Maternal-Fetal Medicine Practice Questions

Q: Magnesium sulfate (MgSO4) is indicated in which of the following conditions?

Severe pre-eclampsia. **Explanation:** **1. Why Severe Pre-eclampsia is Correct:** Magnesium sulfate ($MgSO_4$) is the **drug of choice** for the prevention of seizures in severe pre-eclampsia (prophylaxis) and the control of seizures in eclampsia (treatment). Its primary mechanism involves blocking NMDA receptors in the brain, increasing the seizure threshold, and causing cerebral vasodilation to reduce ischemia. According to the **Pritchard Regimen** or **Zuspan Regimen**, it is initiated to prevent the progression of pre-eclampsia to eclampsia, significantly reducing maternal morbidity. **2. Why Other Options are Incorrect:** * **Gestational Trophoblastic Disease (GTD):** While GTD can cause early-onset hypertension, $MgSO_4$ is not a routine treatment unless the patient develops features of severe pre-eclampsia. * **Gestational Diabetes (GDM):** This is a metabolic disorder of glucose intolerance. Management involves medical nutrition therapy (MNT) or insulin, not anticonvulsants. * **Placenta Previa:** This is a hemorrhagic complication (antepartum hemorrhage). Management focuses on hemodynamic stability and timely delivery, not seizure prophylaxis. **3. NEET-PG High-Yield Pearls:** * **Therapeutic Level:** 4–7 mEq/L. * **Monitoring:** Always check for the presence of **Patellar reflex** (first sign of toxicity is loss of reflex), **Respiratory rate** (>12/min), and **Urine output** (>30 ml/hr or 100 ml/4hr). * **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (administered slowly over 10 minutes). * **Neuroprotection:** $MgSO_4$ is also used for fetal neuroprotection in anticipated preterm deliveries <32 weeks to reduce the risk of cerebral palsy.

Q: What is a common cause of recurrent missed abortion at 10 weeks gestation?

Chromosomal abnormality. **Explanation:** **1. Why Chromosomal Abnormality is Correct:** Chromosomal abnormalities are the most common cause of spontaneous pregnancy loss in the first trimester (up to 12 weeks), accounting for approximately 50–60% of cases. Even in cases of **recurrent** pregnancy loss, genetic factors remain a leading etiology. At 10 weeks gestation, an embryonic demise is most frequently due to **autosomal trisomies** (the most common being Trisomy 16), followed by polyploidy and Monosomy X (Turner syndrome). These defects lead to improper embryonic development, resulting in a missed abortion. **2. Analysis of Incorrect Options:** * **B. Cervical Incompetence:** This typically causes **painless cervical dilatation** leading to mid-trimester (second trimester) losses, usually between 16–24 weeks, rather than early first-trimester missed abortions. * **C. Corpus Luteum Failure:** While progesterone is vital for pregnancy maintenance, the placenta takes over progesterone production (luteal-placental shift) by **7–9 weeks**. Therefore, primary corpus luteum failure is an uncommon cause of loss as late as 10 weeks. * **D. Retroverted Uterus:** This is considered a **normal anatomical variant** in many women and does not increase the risk of miscarriage. It only rarely causes "incarceration of the uterus" in the second trimester, but not missed abortion. **3. NEET-PG High-Yield Pearls:** * **Most common chromosomal cause of abortion:** Autosomal trisomy (Overall). * **Most common specific trisomy:** Trisomy 16. * **Most common single chromosomal anomaly:** Monosomy X (45,X). * **Investigation of choice for Recurrent Pregnancy Loss (RPL):** Parental karyotyping to rule out balanced translocations. * **Definition of RPL (WHO):** 3 or more consecutive pregnancy losses before 20 weeks; however, ASRM defines it as 2 or more losses.

Q: A 25-week pregnant woman presents with hypertension (160/95 mmHg), proteinuria, generalized edema, hyperuricemia, and elevated liver enzymes. Which of the following usually provides definitive therapy for this condition?

Delivery. **Explanation:** The patient presents with classic features of **Preeclampsia with severe features** (BP ≥160/110 mmHg, proteinuria, and biochemical evidence of end-organ dysfunction like elevated liver enzymes and hyperuricemia). **Why Delivery is the Correct Answer:** The underlying pathophysiology of preeclampsia is rooted in **abnormal placentation** and placental ischemia, which triggers systemic endothelial dysfunction. Since the placenta is the source of the pathology, the only **definitive (curative) treatment** is the removal of the placenta, which is achieved through **delivery**. While the timing of delivery depends on gestational age and maternal-fetal stability, it remains the only way to halt the disease progression. **Why Other Options are Incorrect:** * **A. Antihypertensive medical therapy:** Drugs like Labetalol or Hydralazine are used to prevent maternal complications (e.g., stroke) but do not cure the disease or prevent its progression. * **C. Low-dose aspirin:** This is a **preventive** measure started early in pregnancy (before 16 weeks) for high-risk patients; it has no role as a definitive treatment once preeclampsia is established. * **D. Oxygen supplementation:** This is supportive care and does not address the underlying placental pathology. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC)** for seizure prophylaxis in preeclampsia/eclampsia: **Magnesium Sulfate ($MgSO_4$)** (Pritchard Regimen). * **Antidote for $MgSO_4$ toxicity:** Calcium Gluconate (10% solution, 10ml IV). * **Hyperuricemia** (Serum Uric acid >4.5 mg/dL) is a sensitive marker for the severity of preeclampsia and correlates with poor fetal outcomes. * **Definitive Management:** Delivery is indicated regardless of gestational age if there is evidence of HELLP syndrome, eclampsia, or placental abruption.

Q: Which of the following is an impending sign of eclampsia in pregnancy-induced hypertension (PIH)?

Visual symptoms. **Explanation:** The transition from pre-eclampsia to eclampsia is marked by "impending signs" that indicate severe multi-system involvement and cerebral irritability. **1. Why Visual Symptoms are Correct:** Visual disturbances (scotoma, blurring of vision, photophobia, or temporary blindness) are classic **premonitory signs** of eclampsia. They occur due to retinal artery vasospasm, retinal edema, or occipital lobe ischemia (as seen in PRES - Posterior Reversible Encephalopathy Syndrome). These symptoms, along with severe persistent headache and epigastric pain, indicate that a seizure is imminent. **2. Analysis of Incorrect Options:** * **Weight gain (2 lb/week):** While rapid weight gain due to occult edema is a diagnostic feature of pre-eclampsia, it is a non-specific finding and does not necessarily signal an immediate progression to seizures. * **Severe proteinuria (10 g):** According to current ACOG and NHBPEP guidelines, the *degree* of proteinuria is no longer used to classify "severity" or predict eclamptic fits. Massive proteinuria is a sign of renal involvement but not an impending sign of a seizure. * **Pedal Edema:** This is common in normal pregnancies (physiological) and is no longer included in the diagnostic criteria for PIH. It is not a reliable predictor of eclampsia. **Clinical Pearls for NEET-PG:** * **The "Triad" of Impending Eclampsia:** 1. Severe headache (frontal/occipital), 2. Epigastric/Right Upper Quadrant pain (liver capsule stretch), 3. Visual disturbances. * **Hyperreflexia:** Brisk patellar reflex (clonus) is a critical physical sign of neuromuscular irritability preceding a fit. * **Drug of Choice:** Magnesium Sulfate ($MgSO_4$) is the treatment of choice for both prophylaxis and management of eclamptic seizures (Pritchard Regimen).

Q: A 29-week pregnant patient presents with jaundice and severe pre-eclampsia (BP 170/110, urine albumin 3+). Investigations show Hb 7 gm%, platelet count 70,000, TLC 13,000, SGOT 230, bilirubin 2 mg/dL, and INR 2. What is the most likely diagnosis?

HELLP syndrome. **Explanation:** The clinical presentation of severe pre-eclampsia (BP 170/110, proteinuria) combined with biochemical evidence of multi-organ involvement points directly to **HELLP Syndrome** (Hemolysis, Elevated Liver enzymes, Low Platelets). **Why HELLP Syndrome is correct:** The diagnosis is based on the **Tennessee Classification** or **Mississippi Criteria**: * **Hemolysis:** Suggested by low Hb (7 gm%) and jaundice (bilirubin 2 mg/dL). * **Elevated Liver Enzymes:** SGOT (230 U/L) is significantly elevated (typically >70 U/L). * **Low Platelets:** Platelet count is 70,000/mm³ (Thrombocytopenia <100,000/mm³). The elevated INR (2) indicates impaired hepatic synthetic function or incipient DIC, which are known complications of severe HELLP. **Why other options are incorrect:** * **Acute Cholecystitis:** Presents with RUQ pain, fever, and Murphy’s sign; it does not explain severe hypertension, proteinuria, or profound thrombocytopenia. * **Hepatic Rupture:** A catastrophic complication of HELLP/Eclampsia presenting with sudden severe abdominal pain and hypovolemic shock. While possible, HELLP is the primary underlying diagnosis. * **IHCP:** Characterized by intense pruritus (palms/soles) and elevated bile acids. It does not cause hypertension, proteinuria, or hemolysis. **Clinical Pearls for NEET-PG:** * **Treatment of Choice:** Delivery is the definitive management (regardless of gestational age if >34 weeks or if maternal/fetal condition deteriorates). * **Dexamethasone:** Used to increase platelet counts in HELLP, though it doesn't improve maternal outcomes. * **Differential:** Always differentiate from **Acute Fatty Liver of Pregnancy (AFLP)**, where hypoglycemia and markedly prolonged PT/INR are more prominent than in HELLP.

Q: Cervical cerclage is advised in an antenatal woman with a prior preterm birth if the cervical length measures?

< 2.5 cm. **Explanation:** The correct answer is **D. < 2.5 cm**. This question addresses the management of **Ultrasound-indicated Cerclage** (also known as "rescue" or "history-indicated" cerclage depending on context). In women with a singleton pregnancy and a history of spontaneous preterm birth (PTB), serial transvaginal ultrasound (TVU) monitoring of cervical length is the standard of care. **Why < 2.5 cm is correct:** According to ACOG and RCOG guidelines, a cervical length of **less than 25 mm (< 2.5 cm)** before 24 weeks of gestation in a woman with a prior spontaneous PTB is a definitive indication for cervical cerclage. At this threshold, the risk of recurrent preterm birth significantly increases, and cerclage has been proven to reduce that risk and improve neonatal outcomes. **Analysis of Incorrect Options:** * **Option A:** Incorrect. Cervical length is the primary objective predictor used to determine the need for cerclage in high-risk asymptomatic women. * **Option B & C:** Incorrect. A cervical length of **> 3 cm** is considered normal and reassuring. While lengths between **2.5 and 2.9 cm** are borderline, they generally do not warrant surgical intervention; instead, they may require closer monitoring or vaginal progesterone. **High-Yield Clinical Pearls for NEET-PG:** * **Types of Cerclage:** 1. **History-indicated:** Based on ≥3 unexplained mid-trimester losses or PTBs (placed at 12–14 weeks). 2. **Ultrasound-indicated:** Prior PTB + Cervical length < 25 mm (placed before 24 weeks). 3. **Physical exam-indicated (Emergency):** Dilated cervix with visible membranes. * **McDonald’s Technique:** The most common suture method; placed at the cervicovaginal junction. * **Shirodkar Technique:** Involves bladder reflection; suture is placed higher up at the internal os. * **Removal:** Elective removal is typically performed at **36–37 weeks** of gestation or immediately if labor begins.

Q: All are causes of Antepartum hemorrhage (APH) except?

Battledore placenta. **Explanation:** Antepartum hemorrhage (APH) is defined as bleeding from or into the genital tract occurring from the 28th week of pregnancy until the birth of the baby. Causes are broadly classified into **Placental** (70%), **Extraplacental** (local causes like cervical polyps or trauma), and **Unexplained**. **Why Battledore Placenta is the correct answer:** Battledore placenta (Marginal insertion of the cord) refers to the attachment of the umbilical cord to the very margin of the placenta. While it is an anatomical variation, it **does not typically cause APH**. It is clinically significant primarily because it may lead to preterm labor or cord avulsion during the third stage of labor, but it is not a recognized cause of antepartum bleeding. **Analysis of other options:** * **Placenta Previa:** A leading placental cause of APH where the placenta is implanted in the lower uterine segment. Bleeding occurs as the lower segment stretches and the placenta separates. * **Abruptio Placentae:** The premature separation of a normally situated placenta. It is a major cause of painful APH and is often associated with hypertension. * **Circumvallate Placenta:** A morphological variation where the chorionic plate is smaller than the basal plate, causing the membranes to double back. This "shelf" of tissue is prone to marginal separation, leading to APH (often "unexplained" or "warning" bleeds). **NEET-PG High-Yield Pearls:** * **Vasa Previa:** Often confused with Battledore placenta; however, Vasa Previa involves fetal vessels running across the internal os and **is** a cause of APH (specifically fetal blood loss). * **Most common cause of APH:** Abruptio Placentae. * **Most common cause of painless APH:** Placenta Previa. * **Circumvallate Placenta** is also associated with hydrorrhea gravidarum (excessive watery discharge).

Q: Which of the following is an indicator of severe pre-eclampsia?

Intrauterine growth restriction (IUGR). **Explanation:** In the context of the **latest ACOG and NHBPEP guidelines**, the classification of pre-eclampsia has shifted. While severe hypertension and organ dysfunction remain hallmarks, the presence of **Intrauterine Growth Restriction (IUGR)** is a critical indicator of placental insufficiency and is classified as a feature of **severe pre-eclampsia**. It reflects the chronic fetal impact of reduced uteroplacental perfusion. **Analysis of Options:** * **A. IUGR (Correct):** IUGR, along with oligohydramnios and abnormal Doppler studies (e.g., reversed end-diastolic flow in the umbilical artery), signifies significant placental compromise, categorizing the condition as severe. * **B, C, & D (Incorrect):** While these are indeed features of severe pre-eclampsia, the question asks for the *indicator* among the choices provided. In many standardized NEET-PG patterns, if multiple "severity markers" are present, the focus often shifts to fetal well-being or specific diagnostic criteria. However, it is important to note that **Systolic BP ≥ 160 mmHg**, **Diastolic BP ≥ 110 mmHg**, and **Pulmonary Edema** are also "severity features." In this specific question context, IUGR is highlighted as the definitive fetal indicator of severity. **High-Yield Clinical Pearls for NEET-PG:** * **New Criteria:** Proteinuria is no longer mandatory for a diagnosis of pre-eclampsia if other "severity features" (thrombocytopenia, renal insufficiency, liver dysfunction, or cerebral symptoms) are present. * **BP Thresholds:** Severe hypertension is defined as ≥160/110 mmHg on two occasions at least 4 hours apart. * **Drug of Choice:** **Magnesium Sulfate** is the DOC for seizure prophylaxis in severe pre-eclampsia (Pritchard Regimen). * **Definitive Management:** Delivery of the fetus and placenta is the only cure; for severe pre-eclampsia, this is usually indicated at **34 weeks** gestation.

Question 1

Magnesium sulfate (MgSO4) is indicated in which of the following conditions?

Accepted Answer

Severe pre-eclampsia

Answer

Gestational trophoblastic disease

Answer

Gestational diabetes

Answer

Placenta previa

Question 2

What is a common cause of recurrent missed abortion at 10 weeks gestation?

Accepted Answer

Chromosomal abnormality

Answer

Cervical incompetence

Answer

Corpus luteum failure

Answer

Retroverted uterus

Question 3

A 25-week pregnant woman presents with hypertension (160/95 mmHg), proteinuria, generalized edema, hyperuricemia, and elevated liver enzymes. Which of the following usually provides definitive therapy for this condition?

Accepted Answer

Delivery

Answer

Antihypertensive medical therapy

Answer

Low dose aspirin

Answer

Oxygen supplementation

Question 4

Which of the following is an impending sign of eclampsia in pregnancy-induced hypertension (PIH)?

Accepted Answer

Visual symptoms

Answer

Weight gain of 2 lb per week

Answer

Severe proteinuria of 10 g

Answer

Pedal edema

Question 5

On transvaginal sonography (TVS), which of the following cervical shapes indicates a high chance of miscarriage?

Accepted Answer

U-shaped

Answer

T-shaped

Answer

Y-shaped

Answer

O-shaped

Question 6

A 29-week pregnant patient presents with jaundice and severe pre-eclampsia (BP 170/110, urine albumin 3+). Investigations show Hb 7 gm%, platelet count 70,000, TLC 13,000, SGOT 230, bilirubin 2 mg/dL, and INR 2. What is the most likely diagnosis?

Accepted Answer

HELLP syndrome

Answer

Acute Cholecystitis

Answer

Hepatic rupture

Answer

Intrahepatic Cholestasis of Pregnancy (IHCP)

Question 7

Diagnosis of gestational hypertension is made if blood pressure is:

Accepted Answer

> 140/90 mmHg after 20 weeks in a previously normotensive patient

Answer

> 130/90 mmHg after 20 weeks in a previously normotensive patient

Answer

> 150/90 mmHg after 20 weeks in a previously normotensive patient

Answer

> 160/90 mmHg after 20 weeks in a previously normotensive patient

Question 8

Cervical cerclage is advised in an antenatal woman with a prior preterm birth if the cervical length measures?

Accepted Answer

< 2.5 cm

Answer

Not related to cervical length

Answer

Between 3-4 cm

Answer

Between 2.5 to 2.9 cm

Question 9

All are causes of Antepartum hemorrhage (APH) except?

Accepted Answer

Battledore placenta

Answer

Placenta previa

Answer

Abruptio placentae

Answer

Circumvallate placenta

Question 10

Which of the following is an indicator of severe pre-eclampsia?

Accepted Answer

Intrauterine growth restriction (IUGR)

Answer

Diastolic blood pressure > 110 mm Hg

Answer

Pulmonary edema

Answer

Systolic blood pressure > 160 mm Hg

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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