Maternal-Fetal Medicine Practice Questions

Q: All of the following are true about cholestasis of pregnancy EXCEPT?

Bilirubin more than 5 mg%. **Intrahepatic Cholestasis of Pregnancy (ICP)** is a reversible type of hormone-induced cholestasis occurring typically in the third trimester. It is characterized by the impairment of bile flow, leading to the accumulation of bile acids in the serum and skin. ### **Explanation of Options:** * **A. Bilirubin more than 5 mg% (Correct Answer):** In ICP, while serum bile acids are significantly elevated, jaundice is uncommon (occurring in only 10–20% of cases). Even when present, the total bilirubin levels are typically mild, rarely exceeding **2–5 mg/dL**. A bilirubin level >5 mg% should prompt a search for other causes like viral hepatitis or hemolytic disorders. * **B. Intense pruritus:** This is the hallmark clinical feature. It typically starts on the palms and soles, worsens at night, and occurs in the absence of a primary skin rash. * **C. SGPT, SGOT may be normal:** While transaminases (ALT/AST) are often elevated (up to 2–10 times the upper limit), they can remain within the normal range in mild or early cases. * **D. Increased alkaline phosphatase:** Serum ALP is characteristically elevated in ICP. However, it is a less specific marker because ALP levels naturally increase during pregnancy due to placental production. ### **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** The most sensitive and specific marker is **elevated Serum Bile Acids (>10 μmol/L)**. * **Treatment:** **Ursodeoxycholic Acid (UDCA)** is the drug of choice; it improves maternal symptoms and biochemical profiles. * **Fetal Risks:** ICP is associated with increased risks of **meconium-stained amniotic fluid, preterm labor, and sudden intrauterine fetal death (IUFD)**. * **Delivery Timing:** Due to the risk of stillbirth, delivery is usually recommended between **36 0/7 and 39 0/7 weeks**, depending on bile acid levels.

Q: Which of the following treatments is not indicated in ectopic pregnancy?

Salpingo-oophorectomy. The management of ectopic pregnancy focuses on removing the conceptus while preserving as much reproductive function as possible. **Explanation of the Correct Answer:** **Salpingo-oophorectomy (Option B)** involves the removal of both the fallopian tube and the ovary. This is **not indicated** because the ovary is rarely involved in a tubal ectopic pregnancy. Preserving the ovary is crucial for maintaining hormonal function and future fertility. Even in cases of ruptured tubal pregnancy with significant hemorrhage, the ovary has a separate blood supply (ovarian artery) and can almost always be salvaged. **Analysis of Incorrect Options:** * **Salpingectomy (Option A):** This is the standard surgical treatment for a ruptured ectopic pregnancy or when the tube is severely damaged. It involves the total removal of the affected fallopian tube. * **Salpingostomy (Option C):** This is a conservative surgical procedure where a longitudinal incision is made on the tube to remove the products of conception, leaving the tube intact. It is preferred in hemodynamically stable patients who desire future fertility. * **Resection of involved segment (Option D):** This is specifically indicated for **isthmic ectopic pregnancies**. Since the isthmus is narrow, salpingostomy can lead to scarring and occlusion; therefore, segmental resection followed by delayed re-anastomosis is often preferred. **NEET-PG High-Yield Pearls:** * **Most common site:** Ampulla of the fallopian tube. * **Most common site for rupture:** Isthmus (due to its narrow lumen). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Quantitative β-hCG (Discriminatory zone: 1500–2000 mIU/mL). * **Medical Management:** Methotrexate is the drug of choice if the patient is stable, the mass is <3.5–4 cm, and there is no fetal cardiac activity.

Q: Which congenital infection in a fetus carries minimal teratogenic risk?

HIV. **Explanation:** The core concept in this question is the distinction between **teratogenicity** (structural malformations during organogenesis) and **vertical transmission** (infection of the fetus). **Why HIV is the correct answer:** While HIV carries a significant risk of vertical transmission (mother-to-child transmission) during pregnancy, labor, or breastfeeding, it is **not considered a teratogen**. HIV does not disrupt embryogenesis or cause specific structural birth defects. The primary concern with HIV in pregnancy is the risk of the infant developing neonatal HIV/AIDS, which is managed with Antiretroviral Therapy (ART) and elective cesarean sections, rather than structural anomalies. **Why the other options are incorrect:** * **Rubella (Option B):** Highly teratogenic. **Congenital Rubella Syndrome (CRS)** presents with the classic triad of cataracts, sensorineural deafness, and cardiac defects (PDA), especially if contracted in the first trimester. * **Varicella (Option C):** Causes **Congenital Varicella Syndrome** if contracted between 8–20 weeks of gestation. It is characterized by skin scarring (cicatrices), limb hypoplasia, and chorioretinitis. * **CMV (Option D):** The most common congenital infection. It is a potent teratogen causing microcephaly, periventricular calcifications, and sensorineural hearing loss. **High-Yield NEET-PG Pearls:** * **Highest risk of transmission:** HIV transmission risk is highest during **delivery** (intrapartum), whereas Rubella risk is highest in the **first trimester**. * **Zika Virus:** Another high-yield teratogen to remember, specifically associated with **microcephaly** and "fetal brain disruption sequence." * **Rule of Thumb:** Most "TORCH" infections are teratogenic; HIV and Hepatitis B are notable exceptions that cause neonatal infection without structural malformations.

Q: A young female with 2 months of amenorrhea presents with sudden abdominal pain and an adnexal mass. Urine pregnancy test is positive. What is the most likely diagnosis?

Ectopic pregnancy. ### **Explanation** The clinical presentation of **amenorrhea, sudden-onset abdominal pain, and an adnexal mass** in a woman of reproductive age is the classic triad for **Ectopic Pregnancy**. **Why Ectopic Pregnancy is Correct:** The positive urine pregnancy test (UPT) confirms a gestational state. In a patient with amenorrhea (typically 6–8 weeks), sudden sharp pain usually indicates a **ruptured or tubal abortion**, leading to hemoperitoneum. The adnexal mass represents the gestational sac, blood clots, or the affected fallopian tube. In NEET-PG, any "pregnancy + pain + mass" scenario must be considered an ectopic pregnancy until proven otherwise, as it is a life-threatening emergency. **Why Other Options are Incorrect:** * **Ovarian tumor:** While it can present as an adnexal mass, it does not typically cause a positive pregnancy test or sudden amenorrhea unless coincidental. * **Pelvic tumor:** This is a non-specific term (e.g., fibroids). While they cause masses, they do not explain the positive UPT or the acute nature of the pain. * **Ovarian cyst:** A corpus luteum cyst is common in early pregnancy, but a simple cyst wouldn't explain the acute "sudden" pain unless it underwent torsion or rupture. However, given the triad, ectopic pregnancy is the more definitive and high-stakes diagnosis. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Transvaginal Ultrasound (TVS). * **Discriminatory Zone:** If serum β-hCG is >1,500–2,000 mIU/mL and the uterus is empty on TVS, suspect ectopic pregnancy. * **Most Common Site:** Ampulla of the Fallopian tube (80%). * **Most Common Site for Rupture:** Isthmus (due to its narrow lumen). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on histology, characteristic of (but not pathognomonic for) ectopic pregnancy.

Q: A 29-year-old G3 P2 female at 32 weeks of gestation presents to the emergency department with a small amount of vaginal bleeding. She does not have any pain. Fetal heart rate tracings show fetal distress and late decelerations. What is the best course of action?

Emergent cesarean section. **Explanation:** The clinical presentation of painless vaginal bleeding in the third trimester is highly suggestive of **Placenta Previa**. However, the management priority in any obstetric emergency is dictated by the maternal and fetal status. 1. **Why Option A is correct:** The presence of **fetal distress** (evidenced by late decelerations) is a critical "red flag." Regardless of the underlying cause of bleeding (previa or abruption), fetal distress at 32 weeks indicates that the fetus is not tolerating the intrauterine environment. An emergent cesarean section is the definitive management to prevent fetal demise or permanent neurological injury. 2. **Why the other options are incorrect:** * **Option B:** Fetal umbilical blood transfusion is used for fetal anemia (e.g., Rh isoimmunization), not for acute fetal distress or late decelerations. * **Option C:** Expectant management (Macafee-Johnson protocol) is only appropriate for placenta previa if the mother is hemodynamically stable, bleeding has ceased, and the **fetal heart rate is reassuring**. * **Option D:** Induction of labor is contraindicated in placenta previa (due to risk of catastrophic hemorrhage) and is inappropriate in the setting of acute fetal distress, where immediate delivery is required. **Clinical Pearls for NEET-PG:** * **Painless bleeding = Placenta Previa** until proven otherwise. **Painful bleeding = Abruptio Placentae.** * **Late Decelerations** signify uteroplacental insufficiency and are always considered "pathological" or "non-reassuring." * In any case of antepartum hemorrhage (APH), the first steps are maternal stabilization (ABC) and assessing fetal well-being. If the fetus is in distress, **immediate delivery** is the rule, irrespective of gestational age.

Q: Which of the following is NOT a criterion for the diagnosis of ovarian pregnancy?

The fetal sac must be found lateral to the ovary.. ### Explanation The diagnosis of an ovarian pregnancy is based on the **Spiegelberg Criteria**, established to differentiate a primary ovarian pregnancy from a tubal pregnancy that has secondary involvement of the ovary. **Why Option D is the Correct Answer:** According to Spiegelberg’s criteria, the gestational sac must occupy the **position of the ovary**; it is typically embedded within the ovarian stroma. Stating that the sac is "lateral to the ovary" implies it is a separate entity (likely tubal), which contradicts the definition of an ovarian pregnancy. **Analysis of Other Options (Spiegelberg Criteria):** * **Option A (The tube must be intact):** This is a mandatory criterion. The fallopian tube on the affected side must be anatomically normal and separate from the gestational sac to rule out a tubal ectopic pregnancy. * **Option B (Ovarian tissue in the sac wall):** Histopathological confirmation is required. Ovarian tissue must be present in the wall of the gestational sac to prove the pregnancy originated within the ovary. * **Option C (Connection via the ovarian ligament):** The gestational sac/ovary must occupy the normal anatomical position and be attached to the uterus by the utero-ovarian ligament. **High-Yield Clinical Pearls for NEET-PG:** * **Incidence:** Ovarian pregnancy accounts for approximately 0.5% to 3% of all ectopic pregnancies. * **Risk Factor:** Unlike tubal pregnancies (linked to PID), ovarian pregnancies are strongly associated with the use of **Intrauterine Devices (IUDs)**. * **Management:** Surgical management (cystectomy or wedge resection) is preferred over oophorectomy to preserve fertility. Medical management with Methotrexate can be considered if the patient is hemodynamically stable. * **Mnemonic for Spiegelberg Criteria:** **T**ube intact, **O**vary position, **O**varian ligament attachment, **H**istology (ovarian tissue in wall).

Question 1

All of the following are true about cholestasis of pregnancy EXCEPT?

Accepted Answer

Bilirubin more than 5 mg%

Answer

Intense pruritus

Answer

SGPT, SGOT may be normal

Answer

Increased alkaline phosphatase

Question 2

In pregnant diabetic patients, intrauterine fetal mortality increases after which week of gestation?

Accepted Answer

40th week

Answer

30th week

Answer

36th week

Answer

25th week

Question 3

Which of the following treatments is not indicated in ectopic pregnancy?

Accepted Answer

Salpingo-oophorectomy

Answer

Salpingectomy

Answer

Salpingostomy

Answer

Resection of involved segment

Question 4

Which congenital infection in a fetus carries minimal teratogenic risk?

Accepted Answer

HIV

Answer

Rubella

Answer

Varicella

Answer

CMV

Question 5

A young female with 2 months of amenorrhea presents with sudden abdominal pain and an adnexal mass. Urine pregnancy test is positive. What is the most likely diagnosis?

Accepted Answer

Ectopic pregnancy

Answer

Ovarian tumor

Answer

Pelvic tumor

Answer

Ovarian cyst

Question 6

A 29-year-old G3 P2 female at 32 weeks of gestation presents to the emergency department with a small amount of vaginal bleeding. She does not have any pain. Fetal heart rate tracings show fetal distress and late decelerations. What is the best course of action?

Accepted Answer

Emergent cesarean section

Answer

Fetal umbilical blood transfusion

Answer

Expectant management

Answer

Induction of labor with prostaglandins

Question 7

A 21-year-old girl with 8 weeks of amenorrhea presents in shock. What is the most likely diagnosis?

Accepted Answer

Ruptured ectopic pregnancy

Answer

Incarcerated amnion

Answer

Twisted ovarian cyst

Answer

Threatened abortion

Question 8

Which of the following is NOT a criterion for the diagnosis of ovarian pregnancy?

Accepted Answer

The fetal sac must be found lateral to the ovary.

Answer

The fallopian tube on the affected side must be intact.

Answer

Ovarian tissue must be located in the sac wall.

Answer

The ovary must be connected to the uterus by the ovarian ligament.

Question 9

What is the recommended treatment for a pregnant woman with epilepsy who is currently on phenytoin therapy?

Accepted Answer

Taper phenytoin to the lowest effective level and continue the pregnancy.

Answer

Terminate the pregnancy and continue phenytoin.

Answer

Replace phenytoin with carbamazepine.

Answer

Continue the pregnancy with phenytoin therapy.

Question 10

All are true about antenatal umbilical artery Doppler except?

Accepted Answer

S/D Ratio is decreased in smoking females

Answer

Decreased diastolic flow of umbilical artery is suggestive of IUGR

Answer

S/D Ratio of umbilical artery is less than S/D ratio of Fetal MCA

Answer

Reversal of diastolic flow in umbilical artery Doppler suggests impending fetal demise

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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