Maternal-Fetal Medicine Practice Questions

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 This reflects the outdated "Option B" strategy.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: A primigravida presents at 32 weeks gestation with acute abdominal pain for 2 hours, vaginal bleeding, and decreased fetal movements. How should she be managed?

Immediate induction of labor. **Explanation:** The clinical presentation of acute abdominal pain, vaginal bleeding, and decreased fetal movements in a third-trimester pregnancy is a classic triad for **Abruptio Placentae**. In this scenario, the priority is to stabilize the mother and proceed with delivery, as placental abruption is a life-threatening obstetric emergency. **Why Option B is Correct:** In cases of placental abruption, **vaginal delivery is the preferred route** if the fetus is dead or if the mother is stable and labor is progressing. Even at 32 weeks (preterm), once a significant abruption occurs, the pregnancy must be terminated to prevent complications like DIC, Couvelaire uterus, or maternal shock. Induction of labor (usually with oxytocin or ARM) is initiated to expedite delivery. **Why Other Options are Incorrect:** * **Option A:** Cesarean section is indicated only if there is fetal distress (live fetus), maternal instability, or obstetric contraindications to vaginal delivery. It is not the "immediate" first choice for all cases. * **Option C:** Tocolytics are strictly **contraindicated** in placental abruption, as they can mask symptoms, worsen hemorrhage, and delay necessary delivery. * **Option D:** While MgSO4 is used for neuroprotection in preterm labor or for eclampsia, it is not the definitive management for the primary pathology (abruption) here. **NEET-PG High-Yield Pearls:** * **Most common cause of DIC in pregnancy:** Placental Abruption. * **Couvelaire Uterus:** Extravasation of blood into the myometrium, seen in severe abruption; managed with oxytocics (rarely requires hysterectomy). * **Key Distinction:** Unlike Placenta Previa (painless bleeding), Abruption presents with **painful** bleeding and a **rigid/tender uterus**.

Q: Which of the following statements is NOT true about antenatal Doppler analysis?

In normal gestation, placental resistance is high.. ### Explanation **Core Concept: The Low-Resistance Placental Bed** In a normal pregnancy, the physiological remodeling of maternal spiral arteries by trophoblastic invasion transforms them into high-capacitance, **low-resistance** vessels. This ensures continuous, high-volume blood flow to the fetus even during diastole. Therefore, the statement that placental resistance is high in normal gestation is **incorrect**. **Analysis of Options:** * **Option C (Correct Answer):** In normal pregnancy, placental resistance is **low**. High resistance is a pathological state often seen in pre-eclampsia or placental insufficiency. * **Option A & B:** As placental resistance increases (due to placental dysfunction), the diastolic flow in the Umbilical Artery decreases. A **reduction in end-diastolic flow (REDF)** or **absent/reversed end-diastolic flow (AREDF/REDF)** is a hallmark of **Intrauterine Growth Restriction (IUGR)** and is strongly associated with poor perinatal outcomes, including fetal hypoxia and acidosis. * **Option D:** The **S/D Ratio** (Systolic/Diastolic) measures the relationship between peak systole and end-diastole. In IUGR, the denominator (diastole) decreases due to high resistance, causing the overall **S/D ratio to increase**. **High-Yield Clinical Pearls for NEET-PG:** * **Umbilical Artery Doppler:** Primarily reflects **placental** health. Normal flow is forward throughout the cardiac cycle. * **Middle Cerebral Artery (MCA) Doppler:** Used to detect the **"Brain Sparing Effect."** In fetal hypoxia, resistance in the MCA decreases (vasodilation) to protect the brain. * **Ductus Venosus:** The most critical indicator of fetal cardiac failure; an "a-wave" reversal is a late sign of fetal distress. * **Uterine Artery Doppler:** High resistance with "diastolic NOTCHING" after 24 weeks is a predictor for the development of Pre-eclampsia.

Q: All are true about cancers during pregnancy, except:

Lymphoma is the most common cancer during pregnancy.. **Explanation** The incidence of cancer during pregnancy is relatively low, but it remains a significant clinical challenge. **1. Why Option D is the correct answer (The Exception):** While lymphoma (specifically Hodgkin’s lymphoma) is one of the most common malignancies in pregnancy, it is **not the most common**. Statistically, **Breast Cancer** is the most frequently diagnosed cancer during pregnancy, followed closely by cervical cancer. Therefore, the statement that lymphoma is the most common is incorrect. **2. Analysis of Incorrect Options:** * **Option A:** This is a statistically accurate statement. The incidence of malignancy complicating pregnancy is approximately **1 in 1,000 pregnancies**. * **Option B:** Because most cancers occur in older age groups, only a small fraction (**less than 1%**) of all female cancers are diagnosed during pregnancy. * **Option C:** This list correctly identifies the "Big Four" malignancies associated with pregnancy. **Breast cancer** (1 in 3,000) and **Cervical cancer** (1 in 2,500) are the most prevalent, followed by **Melanoma** and **Lymphoma**. **NEET-PG High-Yield Pearls:** * **Most common cancer in pregnancy:** Breast Cancer. * **Most common gynecological cancer in pregnancy:** Cervical Cancer. * **Diagnostic Caveat:** Pregnancy-associated breast cancer (PABC) is often diagnosed at a later stage due to physiological changes (engorgement/lactation) masking lumps. * **Management Rule:** Termination of pregnancy does not generally improve the prognosis of the maternal cancer. * **Chemotherapy:** Generally contraindicated in the 1st trimester (organogenesis) but can often be administered in the 2nd and 3rd trimesters. * **Radiotherapy:** Usually contraindicated throughout pregnancy due to fetal risks.

Q: A patient presents at 28 weeks gestation with severe abdominal pain, bleeding, and hypertension. What is the most likely diagnosis?

Abruptio placentae. **Explanation:** The clinical triad of **severe abdominal pain, vaginal bleeding, and hypertension** in the third trimester is a classic presentation of **Abruptio Placentae** (premature separation of a normally situated placenta). Hypertension (chronic or pregnancy-induced) is the most significant risk factor for placental abruption. The pain results from blood extravasating into the myometrium (Couvelaire uterus), causing uterine hypertonicity and tenderness. **Why the other options are incorrect:** * **Placenta Previa:** Characteristically presents as **painless**, bright red, causeless, and recurrent bleeding. The abdomen is typically soft and non-tender, and the fetal head is usually high or malpresented. * **Vasa Previa:** Presents with painless vaginal bleeding occurring immediately after the **rupture of membranes**. The bleeding is fetal in origin, leading to rapid fetal distress/demise while maternal vitals remain stable. * **Rupture of Ectopic Pregnancy:** While it causes pain and bleeding, it typically occurs in the **first trimester** (usually before 12 weeks). A patient at 28 weeks is in the third trimester. **NEET-PG High-Yield Pearls:** * **Most common cause of DIC in pregnancy:** Abruptio Placentae. * **Couvelaire Uterus:** A complication of abruption where blood seeps into the uterine musculature, giving it a port-wine appearance. * **Management:** If the patient is unstable or there is fetal distress, immediate delivery (usually via Cesarean section) is indicated regardless of gestational age. * **Diagnosis:** Primarily clinical; ultrasound has low sensitivity for detecting retroplacental clots.

Q: Which of the following is NOT a cause of hydramnios?

Posterior urethral valve. **Explanation:** The volume of amniotic fluid is a dynamic balance between production (primarily fetal urine) and removal (primarily fetal swallowing). **Hydramnios (Polyhydramnios)** occurs when there is either excessive production of urine or an inability of the fetus to swallow and absorb fluid. **Why Posterior Urethral Valve (PUV) is the correct answer:** PUV is a condition found in male fetuses where an obstructing membrane in the urethra prevents the bladder from emptying. This leads to **reduced fetal urine output** (oliguria/anuria). Since fetal urine is the primary source of amniotic fluid in the second and third trimesters, PUV results in **Oligohydramnios**, not hydramnios. **Analysis of Incorrect Options:** * **Anencephaly:** Causes hydramnios due to two mechanisms: the absence of the swallowing reflex and the transudation of fluid from the exposed meninges (cerebrospinal fluid) into the amniotic sac. * **Esophageal Atresia:** This creates a mechanical GI tract obstruction. The fetus is unable to swallow amniotic fluid, preventing its absorption by the intestines, leading to fluid accumulation. * **Twins:** Multiple gestations (especially Monochorionic) are associated with hydramnios, often due to Twin-to-Twin Transfusion Syndrome (TTTS), where the recipient twin develops polyuria. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Amniotic Fluid Index (AFI) > 25 cm or Single Deepest Pocket (SDP) > 8 cm. * **Most common cause:** Idiopathic (approx. 50-60%), followed by Maternal Diabetes. * **Mnemonic for Oligohydramnios (DRIPPC):** **D**eath of fetus, **R**enal agenesis (Potter’s), **I**UGR, **P**rom (Premature Rupture of Membranes), **P**ost-term pregnancy, **C**hromosomal anomalies.

Q: Obesity in pregnancy causes all of the following complications except?

Precipitate labor. **Explanation:** Obesity in pregnancy (BMI >30 kg/m²) is associated with significant maternal and fetal morbidity. The correct answer is **Precipitate labor** because obesity is actually associated with **prolonged labor**, not rapid delivery. **1. Why Precipitate Labor is the Correct Answer:** Precipitate labor is defined as labor lasting less than 3 hours. In obese women, labor is typically slower, particularly in the first stage. This is attributed to increased soft tissue resistance in the birth canal and a higher incidence of **abnormal uterine action** (inefficient contractions), leading to a higher rate of induction and cesarean sections. **2. Why the other options are complications of obesity:** * **Abnormal uterine action:** Excess adipose tissue is thought to alter myometrial function and hormonal signaling (e.g., leptin and cholesterol levels), leading to poor uterine contractility and dystocia. * **Fetal neural tube defects (NTDs):** Obesity is a known independent risk factor for NTDs. This may be due to metabolic disturbances, undiagnosed hyperglycemia, or difficulties in achieving adequate folate levels. * **Venous thrombosis:** Pregnancy is a hypercoagulable state; obesity further increases venous stasis and inflammation, significantly raising the risk of Deep Vein Thrombosis (DVT) and Pulmonary Embolism. **Clinical Pearls for NEET-PG:** * **Shoulder Dystocia:** Obese women have a higher risk due to fetal macrosomia. * **Anesthesia risks:** Increased difficulty with regional anesthesia and "failed intubation" in general anesthesia. * **Postpartum Hemorrhage (PPH):** Higher risk due to uterine atony and trauma. * **Dosing:** Obese patients often require higher doses of prophylactic anticoagulants and folic acid (5mg/day).

Q: During ultrasonography, fetal abdominal circumference is measured at the level of which structures?

Stomach and umbilical vein, perpendicular to the spine. **Explanation:** The **Abdominal Circumference (AC)** is the most sensitive ultrasound parameter for assessing fetal growth and detecting Intrauterine Growth Restriction (IUGR) or macrosomia, as it reflects the size of the liver and subcutaneous fat stores. **Why Option A is Correct:** To ensure accuracy and reproducibility, the AC must be measured at a specific transverse plane. The anatomical landmarks required are: 1. **The Stomach bubble:** Representing the left side. 2. **The Umbilical Vein (specifically the "J-shape" junction with the left portal vein):** This ensures the slice is not too low in the abdomen. 3. **The Spine:** The cross-section must be **perpendicular** to the spine to ensure a circular, rather than elliptical, measurement. **Why Other Options are Incorrect:** * **Option B (Kidneys):** The kidneys are located retroperitoneally and inferior to the ideal AC plane. Including them indicates the slice is too low, which would underestimate the circumference. * **Option C (Parallel to the spine):** A parallel (longitudinal) orientation would measure the length of the abdomen, not the circumference. * **Option D (Liver and Spleen):** While the liver occupies most of the AC plane, the spleen is not a standardized landmark for this measurement. **High-Yield Clinical Pearls for NEET-PG:** * **Formula:** $AC = 2\pi r$ (if circular) or $1.57 \times (D1 + D2)$ using the Hadlock method. * **IUGR:** AC is the first parameter to lag in **Asymmetrical IUGR** (Head-sparing effect). * **Technical Tip:** The umbilical vein should be seen within the liver, but it should **not** meet the anterior abdominal wall in the measurement plane. * **Accuracy:** AC has the largest reporting error among all fetal biometry parameters but is the best predictor of birth weight.

Question 1

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 2

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 3

A primigravida presents at 32 weeks gestation with acute abdominal pain for 2 hours, vaginal bleeding, and decreased fetal movements. How should she be managed?

Accepted Answer

Immediate induction of labor

Answer

Immediate cesarean section

Answer

Tocolytic therapy

Answer

Magnesium sulfate therapy

Question 4

Which of the following statements is NOT true about antenatal Doppler analysis?

Accepted Answer

In normal gestation, placental resistance is high.

Answer

Reduction in end diastolic flow is associated with poor outcome.

Answer

Reduction in end diastolic flow is associated with IUGR.

Answer

S/D ratio is high in IUGR.

Question 5

All are true about cancers during pregnancy, except:

Accepted Answer

Lymphoma is the most common cancer during pregnancy.

Answer

Cancer develops during approximately 1 in every 1000 pregnancies.

Answer

Of all cancers that occur in women, less than 1% are seen in pregnant ladies.

Answer

The four cancers most commonly developing during pregnancy are cervical cancer, breast cancer, melanoma, and lymphoma (usually Hodgkin's lymphoma).

Question 6

A patient presents at 28 weeks gestation with severe abdominal pain, bleeding, and hypertension. What is the most likely diagnosis?

Accepted Answer

Abruptio placentae

Answer

Placenta previa

Answer

Vasa previa

Answer

Rupture of ectopic pregnancy

Question 7

Which of the following is NOT a cause of hydramnios?

Accepted Answer

Posterior urethral valve

Answer

Anencephaly

Answer

Esophageal atresia

Answer

Twins

Question 8

Obesity in pregnancy causes all of the following complications except?

Accepted Answer

Precipitate labor

Answer

Abnormal uterine action

Answer

Fetal neural tube defect

Answer

Venous thrombosis

Question 9

A 33-year-old patient has an infection during pregnancy. Which of the following infections is a reactivation and therefore not a risk to the fetus?

Accepted Answer

Shingles

Answer

Group B coxsackievirus

Answer

Rubella virus

Answer

Toxoplasmosis

Question 10

During ultrasonography, fetal abdominal circumference is measured at the level of which structures?

Accepted Answer

Stomach and umbilical vein, perpendicular to the spine

Answer

Kidneys

Answer

Stomach, parallel to the spine

Answer

Liver and spleen

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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