Maternal-Fetal Medicine Practice Questions

Q: Which maternal condition is associated with fetal Long-Chain Hydroxyacyl-CoA Dehydrogenase (LCHAD) deficiency?

HELLP syndrome. **Explanation:** The association between fetal **Long-Chain Hydroxyacyl-CoA Dehydrogenase (LCHAD) deficiency** and maternal liver diseases like **HELLP syndrome** and **Acute Fatty Liver of Pregnancy (AFLP)** is a high-yield concept in obstetric medicine. **Why HELLP syndrome is correct:** LCHAD is a mitochondrial enzyme involved in the beta-oxidation of fatty acids. When a fetus has an autosomal recessive LCHAD deficiency, it cannot metabolize long-chain fatty acids. These intermediate fatty acid metabolites (3-hydroxyacyl compounds) accumulate in the fetal circulation and cross the placenta into the maternal circulation. Because the mother is a carrier (heterozygous) for the mutation, her liver has reduced capacity to process these extra metabolites. This leads to lipotoxicity, causing maternal hepatocyte damage, which manifests clinically as **HELLP syndrome** (Hemolysis, Elevated Liver enzymes, Low Platelets) or **AFLP**. **Why the other options are incorrect:** * **PCOS:** This is an endocrine disorder characterized by hyperandrogenism and insulin resistance; it has no metabolic link to fetal fatty acid oxidation. * **Molar pregnancy:** This is a gestational trophoblastic disease resulting from abnormal fertilization; it is not associated with fetal metabolic enzyme deficiencies. * **Ectopic pregnancy:** This refers to implantation outside the uterine cavity and is unrelated to fetal metabolic pathways. **Clinical Pearls for NEET-PG:** * **AFLP and LCHAD:** Approximately 15–20% of mothers carrying an LCHAD-deficient fetus will develop AFLP or HELLP. * **Management:** If a mother develops AFLP/HELLP, the newborn should be screened for LCHAD deficiency immediately after birth to prevent fatal hypoglycemia and liver failure. * **Inheritance:** LCHAD deficiency follows an **Autosomal Recessive** pattern.

Q: A 25-year-old female presents to the casualty with a history of amenorrhea for two and a half months, and abdominal pain and bleeding per vaginum for one day. On examination, vital parameters and other systems are normal. On speculum examination, bleeding is found to come from the os. On bimanual examination, the uterus is of 10 weeks size, soft, and the os admits one finger. What is the most likely diagnosis?

Inevitable abortion. ### Explanation The clinical presentation points toward a diagnosis of **Inevitable Abortion**. The key diagnostic feature in this case is the combination of vaginal bleeding and an **open cervical os** (os admits one finger) in the presence of a viable-sized uterus, where the products of conception have not yet been expelled. #### Why Inevitable Abortion is Correct: In **Inevitable Abortion**, the clinical process has progressed to a state where termination of pregnancy is certain. The diagnostic hallmarks are: 1. **History:** Amenorrhea, abdominal pain (colicky), and bleeding. 2. **Examination:** The internal os is **dilated (open)**, but the products of conception are still inside the uterus (indicated by the uterus being 10 weeks size, corresponding to her period of amenorrhea). #### Why Other Options are Incorrect: * **Threatened Abortion:** While bleeding occurs, the **cervical os remains closed**, and the pain is usually minimal or absent. The pregnancy may still continue. * **Missed Abortion:** The fetus has died in utero but is retained. The **cervical os is closed**, and there is often a regression of pregnancy symptoms; the uterine size is typically smaller than the period of gestation. * **Incomplete Abortion:** Some products of conception have already been expelled. While the os is open, the **uterine size would be smaller** than the expected period of gestation. #### NEET-PG High-Yield Pearls: * **Os Status is Key:** If the Os is **Closed**, consider Threatened or Missed abortion. If the Os is **Open**, consider Inevitable or Incomplete abortion. * **Uterine Size:** In Inevitable abortion, Uterine Size = Period of Amenorrhea (POA). In Incomplete abortion, Uterine Size < POA. * **Management:** For inevitable abortion, the management is usually hospitalization and evacuation of the uterus (Suction & Evacuation) if the gestation is <12 weeks.

Q: Which of the following is NOT true about cervical incompetence?

Associated with first-trimester abortion. **Explanation:** Cervical incompetence (now often termed cervical insufficiency) refers to the inability of the cervix to retain a pregnancy in the absence of signs and symptoms of clinical contractions, labor, or both. **Why Option A is the correct answer:** Cervical incompetence is characteristically associated with **painless, mid-trimester (second-trimester) pregnancy loss**, typically occurring between 16 and 24 weeks of gestation. First-trimester abortions (before 12 weeks) are most commonly due to chromosomal abnormalities or endocrine factors, not structural cervical weakness. **Analysis of other options:** * **Option B:** In a non-pregnant state, the diagnosis can be suggested if a **No. 8 Hegar dilator** passes through the internal os without resistance or pain. Other diagnostic tests include the "balloon test" or hysterosalpingography showing a "funneling" of the cervix. * **Option C:** Cervical incompetence can be **acquired** due to surgical trauma (e.g., D&C, conization, or cervical lacerations during previous deliveries) or can be congenital (e.g., DES exposure or collagen disorders like Ehlers-Danlos syndrome). * **Option D:** As mentioned, the hallmark of this condition is recurrent second-trimester losses preceded by spontaneous rupture of membranes or painless cervical dilation. **High-Yield NEET-PG Pearls:** * **Gold Standard Treatment:** Cervical Cerclage (McDonald or Shirodkar technique). * **Timing of Cerclage:** Usually performed between **12–14 weeks** of gestation. * **Removal:** The stitch is typically removed at **37 weeks** or at the onset of labor. * **Ultrasound Finding:** "Funneling" of the internal os and a cervical length of **<25 mm** before 24 weeks are significant markers.

Q: A gravida 3 female with a history of 2 previous second-trimester abortions presents at 22 weeks of gestation with cervical funneling. What is the most appropriate management?

Apply McDonald suture. **Explanation:** The clinical presentation of a patient with a history of recurrent second-trimester losses and current ultrasound findings of **cervical funneling** is diagnostic of **Cervical Insufficiency** (Incompetence). 1. **Why Option D is Correct:** The management of choice for cervical insufficiency is **Cervical Cerclage**. The **McDonald suture** is the most commonly performed technique. It involves a purse-string suture placed at the cervicovaginal junction to provide mechanical support to the internal os, preventing premature dilation. In this case, since the patient is already at 22 weeks with funneling, this is considered an **"Ultrasound-indicated" or "Urgent" cerclage**, typically performed between 14–24 weeks when cervical changes are detected. 2. **Why Other Options are Incorrect:** * **Options A & B (Dinoprostone/Misoprostol):** These are prostaglandins used for cervical ripening and induction of labor or abortion. Administering them would worsen the condition by further softening the cervix and inducing contractions. * **Option C (Fothergill Suture):** This is a component of the Fothergill (Manchester) operation used for treating **pelvic organ prolapse**, not cervical incompetence. It involves shortening the cardinal ligaments and is contraindicated during pregnancy. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) showing a cervical length **<25 mm** or significant **funneling** (beaking of internal os). * **Timing:** Prophylactic (History-based) cerclage is usually done at **12–14 weeks**. * **Shirodkar Technique:** An alternative to McDonald’s where the suture is placed submucosally; it is technically more difficult but may be used if the McDonald suture fails. * **Contraindications to Cerclage:** Chorioamnionitis, ruptured membranes, active bleeding, or fetal anomalies.

Q: What predicted beta-hCG levels are indicative of an ectopic pregnancy?

1500 mIU/mL. The correct answer is **1500 mIU/mL**. ### **Explanation of the Correct Answer** The core concept here is the **Discriminatory Zone (DZ)**. This is the threshold level of serum beta-hCG above which a normal intrauterine pregnancy (IUP) should consistently be visible via transvaginal sonography (TVS). * According to the **ACOG guidelines** and standard textbooks (Williams Obstetrics), the most widely accepted discriminatory zone is **1500 to 2000 mIU/mL**. * If the beta-hCG is above 1500 mIU/mL and the uterus is empty on TVS, the clinician must highly suspect an **ectopic pregnancy** or a non-viable IUP. ### **Analysis of Incorrect Options** * **A (1000 mIU/mL):** This was the historical threshold for older ultrasound machines. Modern high-resolution TVS can often see a sac at this level, but it is not the standard "discriminatory" cutoff used to diagnose ectopic pregnancy. * **C & D (2000 & 2500 mIU/mL):** While some institutions use 2000 mIU/mL to increase specificity (to avoid accidental termination of a desired pregnancy), **1500 mIU/mL** remains the classic, most frequently tested "lower limit" of the discriminatory zone for NEET-PG. 2500 mIU/mL is generally considered too high for a primary diagnostic threshold. ### **Clinical Pearls for NEET-PG** 1. **Doubling Time:** In a healthy IUP, beta-hCG levels should increase by at least **35-53% every 48 hours**. A rise of less than this suggests ectopic pregnancy or miscarriage. 2. **Transabdominal Ultrasound (TAS):** The discriminatory zone for TAS is much higher, typically **6000–6500 mIU/mL**. 3. **Gold Standard Diagnosis:** While beta-hCG and TVS are the primary tools, the definitive diagnosis of ectopic pregnancy is via **laparoscopy**. 4. **Medical Management:** Methotrexate is indicated if the patient is stable, the sac is <4 cm, and beta-hCG is <5000 mIU/mL.

Q: Which of the following describes the radiographic finding of a flattened, overlapping arch of the fetal skull, indicating fetal death?

Spalding Sign. **Explanation:** **Spalding’s Sign (Option A)** is the correct answer. It refers to the overlapping of the fetal skull bones caused by the liquefaction of the brain matter and the loss of intracranial pressure following intrauterine fetal death (IUFD). This radiographic sign typically appears 4 to 7 days after fetal demise. It is a classic high-yield finding in obstetric imaging, though it has largely been replaced by ultrasound in modern practice. **Analysis of Incorrect Options:** * **Robert’s Sign (Option B):** This refers to the presence of gas (usually nitrogen) in the fetal heart and great vessels. It is one of the earliest radiological signs of fetal death, appearing as early as 12 hours after demise. * **Wood’s Sign (Option C):** This is not a standard term for fetal death. It may be confused with the "Wood’s Screw Maneuver," which is a clinical technique used to manage shoulder dystocia by rotating the posterior shoulder. * **Normal Pregnancy (Option D):** In a viable pregnancy, the fetal skull bones are well-aligned without overlapping, maintained by normal intracranial pressure and brain volume. **Clinical Pearls for NEET-PG:** * **Earliest Sign of IUFD on X-ray:** Robert’s Sign (Gas in the circulatory system). * **Most Reliable Sign of IUFD:** Absence of fetal heart activity on Real-time Ultrasound (M-mode). * **Deuel’s Halo Sign:** Another sign of IUFD, characterized by the elevation of the scalp soft tissues (edema) creating a "halo" appearance around the fetal skull. * **Spalding’s Sign Caution:** It can occasionally be seen in a living fetus during labor when the head is deeply engaged and undergoing significant molding.

Q: What is the single best parameter to assess fetal well-being?

Biophysical profile. The **Biophysical Profile (BPP)** is the gold standard for assessing acute and chronic fetal well-being because it combines multiple dynamic parameters to evaluate the integrity of the fetal central nervous system. ### **Why Biophysical Profile (D) is correct:** The BPP evaluates five parameters: **Fetal breathing movements, Fetal tone, Gross body movements, Amniotic fluid volume, and the Non-Stress Test (NST).** * **Acute markers** (Breathing, Tone, Movement, NST) reflect the immediate oxygenation of the fetal brain. * **Chronic markers** (Amniotic fluid) reflect long-term placental perfusion. Because it assesses both immediate neurological status and placental reserve, it is the most reliable predictor of fetal health and the risk of intrauterine death. ### **Why other options are incorrect:** * **Femur Length (A):** This is a biometric parameter used primarily to assess gestational age and skeletal growth, not acute well-being. * **Abdominal Circumference (B):** While this is the most sensitive indicator for **fetal growth restriction (IUGR)** and nutritional status (liver glycogen stores), it does not provide a real-time assessment of fetal hypoxia or distress. * **Head Circumference (C):** This is used for dating and monitoring brain growth but does not reflect the current physiological state of the fetus. ### **High-Yield Clinical Pearls for NEET-PG:** * **Manning’s Score:** The BPP is scored out of 10. A score of **8-10 is normal**, while **0-2 indicates certain fetal asphyxia** and requires immediate delivery. * **Modified BPP:** Consists of only the **NST** (acute) and **Amniotic Fluid Index** (chronic). It is as predictive as the full BPP. * **Sequence of Loss:** In fetal hypoxia, the first parameter to disappear is the **NST (reactivity)**, followed by breathing, and finally fetal tone (the last to disappear).

Question 1

Which maternal condition is associated with fetal Long-Chain Hydroxyacyl-CoA Dehydrogenase (LCHAD) deficiency?

Accepted Answer

HELLP syndrome

Answer

Polycystic Ovarian Syndrome (PCOS)

Answer

Molar pregnancy

Answer

Ectopic pregnancy

Question 2

In valvular heart disease complicating pregnancy, which of the following statements is NOT true?

Accepted Answer

Open heart surgery is associated with a reduction in fetal loss.

Answer

A closed mitral valvotomy can be carried out if symptoms of mitral stenosis are severe.

Answer

Mitral regurgitation is usually well tolerated.

Answer

A maternal mortality of 15% has been reported in women with critical aortic stenosis.

Question 3

A 25-year-old female presents to the casualty with a history of amenorrhea for two and a half months, and abdominal pain and bleeding per vaginum for one day. On examination, vital parameters and other systems are normal. On speculum examination, bleeding is found to come from the os. On bimanual examination, the uterus is of 10 weeks size, soft, and the os admits one finger. What is the most likely diagnosis?

Accepted Answer

Inevitable abortion

Answer

Threatened abortion

Answer

Missed abortion

Answer

Incomplete abortion

Question 4

Which of the following conditions poses the greatest risk for development of pre-eclampsia?

Accepted Answer

Polyarteritis nodosa

Answer

Chronic glomerulonephritis

Answer

Polycystic kidney disease

Answer

Renal artery stenosis

Question 5

Which of the following is NOT true about cervical incompetence?

Accepted Answer

Associated with first-trimester abortion

Answer

Hegar's dilator can be passed into the uterine cavity in a non-pregnant state

Answer

History of trauma can precede its development

Answer

Associated with second-trimester abortion

Question 6

A gravida 3 female with a history of 2 previous second-trimester abortions presents at 22 weeks of gestation with cervical funneling. What is the most appropriate management?

Accepted Answer

Apply McDonald suture

Answer

Administer dinoprostone and bed rest

Answer

Administer misoprostol and bed rest

Answer

Apply Fothergill suture

Question 7

What predicted beta-hCG levels are indicative of an ectopic pregnancy?

Accepted Answer

1500 mIU/mL

Answer

1000 mIU/mL

Answer

2000 mIU/mL

Answer

2500 mIU/mL

Question 8

Which of the following describes the radiographic finding of a flattened, overlapping arch of the fetal skull, indicating fetal death?

Accepted Answer

Spalding Sign

Answer

Robe's Sign

Answer

Wood's Sign

Answer

Normal pregnancy

Question 9

What is the single best parameter to assess fetal well-being?

Accepted Answer

Biophysical profile

Answer

Femur length

Answer

Abdominal circumference

Answer

Head circumference

Question 10

A 29-year-old primigravida in her 4th month of pregnancy has a history of juvenile myoclonic epilepsy and is regularly taking sodium valproate. She is seeking advice regarding her anti-epileptic regimen. What would you suggest?

Accepted Answer

Continue Valproate with monitoring of drug level

Answer

Immediately taper Valproate and start Lamotrigine

Answer

Switch to Carbamazepine

Answer

Add Lamotrigine

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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