Maternal-Fetal Medicine — MCQs

A 21-year-old healthy woman, who is in week 34 of a normal pregnancy, complains of itching with burning pain in the perianal region for the past 4 months. She noted a small amount of bright red blood on toilet paper last week. Which of the following underlying conditions is most likely to be present in this patient?

Q809Easy

What is the most common fetal response to acute hypoxia?

Q810Medium

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?

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 801: All the following are signs of intrauterine fetal death except?

A. Spalding's sign
B. Hegar's sign (Correct Answer)
C. Robe's sign
D. Halo sign

Explanation: **Explanation:** The correct answer is **Hegar’s sign** because it is a sign of **early pregnancy**, not fetal death. **1. Why Hegar’s sign is the correct answer:** Hegar’s sign is a clinical indicator of pregnancy typically elicited between **6–10 weeks of gestation**. It refers to the softening of the uterine isthmus, allowing the fingers of the examiner to seemingly meet during a bimanual examination. Since it is a physiological change of a progressing early pregnancy, it has no diagnostic value in identifying intrauterine fetal death (IUFD). **2. Analysis of Radiological Signs of IUFD (Incorrect Options):** The other options represent classic radiological signs seen on X-ray (though now largely replaced by Ultrasound) following fetal demise: * **Spalding’s sign:** Overlapping of the fetal skull bones due to liquefaction of the brain and loss of intra-cranial pressure. It usually appears 4–7 days after death. * **Robert’s sign:** The presence of gas (usually nitrogen) in the fetal heart and large vessels. It is often the earliest radiological sign, appearing within 12 hours of death. * **Halo sign (Deuel’s sign):** Elevation of the fetal scalp fat due to edema, creating a "halo" appearance around the skull. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Real-time **Ultrasonography** (demonstrating absence of fetal cardiac activity) is the definitive investigation for IUFD. * **Deuel’s Sign vs. Spalding’s:** Spalding’s involves bone; Deuel’s involves soft tissue (scalp edema). * **Other signs:** **Rolander’s sign** (excessive curvature of the fetal spine) is also associated with IUFD.

Question 802: What is the recommended time for termination of pregnancy in a female with type 1 diabetes controlled with insulin?

A. 40 weeks
B. 32 weeks
C. 37+ weeks (Correct Answer)
D. 34 weeks

Explanation: **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.

Question 803: All of the following may be observed in a normal pregnancy except?

A. Fall in serum iron concentration
B. Increase in serum iron binding capacity
C. Increase in blood viscosity (Correct Answer)
D. Increase in blood oxygen carrying capacity

Explanation: **Explanation:** The correct answer is **C. Increase in blood viscosity**. In a normal pregnancy, blood viscosity actually **decreases**. This is due to the disproportionate increase in plasma volume (approx. 40-50%) compared to the increase in red cell mass (approx. 20-30%). This "hemodilution" results in a lower hematocrit and reduced blood viscosity, which ensures better perfusion of the placental bed and reduces cardiac afterload. **Analysis of Options:** * **A. Fall in serum iron concentration:** Despite an increase in total red cell mass, the demand for iron by the fetus and the expanding maternal blood volume exceeds dietary intake. This leads to a physiological fall in serum iron levels. * **B. Increase in serum iron binding capacity (TIBC):** In response to lower iron stores and increased demand, the liver increases the production of Transferrin. Consequently, the Total Iron Binding Capacity (TIBC) rises during pregnancy. * **D. Increase in blood oxygen carrying capacity:** Although there is "physiological anemia" due to hemodilution, the absolute number of red blood cells and the total hemoglobin mass increase. Therefore, the total oxygen-carrying capacity of the blood is higher than in the non-pregnant state to meet fetal demands. **High-Yield Clinical Pearls for NEET-PG:** * **Plasma Volume vs. RBC Mass:** Plasma volume starts increasing at 6 weeks and peaks at 32-34 weeks. * **Physiological Anemia:** Defined by the WHO as Hb < 11 g/dL in pregnancy. * **Cardiac Output:** Increases by 30-50%, peaking by the end of the second trimester. * **Hypercoagulability:** Pregnancy is a pro-thrombotic state (increased Factors VII, VIII, IX, X, and Fibrinogen), but viscosity remains low due to hemodilution.

Question 804: Which of the following is NOT a cause of intrauterine growth retardation?

A. Severe anemia
B. Pregnancy-induced hypertension
C. Maternal heart disease
D. Gestational diabetes (Correct Answer)

Explanation: **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.

Question 805: Which of the following has been proved to be effective in the management of preeclampsia?

A. Zinc
B. Calcium
C. Magnesium (Correct Answer)
D. None of the above

Explanation: **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).

Question 806: Which of the following parameters is NOT used for the diagnosis of Intrauterine Growth Restriction (IUGR) on ultrasonography?

A. Abdominal circumference (Correct Answer)
B. Elevated S/D ratio
C. Decreased placental Doppler ratio
D. Reduction in fetal facial fat stores

Explanation: The diagnosis of **Intrauterine Growth Restriction (IUGR)** relies on identifying a fetus that has failed to reach its biological growth potential. This question focuses on the distinction between **biometric measurements** used for estimation and **diagnostic markers** used to confirm growth restriction. ### Why "Abdominal Circumference" is the Correct Answer While **Abdominal Circumference (AC)** is the most sensitive *biometric* parameter for detecting a small-for-gestational-age (SGA) fetus, it is **not used in isolation to diagnose IUGR**. AC measures the size of the liver and subcutaneous fat; a low AC indicates a small fetus but does not differentiate between a "constitutionally small" healthy fetus and a "growth-restricted" fetus. Diagnosis of IUGR requires evidence of **pathological growth failure**, typically confirmed by Doppler abnormalities or longitudinal growth velocity. ### Explanation of Other Options * **Elevated S/D Ratio:** An increased Systolic/Diastolic ratio in the Umbilical Artery indicates increased placental vascular resistance, a hallmark of placental insufficiency in IUGR. * **Decreased Placental Doppler Ratio:** Specifically the **Cerebroplacental Ratio (CPR)** (Middle Cerebral Artery PI / Umbilical Artery PI). A decreased ratio indicates "brain sparing," a diagnostic sign of fetal redistribution in IUGR. * **Reduction in Fetal Facial Fat Stores:** This is a specialized sonographic marker. Loss of buccal fat pads is a specific sign of malnutrition and is used to distinguish IUGR from constitutional smallness. ### High-Yield Clinical Pearls for NEET-PG * **Most sensitive parameter for SGA:** Abdominal Circumference (AC). * **Most reliable parameter for Gestational Age (1st Trimester):** Crown-Rump Length (CRL). * **Ponderal Index:** Used to differentiate Symmetrical vs. Asymmetrical IUGR. * **Asymmetrical IUGR:** Most common type (70-80%), usually due to placental insufficiency (Head sparing). * **Symmetrical IUGR:** Usually due to early insults like chromosomal anomalies or TORCH infections.

Question 807: 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?

A. Renal agenesis (Correct Answer)
B. Anencephaly
C. Trisomy 18
D. Duodenal atresia

Explanation: **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.

Question 808: A 21-year-old healthy woman, who is in week 34 of a normal pregnancy, complains of itching with burning pain in the perianal region for the past 4 months. She noted a small amount of bright red blood on toilet paper last week. Which of the following underlying conditions is most likely to be present in this patient?

A. Filariasis
B. Polyarteritis nodosa
C. External hemorrhoid (Correct Answer)
D. Micronodular cirrhosis

Explanation: **Explanation:** The patient presents with classic symptoms of **external hemorrhoids**, a common condition in late pregnancy. The combination of perianal itching, burning pain, and bright red blood on toilet paper (hematochezia) in a healthy 34-week pregnant woman strongly points to this diagnosis. **Why External Hemorrhoids are correct:** During the third trimester, several physiological factors predispose women to hemorrhoids: 1. **Increased Venous Pressure:** The gravid uterus compresses the inferior vena cava and iliac veins, leading to venous congestion in the pelvic and hemorrhoidal plexuses. 2. **Hormonal Changes:** High progesterone levels cause smooth muscle relaxation, leading to venous dilation and increased constipation (which exacerbates straining). 3. **Increased Blood Volume:** The general hypervolemia of pregnancy increases pressure within the rectal venous cushions. **Why other options are incorrect:** * **Filariasis:** While it can cause lymphatic obstruction and genital swelling, it typically presents with chronic lymphedema (elephantiasis) and is not a common cause of acute perianal bleeding in pregnancy. * **Polyarteritis nodosa (PAN):** This is a systemic necrotizing vasculitis. While it can affect the GI tract, it presents with multi-system involvement (renal, skin, nerves) rather than isolated perianal symptoms. * **Micronodular cirrhosis:** While cirrhosis causes portal hypertension and esophageal varices, "rectal varices" are distinct from hemorrhoids. This patient is described as "healthy," making underlying cirrhosis highly unlikely. **NEET-PG High-Yield Pearls:** * **First-line treatment:** Conservative management (high-fiber diet, stool softeners, sitz baths, and topical anesthetics). * **Differential Diagnosis:** Always rule out anal fissures if the pain is sharp and occurs specifically during defecation. * **Prevalence:** Up to 30-40% of pregnant women develop hemorrhoids, most commonly in the third trimester.

Question 809: What is the most common fetal response to acute hypoxia?

A. Tachycardia
B. Tachypnea
C. Bradycardia (Correct Answer)
D. Arrhythmia

Explanation: **Explanation:** The fetal response to acute hypoxia is fundamentally different from that of an adult. In the fetus, the primary mechanism for managing a sudden drop in oxygen is the **Chemoreceptor Reflex**. **1. Why Bradycardia is Correct:** When acute hypoxia occurs (e.g., cord prolapse or placental abruption), fetal chemoreceptors (located in the carotid and aortic bodies) are stimulated. This triggers a powerful **vagal (parasympathetic) response**, leading to a rapid decrease in fetal heart rate (bradycardia). This is a protective, energy-conserving mechanism that reduces myocardial oxygen consumption and allows for better diastolic filling, ensuring that the limited oxygen available is diverted to vital organs like the brain, heart, and adrenals (the "diving reflex"). **2. Why the other options are incorrect:** * **Tachycardia:** While mild or chronic hypoxia may initially cause a sympathetic surge (tachycardia) to increase cardiac output, **acute** and severe hypoxia characteristically results in bradycardia due to the dominant vagal reflex. * **Tachypnea:** The fetus does not breathe air in utero. While fetal breathing movements (FBM) exist, they actually **decrease or cease** during hypoxia to conserve energy. * **Arrhythmia:** While hypoxia can lead to myocardial irritability, it does not consistently produce a specific arrhythmia other than sinus bradycardia or late decelerations. **Clinical Pearls for NEET-PG:** * **Late Decelerations:** These are the hallmark of uteroplacental insufficiency and are caused by the same chemoreceptor-mediated vagal response to hypoxia. * **The "Rule of 3s" for Bradycardia:** A fetal heart rate <110 bpm for >3 minutes is a medical emergency requiring immediate intrauterine resuscitation or delivery. * **Primary Fetal Energy Source:** The fetus relies on anaerobic glycolysis during periods of hypoxia, leading to the accumulation of lactic acid and metabolic acidosis.

Question 810: 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?

A. Normal reproductive outcome
B. Twin-to-twin transfusion syndrome (TTTS) (Correct Answer)
C. Twin reversed arterial perfusion sequence (TRAP)
D. Discordant twins

Explanation: ### 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 <2cm in one sac and >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.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

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Intrauterine Growth Restriction

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Multiple Gestation

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Rh Isoimmunization and Other Blood Group Incompatibilities

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Intrauterine Fetal Therapy

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Prenatal Diagnosis and Genetic Counseling

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Placental Abnormalities

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Preterm Labor and Delivery

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Management of Medical Disorders in Pregnancy

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