaphragmatic splinting and respiratory discomfort.

Question 564: Which of the following is NOT true about diabetes in pregnancy?

A. Glucose challenge test is typically performed between 24-28 weeks of gestation.
B. A 50-gram oral glucose load is used for the screening test.
C. Insulin resistance decreases during pregnancy. (Correct Answer)
D. Controlling diabetes prior to conception is crucial to prevent malformations.

Explanation: **Explanation:** The correct answer is **C (Insulin resistance decreases during pregnancy)** because it is a false statement. In reality, pregnancy is a **diabetogenic state** characterized by a progressive **increase in insulin resistance**, particularly in the second and third trimesters. This physiological change is primarily driven by placental hormones such as **Human Placental Lactogen (hPL)**, growth hormone, cortisol, and progesterone. These hormones act as insulin antagonists to ensure a continuous supply of glucose to the fetus. **Analysis of other options:** * **Option A & B:** These are correct clinical protocols. The **Glucose Challenge Test (GCT)**, involving a **50g oral glucose load**, is the standard screening tool performed between **24-28 weeks** (the period when insulin resistance peaks). In India, the DIPSI guidelines often utilize a 75g load for both screening and diagnosis. * **Option D:** This is correct. Pre-gestational diabetes is associated with a high risk of **congenital malformations** (e.g., Sacral Agenesis, Cardiac defects). Since organogenesis occurs early (weeks 3-8), strict glycemic control **prior to conception** (HbA1c < 6.5%) is vital to reduce these risks. **High-Yield NEET-PG Pearls:** * **Most common malformation:** Ventricular Septal Defect (VSD). * **Most specific malformation:** Caudal Regression Syndrome (Sacral Agenesis). * **Target Blood Sugars:** Fasting < 95 mg/dL, 1-hour postprandial < 140 mg/dL, 2-hour postprandial < 120 mg/dL. * **Drug of Choice:** Insulin remains the gold standard, though Metformin is increasingly used in specific GDM cases.

Question 565: The Nile blue sulphate test in amniotic fluid is used to assess which of the following?

A. Lung maturity (Correct Answer)
B. Kidney maturity
C. Liver maturity
D. Skin maturity

Explanation: **Explanation:** The **Nile blue sulphate test** is a cytological method used to estimate fetal maturity by examining cells in the amniotic fluid. The test identifies **orange-stained sebaceous cells** (lipid-containing cells) shed from the fetal skin. **Why Lung Maturity is the Correct Answer:** While the test technically measures the presence of exfoliated skin cells, its primary clinical application in traditional obstetrics was as an indirect surrogate marker for **fetal lung maturity**. When the concentration of these orange-stained cells exceeds **20%**, it correlates strongly with a gestational age of more than 36 weeks and indicates that the fetal lungs are likely mature enough to prevent Respiratory Distress Syndrome (RDS). In the context of NEET-PG, this is the standard "textbook" association. **Analysis of Incorrect Options:** * **B & C (Kidney and Liver Maturity):** These organs do not shed cells into the amniotic fluid that can be identified via lipid-staining techniques. Kidney maturity is better assessed via amniotic fluid creatinine levels. * **D (Skin Maturity):** Although the cells originate from the skin, the test's *clinical purpose* is to predict overall fetal readiness for delivery, specifically lung functional status. **High-Yield Clinical Pearls for NEET-PG:** * **The Cut-off:** >50% orange cells indicates certain maturity; <1% indicates a gestational age of less than 34 weeks. * **Modern Standard:** Today, the Nile blue test is largely obsolete, replaced by more accurate biochemical tests for lung maturity, such as the **L/S Ratio (Lecithin/Sphingomyelin)** > 2:1 or the presence of **Phosphatidylglycerol (PG)**. * **Amniotic Fluid Color:** Remember that Nile blue sulphate turns the lipid-rich cells **orange**, while the rest of the cells (nucleated) stain **blue**.

Question 566: Which of the following is NOT a feature of postdated pregnancy?

A. Cord compression
B. Fetal distress
C. Intrauterine growth restriction (IUGR)
D. Polyhydramnios (Correct Answer)

Explanation: **Explanation:** Postdated pregnancy (defined as a pregnancy extending beyond 42 weeks) is characterized by a progressive decline in placental function. The correct answer is **Polyhydramnios** because postdated pregnancies are actually associated with **Oligohydramnios** (decreased amniotic fluid). **Why Polyhydramnios is the correct choice (the "NOT" feature):** As the placenta ages (placental insufficiency), fetal perfusion decreases. This leads to reduced fetal renal blood flow, resulting in decreased fetal urine output—the primary source of amniotic fluid in late pregnancy. Therefore, oligohydramnios is a hallmark of postterm pregnancy, not polyhydramnios. **Analysis of incorrect options:** * **Cord compression:** Due to the reduction in amniotic fluid (oligohydramnios), the umbilical cord is no longer cushioned, making it highly susceptible to compression during contractions or fetal movement. * **Fetal distress:** Placental insufficiency leads to chronic hypoxia. This, combined with cord compression, significantly increases the risk of non-reassuring fetal heart rate patterns and fetal distress. * **Intrauterine growth restriction (IUGR):** While many postterm fetuses are macrosomic, a subset experiences "Dysmaturity Syndrome" (Clifford’s Syndrome) due to placental failure, leading to loss of subcutaneous fat and growth restriction. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Postterm is ≥42 weeks; Late-term is 41 weeks to 41 weeks 6 days. * **Most common cause:** Inaccurate dating (wrong dates). * **Amniotic Fluid Index (AFI):** An AFI <5 cm or a single deepest pocket <2 cm is a critical indicator for induction in postterm cases. * **Meconium Aspiration Syndrome (MAS):** Risk increases significantly post-42 weeks due to increased meconium passage in utero (triggered by vagal stimulation from cord compression).

Question 567: A 28-year-old female with a history of 8 weeks of amenorrhea complains of vaginal bleeding and lower abdominal pain. On USG examination, there is a gestational sac with absent fetal parts. What is the diagnosis?

A. Ectopic pregnancy
B. Incomplete abortion (Correct Answer)
C. Threatened abortion
D. Corpus luteum cyst

Explanation: **Explanation:** The clinical presentation of vaginal bleeding and abdominal pain following amenorrhea, combined with the ultrasound finding of a gestational sac with absent fetal parts, points toward an **Incomplete Abortion**. **1. Why Incomplete Abortion is correct:** In an incomplete abortion, the products of conception (POC) have partially expelled from the uterus. On ultrasound, this typically manifests as an irregular gestational sac, a collapsed sac, or heterogeneous echogenic material (retained products) within the uterine cavity. The absence of fetal parts in a sac that previously contained them, or a disorganized sac at 8 weeks, confirms that the pregnancy is no longer viable and is in the process of expulsion. **2. Why other options are incorrect:** * **Ectopic Pregnancy:** While it presents with pain and bleeding, the ultrasound would typically show an empty uterus and an adnexal mass. A gestational sac *inside* the uterus (as stated in the question) makes this less likely. * **Threatened Abortion:** In this condition, bleeding occurs but the pregnancy remains viable. Ultrasound would show a well-formed gestational sac with a visible fetal pole and cardiac activity (at 8 weeks). * **Corpus Luteum Cyst:** This is a functional physiological cyst of pregnancy. While it may cause mild pain, it does not cause vaginal bleeding or the presence of a non-viable gestational sac. **High-Yield Clinical Pearls for NEET-PG:** * **Cervical Os Status:** In Incomplete and Inevitable abortions, the internal os is **open**. In Threatened and Missed abortions, the os is **closed**. * **Management:** Incomplete abortion is managed by medical evacuation (Misoprostol) or surgical evacuation (D&E/MVA). * **USG Hallmark:** The "Snowstorm appearance" is specific to Molar pregnancy, while an "Empty sac" >25mm MSD (Mean Sac Diameter) defines a Blighted Ovum (Anembryonic pregnancy).

Question 568: Magnesium sulfate has no role in the prevention of which of the following?

A. Seizures in severe pre-eclampsia
B. Respiratory distress syndrome in a premature baby (Correct Answer)
C. Recurrent seizures in eclampsia
D. Neuroprotection

Explanation: **Explanation:** Magnesium sulfate ($MgSO_4$) is the drug of choice in obstetric practice for seizure prophylaxis and neuroprotection, but it does not have a direct role in fetal lung maturation. 1. **Why Option B is Correct:** Respiratory Distress Syndrome (RDS) is prevented by the administration of **antenatal corticosteroids** (such as Betamethasone or Dexamethasone), which stimulate surfactant production. $MgSO_4$ does not affect surfactant synthesis and therefore has no role in preventing RDS. 2. **Why Options A & C are Incorrect:** $MgSO_4$ is the gold standard for both the **prevention** of seizures in women with severe pre-eclampsia (prophylaxis) and the **control/prevention of recurrence** in eclampsia (treatment). It acts by increasing the seizure threshold and causing cerebral vasodilation. 3. **Why Option D is Incorrect:** $MgSO_4$ is administered for **fetal neuroprotection** in anticipated preterm births (usually <32 weeks). It reduces the risk of cerebral palsy and severe motor dysfunction in the neonate by stabilizing neuronal membranes and reducing oxidative stress. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** $MgSO_4$ is an NMDA receptor antagonist and a calcium channel blocker. * **Therapeutic Range:** 4–7 mEq/L. * **Toxicity Signs:** Loss of patellar reflex (earliest sign, 8–10 mEq/L) → Respiratory depression (12–15 mEq/L) → Cardiac arrest (>25 mEq/L). * **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (administered slowly). * **Excretion:** Exclusively via kidneys; hence, dose adjustment is mandatory in renal failure.

Question 569: What is the fetal anomaly characterized by the absence of the cranium?

A. Cephalocele
B. Holoprosencephaly
C. Anencephaly (Correct Answer)
D. Dandy-Walker Malformation

Explanation: ### Explanation **Correct Answer: C. Anencephaly** **Anencephaly** is the most common lethal neural tube defect (NTD). It results from the failure of the **cephalic (rostral) end of the neural tube** to close between the 23rd and 26th day of conception. This failure leads to the absence of the cranial vault (acrania) and the cerebral hemispheres. The exposed brain tissue undergoes degeneration, leaving behind a vascular mass called the *area cerebrovasculosa*. On ultrasound, this presents as the characteristic **"Frog-eye appearance"** due to prominent orbits and the absence of the calvarium. **Analysis of Incorrect Options:** * **A. Cephalocele:** This is a protrusion of the cranial contents through a defect in the skull (usually occipital). Unlike anencephaly, the rest of the cranium is present. * **B. Holoprosencephaly:** This is a failure of the prosencephalon (forebrain) to divide into two cerebral hemispheres. While it involves brain malformation and facial defects (like cyclopia), the skull vault is typically present. * **C. Dandy-Walker Malformation:** This involves the posterior fossa, characterized by agenesis of the cerebellar vermis, cystic dilation of the fourth ventricle, and an enlarged posterior fossa. The cranium itself is intact. **NEET-PG High-Yield Pearls:** * **Screening:** Elevated **Maternal Serum Alpha-Fetoprotein (MSAFP)** is a classic marker for open NTDs like anencephaly. * **Prevention:** Periconceptional intake of **Folic Acid (400 mcg/day)** reduces the risk by 70%. For women with a previous affected pregnancy, the dose is increased to **4 mg/day**. * **Associated Finding:** **Polyhydramnios** is frequently seen in the third trimester because the fetus lacks the swallowing reflex due to neurological impairment.

Question 570: What is the desired level of HbA1c in pregnant women with diabetes?

A. Less than or equal to 5%
B. Less than or equal to 5.5%
C. Less than or equal to 6% (Correct Answer)
D. Less than or equal to 7%

Explanation: **Explanation:** The primary goal of glycemic control in pregnancy is to minimize the risk of congenital malformations, macrosomia, and preeclampsia. **1. Why Option C is Correct:** According to the American Diabetes Association (ADA) and ACOG guidelines, the target HbA1c in pregnancy is **<6% (42 mmol/mol)**, provided this can be achieved without significant hypoglycemia. In pregnancy, red blood cell turnover increases, which naturally lowers HbA1c levels. A target of <6% is associated with the lowest rates of adverse fetal outcomes, particularly congenital anomalies (which are significantly higher when HbA1c exceeds 6.5–7%). **2. Analysis of Incorrect Options:** * **Options A & B (≤5% or ≤5.5%):** While these levels represent "normal" non-diabetic ranges, they are not the clinical target for diabetic patients. Aiming for such low levels significantly increases the risk of maternal **hypoglycemia**, which can be life-threatening. * **Option D (≤7%):** This is the standard target for non-pregnant adults. In pregnancy, a level of 7% is considered suboptimal and is associated with an increased risk of fetal macrosomia and polyhydramnios. **3. NEET-PG High-Yield Pearls:** * **Pre-conception Target:** Ideally, HbA1c should be **<6.5%** before conception to reduce the risk of anomalies like Sacral Agenesis (most specific) and VSD (most common). * **Monitoring Frequency:** HbA1c should be measured **every trimester** (or every 4-6 weeks) in pregnant women with pre-existing diabetes. * **Self-Monitoring (SMBG):** The gold standard for daily management. Targets: Fasting **<95 mg/dL**, 1-hour postprandial **<140 mg/dL**, or 2-hour postprandial **<120 mg/dL**. * **HbA1c Limitation:** It reflects glycemic control over the past 2–3 months but cannot detect daily glycemic variability or acute hypoglycemic episodes.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

Practice Questions

Multiple Gestation

Practice Questions

Rh Isoimmunization and Other Blood Group Incompatibilities

Practice Questions

Intrauterine Fetal Therapy

Practice Questions

Prenatal Diagnosis and Genetic Counseling

Practice Questions

Placental Abnormalities

Practice Questions

Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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