Maternal-Fetal Medicine Practice Questions

Q: A 26-week gestation pregnant woman with G2P1L1, carrying monochorionic twins, undergoes a routine obstetric scan. The scan reveals oligohydramnios in one fetus and polyhydramnios in the other. What is the most suspected condition?

Twin-to-twin transfusion syndrome (TTTS). ### Explanation **Correct Answer: B. Twin-to-twin transfusion syndrome (TTTS)** **Why it is correct:** TTTS is a serious complication unique to **monochorionic (MC)** pregnancies, occurring in approximately 10–15% of cases. It is caused by unbalanced blood flow through deep **arteriovenous (AV) anastomoses** in the shared placenta. * **The Donor Twin:** Becomes hypovolemic, leading to decreased renal perfusion and **oligohydramnios** (stuck twin). * **The Recipient Twin:** Becomes hypervolemic, leading to polyuria and **polyhydramnios**. The diagnostic hallmark of TTTS is the **"Oli-Poly Sequence"** (Deepest Vertical Pocket 8cm in the other). **Why the other options are incorrect:** * **A. Normal reproductive outcome:** A significant discrepancy in liquor volume in MC twins is never normal and indicates a high risk of fetal morbidity/mortality. * **C. Twin reversed arterial perfusion sequence (TRAP):** This involves an "acardiac twin" perfused by a "pump twin" via large artery-to-artery anastomoses. While it occurs in MC twins, the primary finding is a malformed fetus without a functioning heart, not just liquor discrepancy. * **D. Discordant twins:** This refers to a significant weight difference (usually >20-25%) between twins. While TTTS twins are often discordant, discordancy can occur in dichorionic twins due to placental insufficiency without the Oli-Poly sequence. **High-Yield NEET-PG Pearls:** * **Staging:** TTTS is staged using the **Quintero Staging System** (Stage I: Oli-Poly; Stage II: Absent bladder in donor; Stage III: Abnormal Dopplers; Stage IV: Hydrops; Stage V: Death). * **Treatment of Choice:** Fetoscopic **Laser ablation** of placental anastomoses (Solomon technique) is the gold standard. * **Screening:** Monochorionic twins should be monitored via ultrasound every **2 weeks** starting from 16 weeks to detect TTTS early.

Q: What is the utero-placental blood flow at term?

500-700 ml/min. **Explanation:** The correct answer is **B. 500-700 ml/min**. **1. Understanding the Correct Answer:** During pregnancy, the cardiovascular system undergoes significant remodeling to meet the metabolic demands of the growing fetus. The uterine blood flow increases dramatically from approximately 50 ml/min in the non-pregnant state to **500–700 ml/min at term**. This represents about **10–15% of the total maternal cardiac output**. This increase is achieved through the massive vasodilation of the spiral arteries (mediated by trophoblastic invasion) and a decrease in vascular resistance, ensuring adequate oxygen and nutrient exchange across the placenta. **2. Analysis of Incorrect Options:** * **Option A (300-500 ml/min):** This range represents uterine blood flow during the mid-trimester. It is insufficient for the metabolic requirements of a full-term fetus. * **Options C & D (700-1100 ml/min):** While some textbooks may cite upper limits near 750-800 ml/min in twin pregnancies or exceptionally large placentas, 500-700 ml/min is the standard physiological range for a singleton pregnancy at term used in most standard textbooks (like Williams Obstetrics). **3. High-Yield Clinical Pearls for NEET-PG:** * **Distribution:** At term, approximately 80% of the uterine blood flow goes to the placenta (intervillous space), while the remaining 20% supplies the myometrium. * **Regulation:** Uterine blood flow is **not autoregulated**; it is dependent on maternal systemic blood pressure. Therefore, maternal hypotension (e.g., from spinal anesthesia or supine hypotension syndrome) can lead to immediate fetal hypoxia. * **Resistance:** The uterine artery Doppler shows a **low-resistance flow** pattern in normal pregnancy. Persistence of a "diastolic notch" after 24 weeks is a predictor of pre-eclampsia and IUGR.

Q: A 4-month pregnant lady on regular treatment with valproate asks for advice regarding continuing the drug during pregnancy. What is the best course of action?

Continue valproate and monitor blood levels. **Explanation:** The management of epilepsy during pregnancy is governed by a critical principle: **Never change or stop an effective anti-epileptic drug (AED) once pregnancy is confirmed.** **1. Why Option C is Correct:** By the time a woman realizes she is 4 months pregnant (second trimester), the period of organogenesis (weeks 3–8) is already complete. Valproate is associated with **Neural Tube Defects (NTDs)**, but these occur very early in the first trimester. Switching drugs now will not reverse any potential malformations but will expose the fetus to a new drug and risk breakthrough seizures in the mother. Seizures during pregnancy can cause fetal hypoxia, placental abruption, and miscarriage. Therefore, the safest approach is to continue the current effective dose and monitor serum levels, as physiological changes in pregnancy can alter drug pharmacokinetics. **2. Why Incorrect Options are Wrong:** * **Option A & B:** Switching to Lamotrigine or Carbamazepine at 4 months is futile for preventing teratogenicity. Furthermore, polytherapy or rapid switching increases the risk of "status epilepticus," which is more dangerous to the fetus than the drug itself. * **Option D:** Tapering the dose risks loss of seizure control. The goal is to maintain the lowest effective dose that was controlling seizures prior to pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Pre-conception:** If a patient is planning pregnancy, Valproate should be avoided and switched to safer alternatives like **Lamotrigine or Levetiracetam**. * **Folic Acid:** High-dose folic acid (5 mg/day) should be started *before* conception to reduce NTD risk. * **Valproate Syndrome:** Characterized by spina bifida, craniofacial anomalies, and cognitive impairment. * **Vitamin K:** If the mother is on enzyme-inducing AEDs (e.g., Phenytoin, Carbamazepine), Vitamin K is given to the neonate to prevent hemorrhagic disease.

Q: The following CTG indicates:

Cord compression. ***Cord compression*** - **Variable decelerations** are the hallmark of cord compression, appearing as abrupt drops in FHR with **variable timing** relative to contractions. - These decelerations have a characteristic **"V" or "W" shape** and can occur before, during, or after contractions due to intermittent cord occlusion. *Fetal head compression* - Causes **early decelerations** that mirror uterine contractions, starting with contraction onset and returning to baseline as contractions end. - These decelerations are **gradual** (≥30 seconds from onset to nadir) and have a **smooth, uniform shape** that matches contraction intensity. *Normal tracing* - A normal CTG shows **baseline FHR of 110-160 bpm**, **moderate variability** (6-25 bpm), and **no decelerations**. - May include **accelerations** with fetal movement, indicating good fetal oxygenation and neurological function. *Fetal anemia* - Produces a **sinusoidal pattern** with smooth, wave-like oscillations of the baseline FHR resembling a sine wave. - This pattern shows **absent variability** and **no accelerations**, typically associated with severe fetal compromise or Rh isoimmunization.

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.

Question 1

A 26-week gestation pregnant woman with G2P1L1, carrying monochorionic twins, undergoes a routine obstetric scan. The scan reveals oligohydramnios in one fetus and polyhydramnios in the other. What is the most suspected condition?

Accepted Answer

Twin-to-twin transfusion syndrome (TTTS)

Answer

Normal reproductive outcome

Answer

Twin reversed arterial perfusion sequence (TRAP)

Answer

Discordant twins

Question 2

What is the utero-placental blood flow at term?

Accepted Answer

500-700 ml/min

Answer

300-500 ml/min

Answer

700-900 ml/min

Answer

900-1100 ml/min

Question 3

A 4-month pregnant lady on regular treatment with valproate asks for advice regarding continuing the drug during pregnancy. What is the best course of action?

Accepted Answer

Continue valproate and monitor blood levels

Answer

Immediately stop valproate and start lamotrigine

Answer

Change to carbamazepine

Answer

Slowly taper the dose of valproate

Question 4

The following CTG indicates:

Accepted Answer

Cord compression

Answer

Fetal head compression

Answer

Normal tracing

Answer

Fetal anemia

Question 5

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 6

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 7

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 8

Which congenital infection in a fetus carries minimal teratogenic risk?

Accepted Answer

HIV

Answer

Rubella

Answer

Varicella

Answer

CMV

Question 9

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 10

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

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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