Maternal-Fetal Medicine Practice Questions

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.

Q: Which of the following is NOT a prognostic indicator of pregnancy-induced hypertension?

Serum sodium. In Pregnancy-Induced Hypertension (PIH) and Preeclampsia, prognosis is determined by the degree of multi-organ involvement resulting from widespread endothelial dysfunction and vasospasm. **Why Serum Sodium is the Correct Answer:** Serum sodium levels (Option B) are generally **not** used as a prognostic indicator in PIH. While severe preeclampsia can occasionally lead to hyponatremia due to high levels of ADH or fluid overload, it is not a standard marker for predicting disease severity, fetal outcome, or the risk of eclampsia. **Explanation of Incorrect Options (Prognostic Indicators):** * **Low Platelets (Option A):** Thrombocytopenia (<100,000/mm³) indicates microangiopathic hemolytic anemia and is a hallmark of HELLP syndrome. It signifies severe disease and an increased risk of maternal hemorrhage. * **Elevated Liver Enzymes (Option B):** Rising AST and ALT levels indicate hepatic ischemia or periportal necrosis. This is a critical prognostic sign of worsening preeclampsia and potential liver rupture. * **Serum Uric Acid (Option D):** This is one of the **earliest and most reliable markers** of preeclampsia. Hyperuricemia (>4.5–6 mg/dL) results from decreased renal clearance and correlates strongly with the severity of placental lesions and poor fetal outcomes (IUGR). **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Proteinuria:** 24-hour urine collection (>300 mg) or Protein:Creatinine ratio (≥0.3). * **Serum Uric Acid:** Best marker for differentiating Preeclampsia from Chronic Hypertension. * **Serum Creatinine:** Levels >1.1 mg/dL indicate severe features (renal dysfunction). * **Definitive Treatment:** Delivery of the fetus and placenta is the only cure for PIH.

Q: Oligohydramnios is seen in all except:

Rh incompatibility. **Explanation:** Amniotic fluid volume is primarily maintained by a balance between fetal urine production (the main source) and fetal swallowing (the main clearance). **Oligohydramnios** occurs when there is a decrease in production or an increase in loss/clearance. **Why Rh Incompatibility is the correct answer:** Rh isoimmunization typically leads to **Polyhydramnios**, not oligohydramnios. In severe Rh incompatibility, fetal anemia leads to high-output cardiac failure. This causes increased hydrostatic pressure and decreased oncotic pressure, resulting in fetal hydrops. The increased cardiac output leads to increased renal perfusion and excessive fetal urination, causing an increase in amniotic fluid volume. **Analysis of incorrect options:** * **Renal Agenesis (Potter’s Syndrome):** Since fetal urine is the primary source of amniotic fluid from the second trimester onwards, the absence of kidneys leads to severe, early-onset oligohydramnios. * **IUGR (Intrauterine Growth Restriction):** In placental insufficiency, the fetus redistributes blood flow to vital organs (brain-sparing effect) at the expense of the kidneys. Decreased renal perfusion leads to decreased urine output and oligohydramnios. * **Postmaturity:** After 40–42 weeks, placental function declines and the fetal glomerular filtration rate (GFR) naturally decreases, leading to a progressive reduction in amniotic fluid. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Amniotic Fluid Index (AFI) < 5 cm or Single Deepest Pocket (SDP) < 2 cm. * **Most common cause of Oligohydramnios:** Premature Rupture of Membranes (PROM). * **Most common cause of Polyhydramnios:** Idiopathic (followed by Maternal Diabetes). * **Potter’s Sequence:** Oligohydramnios → Pulmonary hypoplasia, flattened facies, and limb deformities.

Q: Nonimmune hydrops fetalis is seen in all of the following conditions except?

Rh-incompatibility. ### Explanation Hydrops fetalis is defined as the abnormal accumulation of fluid in two or more fetal compartments (e.g., ascites, pleural effusion, pericardial effusion, or skin edema). It is categorized into two types: **Immune** and **Non-immune**. **1. Why Rh-incompatibility is the correct answer:** Rh-incompatibility is the classic cause of **Immune Hydrops Fetalis**. It occurs when an Rh-negative mother is sensitized to Rh-positive fetal red blood cells, leading to the production of IgG antibodies. These antibodies cross the placenta and cause immune-mediated hemolysis of fetal RBCs, resulting in severe anemia and subsequent heart failure. **2. Why the other options are incorrect (Causes of Non-immune Hydrops):** Non-immune hydrops (NIHF) accounts for nearly 90% of cases today due to the success of Rh-immunoglobulin prophylaxis. * **Alpha-thalassemia (Hb Bart’s):** This is the most common hematological cause of NIHF. The absence of alpha-globin chains leads to high-affinity hemoglobin that does not release oxygen to tissues, causing severe tissue hypoxia and high-output cardiac failure. * **Parvovirus B19:** This is the most common infectious cause of NIHF. The virus infects and destroys fetal erythroid progenitor cells, leading to aplastic anemia and hydrops. **Clinical Pearls for NEET-PG:** * **Most common cause of NIHF overall:** Cardiovascular anomalies (e.g., structural defects or arrhythmias). * **Most common chromosomal cause:** Turner Syndrome (45, XO) – often associated with cystic hygromas. * **Diagnosis:** Ultrasound is the gold standard; look for "Mirror Syndrome" (maternal edema mimicking fetal hydrops). * **Management of Rh-isoimmunization:** Monitored via MCA-PSV (Middle Cerebral Artery Peak Systolic Velocity) doppler to detect fetal anemia.

Question 1

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 2

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 3

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 4

Hypothyroidism in pregnancy is least likely associated with which of the following complications?

Accepted Answer

Polyhydramnios

Answer

Recurrent abortions

Answer

Pregnancy induced hypertension (PIH)

Answer

Prematurity

Question 5

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 6

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 7

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

Question 8

Which of the following is NOT a prognostic indicator of pregnancy-induced hypertension?

Accepted Answer

Serum sodium

Answer

Low platelets

Answer

Elevated liver enzymes

Answer

Serum uric acid

Question 9

Oligohydramnios is seen in all except:

Accepted Answer

Rh incompatibility

Answer

Renal agenesis

Answer

IUGR

Answer

Postmaturity

Question 10

Nonimmune hydrops fetalis is seen in all of the following conditions except?

Accepted Answer

Rh-incompatibility

Answer

Alpha-thalassemia

Answer

Parvovirus B19

Answer

All

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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