Maternal-Fetal Medicine Practice Questions

Q: A pregnant patient at 34 weeks gestation presents with leakage. Which investigation can be done to diagnose the leak?

Speculum examination. The diagnosis of **Preterm Prelabor Rupture of Membranes (PPROM)** is primarily clinical. **Why Speculum Examination is the Correct Answer:** A sterile speculum examination is the **gold standard** initial investigation for diagnosing a liquor leak. It allows for direct visualization of fluid pooling in the posterior vaginal fornix. Furthermore, it enables the clinician to perform the **Nitrazine test** (pH paper turns blue) and collect fluid for the **Fern test** (arborization pattern on microscopy). Importantly, digital vaginal examinations should be avoided as they increase the risk of chorioamnionitis. **Why Other Options are Incorrect:** * **Ultrasound (USG):** While USG can detect *Oligohydramnios* (low amniotic fluid), it cannot differentiate between a leak, renal anomalies, or placental insufficiency. It is supportive but not diagnostic of a leak. * **Non-stress test (NST):** This is used to monitor fetal well-being and reactivity. It does not diagnose the rupture of membranes. * **Three Swab Test:** This is the diagnostic test for **Vesicovaginal Fistula (VVF)**, used to differentiate between urinary incontinence and a fistula, not for amniotic fluid leaks. **High-Yield Clinical Pearls for NEET-PG:** * **Amnisure:** A rapid bedside immunoassay that detects **Placental Alpha Microglobulin-1 (PAMG-1)**; it has a very high sensitivity and specificity for PROM. * **Management at 34 weeks:** According to ACOG/RCOG, if PPROM occurs at $\geq$ 34 weeks, delivery is generally recommended as the risk of infection outweighs the risks of prematurity. * **Prophylaxis:** Corticosteroids (for lung maturity) and antibiotics (to delay latency) are indicated if PPROM occurs before 34 weeks.

Q: Undiagnosed or undetected ectopic pregnancy is a common cause of maternal death during the first trimester. What is the most valuable diagnostic test in a case of suspected ectopic pregnancy?

Transvaginal ultrasonography (USG). **Explanation:** The diagnosis of ectopic pregnancy relies on the "Discriminatory Zone" concept—the level of hCG at which an intrauterine pregnancy (IUP) should be visible on ultrasound. **Why Transvaginal Ultrasonography (TVS) is the Correct Answer:** TVS is the **single most valuable diagnostic tool** because it can directly visualize an extrauterine gestational sac, an adnexal mass, or "free fluid" in the Pouch of Douglas. More importantly, the definitive identification of an **intrauterine** pregnancy via TVS effectively rules out ectopic pregnancy (except in rare heterotopic cases). TVS is superior to transabdominal USG as it can detect a gestational sac as early as 4.5–5 weeks. **Analysis of Incorrect Options:** * **Serial hCG levels:** While crucial for monitoring pregnancy viability, a single hCG value cannot diagnose an ectopic pregnancy. Serial levels help determine if a pregnancy is failing, but they do not provide anatomical localization. * **Progesterone measurement:** Low levels (<5 ng/mL) suggest a non-viable pregnancy but cannot distinguish between a miscarriage and an ectopic pregnancy. * **Culdocentesis:** Historically used to detect hemoperitoneum in ruptured ectopics, it is now considered obsolete due to the high sensitivity and non-invasive nature of TVS. **High-Yield Clinical Pearls for NEET-PG:** * **Discriminatory Zone:** For TVS, the hCG threshold is typically **1,500–2,000 mIU/mL**. If hCG is above this and the uterus is empty, ectopic pregnancy must be suspected. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Most common site:** Ampulla of the Fallopian tube. * **Gold Standard for Diagnosis:** Laparoscopy (allows for both definitive diagnosis and surgical management).

Q: Saffron colored meconium is seen in which condition?

Postmaturity. **Explanation:** The color of the amniotic fluid (liquor amnii) serves as a vital clinical indicator of fetal well-being. In a normal pregnancy, liquor is clear or straw-colored. **Why Postmaturity is correct:** In **post-term pregnancies** (gestation >42 weeks), the presence of meconium is common. **Saffron-colored** (yellowish-green) meconium is a classic sign of postmaturity. This specific hue occurs because the meconium has been present in the amniotic fluid for a prolonged period, leading to the staining of the fetal skin, nails, and umbilical cord. **Analysis of Incorrect Options:** * **Toxemia of Pregnancy (Preeclampsia):** This is typically associated with **Golden-yellow** liquor, which is also seen in Rh-isoimmunization due to excessive bilirubin. * **Breech Presentation:** While meconium passage is common in breech delivery due to physical compression of the fetal abdomen during labor, it usually appears as **fresh green** meconium rather than saffron-colored. * **Normal Appearance:** Normal liquor is **clear/colorless** at term. **High-Yield Clinical Pearls for NEET-PG:** * **Green (Fresh Meconium):** Indicates acute fetal distress. * **Golden Yellow:** Rh-isoimmunization (due to bilirubin). * **Greenish-Yellow (Saffron):** Postmaturity. * **Dark Red (Corn-syrup/Meat-wash):** Accidental hemorrhage (Abruptio Placentae). * **Dark Brown (Tobacco juice):** Intrauterine Fetal Death (IUD). Understanding these color variations is essential for diagnosing underlying fetal conditions during the intrapartum period.

Q: A 35-year-old female with Gravida-2 and Parity 1+0 is suffering from hepatic encephalopathy. What is the likely cause?

Hepatitis E. **Explanation:** **Hepatitis E Virus (HEV)** is the most common cause of acute viral hepatitis and hepatic encephalopathy in pregnant women, particularly in developing countries. While HEV is typically a self-limiting infection in the general population, it takes a fulminant course in pregnancy, especially during the **second and third trimesters**. The case describes a G2P1 patient (multigravida) with hepatic encephalopathy, which is a hallmark of Fulminant Hepatic Failure (FHF). * **Why Hepatitis E is Correct:** HEV is a water-borne RNA virus (Hepeviridae family). In pregnancy, the case fatality rate can reach as high as **15–25%**. The severity is attributed to high viral loads, altered maternal immune response (Th2 shift), and high levels of progesterone/estrogen which may enhance viral replication. * **Why Other Options are Incorrect:** * **Hepatitis A:** Also water-borne, but rarely causes fulminant failure or encephalopathy in pregnancy. * **Hepatitis B:** A DNA virus transmitted parenterally. While it can cause chronic liver disease and vertical transmission, it is less likely than HEV to cause acute encephalopathy in a pregnant patient unless there is a superinfection. * **Hepatitis D:** Requires co-infection with Hepatitis B to replicate; it is not the primary cause of epidemic-style fulminant hepatitis in pregnancy. **High-Yield NEET-PG Pearls:** * **Mode of Transmission:** Fecal-oral (contaminated water). * **Most common cause of jaundice in pregnancy:** Hepatitis E (globally). * **Vertical Transmission:** High rates of transplacental transmission are seen with HEV, often leading to neonatal hypoglycemia and jaundice. * **Prognosis:** If a pregnant woman develops HEV-induced FHF, the mortality is significantly higher than any other viral hepatitis.

Q: Expectant management of placenta previa includes all of the following except?

Cervical cerclage. **Explanation:** The expectant management of placenta previa (also known as **MacAfee and Johnson’s protocol**) aims to prolong the pregnancy until fetal lung maturity is achieved, provided the mother and fetus remain stable. **Why Cervical Cerclage is the Correct Answer:** Cervical cerclage is a surgical procedure used to treat cervical insufficiency. In the context of placenta previa, it is **not** a standard component of expectant management. Performing a cerclage or any vaginal/cervical manipulation in a patient with placenta previa is contraindicated as it can trigger massive, life-threatening hemorrhage by disturbing the placental site. **Analysis of Incorrect Options:** * **Anti-D Immunoglobulin:** Essential for all Rh-negative unsensitized mothers experiencing vaginal bleeding (antepartum hemorrhage) to prevent isoimmunization. * **Blood Transfusion:** A cornerstone of management. The goal is to maintain maternal hemoglobin levels (ideally >10 g/dL) to ensure hemodynamic stability in case of sudden, recurrent bleeding. * **Steroids:** Administered (e.g., Betamethasone or Dexamethasone) between 24 and 34 weeks of gestation to accelerate fetal lung maturity, reducing the risk of Respiratory Distress Syndrome (RDS) if preterm delivery becomes necessary. **High-Yield Clinical Pearls for NEET-PG:** * **MacAfee Protocol Criteria:** Pregnancy <37 weeks, bleeding is not life-threatening, and the fetus is alive and stable. * **Contraindication:** **Vaginal examination (PV)** is strictly contraindicated in placenta previa unless performed in an "Operation Theatre" setting (Double Setup Examination). * **Investigation of Choice:** Transvaginal Sonography (TVS) is the gold standard for diagnosing the exact location of the placenta (safe when performed by experts). * **Delivery Timing:** In stable cases, elective delivery is usually planned at **37 weeks**.

Q: A 29-year-old primigravida at 36 weeks gestation with Rh-negative blood type presents with vaginal bleeding and a history of abdominal trauma. Which of the following tests is advised to estimate the size of fetomaternal hemorrhage?

Kleihauer acid elution test. **Explanation:** In an Rh-negative mother, abdominal trauma can cause **Fetomaternal Hemorrhage (FMH)**, leading to isoimmunization. To prevent this, Anti-D immunoglobulin must be administered. While a standard dose (300 mcg) covers up to 30 mL of fetal whole blood, the **Kleihauer-Betke (KB) test** is required to quantify larger bleeds and calculate the exact dose of Anti-D needed. * **Why Option B is Correct:** The Kleihauer-Betke test is based on the principle that **Fetal Hemoglobin (HbF)** is resistant to acid elution, whereas adult hemoglobin (HbA) is not. When a maternal blood smear is treated with acid, adult cells become "ghost cells," while fetal RBCs remain dark pink. This allows for the **quantification** of fetal cells to estimate the volume of hemorrhage. * **Why Other Options are Incorrect:** * **A. Rosette Test:** This is a **qualitative** (screening) test. It detects the presence of fetal cells but cannot quantify the volume of the bleed. If positive, it must be followed by a KB test. * **C. Indirect Coombs Test (ICT):** This detects maternal antibodies against Rh antigens. It is used for screening sensitization, not for quantifying an acute bleed. * **D. MCA-PSV:** This Doppler ultrasound parameter is the gold standard for detecting **fetal anemia**, not for quantifying the volume of maternal-fetal hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **Formula for Anti-D dose:** (Volume of fetal bleed in mL / 30) + 1 (safety factor). * **Timing:** Anti-D should ideally be given within **72 hours** of the sensitizing event. * **Flow Cytometry:** This is an automated alternative to the KB test, offering better precision and less inter-observer variation.

Q: In twin pregnancy, vaginal delivery is contraindicated in which of the following conditions?

Monochorionic monoamniotic twins. **Explanation:** The mode of delivery in twin pregnancies depends primarily on the presentation of the twins and the type of placentation. **Why Option A is Correct:** **Monochorionic Monoamniotic (MCMA) twins** are a high-risk category where both fetuses share a single amniotic sac. Vaginal delivery is **contraindicated** (elective Cesarean section is recommended at 32–34 weeks) due to the extremely high risk of **cord entanglement** and cord prolapse. As the first twin descends, the entangled cords can tighten, leading to acute fetal distress or sudden fetal demise of one or both twins. **Why the other options are Incorrect:** * **B. First twin vertex, second twin breech:** This is the most common "discordant" presentation. Vaginal delivery is generally favorable. After the birth of the first twin, the second twin can be delivered via assisted breech delivery or internal podalic version. * **C. Second twin transverse:** If the first twin is vertex, a transverse second twin is not an absolute contraindication to vaginal delivery. After the first birth, the second twin often converts to longitudinal lie spontaneously, or the clinician can perform external or internal version. * **D. First twin mentoanterior:** While a mentoposterior presentation requires a C-section, a **mentoanterior** presentation (face presentation) is a vaginal delivery-possible position, provided the pelvis is adequate and there is no cephalopelvic disproportion. **High-Yield Clinical Pearls for NEET-PG:** * **Locked Twins:** Occurs most commonly when the first twin is breech and the second is vertex (Breech-Vertex). This is a classic indication for C-section. * **Ideal Delivery Timing:** MCMA twins (32–34 weeks via C-section); MCDA twins (36–37 weeks); DCDA twins (37–38 weeks). * **Prerequisite for Vaginal Delivery:** The first twin **must** be in vertex presentation. If the first twin is non-vertex, C-section is mandatory.

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

Apply McDonald suture. ### Explanation The clinical presentation of a patient with a history of mid-trimester abortions and current cervical "funneling" (opening of the internal os) at 22 weeks is diagnostic of **Cervical Insufficiency**. **1. Why Option D is Correct:** The management of cervical insufficiency is **Cervical Cerclage**. Since the patient is currently pregnant (22 weeks), a **McDonald suture** is the most appropriate choice. It is a non-absorbable, purse-string suture placed at the cervicovaginal junction to provide mechanical support to the weak cervix, preventing further dilation and premature birth. **2. Why Incorrect Options are Wrong:** * **Options A & B (Dinoprostone/Misoprostol):** These are prostaglandins used for cervical ripening and induction of labor or abortion. Administering them would worsen the condition by further softening the cervix and inducing uterine contractions. * **Option C (Fothergill Suture):** This is a component of the Fothergill (Manchester) operation used for treating **pelvic organ prolapse** in women who wish to retain their uterus. It involves amputation of the cervix and is never performed during pregnancy. **3. High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Cerclage is ideally performed between **12–14 weeks** (Elective/Prophylactic). In this case, it is an **Emergency/Rescue Cerclage** (performed after cervical changes have started). * **Diagnosis:** On Ultrasound, a cervical length **<25 mm** or significant **funneling** (T, Y, V, U shapes) before 24 weeks indicates insufficiency. * **Shirodkar Cerclage:** An alternative technique where the suture is placed higher (submucosal), often requiring bladder dissection. * **Removal:** The suture is typically removed at **37 completed weeks** or at the onset of labor to allow vaginal delivery.

Q: A patient presents with 6 weeks of amenorrhea and features of shock. What is the most likely diagnosis?

Ectopic pregnancy. ### Explanation The clinical presentation of **amenorrhea followed by sudden shock** in a woman of reproductive age is a classic medical emergency, pointing directly to a **Ruptured Ectopic Pregnancy**. **1. Why Ectopic Pregnancy is Correct:** In an ectopic pregnancy, the blastocyst implants outside the uterine cavity (most commonly in the ampulla of the fallopian tube). As the embryo grows, the tube eventually ruptures (typically between 6–8 weeks), leading to massive **intraperitoneal hemorrhage**. This internal bleeding causes **hemorrhagic shock**, characterized by hypotension, tachycardia, and fainting, often preceded by sharp pelvic pain. **2. Why Other Options are Incorrect:** * **Hydatidiform Mole:** While it presents with amenorrhea and vaginal bleeding, it typically presents with "size greater than dates," hyperemesis, and high hCG levels. It does not cause sudden shock unless there is a rare uterine perforation or severe hemorrhage, which is not the standard presentation. * **Twin Pregnancy:** This is a physiological variation of pregnancy. While it may cause increased morning sickness or larger uterine size, it does not lead to acute shock. **3. Clinical Pearls for NEET-PG:** * **Classic Triad:** Amenorrhea (75%), abdominal pain (95-100%), and vaginal bleeding (60-80%). * **Golden Rule:** Any woman of reproductive age presenting with abdominal pain and shock is a Ruptured Ectopic Pregnancy until proven otherwise. * **Diagnosis:** The investigation of choice is a **Transvaginal Ultrasound (TVS)** combined with **Serum β-hCG** (Discriminatory zone: 1500–2000 mIU/mL). * **Management:** In a patient with shock (hemodynamically unstable), the immediate treatment is **emergency laparotomy** to stop the bleeding. Salpingectomy is the standard procedure.

Question 1

A pregnant patient at 34 weeks gestation presents with leakage. Which investigation can be done to diagnose the leak?

Accepted Answer

Speculum examination

Answer

Ultrasound (USG)

Answer

Non-stress test (NST)

Answer

Three swab test

Question 2

Undiagnosed or undetected ectopic pregnancy is a common cause of maternal death during the first trimester. What is the most valuable diagnostic test in a case of suspected ectopic pregnancy?

Accepted Answer

Transvaginal ultrasonography (USG)

Answer

Serial human chorionic gonadotropin (hCG) levels

Answer

Progesterone measurement

Answer

Culdocentesis

Question 3

Saffron colored meconium is seen in which condition?

Accepted Answer

Postmaturity

Answer

Toxemia of pregnancy

Answer

Breech presentation

Answer

Normal in appearance

Question 4

A 35-year-old female with Gravida-2 and Parity 1+0 is suffering from hepatic encephalopathy. What is the likely cause?

Accepted Answer

Hepatitis E

Answer

Hepatitis B

Answer

Hepatitis D

Answer

Hepatitis A

Question 5

Expectant management of placenta previa includes all of the following except?

Accepted Answer

Cervical cerclage

Answer

Anti-D immunoglobulin

Answer

Blood transfusion

Answer

Steroids

Question 6

A 29-year-old primigravida at 36 weeks gestation with Rh-negative blood type presents with vaginal bleeding and a history of abdominal trauma. Which of the following tests is advised to estimate the size of fetomaternal hemorrhage?

Accepted Answer

Kleihauer acid elution test

Answer

Rosette test

Answer

Indirect Coombs test

Answer

Middle cerebral artery peak systolic velocity

Question 7

In twin pregnancy, vaginal delivery is contraindicated in which of the following conditions?

Accepted Answer

Monochorionic monoamniotic twins

Answer

First twin vertex, second twin breech

Answer

Second twin transverse

Answer

First twin mentoanterior

Question 8

A gravida 3 female with two previous second-trimester abortions presents at 22 weeks of gestation with funneling of the cervix. 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

A patient presents with 6 weeks of amenorrhea and features of shock. What is the most likely diagnosis?

Accepted Answer

Ectopic pregnancy

Answer

Hydatidiform mole

Answer

Twin pregnancy

Answer

None of the above

Question 10

All of the following are maternal adverse outcomes that are increased in women with threatened abortion, except?

Accepted Answer

Gestational diabetes

Answer

Placenta previa

Answer

Placental abruption

Answer

Manual removal of placenta

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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