Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 641: For intrahepatic cholestasis of pregnancy, at what gestational age should delivery be planned?

A. 34 weeks
B. 36 weeks
C. 38 weeks (Correct Answer)
D. 40 weeks

Explanation: **Explanation:** **Intrahepatic Cholestasis of Pregnancy (ICP)** is a condition characterized by pruritus (typically on palms and soles) and elevated serum bile acids, usually occurring in the third trimester. The primary concern in ICP is the increased risk of **sudden intrauterine fetal death (IUFD)**, which is believed to be caused by bile acid-induced fetal arrhythmias or vasospasm of placental vessels. **Why 38 weeks is correct:** Current clinical guidelines (including RCOG and ACOG) recommend planned delivery between **37 0/7 and 38 6/7 weeks** of gestation for most patients with ICP. This timing balances the risk of stillbirth, which increases significantly as the pregnancy approaches term, against the risks of neonatal prematurity. If bile acid levels are significantly elevated (e.g., >100 µmol/L), earlier delivery at 34–36 weeks may be considered. **Why other options are incorrect:** * **A & B (34 & 36 weeks):** These are considered late preterm. Delivery at this stage is reserved only for severe cases with total bile acids ≥100 µmol/L or cases with worsening clinical symptoms/jaundice. * **D (40 weeks):** Waiting until the due date is contraindicated in ICP because the risk of sudden fetal demise increases exponentially after 39 weeks. **High-Yield Clinical Pearls for NEET-PG:** * **Pathognomonic Symptom:** Pruritus without a rash, worse at night, starting on palms and soles. * **Biochemical Marker:** Elevated **Serum Bile Acids** (most sensitive) and raised ALT/AST. * **Drug of Choice:** **Ursodeoxycholic Acid (UDCA)** – it improves maternal symptoms and biochemical markers, though its role in preventing stillbirth is still debated. * **Fetal Monitoring:** Standard NST/BPP are notoriously poor at predicting or preventing sudden IUFD in ICP.

Question 642: Which of the following is true about ectopic pregnancy?

A. Transvaginal ultrasonography is the first imaging test of choice.
B. It is associated with a decidual reaction.
C. An interstitial ring sign is seen in interstitial ectopic pregnancies.
D. All of the above. (Correct Answer)

Explanation: This question addresses the diagnostic hallmarks of ectopic pregnancy, a critical high-yield topic for NEET-PG. **Explanation of Options:** * **Option A:** **Transvaginal Ultrasonography (TVS)** is the gold standard and first-line imaging modality. It has higher sensitivity than transabdominal scans, allowing for the identification of an intrauterine gestational sac as early as 4.5–5 weeks. In ectopic cases, it helps identify an adnexal mass or the "empty uterus" sign. * **Option B:** A **decidual reaction** occurs due to progesterone production from the corpus luteum, regardless of the pregnancy's location. The endometrium thickens and becomes secretory to prepare for implantation. On ultrasound, this may manifest as a **pseudogestational sac** (a midline fluid collection without a double decidual sign), which is often confused with an early intrauterine pregnancy. * **Option C:** The **interstitial ring sign** (or "eccentric sac" sign) is a specific sonographic marker for interstitial (cornual) pregnancies. It refers to a gestational sac surrounded by a thin layer of myometrium (<5 mm) located high in the uterine fundus, separate from the central endometrial cavity. **Conclusion:** Since all statements are clinically accurate, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** 1. **Discriminatory Zone:** The serum β-hCG level at which an intrauterine sac should be visible on TVS is **1500–2000 mIU/mL**. If the level is above this and the uterus is empty, suspect ectopic pregnancy. 2. **Most Common Site:** The **Ampulla** of the fallopian tube (70%). 3. **Most Dangerous Site:** The **Interstitial/Cornual** portion, due to high vascularity and risk of late rupture with massive hemorrhage. 4. **Arias-Stella Reaction:** A characteristic histological change in the endometrium (hypersecretory glands with nuclear pleomorphism) seen in ectopic pregnancy, though not pathognomonic.

Question 643: What is the most important feature for diagnosing fetal aneuploidy?

A. Absent nasal bone
B. Nuchal translucency (Correct Answer)
C. Increased frontomaxillary angle
D. Reversal of ductus venosus flow

Explanation: **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.

Question 644: A 25-year-old female at 16 weeks of gestation presents with excess vomiting, apathy, ataxia, nystagmus, and ophthalmoplegia. What is the most likely diagnosis?

A. Wernicke's encephalopathy (Correct Answer)
B. Hyperemesis gravidarum
C. Chorea gravidarum
D. Korsakoff's encephalopathy

Explanation: ### Explanation **Correct Answer: A. Wernicke’s encephalopathy** **1. Why it is correct:** The patient presents with the classic clinical triad of **Wernicke’s encephalopathy (WE)**: **Ophthalmoplegia** (including nystagmus), **Ataxia**, and **Confusion/Apathy**. In the context of pregnancy, WE is a rare but life-threatening complication of severe **Hyperemesis Gravidarum (HG)**. Prolonged vomiting leads to a critical deficiency of **Vitamin B1 (Thiamine)**. Thiamine is a co-factor for glucose metabolism; when depleted, it causes neuronal cell death, particularly in the mammillary bodies and dorsomedial thalamus. **2. Why the other options are incorrect:** * **B. Hyperemesis gravidarum:** While HG is the *underlying cause* of the thiamine deficiency, it refers specifically to the severe nausea and vomiting. Once neurological symptoms (ataxia, nystagmus) appear, the diagnosis progresses to WE. * **C. Chorea gravidarum:** This is a movement disorder characterized by involuntary, jerky, purposeless movements (chorea) during pregnancy, often associated with a history of rheumatic fever or SLE. It does not present with ophthalmoplegia or ataxia. * **D. Korsakoff’s encephalopathy:** This is the chronic, irreversible stage following WE. It is characterized by profound **anterograde amnesia and confabulation**. The acute presentation of eye signs and ataxia points specifically to Wernicke’s. **3. NEET-PG High-Yield Pearls:** * **The Golden Rule:** Always administer **Thiamine BEFORE Glucose** in a patient with HG. Giving IV dextrose first can precipitate or worsen WE by consuming the last remaining thiamine stores during glycolysis. * **Diagnosis:** Primarily clinical, but MRI may show bilateral symmetrical high signal intensities in the mammillary bodies. * **Triad:** Confusion, Ataxia, and Ophthalmoplegia (only present in ~16-38% of cases, making high clinical suspicion vital).

Question 645: Fetal anemia is seen in which of the following patterns?

A. Early deceleration
B. Late deceleration
C. Variable deceleration
D. Sinusoidal pattern (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Sinusoidal pattern**. A **sinusoidal heart rate pattern** is a high-yield finding on Cardiotocography (CTG) characterized by a smooth, sine-wave-like undulating pattern with a frequency of 3–5 cycles per minute and an amplitude of 5–15 bpm. It signifies **severe fetal anemia** or severe fetal hypoxia. **Why it occurs:** The pattern reflects a loss of autonomic nervous system control over the heart rate due to severe hemodynamic compromise. It is most commonly associated with: * **Rh isoimmunization** (leading to fetal hemolysis). * **Fetomaternal hemorrhage**. * Twin-to-twin transfusion syndrome. * Parvovirus B19 infection. **Analysis of Incorrect Options:** * **A. Early deceleration:** Caused by **fetal head compression** during labor. It is a physiological response (vagal reflex) and is not considered pathological. * **B. Late deceleration:** Caused by **uteroplacental insufficiency**. It indicates fetal hypoxia and acidosis but is not specific to anemia. * **C. Variable deceleration:** Caused by **umbilical cord compression**. These are the most common decelerations seen during labor. **NEET-PG High-Yield Pearls:** 1. **Pseudo-sinusoidal pattern:** A transient, less regular pattern often seen after maternal administration of opioids (e.g., Pethidine). It is benign and resolves as the drug wears off. 2. **Management:** A true sinusoidal pattern is a **Category III (Abnormal) tracing** and usually necessitates immediate delivery or intrauterine fetal blood transfusion if the fetus is pre-viable. 3. **Saltatory Pattern:** Characterized by rapid oscillations (amplitude >25 bpm); usually indicates acute cord compression or fetal hypoxia.

Question 646: What is the typical amount of amniotic fluid at 12 weeks of gestation?

A. 50 ml (Correct Answer)
B. 100 ml
C. 200 ml
D. 400 ml

Explanation: **Explanation:** The volume of amniotic fluid is a dynamic parameter that changes throughout pregnancy, reflecting fetal well-being and renal function. **1. Why 50 ml is correct:** At **12 weeks of gestation**, the amniotic fluid volume is approximately **50 ml**. During the first trimester, amniotic fluid is primarily derived from the ultrafiltration of maternal plasma across the fetal membranes or the fetal surface of the placenta. As the pregnancy progresses into the second trimester, fetal urine becomes the major contributor. **2. Analysis of Incorrect Options:** * **100 ml (Option B):** This volume is typically reached around **14 weeks** of gestation. * **200 ml (Option C):** This is the approximate volume at **16 weeks**. * **400 ml (Option D):** This volume is characteristic of **20 weeks** of gestation. **3. High-Yield Facts for NEET-PG:** * **Peak Volume:** Amniotic fluid reaches its maximum volume of approximately **800 ml at 34–36 weeks**. * **Term Volume:** At full term (40 weeks), the volume decreases to about **600 ml**. * **Post-term:** Beyond 42 weeks, the volume significantly reduces (often <400 ml), increasing the risk of oligohydramnios. * **Composition:** Early in pregnancy, it is isotonic to maternal plasma; as fetal kidneys mature, it becomes hypotonic due to fetal urine. * **Clinical Marker:** Amniotic Fluid Index (AFI) is the standard method for assessment; a normal range is typically **5 to 24 cm**.

Question 647: A patient receives a score of 8 on her biophysical profile. What do these results indicate?

A. The results are equivocal, and she should have a repeat BPP within 24 hours.
B. The results are abnormal, and she should be induced.
C. The results are normal. (Correct Answer)
D. The results are abnormal, and she should undergo emergent cesarean section.

Explanation: 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.

Question 648: What is the normal pH of amniotic fluid?

A. 6.8 to 6.9
B. 7.1 to 7.3 (Correct Answer)
C. 7.1 to 7.3
D. 6.7 to 6.8

Explanation: **Explanation:** The correct answer is **7.1 to 7.3**. Amniotic fluid is a dynamic medium that is slightly **alkaline** in nature. During the second and third trimesters, its composition is primarily derived from fetal urine and lung secretions, maintaining a pH range that typically stays between 7.0 and 7.5. **Why it is correct:** The physiological pH of amniotic fluid (7.1–7.3) is crucial for clinical diagnostics, specifically the **Nitrazine Test**. Normal vaginal pH is acidic (3.8–4.5). When the fetal membranes rupture (PROM), the alkaline amniotic fluid leaks into the vagina, raising the local pH. This causes Nitrazine paper to turn blue (positive result), indicating a pH above 6.0. **Analysis of Incorrect Options:** * **Options A and D (6.7 to 6.9):** These values are acidic. Amniotic fluid is not acidic; an acidic environment in the gestational sac would be incompatible with fetal well-being and would not trigger the diagnostic color changes used in clinical practice. * **Option C:** This is a duplicate of the correct range but reinforces that the fluid remains consistently on the alkaline side of neutral. **NEET-PG High-Yield Pearls:** * **Specific Gravity:** 1.008 to 1.010. * **Osmolarity:** Approximately 250 mOsm/L (hypotonic to maternal plasma in late pregnancy). * **Fern Test:** Another diagnostic for ROM; amniotic fluid crystals (due to high sodium chloride content) form a "fern-like" pattern under a microscope. * **Color Changes:** * *Golden yellow:* Rh incompatibility. * *Green:* Meconium staining (fetal distress). * *Dark brown (Tobacco juice):* Intrauterine death (IUD). * *Dark red (Saffron):* Post-maturity.

Question 649: According to international standards, what is the minimum weight of a fetus defined as stillbirth?

A. 500 gm
B. 850 gm
C. 1000 gm (Correct Answer)
D. 2000 gm

Explanation: **Explanation:** The definition of **stillbirth** varies depending on the reporting standards used (National vs. International). According to the **World Health Organization (WHO)** for international comparisons and ICD-10/11 reporting, a stillbirth is defined as a baby born with no signs of life at or after **28 weeks of gestation** or weighing **≥1000 grams**. **Why 1000 gm is correct:** The WHO sets the threshold at 1000 gm (or 28 weeks) for international statistics to ensure data comparability across countries with varying levels of neonatal care. In many developing nations, including India (under National Health Mission guidelines), this 1000 gm/28-week cutoff is the standard for defining stillbirth. **Analysis of Incorrect Options:** * **A. 500 gm:** This is the threshold for **Abortion/Miscarriage** (less than 500 gm or 22 weeks) according to WHO. However, in many developed countries (like the US or UK), fetal death at 500 gm or 20–24 weeks is classified as a stillbirth due to higher viability rates. * **B. 850 gm:** This value does not correspond to any standard legal or clinical definition for stillbirth or viability. * **D. 2000 gm:** This weight characterizes a low-birth-weight infant but is far beyond the threshold for defining the onset of stillbirth. **High-Yield Clinical Pearls for NEET-PG:** * **Viability in India:** Legally and clinically, the limit of viability in India is traditionally considered **28 weeks**, though with advancing NICU care, it is shifting towards 24 weeks in premier institutes. * **Stillbirth vs. Abortion:** If the fetus is <500g/22 weeks = Abortion; if ≥1000g/28 weeks = Stillbirth. * **Early vs. Late Fetal Death:** Deaths between 22–28 weeks (500–1000g) are often termed "Early Fetal Deaths," while those ≥28 weeks are "Late Fetal Deaths" (Stillbirths).

Question 650: What is the significance of finding a single umbilical artery upon examination of the umbilical cord after delivery?

A. Insignificant finding
B. Equal in incidence across all races
C. An indicator of a considerably increased incidence of major fetal malformations (Correct Answer)
D. Equally common in newborns of diabetic and nondiabetic mothers

Explanation: **Explanation:** The umbilical cord normally contains two arteries and one vein. A **Single Umbilical Artery (SUA)**, or "2-vessel cord," occurs when one artery is absent (usually the left). **Why Option C is correct:** SUA is a significant clinical marker because it is associated with a **considerably increased incidence (up to 20-30%) of major fetal malformations**. The most common associated anomalies involve the **genitourinary system** (e.g., renal agenesis), followed by cardiovascular, gastrointestinal, and central nervous system defects. It is also associated with chromosomal trisomies (especially Trisomy 18 and 13) and Intrauterine Growth Restriction (IUGR). **Why other options are incorrect:** * **Option A:** It is not insignificant; its presence necessitates a thorough neonatal examination and often a renal ultrasound to rule out internal anomalies. * **Option B:** The incidence is not equal; it is more common in **Caucasian** populations compared to others. * **Option D:** SUA is significantly **more common in newborns of diabetic mothers** (incidence is 3-4 times higher) compared to nondiabetic mothers. It is also more frequent in twin gestations. **High-Yield Clinical Pearls for NEET-PG:** * **Incidence:** ~0.5–1% in singletons; ~5% in twin pregnancies. * **Most common associated anomaly:** Renal/Genitourinary malformations. * **Management:** If detected on prenatal USG, a detailed **Level II anomaly scan** and fetal echocardiography are indicated. If found at birth in an otherwise healthy-looking neonate, a screening renal ultrasound is often recommended. * **Association:** Highly associated with **Trisomy 18 (Edwards Syndrome)**.

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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