Maternal-Fetal Medicine Practice Questions

Q: A 30-week gestation patient presents with a history of vaginal bleeding and is admitted for evaluation. Fetal heart rate is 130 bpm with normal variability. Ultrasonography reveals a placenta partially covering the internal cervical os. Currently, there is no active vaginal bleeding. What is the best management for this patient?

Resuscitation and observation in a high-risk ward. ### Explanation The patient presents with **Placenta Previa** (partial) at 30 weeks gestation. The management of placenta previa depends on the hemodynamic stability of the mother, the fetal condition, and the gestational age. **Why Option B is Correct:** The primary goal in a preterm patient (30 weeks) who is currently stable with no active bleeding is **expectant management (Macafee and Johnson protocol)**. This approach aims to prolong the pregnancy to achieve fetal maturity while ensuring the patient is in a setting where immediate intervention is possible if bleeding recurs. Observation in a high-risk ward allows for bed rest, monitoring of vitals, and administration of corticosteroids for lung maturity. **Why Other Options are Incorrect:** * **Option A:** Immediate cesarean delivery is indicated only if there is maternal hemodynamic instability, fetal distress, or if the pregnancy has reached 37 weeks. At 30 weeks, delivery should be avoided unless life-threatening bleeding occurs. * **Option C:** Amniocentesis is invasive and unnecessary. Current guidelines favor steroids and expectant management until 36–37 weeks rather than testing for lung maturity. * **Option D:** **Digital vaginal examination is strictly contraindicated** in suspected placenta previa ("No P/V"). It can cause massive, life-threatening hemorrhage by dislodging a clot or piercing the placenta. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) is safer and more accurate than transabdominal ultrasound for locating the placenta. * **Macafee Protocol:** Indicated if gestation is <37 weeks, bleeding is not life-threatening, and the fetus is healthy. * **Steroids:** Administered between 24–34 weeks to reduce the risk of RDS. * **Anti-D:** Must be given to Rh-negative unsensitized mothers following any bleeding episode.

Q: All of the following are used in inherited thrombophilia testing in pregnancy, except:

Lupus anticoagulant. **Explanation:** The core of this question lies in distinguishing between **inherited** and **acquired** thrombophilias. **Why Lupus Anticoagulant is the correct answer:** Lupus anticoagulant (LA) is a component of **Antiphospholipid Antibody Syndrome (APS)**, which is an **acquired** autoimmune thrombophilia. While it is a significant cause of recurrent pregnancy loss and maternal thrombosis, it is not a genetic/inherited condition. Therefore, it does not belong in a panel for *inherited* thrombophilia testing. **Analysis of incorrect options (Inherited Thrombophilias):** * **Antithrombin (AT) deficiency (Option A):** An inherited deficiency. It is the most thrombogenic of all inherited thrombophilias, carrying the highest risk of venous thromboembolism (VTE) during pregnancy. * **Protein C deficiency (Option B):** An inherited autosomal dominant condition. Along with Protein S deficiency, it leads to a failure in neutralizing Factors Va and VIIIa. * **Factor V Leiden mutation (Option C):** The **most common** inherited thrombophilia in Caucasian populations. It involves a point mutation that makes Factor V resistant to inactivation by activated Protein C. **Clinical Pearls for NEET-PG:** * **Most common inherited thrombophilia:** Factor V Leiden mutation. * **Highest risk of VTE in pregnancy:** Antithrombin III deficiency. * **Testing Caution:** Protein S levels naturally decrease during pregnancy; therefore, testing for Protein S deficiency is unreliable during the gestational period and should be done postpartum. * **Screening Indication:** Inherited thrombophilia screening is generally indicated for women with a personal history of VTE or a first-degree relative with high-risk thrombophilia.

Q: Which type of placenta previa is described?

Type 2. ***Type 2*** - **Marginal placenta previa** occurs when the placental edge reaches the **internal cervical os** but does not cover it completely. - This type allows for the possibility of **vaginal delivery** in some cases, unlike complete previa, as the cervical opening remains accessible. *Type 4* - **Complete placenta previa** occurs when the placenta completely covers the **internal cervical os**. - This type always requires **cesarean delivery** as vaginal delivery is impossible due to complete obstruction of the birth canal. *Type 1* - **Low-lying placenta previa** occurs when the placental edge is within **2-3 cm** of the internal os but does not reach it. - This is the mildest form and often allows for **normal vaginal delivery** with close monitoring. *Type 3* - **Partial placenta previa** occurs when the placenta **partially covers** the internal cervical os. - This type typically requires **cesarean delivery** due to significant obstruction of the cervical opening during labor.

Q: MgSO4 is contraindicated in eclampsia during treatment EXCEPT when which of the following occurs?

Respiratory rate is < 16/min. **Explanation:** Magnesium sulfate ($MgSO_4$) is the drug of choice for controlling and preventing seizures in eclampsia. However, it has a narrow therapeutic index and is excreted solely by the kidneys. Monitoring for magnesium toxicity is critical to prevent respiratory paralysis and cardiac arrest. **Why Option B is the Correct Answer:** The question asks when $MgSO_4$ is **NOT** contraindicated (i.e., when it can still be administered). According to standard protocols (Pritchard’s regimen), the clinical monitoring parameters for continuing $MgSO_4$ are: 1. **Respiratory Rate (RR) $\geq$ 12–14/min:** A rate of **16/min** is within the normal range and indicates no respiratory depression. Therefore, $MgSO_4$ is **not** contraindicated at this rate. 2. **Presence of Patellar Reflex (Knee Jerk):** Its disappearance is the first sign of toxicity. 3. **Urine Output $\geq$ 30 ml/hr:** To ensure adequate drug clearance. **Analysis of Incorrect Options:** * **Option A (Urine output < 30 ml/hr):** This indicates renal impairment. Since $MgSO_4$ is excreted by kidneys, continuing it would lead to toxic accumulation. * **Option D (Knee jerk is absent):** Loss of deep tendon reflexes (DTRs) occurs at plasma levels of 7–10 mEq/L and is the earliest warning sign of toxicity. Administration must be stopped. * **Option C (Diastolic BP < 90 mmHg):** While not a direct contraindication for $MgSO_4$ toxicity, it is irrelevant to the specific safety monitoring of Magnesium. $MgSO_4$ is an anticonvulsant, not primarily an antihypertensive. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic range:** 4–7 mEq/L. * **Sequence of Toxicity:** Loss of Knee Jerk (7–10 mEq/L) $\rightarrow$ Respiratory Depression (11–15 mEq/L) $\rightarrow$ Cardiac Arrest (>15 mEq/L). * **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (administered slowly over 10 minutes).

Q: A Rh negative G4P3+0 patient has an antibody level of 15 IU/ml (IAT 1:32) at 27 weeks gestation. What is the most appropriate next step in management?

Estimate middle cerebral artery peak systolic velocity. In Rh-isoimmunized pregnancies, the management goal is to detect fetal anemia before hydrops develops. **Explanation of the Correct Answer:** The patient is sensitized (Antibody titer ≥ 1:16 or > 4 IU/ml), which puts the fetus at risk for Hemolytic Disease of the Fetus and Newborn (HDFN). **Middle Cerebral Artery Peak Systolic Velocity (MCA-PSV)** is the current gold standard for non-invasive screening of fetal anemia. * **Mechanism:** In fetal anemia, blood viscosity decreases and cardiac output increases to maintain oxygen delivery. This results in a higher velocity of blood flow. * **Threshold:** An MCA-PSV **> 1.5 MoM** (Multiples of Median) indicates severe anemia and is the trigger for invasive intervention. **Why Other Options are Incorrect:** * **A. Amniotic fluid bilirubin (Liley’s Chart):** Historically used to measure ΔOD450, this is now largely obsolete because it is invasive and less accurate than MCA-PSV, especially in the second trimester. * **B. Cordocentesis:** This is an invasive procedure with a 1-2% risk of fetal loss. It is used for definitive diagnosis and to prepare for transfusion, but it is not the *initial* screening step. * **D. Intrauterine Transfusion (IUT):** This is a therapeutic intervention, not a diagnostic step. It is only performed if fetal hemoglobin is confirmed to be 2 SD below the mean for gestational age. **Clinical Pearls for NEET-PG:** * **Critical Titer:** 1:16 is generally considered the threshold for monitoring; below this, the risk of hydrops is negligible. * **Best Timing:** MCA-PSV is most accurate between 18 and 35 weeks of gestation. * **First Step in Sensitized Pregnancy:** Always determine the paternal Rh status and zygosity first. If the father is heterozygous, fetal RHD genotyping (via cffDNA) is the next step.

Q: A gravida 3 female with a history of 2 previous second-trimester abortions presents at 22 weeks of gestation with cervical funneling. What is the most appropriate management?

Apply McDonald suture. ### Explanation The clinical presentation of a patient with a history of recurrent second-trimester abortions and current cervical funneling (shortening and opening of the internal os) is diagnostic of **Cervical Insufficiency**. **1. Why Option D is Correct:** The management of cervical insufficiency is **Cervical Cerclage**. Since the patient is currently at 22 weeks and demonstrating ultrasound changes (funneling), this is classified as **Ultrasound-Indicated Cerclage** (also known as "Rescue" or "Emergency" cerclage if the cervix is dilated). The **McDonald suture** is the most commonly performed technique; it involves a non-absorbable purse-string suture placed at the cervicovaginal junction to provide mechanical support to the weak cervix, thereby preventing premature delivery. **2. Why Other Options are Incorrect:** * **Options A & B (Dinoprostone/Misoprostol):** These are prostaglandins used for cervical ripening and induction of labor or abortion. Administering them in this scenario would be contraindicated as they would further soften the cervix and lead to pregnancy loss. * **Option C (Fothergill Suture):** This is a component of the Manchester operation used for treating **pelvic organ prolapse** (uterine descent) in women who wish to retain their uterus. It is not used for cervical insufficiency in pregnancy. **3. NEET-PG High-Yield Pearls:** * **Timing:** Prophylactic (History-indicated) cerclage is typically performed at **12–14 weeks**. * **Diagnosis:** On Ultrasound, a cervical length **<25 mm** or significant **funneling** (T, Y, V, U shapes) before 24 weeks indicates insufficiency. * **Suture Material:** Usually Mersilene tape (non-absorbable). * **Removal:** The suture is electively removed at **36–37 weeks** or immediately if labor starts to prevent cervical laceration. * **Contraindications:** Chorioamnionitis, active bleeding, ruptured membranes, or fetal anomalies.

Q: What is the most reliable method for diagnosing fetal wellbeing?

Ultrasound. **Explanation:** The assessment of fetal wellbeing has evolved from biochemical markers to real-time biophysical evaluation. **Ultrasound** is currently the most reliable method because it allows for a comprehensive, non-invasive, and immediate assessment of the fetus. It forms the basis of the **Biophysical Profile (BPP)** and **Doppler velocimetry**, which evaluate acute markers (fetal breathing, movements, tone, and heart rate) and chronic markers (amniotic fluid index and placental perfusion). **Analysis of Options:** * **A. L:S Ratio (Lecithin-Sphingomyelin):** This is a marker of **fetal lung maturity**, not overall wellbeing. While it predicts the risk of Respiratory Distress Syndrome (RDS), it does not provide information regarding acute fetal distress or placental function. * **B. HPL (Human Placental Lactogen) levels:** Formerly used as a "placental function test," HPL levels are no longer considered reliable. They have a wide range of normal values and poor sensitivity in predicting acute fetal compromise. * **C. Kick Test (Daily Fetal Movement Count):** While a valuable screening tool for mothers to monitor at home, it is **subjective** and can be influenced by maternal perception, obesity, or fetal sleep cycles. It is less reliable than objective ultrasound findings. **High-Yield Clinical Pearls for NEET-PG:** * **Modified BPP:** Combines the Non-Stress Test (NST) (acute indicator) and Amniotic Fluid Index (AFI) (chronic indicator). * **Umbilical Artery Doppler:** The most sensitive tool for monitoring growth-restricted (IUGR) fetuses; "Absent or Reversed End-Diastolic Flow" is a critical sign of impending compromise. * **First sign to disappear in fetal distress:** Fetal breathing movements. * **Last sign to disappear:** Fetal tone (indicates severe acidemia).

Question 1

A 30-week gestation patient presents with a history of vaginal bleeding and is admitted for evaluation. Fetal heart rate is 130 bpm with normal variability. Ultrasonography reveals a placenta partially covering the internal cervical os. Currently, there is no active vaginal bleeding. What is the best management for this patient?

Accepted Answer

Resuscitation and observation in a high-risk ward

Answer

Immediate cesarean delivery

Answer

Amniocentesis to assess fetal lung maturity and plan delivery

Answer

Gentle digital cervical examination to assess dilatation and membrane status

Question 2

All of the following are used in inherited thrombophilia testing in pregnancy, except:

Accepted Answer

Lupus anticoagulant

Answer

Antithrombin deficiency

Answer

Protein C deficiency

Answer

Factor V Leiden mutation

Question 3

Which type of placenta previa is described?

Accepted Answer

Type 2

Answer

Type 4

Answer

Type 1

Answer

Type 3

Question 4

In accidental hemorrhage, what is the definitive treatment?

Accepted Answer

Simultaneous emptying of the uterus and blood transfusion

Answer

Induction of labor

Answer

Treatment of hypofibrinogenemia followed by blood transfusion

Answer

Wait and watch

Question 5

MgSO4 is contraindicated in eclampsia during treatment EXCEPT when which of the following occurs?

Accepted Answer

Respiratory rate is < 16/min

Answer

Urine output is < 30 ml/hr

Answer

Diastolic blood pressure is < 90 mmHg

Answer

Knee jerk is absent

Question 6

A Rh negative G4P3+0 patient has an antibody level of 15 IU/ml (IAT 1:32) at 27 weeks gestation. What is the most appropriate next step in management?

Accepted Answer

Estimate middle cerebral artery peak systolic velocity

Answer

Estimate amniotic fluid bilirubin levels

Answer

Estimate fetal hemoglobin levels by cordocentesis

Answer

Perform intrauterine transfusion

Question 7

A 24-year-old woman at 8 weeks of gestation presents with a history of pulmonary embolism 7 years ago during her first pregnancy. She was treated with intravenous heparin followed by several months of oral warfarin and has had no further evidence of thromboembolic disease for over 6 years. Which of the following statements about her current condition is true?

Accepted Answer

The patient should be placed on low-dose heparin therapy throughout pregnancy and puerperium.

Answer

Having no evidence of disease for over 5 years means that the risk of thromboembolism is not greater than normal.

Answer

Impedance plethysmography is not a useful study to evaluate for deep venous thrombosis in pregnancy.

Answer

Doppler ultrasonography is not a useful technique to evaluate for deep venous thrombosis in pregnancy.

Question 8

A gravida 3 female with a history of 2 previous second-trimester abortions presents at 22 weeks of gestation with cervical funneling. What is the most appropriate management?

Accepted Answer

Apply McDonald suture

Answer

Administer dinoprostone and bed rest

Answer

Administer misoprostol and bed rest

Answer

Apply Fothergill suture

Question 9

Which of the following situations poses the greatest risk of Rh incompatibility?

Accepted Answer

Rh-ve mother with a second Rh+ve child

Answer

Rh+ve mother with a second Rh-ve child

Answer

Rh+ve mother with a first Rh-ve child

Answer

Rh-ve mother with a first Rh+ve child

Question 10

What is the most reliable method for diagnosing fetal wellbeing?

Accepted Answer

Ultrasound

Answer

L:S ratio

Answer

HPL levels

Answer

Kick test

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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