Maternal-Fetal Medicine Practice Questions

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.

Q: A patient at 28 weeks gestation presents with low-grade fever, malaise, and vomiting for one week. On examination, she is icteric. Her Hb is 10 gm%, bilirubin is 5 mg/dL, SGOT and SGPT are 630 and 600 respectively, with a normal platelet count. What is the most probable cause of her jaundice?

Viral hepatitis. ### Explanation The clinical presentation of low-grade fever, malaise, and vomiting followed by jaundice (bilirubin 5 mg/dL) and significantly elevated transaminases (SGOT/SGPT > 500 IU/L) is classic for **Viral Hepatitis**. In pregnancy, viral hepatitis is the most common cause of jaundice worldwide. **Why Viral Hepatitis is correct:** * **Transaminase levels:** SGOT and SGPT levels in the 600s indicate acute hepatocellular injury. In most pregnancy-specific conditions, these levels rarely exceed 300–500 IU/L. * **Prodromal symptoms:** Fever, malaise, and vomiting are typical of a viral prodrome. * **Bilirubin:** A level of 5 mg/dL is consistent with hepatic parenchymal inflammation. **Why the other options are incorrect:** * **Intrahepatic Cholestasis of Pregnancy (IHCP):** Characterized primarily by intense pruritus (palms and soles) and elevated bile acids. Transaminases are only mildly elevated, and jaundice is usually mild or absent. * **Hyperemesis Gravidarum:** This occurs in the *first trimester* (usually <16 weeks). While it can cause mild transaminase elevation, it would not present at 28 weeks with fever and significant jaundice. * **HELLP Syndrome:** This is a triad of Hemolysis (low Hb, high LDH), Elevated Liver enzymes, and **Low Platelets**. The patient has a normal platelet count and no evidence of hemolysis, making this diagnosis unlikely. **NEET-PG High-Yield Pearls:** * **Most common cause of jaundice in pregnancy:** Viral Hepatitis (Hepatitis E is particularly associated with high mortality in pregnancy). * **AFLP vs. HELLP:** Acute Fatty Liver of Pregnancy (AFLP) presents with hypoglycemia and deranged coagulation (high PT/INR), which helps differentiate it from HELLP. * **Rule of Thumb:** If SGOT/SGPT are >1000 IU/L in pregnancy, always suspect Viral Hepatitis or drug-induced injury first.

Q: A 22-year-old primigravida at 11 weeks of gestational age has a blood pressure reading of 150/100 mm Hg obtained during a routine visit. The patient denies any headache, visual changes, nausea, vomiting, or abdominal pain. Her repeat BP is 160/90 mm Hg, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?

Chronic hypertension. ### Explanation **1. Why Chronic Hypertension is Correct:** The diagnosis of hypertensive disorders in pregnancy is primarily based on the **gestational age** at onset. Chronic hypertension is defined as high blood pressure (≥140/90 mm Hg) that is present **before pregnancy** or diagnosed **before 20 weeks of gestation**. In this case, the patient is at 11 weeks (first trimester) with a BP of 150/100 mm Hg. Since the hypertension manifested before the 20-week cutoff, it is classified as chronic hypertension. **2. Why Other Options are Incorrect:** * **Preeclampsia:** This is a multi-system disorder characterized by hypertension arising **after 20 weeks** of gestation, typically accompanied by proteinuria or end-organ dysfunction. Since this patient is only at 11 weeks and has no proteinuria, preeclampsia is excluded. * **Gestational Hypertension:** This refers to new-onset hypertension (without proteinuria) occurring **after 20 weeks** of gestation in a previously normotensive woman. * **Eclampsia:** This is the onset of generalized tonic-clonic seizures in a woman with preeclampsia. This patient is asymptomatic (no seizures, no headache) and does not meet the criteria for preeclampsia. **3. NEET-PG High-Yield Pearls:** * **The 20-Week Rule:** This is the "Golden Rule" for PG exams. Hypertension 20 weeks = Gestational HTN or Preeclampsia. * **Exception to the Rule:** If hypertension and proteinuria appear before 20 weeks, consider **Hydatidiform Mole** or multiple pregnancy. * **Superimposed Preeclampsia:** This occurs when a patient with known chronic hypertension develops new-onset proteinuria or sudden worsening of BP/symptoms after 20 weeks. * **White Coat Hypertension:** Defined as elevated BP in the clinic but normal readings at home; it affects up to 15% of pregnant women.

Q: All of the following can be administered in acute hypertension during labor EXCEPT?

IV Nitroprusside. **Explanation:** The management of acute severe hypertension in labor (Systolic BP ≥160 mmHg or Diastolic BP ≥110 mmHg) aims to prevent maternal cerebrovascular accidents while maintaining placental perfusion. **Why IV Nitroprusside is the Correct Answer:** IV Nitroprusside is generally **avoided** in labor and pregnancy. Its metabolism involves the release of cyanide; while the mother can detoxify small amounts, the fetus lacks the necessary enzymes, leading to potential **fetal cyanide poisoning**. Additionally, it can cause a sudden, drastic drop in blood pressure, potentially compromising uteroplacental blood flow. It is reserved only as a last resort for refractory hypertension when all other agents have failed. **Analysis of Other Options:** * **IV Labetalol (Option A):** A combined alpha and beta-blocker. It is considered a **first-line agent** for acute hypertensive emergencies in pregnancy due to its rapid onset and favorable safety profile. * **IV Esmolol (Option B):** An ultra-short-acting beta-blocker. While not first-line like Labetalol, it can be used in specific acute settings (e.g., during intubation or aortic dissection in pregnancy) under close monitoring. * **IV Hydralazine (Option C):** A direct vasodilator. It is a traditional **first-line drug** for acute hypertensive crisis in pregnancy, though it carries a slightly higher risk of maternal hypotension compared to Labetalol. **High-Yield Clinical Pearls for NEET-PG:** * **First-line drugs for Acute HTN in Pregnancy:** IV Labetalol, IV Hydralazine, and Oral Nifedipine (Immediate Release). * **Drug of Choice for Eclampsia Prophylaxis:** Magnesium Sulfate ($MgSO_4$). * **Contraindicated Antihypertensives in Pregnancy:** ACE Inhibitors and ARBs (due to teratogenicity/renal agenesis) and Sodium Nitroprusside (due to cyanide toxicity). * **Target BP:** Aim to lower BP to 140–150/90–100 mmHg; avoid normalization to prevent placental hypoperfusion.

Q: Angular pregnancy refers to:

Intrauterine pregnancy. ### Explanation **Angular pregnancy** is defined as the implantation of the embryo in the lateral angle of the uterine cavity, specifically medial to the uterotubal junction and the round ligament. **1. Why the correct answer is right:** The key distinction is that an angular pregnancy is an **intrauterine pregnancy**. Although the embryo implants in a corner (angle) of the uterus, it remains within the endometrial cavity. While it carries a higher risk of spontaneous abortion or uterine rupture compared to a normal mid-cavity pregnancy, it is potentially viable and can sometimes progress to a full-term delivery. **2. Why the incorrect options are wrong:** * **Option A (Interstitial Pregnancy):** This is a type of **ectopic pregnancy**. The embryo implants within the intramural portion of the fallopian tube, which is lateral to the round ligament. Unlike angular pregnancy, interstitial pregnancy is life-threatening and cannot result in a viable birth. * **Option C (Heterotopic Pregnancy):** This refers to the simultaneous occurrence of an intrauterine and an extrauterine (ectopic) pregnancy. * **Option D (Broad Ligament Pregnancy):** This is a rare form of abdominal (ectopic) pregnancy where the fetus develops between the leaves of the broad ligament. **3. Clinical Pearls for NEET-PG:** * **The "Round Ligament Sign":** This is the gold standard for differentiation. In **Angular pregnancy**, the bulge is **medial** to the round ligament. In **Interstitial pregnancy**, the bulge is **lateral** to the round ligament. * **Wassermann’s Sign:** Clinical presentation of angular pregnancy often includes severe pain and asymmetric uterine enlargement. * **Management:** Unlike ectopic pregnancies which require termination (medical/surgical), angular pregnancies are managed expectantly with close ultrasound monitoring, as they may shift toward the center of the uterus as the pregnancy progresses.

Q: Intrauterine growth retardation can be caused by all of the following except:

Phenothiazine. **Explanation:** Intrauterine Growth Restriction (IUGR) occurs when a fetus does not reach its biological growth potential due to maternal, placental, or fetal factors. The correct answer is **Phenothiazine**, as it is not typically associated with fetal growth restriction. **1. Why Phenothiazine is the correct answer:** Phenothiazines (antipsychotics like chlorpromazine) are generally considered safe regarding fetal growth. While some studies suggest a potential risk of neonatal withdrawal or extrapyramidal symptoms if used near term, they are **not** known to cause IUGR. **2. Why the other options are incorrect:** * **Nicotine:** Smoking/Nicotine causes vasoconstriction of utero-placental vessels and increases carboxyhemoglobin levels, leading to fetal hypoxia and significant IUGR. * **Alcohol:** Chronic alcohol consumption leads to Fetal Alcohol Syndrome (FAS). Ethanol and its metabolite, acetaldehyde, interfere with cell division and nutrient transport, making IUGR a hallmark feature. * **Propranolol:** Beta-blockers, particularly Propranolol and Atenolol, are well-documented causes of IUGR. They can cause bradycardia and increase uterine activity, leading to decreased placental perfusion. **Clinical Pearls for NEET-PG:** * **Most common cause of IUGR:** Maternal vascular disease (e.g., Preeclampsia, Chronic Hypertension). * **Symmetric vs. Asymmetric IUGR:** Symmetric IUGR (early onset) is often due to chromosomal anomalies or TORCH infections; Asymmetric IUGR (late onset) is usually due to placental insufficiency. * **Drug-induced IUGR:** Other high-yield drugs include Antimetabolites (Methotrexate), Anticonvulsants (Phenytoin), and Warfarin. * **Ponderal Index:** Used to identify the severity of asymmetric IUGR (Formula: $[Weight (g) \times 100] / [Length (cm)]^3$).

Question 1

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 2

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 3

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 4

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

Question 5

A patient at 28 weeks gestation presents with low-grade fever, malaise, and vomiting for one week. On examination, she is icteric. Her Hb is 10 gm%, bilirubin is 5 mg/dL, SGOT and SGPT are 630 and 600 respectively, with a normal platelet count. What is the most probable cause of her jaundice?

Accepted Answer

Viral hepatitis

Answer

Intrahepatic cholestasis of pregnancy (IHCP)

Answer

Hyperemesis gravidarum

Answer

HELLP syndrome

Question 6

A 22-year-old primigravida at 11 weeks of gestational age has a blood pressure reading of 150/100 mm Hg obtained during a routine visit. The patient denies any headache, visual changes, nausea, vomiting, or abdominal pain. Her repeat BP is 160/90 mm Hg, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?

Accepted Answer

Chronic hypertension

Answer

Preeclampsia

Answer

Eclampsia

Answer

Gestational hypertension

Question 7

All of the following can be administered in acute hypertension during labor EXCEPT?

Accepted Answer

IV Nitroprusside

Answer

IV Labetalol

Answer

IV Esmolol

Answer

IV Hydralazine

Question 8

Angular pregnancy refers to:

Accepted Answer

Intrauterine pregnancy

Answer

Ectopic pregnancy of the interstitial part of the fallopian tube

Answer

Heterotopic pregnancy

Answer

Ectopic pregnancy of the broad ligament

Question 9

Intrauterine growth retardation can be caused by all of the following except:

Accepted Answer

Phenothiazine

Answer

Nicotine

Answer

Alcohol

Answer

Propranolol

Question 10

Which of the following is NOT true about premature rupture of membranes (PROM)?

Accepted Answer

Amnioinfusion is indicated.

Answer

Amoxiclav antibiotic prophylaxis should be administered.

Answer

Cervical examination should be performed aseptically.

Answer

Steroids are used for fetal lung maturation.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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