Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 671: All the following are true regarding HIV transmission from mother to infant, EXCEPT:

A. Nevirapine prophylaxis is used for the prevention of vertical transmission.
B. Zidovudine should be given to both pregnant women and infants.
C. Emergency Cesarean section increases the chance of transmission. (Correct Answer)
D. Avoid breastfeeding.

Explanation: **Explanation:** The goal of managing HIV in pregnancy is to reduce the **Mother-to-Child Transmission (MTCT)** rate from approximately 25-40% to less than 2%. **Why Option C is the correct answer (The Exception):** The risk of HIV transmission is highest during labor and delivery due to exposure to infected maternal blood and cervicovaginal secretions. **Elective (Planned) Cesarean Section** at 38 weeks (before the rupture of membranes and onset of labor) significantly reduces transmission risk. However, an **Emergency Cesarean Section**, performed after the rupture of membranes or onset of labor, does **not** provide the same protective benefit and does not significantly increase the risk compared to vaginal delivery; rather, it is the prolonged duration of ruptured membranes that increases transmission. **Analysis of other options:** * **Option A:** Nevirapine is a Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) used in prophylaxis protocols (e.g., WHO Option B+) to prevent vertical transmission. * **Option B:** Zidovudine (AZT) is the backbone of PMTCT. It is administered antenatally, intrapartum (IV), and to the neonate for 6 weeks to reduce viral load and provide post-exposure prophylaxis. * **Option D:** Breast milk contains the virus. In resource-rich settings, avoiding breastfeeding is mandatory. In resource-limited settings, exclusive breastfeeding is recommended only if replacement feeding is not "AFASS" (Affordable, Feasible, Acceptable, Sustainable, and Safe). **High-Yield Clinical Pearls for NEET-PG:** * **Most common route of transmission:** Intrapartum (during labor). * **Best predictor of transmission risk:** Maternal viral load near delivery. * **Goal Viral Load:** If <1000 copies/mL, vaginal delivery is considered safe. * **Procedures to avoid:** Artificial rupture of membranes (ARM), fetal scalp electrodes, and instrumental delivery (forceps/vaccum), as they increase blood exposure.

Question 672: Which of the following findings is considered a positive interpretation in a contraction stress test?

A. Early deceleration
B. Early acceleration
C. Persistent late deceleration (Correct Answer)
D. Variable deceleration

Explanation: **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.

Question 673: The 'T sign' is characteristic of which condition?

A. Genital Tuberculosis
B. Membrane in twin pregnancy (Correct Answer)
C. Molar pregnancy
D. Choriocarcinoma

Explanation: The **'T sign'** is a classic ultrasonographic marker used to determine the chorionicity of a twin pregnancy. ### 1. Why Option B is Correct The 'T sign' is characteristic of **Monochorionic Diamniotic (MCDA)** twin pregnancies. It refers to the appearance of the inter-twin membrane as it meets the placenta. In MCDA twins, there is a single placenta and two amniotic sacs. Because there is no intervening chorionic tissue between the two layers of amnion, the membrane is very thin and joins the placenta at a sharp 90-degree angle, resembling the letter **'T'**. ### 2. Why Other Options are Incorrect * **Genital Tuberculosis:** This condition is associated with radiographic signs like the 'Beaded tube' or 'Lead pipe' appearance on HSG, but not the T sign. * **Molar Pregnancy:** Characterized by a 'Snowstorm' or 'Bunch of grapes' appearance on ultrasound due to hydropic villi. * **Choriocarcinoma:** Presents as a highly vascular, solid mass with areas of necrosis and hemorrhage, often showing high-velocity flow on Doppler. ### 3. Clinical Pearls for NEET-PG * **Lambda (λ) Sign / Twin Peak Sign:** This is the hallmark of **Dichorionic Diamniotic (DCDA)** twins. It occurs when a wedge of chorionic tissue grows into the base of the inter-twin membrane, creating a triangular shape. * **Timing of Cleavage:** * 0–3 days: DCDA (Lambda sign) * 4–8 days: MCDA (T sign) * 8–13 days: MCMA (No membrane) * >13 days: Conjoined twins * **Significance:** Determining chorionicity is most accurate in the **first trimester (10–14 weeks)**. It is crucial because monochorionic twins are at risk for Twin-to-Twin Transfusion Syndrome (TTTS).

Question 674: Pregnancy should be strongly discouraged in women with which of the following conditions?

A. Mitral stenosis
B. Atrial septal defect (ASD)
C. Ventricular septal defect (VSD)
D. Eisenmenger's syndrome (Correct Answer)

Explanation: **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 <30%, NYHA III-IV). 4. Previous Peripartum Cardiomyopathy with residual dysfunction. 5. Severe Coarctation of the Aorta or Marfan Syndrome with aorta >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 675: What is true about heterotopic pregnancy?

A. Its incidence is 10%
B. It occurs following assisted reproductive techniques (Correct Answer)
C. It has two extrauterine gestational sacs
D. It has one gestational sac in the fallopian tube and another intrauterine

Explanation: **Explanation:** **Heterotopic pregnancy** is defined as the simultaneous occurrence of two or more implantation sites, where one is **intrauterine** and the other is **extrauterine** (most commonly in the fallopian tube). **1. Why Option B is Correct:** In the general population, the incidence of heterotopic pregnancy is rare (approx. 1 in 30,000). However, there is a significant rise in incidence (up to 1 in 100–500) following **Assisted Reproductive Techniques (ART)** like IVF. This is due to factors such as the transfer of multiple embryos, the high volume of transfer media which may carry embryos into the tubes, and underlying tubal pathology in subfertile women. **2. Why the other options are incorrect:** * **Option A:** The incidence is nowhere near 10%. Even in ART pregnancies, it remains below 1%. In natural conceptions, it is extremely rare (0.003%). * **Option C:** This describes a bilateral ectopic pregnancy, not heterotopic. Heterotopic pregnancy must involve at least one intrauterine sac. * **Option D:** While this describes the most common *type* of heterotopic pregnancy, it is not a "true" statement defining the condition as a whole. A heterotopic pregnancy can involve an intrauterine sac and an extrauterine sac in locations other than the tube (e.g., cervical, ovarian, or abdominal). Option B is the stronger clinical association tested in exams. **High-Yield Clinical Pearls for NEET-PG:** * **The "Double Sac" Sign:** On ultrasound, the presence of an intrauterine gestational sac does **not** rule out an ectopic pregnancy, especially if the patient underwent ART. * **Management:** The goal is to surgically remove the ectopic pregnancy (usually via laparoscopic salpingectomy) while preserving the viable intrauterine pregnancy. * **Clinical Triad:** Abdominal pain, adnexal mass, and an enlarged uterus (though symptoms are often masked by the intrauterine pregnancy).

Question 676: Which of the following cardiac diseases is associated with safe pregnancy?

A. Congenital acyanotic heart disease (Correct Answer)
B. Marfan's syndrome
C. Idiopathic pulmonary hypertension
D. Ebstein anomaly

Explanation: **Explanation:** In maternal-fetal medicine, cardiac diseases are categorized by risk using the **WHO Classification of Maternal Cardiovascular Risk**. **Why Option A is Correct:** **Congenital acyanotic heart diseases**, such as small Atrial Septal Defects (ASD), Ventricular Septal Defects (VSD), or Patent Ductus Arteriosus (PDA), are generally well-tolerated during pregnancy. These conditions involve left-to-right shunts. Since systemic vascular resistance (SVR) decreases during pregnancy, the shunt volume often decreases or remains stable, placing minimal additional strain on the heart. These fall under WHO Class I or II (low to moderate risk). **Why Other Options are Incorrect:** * **B. Marfan’s Syndrome:** This is high-risk (WHO Class III or IV), especially if the aortic root is dilated (>40mm). Pregnancy increases the risk of life-threatening **aortic dissection** or rupture due to hormonal changes affecting the vessel wall. * **C. Idiopathic Pulmonary Hypertension:** This is a **strict contraindication** to pregnancy (WHO Class IV). The inability of the fixed pulmonary vascular resistance to adapt to increased cardiac output leads to right heart failure, with maternal mortality rates as high as 30-50%. * **D. Ebstein Anomaly:** While some mild cases tolerate pregnancy, it is often associated with cyanosis, right-sided heart failure, and arrhythmias (Wolff-Parkinson-White syndrome), making it significantly higher risk than simple acyanotic defects. **Clinical Pearls for NEET-PG:** * **Absolute Contraindications to Pregnancy:** Pulmonary Hypertension (Eisenmenger syndrome), Severe Aortic Stenosis, Marfan’s with aortic root >45mm, and previous Peripartum Cardiomyopathy with residual dysfunction. * **Most common heart disease in pregnancy (India):** Rheumatic Heart Disease (Mitral Stenosis is the most common lesion). * **Highest risk period:** Immediate postpartum (first 24-48 hours) due to "autotransfusion" from the uterus and relief of IVC compression, leading to sudden fluid overload.

Question 677: Implantation bleeding is called:

A. Haman's sign (Correct Answer)
B. Arias-Stella sign
C. Hoffman's sign
D. Reinz's sign

Explanation: **Explanation:** **Correct Answer: A. Hartman’s sign** *(Note: The question likely refers to **Hartman’s sign**, though it is occasionally misspelled as Haman’s in some question banks. Haman’s sign is traditionally a cardiac finding, but in the context of early pregnancy and implantation, Hartman’s sign is the standard term.)* **Hartman’s sign** refers to the slight spotting or bleeding that occurs during the process of implantation. This typically happens about 6–12 days after fertilization (around the time of the expected missed period). It occurs as the blastocyst burrows into the vascular endometrium (decidua), causing minor erosions of maternal capillaries. It is a physiological phenomenon and should not be confused with a threatened abortion. **Analysis of Incorrect Options:** * **B. Arias-Stella sign:** This refers to specific hypertrophic changes in the endometrial glandular epithelium (hyperchromatic nuclei and vacuolated cytoplasm). It is a histological finding associated with the presence of chorionic tissue, often seen in ectopic pregnancies, but it is not a clinical sign of bleeding. * **C. Hoffman’s sign:** In obstetrics, this refers to a technique used to evert flat or inverted nipples during pregnancy. In neurology, it is a reflex indicating upper motor neuron lesions. * **D. Reinz’s sign:** This is not a recognized clinical sign in standard Obstetrics and Gynecology. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Implantation bleeding occurs roughly at the 4th week of gestation (calculated from LMP). * **Distinction:** Unlike menstruation, Hartman’s sign is usually brief (1–2 days), light in flow, and pinkish-brown in color. * **Decidualization:** The endometrium of pregnancy is called the **Decidua**. The part where the blastocyst implants is the **Decidua Basalis**.

Question 678: What is the most common feature of ectopic pregnancy?

A. Abdominal pain (Correct Answer)
B. Amenorrhea
C. Fainting attack
D. Per vaginal bleeding

Explanation: **Explanation:** Ectopic pregnancy is a life-threatening condition where the blastocyst implants outside the uterine cavity, most commonly in the ampulla of the fallopian tube. **Why Abdominal Pain is the Correct Answer:** Abdominal pain is the **most common clinical feature**, present in approximately **95–100%** of cases. The pain is typically caused by tubal distension, peritoneal irritation by leaking blood, or tubal rupture. While the "classic triad" includes abdominal pain, amenorrhea, and vaginal bleeding, pain is the most consistent symptom across both ruptured and unruptured presentations. **Analysis of Incorrect Options:** * **B. Amenorrhea:** While a common sign (seen in ~75–90% of cases), it is not as universal as pain. Patients may sometimes mistake early vaginal bleeding for a normal period, leading to a reported absence of amenorrhea. * **C. Fainting attack:** This is a sign of **ruptured** ectopic pregnancy leading to hemoperitoneum and hypovolemic shock. While highly specific for a surgical emergency, it occurs in only about 30–50% of cases. * **D. Per vaginal bleeding:** This occurs in about 70–80% of cases due to the breakdown of the decidua (as hCG levels are insufficient to maintain it). It usually follows the onset of pain, making it less frequent and less early a sign than pain itself. **NEET-PG High-Yield Pearls:** * **Most common site:** Fallopian tube (97%), specifically the **Ampulla** (70%). * **Most common site for rupture:** Isthmus (due to its narrow lumen). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) + Serum Beta-hCG (Discriminatory zone: 1500–2000 mIU/ml). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on curettage; it is suggestive but not diagnostic of ectopic pregnancy.

Question 679: In the second trimester of pregnancy, the diagnosis of IUGR can be best made by assessing which of the following parameters?

A. Head Circumference (HC)
B. Abdominal Circumference (AC)
C. Crown-Rump Length (CRL)
D. Biparietal Diameter (BPD) (Correct Answer)

Explanation: **Explanation:** In the second trimester, the diagnosis of Intrauterine Growth Restriction (IUGR) is primarily established by identifying a lag in fetal growth parameters compared to the expected gestational age. Among the options provided, **Biparietal Diameter (BPD)** is considered the most reliable single parameter for dating and identifying growth deviations during the early-to-mid second trimester (up to 20–24 weeks). A significant discrepancy between the BPD-derived age and the menstrual age is a classic indicator of early-onset IUGR. **Analysis of Options:** * **Biparietal Diameter (BPD) [Correct]:** It is the standard parameter for assessing fetal growth in the second trimester. While Abdominal Circumference (AC) is more sensitive for *late* IUGR (asymmetric), BPD remains the benchmark for identifying growth restriction in the second trimester. * **Abdominal Circumference (AC):** This is the most sensitive indicator for **asymmetric IUGR** in the **third trimester**, as it reflects fetal liver size and glycogen stores (which deplete first during placental insufficiency). * **Crown-Rump Length (CRL):** This is the most accurate parameter for gestational age assessment, but only in the **first trimester** (up to 13 weeks 6 days). It is not used for IUGR diagnosis in the second trimester. * **Head Circumference (HC):** While useful for calculating the HC/AC ratio to differentiate between symmetric and asymmetric IUGR, it is generally less specific than BPD for the initial diagnosis in the second trimester. **Clinical Pearls for NEET-PG:** * **Most accurate for dating (1st Trimester):** CRL. * **Most accurate for dating (2nd Trimester):** BPD. * **Best predictor of IUGR/Macrosomia (3rd Trimester):** Abdominal Circumference (AC). * **Ponderal Index:** Used to diagnose asymmetric IUGR after birth. * **Symmetric IUGR:** Usually due to early insults (chromosomal, TORCH infections); all parameters (BPD, HC, AC) are equally reduced. * **Asymmetric IUGR:** Usually due to placental insufficiency; "Head sparing" effect is seen (AC is reduced more than BPD/HC).

Question 680: A 32-week pregnant woman presents with mild uterine contractions. On examination, her vital signs are stable, and placenta previa type III is present. What is the best management?

A. Bed rest + Dexamethasone
B. Bed rest + Nifedipine and Dexamethasone (Correct Answer)
C. Bed rest + Sedation
D. Immediate cesarean section

Explanation: This question tests the management of **Expectant Management (Macafee and Johnson Protocol)** in a patient with symptomatic placenta previa before 37 weeks of gestation. ### **Why Option B is Correct** The primary goal in a stable patient with placenta previa at 32 weeks is to prolong the pregnancy to improve fetal lung maturity while ensuring maternal safety. 1. **Bed Rest:** Reduces pressure on the lower uterine segment, minimizing the risk of further bleeding. 2. **Dexamethasone:** Essential for promoting fetal lung maturity and reducing the risk of Respiratory Distress Syndrome (RDS) in preterm deliveries (before 34 weeks). 3. **Nifedipine (Tocolysis):** Used to suppress uterine contractions. In placenta previa, contractions can cause cervical effacement and further placental separation, leading to life-threatening hemorrhage. ### **Why Other Options are Incorrect** * **Option A:** While bed rest and steroids are necessary, it lacks a tocolytic (Nifedipine) to stop the contractions that are currently present. * **Option C:** Sedation may calm the patient but does not address the physiological need to stop contractions or mature the fetal lungs. * **Option D:** Immediate Cesarean Section is indicated only if there is profuse bleeding, maternal instability, fetal distress, or if the pregnancy has reached 37 weeks. At 32 weeks with stable vitals, expectant management is preferred. ### **NEET-PG High-Yield Pearls** * **Macafee Protocol Criteria:** Pregnancy <37 weeks, bleeding is not life-threatening, and the fetus is alive and stable. * **Tocolysis in Previa:** Only used if contractions are present and the patient is hemodynamically stable. * **Vaginal Examination:** Strictly contraindicated (**"No PV"**) in suspected placenta previa as it can provoke torrential hemorrhage. Diagnosis is confirmed via Transvaginal Ultrasound (TVS), which is safe and the gold standard. * **Delivery Timing:** For uncomplicated placenta previa, elective delivery is usually planned at **36–37 weeks**.

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

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Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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