Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 741: What is a common cause of recurrent missed abortion at 10 weeks gestation?

A. Chromosomal abnormality (Correct Answer)
B. Cervical incompetence
C. Corpus luteum failure
D. Retroverted uterus

Explanation: **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.

Question 742: Extrachorial placentation increases the risk of which of the following?

A. Abruptio placenta
B. Stillbirth
C. Intra-partum fetal acidosis
D. None of the above (Correct Answer)

Explanation: **Explanation:** **Extrachorial placentation** refers to a morphological variation where the chorionic plate (the fetal surface) is smaller than the basal plate (the maternal surface). This results in the fetal membranes attaching to the fetal surface of the placenta at some distance from the edge, rather than at the margin. There are two types: **Circumvallate placenta** (associated with a raised, thickened white ring) and **Circummarginate placenta** (a flat transition). **Why "None of the above" is correct:** While older textbooks occasionally linked extrachorial placentation (specifically the circumvallate type) with complications like antepartum hemorrhage or preterm labor, modern large-scale obstetric studies and evidence-based guidelines (including those referenced in Williams Obstetrics) have shown that these variations are generally **clinically insignificant**. They do not show a statistically significant correlation with acute catastrophic events like **Abruptio placenta (A)**, **Stillbirth (B)**, or **Intra-partum fetal acidosis (C)**. Most cases are diagnosed incidentally during postpartum placental examination. **Analysis of Incorrect Options:** * **Abruptio placenta:** While circumvallate placenta may rarely be associated with mild marginal sinus bleeding, it is not a recognized risk factor for clinical placental abruption. * **Stillbirth & Fetal Acidosis:** These are outcomes of severe placental insufficiency or acute distress. Extrachorial placentation does not compromise the functional exchange area of the villi enough to cause chronic hypoxia or acute intrapartum acidosis. **High-Yield Clinical Pearls for NEET-PG:** * **Circumvallate Placenta:** The most clinically relevant form of extrachorial placentation; characterized by a double fold of amnion and chorion. * **Clinical Association:** If any association exists, it is most commonly linked to **preterm premature rupture of membranes (PPROM)** or mild antepartum bleeding, but not fetal compromise. * **Diagnosis:** Usually made by gross pathological examination after delivery; ultrasound diagnosis is difficult and often unreliable.

Question 743: 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?

A. Antihypertensive medical therapy
B. Delivery (Correct Answer)
C. Low dose aspirin
D. Oxygen supplementation

Explanation: **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.

Question 744: What is the earliest sign of intrauterine fetal demise?

A. Gas in blood vessels (Correct Answer)
B. Hyperflexion of the fetal spine
C. Spalding's sign
D. Aboion

Explanation: **Explanation:** Intrauterine fetal demise (IUFD) is associated with several radiological signs, but the **earliest** to appear is the presence of gas in the fetal blood vessels and heart, known as **Robert’s Sign**. 1. **Robert’s Sign (Gas in blood vessels):** This occurs due to the release of nitrogen from the blood into the heart and large vessels (like the aorta). It can be seen on an X-ray or ultrasound as early as **12 hours** after fetal death. It is the most sensitive early radiological indicator. **Analysis of Incorrect Options:** * **Spalding’s Sign (Option C):** This refers to the overlapping of fetal skull bones due to the liquefaction of the brain and loss of intracranial pressure. It typically takes **4 to 7 days** to develop after death. * **Hyperflexion of the fetal spine (Option B):** Also known as **Hartley’s Sign**, this occurs due to the loss of fetal muscle tone. It usually appears after Spalding’s sign, often around the **1st week** post-demise. * **Aboion (Option D):** This is likely a distractor or misspelling. In the context of IUFD, **Deuel’s Halo Sign** (edema of fetal scalp) is a known sign, but it also appears later (usually after 48 hours). **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** The most reliable and immediate method to diagnose IUFD today is the **absence of fetal cardiac activity on Ultrasound.** * **Sequence of Signs:** Robert’s Sign (12 hrs) → Spalding’s Sign (4-7 days) → Hartley’s Sign (7 days+). * **Spalding’s Sign Caveat:** It is only valid if the mother is not in labor and the fetal head is not engaged, as molding during labor can mimic this sign.

Question 745: On transvaginal sonography (TVS), which of the following cervical shapes indicates a high chance of miscarriage?

A. T-shaped
B. Y-shaped
C. U-shaped (Correct Answer)
D. O-shaped

Explanation: This question addresses **Cervical Incompetence (Cervical Insufficiency)** and the sonographic progression of cervical effacement, often remembered by the mnemonic **"TRUST" (T-Y-V-U).** ### Explanation of the Correct Answer In a normal pregnancy, the internal os remains closed, appearing as a **T-shape** on TVS. As the cervix begins to fail or shorten, the internal os opens, and fetal membranes prolapse into the cervical canal. This process follows a specific sequence: 1. **T-shape:** Normal (closed). 2. **Y-shape:** Early funneling at the internal os. 3. **V-shape:** Funneling reaches the mid-portion of the cervix. 4. **U-shape:** This represents the most advanced stage of funneling. The cervix is significantly shortened, and the membranes form a wide, rounded "U" shape. This indicates **imminent cervical failure** and carries the highest risk of mid-trimester miscarriage or preterm birth. ### Analysis of Incorrect Options * **A. T-shaped:** This is the normal appearance of a competent cervix where the internal and external os are closed. * **B. Y-shaped:** This represents the earliest stage of funneling. While it indicates a risk, it is less severe than the U-shape. * **D. O-shaped:** This is not a standard sonographic term used to describe cervical funneling or the progression of cervical incompetence. ### NEET-PG High-Yield Pearls * **Gold Standard Diagnosis:** Transvaginal Sonography (TVS) is superior to transabdominal ultrasound for measuring cervical length. * **Critical Threshold:** A cervical length of **<25 mm** before 24 weeks of gestation is a significant predictor of preterm birth. * **The "TRUST" Mnemonic:** To remember the progression of funneling from least to most severe: **T**hey **R**eally **U**ntie **S**o **T**erribly (**T → Y → V → U**). * **Management:** For a short cervix or funneling identified early, options include **Progesterone** supplementation or **Cervical Cerclage** (e.g., McDonald or Shirodkar technique).

Question 746: Diagnosis of gestational hypertension is made if blood pressure is:

A. > 130/90 mmHg after 20 weeks in a previously normotensive patient
B. > 140/90 mmHg after 20 weeks in a previously normotensive patient (Correct Answer)
C. > 150/90 mmHg after 20 weeks in a previously normotensive patient
D. > 160/90 mmHg after 20 weeks in a previously normotensive patient

Explanation: ### Explanation **Correct Answer: B. > 140/90 mmHg after 20 weeks in a previously normotensive patient** **Underlying Medical Concept:** Gestational Hypertension (GH) is defined by the **ACOG and NHBPEP** criteria as a systolic blood pressure (SBP) **≥ 140 mmHg** and/or a diastolic blood pressure (DBP) **≥ 90 mmHg**. This must occur for the first time **after 20 weeks of gestation** in a woman who was previously normotensive. Crucially, GH is characterized by the **absence of proteinuria** or other systemic features of preeclampsia. Blood pressure typically returns to normal within 12 weeks postpartum. **Analysis of Incorrect Options:** * **Option A (> 130/90):** While the AHA/ACC guidelines for non-pregnant adults define Stage 1 hypertension at 130/80 mmHg, obstetric guidelines strictly adhere to the 140/90 mmHg threshold to avoid over-diagnosis and unnecessary intervention. * **Option C (> 150/90):** This value is above the diagnostic threshold. While a patient with 150/90 mmHg *has* hypertension, the diagnostic "cutoff" starts at 140/90 mmHg. * **Option D (> 160/90):** An SBP ≥ 160 mmHg or DBP ≥ 110 mmHg is classified as **Severe Hypertension**. In the context of pregnancy, this indicates "hypertension with severe features," requiring urgent antihypertensive therapy (e.g., Labetalol or Hydralazine) to prevent maternal stroke. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Hypertension before 20 weeks is usually **Chronic Hypertension**, unless it is a Molar Pregnancy. * **Proteinuria:** If 140/90 mmHg is accompanied by proteinuria (>300mg/24hr or 1+ on dipstick), the diagnosis shifts to **Preeclampsia**. * **Gold Standard Measurement:** BP should be measured in a sitting position with an appropriate cuff size, on two occasions at least 4 hours apart. * **Progression:** Approximately 15-25% of women diagnosed with GH will eventually develop Preeclampsia.

Question 747: What is fetal scalp blood pH used to determine?

A. Intrauterine growth restriction (IUGR)
B. Fetal hypoxia (Correct Answer)
C. Fetal diabetes
D. Estimation of alpha-fetoprotein

Explanation: ### Explanation **Correct Answer: B. Fetal hypoxia** **Why it is correct:** Fetal scalp blood sampling (FBS) is a diagnostic procedure used to assess the acid-base status of a fetus when a Cardiotocograph (CTG) shows a non-reassuring or pathological pattern. When a fetus experiences **hypoxia** (oxygen deprivation), it shifts from aerobic to anaerobic metabolism, leading to the production of lactic acid. This results in **metabolic acidosis**, which is reflected by a drop in the fetal blood pH. * **pH >7.25:** Normal. * **pH 7.20 – 7.25:** Borderline (Pre-acidosis); repeat in 30 minutes. * **pH <7.20:** Significant acidosis (Hypoxia); indicates immediate delivery. **Why the other options are incorrect:** * **A. IUGR:** This is a clinical and sonographic diagnosis (using abdominal circumference and Doppler studies), not a biochemical one. * **C. Fetal diabetes:** There is no such clinical entity as "fetal diabetes." Maternal diabetes is monitored via maternal HbA1c and blood glucose levels. * **D. Alpha-fetoprotein (AFP):** This is a screening marker measured in maternal serum or amniotic fluid to detect neural tube defects or chromosomal anomalies, not via fetal scalp blood. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisites for FBS:** Ruptured membranes, cervix dilated at least 3 cm, and the fetal head must be engaged. * **Contraindications:** Fetal bleeding disorders (e.g., Hemophilia), maternal infections (HIV, Hepatitis B/C, active Herpes), and prematurity (<34 weeks). * **Lactate vs. pH:** Modern practice often uses **fetal scalp lactate** instead of pH, as it requires a smaller blood volume and is equally effective in identifying hypoxia.

Question 748: Cervical cerclage is advised in an antenatal woman with a prior preterm birth if the cervical length measures?

A. Not related to cervical length
B. Between 3-4 cm
C. Between 2.5 to 2.9 cm
D. < 2.5 cm (Correct Answer)

Explanation: **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.

Question 749: All are causes of Antepartum hemorrhage (APH) except?

A. Placenta previa
B. Abruptio placentae
C. Circumvallate placenta
D. Battledore placenta (Correct Answer)

Explanation: **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).

Question 750: Which of the following is an indicator of severe pre-eclampsia?

A. Intrauterine growth restriction (IUGR) (Correct Answer)
B. Diastolic blood pressure > 110 mm Hg
C. Pulmonary edema
D. Systolic blood pressure > 160 mm Hg

Explanation: **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.

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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