Maternal-Fetal Medicine Practice Questions

Q: What type of placenta is depicted?

Monochorionic Monoamniotic. ***Monochorionic Monoamniotic*** - Characterized by the **absence of an inter-twin dividing membrane** between the two fetuses, allowing them to share both the same **chorion** and **amniotic cavity**. - This type represents the highest risk twin pregnancy due to potential **cord entanglement** and **conjoined twinning**, occurring when embryonic division happens after day 8-13. *Monochorionic Diamniotic* - Features **two separate amniotic sacs** divided by a **thin membrane** (lambda sign absent, T-sign present), but shares a single chorion. - The presence of a **dividing membrane** between the twins would be clearly visible, distinguishing it from the monoamniotic type. *Dichorionic Diamniotic* - Shows **two separate chorions** and **two separate amniotic sacs** with a **thick dividing membrane** and characteristic **lambda sign** at the placental insertion. - Each twin has its own **placental territory** with separate vascular systems, making it the safest type of twin pregnancy. *Twin-to-twin transfusion syndrome* - This is a **complication** that can occur in monochorionic pregnancies, not a placental type itself. - Results from **unbalanced vascular anastomoses** in the shared placenta, leading to **donor-recipient** blood flow imbalance between twins.

Q: A pregnant woman, G2P1, at 35 weeks gestation complains of decreased fetal movement. What is the next step in management?

Non-stress test (NST). ### Explanation **1. Why Non-stress Test (NST) is the Correct Answer:** Decreased fetal movement (DFM) is a clinical warning sign of potential fetal compromise. The primary goal in management is to assess fetal well-being promptly using the least invasive method. The **Non-stress Test (NST)** is the standard **first-line screening tool** for evaluating fetal heart rate (FHR) reactivity in the third trimester (after 28–32 weeks). A reactive NST (two or more accelerations in 20 minutes) indicates a functional fetal brainstem and an intact autonomic nervous system, effectively ruling out immediate acidemia. **2. Analysis of Incorrect Options:** * **A. Observation:** This is inappropriate and dangerous. DFM can be a precursor to stillbirth; therefore, objective fetal surveillance is mandatory. * **C. Contraction Stress Test (CST):** This is a second-line test used when the NST is non-reactive. It involves inducing contractions (via oxytocin or nipple stimulation) to check for late decelerations. It is more time-consuming and contraindicated in certain conditions (e.g., placenta previa). * **D. Biophysical Profile Score (BPS):** While BPS is a highly accurate predictor of fetal health, it is typically reserved as a **follow-up test** if the NST is non-reactive or if the patient is high-risk. It requires ultrasound equipment and more time than a bedside NST. **3. Clinical Pearls for NEET-PG:** * **Definition of DFM:** Usually defined as <10 movements in 2 hours (Sadovsky’s method) or <3 movements in 1 hour (Cardiff "Count-to-Ten"). * **Sequence of Assessment:** DFM → Clinical History/Auscultation → **NST** → (if non-reactive) → **BPS** or CST. * **Modified BPS:** Consists of NST + Amniotic Fluid Index (AFI). This is a common high-yield alternative for rapid assessment. * **Reactive NST:** 2 accelerations of 15 bpm lasting 15 seconds in a 20-minute window (15x15 rule). For <32 weeks, use the 10x10 rule.

Q: Which of the following strategies for administering magnesium sulfate for eclampsia prophylaxis should be used in the setting of an elevated serum creatinine?

None of the above. **Explanation:** The management of magnesium sulfate ($MgSO_4$) in patients with renal impairment (elevated serum creatinine) is a high-yield topic in NEET-PG. Magnesium is almost exclusively excreted by the kidneys; therefore, in the setting of renal insufficiency, the risk of magnesium toxicity increases significantly. **Why "None of the above" is correct:** The standard protocol for eclampsia prophylaxis in patients with renal impairment (Serum Creatinine > 1.1 mg/dL) involves: 1. **Maintaining the standard loading dose:** A full loading dose (4–6g IV) is necessary to achieve therapeutic serum levels rapidly. 2. **Reducing or omitting the maintenance dose:** The maintenance infusion should be halved (to 1g/hr) or omitted entirely if the creatinine is significantly elevated, as the drug will not be cleared efficiently. **Analysis of Incorrect Options:** * **Option A & B:** A 3g loading dose is sub-therapeutic. The standard loading dose remains 4–6g regardless of renal function to ensure the patient reaches the therapeutic window (4–7 mEq/L) immediately. * **Option C:** Starting an infusion without a loading dose is dangerous in eclampsia prophylaxis, as it takes too long to reach steady-state therapeutic levels, leaving the patient at risk for seizures. **Clinical Pearls for NEET-PG:** * **Therapeutic Range:** 4–7 mEq/L (or 4.8–8.4 mg/dL). * **Monitoring:** Always monitor **Patellar reflex** (lost at 7–10 mEq/L), **Respiratory rate** (depressed at >12 mEq/L), and **Urine output** (should be >30 ml/hr). * **Antidote:** 10 ml of 10% **Calcium Gluconate** IV administered over 10 minutes. * **Renal Adjustment:** If Creatinine > 1.1 mg/dL, use a 4g loading dose and a 1g/hr maintenance dose with frequent serum level monitoring.

Q: Which of the following findings is considered a positive interpretation in a contraction stress test?

Persistent late deceleration. **Explanation:** The **Contraction Stress Test (CST)**, also known as the Oxytocin Challenge Test, evaluates the respiratory function of the placenta and the fetal ability to withstand the transient hypoxia induced by uterine contractions. **Why Persistent Late Deceleration is Correct:** A **Positive CST** is defined by the presence of **late decelerations** following 50% or more of the contractions (even if the frequency is less than 3 in 10 minutes). Late decelerations indicate **uteroplacental insufficiency**. During a contraction, intramyometrial pressure exceeds capillary perfusion pressure; a healthy fetus has enough oxygen reserve to tolerate this, but a compromised fetus develops hypoxia, leading to myocardial depression or chemoreceptor-mediated late decelerations. **Analysis of Incorrect Options:** * **Early Deceleration:** These are caused by fetal head compression and are considered physiological (benign). They do not indicate fetal distress or placental compromise. * **Early Acceleration:** Accelerations are a sign of fetal well-being and reactive sympathetic nervous system. They are the hallmark of a reassuring Non-Stress Test (NST). * **Variable Deceleration:** These are typically caused by umbilical cord compression. While they may occur during a CST, they do not constitute a "Positive" result; if significant, the test may be labeled as "Suspicious." **NEET-PG High-Yield Pearls:** * **Negative CST (Normal):** No late or significant variable decelerations with a minimum of 3 contractions in 10 minutes. This is highly reassuring (NPV for fetal demise >99%). * **Contraindications:** CST should be avoided in conditions where labor is contraindicated, such as **Placenta Previa, previous classical Cesarean section, or Preterm Rupture of Membranes (PROM).** * **Suspicious/Equivocal:** Intermittent late decelerations or significant variable decelerations.

Q: All of the following are true about placenta previa EXCEPT:

Increased uterine tone. **Explanation:** Placenta previa is characterized by the implantation of the placenta in the lower uterine segment. The hallmark clinical presentation is **painless, causeless, and recurrent bright red vaginal bleeding.** **Why "Increased uterine tone" is the correct answer (EXCEPT):** In placenta previa, the bleeding is **extra-vaginal** and does not involve the formation of a retroplacental clot. Consequently, the uterus remains **soft, relaxed, and non-tender** on palpation. Increased uterine tone (uterine hypertonicity or "woody hard" uterus) and abdominal pain are classic features of **Abruptio Placentae**, not placenta previa. **Analysis of Incorrect Options:** * **A & B (Bright red/Painless bleeding):** Since the bleeding occurs from the lower uterine segment (where there is less contractile tissue) and escapes directly through the cervix, it is typically bright red and occurs without the pain associated with uterine contractions or placental shearing. * **D (Malpresentations):** Because the placenta occupies the lower uterine segment, it prevents the fetal head from engaging. This leads to a high frequency of malpresentations (e.g., breech or transverse lie) and a high presenting part. **NEET-PG High-Yield Pearls:** * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pressed into the pelvis, which recovers when pressure is released; suggestive of posterior placenta previa. * **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the gold standard (more accurate than transabdominal). * **Contraindication:** **Digital vaginal examination** is strictly contraindicated unless the patient is in the operation theater for a "Double Setup Examination," as it can provoke torrential hemorrhage.

Q: Saffron-colored meconium is typically seen in which of the following conditions?

Post-term gestation. **Explanation:** The color of the amniotic fluid (liquor) and meconium provides critical diagnostic clues regarding fetal well-being and gestational age. **Post-term gestation (Correct Answer):** In pregnancies exceeding 42 weeks, the meconium often takes on a characteristic **saffron or golden-yellow** hue. This occurs because the meconium becomes more concentrated and undergoes chemical changes over time. Additionally, in post-maturity syndrome (Ballantyne-Runge syndrome), the vernix caseosa disappears, allowing the yellow pigment to stain the fetal skin and nails. **Incorrect Options:** * **Tuberculosis:** This is associated with **"Rice water"** appearance of the amniotic fluid, not saffron-colored meconium. * **Breech presentation:** While meconium passage is common in breech presentation due to physical compression of the fetal abdomen during labor, the color remains typically **dark green/black** (fresh meconium) rather than saffron. * **Normal newborn appearance:** Normal liquor is clear or straw-colored. Fresh meconium passed by a healthy newborn is thick, tenacious, and dark green. **Clinical Pearls for NEET-PG:** * **Green (Dark Green):** Fresh meconium (suggests fetal distress or breech). * **Golden Yellow:** Rh-isoimmunization (due to bilirubin from hemolysis). * **Greenish-Yellow (Saffron):** Post-maturity. * **Dark Red (Meat washings):** Intrauterine Fetal Death (IUFD) due to blood-stained liquor. * **Rice Water:** Congenital Tuberculosis.

Q: Pregnancy should be strongly discouraged in women with which of the following conditions?

Eisenmenger's syndrome. **Explanation:** The correct answer is **Eisenmenger’s syndrome**. This condition represents the final stage of a long-standing left-to-right shunt (like ASD or VSD) that has resulted in irreversible pulmonary hypertension and a reversal of the shunt (right-to-left). **Why Eisenmenger’s Syndrome is the Correct Answer:** In pregnancy, systemic vascular resistance (SVR) normally decreases. In patients with Eisenmenger’s, this drop in SVR exacerbates the right-to-left shunt, leading to profound hypoxemia, cyanosis, and often sudden cardiovascular collapse. The maternal mortality rate is exceptionally high (30–50%), making it a **WHO Class IV** cardiac condition where pregnancy is strictly contraindicated and termination is advised. **Analysis of Incorrect Options:** * **Mitral Stenosis (A):** While it is the most common rheumatic heart lesion in pregnancy and carries risks (especially pulmonary edema due to tachycardia), it is generally manageable with beta-blockers and activity restriction. It is not an absolute contraindication unless extremely severe. * **Atrial Septal Defect (B) & Ventricular Septal Defect (C):** These are usually well-tolerated during pregnancy provided there is no associated pulmonary hypertension. Most women with isolated, uncomplicated shunts have successful pregnancies. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications to Pregnancy (WHO Class IV):** 1. Eisenmenger’s Syndrome. 2. Pulmonary Arterial Hypertension (PAH). 3. Severe Systemic Ventricular Dysfunction (LVEF 45mm. * **Management:** If a woman with Eisenmenger’s becomes pregnant, the gold standard recommendation is **early therapeutic abortion**. If she continues the pregnancy, strict bed rest and hospitalization are required.

Question 1

What type of placenta is depicted?

Accepted Answer

Monochorionic Monoamniotic

Answer

Monochorionic Diamniotic

Answer

Dichorionic Diamniotic

Answer

Twin-to-twin transfusion syndrome

Question 2

The risk of thromboembolism increases in pregnancy because:

Accepted Answer

Increased hepatic production of clotting factors

Answer

Viscosity of blood increases

Answer

Increased antithrombin III levels

Answer

Increased progesterone levels

Question 3

A pregnant woman, G2P1, at 35 weeks gestation complains of decreased fetal movement. What is the next step in management?

Accepted Answer

Non-stress test (NST)

Answer

Observation

Answer

Contraction stress test (CST)

Answer

Biophysical profile score (BPS)

Question 4

All the following are true regarding HIV transmission from mother to infant, EXCEPT:

Accepted Answer

Emergency Cesarean section increases the chance of transmission.

Answer

Nevirapine prophylaxis is used for the prevention of vertical transmission.

Answer

Zidovudine should be given to both pregnant women and infants.

Answer

Avoid breastfeeding.

Question 5

A primigravida presents with vaginal bleeding at term, but her vital signs are normal. What is the most appropriate management?

Accepted Answer

Examination under anesthesia with amniotomy

Answer

Immediate low-cesarean section

Answer

Conservative management

Answer

Classical cesarean section

Question 6

Which of the following strategies for administering magnesium sulfate for eclampsia prophylaxis should be used in the setting of an elevated serum creatinine?

Accepted Answer

None of the above

Answer

Give 3g loading dose followed by 2g/hr infusion

Answer

Give 3g loading dose, check magnesium level, and then titrate infusion rate

Answer

Give no loading dose and start infusion at 2g/hr

Question 7

Which of the following findings is considered a positive interpretation in a contraction stress test?

Accepted Answer

Persistent late deceleration

Answer

Early deceleration

Answer

Early acceleration

Answer

Variable deceleration

Question 8

All of the following are true about placenta previa EXCEPT:

Accepted Answer

Increased uterine tone

Answer

Bright red blood loss

Answer

Painless vaginal bleeding

Answer

Malpresentations usually found

Question 9

Saffron-colored meconium is typically seen in which of the following conditions?

Accepted Answer

Post-term gestation

Answer

Tuberculosis

Answer

Breech presentation

Answer

Normal newborn appearance

Question 10

Pregnancy should be strongly discouraged in women with which of the following conditions?

Accepted Answer

Eisenmenger's syndrome

Answer

Mitral stenosis

Answer

Atrial septal defect (ASD)

Answer

Ventricular septal defect (VSD)

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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