Maternal-Fetal Medicine Practice Questions

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).

Q: A 36-year-old G1P0 woman presents for her first prenatal visit late in her first trimester of pregnancy; she complains of persistent vaginal bleeding, nausea, and pelvic pain. Physical examination is notable for a gravid uterus larger than expected for gestational age. Fetal heart tones are absent. Which of the following is most likely to be true?

Beta-hCG levels will be higher than normal. ### Explanation The clinical presentation—**vaginal bleeding, hyperemesis (nausea), pelvic pain, a uterus larger than dates, and absent fetal heart tones**—is a classic triad for **Molar Pregnancy (Hydatidiform Mole)**. **1. Why Option A is Correct:** In a hydatidiform mole, there is an abnormal proliferation of trophoblastic tissue. Since syncytiotrophoblasts produce human chorionic gonadotropin, the massive overgrowth leads to **markedly elevated Beta-hCG levels** (often >100,000 mIU/mL). These extreme levels are responsible for the exaggerated pregnancy symptoms like severe nausea (hyperemesis gravidarum) and the "snowstorm" appearance on ultrasound. **2. Why the Other Options are Incorrect:** * **Option B:** Lower than normal Beta-hCG is typically associated with ectopic pregnancies or impending miscarriages, not molar pregnancies. * **Option C:** In approximately 50% of molar pregnancies, the **uterus is larger than gestational age** due to the rapid proliferation of chorionic villi and accumulated intrauterine blood. * **Option D:** High levels of Beta-hCG can cross-react with the TSH receptor because they share a common alpha-subunit. This leads to a **thyrotoxic state**, resulting in **decreased TSH** and increased T3/T4 levels. **Clinical Pearls for NEET-PG:** * **Diagnosis:** Ultrasound is the gold standard, showing a **"Snowstorm appearance"** (complete mole) or "Swiss cheese" appearance. * **Theca Lutein Cysts:** High hCG can cause bilateral ovarian enlargement (Theca Lutein cysts). * **Complication:** Patients are at risk for early-onset **Preeclampsia** (occurring before 20 weeks gestation). * **Management:** Suction and evacuation followed by serial Beta-hCG monitoring to rule out Gestational Trophoblastic Neoplasia (GTN).

Q: In hydrops foetalis, what is the earliest sonographic sign observed?

Skin edema. **Explanation:** **Hydrops Foetalis** is defined as the abnormal accumulation of fluid in two or more fetal compartments (e.g., ascites, pleural effusion, pericardial effusion, or skin edema). It is often associated with polyhydramnios and placental thickening. **Why Skin Edema is the Correct Answer:** Among the sonographic markers of hydrops, **skin edema (anasarca)** is traditionally considered the **earliest sign**. It is defined as a skin thickness of **>5 mm**. The physiological basis lies in the initial increase in hydrostatic pressure or decrease in oncotic pressure within the fetal subcutaneous tissues, which manifests before significant fluid collection occurs in the serous cavities. **Analysis of Incorrect Options:** * **Ascites (B):** While ascites is often the most *easily* recognized sign and frequently the first sign of fluid in the *serous cavities*, it typically appears after the initial subcutaneous changes. * **Pericardial Effusion (A):** This is often a later finding. A small amount of fluid in the pericardium (up to 2 mm) can be physiological in a normal fetus; therefore, it is not a reliable early marker. * **Pleural Effusion (C):** This usually develops after ascites and skin edema as the hydrostatic pressure continues to rise or lymphatic drainage fails. **NEET-PG High-Yield Pearls:** * **Definition:** Fluid in $\geq$ 2 fetal compartments. * **Most common cause (Worldwide):** Non-immune hydrops (e.g., chromosomal anomalies like Turner syndrome, cardiovascular defects). * **Immune Hydrops:** Most commonly due to Rh isoimmunization. * **Mirror Syndrome:** A rare condition where the mother "mirrors" the fetal hydrops, developing edema and preeclampsia-like symptoms. * **Diagnostic Threshold:** Skin thickness >5 mm and placental thickness >4 cm are key sonographic criteria.

Q: What is the management for a patient presenting with central placenta previa at 37 weeks of gestation?

Elective cesarean section. **Explanation:** **1. Why Option B is Correct:** Central (Type IV/Total) placenta previa occurs when the placenta completely covers the internal os. At 37 weeks, the fetus is considered full-term. In central placenta previa, vaginal delivery is physically impossible and life-threatening due to the risk of catastrophic maternal hemorrhage as the cervix dilates. Therefore, an **elective cesarean section** is the definitive management once fetal maturity is reached (typically scheduled between 36-37 weeks) to prevent spontaneous labor or bleeding. **2. Why Other Options are Incorrect:** * **Option A:** Vaginal delivery is contraindicated in central placenta previa. Artificial rupture of membranes (ARM) is only considered in low-lying placenta (Type I) where the fetal head can compress the placental edge to control bleeding. * **Option C:** Waiting for bleeding to start is dangerous. Management aims to be proactive; emergency surgery carries higher morbidity than an elective, controlled procedure. * **Option D:** Conservative management (Macafee-Johnson regime) is indicated only for preterm patients (<37 weeks) who are hemodynamically stable, to gain fetal maturity. At 37 weeks, there is no benefit to further delay. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) is safer and more accurate than transabdominal ultrasound for locating the placental edge. * **The "Double Setup" Examination:** Only performed in the OT for borderline cases (Type I/II anterior); it is strictly contraindicated in known central previa. * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pressed into the pelvis, seen in posterior placenta previa. * **Warning Hemorrhage:** The first episode of bleeding in placenta previa is usually painless, causeless, and recurrent.

Question 1

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 2

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 3

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

Accepted Answer

Nevirapine

Answer

Lamivudine

Answer

Stavudine

Answer

Abacavir

Question 4

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 5

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 6

Which of the following describes a dangerous placenta?

Accepted Answer

Type II posterior

Answer

Type I

Answer

Type II anterior

Answer

Type III

Question 7

A 36-year-old G1P0 woman presents for her first prenatal visit late in her first trimester of pregnancy; she complains of persistent vaginal bleeding, nausea, and pelvic pain. Physical examination is notable for a gravid uterus larger than expected for gestational age. Fetal heart tones are absent. Which of the following is most likely to be true?

Accepted Answer

Beta-hCG levels will be higher than normal

Answer

Beta-hCG levels will be lower than normal

Answer

Uterus will be of normal size for gestational age

Answer

TSH levels will be increased

Question 8

Which of the following statements about the placenta is NOT true?

Accepted Answer

At term, approximately four-fifths of the placenta is of maternal origin.

Answer

The number of cotyledons increases with gestational age.

Answer

The weight of the fetus and placenta are approximately equal at 4 months of gestation.

Answer

After delivery, the weight of the placenta is typically around 500 gm.

Question 9

In hydrops foetalis, what is the earliest sonographic sign observed?

Accepted Answer

Skin edema

Answer

Pericardial effusion

Answer

Ascites

Answer

Pleural effusion

Question 10

What is the management for a patient presenting with central placenta previa at 37 weeks of gestation?

Accepted Answer

Elective cesarean section

Answer

Vaginal delivery with artificial rupture of membranes

Answer

Cesarean section when bleeding starts

Answer

Conservative management and wait until 38 weeks of gestation

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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