Maternal-Fetal Medicine Practice Questions

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.

Q: Which drug is given to prevent vertical transmission of HIV from mother to child?

Nevirapine. **Explanation:** The prevention of mother-to-child transmission (PMTCT) of HIV is a high-yield topic for NEET-PG. **Nevirapine**, a Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI), is the drug of choice for prophylaxis in newborns. **Why Nevirapine is correct:** Nevirapine is highly effective because it has a long half-life and rapidly crosses the placenta. In the standard WHO/NACO protocol, a single dose of Nevirapine is administered to the infant immediately after birth (within 72 hours) to prevent vertical transmission during the intrapartum and early postpartum period. For the mother, the current "Option B+" strategy involves a lifelong Triple ART regimen (Tenofovir + Lamivudine + Efavirenz), but Nevirapine remains the classic answer for infant prophylaxis. **Why other options are incorrect:** * **Lamivudine (3TC):** While used as part of the mother’s triple-drug ART regimen, it is not typically used as a standalone prophylactic agent for the neonate unless in specific dual-therapy scenarios. * **Stavudine (d4T):** This drug is largely phased out of modern protocols due to significant mitochondrial toxicity and lipodystrophy. * **Abacavir (ABC):** Used in pediatric HIV treatment, but not used for immediate post-exposure prophylaxis in newborns due to the risk of hypersensitivity reactions (linked to HLA-B*5701). **Clinical Pearls for NEET-PG:** * **Most common route of transmission:** Intrapartum (during labor/delivery). * **Best method to reduce transmission:** Elective Cesarean Section (if viral load >1000 copies/mL) and avoiding breastfeeding. * **Infant Prophylaxis duration:** Usually 6 weeks of daily Nevirapine. * **Diagnosis in infants:** DNA-PCR is the gold standard (Antibody tests like ELISA are unreliable until 18 months due to maternal antibodies).

Q: Hypertension, proteinuria, and pitting edema are noted in the second month of the first pregnancy in a 25-year-old woman. The pathogenesis of her presenting complaints is most closely associated with which of the following?

A benign tumor of the chorionic villi. **Explanation:** The clinical triad of **hypertension, proteinuria, and edema** (Preeclampsia) occurring in the **first half of pregnancy** (before 20 weeks) is a classic diagnostic hallmark for a **Hydatidiform Mole** (molar pregnancy). **1. Why Option A is Correct:** A hydatidiform mole is a **benign tumor of the chorionic villi** characterized by trophoblastic proliferation and hydropic degeneration of the villi. While preeclampsia typically occurs after 20 weeks of gestation, its appearance in the first or early second trimester (as seen in this 25-year-old patient at two months) strongly suggests gestational trophoblastic disease (GTD). The pathogenesis involves abnormal placental development and excessively high levels of hCG, which are thought to trigger early-onset preeclamptic features. **2. Why the other options are incorrect:** * **Option B (Gestational Diabetes):** While GDM increases the risk of preeclampsia later in pregnancy, it does not cause early-onset hypertension in the second month. * **Options C & D (Primary Endometrial Cancer):** Endometrial cancer is rare in a 25-year-old and typically presents with abnormal uterine bleeding, not the systemic signs of preeclampsia or a positive pregnancy state. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of Thumb:** Preeclampsia before 20 weeks = **Think Hydatidiform Mole** until proven otherwise. * **Diagnostic Investigation:** The gold standard is an **Ultrasound**, which reveals a characteristic **"Snowstorm appearance"** and absence of a fetus (in complete mole). * **Biochemical Marker:** Markedly elevated **serum β-hCG** levels (often >100,000 mIU/mL) are characteristic. * **Other Early-Onset Preeclampsia Causes:** Apart from molar pregnancy, consider Systemic Lupus Erythematosus (SLE) or Antiphospholipid Syndrome (APLS).

Question 1

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 2

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 3

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 4

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

Question 5

A 38-year-old woman is in her first pregnancy, which has been uneventful until the 34th week, when she develops swelling of feet and hands. An obstetric check-up reveals that she also has hypertension and proteinuria. Laboratory analysis shows elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) and slightly decreased platelets. What is the initial event in the pathogenesis of her condition?

Accepted Answer

Placental ischemia

Answer

Chorioamnionitis

Answer

Disseminated intravascular coagulation

Answer

Maternal hypertension

Question 6

All of the following are true of placenta previa EXCEPT:

Accepted Answer

Postpartum hemorrhage is infrequent

Answer

First-trimester bleeding is not uncommon

Answer

Premature labor is common

Answer

Malposition and malpresentation are common

Question 7

Which drug is given to prevent vertical transmission of HIV from mother to child?

Accepted Answer

Nevirapine

Answer

Lamivudine

Answer

Stavudine

Answer

Abacavir

Question 8

Ventricular function improves with pregnancy in which of the following conditions?

Accepted Answer

Mitral insufficiency

Answer

Mitral stenosis

Answer

Aortic stenosis

Answer

Pulmonary stenosis

Question 9

Hypertension, proteinuria, and pitting edema are noted in the second month of the first pregnancy in a 25-year-old woman. The pathogenesis of her presenting complaints is most closely associated with which of the following?

Accepted Answer

A benign tumor of the chorionic villi

Answer

Gestational diabetes mellitus

Answer

Primary endometrial cancer

Answer

Primary endometrial cancer

Question 10

Which of the following describes a dangerous placenta?

Accepted Answer

Type II posterior

Answer

Type I

Answer

Type II anterior

Answer

Type III

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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