Maternal-Fetal Medicine Practice Questions

Q: Indications for termination of pregnancy include all of the following except:

Tricuspid stenosis. 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.

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

Epilepsy. **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.

Q: 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?

25%. **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).

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

Oligohydramnios. **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).

Q: 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?

Evan's syndrome. **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.

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

Ruptured ectopic pregnancy. **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 1

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

Accepted Answer

Tricuspid stenosis

Answer

Aortic stenosis

Answer

Eisenmenger syndrome

Answer

NYHA grade 4 heart disease

Question 2

What is the most common neurological disorder encountered in pregnancy?

Accepted Answer

Epilepsy

Answer

Alzheimer's disease

Answer

Cerebrovascular disorders

Answer

Multiple sclerosis

Question 3

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?

Accepted Answer

Bed rest and Progesterone

Answer

Estrogen plus Progesterone therapy

Answer

Dilatation and Curettage

Answer

Beta hCG

Question 4

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?

Accepted Answer

25%

Answer

No risk with the first episode

Answer

5%

Answer

15%

Question 5

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

Accepted Answer

Oligohydramnios

Answer

Abortion

Answer

Preeclampsia

Answer

Infection

Question 6

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?

Accepted Answer

Evan's syndrome

Answer

Thrombotic Thrombocytopenic Purpura (TTP)

Answer

Disseminated Intravascular Coagulation (DIC)

Answer

HELLP syndrome

Question 7

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

Accepted Answer

Fetal hypoxia

Answer

Placenta previa

Answer

Hydramnios

Answer

Cord prolapse

Question 8

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

Accepted Answer

11-13 weeks

Answer

8-10 weeks

Answer

13-15 weeks

Answer

16-18 weeks

Question 9

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

Accepted Answer

Ruptured ectopic pregnancy

Answer

Incarcerated amnion

Answer

Torsed ovarian cyst

Answer

Threatened abortion

Question 10

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?

Accepted Answer

A high incidence of congenital heart anomalies is common in infants of diabetic mothers.

Answer

Hyperglycemia occurs in all infants of diabetic mothers.

Answer

Infants are typically small for gestational age.

Answer

There is a high incidence of metabolic syndrome in later life.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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