Maternal-Fetal Medicine Practice Questions

Q: Early diastolic notching of the uterine artery disappears by which week of gestation?

22 weeks. **Explanation:** The correct answer is **22 weeks**. **Underlying Medical Concept:** In a non-pregnant state, the uterine artery is a high-resistance vessel characterized by an **early diastolic notch**. During a normal pregnancy, trophoblastic invasion of the spiral arteries occurs in two waves (at 8–10 weeks and 16–18 weeks). This process converts the uterine circulation from a high-resistance to a low-resistance, high-flow system to ensure adequate placental perfusion. As resistance falls, the diastolic flow increases, and the early diastolic notch typically disappears by **22–24 weeks** of gestation. Persistence of this notch beyond 24 weeks is a significant predictor of placental insufficiency. **Analysis of Options:** * **A & B (20 & 21 weeks):** While the transition begins earlier, the physiological remodeling is often incomplete at this stage. Using these weeks as a cutoff would result in a high false-positive rate for predicting complications. * **C (22 weeks):** This is the standard clinical benchmark. By the end of the 22nd week, the notch should ideally disappear in a healthy pregnancy. * **D (24 weeks):** While some sources mention 24 weeks as the absolute upper limit, **22 weeks** is the most frequently tested "milestone" week for the disappearance of the notch in competitive exams like NEET-PG. **High-Yield Clinical Pearls for NEET-PG:** * **Persistence of the notch:** If the notch persists beyond 24 weeks, it indicates a high risk for **Preeclampsia** and **Intrauterine Growth Restriction (IUGR)**. * **Best time for screening:** Uterine artery Doppler screening for preeclampsia is ideally performed between **11–14 weeks** (PI) and **20–24 weeks** (Notching). * **Reversed End-Diastolic Flow (REDF):** In the umbilical artery, this is a critical sign of fetal distress and often an indication for urgent delivery.

Q: What does the following ultrasound show?

Ectopic pregnancy. ***Ectopic pregnancy*** - Classic **transvaginal ultrasound** findings include the **adnexal ring sign** (hyperechoic ring in the fallopian tube) and an **empty uterine cavity** despite positive pregnancy test. - Often shows **free fluid** in the **pouch of Douglas** indicating potential tubal rupture or bleeding. *Normal pregnancy* - Shows a **gestational sac** within the **uterine cavity** with appropriate size for gestational age. - **Fetal pole** and **cardiac activity** are visible in viable intrauterine pregnancies after 6-7 weeks. *Hydatidiform mole* - Characteristic **"snowstorm appearance"** with multiple **cystic spaces** and **echogenic material** filling the uterine cavity. - Absence of **normal fetal structures** and markedly elevated **β-hCG levels** compared to gestational age. *Ovarian cyst* - Appears as a **simple fluid-filled structure** with **thin walls** and **anechoic contents** in the ovary. - **Uterine cavity** would show normal intrauterine pregnancy if patient is pregnant, not the empty uterus seen in ectopic pregnancy.

Q: What is the drug of choice for the prevention of seizures in a patient with severe preeclampsia?

Magnesium sulphate. **Explanation:** **Magnesium sulphate ($MgSO_4$)** is the gold standard and drug of choice for both the **prevention (prophylaxis)** of seizures in severe preeclampsia and the **control** of seizures in eclampsia. Its superiority over other anticonvulsants was definitively established by the **MAGPIE trial**. It acts primarily by blocking NMDA receptors in the brain, increasing the seizure threshold, and causing cerebral vasodilation to reduce ischemia. **Analysis of Incorrect Options:** * **A. Phenytoin:** While an effective antiepileptic, it is less effective than $MgSO_4$ in preventing eclamptic seizures and carries a higher risk of maternal toxicity and fetal side effects. * **C. Diazepam:** Formerly used for seizure control, it is now avoided as a first-line agent because it causes significant maternal respiratory depression and neonatal "Floppy Infant Syndrome." * **D. Nifedipine:** This is a Calcium Channel Blocker used as an **antihypertensive** to manage blood pressure in preeclampsia, but it has no anticonvulsant properties. **High-Yield Clinical Pearls for NEET-PG:** * **Regimen:** The **Pritchard Regimen** (IM) and **Zuspan Regimen** (IV) are the standard protocols. * **Therapeutic Window:** 4–7 mEq/L. * **Monitoring:** Always check for **Patellar reflex** (first sign of toxicity is loss of reflex), **Respiratory rate** (>12/min), and **Urine output** (>30 ml/hr) before each dose. * **Antidote:** **Calcium gluconate** (10 ml of 10% solution administered IV over 10 minutes). * **Excretion:** It is exclusively cleared by the kidneys; hence, dose adjustment is mandatory in renal failure.

Q: In post-term pregnancy, what is the increased risk for the fetus, excluding one option?

Postpartum hemorrhage. **Explanation:** The question asks to identify the option that is **not** a direct fetal risk of post-term pregnancy (defined as ≥42 weeks of gestation). **1. Why Postpartum Hemorrhage (PPH) is the correct answer:** Postpartum hemorrhage is a **maternal complication**, not a fetal one. While post-term pregnancy increases the risk of PPH (often due to macrosomia causing uterine atony or extensive perineal tears), it does not represent a direct risk to the fetus itself. **2. Analysis of Fetal Risks (Incorrect Options):** * **Meconium Aspiration Syndrome (MAS):** As the fetus matures, motilin levels increase, leading to increased bowel peristalsis and passage of meconium. Combined with reduced amniotic fluid (oligohydramnios), the meconium becomes thick, significantly increasing the risk of aspiration. * **Intracranial Hemorrhage:** Post-term fetuses often have increased birth weight (macrosomia) and advanced bone ossification of the skull. This leads to reduced molding during labor, increasing the risk of birth trauma and intracranial hemorrhage during a difficult vaginal delivery. * **Placental Insufficiency:** The placenta has a finite lifespan. After 40-42 weeks, "placental senescence" occurs, characterized by infarctions and calcifications. This reduces oxygen and nutrient transfer, leading to fetal hypoxia and potentially stillbirth. **High-Yield Clinical Pearls for NEET-PG:** * **Post-term Definition:** Pregnancy extending to or beyond 42 weeks (294 days). * **Most Common Cause:** Incorrect dating (wrong LMP). * **Dysmaturity Syndrome (Post-maturity):** Seen in 20% of post-term neonates; characterized by loss of subcutaneous fat, wrinkled skin (parchment-like), and long nails. * **Management:** Induction of labor is generally recommended between 41 and 42 weeks to reduce perinatal morbidity.

Q: What is the earliest fetal anomaly detectable by ultrasound?

Anencephaly. **Explanation:** **Anencephaly** is the correct answer because it is the earliest fetal anomaly detectable by ultrasound, typically identifiable by the **10th to 12th week** of gestation (late first trimester). It is a lethal neural tube defect characterized by the absence of the cranial vault and cerebral hemispheres. On ultrasound, it presents with the classic **"Frog-eye appearance"** (Mickey Mouse sign) due to prominent orbits and the absence of the calvarium above the level of the orbits. **Analysis of Incorrect Options:** * **Hydrocephalus:** This involves the enlargement of cerebral ventricles. It is generally not diagnosed until the **second trimester** (usually after 18 weeks) because the choroid plexus normally fills the ventricles in the first trimester, making early detection difficult. * **Achondroplasia:** This is the most common form of skeletal dysplasia. It is typically diagnosed in the **third trimester** (after 26–28 weeks) when the characteristic rhizomelic (proximal) limb shortening becomes ultrasonographically evident. * **Spina Bifida:** While screening begins with the "Lemon" and "Banana" signs in the early second trimester (16–20 weeks), it is rarely diagnosed as early as anencephaly because the ossification of the spine is incomplete in the first trimester. **High-Yield Clinical Pearls for NEET-PG:** * **Folic Acid:** 400 mcg/day (standard) or 4 mg/day (previous history) prevents 70% of neural tube defects. * **AFP Levels:** Anencephaly is associated with significantly **elevated Maternal Serum Alpha-Fetoprotein (MSAFP)**. * **Polyhydramnios:** This is a common complication of anencephaly due to the failure of the fetus to swallow amniotic fluid.

Q: A 35-year-old lady, G4 P3, presents with amenorrhea of 12 weeks, excessive vomiting, and bleeding per vaginam. On examination, her pulse is 90/min, BP is 150/110 mm Hg, and the uterus is of 20 weeks size on palpation. What is your most probable diagnosis?

Molar pregnancy. **Explanation:** The clinical presentation is classic for a **Molar Pregnancy (Hydatidiform Mole)**. The diagnosis is based on the following triad: 1. **Size-Date Discrepancy:** The uterus (20 weeks) is significantly larger than the period of amenorrhea (12 weeks). 2. **Early-onset Preeclampsia:** Hypertension (150/110 mm Hg) occurring before 20 weeks of gestation is a hallmark sign of a molar pregnancy. 3. **Hyperemesis:** Excessive vomiting occurs due to abnormally high levels of hCG. **Analysis of Options:** * **Gestational Hypertension:** By definition, this occurs *after* 20 weeks of gestation. Hypertension in the first trimester strongly suggests a molar pregnancy or pre-existing chronic hypertension. * **Polyhydramnios:** While it causes a "size > dates" discrepancy, it typically manifests in the second or third trimester and is not associated with early-onset hypertension or excessive bleeding at 12 weeks. * **Antepartum Hemorrhage (APH):** This refers to bleeding from the genital tract after 28 weeks of gestation. At 12 weeks, bleeding is classified as an abortion or molar pregnancy. **NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** Pelvic Ultrasound showing a **"Snowstorm appearance"** (due to hydropic villi). * **hCG Levels:** Extremely high (often >100,000 mIU/mL). * **Associated Findings:** Theca lutein cysts (bilateral ovarian enlargement) and hyperthyroidism (hCG mimics TSH). * **Treatment of Choice:** Suction and Evacuation (S&E), regardless of uterine size. * **Follow-up:** Weekly serum hCG monitoring until three consecutive negative results to rule out Gestational Trophoblastic Neoplasia (GTN).

Q: A 28-week pregnant patient presents with abdominal pain and fever. Ultrasonography reveals the presence of a fibroid. What is the next line of management?

Conservative management. ### Explanation The correct management for a fibroid during pregnancy, even when symptomatic, is **Conservative Management**. **Why it is correct:** The clinical presentation of abdominal pain and fever in a pregnant patient with a known fibroid strongly suggests **Red Degeneration** (Necrobiosis). This occurs most commonly in the second or third trimester when the fibroid outgrows its blood supply, leading to ischemia and infarction. This is a self-limiting condition. Management focuses on hospitalization, bed rest, intravenous hydration, and analgesia (usually NSAIDs like Ibuprofen, though used with caution near term). Symptoms typically resolve within 4–7 days. **Why the other options are incorrect:** * **Hysterectomy:** This is contraindicated during pregnancy due to the extreme risk of life-threatening hemorrhage from the hypervascular gravid uterus. * **Termination:** Fibroids are not an indication for termination of pregnancy. Most pregnancies with fibroids proceed to a successful term delivery. * **Myomectomy:** Surgical removal of a fibroid is generally avoided during pregnancy due to the risk of uncontrollable bleeding and miscarriage/preterm labor. It is only considered in rare, extreme cases (e.g., a pedunculated fibroid with torsion). **High-Yield Clinical Pearls for NEET-PG:** * **Most common change** in a fibroid during pregnancy: **Asymptomatic** (though size may increase due to estrogen). * **Most common complication** of fibroid in pregnancy: **Red Degeneration**. * **Ultrasound finding:** A "flesh-colored" or "beefy red" appearance is seen pathologically; sonographically, it shows cystic changes or internal echoes. * **Delivery:** Fibroids are not an absolute indication for C-section unless they obstruct the birth canal (Previa fibroid).

Question 1

Early diastolic notching of the uterine artery disappears by which week of gestation?

Accepted Answer

22 weeks

Answer

20 weeks

Answer

21 weeks

Answer

24 weeks

Question 2

A 22-year-old woman presents with sudden onset of severe lower abdominal pain. Physical examination reveals no masses but severe tenderness in the right lower quadrant. Pelvic examination shows no lesions of the cervix or vagina. Bowel sounds are present. An abdominal ultrasound scan shows a 4-cm focal enlargement of the proximal right fallopian tube. A dilation and curettage procedure reveals decidua only from the endometrial cavity. Which of the following laboratory findings is most likely to be reported for this patient?

Accepted Answer

Detection of human chorionic gonadotropin in serum

Answer

Cervical culture positive for Neisseria gonorrhoeae

Answer

69, XXY karyotype on decidual tissue cells

Answer

Pap smear showing pseudo hyphae of Candida

Question 3

What does the following ultrasound show?

Accepted Answer

Ectopic pregnancy

Answer

Normal pregnancy

Answer

Hydatidiform mole

Answer

Ovarian cyst

Question 4

What is the drug of choice for the prevention of seizures in a patient with severe preeclampsia?

Accepted Answer

Magnesium sulphate

Answer

Phenytoin

Answer

Diazepam

Answer

Nifedipine

Question 5

In post-term pregnancy, what is the increased risk for the fetus, excluding one option?

Accepted Answer

Postpartum hemorrhage

Answer

Meconium aspiration syndrome

Answer

Intracranial hemorrhage

Answer

Placental insufficiency leading to fetal hypoxia

Question 6

What is the treatment of choice for intrahepatic cholestasis of pregnancy?

Accepted Answer

Ursodiol (Ursodeoxycholic acid)

Answer

Cholestyramine

Answer

Corticosteroids (Dexamethasone)

Answer

Antihistamines

Question 7

What is the earliest fetal anomaly detectable by ultrasound?

Accepted Answer

Anencephaly

Answer

Hydrocephalus

Answer

Achondroplasia

Answer

Spina bifida

Question 8

A 32-year-old primi gravida presents with deep vein thrombosis (DVT). There is a history of two episodes of DVT in the past and she was diagnosed to have antiphospholipid antibody syndrome. What is the next step in management?

Accepted Answer

Aspirin and heparin

Answer

Aspirin alone

Answer

Low molecular weight heparin (LMWH)

Answer

Warfarin for 6 months

Question 9

A 35-year-old lady, G4 P3, presents with amenorrhea of 12 weeks, excessive vomiting, and bleeding per vaginam. On examination, her pulse is 90/min, BP is 150/110 mm Hg, and the uterus is of 20 weeks size on palpation. What is your most probable diagnosis?

Accepted Answer

Molar pregnancy

Answer

Gestational hypertension

Answer

Polyhydramnios

Answer

Antepartum hemorrhage

Question 10

A 28-week pregnant patient presents with abdominal pain and fever. Ultrasonography reveals the presence of a fibroid. What is the next line of management?

Accepted Answer

Conservative management

Answer

Hysterectomy

Answer

Termination

Answer

Myomectomy

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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