Maternal-Fetal Medicine Practice Questions

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.

Q: The separation of a normally situated placenta in a case of multiple pregnancy may be due to the following, except:

Deficiency of folic acid. **Explanation:** The question asks for the factor **not** associated with placental abruption (abruptio placentae) in multiple pregnancies. **Why Folic Acid Deficiency is the Correct Answer:** Historically, folic acid deficiency was thought to be linked to placental abruption due to its role in DNA synthesis and vascular integrity. However, modern evidence-based obstetrics has established that **folic acid deficiency is not a causative factor** for abruption. While folic acid is crucial for preventing Neural Tube Defects (NTDs), its deficiency does not trigger the retroplacental hemorrhage seen in abruption. **Analysis of Incorrect Options:** * **A. Increased incidence of toxaemia:** Multiple pregnancies have a significantly higher risk of Pre-eclampsia (Toxaemia). Hypertension is the most common pathological cause of placental abruption due to degenerative changes in maternal arterioles. * **B. Sudden escape of liquor:** In twin pregnancies, the sudden decompression of the uterus (following the rupture of membranes of the first twin or polyhydramnios) causes a rapid decrease in intrauterine surface area. This mechanical "shearing force" leads to the separation of the placenta. * **C. Deficiency of Vitamin B12:** Hyperhomocysteinemia (often caused by B12 or B6 deficiency) is a recognized risk factor for placental vasculopathy and abruption. While less common than hypertension, it remains a documented etiological factor. **NEET-PG High-Yield Pearls:** * **Most common cause of Abruption:** Maternal Hypertension (Preeclampsia/Chronic HTN). * **Most common cause of DIC in Obstetrics:** Abruptio Placentae. * **Couvelaire Uterus:** Also known as uteroplacental apoplexy; it is a complication of severe concealed abruption where blood extravasates into the myometrium. * **Multiple Pregnancy Risk:** The risk of abruption is highest immediately after the delivery of the first twin.

Q: Regarding intrahepatic cholestasis of pregnancy, all are true except?

Usually onset is in early trimester.. **Explanation:** Intrahepatic Cholestasis of Pregnancy (ICP) is the most common pregnancy-specific liver disease, characterized by pruritus (typically on palms and soles) and elevated serum bile acids. **Why Option D is the Correct Answer (The False Statement):** ICP typically manifests in the **late second or third trimester** (usually after 28 weeks). This is because the levels of estrogen and progesterone, which inhibit the bile salt export pump, reach their peak during the later stages of pregnancy. Onset in the early trimester is extremely rare and should prompt investigation for alternative liver pathology. **Analysis of Other Options:** * **Option A:** ICP is significantly **more common in multifetal gestations** (twins/triplets) due to the higher circulating levels of placental hormones compared to singleton pregnancies. * **Option B:** The condition is reversible; symptoms and biochemical abnormalities typically **disappear rapidly after delivery** (usually within 2–4 weeks) once the hormonal trigger (the placenta) is removed. * **Option C:** Genetic predisposition plays a major role. Mutations in the **ABCB4 (MDR3) gene**, which encodes the hepatocyte phospholipid transporter, are strongly implicated in the pathogenesis of ICP. **NEET-PG High-Yield Pearls:** * **Primary Symptom:** Pruritus without a rash, worse at night, starting on palms and soles. * **Diagnostic Gold Standard:** Elevated **Total Serum Bile Acids (TSBA)** >10 µmol/L. * **Fetal Risks:** Increased risk of meconium-stained amniotic fluid, preterm labor, and **sudden intrauterine fetal death (IUFD)**, especially if bile acids exceed 100 µmol/L. * **Management:** **Ursodeoxycholic acid (UDCA)** is the drug of choice to improve maternal symptoms and biochemical markers. Delivery is usually recommended by 37–38 weeks to prevent stillbirth.

Q: Which of the following is a true statement regarding renal changes in preeclampsia?

Glomeruloendotheliosis. **Explanation:** **1. Why Glomeruloendotheliosis is Correct:** Glomeruloendotheliosis is the **pathognomonic** renal lesion of preeclampsia. It is characterized by the swelling of glomerular endothelial cells and the deposit of fibrinoid material under the basement membrane, which leads to the narrowing of the capillary lumens. This endothelial dysfunction is driven by anti-angiogenic factors (like sFlt-1) released from the placenta, which neutralize Vascular Endothelial Growth Factor (VEGF) required for maintaining glomerular health. **2. Why Other Options are Incorrect:** * **A & C (Increased GFR and Renal Blood Flow):** In a normal pregnancy, GFR and renal blood flow increase by nearly 50%. However, in **preeclampsia**, the narrowing of glomerular capillaries (due to endotheliosis) and vasospasm lead to a **decrease** in both GFR and renal blood flow. This explains the rise in serum creatinine and uric acid seen in severe cases. * **D (Persistent after delivery):** Unlike chronic kidney disease, the renal changes in preeclampsia are typically **reversible**. Glomeruloendotheliosis usually resolves within weeks postpartum as the placental triggers are removed. **3. High-Yield Clinical Pearls for NEET-PG:** * **Proteinuria:** Defined as ≥300 mg/24 hours or a protein:creatinine ratio ≥0.3. It is a direct clinical consequence of the damaged glomerular barrier. * **Hyperuricemia:** An elevated serum uric acid level is often one of the earliest laboratory markers of preeclampsia, reflecting decreased renal clearance. * **Podocyturia:** The shedding of podocytes in urine is a specific marker currently being researched for early diagnosis.

Question 1

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 2

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 3

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 4

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 5

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 6

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.

Question 7

The separation of a normally situated placenta in a case of multiple pregnancy may be due to the following, except:

Accepted Answer

Deficiency of folic acid

Answer

Increased incidence of toxaemia

Answer

Sudden escape of liquor following rupture of membranes

Answer

Deficiency of vitamin B12

Question 8

Regarding intrahepatic cholestasis of pregnancy, all are true except?

Accepted Answer

Usually onset is in early trimester.

Answer

More common in multifetal gestation.

Answer

Disappears after delivery.

Answer

Mutation of ABCB4 gene is implicated to cause.

Question 9

A mother at 10 weeks gestation has a history of a previous delivery with an open neural tube defect. Which statement is true regarding her current pregnancy?

Accepted Answer

Sodium valproate use is associated with an increased risk of open neural tube defects.

Answer

The risk of recurrence of open neural tube defects is approximately 10%.

Answer

Amniocentesis should be performed to assess for open neural tube defects.

Answer

The mother should be advised to take multivitamins.

Question 10

Which of the following is a true statement regarding renal changes in preeclampsia?

Accepted Answer

Glomeruloendotheliosis

Answer

Increased GFR

Answer

Increased renal blood flow

Answer

Persistent after delivery

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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