Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 681: 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?

A. Ectopic pregnancy (Correct Answer)
B. Pelvic hematocele
C. Threatened abortion
D. Twisted ovarian cyst

Explanation: ### 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 682: In anencephaly, polyhydramnios is seen due to all of the following EXCEPT?

A. Transudation of CSF
B. Absence of swallowing
C. Absent fetal pituitary
D. Uteroplacental insufficiency (Correct Answer)

Explanation: Explanation: In anencephaly, polyhydramnios occurs due to an imbalance between amniotic fluid production and its removal. **Uteroplacental insufficiency** is the correct answer because it is actually associated with **oligohydramnios**, not polyhydramnios [3]. Reduced placental perfusion leads to decreased fetal renal blood flow, resulting in diminished fetal urine output. **Why the other options cause Polyhydramnios in Anencephaly:** * **Absence of swallowing (Option B):** This is the primary cause. The defect in the neural tube often involves the swallowing centers in the brainstem and mechanical defects in the oropharynx, preventing the fetus from recycling amniotic fluid. * **Transudation of CSF (Option A):** In anencephaly, the exposed neural tissue and meninges lack a bony covering (cranium). This allows for the direct transudation of cerebrospinal fluid and other fluids into the amniotic sac, increasing the volume. * **Absent fetal pituitary (Option C):** The absence of the fetal pituitary gland leads to a lack of Antidiuretic Hormone (ADH) [1]. This results in fetal "diabetes insipidus," where the kidneys produce excessive amounts of dilute urine, further contributing to polyhydramnios. **High-Yield Clinical Pearls for NEET-PG:** * **Alpha-Fetoprotein (AFP):** Markedly elevated in maternal serum and amniotic fluid in anencephaly (Open Neural Tube Defect) [1, 3]. * **"Frog-like" appearance:** A classic description of the anencephalic fetus on ultrasound due to prominent orbits and absent calvarium [1]. * **Face Presentation:** Anencephaly is a common cause of face presentation during labor. * **Post-term Pregnancy:** Anencephaly can lead to prolonged pregnancy due to the absence of the fetal hypothalamus-pituitary-adrenal axis, which is essential for the initiation of labor [1].

Question 683: "Giant's roll over" test for Pregnancy Induced Hypertension is done at what gestational age?

A. 22-24 weeks
B. 28-32 weeks (Correct Answer)
C. 24-26 weeks
D. 32-34 weeks

Explanation: **Explanation:** The **Giant’s Roll-Over Test** (also known as the Supine Pressor Test) is a clinical screening tool used to predict the development of Pregnancy-Induced Hypertension (PIH) or Preeclampsia. **Why 28–32 weeks is the correct answer:** The test is most predictive when performed between **28 and 32 weeks** of gestation. At this stage, the maternal cardiovascular system is under significant physiological stress, and the pathological changes of preeclampsia (such as increased sensitivity to angiotensin II) begin to manifest clinically. **Mechanism:** The patient is placed in the left lateral recumbent position until the blood pressure stabilizes, then turned to the supine position. A **rise in diastolic blood pressure of ≥15 mmHg** is considered a positive result, indicating a high risk for developing PIH. This occurs because, in susceptible women, the compression of the inferior vena cava in the supine position triggers a compensatory sympathetic overactivity and vasoconstriction. **Analysis of Incorrect Options:** * **22–26 weeks (Options A & C):** Performing the test too early often yields false negatives, as the systemic vascular resistance is at its nadir and the vasopressor response is not yet fully sensitized. * **32–34 weeks (Option D):** While the test can be done later, its primary value is as a predictive screening tool; by 34 weeks, many patients may have already developed clinical hypertension, reducing the test's utility for early intervention. **Clinical Pearls for NEET-PG:** * **Sensitivity:** While historically popular, the Roll-Over Test has low sensitivity and high false-positive rates; it is now largely replaced by Doppler studies of the uterine artery. * **Uterine Artery Doppler:** The presence of a **diastolic notch** at 24 weeks is a more reliable high-yield predictor of preeclampsia. * **Other Predictors:** Serum markers like low PAPP-A (early) and an increased sFlt-1:PlGF ratio (late) are modern diagnostic favorites.

Question 684: Which of the following is a contraindication for MgSO4, except?

A. Renal Failure
B. Hypocalcemia
C. Myasthenia Gravis
D. Imminent eclampsia (Correct Answer)

Explanation: **Explanation:** Magnesium Sulfate ($MgSO_4$) is the drug of choice for both the prophylaxis and treatment of seizures in Eclampsia and Severe Pre-eclampsia. **Why "Imminent Eclampsia" is the correct answer:** Imminent eclampsia (characterized by severe hypertension, headache, blurring of vision, and epigastric pain) is an **indication**, not a contraindication, for $MgSO_4$ therapy. It is administered to prevent the onset of tonic-clonic seizures. **Analysis of Contraindications (Incorrect Options):** * **Myasthenia Gravis:** $MgSO_4$ inhibits the release of acetylcholine at the neuromuscular junction. In patients with Myasthenia Gravis, this can precipitate a severe neuromuscular blockade and trigger a life-threatening myasthenic crisis. * **Renal Failure:** Magnesium is excreted almost exclusively by the kidneys. In renal failure (Oliguria <30 ml/hr or Creatinine >1.1 mg/dL), magnesium accumulates rapidly, leading to toxicity. While not an absolute contraindication, it requires extreme caution or dose reduction. * **Hypocalcemia:** Magnesium is a calcium channel antagonist. Administering $MgSO_4$ in a hypocalcemic state can worsen symptoms and potentially lead to cardiac conduction defects. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic Range:** 4–7 mEq/L. * **Monitoring Parameters:** Patellar reflex (first to disappear at 8–10 mEq/L), Respiratory rate (>12/min), and Urine output (>30 ml/hr). * **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (administered slowly over 10 minutes). * **Mechanism:** It acts as a CNS depressant and a vasodilator, primarily by blocking NMDA receptors.

Question 685: Intrauterine growth restriction (IUGR) is caused by all of the following except?

A. Diabetes (Correct Answer)
B. Alcohol
C. Smoking
D. Chronic renal failure

Explanation: **Explanation:** The correct answer is **Diabetes (Option A)**. In the context of pregnancy, maternal diabetes (specifically pre-gestational or gestational diabetes) is classically associated with **fetal macrosomia** (birth weight >4000g or >90th percentile) rather than growth restriction. This occurs because maternal hyperglycemia leads to fetal hyperglycemia, which stimulates the fetal pancreas to secrete excess insulin. Since insulin is a potent anabolic growth factor, it results in excessive fetal growth and fat deposition. *Note: The only exception is long-standing diabetes with advanced vascular complications (White’s Class F or R), which can cause placental insufficiency and lead to IUGR. However, as a general rule for NEET-PG, diabetes is the "odd one out" as it primarily causes large-for-gestational-age (LGA) babies.* **Why other options are incorrect:** * **Alcohol (Option B):** Alcohol is a known teratogen and a leading cause of symmetric IUGR. It interferes with cell division and protein synthesis. * **Smoking (Option C):** Nicotine and carbon monoxide cause vasoconstriction and reduce the oxygen-carrying capacity of fetal blood, leading to placental insufficiency and asymmetric IUGR. * **Chronic Renal Failure (Option D):** Maternal chronic disease leads to systemic hypertension and impaired uteroplacental blood flow, which are major risk factors for growth restriction. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of IUGR:** Placental insufficiency (often due to maternal hypertension). * **Symmetric IUGR:** Occurs early in pregnancy (e.g., chromosomal anomalies, TORCH infections). * **Asymmetric IUGR:** Occurs later in pregnancy; "Head sparing" effect is seen (e.g., Preeclampsia, Smoking). * **Ponderal Index:** Used to differentiate between symmetric and asymmetric IUGR.

Question 686: Cholestasis of pregnancy is characterized by:

A. Increased perinatal mortality and recurrence in subsequent pregnancies (Correct Answer)
B. Commonly occurs in the 1st trimester of pregnancy, increased perinatal mortality, and recurrence in subsequent pregnancies
C. Increased maternal mortality, increased perinatal mortality, and recurrence in subsequent pregnancies
D. Commonly occurs in the 1st trimester of pregnancy and recurrence in subsequent pregnancies

Explanation: **Explanation:** **Intrahepatic Cholestasis of Pregnancy (ICP)** is a reversible form of hormone-induced cholestasis occurring in the late second or third trimester. It is characterized by intense pruritus (typically starting on the palms and soles) and elevated serum bile acids. 1. **Why Option A is Correct:** * **Perinatal Mortality:** Elevated maternal bile acids cross the placenta and are toxic to the fetus. They can cause sudden intrauterine fetal death (IUFD), meconium-stained amniotic fluid, and preterm labor. * **Recurrence:** ICP has a strong genetic predisposition and hormonal basis; therefore, it recurs in **40–60%** of subsequent pregnancies. 2. **Why Other Options are Incorrect:** * **Timing (Options B & D):** ICP is a disease of the **late second or third trimester** (when estrogen levels peak). It does not commonly occur in the 1st trimester. * **Maternal Mortality (Option C):** While ICP causes significant maternal distress due to pruritus and carries a risk of postpartum hemorrhage (due to Vitamin K malabsorption), it is **not** associated with increased maternal mortality. The prognosis for the mother is generally excellent, with symptoms resolving rapidly after delivery. **High-Yield Clinical Pearls for NEET-PG:** * **Hallmark Symptom:** Pruritus without a rash, worse at night, involving palms and soles. * **Diagnostic Gold Standard:** Elevated **Serum Bile Acids** (>10 µmol/L). * **Treatment of Choice:** **Ursodeoxycholic Acid (UDCA)** – it improves pruritus and lowers bile acid levels. * **Delivery Timing:** Due to the risk of sudden IUFD, delivery is usually recommended between **37 0/7 and 38 6/7 weeks** (or earlier if bile acids are >100 µmol/L). * **Associated Risk:** Increased risk of gallstones and cholecystitis later in life.

Question 687: What is the primary benefit of using steroids in the treatment of HELLP syndrome?

A. Decrease maternal mortality rate.
B. Decrease rate of acute renal failure.
C. Increase platelet count in severe thrombocytopenia. (Correct Answer)
D. Increase rate of recovery of liver enzymes.

Explanation: **Explanation:** The primary clinical benefit of administering corticosteroids (such as Dexamethasone) in HELLP syndrome is the **transient increase in maternal platelet count**. While steroids do not cure the underlying pathophysiology of HELLP, they stabilize endothelial membranes and reduce the inflammatory response, which helps in elevating the platelet count. This is particularly crucial for patients with severe thrombocytopenia (<50,000/µL) to facilitate safer anesthesia (e.g., regional anesthesia) and reduce the risk of surgical site bleeding during delivery. **Analysis of Options:** * **Option A & B:** Large-scale randomized controlled trials (such as the COPE trial) and Cochrane reviews have demonstrated that steroids **do not** significantly reduce maternal mortality, the incidence of acute renal failure, or the need for blood transfusions. * **Option D:** While some studies show a slight improvement in laboratory parameters, the effect on liver enzyme recovery is inconsistent and not considered the "primary" clinical benefit compared to the stabilization of platelets for delivery management. **High-Yield NEET-PG Pearls:** * **Drug of Choice:** Dexamethasone (10 mg IV every 12 hours) is preferred over Betamethasone because it has a more potent effect on increasing platelet counts. * **Definitive Treatment:** The only definitive treatment for HELLP syndrome is **delivery** (usually after 34 weeks or if maternal/fetal condition deteriorates). * **Mississippi Classification:** Class 1 HELLP (Platelets ≤ 50,000/µL) is the most severe form and the primary indication for considering steroid therapy to "buy time" for delivery preparation. * **Postpartum:** Steroids may also be used postpartum to accelerate the recovery of platelet counts in refractory cases.

Question 688: A 24-week pregnant female has developed gestational diabetes. Which of the following congenital anomalies is MOST characteristic of diabetic pregnancy?

A. Multicystic kidneys
B. Esophageal atresia
C. Caudal regression syndrome (Correct Answer)
D. Duodenal atresia

Explanation: **Explanation:** **Why Caudal Regression Syndrome is the Correct Answer:** While the most common congenital malformations in infants of diabetic mothers (IDM) are **cardiac defects** (specifically Ventricular Septal Defects), **Caudal Regression Syndrome** (Sacral Agenesis) is the **most characteristic** or specific anomaly. This condition involves the incomplete development of the lower spine and sacrum, often associated with lower limb deformities and bowel/bladder dysfunction. Its incidence is nearly 200 times higher in diabetic pregnancies compared to the general population, making it a pathognomonic marker for pre-gestational diabetes. **Analysis of Incorrect Options:** * **A. Multicystic kidneys:** While renal anomalies (like renal agenesis or hydronephrosis) can occur in IDM, they are not as specific or characteristic as caudal regression. * **B. Esophageal atresia:** Gastrointestinal anomalies are increased in diabetic pregnancies, but esophageal atresia is less frequently associated with diabetes than cardiac or skeletal defects. * **D. Duodenal atresia:** This is most classically associated with **Down Syndrome (Trisomy 21)**, not maternal diabetes. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Anomaly:** Cardiac defects (VSD is #1; Transposition of Great Arteries is also highly associated). * **Most Specific Anomaly:** Caudal Regression Syndrome. * **Critical Period:** These anomalies occur during **organogenesis** (first 8 weeks), meaning they are associated with pre-gestational diabetes or poorly controlled blood sugar at conception, rather than gestational diabetes developing in the second trimester. * **Neural Tube Defects:** There is a 10-fold increased risk of NTDs in diabetic pregnancies.

Question 689: Which of the following is NOT true about vasa previa?

A. Incidence is 1:1500
B. Mortality rate of 20% with undiagnosed cases (Correct Answer)
C. Associated with low-lying placenta
D. Cesarean section is indicated

Explanation: **Explanation:** **Vasa Previa** is a critical obstetric emergency where fetal vessels run through the membranes, unprotected by Wharton’s jelly or placental tissue, across the internal os. **Why Option B is the Correct Answer (The False Statement):** The mortality rate for **undiagnosed** vasa previa is significantly higher than 20%; it is estimated to be between **50% and 95%**. Because the blood loss is entirely fetal, even a small amount of bleeding (e.g., 100ml) can lead to rapid fetal exsanguination and death. The 20% figure is inaccurate as it underestimates the lethal nature of this condition when not managed prenatally. **Analysis of Other Options:** * **Option A:** The incidence is approximately **1:1500 to 1:2500** deliveries, making it a rare but high-stakes condition. * **Option C:** It is strongly associated with **low-lying placentas**, placenta previa, velamentous cord insertion, and succenturiate placental lobes. * **Option D:** **Cesarean section** is the mandatory mode of delivery. If diagnosed prenatally, an elective CS is usually performed at 34–36 weeks to avoid the rupture of membranes and subsequent fetal hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** 1. **Classic Triad:** Rupture of membranes + Painless vaginal bleeding + Fetal bradycardia/distress. 2. **Diagnosis:** Antenatal diagnosis is made via **Transvaginal Color Doppler Ultrasound** (showing "bird's nest" vessels over the os). 3. **Apt Test:** Used to differentiate fetal hemoglobin from maternal hemoglobin in vaginal blood. 4. **Management:** If diagnosed during labor (vessels felt on PV exam or bleeding starts), immediate **Emergency Cesarean Section** is the only life-saving intervention.

Question 690: Molar pregnancy is typically diagnosed in which trimester?

A. First trimester (Correct Answer)
B. Second trimester
C. Third trimester
D. All of the above

Explanation: **Explanation:** **Why the First Trimester is Correct:** In modern obstetric practice, molar pregnancy (Hydatidiform mole) is typically diagnosed in the **first trimester (usually between 8–12 weeks)**. This shift from historical second-trimester diagnoses is due to the routine use of high-resolution **transvaginal ultrasonography (TVS)** and sensitive **quantitative β-hCG assays** during early pregnancy check-ups. Most patients present early with vaginal bleeding (the most common symptom) or are diagnosed incidentally during a dating scan showing the characteristic "snowstorm appearance" or "cluster of grapes" pattern. **Why Other Options are Incorrect:** * **Second Trimester:** Historically, molar pregnancies were diagnosed here when patients presented with "classical" signs like pre-eclampsia before 20 weeks, hyperthyroidism, or the passage of vesicles. Today, early screening makes second-trimester diagnosis rare. * **Third Trimester:** A molar pregnancy cannot progress to the third trimester. If left untreated, it will inevitably result in spontaneous abortion, severe hemorrhage, or the development of gestational trophoblastic neoplasia (GTN) much earlier. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Symptom:** Vaginal bleeding (often described as "prune juice" discharge). * **USG Finding:** "Snowstorm appearance" (due to hydropic villi) and absence of a fetus in a Complete Mole. * **Pathognomonic Sign:** Passage of grape-like vesicles per vaginum. * **Theca Lutein Cysts:** Often seen bilaterally due to extremely high β-hCG levels. * **Associated Complication:** Early-onset Preeclampsia (occurring before 20 weeks gestation) is highly suggestive of a molar pregnancy.

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

Practice Questions

Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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