Maternal-Fetal Medicine Practice Questions

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.

Q: 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 dates, and fetal heart sounds are absent. What is the most likely diagnosis?

Concealed hemorrhage. This question describes a classic presentation of **Abruptio Placentae**, specifically the **concealed variety**. ### **Explanation of the Correct Answer** In **concealed accidental hemorrhage**, blood collects behind the placenta (retroplacental clot) and does not escape through the cervix. This leads to several key clinical findings: * **Uterine size > Dates:** The accumulation of blood within the uterine cavity increases the fundal height beyond what is expected for the gestational age. * **Abdominal Pain:** The uterus becomes tense, tender, and "board-like" due to the irritating effect of the retroplacental hematoma. * **Absent Fetal Heart Sounds (FHS):** Severe placental separation leads to acute fetal hypoxia and intrauterine fetal death. * **Slight Bleeding:** Even in "concealed" cases, a small amount of dark vaginal bleeding (revealed component) is often present. ### **Why Other Options are Incorrect** * **A. Hydramnios:** While this causes a uterus larger than dates, it is usually painless and associated with easily audible (though muffled) FHS. It does not cause vaginal bleeding. * **C. Active Labor:** Labor presents with rhythmic contractions and cervical changes. It does not explain a uterus larger than dates or the sudden absence of FHS. * **D. Uterine Rupture:** This typically occurs during labor (often in a scarred uterus). On examination, fetal parts are easily palpable under the skin, and the uterus usually becomes **smaller** or recedes as the fetus is extruded into the peritoneal cavity. ### **NEET-PG High-Yield Pearls** * **Couvelaire Uterus:** A complication of concealed abruption where blood infiltrates the myometrium, giving it a port-wine appearance. * **Consumptive Coagulopathy (DIC):** More common in the concealed variety due to the release of thromboplastin into the maternal circulation. * **Classic Triad of Abruption:** Abdominal pain, uterine tenderness/hypertonicity, and vaginal bleeding.

Q: Which of the following is true about the amnion, except:

It has a rich blood supply.. The amnion is the innermost fetal membrane, characterized by its tough, thin, and transparent nature. Understanding its histology and function is high-yield for NEET-PG. ### **Explanation of the Correct Answer** **Option B (It has a rich blood supply)** is the correct answer because it is a **false statement**. The amnion is entirely **avascular**. It contains no blood vessels, lymphatics, or nerves. It derives its nutrition and oxygen primarily via diffusion from the amniotic fluid and the underlying vascularized decidua/chorion. ### **Analysis of Other Options** * **Option A (No lymph supply):** This is a true statement. As an avascular structure, it lacks a lymphatic drainage system. * **Option C (No nerve supply):** This is a true statement. The lack of nerve supply explains why procedures like amniocentesis do not cause pain when the needle pierces the amniotic sac (the pain felt is from the maternal abdominal wall and uterus). * **Option D (Dilates the cervix):** This is a true statement. During the first stage of labor, the intact "bag of waters" (amnion and chorion) acts as a hydrostatic wedge. According to **Pascal’s Law**, it transmits intrauterine pressure evenly to the cervix, aiding in effacement and dilatation. ### **High-Yield Clinical Pearls for NEET-PG** * **Structure:** The amnion consists of five layers, the innermost being a single layer of cuboidal/columnar epithelium. * **Tensile Strength:** The amnion provides the majority of the tensile strength of the fetal membranes, largely due to its **Type IV and V collagen** content. * **Amniotic Fluid Production:** Early in pregnancy, the amnion contributes to amniotic fluid production via active transport of solutes. * **Clinical Correlation:** Rupture of membranes (ROM) leads to the loss of the hydrostatic wedge, often resulting in a change in the mechanics of labor.

Q: Which of the following is true regarding vasa previa, except?

Mortality rate is 20% with undiagnosed cases. **Explanation:** **Vasa Previa** is a rare but life-threatening obstetric emergency where fetal vessels run through the fetal membranes, unprotected by placental tissue or the umbilical cord, across the internal os. **Why Option B is the correct answer (The "Except" statement):** The mortality rate for **undiagnosed** vasa previa is significantly higher than 20%, often cited between **50% and 95%**. Because the vessels are fetal in origin, rupture of membranes (spontaneous or artificial) leads to rapid fetal exsanguination. The 20% figure is inaccurate; conversely, when diagnosed prenatally, the survival rate increases to over 95%. **Analysis of other options:** * **Option A:** The incidence is approximately **1 in 2,500 to 1 in 5,000** pregnancies, though some studies suggest it may be as high as 1:1500 in high-risk populations (like IVF). It is considered a rare condition. * **Option C:** Risk factors include a **low-lying placenta**, placenta previa, velamentous cord insertion, succenturiate placental lobes, and pregnancies resulting from IVF. * **Option D:** Once diagnosed, a **planned Cesarean section** is mandatory (usually at 34–36 weeks) to avoid labor and the risk of membrane rupture, which would be fatal for the fetus. **NEET-PG High-Yield Pearls:** * **Classic Triad:** Rupture of membranes + Painless vaginal bleeding + Fetal bradycardia/distress. * **Diagnostic Test:** **Apt test** or **Ogita test** can differentiate fetal hemoglobin from maternal blood. * **Gold Standard Diagnosis:** Antenatal **Color Doppler Ultrasound** (showing pulsating vessels over the internal os). * **Management:** If diagnosed prenatally, admit by 30–32 weeks for monitoring and deliver via elective LSCS before labor begins.

Q: Which of the following antibodies is NOT typically involved in Rh isoimmunization?

Anti-Lewis. **Explanation:** Rh isoimmunization occurs when maternal antibodies cross the placenta and target fetal red blood cell antigens, leading to Hemolytic Disease of the Fetus and Newborn (HDFN). **Why Anti-Lewis is the correct answer:** The Lewis antigens (Le^a and Le^b) are not integral to the red cell membrane; they are plasma glycosphingolipids adsorbed onto the RBC surface. Most importantly, **Anti-Lewis antibodies are typically IgM.** Since IgM antibodies are large pentamers, they **cannot cross the placenta**. Furthermore, Lewis antigens are poorly expressed on fetal erythrocytes. Consequently, Anti-Lewis antibodies do not cause HDFN and are clinically insignificant in Rh isoimmunization. **Analysis of incorrect options:** * **Anti-D (Option D):** This is the most common and clinically significant antibody involved in Rh isoimmunization, occurring in Rh-negative mothers carrying Rh-positive fetuses. * **Anti-C and Anti-E (Options A & B):** These belong to the Rh blood group system (C, c, E, e). While less common than Anti-D, these are **IgG antibodies** that can cross the placenta and cause significant fetal hemolysis. **Clinical Pearls for NEET-PG:** * **"Lewis Lives" (mnemonic):** Lewis antibodies do not "kill" the fetus because they don't cross the placenta. * **Kell Antibodies:** "Kell Kills." Anti-Kell is the second most common cause of severe HDFN; it causes hemolysis AND suppresses fetal erythropoiesis. * **Antibody Titers:** For Anti-D, a critical titer (usually 1:16) indicates a high risk for fetal hydrops and necessitates further fetal surveillance (e.g., MCA-PSV doppler).

Q: What is pathognomonic of ectopic pregnancy?

Decidual casts. **Explanation:** **Why Decidual Casts are Correct:** A **decidual cast** is the pathognomonic finding of an ectopic pregnancy. It occurs when the endometrium, which has thickened and become "decidualized" due to rising progesterone levels from the pregnancy, is shed in its entirety as a single, fleshy, triangular piece of tissue. This happens because the ectopic pregnancy cannot sustain the hormonal levels required to maintain the uterine lining. While it mimics a miscarriage, the absence of chorionic villi on histopathological examination (Arias-Stella reaction may be present) confirms that the pregnancy is extrauterine. **Analysis of Incorrect Options:** * **A. Purple hemorrhagic pregnancy in the lower vagina:** This describes a **Choriocarcinoma** or a vaginal metastasis of a gestational trophoblastic neoplasm, not an ectopic pregnancy. * **C. Chadwick sign:** This is a bluish discoloration of the cervix, vagina, and labia caused by increased vascularity. It is a **presumptive sign of pregnancy** (both intrauterine and ectopic) but is not specific or pathognomonic for ectopic pregnancy. * **D. Postcoital hemorrhage:** This is a classic presentation of **Cervical Cancer** or cervical polyps/ectropion, unrelated to the location of a pregnancy. **High-Yield NEET-PG Pearls:** * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Most common site:** Ampulla of the Fallopian tube. * **Arias-Stella Reaction:** Hypersecretory endometrium seen in ectopic pregnancy; it is suggestive but *not* pathognomonic (can occur in IUGR or molar pregnancy). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serum β-hCG (Discriminatory zone: 1500–2000 mIU/mL).

Question 1

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 2

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 3

All are causes of Antepartum hemorrhage (APH) except?

Accepted Answer

Battledore placenta

Answer

Placenta previa

Answer

Abruptio placentae

Answer

Circumvallate placenta

Question 4

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

Question 5

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 dates, 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 6

Which of the following is true about the amnion, except:

Accepted Answer

It has a rich blood supply.

Answer

It has no lymph supply.

Answer

It has no nerve supply.

Answer

It dilates the cervix during labor.

Question 7

In a case of antepartum hemorrhage with BP = 80/60 mmHg, what is the treatment of choice?

Accepted Answer

Blood transfusion

Answer

Morphine

Answer

Placentography

Answer

Panhysterectomy

Question 8

Which of the following is true regarding vasa previa, except?

Accepted Answer

Mortality rate is 20% with undiagnosed cases

Answer

Incidence is 1:1500

Answer

Associated with low-lying placenta

Answer

Cesarean section is indicated

Question 9

Which of the following antibodies is NOT typically involved in Rh isoimmunization?

Accepted Answer

Anti-Lewis

Answer

Anti C

Answer

Anti E

Answer

Anti D

Question 10

What is pathognomonic of ectopic pregnancy?

Accepted Answer

Decidual casts

Answer

Purple hemorrhagic pregnancy in the lower vagina

Answer

Chadwick sign

Answer

Postcoital hemorrhage

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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