Maternal-Fetal Medicine Practice Questions

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 It is a classic high-yield finding in obstetric imaging, though it has largely been replaced by ultrasound in modern practice.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).

Q: During her eighth month of pregnancy, a 29-year-old woman is noted to have polyhydramnios. Further testing shows anencephaly. Polyhydramnios in this patient is caused by which of the following?

Impairment of the fetus's swallowing mechanism. **Explanation:** **Why Option A is correct:** Amniotic fluid volume is maintained by a delicate balance between production (fetal urine and lung fluid) and clearance (fetal swallowing and intramembranous absorption). In a normal pregnancy, the fetus swallows approximately 500–700 ml of amniotic fluid daily, which is then absorbed through the gastrointestinal tract. **Anencephaly**, a neural tube defect, results in the absence of a major portion of the brain and skull. This leads to a lack of the neural control required for the **swallowing reflex**. Additionally, the exposed area cerebrovasculosa may cause transudation of fluid, but the primary mechanism for polyhydramnios in these cases is the failure of the fetus to swallow and process the fluid. **Why incorrect options are wrong:** * **Option B:** While intracranial tumors can occur, anencephaly is a defect of "absence" (failure of cranial neuropore closure) rather than a space-occupying lesion. * **Option C:** There is no known placental secretory peptide that significantly increases amniotic fluid volume to the level of polyhydramnios. * **Option D:** Excess ADH (Antidiuretic Hormone) would lead to *decreased* fetal urine production, which would cause **oligohydramnios**, not polyhydramnios. **High-Yield Clinical Pearls for NEET-PG:** * **Common causes of Polyhydramnios:** Fetal anomalies (Anencephaly, Esophageal/Duodenal atresia), Maternal Diabetes, and Rh-isoimmunization. * **Amniotic Fluid Index (AFI):** Polyhydramnios is defined as an AFI > 24–25 cm or a Single Deepest Pocket (SDP) > 8 cm. * **Anencephaly Screening:** Elevated Maternal Serum Alpha-Fetoprotein (MSAFP) and "frog-eye" appearance on ultrasound. * **Therapeutic Management:** If symptomatic, medicinal management includes Indomethacin (reduces fetal urine) or therapeutic amniocentesis (amniodrainage).

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.

Question 1

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 2

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 3

In a patient with sickle cell anaemia, blood transfusion is indicated in which of the following conditions?

Accepted Answer

All of the above

Answer

Frequent sickling episodes

Answer

Twin pregnancy

Answer

Poor obstetrical outcome

Question 4

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 5

During her eighth month of pregnancy, a 29-year-old woman is noted to have polyhydramnios. Further testing shows anencephaly. Polyhydramnios in this patient is caused by which of the following?

Accepted Answer

Impairment of the fetus's swallowing mechanism

Answer

Tumor of the fetus's brain

Answer

A secretory peptide from the placenta

Answer

Excess antidiuretic hormone (ADH) from the fetus

Question 6

What is the most common cause of multiple fetal anomalies?

Accepted Answer

Rubella

Answer

Syphilis

Answer

Tetracycline

Answer

Rubeola

Question 7

Ectopic pregnancy is most common in which of the following conditions?

Accepted Answer

Previous history of recurrent pelvic inflammatory disease (PID)

Answer

Previous history of abortion

Answer

Previous history of twin pregnancy

Answer

Endometriosis

Question 8

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 9

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 10

What is the commonest congenital malformation in an infant of a diabetic mother?

Accepted Answer

Anencephaly

Answer

Neural tube defect

Answer

Hydrocephalus

Answer

Sacral agenesis

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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