Maternal-Fetal Medicine Practice Questions

Q: All of the following are true of placenta previa except?

Premature labor is common.. **Explanation:** Placenta previa occurs when the placenta implants in the lower uterine segment, partially or completely covering the internal os. **Why Option C is the correct answer (The False Statement):** Contrary to common belief, **premature labor is actually infrequent** in placenta previa. While "preterm delivery" is very common, it is usually **iatrogenic** (physician-induced) due to heavy bleeding necessitating emergency delivery, rather than spontaneous onset of labor. The lower segment is passive, and the presence of the placenta there does not typically trigger the biochemical cascade of labor. **Analysis of Incorrect Options (True Statements):** * **Option A:** Postpartum hemorrhage (PPH) is a major risk. The lower uterine segment is less muscular and lacks the "living ligatures" (interlocking muscle fibers) found in the fundus. Consequently, it cannot contract effectively to compress vessels after placental separation. * **Option B:** While the classic presentation is painless bleeding in the third trimester (warning hemorrhage), early "threatened abortion" or first-trimester spotting is not uncommon due to the low implantation. * **Option C:** There is a strong correlation between a scarred uterus (previous LSCS or myomectomy) and placenta previa. The risk increases linearly with the number of previous cesarean sections. **NEET-PG High-Yield Pearls:** * **Classic Presentation:** Painless, causative, recurrent, bright red vaginal bleeding. * **Stallworthy’s Sign:** Posterior placenta previa prevents the head from engaging, causing the fetal heart rate to drop when the head is pushed into the pelvis (due to cord compression). * **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the gold standard (safer and more accurate than transabdominal). * **Contraindication:** **Never** perform a per-vaginal (PV) examination in a suspected case of placenta previa, as it can provoke torrential hemorrhage.

Q: What is the most common cause of multiple fetal anomalies?

Rubella. **Explanation:** **Rubella (German Measles)** is the correct answer because it is a potent teratogen known for causing **Congenital Rubella Syndrome (CRS)**. When infection occurs during the first trimester (the period of organogenesis), the virus causes chronic focal destruction of developing cells, leading to a classic triad of anomalies: **Cataracts, Sensorineural deafness, and Congenital Heart Disease** (most commonly Patent Ductus Arteriosus). Because it affects multiple organ systems simultaneously (eyes, ears, heart, and CNS), it is the most common infectious cause of multiple fetal anomalies. **Why other options are incorrect:** * **Syphilis:** Caused by *Treponema pallidum*, it typically presents with features like snuffles, Hutchinson’s teeth, and hepatosplenomegaly. However, it is generally considered a "late" fetal infection (usually manifesting after the 16th week) rather than a cause of early structural malformations. * **Tetracycline:** This is a drug-induced teratogen. Its primary effect is localized to the **calcification of teeth** (discoloration) and inhibition of bone growth. It does not typically cause a wide spectrum of "multiple" structural anomalies. * **Rubeola (Measles):** While it can cause maternal morbidity and is associated with an increased risk of miscarriage or preterm labor, the Rubeola virus is **not teratogenic** and does not cause structural fetal malformations. **High-Yield Clinical Pearls for NEET-PG:** * **Gregg’s Triad:** Cataract, Deafness, and Cardiac defects (PDA). * **Timing:** The risk of fetal malformation is highest (up to 80%) if the infection occurs within the first 12 weeks of gestation. * **Blueberry Muffin Rash:** A characteristic neonatal presentation of CRS due to extramedullary hematopoiesis. * **Vaccination:** Rubella is a live attenuated vaccine (RA 27/3); it is **contraindicated during pregnancy**, and pregnancy should be avoided for 1 month post-vaccination.

Q: A 15 cms X 15 cms ovarian cyst has been diagnosed in an 8-week pregnant lady. What is the recommended further management?

Laparotomy at 14-16 weeks. ### Explanation **1. Why Option B is Correct:** The management of an ovarian cyst in pregnancy depends on its size, symptoms, and gestational age. A cyst measuring **15 cm** is considered large (typically >6 cm is the threshold for concern). Large cysts carry a high risk of **torsion, rupture, or labor obstruction**. The ideal time for surgery is the **early second trimester (14–16 weeks)** because: * **Organogenesis is complete**, reducing teratogenic risk from anesthesia. * The **placenta has taken over progesterone production**, so removing the corpus luteum (if necessary) will not cause miscarriage. * The uterus is not yet large enough to technically hinder the surgery, unlike in the third trimester. **2. Why Other Options are Incorrect:** * **Option A:** Follow-up is only appropriate for small (<6 cm), simple, asymptomatic cysts (likely functional), which often regress. A 15 cm cyst is unlikely to regress and poses a high risk of complications. * **Option C & D:** Waiting until term or postpartum is dangerous. As the uterus grows, the risk of **adnexal torsion** increases significantly. Furthermore, a 15 cm cyst in the pelvis can cause **soft tissue dystocia**, necessitating an emergency Cesarean section, which is riskier than elective mid-trimester surgery. **3. Clinical Pearls for NEET-PG:** * **Most common ovarian cyst in pregnancy:** Corpus luteal cyst (usually regresses by 12–14 weeks). * **Most common benign tumor in pregnancy:** Mature cystic teratoma (Dermoid). * **Most common complication:** Torsion (most frequent in the 1st trimester or early puerperium). * **Surgical approach:** While laparotomy is the traditional answer, **laparoscopy** is now considered safe and preferred in the second trimester by experienced surgeons.

Q: What is the blood pressure reading in severe pregnancy-induced hypertension (PIH)?

160/110 mm Hg. **Explanation:** Pregnancy-Induced Hypertension (PIH), specifically Preeclampsia, is defined as new-onset hypertension (BP ≥140/90 mm Hg) after 20 weeks of gestation. The classification into "Severe" features is critical for clinical management and timing of delivery. **1. Why Option A is Correct:** According to ACOG and NHBPEP guidelines, **Severe Hypertension** in pregnancy is defined as a Systolic Blood Pressure (SBP) **≥160 mm Hg** and/or a Diastolic Blood Pressure (DBP) **≥110 mm Hg**, measured on two occasions at least 4 hours apart (unless antihypertensive therapy is initiated sooner). This threshold is used because pressures above this level significantly increase the risk of maternal cerebrovascular accidents (stroke) and placental abruption. **2. Analysis of Incorrect Options:** * **Option B (150/100 mm Hg):** This falls under the category of "Mild to Moderate" hypertension (SBP 140–159 or DBP 90–109 mm Hg). While abnormal, it does not meet the criteria for severe PIH. * **Option C (260/100 mm Hg):** While the systolic value is dangerously high, this is not the standard diagnostic threshold for defining the onset of severe PIH. * **Option D (120/80 mm Hg):** This represents a normal physiological blood pressure reading in a healthy adult. **3. NEET-PG High-Yield Pearls:** * **Proteinuria:** No longer mandatory for the diagnosis of Preeclampsia if other "Severe Features" (thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral/visual symptoms) are present. * **Drug of Choice (Acute Crisis):** Intravenous Labetalol or Hydralazine. * **Drug of Choice (Seizure Prophylaxis):** Magnesium Sulfate ($MgSO_4$) is the gold standard for preventing eclampsia in severe PIH. * **Definitive Treatment:** Delivery of the fetus and placenta.

Q: What is the most common cause of perinatal mortality in twins?

Prematurity. **Explanation:** **Prematurity (Option C)** is the single most common cause of perinatal morbidity and mortality in twin gestations. Approximately 50–60% of twin pregnancies result in preterm birth (before 37 weeks), compared to only 10% in singletons. The primary driver is uterine overdistension, which triggers early labor or premature rupture of membranes (PROM). Complications arising from prematurity—such as Respiratory Distress Syndrome (RDS), intraventricular hemorrhage, and necrotizing enterocolitis—account for the majority of neonatal deaths. **Analysis of Incorrect Options:** * **Single fetal demise (Option A):** While it increases the risk of neurological damage or death in the surviving twin (especially in monochorionic twins), it is statistically less common than complications from early delivery. * **Twin-to-Twin Transfusion Syndrome (TTTS) (Option B):** This is a serious complication unique to monochorionic diamniotic (MCDA) twins. While it has a high mortality rate if untreated, it only affects about 10–15% of monochorionic pregnancies, making it less frequent than prematurity overall. * **Intrauterine Growth Restriction (IUGR) (Option D):** Twins are at higher risk for growth restriction due to placental insufficiency or unequal sharing. While IUGR increases vulnerability, prematurity remains the leading cause of death. **High-Yield Clinical Pearls for NEET-PG:** * **Average duration of pregnancy:** Singletons (40 weeks), Twins (37 weeks), Triplets (33 weeks). * **Most common complication of twins:** Prematurity. * **Most common type of twins:** Dizygotic (70-80%). * **Vanishing Twin Syndrome:** Death of one fetus in the first trimester (occurs in ~20% of twin pregnancies). * **Bed rest:** Routine hospitalization or bed rest does *not* prevent preterm labor in twins and is not recommended.

Q: A 35-year-old multiparous lady at 30 weeks gestation presents with sudden onset painless vaginal bleeding. Ultrasound shows the following:

Placenta previa. ***Placenta previa*** - **Painless vaginal bleeding** at 30 weeks gestation is the classic presentation of placenta previa, where the placenta covers or lies close to the **internal cervical os**. - Ultrasound would show the **placental edge covering the internal os**, confirming the diagnosis and explaining the bleeding mechanism during cervical changes. *Abruption placenta* - Characterized by **painful vaginal bleeding** with **uterine contractions** and tenderness, unlike the painless nature described here. - Ultrasound typically shows a **retroplacental hematoma** or **placental separation**, not placental positioning over the cervical os. *Vasa previa* - Involves **fetal blood vessels** crossing the **internal os** ahead of the presenting part, causing **fetal blood loss** rather than maternal bleeding. - Diagnosed by **color Doppler ultrasound** showing vessels over the cervical os, and would present with **fetal distress** and **sinusoidal fetal heart rate pattern**. *Sub-amniotic cyst* - Represents an **incidental finding** of a small cyst within the **amniotic cavity** that does not cause vaginal bleeding. - This is a **benign condition** with no clinical significance and would not explain the acute presentation of bleeding.

Q: Which of the statements is FALSE regarding acute fatty liver of pregnancy?

More commonly seen in women with a female fetus.. **Explanation:** Acute Fatty Liver of Pregnancy (AFLP) is a rare but life-threatening obstetric emergency characterized by microvesicular steatosis of the liver. **1. Why Option C is the correct (False) statement:** AFLP is actually more commonly associated with a **male fetus**, not a female fetus. While the exact reason is not fully understood, it is a high-yield epidemiological association frequently tested in PG exams. **2. Analysis of other options:** * **Option A (True):** AFLP is strongly linked to a fetal deficiency of the enzyme **Long-Chain 3-Hydroxyacyl-CoA Dehydrogenase (LCHAD)**. If the fetus is homozygous for this deficiency, they cannot oxidize fatty acids, leading to accumulation in the maternal circulation. Postnatally, these neonates are at high risk for hepatic failure, cardiomyopathy, and fatty infiltration of the liver. * **Option B (True):** AFLP typically manifests in the **late third trimester** (usually between 30–38 weeks) or the immediate postpartum period. * **Option C (True):** Hyperuricemia is a common laboratory finding in AFLP, often occurring early due to decreased renal clearance, even before significant elevations in creatinine or transaminases. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Liver biopsy (shows microvesicular fat), but rarely done as diagnosis is usually clinical. * **Clinical Criteria:** **Swansea Criteria** are used for diagnosis (requires ≥6 of 14 clinical/biochemical findings). * **Key Lab Findings:** Hypoglycemia (severe), elevated ammonia, prolonged PT/INR, and hyperbilirubinemia. * **Management:** Immediate stabilization and **expeditious delivery**, regardless of gestational age. It does not recur in subsequent pregnancies unless the LCHAD mutation is present.

Q: Which of the following findings can be seen during clinical examination of a pregnant female with heart disease compared to a normal pregnancy?

Engorged neck veins. In clinical practice, distinguishing between the physiological changes of pregnancy and pathological signs of heart disease is a common challenge. ### **Why "Engorged Neck Veins" is the Correct Answer** In a normal pregnancy, despite an increase in blood volume (up to 50%), the **Jugular Venous Pressure (JVP)** remains normal because the venous system accommodates the extra volume through vasodilation. Therefore, **engorged neck veins (elevated JVP)** or a sustained hepatojugular reflux are always pathological and indicate right-sided heart failure or fluid overload. ### **Why Other Options are Incorrect** * **Pedal Edema (A):** This is a common physiological finding in late pregnancy due to the compression of the inferior vena cava by the gravid uterus and sodium/water retention. It is not specific to heart disease. * **Dyspnea (C):** "Physiological dyspnea" occurs in about 75% of normal pregnancies. It is caused by the hyperventilation effect of **progesterone** (which increases sensitivity to CO2) and the upward displacement of the diaphragm. * **Exercise Intolerance (D):** Normal pregnant women experience a decrease in exercise tolerance due to increased body weight, altered center of gravity, and increased oxygen demand. ### **High-Yield Clinical Pearls for NEET-PG** * **Normal findings in pregnancy that mimic heart disease:** S3 gallop (due to rapid ventricular filling), soft systolic murmur (Grade I/II ejection systolic), and laterally displaced apex beat. * **Definitive signs of Heart Disease in pregnancy:** 1. Diastolic murmur (Always pathological). 2. Continuous murmur (unless it is a mammary souffle). 3. Loud/Harsh Systolic murmur (Grade III or higher). 4. Persistent orthopnea or paroxysmal nocturnal dyspnea (PND). 5. Cardiac arrhythmias or fixed split S2. * **Most common heart disease in pregnancy (India):** Rheumatic Heart Disease (Mitral Stenosis is the most common lesion).

Q: Which of the following is not a criterion for antenatal diagnosis of Twin-Twin transfusion syndrome?

Dichorionicity. ### Explanation **1. Why Dichorionicity is the Correct Answer:** Twin-Twin Transfusion Syndrome (TTTS) is a complication exclusive to **Monochorionic (MC)** twins. It occurs due to unbalanced blood flow through deep arteriovenous anastomoses in a single shared placenta. In **Dichorionic** twins, each fetus has its own separate placenta; therefore, vascular communications do not exist, making TTTS physiologically impossible. Thus, dichorionicity is an exclusion criterion, not a diagnostic one. **2. Analysis of Incorrect Options:** * **Oligohydramnios in donor fetus (Option A):** This is a hallmark diagnostic criterion. The donor twin suffers from hypovolemia and decreased renal perfusion, leading to oligohydramnios (Maximum Vertical Pocket 8 cm). * **Hemoglobin difference (Option C):** While modern antenatal diagnosis relies primarily on ultrasound (Quintero stages), a significant hemoglobin discrepancy (> 5 g/dL) is a classic postnatal finding used to confirm the diagnosis of chronic transfusion. * **Weight difference (Option D):** Selective Fetal Growth Restriction (sFGR) often coexists with TTTS. A weight discordance of > 20% is a common clinical feature used to support the diagnosis of unequal nutrient distribution between the twins. **3. High-Yield Clinical Pearls for NEET-PG:** * **Quintero Staging:** Used to grade TTTS severity (Stage I: Poly/Oli; Stage II: Absent bladder in donor; Stage III: Abnormal Dopplers; Stage IV: Hydrops; Stage V: Death). * **Gold Standard Treatment:** Fetoscopic Laser Photocoagulation of placental anastomoses (best performed between 16–26 weeks). * **Stuck Twin Phenomenon:** Refers to the donor twin being "shrink-wrapped" against the uterine wall due to severe oligohydramnios. * **Most Common Type of Twins:** Dizygotic (always Dichorionic). TTTS only occurs in Monozygotic twins that result in a Monochorionic Diamniotic (MCDA) pregnancy.

Question 1

Which of the following is a grave prognostic factor in a woman with pre-eclampsia?

Accepted Answer

Serum creatinine >1.4 mg/dL

Answer

Remission for 6 months

Answer

24-h urine protein excretion < 2.6 g

Answer

All of the above

Question 2

All of the following are true of placenta previa except?

Accepted Answer

Premature labor is common.

Answer

Postpartum hemorrhage is infrequent.

Answer

First-trimester bleeding is not uncommon.

Answer

Higher incidence in women with lower segment cesarean section.

Question 3

What is the most common cause of multiple fetal anomalies?

Accepted Answer

Rubella

Answer

Syphilis

Answer

Tetracycline

Answer

Rubeola

Question 4

A 15 cms X 15 cms ovarian cyst has been diagnosed in an 8-week pregnant lady. What is the recommended further management?

Accepted Answer

Laparotomy at 14-16 weeks

Answer

Only follow up without surgical intervention

Answer

Cesarean delivery and ovariotomy at term

Answer

Surgery after delivery

Question 5

What is the blood pressure reading in severe pregnancy-induced hypertension (PIH)?

Accepted Answer

160/110 mm Hg

Answer

150/100 mm Hg

Answer

260/100 mm Hg

Answer

120/80 mm Hg

Question 6

What is the most common cause of perinatal mortality in twins?

Accepted Answer

Prematurity

Answer

Single fetal demise

Answer

Twin to twin transfusion syndrome

Answer

Intrauterine growth restriction

Question 7

A 35-year-old multiparous lady at 30 weeks gestation presents with sudden onset painless vaginal bleeding. Ultrasound shows the following:

Accepted Answer

Placenta previa

Answer

Abruption placenta

Answer

Vasa previa

Answer

Sub-amniotic cyst

Question 8

Which of the statements is FALSE regarding acute fatty liver of pregnancy?

Accepted Answer

More commonly seen in women with a female fetus.

Answer

The neonate is at risk of fatty infiltration of liver.

Answer

More commonly occurs in 3rd trimester.

Answer

May be associated with hyperuricemia.

Question 9

Which of the following findings can be seen during clinical examination of a pregnant female with heart disease compared to a normal pregnancy?

Accepted Answer

Engorged neck veins

Answer

Pedal edema

Answer

Dyspnea

Answer

Exercise intolerance

Question 10

Which of the following is not a criterion for antenatal diagnosis of Twin-Twin transfusion syndrome?

Accepted Answer

Dichorionicity

Answer

Oligohydramnios in donor fetus

Answer

Hemoglobin difference of > 5 g/dL between the two fetuses

Answer

Weight difference of > 20% between the two fetuses

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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