Maternal-Fetal Medicine Practice Questions

Q: A 14-week pregnant woman presents with abdominal pain. Ultrasound reveals the fetus is located in a rudimentary uterine horn. What is the most appropriate management in this situation?

Surgical removal of the pregnant rudimentary uterine horn. **Explanation:** A **rudimentary horn pregnancy** is a rare but life-threatening form of ectopic pregnancy occurring in a non-communicating horn of a unicornuate uterus (Müllerian anomaly Class II). **1. Why the correct answer is right:** The myometrium of a rudimentary horn is typically underdeveloped and cannot accommodate a growing fetus. This leads to a high risk of **spontaneous rupture**, usually in the second trimester (10–20 weeks), resulting in massive hemoperitoneum. Once diagnosed, the standard of care is **surgical removal of the pregnant rudimentary horn (excision)** to prevent rupture and maternal mortality. The ipsilateral fallopian tube is also typically removed to prevent a future ectopic pregnancy in that remnant. **2. Why incorrect options are wrong:** * **Hysterectomy (A):** This is overly radical for a 14-week pregnancy in a young patient. The main unicornuate uterus is functional and should be preserved to allow for future pregnancies. * **Induction of labor (C):** Most rudimentary horns do not communicate with the cervix. Therefore, prostaglandins will cause uterine contractions against an obstructed outlet, inevitably leading to rupture rather than delivery. * **Conservative management (D):** This is contraindicated due to the near-certainty of rupture and life-threatening hemorrhage as the pregnancy advances. **Clinical Pearls for NEET-PG:** * **Classic Presentation:** Severe abdominal pain and collapse in the second trimester (unlike tubal ectopics which rupture in the first trimester). * **Baartman’s Sign:** A clinical finding where the pregnant horn is palpated as a mass separated from the uterus by a groove. * **Ultrasound Finding:** A "pseudo-asymmetrical" uterus with a gestational sac surrounded by myometrium, separate from the main uterine body. * **Risk:** 80-90% of these pregnancies end in rupture.

Q: What is true about heterotopic pregnancy?

It occurs following assisted reproductive techniques. **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).

Q: What is the most common feature of ectopic pregnancy?

Abdominal pain. **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.

Q: In an unruptured ectopic pregnancy patient who underwent a salpingostomy procedure, what is the typical management of the tubal incision?

The tubal incision is left open for secondary healing.. ### Explanation In the surgical management of an unruptured ectopic pregnancy, **Salpingostomy** is the preferred fertility-preserving procedure. **1. Why Option A is Correct:** During a linear salpingostomy, a longitudinal incision is made on the antimesenteric border of the fallopian tube over the site of the ectopic gestation. After the products of conception are removed and hemostasis is achieved, the **incision is left open to heal by secondary intention**. Studies have shown that suturing the thin, delicate tubal wall (primary closure) does not improve future pregnancy rates and may actually increase the risk of tubal scarring, narrowing, and subsequent recurrent ectopic pregnancy. **2. Why Other Options are Incorrect:** * **Option B:** Closing the incision with sutures (Salpingotomy) is generally avoided as it increases operative time and the risk of tubal lumen stenosis without providing any clinical benefit over salpingostomy. * **Option C:** "Milking" or tubal expression involves pushing the pregnancy out through the fimbrial end. This is associated with a higher risk of persistent trophoblastic tissue and a higher recurrence rate compared to salpingostomy. * **Option D:** Partial excision (Salpingectomy) is the treatment of choice for a **ruptured** ectopic pregnancy or when the tube is severely damaged, but it is not the standard for a simple salpingostomy. ### High-Yield Clinical Pearls for NEET-PG: * **Gold Standard for Diagnosis:** Transvaginal Ultrasound (TVS) + Serum β-hCG. * **Surgical Approach:** Laparoscopy is the gold standard for hemodynamically stable patients. * **Persistent Trophoblast:** The most common complication of salpingostomy. Post-operative weekly β-hCG monitoring is mandatory until levels are <5 mIU/mL. * **Rh-Negative Mothers:** Always administer Anti-D immunoglobulin post-procedure to prevent isoimmunization.

Q: What is the drug of choice to control convulsions in eclampsia?

Magnesium sulphate. **Explanation:** **Magnesium Sulphate ($MgSO_4$)** is the gold standard and drug of choice for both the prevention and control of seizures in eclampsia. Its superiority over other anticonvulsants was established by the landmark **Collaborative Eclampsia Trial**. **Why it is the Correct Choice:** $MgSO_4$ acts primarily by blocking **NMDA receptors** in the brain, which raises the seizure threshold. It also acts as a potent cerebral vasodilator, reversing the vasospasm associated with eclampsia. Additionally, it inhibits acetylcholine release at the neuromuscular junction, providing a mild muscle-relaxant effect. Unlike other anticonvulsants, it effectively prevents recurrent seizures without causing significant maternal CNS depression. **Why Other Options are Incorrect:** * **Pethidine (A):** This is an opioid analgesic used for pain relief during labor. It has no anticonvulsant properties and can cause respiratory depression in the neonate. * **Diazepam (B):** While a potent benzodiazepine for status epilepticus, it is associated with a higher rate of seizure recurrence in eclampsia and can cause "Floppy Infant Syndrome" (neonatal hypotonia and respiratory depression). * **Phenytoin (C):** It is less effective than $MgSO_4$ in preventing recurrent eclamptic fits and requires slow intravenous infusion to avoid cardiac arrhythmias. **High-Yield Clinical Pearls for NEET-PG:** * **Regimens:** Pritchard (IM) and Zuspan (IV) are the standard protocols. * **Therapeutic Window:** 4–7 mEq/L. * **Monitoring:** Always check for **Patellar reflex** (earliest sign of toxicity), **Respiratory rate** (>12/min), and **Urine output** (>30 ml/hr). * **Antidote:** 10 ml of 10% **Calcium Gluconate** (IV) administered over 10 minutes.

Q: Anencephaly is best diagnosed using which of the following methods?

Ultrasound (USG). **Explanation:** **Anencephaly** is a lethal neural tube defect (NTD) characterized by the absence of the cranial vault and cerebral hemispheres. **Why Ultrasound (USG) is the Correct Answer:** Ultrasound is the **gold standard and investigation of choice** for diagnosing anencephaly. It can reliably detect the condition as early as **11–14 weeks** (late first trimester). Key sonographic features include the absence of the calvarium above the orbits (the **"Frog-eye appearance"** or "Mickey Mouse sign") and the presence of a vascular stroma instead of brain tissue (*Area cerebrovasculosa*). Its high sensitivity (nearly 100%), non-invasive nature, and real-time visualization make it superior to biochemical markers. **Analysis of Incorrect Options:** * **Maternal Serum Alpha-Fetoprotein (MSAFP):** This is a **screening tool**, not a diagnostic one. While MSAFP is elevated in 80-90% of open NTDs, it requires confirmation via USG due to high false-positive rates (e.g., multiple gestations, incorrect dating). * **Amniotic Fluid Alpha-Fetoprotein (AFAFP):** This is more specific than MSAFP but requires an invasive procedure (amniocentesis). With the advancement of high-resolution USG, invasive testing for anencephaly is rarely necessary. * **X-ray:** Historically used to see the absence of the skull vault, it is now **obsolete** due to radiation risks and the superior diagnostic accuracy of USG. **Clinical Pearls for NEET-PG:** * **Earliest Diagnosis:** 11 weeks by USG. * **Associated Finding:** **Polyhydramnios** is common in the third trimester due to the fetus's inability to swallow amniotic fluid. * **Prevention:** Periconceptional **Folic Acid (400 mcg/day)** reduces the risk of NTDs. For women with a previous affected pregnancy, the dose is increased to **4 mg/day**. * **Management:** Since it is a lethal anomaly, termination of pregnancy is offered regardless of gestational age.

Q: A young lady presents with acute abdominal pain and a history of 1.5 months of amenorrhea. Ultrasonography reveals a collection of fluid in the pouch of Douglas and an empty uterine cavity. What is the most likely diagnosis?

Ectopic pregnancy. ### Explanation The clinical presentation of **acute abdominal pain** following a period of **amenorrhea** (1.5 months/6 weeks) is a classic triad for **Ectopic Pregnancy** until proven otherwise. **1. Why Ectopic Pregnancy is the correct answer:** The key diagnostic findings here are an **empty uterine cavity** on ultrasound despite a history of amenorrhea, combined with **fluid in the Pouch of Douglas (POD)**. In the context of a suspected pregnancy, fluid in the POD usually represents **hemoperitoneum** resulting from a ruptured or leaking tubal pregnancy. The "empty uterus" sign is crucial; if the β-hCG levels are above the discriminatory zone (usually 1500–2000 mIU/ml) and the uterus is empty, the diagnosis of ectopic pregnancy is highly probable. **2. Why other options are incorrect:** * **Pelvic Hematocele:** While a hematocele (a collection of blood) is often a *sequela* of a ruptured ectopic pregnancy, it is a clinical finding rather than the primary diagnosis. * **Threatened Abortion:** In this condition, the pregnancy is intrauterine. Ultrasound would show a gestational sac within the uterine cavity, not an empty uterus. * **Twisted Ovarian Cyst:** While this causes acute pain, it is usually not associated with amenorrhea. Ultrasound would typically show a cystic adnexal mass with compromised blood flow rather than an empty uterus with free fluid. ### Clinical Pearls for NEET-PG: * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (seen in only 50% of cases). * **Most common site:** Ampulla of the Fallopian tube. * **Gold Standard Diagnosis:** Laparoscopy (though TVS + Serial β-hCG is the standard initial approach). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on histology, characteristic of ectopic pregnancy. * **Pseudosac:** A fluid collection in the midline of the uterus (unlike an eccentric true gestational sac) seen in 10-20% of ectopic cases.

Question 1

A 14-week pregnant woman presents with abdominal pain. Ultrasound reveals the fetus is located in a rudimentary uterine horn. What is the most appropriate management in this situation?

Accepted Answer

Surgical removal of the pregnant rudimentary uterine horn

Answer

Hysterectomy

Answer

Induction of labor using prostaglandins

Answer

Conservative management with no active treatment

Question 2

What is true about heterotopic pregnancy?

Accepted Answer

It occurs following assisted reproductive techniques

Answer

Its incidence is 10%

Answer

It has two extrauterine gestational sacs

Answer

It has one gestational sac in the fallopian tube and another intrauterine

Question 3

A woman has experienced three consecutive second-trimester abortions. She is now presenting for a prenatal checkup. What is the most appropriate investigation among the following?

Accepted Answer

Hysterosalpingography

Answer

Hysteroscopy

Answer

Chromosomal analysis

Answer

Prenatal cerclage

Question 4

What is the most common feature of ectopic pregnancy?

Accepted Answer

Abdominal pain

Answer

Amenorrhea

Answer

Fainting attack

Answer

Per vaginal bleeding

Question 5

In an unruptured ectopic pregnancy patient who underwent a salpingostomy procedure, what is the typical management of the tubal incision?

Accepted Answer

The tubal incision is left open for secondary healing.

Answer

The tubal incision is closed with sutures.

Answer

Milking of the tube is performed.

Answer

Partial excision of the tube is done.

Question 6

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

Accepted Answer

Biparietal Diameter (BPD)

Answer

Head Circumference (HC)

Answer

Abdominal Circumference (AC)

Answer

Crown-Rump Length (CRL)

Question 7

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?

Accepted Answer

Bed rest + Nifedipine and Dexamethasone

Answer

Bed rest + Dexamethasone

Answer

Bed rest + Sedation

Answer

Immediate cesarean section

Question 8

What is the drug of choice to control convulsions in eclampsia?

Accepted Answer

Magnesium sulphate

Answer

Pethidine

Answer

Diazepam

Answer

Phenytoin

Question 9

Anencephaly is best diagnosed using which of the following methods?

Accepted Answer

Ultrasound (USG)

Answer

Maternal serum alpha-fetoprotein

Answer

Amniotic fluid alpha-fetoprotein

Answer

X-ray

Question 10

A young lady presents with acute abdominal pain and a history of 1.5 months of amenorrhea. Ultrasonography reveals a collection of fluid in the pouch of Douglas and an empty uterine cavity. What is the most likely diagnosis?

Accepted Answer

Ectopic pregnancy

Answer

Pelvic hematocele

Answer

Threatened abortion

Answer

Twisted ovarian cyst

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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