Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 601: Indications for termination of pregnancy include all of the following except:

A. Aortic stenosis
B. Eisenmenger syndrome
C. Tricuspid stenosis (Correct Answer)
D. NYHA grade 4 heart disease

Explanation: In maternal-fetal medicine, the decision to terminate a pregnancy is based on the risk of maternal mortality. Heart diseases are classified into risk groups, with certain conditions posing a prohibitively high risk (25–50% mortality). **Why Tricuspid Stenosis is the Correct Answer:** Tricuspid stenosis (TS) is generally well-tolerated during pregnancy. Unlike left-sided obstructive lesions, TS involves the low-pressure venous system. While it may cause peripheral edema and hepatic congestion, it rarely leads to life-threatening pulmonary edema or sudden cardiac death. Therefore, it is **not** an absolute indication for termination. **Analysis of Incorrect Options:** * **Eisenmenger Syndrome:** This carries the highest risk (up to 50% mortality). The drop in systemic vascular resistance during pregnancy worsens the right-to-left shunt, leading to severe hypoxemia and heart failure. Termination is strongly advised. * **Aortic Stenosis (Severe/Symptomatic):** This is a fixed-output state. The heart cannot increase cardiac output to meet pregnancy demands, leading to syncope, heart failure, or sudden death. * **NYHA Grade 4 Heart Disease:** Patients symptomatic at rest have minimal cardiac reserve. The physiological hemodilution and increased cardiac output of pregnancy often lead to decompensation and death. **Clinical Pearls for NEET-PG:** * **WHO Class IV Heart Diseases (Termination Recommended):** Eisenmenger syndrome, Pulmonary Arterial Hypertension (PAH), Severe Aortic Stenosis, Marfan Syndrome with aortic root >40mm, and previous Peripartum Cardiomyopathy with residual dysfunction. * **Mitral Stenosis:** The most common rheumatic valvular lesion in pregnancy; while dangerous, it is often managed medically or via valvuloplasty rather than mandatory termination unless refractory. * **Highest Risk Period:** The immediate postpartum period (first 24–48 hours) due to "autotransfusion" from the involuting uterus.

Question 602: What is the most common neurological disorder encountered in pregnancy?

A. Epilepsy (Correct Answer)
B. Alzheimer's disease
C. Cerebrovascular disorders
D. Multiple sclerosis

Explanation: **Explanation:** **Epilepsy** is the most common major neurological disorder encountered in pregnancy, affecting approximately **0.5% to 1%** of all pregnant women. It is a high-yield topic for NEET-PG because it requires careful management of anti-epileptic drugs (AEDs) to balance maternal seizure control against the risk of fetal malformations. **Why the other options are incorrect:** * **Alzheimer’s Disease:** This is a neurodegenerative condition primarily affecting the elderly. It is extremely rare in the reproductive age group. * **Cerebrovascular Disorders:** While the risk of stroke and venous sinus thrombosis increases during pregnancy and the puerperium due to a hypercoagulable state, these events are statistically less frequent than pre-existing epilepsy. * **Multiple Sclerosis (MS):** MS is the second most common neurological disorder in pregnancy. While it frequently affects women of childbearing age, its prevalence in the pregnant population is lower than that of epilepsy. **High-Yield Clinical Pearls for NEET-PG:** 1. **Pre-conception:** Women should be started on **high-dose Folic Acid (5 mg/day)** to reduce the risk of neural tube defects associated with AEDs. 2. **Teratogenicity:** **Sodium Valproate** is the most teratogenic AED (associated with neural tube defects and lower IQ); **Lamotrigine and Levetiracetam** are generally considered the safest options. 3. **Seizure Frequency:** About 1/3 of patients experience increased seizure frequency, often due to physiological changes (increased volume of distribution) or non-compliance. 4. **Vitamin K:** Infants born to mothers on enzyme-inducing AEDs (e.g., Phenytoin, Phenobarbital) should receive Vitamin K at birth to prevent hemorrhagic disease of the newborn.

Question 603: A 19-year-old primigravida presents with 8 weeks of amenorrhea, light bleeding, and pain. On examination, the uterine size corresponds to the period of gestation, and the os is closed. Ultrasound reveals an intrauterine pregnancy. What is the preferred management in this case?

A. Estrogen plus Progesterone therapy
B. Dilatation and Curettage
C. Bed rest and Progesterone (Correct Answer)
D. Beta hCG

Explanation: ### Explanation **Diagnosis: Threatened Abortion** The clinical presentation of a primigravida with 8 weeks of amenorrhea, light vaginal bleeding, and abdominal pain, combined with a **closed cervical os** and a confirmed **intrauterine pregnancy** on ultrasound, is a classic case of **Threatened Abortion**. **1. Why Option C is Correct:** The management of threatened abortion is primarily conservative. * **Bed Rest:** While strict bed rest is no longer mandatory, "pelvic rest" (avoiding strenuous activity and coitus) is traditionally advised to reduce uterine irritability. * **Progesterone:** Progesterone supplementation (oral, vaginal, or intramuscular) is the mainstay of treatment. It supports the luteal phase, promotes uterine quiescence by inhibiting contractions, and has immunomodulatory effects that favor pregnancy maintenance. **2. Why Other Options are Incorrect:** * **Option A (Estrogen + Progesterone):** Estrogen has no proven role in preventing miscarriage. High doses of estrogen are contraindicated in pregnancy. * **Option B (Dilatation and Curettage):** This is the management for *Inevitable, Incomplete, or Missed abortions*. Since the os is closed and the pregnancy is intrauterine (likely viable), surgical evacuation would terminate a potentially healthy pregnancy. * **Option D (Beta hCG):** While Beta hCG is used for diagnosis and monitoring (especially in ectopic pregnancy or pregnancy of unknown location), it is not a *management* or treatment modality for a confirmed intrauterine threatened abortion. **3. High-Yield Clinical Pearls for NEET-PG:** * **Threatened Abortion:** Bleeding is usually slight; Os is **Closed**; Internal Os is **not** dilated. * **Inevitable Abortion:** Bleeding is heavier; Os is **Open**; Internal Os is dilated; membranes may be ruptured. * **Prognosis:** Approximately 50% of threatened abortions proceed to a normal pregnancy. * **USG Finding:** The presence of fetal cardiac activity is the most reassuring prognostic sign in threatened abortion. * **Anti-D Immunoglobulin:** If the mother is Rh-negative, Anti-D should be administered even in threatened abortion to prevent isoimmunization.

Question 604: A 25-year-old primigravida at 20 weeks of gestation presents with a first episode of symptomatic bacteriuria. What is the risk of developing pyelonephritis?

A. No risk with the first episode
B. 5%
C. 15%
D. 25% (Correct Answer)

Explanation: **Explanation:** The correct answer is **D (25%)**. **Underlying Medical Concept:** Pregnancy induces physiological changes that predispose women to urinary tract infections (UTIs). High levels of progesterone cause smooth muscle relaxation, leading to ureteral dilation (hydroureter) and decreased bladder tone. Additionally, the enlarging uterus causes mechanical compression of the ureters. These factors result in urinary stasis and vesicoureteral reflux. In pregnant women, **asymptomatic bacteriuria (ASB)** or symptomatic cystitis has a high propensity to ascend to the kidneys. If left untreated, approximately **20–30% (average 25%)** of these women will develop acute pyelonephritis, which is associated with severe maternal and fetal complications like preterm labor and sepsis. **Analysis of Incorrect Options:** * **A (No risk):** This is incorrect because pregnancy is a high-risk state for ascending infections due to the physiological changes mentioned above. * **B (5%) & C (15%):** These percentages are too low. While 2–10% is the prevalence of ASB in pregnancy, the risk of *progression* to pyelonephritis from untreated bacteriuria is significantly higher, consistently cited around 25% in standard textbooks like Williams Obstetrics. **High-Yield Clinical Pearls for NEET-PG:** * **Screening:** All pregnant women should be screened for ASB at the first prenatal visit (ideally between 12–16 weeks) using a **midstream urine culture**. * **Definition:** ASB is defined as >10⁵ CFU/mL of a single uropathogen in an asymptomatic patient. * **Most Common Organism:** *E. coli* (70–80% of cases). * **Treatment Goal:** Treatment of ASB reduces the risk of pyelonephritis to <3%. * **Drug of Choice:** Nitrofurantoin or Amoxicillin-Clavulanate are commonly used (avoid Nitrofurantoin at term due to risk of neonatal hemolysis).

Question 605: Which of the following complications is usually not observed in gestational diabetes mellitus?

A. Abortion
B. Preeclampsia
C. Infection
D. Oligohydramnios (Correct Answer)

Explanation: **Explanation:** In **Gestational Diabetes Mellitus (GDM)**, the hallmark pathophysiology is maternal hyperglycemia leading to fetal hyperglycemia. This triggers **fetal osmotic diuresis**, resulting in **polyhydramnios** (excess amniotic fluid), not oligohydramnios. **Why Oligohydramnios is the correct answer:** Oligohydramnios is typically associated with conditions causing placental insufficiency or fetal renal anomalies. In GDM, the increased glucose load in the fetus leads to polyuria, which increases the amniotic fluid volume. Therefore, oligohydramnios is an "atypical" finding in GDM and is usually not observed unless there is co-existing fetal growth restriction (FGR) or premature rupture of membranes. **Analysis of Incorrect Options:** * **Abortion:** While more common in pre-gestational diabetes with poor glycemic control during organogenesis, poorly controlled GDM still carries a slightly increased risk of spontaneous pregnancy loss. * **Preeclampsia:** There is a strong clinical association between GDM and hypertensive disorders. Hyperinsulinemia and insulin resistance contribute to endothelial dysfunction, increasing the risk of preeclampsia. * **Infection:** Hyperglycemia impairs neutrophil function and provides a culture medium for pathogens, making GDM patients prone to monilial vaginitis and urinary tract infections (UTIs). **NEET-PG High-Yield Pearls:** * **Most common fetal complication in GDM:** Macrosomia (due to fetal hyperinsulinemia). * **Most common malformation (Pre-gestational DM):** Cardiac defects (VSD). * **Most specific malformation (Pre-gestational DM):** Caudal Regression Syndrome. * **Amniotic Fluid Index (AFI):** In GDM, look for Polyhydramnios (AFI >24-25 cm).

Question 606: A 25-year-old pregnant lady presents with thrombocytopenia (Platelet count < 50,000) and fragmented RBCs in peripheral smear. Which of the following is the least likely differential diagnosis?

A. Thrombotic Thrombocytopenic Purpura (TTP)
B. Disseminated Intravascular Coagulation (DIC)
C. HELLP syndrome
D. Evan's syndrome (Correct Answer)

Explanation: **Explanation:** The clinical presentation of **thrombocytopenia** and **fragmented RBCs (schistocytes)** on a peripheral smear indicates **Microangiopathic Hemolytic Anemia (MAHA)**. In pregnancy, this triad is a critical diagnostic marker for several life-threatening conditions. **Why Evan’s Syndrome is the least likely (Correct Answer):** Evan’s syndrome is an autoimmune condition characterized by the simultaneous or sequential occurrence of Immune Thrombocytopenic Purpura (ITP) and **Autoimmune Hemolytic Anemia (AIHA)**. Crucially, AIHA is a warm-antibody mediated destruction where RBCs are seen as **spherocytes**, not fragments (schistocytes). Since the question specifies fragmented RBCs, Evan’s syndrome is excluded. **Analysis of Incorrect Options (MAHA causes):** * **HELLP Syndrome:** The most common cause of MAHA in pregnancy. It involves microvascular endothelial damage leading to platelet activation and mechanical shearing of RBCs. * **TTP (Thrombotic Thrombocytopenic Purpura):** Characterized by a deficiency in ADAMTS13, leading to large vWF multimers that cause microthrombi, resulting in severe thrombocytopenia and RBC fragmentation. * **DIC (Disseminated Intravascular Coagulation):** Often secondary to placental abruption or sepsis, it involves systemic activation of coagulation, consumption of factors, and fibrin strands that shear RBCs. **High-Yield Clinical Pearls for NEET-PG:** * **MAHA Triad:** Thrombocytopenia, Schistocytes, and elevated LDH. * **Differential Marker:** To distinguish HELLP from TTP/HUS, look at blood pressure and liver enzymes (elevated in HELLP) vs. neurological symptoms or ADAMTS13 levels (TTP). * **Evan’s Syndrome Diagnosis:** Requires a **Positive Direct Coombs Test (DCT)**, whereas MAHA conditions (HELLP, TTP, DIC) are Coombs-negative.

Question 607: Contraction stress test is used to detect which of the following fetal conditions?

A. Fetal hypoxia (Correct Answer)
B. Placenta previa
C. Hydramnios
D. Cord prolapse

Explanation: **Explanation:** The **Contraction Stress Test (CST)**, also known as the Oxytocin Challenge Test, is a method used to evaluate the **uteroplacental reserve** and the fetus's ability to tolerate the transient hypoxia that occurs during uterine contractions. **1. Why Fetal Hypoxia is Correct:** During a uterine contraction, intramyometrial pressure exceeds capillary perfusion pressure, momentarily stopping blood flow to the intervillous space. A healthy fetus with adequate placental support can tolerate this brief reduction in oxygen. However, a fetus with borderline oxygenation (chronic hypoxia) will exhibit **late decelerations** on the Fetal Heart Rate (FHR) monitor in response to these contractions. Therefore, the CST is specifically designed to unmask **fetal hypoxia** and placental insufficiency. **2. Why Other Options are Incorrect:** * **Placenta Previa:** This is a structural abnormality of placental implantation diagnosed via ultrasound. CST is actually **contraindicated** in placenta previa as contractions can trigger life-threatening hemorrhage. * **Hydramnios:** This refers to an abnormal volume of amniotic fluid, diagnosed via the Amniotic Fluid Index (AFI) on ultrasound, not by fetal heart rate response to stress. * **Cord Prolapse:** This is an obstetric emergency where the umbilical cord descends ahead of the presenting part. It is diagnosed by physical examination or sudden variable decelerations, not by a provocative stress test. **Clinical Pearls for NEET-PG:** * **Criteria for CST:** Requires at least 3 contractions in 10 minutes, each lasting 40–60 seconds. * **Interpretation:** A **Positive CST** (abnormal) is defined by late decelerations following 50% or more of contractions. It indicates a high risk of fetal compromise. * **Contraindications:** Previous classical C-section, preterm rupture of membranes (PROM), and placenta previa. * **Comparison:** Unlike the Non-Stress Test (NST), which assesses fetal well-being via reactivity, the CST specifically assesses placental respiratory function.

Question 608: Embryo reduction of a multiple pregnancy is typically performed at which gestational age?

A. 8-10 weeks
B. 11-13 weeks (Correct Answer)
C. 13-15 weeks
D. 16-18 weeks

Explanation: **Explanation:** Multifetal Pregnancy Reduction (MFPR) is a procedure performed to reduce the number of fetuses in a high-order multiple pregnancy (typically triplets or more) to improve the chances of a healthy outcome for the remaining fetuses and the mother. **Why 11–13 weeks is the correct answer:** This is the "window of choice" for several clinical reasons: 1. **Spontaneous Reduction:** By 11 weeks, most cases of "vanishing twin" or spontaneous early miscarriages have already occurred. Performing it earlier might mean reducing a fetus that would have naturally resorbed. 2. **Aneuploidy Screening:** At 11–13 weeks, a **Nuchal Translucency (NT) scan** and early anatomy survey can be performed. This allows the clinician to selectively reduce the fetus with the highest risk of chromosomal abnormalities or structural defects. 3. **Procedure Safety:** The uterus is large enough to make the transabdominal ultrasound-guided needle insertion technically easier, yet the gestational age is low enough that the risk of total pregnancy loss (approx. 4-5%) is minimized compared to second-trimester procedures. **Analysis of Incorrect Options:** * **A (8–10 weeks):** Too early. Spontaneous fetal loss is still common, and the NT scan cannot be accurately performed to screen for anomalies. * **C & D (13–18 weeks):** These are considered "late" reductions. As gestational age increases, the volume of fetal tissue and amniotic fluid increases, significantly raising the risk of procedure-related complications, such as premature rupture of membranes (PROM), infection, and late miscarriage. **High-Yield Clinical Pearls for NEET-PG:** * **Route of Choice:** Transabdominal ultrasound-guided intracardiac injection of **Potassium Chloride (KCl)** is the gold standard. * **Monochorionic Twins:** Reduction is more complex due to vascular anastomoses; KCl is contraindicated as it can kill the co-twin. Radiofrequency ablation (RFA) or cord occlusion is used instead. * **Goal:** Usually to reduce the pregnancy to twins (dichorionic diamniotic).

Question 609: A 21-year-old female presents with 8 weeks of amenorrhea and is now in shock. What is the most likely diagnosis?

A. Ruptured ectopic pregnancy (Correct Answer)
B. Incarcerated amnion
C. Torsed ovarian cyst
D. Threatened abortion

Explanation: **Explanation:** The clinical presentation of **amenorrhea (8 weeks)** followed by **sudden shock** in a woman of reproductive age is a classic medical emergency. **1. Why Ruptured Ectopic Pregnancy is Correct:** An ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity, most commonly in the **ampulla** of the fallopian tube. As the embryo grows, it distends the tube, eventually leading to rupture (typically between 6–10 weeks). Rupture causes massive **intraperitoneal hemorrhage (hemoperitoneum)**, leading to hypovolemic shock (tachycardia, hypotension, and pallor). In NEET-PG, the triad of amenorrhea, abdominal pain, and vaginal bleeding/shock should always be considered a ruptured ectopic pregnancy until proven otherwise. **2. Why Other Options are Incorrect:** * **Incarcerated Amnion:** This is not a standard clinical term. An incarcerated gravid uterus (usually at 12–16 weeks) causes urinary retention, not sudden shock. * **Torsed Ovarian Cyst:** While this causes acute pelvic pain and potentially localized peritonitis, it rarely causes systemic shock unless it leads to secondary rupture and massive internal bleeding, which is far less common than ectopic rupture. * **Threatened Abortion:** This presents with vaginal bleeding and mild cramping while the cervix remains closed. It does not cause hemodynamic instability or shock. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Transvaginal Ultrasound (TVS) + Serum β-hCG. * **Picket Fence Temperature:** Often seen in ruptured ectopic due to blood irritating the peritoneum. * **Management of Shock:** Immediate resuscitation with IV fluids/blood followed by **emergency laparotomy** (Salpingectomy). Do not wait for an ultrasound if the patient is hemodynamically unstable. * **Arias-Stella Reaction:** A characteristic endometrial change seen in ectopic pregnancy (hypersecretory glands with pleomorphic nuclei).

Question 610: A 28-week pregnant multigravida has an abnormal glucose tolerance test. Her previous child weighed 4 kg at birth. Which of the following is TRUE about infants of diabetic mothers?

A. Hyperglycemia occurs in all infants of diabetic mothers.
B. A high incidence of congenital heart anomalies is common in infants of diabetic mothers. (Correct Answer)
C. Infants are typically small for gestational age.
D. There is a high incidence of metabolic syndrome in later life.

Explanation: **Explanation:** The correct answer is **B: A high incidence of congenital heart anomalies is common in infants of diabetic mothers.** **1. Why the Correct Answer is Right:** Infants of diabetic mothers (IDM) face a significantly higher risk of congenital malformations (3–5 times higher than the general population). The most common anomalies are **cardiovascular**, specifically **Ventricular Septal Defects (VSD)** and **Transposition of the Great Arteries (TGA)**. While **Sacral Agenesis** (Caudal Regression Syndrome) is the most *specific* anomaly for diabetic embryopathy, cardiac defects are more frequent in total numbers. These occur due to the teratogenic effects of maternal hyperglycemia during organogenesis (the first trimester). **2. Why the Incorrect Options are Wrong:** * **Option A:** IDMs experience **Hypoglycemia**, not hyperglycemia. High maternal glucose crosses the placenta, causing fetal hyperinsulinemia. After birth, the glucose supply is cut off, but the high insulin levels persist, leading to a rapid drop in neonatal blood sugar. * **Option C:** IDMs are typically **Large for Gestational Age (LGA)** or macrosomic. Maternal hyperglycemia leads to fetal hyperinsulinemia; since insulin is a potent growth hormone, it causes excessive fat deposition and organomegaly. * **Option D:** While IDMs are at a higher risk for obesity and Type 2 Diabetes later in life, the question asks about the immediate neonatal/infant period. Option B is a more established, classic clinical association for IDMs in the context of maternal-fetal medicine exams. **Clinical Pearls for NEET-PG:** * **Most common anomaly:** Cardiac (VSD). * **Most specific anomaly:** Caudal Regression Syndrome (Sacral Agenesis). * **Metabolic triad in IDM:** Hypoglycemia, Hypocalcemia, and Hypomagnesemia. * **Other complications:** Polycythemia, Hyperbilirubinemia, and Respiratory Distress Syndrome (insulin inhibits surfactant production).

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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