Maternal-Fetal Medicine — MCQs

A 38-year-old woman, gravida 3, para 2, at 32 weeks' gestation presents with vaginal bleeding. She reports passing two quarter-sized clots of blood this morning. She denies contractions, gushes of fluid, or fetal distress. Her obstetrical history includes two low-transverse cesarean deliveries due to non-reassuring fetal heart rate tracings. An ultrasound reveals a complete placenta previa. For which of the following conditions is this patient at highest risk?

Q579Medium

Which of the following statements is true?

Q580Easy

Hemoconcentration is seen in which of the following conditions?

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 571: Recurrent fetal loss is associated with which of the following conditions?

A. Systemic lupus erythematosus (SLE)
B. Lupus anticoagulant
C. Antiphospholipid antibody syndrome (APLAS)
D. All of the above (Correct Answer)

Explanation: **Explanation:** Recurrent fetal loss (RFL) is a significant clinical challenge often rooted in autoimmune and thrombophilic disorders. The correct answer is **All of the above** because these conditions are pathophysiologically linked through the mechanism of placental insufficiency. 1. **Antiphospholipid Antibody Syndrome (APLAS):** This is the most common acquired thrombophilia leading to RFL. It is characterized by the presence of antibodies (Lupus anticoagulant, Anticardiolipin, or Anti-β2 glycoprotein I) that induce a prothrombotic state. This leads to thrombosis of placental vessels, infarction, and subsequent fetal loss, typically after 10 weeks of gestation. 2. **Lupus Anticoagulant (LA):** This is one of the specific antibodies used to diagnose APLAS. Despite its name, it is a potent procoagulant *in vivo*. It has the strongest association with pregnancy complications and adverse outcomes among all antiphospholipid antibodies. 3. **Systemic Lupus Erythematosus (SLE):** Patients with SLE have a higher baseline risk of fetal loss due to active inflammation, vasculitis, and the frequent co-existence of secondary APLAS (found in approximately 30-40% of SLE patients). **High-Yield Clinical Pearls for NEET-PG:** * **APLAS Diagnostic Criteria (Sapporo):** Requires at least one clinical criterion (vascular thrombosis or pregnancy morbidity) and one laboratory criterion (positive LA, ACL, or Anti-β2 GPI on two occasions, 12 weeks apart). * **Pregnancy Morbidity in APLAS:** Defined as ≥3 unexplained consecutive spontaneous abortions before 10 weeks, OR ≥1 death of a morphologically normal fetus at ≥10 weeks, OR ≥1 preterm birth before 34 weeks due to severe pre-eclampsia or placental insufficiency. * **Management:** The standard treatment for APLAS in pregnancy is a combination of **Low-Dose Aspirin (LDA)** and **Low Molecular Weight Heparin (LMWH)**.

Question 572: When the death of one fetus in a multiple pregnancy occurs early in pregnancy, how may it manifest?

A. Fetus papyraceus
B. Vanishing twin (Correct Answer)
C. Fetus compressus
D. Fetus acardiacus

Explanation: ### Explanation The correct answer is **B. Vanishing twin**. **1. Why "Vanishing Twin" is correct:** When a fetus dies **early in pregnancy** (typically during the first trimester), the gestational sac and fetal tissues are often completely reabsorbed by the mother or the surviving twin. On a follow-up ultrasound, the previously documented twin simply "disappears," leaving a single viable fetus. This phenomenon occurs in approximately 20–30% of pregnancies conceived via assisted reproductive techniques. **2. Why the other options are incorrect:** * **A. Fetus papyraceus:** This occurs when fetal death happens in the **second trimester** (usually after 14 weeks). The fetus is too large to be fully reabsorbed; instead, the amniotic fluid is absorbed, and the dead fetus becomes flattened, mummified, and parchment-like due to mechanical compression by the growing survivor. * **C. Fetus compressus:** This is a similar stage to fetus papyraceus. It refers to a fetus that has died and been compressed, but the term "papyraceus" is more specifically used when it is flattened to a paper-thin state. * **D. Fetus acardiacus (TRAP Sequence):** This is a rare complication of monochorionic twinning where one twin has a rudimentary or absent heart and is perfused by the "pump twin" through large artery-to-artery anastomoses. It is a developmental malformation, not a manifestation of early fetal death/reabsorption. **3. Clinical Pearls for NEET-PG:** * **Timing is Key:** Early 1st Trimester = Vanishing Twin; 2nd Trimester = Fetus Papyraceus. * **Prognosis:** If a twin "vanishes" in the 1st trimester, the prognosis for the surviving twin is usually excellent. * **Monochorionic Risk:** Death of a twin in the **2nd or 3rd trimester** in a monochorionic pregnancy carries a high risk of neurological damage (periventricular leukomalacia) or death for the survivor due to acute hemodynamic shifts.

Question 573: Post-term pregnancy is associated with which of the following conditions?

A. Spina bifida
B. Anencephaly (Correct Answer)
C. Congenital adrenal hyperplasia
D. Cerebral palsy

Explanation: **Explanation:** **Post-term pregnancy** is defined as a pregnancy that extends to or beyond **42 weeks (294 days)** from the first day of the last menstrual period. **Why Anencephaly is the Correct Answer:** The initiation of labor is a complex process involving the **fetal-hypothalamic-pituitary-adrenal (HPA) axis**. In a normal pregnancy, the fetal hypothalamus triggers the pituitary to release ACTH, which stimulates the fetal adrenal glands to produce cortisol precursors. This rise in cortisol is a key signal for the onset of labor. In **Anencephaly**, there is a failure of the fetal brain and cranium to develop, leading to the absence of a functional hypothalamus and pituitary gland. Consequently, the HPA axis is disrupted, and the hormonal triggers required to initiate labor are absent or severely delayed, frequently resulting in post-term gestation. **Analysis of Incorrect Options:** * **A. Spina bifida:** While a neural tube defect, it does not typically involve the HPA axis or the brain structures responsible for labor initiation; therefore, it is not a classic cause of post-term pregnancy. * **C. Congenital adrenal hyperplasia (CAH):** In CAH, there is an enzymatic defect leading to excessive androgen production, but the HPA axis is active (often overactive in terms of ACTH). It is not associated with delayed labor. * **D. Cerebral palsy:** This is a permanent movement disorder caused by brain damage occurring during fetal development, birth, or shortly after. It is a *consequence* of birth complications (like birth asphyxia in post-term babies) rather than a *cause* of post-term pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of post-term pregnancy:** Inaccurate dating (wrong dates). * **Fetal causes:** Anencephaly, Fetal Adrenal Hypoplasia, and Placental Sulfatase Deficiency (which leads to low estrogen levels). * **Complications:** Oligohydramnios (most common), Meconium Aspiration Syndrome, and Macrosomia. * **Management:** Induction of labor is generally recommended by 41 weeks to reduce perinatal morbidity.

Question 574: Which of the following is true about magnesium sulfate (MgSO4)?

A. Magnesium sulfate is not a tocolytic.
B. Magnesium sulfate is used in the management of eclampsia. (Correct Answer)
C. Magnesium sulfate does not cause neonatal respiratory depression.
D. Magnesium sulfate can be given in myasthenia gravis.

Explanation: **Explanation:** **Magnesium Sulfate (MgSO₄)** is the drug of choice for both the prophylaxis and treatment of seizures in eclampsia (Pritchard or Zuspan regimens). It acts primarily by blocking NMDA receptors, increasing the seizure threshold, and causing cerebral vasodilation. **Analysis of Options:** * **Option B (Correct):** MgSO₄ is the gold standard for managing eclamptic seizures and preventing progression from pre-eclampsia to eclampsia. * **Option A (Incorrect):** While not the *first-line* choice today (calcium channel blockers are preferred), MgSO₄ **is** a tocolytic. It acts as a calcium antagonist, relaxing uterine smooth muscle to delay preterm labor. * **Option C (Incorrect):** MgSO₄ crosses the placenta. In cases of maternal toxicity or prolonged high-dose infusion, it can cause **neonatal respiratory depression**, hypotonia ("floppy infant syndrome"), and suppressed reflexes. * **Option D (Incorrect):** MgSO₄ is **strictly contraindicated in Myasthenia Gravis**. It inhibits the release of acetylcholine at the neuromuscular junction, which can precipitate a life-threatening myasthenic crisis. **High-Yield Clinical Pearls for NEET-PG:** 1. **Therapeutic Range:** 4–7 mEq/L. 2. **Monitoring:** Always check for **Patellar reflex** (first to disappear at 8–10 mEq/L), **Respiratory rate** (>12/min), and **Urine output** (>30 ml/hr, as it is renally excreted). 3. **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (administered slowly). 4. **Neuroprotection:** MgSO₄ is also used for fetal neuroprotection in imminent preterm births <32 weeks to reduce the risk of cerebral palsy.

Question 575: Grade 2 abruptio placenta is characterized by?

A. Pronounced shock
B. Severe bleeding
C. Coagulation defect
D. Fetal distress (Correct Answer)

Explanation: **Explanation:** Abruptio placentae is the premature separation of a normally situated placenta. To standardize clinical management, the **Sher and Linthicum classification** is used to grade the severity based on clinical findings. **Why Fetal Distress is the Correct Answer:** In **Grade 2 (Moderate) Abruption**, the separation involves approximately 1/4th to 2/3rd of the placental surface. This significant loss of surface area leads to uteroplacental insufficiency. The classic presentation includes uterine tenderness, increased uterine tone, and most characteristically, **evidence of fetal distress** (abnormal heart rate patterns or fetal tachycardia). While the mother may show signs of tachycardia or orthostatic hypotension, she is not yet in profound shock. **Analysis of Incorrect Options:** * **A & B (Pronounced shock & Severe bleeding):** These are hallmarks of **Grade 3 (Severe) Abruption**. In Grade 2, bleeding is mild to moderate, and maternal hemodynamics are usually maintained despite compensated tachycardia. * **C (Coagulation defect):** Consumptive coagulopathy (DIC) is a severe complication typically reserved for **Grade 3** cases, often associated with intrauterine fetal death (IUFD). **NEET-PG High-Yield Pearls:** * **Grade 0:** Asymptomatic; diagnosed retrospectively by finding a retroplacental clot after delivery. * **Grade 1:** Mild; no fetal distress, no maternal shock. * **Grade 3:** Severe; characterized by **maternal shock, fetal death (IUFD), and often DIC.** * **Couvelaire Uterus:** A complication where blood extravasates into the myometrium (port-wine appearance); it is a clinical diagnosis made during laparotomy. * **Most common risk factor:** Maternal hypertension (Chronic or PIH).

Question 576: Funneling in cervicogram is seen in which of the following conditions?

A. During labor
B. Cervical incompetence (Correct Answer)
C. Cervical ectopic pregnancy
D. During transvaginal sonography (TVS)

Explanation: **Explanation:** **Cervical incompetence** (now often termed cervical insufficiency) is the correct answer. It is characterized by the painless dilation and effacement of the cervix, typically during the second trimester, leading to recurrent pregnancy loss or preterm birth. **Funneling** refers to the protrusion of the amniotic membranes into the internal os as it begins to open, while the external os remains closed. On ultrasound (cervicogram), this creates a characteristic "V" or "U" shaped appearance. **Analysis of Options:** * **A. During labor:** While the cervix dilates and effaces during labor, this is a physiological process driven by uterine contractions. The term "funneling" specifically describes the pre-labor pathological changes seen in an incompetent cervix. * **C. Cervical ectopic pregnancy:** This condition involves the implantation of the blastocyst within the cervical canal. It typically presents with a "hourglass" shaped uterus and a closed internal os, rather than the progressive funneling of membranes. * **D. During TVS:** Transvaginal sonography is the **modality** used to diagnose funneling, not a condition itself. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** TVS is the gold standard. A cervical length **<25 mm** before 24 weeks is a significant risk factor. * **The "Trust" Rule:** The sequence of cervical changes in funneling follows the mnemonic **T-Y-U-V** (T = normal, Y = early funneling, U = advanced funneling, V = imminent loss). * **Management:** The primary treatment is **Cervical Cerclage** (e.g., McDonald or Shirodkar techniques), usually performed between 12–14 weeks of gestation. * **Clinical Sign:** On physical exam, "bulging membranes" or "hourglass membranes" may be visible at the external os.

Question 577: Spalding's ring is seen in which of the following conditions?

A. Stillborn
B. Liveborn
C. Premature
D. Deadborn (Correct Answer)

Explanation: **Explanation:** **Spalding’s Sign** is a classic radiological indicator of **intrauterine fetal death (IUFD)**. It refers to the **overlapping of the fetal skull bones** caused by the liquefaction of the brain matter and the loss of intracranial pressure following fetal demise. 1. **Why "Deadborn" is correct:** When a fetus dies in utero, the brain tissue undergoes autolysis and shrinks. This leads to a collapse of the cranial vault. The resulting loss of alignment causes the parietal bones to overlap at the sutures. This sign typically appears **4 to 7 days** after fetal death has occurred. 2. **Why other options are incorrect:** * **Liveborn/Premature:** In a living fetus (whether term or premature), intracranial pressure is maintained, and the brain provides a structural scaffold that keeps the skull bones aligned. While "molding" can occur during labor in a live birth, it is symmetrical and disappears shortly after delivery, unlike the pathological collapse seen in Spalding’s sign. * **Stillborn:** While "stillborn" and "deadborn" are often used interchangeably in general terms, in the context of this specific radiological sign, it specifically denotes a fetus that has been dead in the uterus for a sufficient period to allow for bone collapse. **High-Yield Clinical Pearls for NEET-PG:** * **Robert’s Sign:** The presence of gas in the fetal heart and great vessels (earliest radiological sign of IUFD, seen within 12 hours). * **Deuel’s Halo Sign:** Edema of the fetal scalp causing a "halo" appearance (indicates fetal death). * **Confirmatory Test:** Today, **Ultrasonography** is the gold standard for diagnosing IUFD, showing the absence of fetal heart activity (cardiac flicker). Spalding's sign is now primarily a historical radiological finding but remains a frequent "favorite" in exams.

Question 578: A 38-year-old woman, gravida 3, para 2, at 32 weeks' gestation presents with vaginal bleeding. She reports passing two quarter-sized clots of blood this morning. She denies contractions, gushes of fluid, or fetal distress. Her obstetrical history includes two low-transverse cesarean deliveries due to non-reassuring fetal heart rate tracings. An ultrasound reveals a complete placenta previa. For which of the following conditions is this patient at highest risk?

A. Dystocia
B. Intrauterine fetal demise (IUFD)
C. Placenta accreta (Correct Answer)
D. Preeclampsia

Explanation: **Explanation:** The correct answer is **Placenta accreta**. The patient presents with two major risk factors for **placenta accreta spectrum (PAS)**: a current **placenta previa** and a history of **multiple prior cesarean deliveries**. Placenta accreta occurs when there is an abnormal attachment of the placenta to the myometrium due to a defective decidua basalis, typically at the site of a previous uterine scar. According to the **Silver and Landon criteria**, the risk of placenta accreta increases significantly with the number of prior cesarean sections in the presence of placenta previa: * 1st C-section: ~3% risk * 2nd C-section: ~11% risk * 3rd C-section: ~40% risk * 4th C-section: ~61% risk Since this patient is undergoing her third pregnancy with two prior scars and a current previa, her risk is approximately **11-25%**, making it the most likely complication among the choices. **Why incorrect options are wrong:** * **Dystocia:** While previa necessitates a C-section, "dystocia" (difficult labor) is not the primary concern because labor is contraindicated in complete previa. * **Intrauterine fetal demise (IUFD):** While previa can cause hemorrhage, it rarely leads to IUFD unless there is massive maternal exsanguination or abruption. The primary fetal risk is prematurity, not demise. * **Preeclampsia:** While advanced maternal age (38) is a risk factor, there is no direct pathophysiological link between placenta previa/prior scars and the development of preeclampsia. **High-Yield Clinical Pearls for NEET-PG:** 1. **The "Golden Rule":** Any patient with a prior C-section and current placenta previa has placenta accreta until proven otherwise. 2. **Diagnosis:** Antenatal diagnosis is primarily via **Color Doppler Ultrasound** (look for loss of retroplacental clear zone and bladder wall irregularities). 3. **Management:** The preferred management is a **planned cesarean hysterectomy** at 34 0/7 to 35 6/7 weeks. 4. **Most common site:** The lower uterine segment (due to poor decidualization).

Question 579: Which of the following statements is true?

A. Mitral stenosis surgery is better avoided in pregnancy.
B. Mitral regurgitation with pulmonary hypertension is a definite indication for termination of pregnancy.
C. Aortic stenosis in young age is usually due to a bicuspid valve.
D. All of the above. (Correct Answer)

Explanation: **Explanation:** This question addresses the management of valvular heart disease in pregnancy, a high-yield topic for NEET-PG. * **Option A:** Mitral Stenosis (MS) is the most common valvular lesion in pregnancy. While medical management is preferred, if surgery is required (due to refractory NYHA Class III/IV symptoms), it is ideally performed **pre-conception**. During pregnancy, the physiological increase in blood volume and heart rate can lead to pulmonary edema. If intervention is unavoidable, Percutaneous Mitral Balloon Valvotomy (PMBV) is preferred over open-heart surgery, which carries a high fetal mortality rate (up to 30%). * **Option B:** While Mitral Regurgitation (MR) is generally well-tolerated in pregnancy due to decreased systemic vascular resistance, the development of **Pulmonary Hypertension (PH)** significantly increases maternal mortality (25-50%). Severe PH is a contraindication to pregnancy and a definite indication for early termination to save the mother's life. * **Option C:** In young patients, **Bicuspid Aortic Valve** is the most common congenital cause of Aortic Stenosis. In the context of pregnancy, it is particularly concerning as it is often associated with aortic root dilation and risk of dissection. **Clinical Pearls for NEET-PG:** 1. **Most common heart disease in pregnancy:** Rheumatic Heart Disease (Mitral Stenosis). 2. **Worst prognosis in pregnancy:** Pulmonary Hypertension (Eisenmenger syndrome). 3. **Anticoagulation:** Warfarin is teratogenic (6-12 weeks); switch to LMWH or Unfractionated Heparin during the first trimester and near term. 4. **Labor Management:** Shorten the second stage of labor (using forceps/ventouse) to avoid the Valsalva maneuver.

Question 580: Hemoconcentration is seen in which of the following conditions?

A. Normal pregnancy
B. Preeclampsia (Correct Answer)
C. Ectopic pregnancy
D. All of the above

Explanation: **Explanation:** In **Preeclampsia**, the fundamental pathophysiology involves widespread endothelial dysfunction. This leads to increased vascular permeability, causing fluid to leak from the intravascular compartment into the interstitial space (resulting in edema). Consequently, there is a **contraction of plasma volume**. While both plasma and red cell mass are affected, the reduction in plasma volume is disproportionately greater, leading to **hemoconcentration** (manifesting as an elevated hematocrit). This is a hallmark of the disease and distinguishes it from the physiological changes of a healthy pregnancy. **Analysis of Incorrect Options:** * **Normal Pregnancy:** This is characterized by **hemodilution**. While both plasma volume and red cell mass increase, the plasma volume increases by ~40–50% while red cell mass increases by only ~20–30%. This disproportion leads to "Physiological Anemia of Pregnancy." * **Ectopic Pregnancy:** If ruptured, this leads to hemorrhage and hypovolemia. Initially, the hematocrit may remain normal, but as compensatory mechanisms shift fluid into the vessels, it results in hemodilution (decreased hematocrit), not hemoconcentration. **High-Yield Clinical Pearls for NEET-PG:** * **Hematocrit Trend:** A rising hematocrit in a hypertensive pregnant woman is an ominous sign indicating worsening disease severity and significant plasma volume depletion. * **The "Gold Standard" Pathophysiology:** Preeclampsia is a disease of "theories," but **endothelial dysfunction** and **vasospasm** are the core mechanisms. * **Fluid Management:** Because patients with preeclampsia are hemoconcentrated but have leaky capillaries, they are at high risk for both pulmonary edema (if over-hydrated) and acute kidney injury (due to low intravascular volume).

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

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free