Maternal-Fetal Medicine Practice Questions

Q: What is the most important feature for diagnosing fetal aneuploidy?

Nuchal translucency. **Explanation:** **Nuchal Translucency (NT)** is the most important and sensitive ultrasound marker for diagnosing fetal aneuploidy, particularly Trisomy 21 (Down Syndrome), during the first-trimester screening (11 to 13+6 weeks). It refers to the subcutaneous collection of fluid behind the fetal neck. An increased NT measurement is associated not only with chromosomal abnormalities but also with structural defects like congenital heart disease. **Analysis of Options:** * **B. Nuchal Translucency (Correct):** It is the primary screening tool. When combined with maternal age and serum markers (PAPP-A and β-hCG), it achieves a detection rate of approximately 90% for Down Syndrome. * **A. Absent Nasal Bone:** While a highly specific marker for Trisomy 21 (absent in ~60-70% of cases), it is considered a "secondary" or "soft" marker that improves the sensitivity of the NT scan rather than replacing it. * **C. Increased Frontomaxillary Angle:** This measures facial flatness. While often increased in Trisomy 21, it is technically difficult to measure and less standardized than NT. * **D. Reversal of Ductus Venosus (DV) Flow:** Abnormal DV flow (absent or reversed a-wave) is a marker of fetal cardiac dysfunction and is associated with aneuploidy, but it is used as a secondary adjunctive marker to refine the risk calculated by NT. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** NT must be measured when the Crown-Rump Length (CRL) is between **45 mm and 84 mm**. * **Cut-off:** An NT value **>3.5 mm** (or >95th percentile for CRL) is generally considered pathological. * **Combined Test:** The "First Trimester Combined Screening" includes NT + PAPP-A + free β-hCG. * **Next Step:** If NT is increased, the definitive diagnostic test is **Chorionic Villus Sampling (CVS)** in the first trimester or **Amniocentesis** after 15 weeks.

Q: All of the following are causes of Disseminated Intravascular Coagulation (DIC), except?

Multiple pregnancy. **Explanation:** Disseminated Intravascular Coagulation (DIC) in obstetrics is a secondary pathological process triggered by the entry of procoagulant substances (like thromboplastin) into the maternal circulation, leading to widespread activation of the clotting cascade and subsequent consumption of clotting factors. **Why Multiple Pregnancy is the correct answer:** Multiple pregnancy, by itself, is a physiological state and not a trigger for DIC. While it increases the risk for complications like Postpartum Hemorrhage (PPH) or Pre-eclampsia, it does not involve the release of thromboplastin into the circulation unless one of those secondary complications occurs. **Why the other options are causes of DIC:** * **Abruptio Placentae:** This is the **most common cause** of DIC in pregnancy. Retroplacental clots release massive amounts of tissue thromboplastin into the maternal venous sinuses. * **Intrauterine Death (IUD) & Missed Abortion:** If a dead fetus is retained for more than 3–4 weeks, the autolysis of fetal tissues and the placenta releases thromboplastin into the maternal circulation, leading to "Dead Fetus Syndrome" and consumption coagulopathy. **NEET-PG High-Yield Pearls:** 1. **Most common cause of DIC in pregnancy:** Abruptio Placentae. 2. **Most common cause of DIC in clinical practice (overall):** Sepsis. 3. **Amniotic Fluid Embolism:** A rare but catastrophic cause of sudden, severe DIC due to the high concentration of procoagulants in amniotic fluid. 4. **Diagnosis:** Look for decreased Fibrinogen (<150 mg/dL), increased D-dimer/FDPs, and prolonged PT/APTT. 5. **Management:** The definitive treatment is the delivery of the fetus and placenta to remove the source of thromboplastin. Blood products (FFP, Cryoprecipitate, Platelets) are used for stabilization.

Q: A G2P1 patient presents at 34 weeks of pregnancy in labor with cervical dilatation of 3 cm and minimal uterine contractions. After artificial rupture of membranes, fresh bleeding is observed along with late decelerations. An emergency cesarean section was performed, but the fetus could not be saved. No abruption or placenta previa was noted. What is the most likely diagnosis?

Vasa previa. **Explanation:** The clinical presentation of **Vasa Previa** is classic: painless vaginal bleeding (fetal blood) occurring immediately after the **rupture of membranes (ROM)**, followed by rapid fetal distress (late decelerations or bradycardia) and fetal demise. In vasa previa, fetal vessels run unprotected by Wharton’s jelly across the internal os. When the membranes rupture, these vessels tear, leading to rapid fetal exsanguination since the total fetal blood volume is very small (~80-100 mL/kg). **Why other options are incorrect:** * **Concealed Abruptio Placentae:** While it causes fetal distress, it is usually associated with severe abdominal pain, a "woody hard" uterus, and the absence of fresh vaginal bleeding. The question specifically ruled out abruption during the C-section. * **Battledore Placenta:** This refers to the insertion of the umbilical cord at the placental margin. While it can lead to vasa previa if vessels traverse the membranes, the term itself describes a placental morphology that does not inherently cause bleeding unless vessels are ruptured. * **Placenta Accreta:** This is a disorder of placental adhesion to the myometrium. It typically presents with a failure of placental separation and massive postpartum hemorrhage, not fetal bleeding during labor. **Clinical Pearls for NEET-PG:** * **Triad of Vasa Previa:** Rupture of membranes + Painless vaginal bleeding + Fetal distress (bradycardia/sinusoidal pattern). * **Apt Test / Kleihauer-Betke Test:** Used to differentiate fetal blood from maternal blood in vaginal discharge. * **Risk Factors:** Velamentous cord insertion, succenturiate placental lobes, and IVF pregnancies. * **Management:** If diagnosed prenatally via Doppler USG, elective C-section is planned at 34–35 weeks. If diagnosed during labor, immediate emergency C-section is mandatory.

Q: A patient receives a score of 8 on her biophysical profile. What do these results indicate?

The results are normal.. The **Biophysical Profile (BPP)** is a crucial antepartum fetal surveillance tool that assesses fetal well-being by combining five parameters: Fetal breathing movements, Fetal body movements, Fetal tone, Amniotic fluid volume (AFV), and the Non-stress test (NST). ### **Explanation of the Correct Answer** Each of the five parameters is assigned a score of either 2 (present/normal) or 0 (absent/abnormal). * A total score of **8/10 or 10/10** is considered **normal** and indicates a low risk of chronic fetal asphyxia. * If the score is 8/10 but the 2-point deduction is due to **oligohydramnios** (decreased amniotic fluid), it is managed differently, but generally, a score of 8 is reassuring. ### **Why Other Options are Incorrect** * **Option A:** A score of **6/10** is considered **equivocal**. This requires a repeat BPP within 24 hours or delivery if the fetus is at term. * **Options B & D:** Scores of **0 to 4** are considered **abnormal** and strongly suggestive of fetal acidemia. A score of 4/10 usually warrants induction or delivery, while a score of 0-2/10 often necessitates immediate evaluation for emergent delivery (Cesarean section) to prevent fetal demise. ### **High-Yield Clinical Pearls for NEET-PG** 1. **Manning’s Criteria:** The original BPP includes 5 components. The **Modified BPP** (more commonly used) includes only the NST and Amniotic Fluid Index (AFI). 2. **Sequence of Loss:** In progressive fetal hypoxia, the first sign to disappear is fetal heart rate reactivity (NST), followed by breathing, and finally fetal tone (the last to disappear). 3. **Amniotic Fluid:** It is the only component of the BPP that reflects **chronic** placental function; the other four reflect **acute** CNS status. 4. **Management Rule:** Regardless of the total score, if **oligohydramnios** is present (AFI < 5cm or single deepest pocket < 2cm), further evaluation or delivery is indicated.

Q: A woman presents at term pregnancy for her first antenatal visit and tests positive for HIV in screening and confirmatory tests. What is the next step in management?

Start ART immediately.. The core principle in managing HIV during pregnancy is the prevention of parent-to-child transmission (PPTCT). According to current WHO and National AIDS Control Organization (NACO) guidelines, the "Test and Treat" policy applies to all pregnant women. **Why Option C is correct:** In this scenario, the woman is already at term. The risk of vertical transmission is highest during labor and delivery. Starting Antiretroviral Therapy (ART) **immediately**—regardless of clinical stage or CD4 count—is critical to rapidly reduce the viral load before delivery. Even a few doses of ART can significantly lower the risk of transmission to the neonate. **Analysis of Incorrect Options:** * **Option A & D:** Waiting for clinical staging or CD4 count results causes unnecessary delay. Under the current guidelines, ART is initiated for all pregnant women immediately upon diagnosis to prioritize fetal protection, irrespective of their immunological or clinical status. * **Option B:** Delaying ART until after delivery misses the window of highest transmission risk. While the mode of delivery (Vaginal vs. Cesarean) may be decided based on viral load, ART must be started as soon as the diagnosis is confirmed. **Clinical Pearls for NEET-PG:** * **Preferred Regimen (NACO):** TLD (Tenofovir + Lamivudine + Dolutegravir) is the first-line ART for pregnant women. * **Zidovudine (AZT):** If the mother's viral load is unknown or >1000 copies/mL near delivery, IV Zidovudine is administered during labor. * **Infant Prophylaxis:** The neonate should receive Nevirapine (NVP) or Zidovudine (AZT) syrup for 6–12 weeks depending on the risk category. * **Breastfeeding:** Exclusive breastfeeding is recommended for the first 6 months, provided the mother is adherent to ART.

Q: A 32-year-old woman is at 34 weeks of gestation. The uterine size is less than her weeks of gestation, and ultrasound reveals oligohydramnios with an AFI of 2.1 cm. Which of the following agents is responsible for this condition?

Angiotensin converting enzyme (ACE) inhibitor. **Explanation:** The correct answer is **A. Angiotensin converting enzyme (ACE) inhibitor.** **Mechanism of Action:** ACE inhibitors (e.g., Enalapril, Lisinopril) are contraindicated in the second and third trimesters of pregnancy. They interfere with the fetal Renin-Angiotensin-Aldosterone System (RAAS), which is essential for maintaining fetal renal perfusion and blood pressure. Inhibition leads to **fetal renal tubular dysgenesis**, resulting in decreased fetal urine production. Since fetal urine is the primary constituent of amniotic fluid in the latter half of pregnancy, its reduction leads to **severe oligohydramnios**. This can further cause the "Potter sequence" (pulmonary hypoplasia, limb contractures, and cranial deformities). **Analysis of Incorrect Options:** * **B. Lithium:** Primarily associated with cardiac malformations, specifically **Ebstein’s anomaly** (atrialization of the right ventricle), when used in the first trimester. It does not typically cause oligohydramnios. * **C. Phenytoin:** Associated with **Fetal Hydantoin Syndrome**, characterized by craniofacial abnormalities (cleft lip/palate), hypoplastic nails/phalanges, and growth restriction, but not specifically oligohydramnios. * **D. Oral Hypoglycemic Agents:** Poorly controlled maternal diabetes (or certain drugs) is more commonly associated with **polyhydramnios** due to fetal osmotic diuresis, rather than oligohydramnios. **High-Yield Clinical Pearls for NEET-PG:** * **ACE Inhibitors/ARBs:** Category D drugs. Key complications: Renal agenesis, oligohydramnios, and hypocalvaria (hypoplasia of skull bones). * **Amniotic Fluid Index (AFI):** Oligohydramnios is defined as an AFI < 5 cm or a Single Deepest Pocket (SDP) < 2 cm. * **Drug of Choice for Hypertension in Pregnancy:** Labetalol (Alpha + Beta blocker), Methyldopa (Centrally acting), or Nifedipine (CCB). ACE inhibitors are strictly avoided.

Q: A hemodynamically stable patient with early pregnancy presents with an adnexal mass of 2.5 x 3 cms and a beta-hCG titre of 1500 mIU/ml, with no intrauterine gestational sac. What is the suitable modality of treatment?

Medical management. ### Explanation The clinical presentation of a stable patient with an adnexal mass, no intrauterine gestational sac, and a beta-hCG of 1500 mIU/ml is diagnostic of an **unruptured ectopic pregnancy**. **Why Medical Management is Correct:** Medical management with **Methotrexate** is the treatment of choice for patients who are hemodynamically stable and meet specific criteria. The standard indications for medical management (as per ACOG/RCOG guidelines) include: 1. **Hemodynamic stability** (no signs of rupture/hemoperitoneum). 2. **Beta-hCG levels < 5000 mIU/ml** (Success rate is highest when < 3000). 3. **Adnexal mass size < 3.5 or 4 cm**. 4. **Absence of fetal cardiac activity** on ultrasound. This patient fits all criteria (Mass 3 cm, hCG 1500 mIU/ml), making medical management the most conservative and appropriate first-line approach. **Why Other Options are Incorrect:** * **A. Progesterone therapy:** Used for luteal phase support or threatened abortion; it has no role in treating an ectopic pregnancy. * **C. Laparoscopic surgery:** This is the gold standard for **surgical** management (Salpingectomy/Salpingostomy). It is indicated if the patient is unstable, the mass is > 4 cm, hCG is > 5000, or medical therapy fails. * **D. Laparotomy:** Reserved for hemodynamically unstable patients with massive hemoperitoneum or when laparoscopy is unavailable/contraindicated. **NEET-PG High-Yield Pearls:** * **Most common site of Ectopic Pregnancy:** Ampulla of the Fallopian tube. * **Most common site of Rupture:** Isthmus (due to its narrow lumen). * **Discriminatory Zone:** The beta-hCG level (usually 1500–2000 mIU/ml) at which an intrauterine sac should be visible on Transvaginal Sonography (TVS). * **Methotrexate Mechanism:** A folic acid antagonist that inhibits Dihydrofolate Reductase, stopping the proliferation of trophoblastic cells.

Question 1

A pregnant woman at 38 weeks gestation presents with painless vaginal bleeding. On examination, the head is engaged and the uterus is non-tender and relaxed. What is the next line of treatment?

Accepted Answer

Termination of pregnancy

Answer

Per speculum examination

Answer

Conservative management

Answer

Ultrasonography

Question 2

What is the most important feature for diagnosing fetal aneuploidy?

Accepted Answer

Nuchal translucency

Answer

Absent nasal bone

Answer

Increased frontomaxillary angle

Answer

Reversal of ductus venosus flow

Question 3

All of the following are causes of Disseminated Intravascular Coagulation (DIC), except?

Accepted Answer

Multiple pregnancy

Answer

Intrauterine death

Answer

Missed abortion

Answer

Abruptio placentae

Question 4

A G2P1 patient presents at 34 weeks of pregnancy in labor with cervical dilatation of 3 cm and minimal uterine contractions. After artificial rupture of membranes, fresh bleeding is observed along with late decelerations. An emergency cesarean section was performed, but the fetus could not be saved. No abruption or placenta previa was noted. What is the most likely diagnosis?

Accepted Answer

Vasa previa

Answer

Concealed abruptio placentae

Answer

Battledore placenta

Answer

Placenta accreta

Question 5

A patient receives a score of 8 on her biophysical profile. What do these results indicate?

Accepted Answer

The results are normal.

Answer

The results are equivocal, and she should have a repeat BPP within 24 hours.

Answer

The results are abnormal, and she should be induced.

Answer

The results are abnormal, and she should undergo emergent cesarean section.

Question 6

A woman presents at term pregnancy for her first antenatal visit and tests positive for HIV in screening and confirmatory tests. What is the next step in management?

Accepted Answer

Start ART immediately.

Answer

Start antiretroviral therapy (ART) after clinical staging.

Answer

Plan an early delivery and start ART after it.

Answer

Start ART after CD4 count results.

Question 7

What is the significance of finding a single umbilical artery upon examination of the umbilical cord after delivery?

Accepted Answer

An indicator of a considerably increased incidence of major fetal malformations

Answer

Insignificant finding

Answer

Equal in incidence across all races

Answer

Equally common in newborns of diabetic and nondiabetic mothers

Question 8

A 32-year-old woman is at 34 weeks of gestation. The uterine size is less than her weeks of gestation, and ultrasound reveals oligohydramnios with an AFI of 2.1 cm. Which of the following agents is responsible for this condition?

Accepted Answer

Angiotensin converting enzyme (ACE) inhibitor

Answer

Lithium exposure

Answer

Phenytoin (Dilantin)

Answer

Oral hypoglycemic agent

Question 9

A hemodynamically stable patient with early pregnancy presents with an adnexal mass of 2.5 x 3 cms and a beta-hCG titre of 1500 mIU/ml, with no intrauterine gestational sac. What is the suitable modality of treatment?

Accepted Answer

Medical management

Answer

Progesterone therapy

Answer

Laparoscopic surgery

Answer

Laparotomy

Question 10

A patient treated for infertility was diagnosed with a twin pregnancy at 6 weeks gestation. On her follow-up ultrasound at 12 weeks, there was a single developing live fetus. What is the further management?

Accepted Answer

Continue pregnancy like a normal singleton pregnancy.

Answer

Advise MTP as the second twin is at increased risk of abortion.

Answer

Watch for coagulation defect in the mother.

Answer

Chorionic villous sampling.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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