Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 631: What is the most common cause of maternal mortality?

A. Sepsis
B. Eclampsia
C. Hemorrhage (Correct Answer)
D. Obstructed labor

Explanation: **Explanation:** **Hemorrhage (Option C)** is the leading cause of maternal mortality worldwide and in India, accounting for approximately 25–30% of maternal deaths. Among hemorrhages, **Postpartum Hemorrhage (PPH)** is the most significant contributor. The primary physiological reason is the high blood flow to the gravid uterus (approx. 600–700 mL/min); if the uterus fails to contract effectively after delivery (Atonic PPH), massive blood loss can occur within minutes, leading to hypovolemic shock and death. **Why other options are incorrect:** * **Sepsis (Option A):** While a major cause of mortality, particularly in settings with poor hygiene or prolonged labor, it usually ranks behind hemorrhage and hypertensive disorders. * **Eclampsia (Option B):** Hypertensive disorders of pregnancy are the second most common cause of maternal death globally. While life-threatening, the incidence of death is statistically lower than that caused by acute hemorrhage. * **Obstructed Labor (Option D):** This is an indirect cause that leads to mortality via secondary complications like uterine rupture, hemorrhage, or sepsis, rather than being the most frequent direct cause itself. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of PPH:** Uterine Atony (80% of cases). * **Active Management of Third Stage of Labor (AMTSL):** The most important intervention to reduce maternal mortality. * **Global vs. India:** Hemorrhage remains #1 in both. However, always check for "Indirect causes"—globally, non-obstetric causes (like cardiac disease or malaria) are rising in proportion. * **Maternal Mortality Ratio (MMR):** Defined as maternal deaths per 100,000 live births.

Question 632: What is a cause of oligohydramnios?

A. Esophageal atresia
B. Duodenal atresia
C. Renal agenesis (Correct Answer)
D. Diabetes

Explanation: **Explanation:** The volume of amniotic fluid is a dynamic balance between production and removal. From the second trimester onwards, **fetal urine production** becomes the primary source of amniotic fluid, while fetal swallowing is the main route of removal. **Why Renal Agenesis is Correct:** In **Renal Agenesis** (Potter’s Syndrome), the kidneys fail to develop, leading to a total absence of fetal urine production. This results in severe **oligohydramnios** (Amniotic Fluid Index <5 cm or Single Deepest Pocket <2 cm). Without adequate fluid, the fetus suffers from pulmonary hypoplasia and limb deformities due to uterine compression. **Why the Other Options are Incorrect:** * **Esophageal and Duodenal Atresia:** These are gastrointestinal obstructions that prevent the fetus from swallowing amniotic fluid. Since the fluid is produced but not removed, these conditions lead to **polyhydramnios**. * **Diabetes:** Maternal diabetes (especially gestational or poorly controlled) causes fetal hyperglycemia, leading to osmotic diuresis (increased fetal urination). This results in **polyhydramnios**. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Oligohydramnios is defined as an AFI < 5 cm or a Single Deepest Pocket (SDP) < 2 cm. * **Common Causes:** Renal anomalies (agenesis, posterior urethral valves), Premature Rupture of Membranes (PROM), Uteroplacental insufficiency (IUGR), and Post-term pregnancy. * **Drug-induced:** ACE inhibitors and NSAIDs (Indomethacin) can cause oligohydramnios by reducing fetal renal blood flow. * **Potter’s Sequence:** Remember the triad of Renal agenesis → Oligohydramnios → Pulmonary hypoplasia (the most common cause of death).

Question 633: What is the risk of vertical transmission of HIV without intervention during pregnancy and breastfeeding?

A. 15% to 30% (Correct Answer)
B. 5% to 10%
C. 10% to 15%
D. 2% to 5%

Explanation: **Explanation:** The risk of vertical transmission (Mother-to-Child Transmission - MTCT) of HIV occurs at three stages: in utero, during labor/delivery, and through breastfeeding. In the absence of any medical intervention (no Antiretroviral Therapy, vaginal delivery, and breastfeeding), the cumulative risk is approximately **15% to 30%**. If breastfeeding continues into the second year, the risk can further increase to 35-45%. * **Why Option A is correct:** Without intervention, the transmission rate is roughly divided as: 5-10% during pregnancy, 10-15% during labor (the period of highest risk per hour), and 5-15% through prolonged breastfeeding. This totals the 15-30% range commonly cited in standard textbooks like Williams Obstetrics. * **Why Options B, C, and D are incorrect:** These figures represent risks *with* some level of intervention. For instance, **Option D (2%)** is the target risk level when a mother is on effective HAART with an undetectable viral load and avoids breastfeeding. Options B and C represent partial interventions (e.g., Zidovudine monotherapy without viral suppression). **High-Yield Clinical Pearls for NEET-PG:** * **Most common timing:** The majority of transmission occurs **intranatally** (during labor and delivery) due to "micro-transfusions" and contact with infected vaginal secretions. * **Gold Standard Goal:** With modern HAART, elective Cesarean Section (if viral load >1000 copies/mL), and avoidance of breastfeeding, the risk can be reduced to **<1-2%**. * **Breastfeeding:** In India, the current WHO/NACO guideline suggests that "Exclusive Breastfeeding" for the first 6 months is recommended even for HIV-positive mothers if they are on ART, as the benefits of nutrition and immunity outweigh the risk of HIV in resource-limited settings. * **Prophylaxis:** Nevirapine is the drug of choice for infant prophylaxis in the immediate postnatal period.

Question 634: Patients with organic heart disease in pregnancy most commonly die during which period?

A. 20-24 weeks of pregnancy
B. First stage of labor
C. Soon following delivery (Correct Answer)
D. Two weeks postpartum

Explanation: **Explanation:** The correct answer is **Soon following delivery** (Option C). The period immediately following the delivery of the placenta is the most critical for a woman with organic heart disease. This is due to a phenomenon known as **"Autotransfusion."** When the placenta is delivered, the compression of the inferior vena cava is relieved, and the blood previously circulating in the uteroplacental unit (approx. 500-800 mL) is shifted back into the maternal systemic circulation. This sudden increase in venous return leads to a massive surge in cardiac output (up to 60-80% above baseline), which can overwhelm a compromised heart, leading to acute pulmonary edema and heart failure. **Analysis of Incorrect Options:** * **A. 20-24 weeks:** While cardiac output begins to rise significantly during the second trimester, it reaches its peak plateau between **28-32 weeks**. This is a period of high risk, but not the most common time for mortality compared to the immediate postpartum surge. * **B. First stage of labor:** Cardiac output increases during labor due to pain, anxiety, and uterine contractions (each contraction pushes ~300-500 mL of blood into circulation), but the peak hemodynamic stress occurs after the fetus is expelled. * **D. Two weeks postpartum:** By this time, hemodynamic stability is usually restored as the excess fluid has been diuresed. **High-Yield Clinical Pearls for NEET-PG:** * **Maximum Risk Periods:** 1. Immediately postpartum (highest risk), 2. During labor, 3. 28-32 weeks of gestation. * **Management:** To prevent heart failure during the third stage, avoid ergometrine (causes vasoconstriction) and use slow IV infusion of oxytocin. * **Positioning:** Encourage the left lateral position to minimize caval compression. * **Vaginal vs. C-Section:** Vaginal delivery with an assisted second stage (forceps/ventouse) to cut short maternal bearing down is preferred over elective Cesarean section.

Question 635: The risk of fetal varicella syndrome is maximum when the mother is infected between which gestational periods?

A. 6 to 10 weeks
B. 8 to 12 weeks
C. 13 to 20 weeks (Correct Answer)
D. 20 to 28 weeks

Explanation: **Explanation:** The risk of **Congenital Varicella Syndrome (CVS)** is directly linked to the gestational age at the time of primary maternal infection. While maternal infection can occur at any time, the period of maximum vulnerability for the fetus is between **13 and 20 weeks** of gestation. 1. **Why 13 to 20 weeks is correct:** During this window, the fetal immune system is immature, and the virus can cross the placenta to cause multi-organ damage. Studies indicate the risk of CVS is approximately **2%** during this period. The hallmark features include cicatricial skin scarring (in a dermatomal distribution), limb hypoplasia, chorioretinitis, and microcephaly. 2. **Why other options are incorrect:** * **6 to 12 weeks (Options A & B):** While infection can occur, the risk of CVS is lower (approximately 0.4% to 1%) compared to the second trimester peak. * **20 to 28 weeks (Option D):** After 20 weeks, the risk of CVS becomes negligible as the fetus develops better immunological defenses, though the virus may remain latent and manifest as childhood herpes zoster. **High-Yield Clinical Pearls for NEET-PG:** * **Maximum Risk Period:** 13–20 weeks (2% risk). * **Varicella Zoster Immunoglobulin (VZIG):** Should be administered to non-immune pregnant women within **10 days** of exposure to prevent or attenuate maternal disease. * **Neonatal Varicella:** If the mother develops a rash **5 days before to 2 days after delivery**, the neonate is at high risk for severe disseminated disease due to lack of transplacental antibodies; the neonate must receive VZIG immediately. * **Treatment:** Oral Acyclovir is the drug of choice for maternal infection to reduce maternal complications (pneumonia).

Question 636: An ultrasound shows a twin pregnancy. Which of the following is a feature of dizygotic twins?

A. Separate amnion and same chorion
B. Separate chorion and amnion (Correct Answer)
C. Always different sex
D. None of the above

Explanation: **Explanation:** **1. Why Option B is Correct:** Dizygotic (fraternal) twins result from the fertilization of **two separate ova by two separate sperm**. Because each zygote undergoes its own independent process of implantation and development, each fetus develops its own placenta, its own outer membrane (chorion), and its own inner sac (amnion). Therefore, dizygotic twins are **always Dichorionic-Diamniotic (DCDA)**. **2. Why the Other Options are Incorrect:** * **Option A (Separate amnion and same chorion):** This describes Monochorionic-Diamniotic (MCDA) twins. This configuration is unique to **monozygotic** (identical) twins where the zygote splits between days 4 and 8 post-fertilization. Dizygotic twins can never share a chorion. * **Option C (Always different sex):** This is a common misconception. Since two separate sperm are involved, the sex of each twin is independent. They can be the same sex (approx. 50% of the time) or different sexes. Only "different sex" twins are guaranteed to be dizygotic, but dizygotic twins are not "always" different sex. **3. NEET-PG High-Yield Pearls:** * **Zygosity vs. Chorionicity:** All dizygotic twins are DCDA. Monozygotic twins can be DCDA, MCDA, or MCMA depending on the timing of the split. * **The "Lambda" vs. "T" Sign:** On ultrasound, a thick membrane with the **Lambda (λ) sign** (or twin-peak sign) indicates DCDA (Dizygotic or early-split Monozygotic). A thin membrane with a **T-sign** indicates MCDA. * **Incidence:** The rate of monozygotic twins is constant worldwide (~1 in 250), whereas the rate of dizygotic twins varies by race (highest in Nigerians, lowest in Japanese), maternal age, and use of assisted reproductive technology (ART).

Question 637: Which of the following complications is seen in pregnancy?

A. Diabetes complicating pregnancy
B. Hypertension complicating pregnancy (Correct Answer)
C. Placenta previa complicating pregnancy
D. Preterm delivery

Explanation: **Explanation:** The correct answer is **Hypertension complicating pregnancy**. This question focuses on the standardized terminology used in maternal-fetal medicine to classify systemic conditions versus obstetric complications. **1. Why Hypertension is the Correct Answer:** Hypertension is the most common medical complication of pregnancy, affecting approximately 5–10% of all gestations. In obstetric nomenclature, when a systemic medical condition (like hypertension or heart disease) exists alongside pregnancy, it is termed as "complicating pregnancy." Hypertensive disorders are categorized into Preeclampsia-Eclampsia, Gestational Hypertension, Chronic Hypertension, and Chronic Hypertension with Superimposed Preeclampsia. **2. Analysis of Incorrect Options:** * **Diabetes complicating pregnancy (Option A):** While a common condition, in the context of standardized NEET-PG questions, hypertension is prioritized as the quintessential "medical complication" due to its higher incidence and role as a leading cause of the maternal mortality triad (Hemorrhage, Infection, Hypertension). * **Placenta Previa (Option C):** This is classified as an **obstetric complication** or an anatomical abnormality of placentation, rather than a systemic medical disease complicating the pregnancy state. * **Preterm Delivery (Option D):** This is an **outcome** or a labor-related complication, not a primary medical disease process. **Clinical Pearls for NEET-PG:** * **The "Rule of 10" in Pregnancy:** Roughly 10% of pregnancies are complicated by hypertension. * **Definition:** Gestational hypertension is defined as BP ≥140/90 mmHg for the first time after 20 weeks of gestation without proteinuria. * **Drug of Choice:** Oral **Labetalol** is the first-line antihypertensive in pregnancy. **Methyldopa** is the safest long-term drug, while **Hydralazine** or IV Labetalol is used for hypertensive emergencies. * **Contraindication:** ACE inhibitors and ARBs are strictly contraindicated due to fetal renal dysgenesis.

Question 638: A 21-week pregnant patient presents with fever and chills, and a diagnosis of Malaria is made. What is the next line of management?

A. Wait until term and start treatment for malaria.
B. Terminate the pregnancy and treat the patient for malaria.
C. Start antimalarial treatment immediately and continue the pregnancy. (Correct Answer)
D. Treat only if it is falciparum malaria; otherwise, wait until term.

Explanation: **Explanation:** **1. Why Option C is Correct:** Malaria in pregnancy is considered a high-risk condition because pregnancy induces a state of relative immunosuppression, making the mother more susceptible to severe complications (e.g., severe anemia, hypoglycemia, acute pulmonary edema, and cerebral malaria). Furthermore, parasites sequester in the placenta, leading to placental insufficiency, intrauterine growth restriction (IUGR), and fetal demise. Therefore, **immediate antimalarial treatment** is mandatory regardless of the gestational age to protect both maternal and fetal health. **2. Why Other Options are Incorrect:** * **Option A & D:** Waiting until term is dangerous. Delaying treatment increases the risk of maternal mortality and adverse obstetric outcomes like miscarriage or stillbirth. All species of malaria (including *P. vivax*) must be treated immediately in pregnancy. * **Option B:** Malaria is a treatable medical condition and is **not** an indication for the termination of pregnancy. Once the infection is cleared, the pregnancy can usually proceed normally with close monitoring. **3. High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice:** According to WHO and NVBDCP guidelines, **Artemisinin-based Combination Therapy (ACT)** is now recommended for uncomplicated *P. falciparum* malaria in **all trimesters** (including the first). * **Quinine:** Historically used in the 1st trimester, but ACT is now preferred if available. * **Avoid:** Primaquine and Tetracyclines are **contraindicated** in pregnancy due to the risk of fetal hemolysis (G6PD risk) and bone/teeth abnormalities, respectively. * **Chemoprophylaxis:** In endemic areas, Proguanil or Chloroquine may be used depending on local resistance patterns.

Question 639: Which of the following is NOT a complication of Rh incompatibility?

A. Antepartum hemorrhage (APH)
B. Postpartum hemorrhage (PPH)
C. Oligohydramnios (Correct Answer)
D. Pregnancy-induced hypertension

Explanation: **Explanation:** Rh isoimmunization occurs when a Rh-negative mother carries a Rh-positive fetus, leading to the production of maternal antibodies that cross the placenta and cause fetal hemolysis. **Why Oligohydramnios is the correct answer:** In Rh incompatibility, fetal hemolysis leads to **anemia**. To compensate, the fetus increases cardiac output, leading to hyperdynamic circulation and eventual heart failure (Hydrops fetalis). A key physiological response to fetal anemia is increased hepatic and splenic erythropoiesis, which causes organomegaly and portal hypertension. Crucially, fetal anemia leads to **Polyhydramnios**, not oligohydramnios. This occurs due to increased fetal cardiac output resulting in increased renal perfusion and fetal urine production, as well as placental edema interfering with fluid exchange. **Analysis of other options:** * **APH & PPH:** Rh isoimmunization is associated with a **large, boggy, and edematous placenta** (Placentomegaly). This increases the risk of placental abruption (leading to APH) and uterine atony after delivery due to overdistension (leading to PPH). * **Pregnancy-induced hypertension (PIH):** The enlarged, "hyperplacentosis" state seen in severe Rh isoimmunization is a known risk factor for the early onset of preeclampsia (Mirror Syndrome). **NEET-PG High-Yield Pearls:** * **Mirror Syndrome (Ballantyne’s Syndrome):** A rare condition where maternal edema "mirrors" fetal and placental hydrops; it is often associated with severe Rh isoimmunization. * **First sign of Hydrops on USG:** Increased thickness of the placenta (>4 cm). * **Most sensitive non-invasive test for fetal anemia:** Peak Systolic Velocity of the Middle Cerebral Artery (MCA-PSV) via Doppler.

Question 640: Which of the following statements regarding alpha-fetoprotein is true?

A. Its major source in fetal life is the yolk sac. (Correct Answer)
B. It is commonly increased in Wilms' tumor.
C. Maximum levels are observed around the 20th week of gestation.
D. Its half-life is 5-7 days.

Explanation: **Explanation:** **Alpha-fetoprotein (AFP)** is a glycoprotein produced during fetal development that serves as the fetal analog of albumin. 1. **Why Option A is Correct:** In early embryonic life, AFP is primarily synthesized by the **yolk sac**. As gestation progresses, the **fetal liver** becomes the predominant source of production. Small amounts are also produced by the fetal gastrointestinal tract. 2. **Why Options B, C, and D are Incorrect:** * **Option B:** AFP is a tumor marker for **Hepatocellular carcinoma** and **Germ cell tumors** (specifically Yolk Sac Tumors/Endodermal Sinus Tumors). It is *not* typically associated with Wilms' tumor (Nephroblastoma). * **Option C:** In fetal serum, AFP levels peak at the end of the **first trimester (approx. 12–14 weeks)**. In maternal serum (MSAFP), levels peak later, around **30–32 weeks**. Screening for neural tube defects is ideally done between **15–20 weeks**. * **Option D:** The biological half-life of AFP is approximately **3 to 5 days**. This is clinically significant when monitoring the clearance of the marker after surgical resection of a tumor. **High-Yield Clinical Pearls for NEET-PG:** * **Elevated MSAFP:** Associated with Neural Tube Defects (NTDs), abdominal wall defects (Omphalocele, Gastroschisis), multiple gestations, and fetal demise. * **Decreased MSAFP:** Associated with **Down Syndrome (Trisomy 21)**, Trisomy 18, gestational trophoblastic disease, and maternal obesity. * **Amniotic Fluid Acetylcholinesterase (AChE):** This is a more specific test than AFP for confirming the diagnosis of an open neural tube defect.

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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