Maternal-Fetal Medicine Practice Questions

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: 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.

Q: A 33-year-old woman, gravida 3, para 2, aborta 0, presents at 9 weeks gestational age with a history of conization for CIN one year prior. She also has a history of preterm births at 30 and 32 weeks during her last two pregnancies. What is the best step in the management of this patient?

Cervical cerclage by 12 weeks. This patient presents with a classic history of **Cervical Insufficiency**. The diagnosis is based on her obstetric history (two prior spontaneous preterm births) and a significant risk factor (history of cervical conization). ### Why Option B is Correct In patients with a history of **two or more** prior spontaneous preterm births or second-trimester losses, a **History-Indicated Cerclage** (prophylactic) is recommended. This is typically performed between **12–14 weeks** of gestation, after confirming fetal viability and screening for chromosomal anomalies (e.g., NT scan). The goal is to provide mechanical support to a cervix weakened by prior surgical trauma (conization). ### Why Other Options are Incorrect * **Option A:** Ultrasound-indicated cerclage is reserved for women with a history of *one* prior preterm birth or those at risk who currently show cervical shortening (<25 mm). Since this patient has a high-risk history of *two* preterm births, waiting for ultrasound changes is inappropriate; she requires immediate prophylactic intervention. * **Option B:** Bed rest has not been proven to prevent preterm birth and increases the risk of venous thromboembolism (VTE) and bone demineralization. * **Option D:** Tocolysis is used to temporarily delay delivery in *acute* preterm labor (to allow for steroid administration); it has no role in the prophylactic management of cervical insufficiency. ### NEET-PG High-Yield Pearls * **Gold Standard Diagnosis:** History of painless cervical dilatation followed by second-trimester expulsion of the fetus. * **McDonald Cerclage:** A simple purse-string suture at the cervicovaginal junction (most common). * **Shirodkar Cerclage:** Submucosal dissection to place the suture higher at the internal os. * **Timing of Removal:** Cerclage is typically removed at **36–37 weeks** or if labor commences.

Q: Blastocyst implantation close to the internal os causes which of the following conditions?

Placenta previa. ### Explanation **1. Why Option A is Correct:** In a normal pregnancy, the blastocyst typically implants in the upper uterine segment (fundus). **Placenta previa** occurs when the blastocyst implants in the lower uterine segment, specifically near or over the **internal os** of the cervix. As the placenta develops in this low position, it may partially or completely cover the cervical opening, leading to the classic clinical presentation of painless, bright red vaginal bleeding in the third trimester. **2. Why Other Options are Incorrect:** * **Options B & C (Placenta Percreta/Increta):** These refer to **Placenta Accreta Spectrum (PAS)**, which is defined by the *depth of invasion* into the uterine wall, not the location relative to the os. * *Increta:* Villi invade the myometrium. * *Percreta:* Villi penetrate through the serosa and may involve adjacent organs (e.g., bladder). * **Option D (Abruptio Placentae):** This is the premature separation of a *normally situated* placenta from the uterine wall before delivery. It is characterized by painful vaginal bleeding and uterine tenderness. **3. High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Previous C-section (strongest risk for both Previa and Accreta), multiparity, and advanced maternal age. * **Diagnosis:** Transvaginal Ultrasound (TVS) is the gold standard for locating the placenta. * **Management Contraindication:** **Digital vaginal examination** is strictly contraindicated in suspected placenta previa until the diagnosis is ruled out, as it can provoke torrential hemorrhage (the "Stallworthy's sign" may be seen on examination). * **Classification:** The latest FIGO classification simplifies previa into "Placenta Previa" (covering the os) and "Low-lying Placenta" (edge <2cm from the os).

Q: Which of the following statements is false regarding vasa previa?

Maternal mortality is around 80%.. **Explanation:** **Vasa Previa** is a rare but life-threatening obstetric emergency where fetal vessels, unsupported by the umbilical cord or placental tissue, run through the fetal membranes across the internal os of the cervix. **1. Why Option A is the correct (False) statement:** The statement that maternal mortality is around 80% is **false**. In vasa previa, the bleeding is entirely **fetal** in origin. Because the total blood volume of a fetus is very small, even a minor bleed (e.g., 100ml) can lead to rapid fetal exsanguination and death (fetal mortality is high, often >50-70% if undiagnosed). However, since there is no maternal blood loss, the **maternal mortality is negligible (0%)**. **2. Analysis of other options:** * **Option B:** It is commonly associated with **velamentous insertion of the umbilical cord** or a **succenturiate lobe** of the placenta, where vessels must travel through the membranes to reach the main placental mass. * **Option C:** By definition, these are unprotected fetal vessels lying over the internal os, **below the presenting part**, making them vulnerable to rupture during the rupture of membranes (ROM). * **Option D:** The **Apt test** (alkali denaturation test) is used to differentiate fetal hemoglobin (HbF) from maternal hemoglobin (HbA). Since the bleeding in vasa previa is fetal, the Apt test will be positive (the solution remains pink), making it a diagnostic tool. **Clinical Pearls for NEET-PG:** * **Classic Triad:** Rupture of membranes + Painless vaginal bleeding + Fetal bradycardia/distress. * **Diagnosis:** Antenatally via **Transvaginal Color Doppler Ultrasound** (Gold Standard). * **Management:** If diagnosed prenatally, elective Cesarean section is planned at 34–36 weeks to avoid labor and ROM. If it occurs acutely during labor, immediate emergency Cesarean is mandatory.

Question 1

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 2

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 3

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 4

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 5

Oligohydramnios is seen in all except:

Accepted Answer

Rh incompatibility

Answer

Renal agenesis

Answer

IUGR

Answer

Postmaturity

Question 6

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

Accepted Answer

Rh-incompatibility

Answer

Alpha-thalassemia

Answer

Parvovirus B19

Answer

All

Question 7

In a patient with Antiphospholipid Antibody syndrome, which of the following treatments is used to prevent further abortions?

Accepted Answer

Aspirin plus low molecular weight heparin

Answer

Corticosteroids

Answer

Intravenous immunoglobulins

Answer

Plasmapheresis

Question 8

A 33-year-old woman, gravida 3, para 2, aborta 0, presents at 9 weeks gestational age with a history of conization for CIN one year prior. She also has a history of preterm births at 30 and 32 weeks during her last two pregnancies. What is the best step in the management of this patient?

Accepted Answer

Cervical cerclage by 12 weeks

Answer

Ultrasound to assess cervical length and guide further management

Answer

Complete bed rest until viability is achieved

Answer

Low-dose tocolysis with salbutamol until viability is achieved

Question 9

Blastocyst implantation close to the internal os causes which of the following conditions?

Accepted Answer

Placenta previa

Answer

Placenta percreta

Answer

Placenta increta

Answer

Abruptio placentae

Question 10

Which of the following statements is false regarding vasa previa?

Accepted Answer

Maternal mortality is around 80%.

Answer

It is seen in velamentous insertion of the placenta.

Answer

Unprotected blood vessels lie below the presenting part.

Answer

The Apt test is diagnostic.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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