Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 721: Placenta previa is characterized by all of the following except?

A. Painless bleeding
B. Causeless bleeding
C. Recurrent bleeding
D. Presents after the first trimester (Correct Answer)

Explanation: **Explanation:** Placenta previa occurs when the placenta implants in the lower uterine segment, partially or completely covering the internal cervical os. **Why Option D is the Correct Answer:** By definition, placenta previa is a cause of **Antepartum Hemorrhage (APH)**. In clinical practice and standard textbooks (like Williams Obstetrics), APH is defined as bleeding from the genital tract occurring **after the 28th week of gestation** (late second or third trimester) but before the birth of the baby. Bleeding in the first trimester or early second trimester is typically classified as an abortion or ectopic pregnancy, not placenta previa, as the "lower uterine segment" is not fully formed until later in pregnancy. **Analysis of Incorrect Options:** * **A. Painless bleeding:** This is the hallmark of placenta previa. Unlike Abruptio Placentae, the bleeding is not associated with uterine contractions or retroplacental clots, making it painless. * **B. Causeless bleeding:** The bleeding usually occurs without any precipitating trauma or obvious external cause; it is often triggered by the physiological formation of the lower uterine segment. * **C. Recurrent bleeding:** Bleeding episodes in previa tend to recur as the lower segment continues to stretch and the cervix begins to efface as term approaches. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) is safer and more accurate than Transabdominal Ultrasound for locating the placental edge. * **Stallworthy’s Sign:** Posterior placenta previa can interfere with the engagement of the fetal head (associated with a higher risk of cord compression). * **Management:** The "Macafee and Johnson" protocol is used for expectant management to achieve fetal maturity. * **Warning:** Digital vaginal examination is **strictly contraindicated** unless the patient is in the operation theater prepared for an immediate cesarean section (Double Setup Examination).

Question 722: Warfarin embryopathy is due to the action of:

A. Osteophysin
B. Osteotensin
C. Osteocalcin (Correct Answer)
D. Osteogenin

Explanation: **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.

Question 723: Which of the following statements concerning placenta previa is true?

A. Its incidence increases with maternal age.
B. The initial hemorrhage is usually painless and rarely fatal. (Correct Answer)
C. Management now includes a double setup examination.
D. Vaginal examination should be avoided on suspicion of placenta previa.

Explanation: **Explanation:** **Placenta Previa** is characterized by the implantation of the placenta in the lower uterine segment, overlying or near the internal os. **Why Option B is correct:** The hallmark of placenta previa is **painless, causative, and recurrent vaginal bleeding**. The bleeding occurs due to the stretching of the lower uterine segment and the subsequent shearing of placental attachments. The initial "warning hemorrhage" is typically mild to moderate and rarely fatal, as it often ceases spontaneously once the pressure equilibrates, allowing time for expectant management. **Analysis of Incorrect Options:** * **Option A:** While maternal age is a risk factor, the **strongest risk factor** is a history of previous Cesarean sections or uterine surgeries. The incidence increases more significantly with parity and prior scarring than with age alone. * **Option C:** The "double setup" examination (performing a vaginal exam in an OR prepared for immediate CS) is largely **obsolete**. Modern diagnosis relies on high-resolution Transvaginal Ultrasound (TVS), which is safer and more accurate. * **Option D:** While this statement is clinically sound advice (to prevent massive hemorrhage), it is **not a "true statement concerning the nature of the condition"** in the context of this specific question's comparison. Furthermore, digital examination is strictly contraindicated, but a speculum examination (to rule out local causes) or TVS is permissible. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) is safer and more accurate than transabdominal ultrasound. * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pressed into the pelvis (seen in posterior placenta previa). * **Management:** If the fetus is preterm and bleeding is not life-threatening, **Macafee’s regimen** (expectant management) is followed until 37 weeks. * **Risk:** Placenta previa is highly associated with **Placenta Accreta Spectrum**, especially in patients with previous C-sections.

Question 724: Elevated acetylcholinesterase levels in amniotic fluid most likely indicate which of the following conditions?

A. Open neural tube defects (Correct Answer)
B. Oesophageal atresia
C. Down syndrome
D. Edward syndrome

Explanation: **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.

Question 725: Which of the following is NOT true regarding lupus and pregnancy?

A. Lupus in pregnancy can result in renal failure.
B. Women with cutaneous lupus usually have no adverse pregnancy outcomes.
C. Lupus in pregnancy can result in preterm labor.
D. Antibodies to ss-A and ss-B antigens can result in ventricular apical fibrosis in the neonate. (Correct Answer)

Explanation: **Explanation:** The correct answer is **D** because it contains a factual error regarding the cardiac pathology caused by neonatal lupus. Anti-Ro (ss-A) and Anti-La (ss-B) antibodies cross the placenta and damage the fetal cardiac conduction system, specifically the **Atrioventricular (AV) node**, leading to **congenital complete heart block (CCHB)** and endocardial fibroelastosis. It does not typically cause "ventricular apical fibrosis." **Analysis of other options:** * **Option A:** Systemic Lupus Erythematosus (SLE) can cause lupus nephritis. Pregnancy may trigger flares or exacerbate pre-existing renal disease, potentially leading to acute or chronic **renal failure**. * **Option B:** Cutaneous (discoid) lupus is generally limited to the skin. Unlike systemic lupus, it lacks the significant systemic autoantibody burden (like anti-phospholipid antibodies) that causes placental insufficiency; thus, pregnancy outcomes are usually **normal**. * **Option C:** SLE is strongly associated with **preterm labor**, often secondary to complications like preeclampsia, fetal growth restriction (FGR), or premature rupture of membranes. **Clinical Pearls for NEET-PG:** * **Best time to conceive:** When SLE has been in remission for at least **6 months**. * **Drug of Choice:** **Hydroxychloroquine** is safe and should be continued throughout pregnancy to prevent flares. * **Contraindicated Drugs:** ACE inhibitors, Cyclophosphamide, and Methotrexate (Teratogenic). * **Neonatal Lupus:** The most serious manifestation is permanent **complete heart block**, which may require a pacemaker at birth. Skin lesions in neonatal lupus are transient and disappear as maternal antibodies wane.

Question 726: Which of the following conditions is associated with the least mortality in a pregnant woman?

A. Pulmonary hypertension
B. Coarctation of aorta
C. Marfan's syndrome
D. Acyanotic heart disease (Correct Answer)

Explanation: **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.

Question 727: 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?

A. Hydramnios
B. Concealed hemorrhage (Correct Answer)
C. Active labor
D. Uterine rupture

Explanation: **Explanation:** The clinical presentation of abdominal pain, vaginal bleeding, and a uterus larger than the period of gestation (POG) in the third trimester is a classic description of **Abruptio Placentae**, specifically the **concealed variety**. 1. **Why Concealed Hemorrhage is correct:** In concealed abruption, blood collects behind the placenta (retroplacental clot) and does not escape through the cervix. This accumulation causes the uterus to distend, making it **larger than expected for gestational age**. The uterus becomes "woody hard" and tender due to the extravasation of blood into the myometrium (Couvelaire uterus). The severity of the internal hemorrhage often leads to fetal hypoxia and **fetal death (absent heart sounds)** before the patient presents. 2. **Why the other options are incorrect:** * **Hydramnios:** While the uterus is larger than POG, it is usually painless, and fetal heart sounds are typically present (though may be muffled). It does not present with vaginal bleeding. * **Active Labor:** Labor presents with rhythmic contractions and "show" (mucoid discharge), but the uterine size should correspond to the POG, and fetal heart sounds are generally present. * **Uterine Rupture:** This usually occurs during labor. While it causes pain and absent fetal heart sounds, the classic finding is **recession of the presenting part** and the uterus becoming **smaller or irregular** as the fetus is extruded into the peritoneal cavity. **NEET-PG High-Yield Pearls:** * **Revealed Abruption:** Bleeding is visible; uterine size corresponds to POG. * **Concealed Abruption:** Bleeding is hidden; uterine size > POG; associated with severe preeclampsia and DIC. * **Placenta Previa vs. Abruption:** Previa is painless and bright red bleeding; Abruption is painful and dark/altered bleeding. * **Couvelaire Uterus:** A complication of concealed abruption where myometrial hematoma causes a purplish, ecchymotic appearance.

Question 728: A pregnant woman is found to be HIV positive in her first trimester. What is the next line of management?

A. Start antiretroviral therapy (ART) now, continue throughout pregnancy and for 6 weeks after delivery.
B. Start ART now, continue throughout pregnancy and lifelong. (Correct Answer)
C. Start ART after the first trimester, continue throughout pregnancy and for 6 weeks after delivery.
D. Start ART after the first trimester, continue throughout pregnancy and lifelong.

Explanation: **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.

Question 729: In abdominal pregnancy, what is the pathognomonic sign?

A. Jacquemier sign
B. Chadwick sign
C. Puskacek sign
D. Weinberg sign (Correct Answer)

Explanation: **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.

Question 730: What is the typical quantity of amniotic fluid at birth in milliliters (ml)?

A. 500
B. 1000 (Correct Answer)
C. 1500
D. 2000

Explanation: **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 < 5 cm). * **1500 ml / 2000 ml:** These volumes are excessive. A volume exceeding 1500 ml or an AFI > 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.

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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