Maternal-Fetal Medicine Practice Questions

Q: In a patient with a history of a previous stillbirth, what is the optimum time for delivery?

39 weeks. **Explanation:** The management of a pregnancy following a previous unexplained stillbirth requires a delicate balance between the risks of recurrent stillbirth and the risks associated with iatrogenic prematurity. **Why 39 weeks is correct:** Current clinical guidelines (including ACOG and RCOG) recommend delivery at **39 weeks 0 days to 39 weeks 6 days** for women with a history of a prior unexplained stillbirth, provided the current pregnancy is otherwise uncomplicated. Delivering at 39 weeks significantly reduces the risk of late-term stillbirth while ensuring the fetus has reached full maturity, thereby minimizing the risks of Respiratory Distress Syndrome (RDS) and NICU admissions associated with early-term delivery. **Analysis of Incorrect Options:** * **37 & 38 weeks (A & B):** Delivery before 39 weeks is considered "early-term." While it further reduces the risk of stillbirth, it is associated with higher rates of neonatal morbidity (respiratory issues, feeding difficulties, and jaundice). These are generally reserved for cases with co-existing complications like preeclampsia or FGR. * **40 weeks (D):** Waiting until the due date or beyond increases the risk of placental insufficiency and stillbirth, which is statistically higher in patients with a prior history of intrauterine fetal death (IUFD). **Clinical Pearls for NEET-PG:** * **Monitoring:** In patients with prior stillbirth, antenatal surveillance (NST/BPP) usually commences at **32–36 weeks**. * **The "Rule of 39":** For most elective inductions or repeat C-sections without maternal/fetal complications, 39 weeks is the "magic number" to ensure optimal neonatal outcomes. * **Recurrence Risk:** The risk of stillbirth in a subsequent pregnancy is approximately 2–5 times higher than in the general population.

Q: What is the most common cause of fetal ventriculomegaly?

Aqueductal stenosis. **Explanation:** **Ventriculomegaly** is defined as an atrial width of the lateral ventricles ≥10 mm. It is a common prenatal ultrasound finding that necessitates a thorough evaluation of the fetal neuroanatomy. **Why Aqueductal Stenosis is the Correct Answer:** **Aqueductal stenosis** is the most common cause of congenital obstructive (non-communicating) hydrocephalus, accounting for approximately **33–43% of cases**. It involves a narrowing or obstruction of the Aqueduct of Sylvius, which connects the third and fourth ventricles. This leads to a characteristic "upstream" dilation of the lateral and third ventricles, while the fourth ventricle remains normal in size. **Analysis of Incorrect Options:** * **Arnold-Chiari Malformation II:** This is a common cause of ventriculomegaly, but it is almost always associated with **neural tube defects** (specifically myelomeningocele). While high-yield, it is statistically less frequent as a primary cause compared to isolated aqueductal stenosis. * **Arnold-Chiari Malformation I:** This involves downward displacement of the cerebellar tonsils. It is rarely diagnosed prenatally and is generally not a common cause of fetal ventriculomegaly. * **Dandy-Walker Malformation:** This involves agenesis/hypoplasia of the cerebellar vermis and cystic dilation of the **fourth ventricle**. While it causes hydrocephalus, it is less common than aqueductal stenosis. **NEET-PG High-Yield Pearls:** * **Normal Atrial Width:** 15 mm is severe/frank hydrocephalus). * **The "Dangling Choroid" Sign:** A classic sonographic feature where the choroid plexus falls toward the dependent wall of the dilated lateral ventricle. * **X-linked Hydrocephalus:** The most common heritable form of aqueductal stenosis (HSAS), associated with the *L1CAM* gene mutation and characterized by "thumb adduction."

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.

Question 1

In a patient with a history of a previous stillbirth, what is the optimum time for delivery?

Accepted Answer

39 weeks

Answer

37 weeks

Answer

38 weeks

Answer

40 weeks

Question 2

A primigravida presents at 36 weeks of gestation with preterm premature rupture of membranes or leaking per vaginum. What is the appropriate management?

Accepted Answer

Lower Segment Caesarean Section (LSCS)

Answer

External Cephalic Version (ECV)

Answer

Induction of labor

Answer

Internal Podalic Version (IPV)

Question 3

What is the most common cause of fetal ventriculomegaly?

Accepted Answer

Aqueductal stenosis

Answer

Arnold Chiari malformation I

Answer

Arnold Chiari malformation II

Answer

Dandy-Walker malformation

Question 4

Which is the most sensitive screening test for congenital malformations in diabetic mothers?

Accepted Answer

Glycosylated hemoglobin (HbA1C)

Answer

Maternal serum alpha-fetoprotein (MS AFP)

Answer

Blood glucose

Answer

Amniotic fluid alpha-fetoprotein (AFP)

Question 5

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 6

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 7

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 8

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 9

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 10

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

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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