Maternal-Fetal Medicine Practice Questions

Q: Warfarin embryopathy is due to the action of:

Osteocalcin. **Explanation:** Warfarin embryopathy (Fetal Warfarin Syndrome) occurs when warfarin is administered during the first trimester of pregnancy (specifically between 6–9 weeks of gestation). **Why Osteocalcin is the correct answer:** Warfarin is a vitamin K antagonist. It inhibits the enzyme **vitamin K epoxide reductase**, which is essential for the gamma-carboxylation of several proteins. One such protein is **osteocalcin** (bone Gla protein), which is synthesized by osteoblasts and is vital for normal bone and cartilage mineralization. When warfarin crosses the placenta, it prevents the carboxylation of osteocalcin, leading to defective bone formation. This results in the classic clinical features of warfarin embryopathy, most notably **stippled epiphyses** (chondrodysplasia punctata) and **nasal hypoplasia**. **Analysis of Incorrect Options:** * **A, B, and D (Osteophysin, Osteotensin, Osteogenin):** These are not the primary proteins involved in the vitamin K-dependent carboxylation pathway related to warfarin’s teratogenic mechanism. While "Osteogenin" (BMP-3) is involved in bone formation, it is not inhibited by vitamin K antagonism. **High-Yield Clinical Pearls for NEET-PG:** * **Critical Period:** 6th to 9th week of gestation. * **Clinical Features:** Nasal hypoplasia, depressed nasal bridge, stippled epiphyses, and limb hypoplasia. * **CNS Effects:** Exposure in later trimesters can cause CNS anomalies (microcephaly, optic atrophy) due to fetal hemorrhage, as warfarin crosses the placenta (unlike Heparin). * **Drug of Choice:** Low Molecular Weight Heparin (LMWH) is the preferred anticoagulant in pregnancy as it does not cross the placenta.

Q: Elevated acetylcholinesterase levels in amniotic fluid most likely indicate which of the following conditions?

Open neural tube defects. **Explanation:** The correct answer is **Open neural tube defects (ONTDs)**. **1. Why it is correct:** Acetylcholinesterase (AChE) is an enzyme primarily found in nervous tissue. In cases of open neural tube defects (such as anencephaly or open spina bifida), the fetal neural tissue is directly exposed to the amniotic fluid. This allows AChE to leak from the exposed cerebrospinal fluid and neural membranes into the amniotic sac. While Alpha-fetoprotein (AFP) is used as a screening tool, it can be elevated in various other conditions (e.g., abdominal wall defects). **Amniotic fluid AChE is highly specific** and serves as the confirmatory biochemical test for ONTDs following an elevated AFP. **2. Why other options are incorrect:** * **Oesophageal atresia:** This condition is associated with polyhydramnios (due to inability to swallow) and may show elevated AFP, but it does not involve exposed neural tissue; therefore, AChE levels remain normal. * **Down syndrome (Trisomy 21):** This is characterized by **decreased** maternal serum AFP and specific ultrasound markers (increased nuchal translucency). AChE is not a marker for chromosomal aneuploidies. * **Edward syndrome (Trisomy 18):** Similar to Down syndrome, this is associated with low maternal serum AFP and HCG levels. It does not typically cause elevated amniotic AChE. **Clinical Pearls for NEET-PG:** * **Sequence of Testing:** Maternal Serum AFP (Screening) → Ultrasound → Amniotic Fluid AFP → **Amniotic Fluid AChE (Confirmatory)**. * **False Positives:** If the amniotic fluid sample is contaminated with fetal blood, AChE can be falsely elevated (pseudocholinesterase). * **Closed NTDs:** Conditions like *spina bifida occulta* do not typically show elevated AFP or AChE because the defect is covered by skin.

Q: Which of the following conditions is associated with the least mortality in a pregnant woman?

Acyanotic heart disease. **Explanation:** The maternal mortality risk in cardiac disease is categorized by the **WHO Classification of Maternal Cardiovascular Risk**. The severity of the lesion and the resulting hemodynamic changes determine the prognosis. **Why Acyanotic Heart Disease is the correct answer:** Acyanotic heart diseases, such as small **Atrial Septal Defects (ASD)**, **Ventricular Septal Defects (VSD)**, or **Patent Ductus Arteriosus (PDA)** without pulmonary hypertension, are generally well-tolerated during pregnancy. These conditions fall under **WHO Class I or II**, where the risk of maternal mortality is extremely low (often <1%). The left-to-right shunt may even decrease slightly due to the physiological drop in systemic vascular resistance (SVR) during pregnancy. **Analysis of Incorrect Options:** * **Pulmonary Hypertension (Option A):** This carries the highest risk (mortality up to 30-50%). The inability of the fixed pulmonary vascular resistance to accommodate increased cardiac output leads to right heart failure. It is a contraindication to pregnancy. * **Coarctation of Aorta (Option B):** This is a high-risk condition (WHO Class III/IV) due to the risk of aortic dissection, rupture, or severe hypertension. * **Marfan’s Syndrome (Option C):** If the aortic root is dilated (>40mm), the risk of dissection or rupture during the hyperdynamic state of pregnancy is very high (WHO Class IV). **NEET-PG High-Yield Pearls:** 1. **Highest Mortality:** Primary Pulmonary Hypertension and Eisenmenger Syndrome (up to 50%). 2. **Most Common Heart Disease in Pregnancy (India):** Rheumatic Heart Disease (Mitral Stenosis is the most common lesion). 3. **Most Common Congenital Heart Disease:** ASD (specifically Secundum type). 4. **Contraindications to Pregnancy:** Pulmonary HTN, Eisenmenger Syndrome, Marfan’s with aortic root >40mm, and Severe Mitral/Aortic Stenosis.

Q: A pregnant woman is found to be HIV positive in her first trimester. What is the next line of management?

Start ART now, continue throughout pregnancy and lifelong.. **Explanation:** The management of HIV in pregnancy is governed by the **WHO "Option B+" strategy**, which has been adopted by NACO (National AIDS Control Organisation) in India. **1. Why Option B is correct:** The current standard of care dictates that all pregnant women testing HIV positive should be started on **Triple Antiretroviral Therapy (ART)** immediately, regardless of their CD4 count or clinical stage. The primary goals are to achieve an undetectable viral load to prevent Mother-to-Child Transmission (MTCT) and to maintain the mother's health. Once started, ART is continued **lifelong** to prevent rebound viremia and improve long-term maternal outcomes. **2. Analysis of Incorrect Options:** * **Options A & C:** These suggest stopping ART 6 weeks after delivery. This reflects the outdated "Option B" strategy. Current guidelines emphasize lifelong treatment to prevent transmission in future pregnancies and to partners. * **Options C & D:** These suggest delaying ART until after the first trimester. Modern guidelines recommend starting ART **immediately upon diagnosis**, even in the first trimester. The benefits of early viral suppression far outweigh the theoretical risks of teratogenicity (including with drugs like Efavirenz or Dolutegravir). **High-Yield Clinical Pearls for NEET-PG:** * **Preferred Regimen (NACO):** TLD regimen (Tenofovir + Lamivudine + Dolutegravir). * **Most common timing of MTCT:** During labor and delivery (Intrapartum). * **Breastfeeding:** In India, exclusive breastfeeding for the first 6 months is recommended even for HIV-positive mothers, provided they are adherent to ART. * **Infant Prophylaxis:** Nevirapine or Zidovudine is typically given to the infant for 6 weeks.

Q: In abdominal pregnancy, what is the pathognomonic sign?

Weinberg sign. **Explanation:** **Abdominal pregnancy** is a rare but serious form of ectopic pregnancy where the fetus develops within the peritoneal cavity. **Why Weinberg Sign is Correct:** The **Weinberg sign** is considered pathognomonic for abdominal pregnancy. It refers to the **demonstration of fetal parts outside the uterine cavity** on imaging (ultrasound or MRI), where the fetus is seen lying in the maternal abdomen, often high up or in the flanks, with the empty uterus visualized separately. Clinically, this corresponds to the ease with which fetal parts can be palpated through the maternal abdominal wall because they are not contained within the thick myometrium. **Analysis of Incorrect Options:** * **A. Jacquemier sign:** This is a presumptive sign of early pregnancy characterized by a **bluish discoloration of the vaginal mucosa** due to increased vascularity. * **B. Chadwick sign:** Similar to Jacquemier sign, this is the **bluish/purplish discoloration of the cervix** and vulva seen around 6–8 weeks of gestation. * **C. Puskacek sign:** This refers to the **asymmetrical enlargement of the uterus** at the site of implantation (usually near the cornua) in early intrauterine pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** The most reliable sign on X-ray (historical but high-yield) is the **fetal parts overlapping the maternal spine** in a lateral view. * **Management:** The primary challenge is the placenta. It is generally advised to **leave the placenta in situ** if it is attached to vital organs (like the bowel or major vessels) to avoid life-threatening hemorrhage; it is then allowed to resorb naturally, often monitored with serial β-hCG levels. * **Risk:** Abdominal pregnancy carries a much higher maternal mortality rate than intrauterine or tubal pregnancies.

Q: What is the typical quantity of amniotic fluid at birth in milliliters (ml)?

1000. **Explanation:** The volume of amniotic fluid undergoes a dynamic change throughout pregnancy, reflecting fetal well-being and renal function. The correct answer is **1000 ml**, which represents the typical volume at full term (38–40 weeks), though it begins to decline slightly as the pregnancy approaches post-term. * **Why 1000 ml is correct:** Amniotic fluid volume increases progressively, reaching its peak of approximately **800–1000 ml at 36–38 weeks** of gestation. At birth (term), the average volume is cited as 600–1000 ml in standard textbooks (like Dutta’s Textbook of Obstetrics). For examination purposes, 1000 ml is the standard high-yield figure for volume at term. * **Why other options are incorrect:** * **500 ml:** This is significantly lower than the average term volume. A volume below 200–500 ml at term is often classified as **Oligohydramnios** (Amniotic Fluid Index 24–25 cm is diagnostic of **Polyhydramnios**, often associated with maternal diabetes or fetal structural anomalies (e.g., esophageal atresia). **High-Yield Clinical Pearls for NEET-PG:** * **12 Weeks:** 50 ml (Fluid is primarily a transudate of maternal/fetal serum). * **20 Weeks:** 400 ml (Fetal urine becomes the major contributor). * **Peak (36–38 weeks):** 1000 ml. * **Post-term (42 weeks):** Drops sharply to ~200 ml. * **Measurement:** Gold standard for assessment is the **Amniotic Fluid Index (AFI)**; normal range is 5–24 cm. The "Single Deepest Pocket" (SDP) normal range is 2–8 cm.

Question 1

Placenta previa is characterized by all of the following except?

Accepted Answer

Presents after the first trimester

Answer

Painless bleeding

Answer

Causeless bleeding

Answer

Recurrent bleeding

Question 2

Warfarin embryopathy is due to the action of:

Accepted Answer

Osteocalcin

Answer

Osteophysin

Answer

Osteotensin

Answer

Osteogenin

Question 3

Which of the following statements concerning placenta previa is true?

Accepted Answer

The initial hemorrhage is usually painless and rarely fatal.

Answer

Its incidence increases with maternal age.

Answer

Management now includes a double setup examination.

Answer

Vaginal examination should be avoided on suspicion of placenta previa.

Question 4

Elevated acetylcholinesterase levels in amniotic fluid most likely indicate which of the following conditions?

Accepted Answer

Open neural tube defects

Answer

Oesophageal atresia

Answer

Down syndrome

Answer

Edward syndrome

Question 5

Which of the following is NOT true regarding lupus and pregnancy?

Accepted Answer

Antibodies to ss-A and ss-B antigens can result in ventricular apical fibrosis in the neonate.

Answer

Lupus in pregnancy can result in renal failure.

Answer

Women with cutaneous lupus usually have no adverse pregnancy outcomes.

Answer

Lupus in pregnancy can result in preterm labor.

Question 6

Which of the following conditions is associated with the least mortality in a pregnant woman?

Accepted Answer

Acyanotic heart disease

Answer

Pulmonary hypertension

Answer

Coarctation of aorta

Answer

Marfan's syndrome

Question 7

A woman at 8 months of pregnancy complains of abdominal pain and slight vaginal bleeding. On examination, the uterine size is larger than expected for gestational age, and fetal heart sounds are absent. What is the most likely diagnosis?

Accepted Answer

Concealed hemorrhage

Answer

Hydramnios

Answer

Active labor

Answer

Uterine rupture

Question 8

A pregnant woman is found to be HIV positive in her first trimester. What is the next line of management?

Accepted Answer

Start ART now, continue throughout pregnancy and lifelong.

Answer

Start antiretroviral therapy (ART) now, continue throughout pregnancy and for 6 weeks after delivery.

Answer

Start ART after the first trimester, continue throughout pregnancy and for 6 weeks after delivery.

Answer

Start ART after the first trimester, continue throughout pregnancy and lifelong.

Question 9

In abdominal pregnancy, what is the pathognomonic sign?

Accepted Answer

Weinberg sign

Answer

Jacquemier sign

Answer

Chadwick sign

Answer

Puskacek sign

Question 10

What is the typical quantity of amniotic fluid at birth in milliliters (ml)?

Accepted Answer

1000

Answer

500

Answer

1500

Answer

2000

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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