Maternal-Fetal Medicine Practice Questions

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.

Q: What is the recommended time for termination of pregnancy in a female with type 1 diabetes controlled with insulin?

37+ weeks. **Explanation:** The management of a pregnant woman with Type 1 Diabetes Mellitus (T1DM) requires a delicate balance between ensuring fetal lung maturity and preventing the risk of late-gestational complications, such as stillbirth and macrosomia. **Why 37+ weeks is correct:** In women with pre-gestational diabetes (Type 1 or Type 2) that is well-controlled with insulin, the current clinical guidelines (ACOG and FIGO) recommend delivery between **37 weeks 0 days and 38 weeks 6 days**. Delivery during the early term period (37+ weeks) is preferred because the risk of intrauterine fetal death (IUFD) increases significantly after 39 weeks due to placental insufficiency and metabolic complications, while fetal lung maturity is generally achieved by this stage. **Why the other options are incorrect:** * **A. 40 weeks:** Waiting until the due date (full term) is avoided in insulin-dependent diabetics due to the high risk of placental aging, sudden fetal demise, and shoulder dystocia from macrosomia. * **B. 32 weeks & D. 34 weeks:** These represent preterm deliveries. Unless there is an acute maternal or fetal indication (e.g., severe preeclampsia, non-reassuring fetal heart rate, or vasculopathy), delivery this early is avoided to prevent complications of prematurity like Respiratory Distress Syndrome (RDS). **High-Yield Clinical Pearls for NEET-PG:** * **Poorly Controlled Diabetes:** If there is poor glycemic control or vascular complications (nephropathy/retinopathy), delivery is often considered earlier, between **34 0/7 and 36 6/7 weeks**. * **Gestational Diabetes (GDM):** If controlled on diet, delivery can wait until **39–40+6 weeks**. If controlled on drugs/insulin, deliver at **39+ weeks**. * **Steroid Cover:** If delivery is planned before 37 weeks, antenatal corticosteroids are indicated to accelerate lung maturity, though they require strict insulin adjustment due to hyperglycemia.

Q: Which of the following is NOT a cause of intrauterine growth retardation?

Gestational diabetes. **Explanation** Intrauterine Growth Retardation (IUGR) occurs when there is a restriction in the delivery of oxygen and nutrients to the fetus, leading to a failure to reach its biological growth potential. **Why Gestational Diabetes (GDM) is the correct answer:** In GDM, maternal hyperglycemia leads to fetal hyperglycemia. This stimulates the fetal pancreas to secrete excess insulin (**fetal hyperinsulinemia**). Since insulin is a potent anabolic hormone (growth promoter), it typically results in **fetal macrosomia** (large for gestational age) rather than growth retardation. *Note: IUGR in diabetes is only seen in long-standing Pre-gestational Diabetes with established vasculopathy (White’s Class D, F, R).* **Analysis of incorrect options:** * **Severe Anemia:** Leads to reduced oxygen-carrying capacity of maternal blood, causing chronic fetal hypoxia and subsequent growth restriction. * **Pregnancy-Induced Hypertension (PIH):** This is the most common cause of IUGR. It causes vasospasm and pathological changes in the placental spiral arteries, leading to **uteroplacental insufficiency**. * **Maternal Heart Disease:** Conditions (especially cyanotic heart disease) result in chronic maternal hypoxemia and reduced cardiac output, limiting nutrient transfer to the fetus. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of IUGR:** Uteroplacental insufficiency (often due to PIH). * **Symmetrical IUGR:** Usually due to early insults like chromosomal anomalies or TORCH infections (Ponderal index is normal). * **Asymmetrical IUGR:** Usually due to placental insufficiency (Head sparing effect; Ponderal index is low). * **GDM Complications:** Macrosomia, shoulder dystocia, neonatal hypoglycemia, and polyhydramnios.

Q: Which of the following has been proved to be effective in the management of preeclampsia?

Magnesium. **Explanation:** The correct answer is **Magnesium (Magnesium Sulfate/MgSO₄)**. In the context of preeclampsia, Magnesium Sulfate is the **drug of choice** for the prevention and treatment of seizures (eclampsia). Its primary mechanism involves blocking NMDA receptors in the brain, raising the seizure threshold, and causing cerebral vasodilation to reduce ischemia. Large-scale clinical trials, such as the **Magpie Trial**, conclusively proved that MgSO₄ reduces the risk of eclampsia by more than 50% in women with severe preeclampsia. **Analysis of Incorrect Options:** * **Zinc:** While some studies have explored the role of trace elements in pregnancy, there is no robust clinical evidence to suggest that zinc supplementation is effective in managing or treating preeclampsia. * **Calcium:** Calcium supplementation (1.5–2g/day) is recommended by the WHO for the **prevention** of preeclampsia in populations with low dietary calcium intake. However, it is not used for the **management** (treatment) of the condition once it has developed. **NEET-PG High-Yield Pearls:** * **Therapeutic Level of MgSO₄:** 4–7 mEq/L (or 4.8–8.4 mg/dL). * **Toxicity Sequence:** Loss of patellar reflex (8–10 mEq/L) → Respiratory depression (12 mEq/L) → Cardiac arrest (>25 mEq/L). * **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (administered over 10 minutes). * **Monitoring:** Before each dose, ensure: Respiratory rate >12/min, Patellar reflex present, and Urine output >30 ml/hr (as MgSO₄ is excreted solely by the kidneys).

Q: A woman with no history of prenatal care is about to deliver a baby. She has no history of amniotic rupture, and ultrasound showed severe oligohydramnios. Which of the following conditions can be a cause of oligohydramnios?

Renal agenesis. **Explanation:** The volume of amniotic fluid is a dynamic balance between production and clearance. From the second trimester onwards, **fetal urine** becomes the primary source of amniotic fluid, while fetal swallowing is the main route of clearance. **1. Why Renal Agenesis is Correct:** In cases of bilateral renal agenesis (Potter’s Syndrome), the fetus fails to produce urine. Since fetal micturition is the major contributor to the amniotic pool after 16 weeks of gestation, its absence leads to **severe oligohydramnios**. This lack of fluid often results in pulmonary hypoplasia and characteristic facial deformities due to uterine pressure. **2. Why the Incorrect Options are Wrong:** * **Anencephaly:** This neural tube defect causes **polyhydramnios**. The mechanism is twofold: a lack of the swallowing reflex and the transudation of fluid from the exposed meninges into the amniotic sac. * **Duodenal Atresia:** This is a classic cause of **polyhydramnios**. The structural obstruction in the gastrointestinal tract prevents the fetus from effectively swallowing and absorbing amniotic fluid. * **Trisomy 18 (Edwards Syndrome):** While chromosomal anomalies can vary, Trisomy 18 is more frequently associated with **polyhydramnios** due to associated GI tract malformations or impaired swallowing. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Oligohydramnios is defined as an Amniotic Fluid Index (AFI) **< 5 cm** or a Single Deepest Pocket (SDP) **< 2 cm**. * **Common Causes:** Renal anomalies (agenesis, posterior urethral valves), Placental insufficiency (IUGR), and Premature Rupture of Membranes (PROM). * **Potter Sequence:** Remember the mnemonic **P-O-T-T-E-R**: **P**ulmonary hypoplasia, **O**ligohydramnios, **T**wisted face (Potter facies), **T**wisted skin, **E**xtremity defects, **R**enal failure.

Q: In a pregnant lady with pregnancy-induced hypertension (PIH) experiencing bleeding per vagina, what is the primary factor determining the decision to continue the pregnancy?

Presence of fetal cardiac activity. **Explanation:** The clinical scenario describes a patient with Pregnancy-Induced Hypertension (PIH) presenting with vaginal bleeding, which is highly suggestive of **Abruptio Placentae** (Placental Abruption). In cases of abruption, the management algorithm is primarily dictated by the **fetal viability and maternal stability.** 1. **Why A is correct:** The presence or absence of fetal cardiac activity is the "deciding factor" for the mode and timing of delivery. If the fetus is alive, an emergency Cesarean section is often indicated to save the fetus, provided the mother is stable. If fetal death has occurred (absent cardiac activity), the goal shifts entirely to maternal safety, usually favoring a controlled vaginal delivery to avoid the surgical risks associated with coagulopathy (DIC), which is common in abruption. 2. **Why the other options are incorrect:** * **B & D:** While blood availability and medical facilities are essential for safe management, they are supportive requirements rather than the primary clinical factor that determines whether to continue the pregnancy or terminate it immediately. * **C:** Maternal blood pressure control is a management goal to prevent complications like stroke or eclampsia, but it does not dictate the decision to continue the pregnancy once a life-threatening complication like abruption has begun. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of DIC in pregnancy:** Abruptio Placentae. * **Couvelaire Uterus:** A complication of severe abruption where blood extravasates into the myometrium; it is not an absolute indication for hysterectomy unless the uterus is atonic. * **Management Rule:** In abruption with a dead fetus, **Vaginal Delivery** is the treatment of choice. In abruption with a live fetus, **Emergency LSCS** is the treatment of choice.

Q: Uterine height more than corresponding gestational age, with complaints of vomiting and pervaginal bleeding, favors which diagnosis?

Hydatidiform mole. **Explanation:** The clinical triad of **uterine size greater than dates**, **hyperemesis gravidarum** (excessive vomiting), and **painless vaginal bleeding** is a classic presentation of a **Hydatidiform Mole** (Molar Pregnancy). 1. **Why Hydatidiform Mole is correct:** In a molar pregnancy, the abnormal proliferation of trophoblastic tissue and the accumulation of fluid within the chorionic villi (hydropic degeneration) lead to rapid uterine enlargement, often exceeding the expected gestational age. The markedly elevated levels of **hCG** (human chorionic gonadotropin) stimulate the chemoreceptor trigger zone, causing severe vomiting. The bleeding occurs due to the separation of the molar tissue from the decidua. 2. **Why other options are incorrect:** * **Threatened Abortion:** While it presents with bleeding, the uterine size is typically **equal** to the gestational age, and hyperemesis is not a defining feature. * **Placenta Previa:** Presents with painless, bright red bleeding, but usually in the **third trimester**. Uterine size is typically appropriate for dates. * **Abruptio Placentae:** Characterized by painful bleeding and a "woody hard" uterus. While the uterus may be slightly larger due to a concealed retroplacental clot, it lacks the hyperemesis and the characteristic "snowstorm" appearance on ultrasound associated with moles. **High-Yield Clinical Pearls for NEET-PG:** * **USG Finding:** "Snowstorm appearance" or "Bunch of grapes" appearance. * **Ovarian Finding:** Bilateral **Theca Lutein Cysts** (due to high hCG). * **Complication:** Early-onset Preeclampsia (before 20 weeks) is highly suggestive of a molar pregnancy. * **Management:** Suction and Evacuation is the treatment of choice.

Question 1

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 2

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 3

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

Accepted Answer

Skin edema

Answer

Pericardial effusion

Answer

Ascites

Answer

Pleural effusion

Question 4

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

Question 5

What is the recommended time for termination of pregnancy in a female with type 1 diabetes controlled with insulin?

Accepted Answer

37+ weeks

Answer

40 weeks

Answer

32 weeks

Answer

34 weeks

Question 6

Which of the following is NOT a cause of intrauterine growth retardation?

Accepted Answer

Gestational diabetes

Answer

Severe anemia

Answer

Pregnancy-induced hypertension

Answer

Maternal heart disease

Question 7

Which of the following has been proved to be effective in the management of preeclampsia?

Accepted Answer

Magnesium

Answer

Zinc

Answer

Calcium

Answer

None of the above

Question 8

A woman with no history of prenatal care is about to deliver a baby. She has no history of amniotic rupture, and ultrasound showed severe oligohydramnios. Which of the following conditions can be a cause of oligohydramnios?

Accepted Answer

Renal agenesis

Answer

Anencephaly

Answer

Trisomy 18

Answer

Duodenal atresia

Question 9

In a pregnant lady with pregnancy-induced hypertension (PIH) experiencing bleeding per vagina, what is the primary factor determining the decision to continue the pregnancy?

Accepted Answer

Presence of fetal cardiac activity

Answer

Availability of blood for transfusion

Answer

Maternal blood pressure control

Answer

Availability of adequate medical facilities

Question 10

Uterine height more than corresponding gestational age, with complaints of vomiting and pervaginal bleeding, favors which diagnosis?

Accepted Answer

Hydatidiform mole

Answer

Threatened abortion

Answer

Placenta previa

Answer

Abruptio placentae

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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