Maternal-Fetal Medicine Practice Questions

Q: A patient presents with signs of an abortus in the uterus and a dilated, open cervical os. This clinical presentation is suggestive of which of the following conditions?

Inevitable abortion. ### Explanation The clinical presentation of products of conception (abortus) still within the uterus accompanied by a **dilated/open cervical os** is the hallmark of an **Inevitable Abortion**. In this stage, the process of miscarriage has progressed to a point where it cannot be stopped or reversed. #### Analysis of Options: * **Inevitable Abortion (Correct):** Defined by vaginal bleeding, uterine cramps, and an **open internal os**. The products of conception are still inside the uterus but are destined to be expelled. * **Missed Abortion:** Characterized by fetal demise where the products of conception are retained in the uterus for a prolonged period. Crucially, the **cervical os remains closed**, and there is often a disappearance of pregnancy symptoms. * **Threatened Abortion:** Presents with vaginal bleeding, but the **cervical os is closed**, and the fetus is alive (cardiac activity present). It is the only stage of spontaneous abortion that is potentially reversible. * **Complete Abortion:** Occurs when all products of conception have been expelled. On examination, the **cervical os has usually closed**, and the uterus is contracted and empty on ultrasound. #### NEET-PG High-Yield Pearls: 1. **Cervical Os Status:** This is the most critical physical finding to differentiate types of abortion. If the os is **open**, it is either Inevitable or Incomplete. If the os is **closed**, it is either Threatened, Missed, or Complete. 2. **Management:** For Inevitable abortion, the management is typically **suction evacuation** (if <12 weeks) or medical induction to prevent infection and heavy hemorrhage. 3. **Incomplete Abortion:** Similar to inevitable (open os), but some products have already been expelled, often described as "fleshy masses" per vaginum.

Q: True regarding rubella infection in pregnancy is:

IgM antibodies in fetus reflects immunity. **Explanation:** **Why Option C is Correct:** The detection of **IgM antibodies** in the fetus or neonate is diagnostic of a congenital infection. Unlike IgG, maternal IgM antibodies are large molecules that **cannot cross the placenta**. Therefore, if IgM is present in the fetal blood (usually detected via cordocentesis after 22 weeks) or in the newborn, it indicates that the fetus has mounted its own immune response to an active infection. In the context of this question, it "reflects immunity" in the sense of an endogenous fetal immune response to the virus. **Analysis of Incorrect Options:** * **Option A:** The risk of **congenital transmission** is actually highest in the **first trimester** (up to 80-90%) and again very late in the third trimester. However, the risk of **congenital malformations** (Congenital Rubella Syndrome) is highest if the infection occurs before 12 weeks and is virtually zero after 20 weeks. * **Option B:** The Rubella vaccine (MMR) is a **Live Attenuated Vaccine**. It is strictly **contraindicated during pregnancy** due to the theoretical risk of infecting the fetus. Women should be advised to avoid pregnancy for at least 1 month (28 days) after vaccination. * **Option D:** Rubella is caused by the Rubivirus, which is a **positive-sense, single-stranded RNA virus** (Togaviridae family), not a DNA virus. **High-Yield Clinical Pearls for NEET-PG:** * **Gregg’s Triad:** The classic presentation of Congenital Rubella Syndrome (CRS) includes **Cataracts, Sensorineural hearing loss (most common), and Cardiac defects** (PDA is most common; Peripheral Pulmonary Artery Stenosis is most specific). * **Blueberry Muffin Rash:** Seen in neonates due to extramedullary hematopoiesis. * **Diagnosis:** If a pregnant woman is exposed, the first step is to check her **IgG status**. If she is IgG positive, she is immune and the fetus is safe.

Q: Biophysical profile includes all except?

Acetylcholine level. The **Biophysical Profile (BPP)**, also known as Manning’s score, is a critical ultrasound-based assessment used to evaluate fetal well-being and identify fetal hypoxia. It consists of five specific parameters, each reflecting the integrity of the fetal central nervous system. ### Why Acetylcholine level is the correct answer: **Acetylcholine level** is not a component of the BPP. While biochemical markers like Alpha-fetoprotein or Acetylcholinesterase are measured in amniotic fluid to screen for neural tube defects, they play no role in the acute assessment of fetal oxygenation or behavioral states. ### Explanation of BPP Components (The Incorrect Options): The BPP evaluates five parameters, scoring each as either 2 (normal) or 0 (abnormal): 1. **Non-stress test (NST):** Assesses fetal heart rate reactivity (the only "non-ultrasound" component). 2. **Fetal muscle tone:** At least one episode of active extension with return to flexion of fetal limbs or trunk. 3. **Amniotic fluid volume:** A marker of chronic fetal well-being (at least one pocket of $2 \text{ cm} \times 2 \text{ cm}$). 4. **Fetal breathing movements:** At least one episode of $\geq 30$ seconds duration within 30 minutes. 5. **Gross body movements:** At least three discrete body or limb movements in 30 minutes. ### High-Yield Clinical Pearls for NEET-PG: * **Modified BPP:** Consists of only two parameters: **NST** (acute indicator) and **Amniotic Fluid Index** (chronic indicator). * **Sequence of Loss:** In progressive fetal acidemia, the first parameter to disappear is the **NST (reactivity)**, followed by breathing, then movement, and finally **tone** (the last to disappear). * **Scoring:** A score of **8–10** is normal; **4 or less** is strongly suggestive of fetal asphyxia and usually warrants immediate delivery.

Q: Which of the following agents is used for neuroprotection in preterm deliveries?

Magnesium sulphate. **Explanation:** **Magnesium Sulphate (MgSO₄)** is the drug of choice for fetal neuroprotection in anticipated preterm deliveries. When administered to mothers at risk of delivery before 32 weeks of gestation, it significantly reduces the risk of **cerebral palsy** and severe motor dysfunction in the offspring. The underlying mechanism involves stabilizing neuronal membranes, reducing pro-inflammatory cytokines, and inhibiting excitatory neurotransmitters like glutamate by blocking NMDA receptors. **Analysis of Incorrect Options:** * **Betamethasone & Dexamethasone (Options A & B):** These are antenatal corticosteroids used to accelerate **fetal lung maturity**. While they reduce the incidence of Respiratory Distress Syndrome (RDS), Intraventricular Hemorrhage (IVH), and Necrotizing Enterocolitis (NEC), they are not primarily classified as neuroprotective agents for cerebral palsy. * **Indomethacin (Option D):** This is a non-steroidal anti-inflammatory drug (NSAID) used as a **tocolytic** to delay preterm labor. It acts by inhibiting prostaglandin synthesis. It is generally avoided after 32 weeks due to the risk of premature closure of the ductus arteriosus. **High-Yield Clinical Pearls for NEET-PG:** * **Gestational Age:** MgSO₄ for neuroprotection is typically recommended for deliveries **<32 weeks** (some protocols say <30 weeks). * **Dosing:** Usually a 4g IV loading dose followed by a 1g/hour maintenance infusion for 24 hours or until delivery. * **Monitoring:** Always monitor for **Magnesium toxicity** (loss of patellar reflex is the first sign, followed by respiratory depression). * **Antidote:** Calcium Gluconate (10ml of 10% solution IV).

Q: A 25-year-old woman complains of abdominal pain of rapid onset in the right lower quadrant. She subsequently undergoes surgery for suspected acute appendicitis. At surgery, however, a tubal pregnancy is discovered. What is the most frequent predisposing factor for this condition?

Pelvic inflammatory disease. **Explanation:** The clinical presentation describes an **Ectopic Pregnancy**, which often mimics acute appendicitis when it occurs in the right fallopian tube. **1. Why Pelvic Inflammatory Disease (PID) is Correct:** PID is the **most common risk factor** for ectopic pregnancy. Infections (primarily *Chlamydia trachomatis* or *Neisseria gonorrhoeae*) lead to salpingitis, causing structural damage to the tubal mucosa, loss of ciliary action, and the formation of intratubal adhesions (endosalpingeal folds). This mechanical and functional impairment hinders the transport of the fertilized ovum, leading to implantation within the tube. **2. Analysis of Incorrect Options:** * **Endometriosis (A):** While pelvic endometriosis can cause adhesions that distort tubal anatomy, it is a much less frequent cause compared to PID. * **Intrauterine Device (B):** IUDs do not *cause* ectopic pregnancy; they are highly effective at preventing all pregnancies. However, if a woman becomes pregnant with an IUD in situ, the *proportion* of those pregnancies being ectopic is higher, but the absolute risk is lower than in non-contraceptive users. * **Leiomyomas (C):** Uterine fibroids may cause infertility or miscarriage by distorting the uterine cavity, but they are rarely implicated in the pathogenesis of tubal pregnancies. **3. NEET-PG High-Yield Pearls:** * **Most common site of Ectopic Pregnancy:** Ampulla of the Fallopian tube (70%). * **Most common site for Tubal Rupture:** Isthmus (occurs early, around 6–8 weeks). * **Strongest Risk Factor:** Prior history of ectopic pregnancy (highest odds ratio). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on histology, characteristic of (but not pathognomonic for) ectopic pregnancy.

Q: What type of seizures are characteristic of eclampsia?

Generalised Tonic-Clonic Seizures. **Explanation:** **Eclampsia** is defined as the onset of seizures in a woman with pre-eclampsia that cannot be attributed to other causes. The characteristic seizure type in eclampsia is **Generalised Tonic-Clonic Seizures (GTCS)**. **Why GTCS is the correct answer:** The pathophysiology involves cerebral vasospasm, edema, and loss of cerebral autoregulation (often termed Posterior Reversible Encephalopathy Syndrome or PRES). This leads to widespread cortical irritability, resulting in a classic four-stage seizure: 1. **Invasion:** Facial twitching. 2. **Tonic phase:** Generalized muscular rigidity (lasts ~20 seconds). 3. **Clonic phase:** Violent rhythmic contractions and tongue biting (lasts ~1-2 minutes). 4. **Coma:** A period of unconsciousness and post-ictal confusion. **Why other options are incorrect:** * **Focal seizures:** These involve a specific area of the brain. While eclampsia can occasionally present with focal neurological deficits, the hallmark seizure is generalized. * **Absence seizures:** These involve brief lapses in consciousness without motor activity, typical of childhood epilepsy, not the violent convulsions of eclampsia. * **Myoclonic seizures:** These are brief, shock-like jerks of a muscle group, which do not follow the tonic-clonic progression seen in eclamptic patients. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC):** Magnesium Sulfate ($MgSO_4$) is the DOC for both prophylaxis and treatment of eclamptic seizures (Pritchard Regimen). * **Antidote for $MgSO_4$:** Calcium Gluconate (10 ml of 10% solution). * **Timing:** Eclampsia most commonly occurs **antepartum** (50%), followed by intrapartum (25%) and postpartum (25%). * **Definitive Treatment:** Delivery of the fetus, regardless of gestational age, once the mother is stabilized.

Q: Which of the following is a pathognomonic feature of ectopic pregnancy?

Decidual casts. ### Explanation **Correct Answer: B. Decidual casts** In ectopic pregnancy, the high levels of progesterone produced by the corpus luteum cause the uterine endometrium to undergo a **decidual reaction** (thickening and vascularization) to prepare for an embryo that never arrives in the uterus. When the ectopic pregnancy begins to fail or the hormonal support drops, the entire decidualized lining sloughs off and is expelled through the cervix in one piece, mimicking the shape of the uterine cavity. This is known as a **decidual cast**. While not present in every case, it is considered a classic, pathognomonic sign of ectopic pregnancy when it occurs. **Analysis of Incorrect Options:** * **A. Purple hemorrhagic mass in the lower vagina:** This is a characteristic finding of **Gestational Trophoblastic Neoplasia (Choriocarcinoma)**, representing vaginal metastasis. * **C. Chadwick sign:** This refers to the bluish discoloration of the cervix, vagina, and labia due to increased vascularity. It is a **presumptive sign of pregnancy** (both intrauterine and ectopic) but is not specific to ectopic pregnancy. * **D. Postcoital hemorrhage:** This is most commonly associated with **cervical pathology**, such as cervical polyps, cervicitis, or cervical cancer. **NEET-PG High-Yield Pearls:** * **Arias-Stella Reaction:** A microscopic finding in the endometrium (hypersecretory glands with enlarged nuclei) seen in ectopic pregnancy; it is suggestive but not pathognomonic as it can also occur in intrauterine pregnancies. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serum β-hCG (Discriminatory zone: 1500–2000 mIU/mL). * **Most Common Site:** Ampulla of the Fallopian tube.

Question 1

What is the best management to prevent heart failure in a pregnant woman with severe mitral stenosis?

Accepted Answer

Balloon mitral valvotomy during the second trimester

Answer

Continuous furosemide therapy throughout pregnancy

Answer

Digoxin for all patients with heart failure

Answer

Admission at 30 weeks gestation

Question 2

A patient presents with signs of an abortus in the uterus and a dilated, open cervical os. This clinical presentation is suggestive of which of the following conditions?

Accepted Answer

Inevitable abortion

Answer

Missed abortion

Answer

Threatened abortion

Answer

Complete abortion

Question 3

A patient at 17 weeks gestation is diagnosed with intrauterine fetal demise. She returns to your office 5 weeks later and has not had a miscarriage, although she has had some occasional spotting. This patient is at increased risk for what complication?

Accepted Answer

Consumptive coagulopathy with hypofibrinogenemia

Answer

Septic abortion

Answer

Recurrent abortion

Answer

Future infertility

Question 4

True regarding rubella infection in pregnancy is:

Accepted Answer

IgM antibodies in fetus reflects immunity

Answer

Risk of congenital infection is more in last trimester

Answer

Vaccination is indicated in pregnancy for protection

Answer

It is caused by DNA virus

Question 5

Biophysical profile includes all except?

Accepted Answer

Acetylcholine level

Answer

Non-stress test (NST)

Answer

Fetal muscle tone

Answer

Amniotic fluid volume

Question 6

Which of the following agents is used for neuroprotection in preterm deliveries?

Accepted Answer

Magnesium sulphate

Answer

Betamethasone

Answer

Dexamethasone

Answer

Indomethacin

Question 7

A 25-year-old woman complains of abdominal pain of rapid onset in the right lower quadrant. She subsequently undergoes surgery for suspected acute appendicitis. At surgery, however, a tubal pregnancy is discovered. What is the most frequent predisposing factor for this condition?

Accepted Answer

Pelvic inflammatory disease

Answer

Endometriosis

Answer

An intrauterine device

Answer

Leiomyomas of the uterus

Question 8

What type of seizures are characteristic of eclampsia?

Accepted Answer

Generalised Tonic-Clonic Seizures

Answer

Focal seizures

Answer

Absence seizures

Answer

Myoclonic seizures

Question 9

Which of the following is a pathognomonic feature of ectopic pregnancy?

Accepted Answer

Decidual casts

Answer

Purple hemorrhagic mass in the lower vagina

Answer

Chadwick sign

Answer

Postcoital hemorrhage

Question 10

A patient in shock is diagnosed with ectopic pregnancy in the right fallopian tube. What is the postulated cause of fetal death in ectopic pregnancy?

Accepted Answer

Vascular accident

Answer

Nutritional adequacy

Answer

Endocrine insufficiency

Answer

Immune response of mother

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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