Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 851: Caudal regression syndrome is seen in which of the following maternal conditions?

A. Preeclampsia
B. Gestational diabetes (Correct Answer)
C. Sickle-Cell anemia
D. Systemic lupus erythematosus

Explanation: **Explanation:** **Caudal Regression Syndrome (CRS)** is a rare congenital defect characterized by varying degrees of developmental failure involving the lower spine (sacrum/lumbar), spinal cord, and corresponding lower limbs. **Why Gestational Diabetes is the Correct Answer:** While the question uses the term "Gestational Diabetes," it is crucial to note that CRS is most strongly associated with **Pre-gestational Diabetes (Type 1 or Type 2)** where hyperglycemia is present during the period of organogenesis (first 8 weeks). Maternal hyperglycemia leads to oxidative stress and altered gene expression in the developing embryo. Although rare, CRS is considered the **most specific** (pathognomonic) fetal malformation associated with maternal diabetes, occurring at a rate 200 times higher than in the general population. **Why Other Options are Incorrect:** * **Preeclampsia:** This is a hypertensive disorder of pregnancy. It is associated with placental insufficiency, IUGR, and abruption, but not specific structural malformations like CRS. * **Sickle-Cell Anemia:** This maternal hematological condition increases the risk of preterm labor and low birth weight but is not teratogenic. * **Systemic Lupus Erythematosus (SLE):** Maternal SLE is classically associated with **Congenital Heart Block** in the fetus (due to anti-Ro/SSA and anti-La/SSB antibodies), not skeletal defects like CRS. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Malformation in Diabetes:** Congenital Heart Defects (specifically **Ventricular Septal Defect**). * **Most Specific Malformation in Diabetes:** Caudal Regression Syndrome (Sacral Agenesis). * **Cardiac Pathognomonic Sign:** Hypertrophic Cardiomyopathy (asymmetric septal hypertrophy). * **HbA1c Correlation:** The risk of malformations increases significantly if maternal HbA1c is >8.5% during the first trimester.

Question 852: What is the most reliable method for diagnosing fetal wellbeing?

A. L:S ratio
B. HPL levels
C. Kick test
D. Ultrasound (Correct Answer)

Explanation: **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 853: What is the specific gravity of amniotic fluid?

A. 1.213
B. 1.01 (Correct Answer)
C. 1.51
D. 1.1

Explanation: **Explanation:** Amniotic fluid is a dynamic, clear to pale-yellow liquid that surrounds the fetus. Its composition changes significantly throughout pregnancy. In the early stages, it is an ultrafiltrate of maternal plasma, but as the pregnancy progresses (especially after 12 weeks), fetal urine becomes the primary contributor. **Why the correct answer is right:** The specific gravity of amniotic fluid typically ranges between **1.008 and 1.010**. This low specific gravity is due to the fact that amniotic fluid is approximately **98–99% water**, with the remaining 1–2% consisting of organic and inorganic solids (proteins, lipids, electrolytes, and urea). As the fetus matures, the specific gravity tends to decrease slightly because the increasing volume of fetal urine is hypotonic. Option B (1.01) is the closest standard value representing this physiological state. **Why the incorrect options are wrong:** * **Options A (1.213) and C (1.51):** These values are far too high. For context, the specific gravity of whole blood is approximately 1.050–1.060. Values above 1.2 would indicate a substance much denser than any normal human body fluid. * **Option D (1.1):** While closer than the others, 1.1 is still significantly higher than the density of amniotic fluid. This value would represent a highly concentrated fluid, whereas amniotic fluid remains relatively dilute throughout gestation. **High-Yield Clinical Pearls for NEET-PG:** * **pH:** Amniotic fluid is slightly **alkaline** (pH 7.0–7.5). This is the basis of the **Nitrazine test** for Rupture of Membranes (ROM), where the paper turns blue. * **Osmolality:** It is nearly isotonic to maternal plasma in early pregnancy but becomes **hypotonic** (approx. 250 mOsm/L) toward term as fetal kidneys mature. * **Volume:** Peaks at approximately **800 ml at 34 weeks** and decreases to about 600 ml at term (40 weeks). * **Color:** Normal is colorless/straw-colored. Abnormal colors include **Green** (Meconium), **Golden** (Rh incompatibility), **Saffron** (Post-maturity), and **Dark Red/Tobacco** (IUD).

Question 854: A pregnant patient at 20 weeks gestation presents with fever and dysuria, leading to a preliminary diagnosis of cystitis. Which of the following antibiotics is safe to use for this patient?

A. Ciprofloxacin
B. Gentamicin
C. Cotrimoxazole
D. Amoxicillin (Correct Answer)

Explanation: **Explanation:** **Correct Answer: D. Amoxicillin** **Why Amoxicillin is correct:** Amoxicillin is a penicillin-group antibiotic and is classified as **FDA Pregnancy Category B**. It is considered safe and effective for treating Urinary Tract Infections (UTIs) in pregnancy because it does not cross the placental barrier in harmful concentrations and lacks teratogenic potential. In pregnant patients, asymptomatic bacteriuria and cystitis must be treated promptly to prevent progression to pyelonephritis, which is associated with preterm labor. **Why the other options are incorrect:** * **A. Ciprofloxacin:** Fluoroquinolones are generally avoided in pregnancy (Category C) as they have a high affinity for bone and cartilage, potentially causing **arthropathy** and permanent cartilage damage in the developing fetus. * **B. Gentamicin:** Aminoglycosides are associated with **ototoxicity** (damage to the 8th cranial nerve) and potential nephrotoxicity in the fetus. They are reserved for life-threatening infections like severe pyelonephritis where no safer alternative exists. * **C. Cotrimoxazole:** This is a combination of Sulfamethoxazole and Trimethoprim. Trimethoprim is a **folate antagonist** (risk of neural tube defects in the 1st trimester), and Sulfonamides can displace bilirubin from albumin, leading to **kernicterus** in the newborn if used near term. **NEET-PG High-Yield Pearls:** * **Drug of Choice for UTI in Pregnancy:** Nitrofurantoin (avoided only at term/near labor due to risk of neonatal hemolysis) or Amoxicillin/Cephalosporins. * **Safe Antibiotics (Category B):** Penicillins, Cephalosporins, Erythromycin (except estolate form), and Azithromycin. * **Teratogenic mnemonic:** "**T**atty **C**ats **A**re **G**reedy" (**T**etracycline - stained teeth; **C**hloramphenicol - Gray baby syndrome; **A**minoglycosides - Ototoxicity; **G**luoroquinolones - Cartilage damage).

Question 855: What does the following ultrasound show?

A. Normal pregnancy
B. Ectopic pregnancy (Correct Answer)
C. Hydatidiform mole
D. Ovarian cyst

Explanation: ***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.

Question 856: Which of the following physiological changes is NOT true in pregnancy?

A. Blood volume is maximum at 36 weeks gestation. (Correct Answer)
B. Cardiac output is maximum at 30 weeks gestation.
C. Ureters dilate maximally in mid-pregnancy.
D. Serum cholesterol levels are maximum at 32 weeks gestation.

Explanation: ### Explanation **1. Why Option A is the Correct Answer (The "Not True" Statement):** In pregnancy, blood volume begins to increase at 6 weeks, rises rapidly until the mid-trimester, and reaches its **peak at 30–32 weeks gestation**. After this peak, it remains relatively plateaued until term. The statement that it is maximum at 36 weeks is physiologically incorrect and a common trap in NEET-PG questions. **2. Analysis of Incorrect Options (True Statements):** * **Option B:** Cardiac output increases by 40–50%. It reaches its maximum at **30–32 weeks** (paralleling blood volume). Note: It also spikes significantly during the second stage of labor and immediately postpartum. * **Option C:** Progesterone causes smooth muscle relaxation, and the enlarging uterus causes mechanical compression. This leads to physiological hydroureter and hydronephrosis, which is most pronounced in **mid-pregnancy** (around 20–24 weeks) and is more common on the right side. * **Option D:** Pregnancy is a state of "physiological hyperlipidemia." Serum cholesterol and triglycerides rise significantly to provide nutrients for the fetus and precursors for steroid hormones, peaking around **32 weeks**. **3. High-Yield Clinical Pearls for NEET-PG:** * **Plasma vs. RBC Mass:** Plasma volume increases (50%) more than RBC mass (20–30%), leading to **physiological anemia** of pregnancy (hemodilution). * **Heart Sounds:** A loud S1 and a physiological S3 are common; however, a **diastolic murmur is always pathological**. * **Blood Pressure:** Diastolic BP decreases more than systolic BP, reaching its nadir at 24–28 weeks. * **Positioning:** Cardiac output is highest in the **left lateral position** due to the relief of aortocaval compression.

Question 857: What is the treatment of choice for intrahepatic cholestasis of pregnancy?

A. Cholestyramine
B. Ursodiol (Ursodeoxycholic acid) (Correct Answer)
C. Corticosteroids (Dexamethasone)
D. Antihistamines

Explanation: **Explanation:** **Intrahepatic Cholestasis of Pregnancy (ICP)** is a reversible form of cholestasis occurring in the late second or third trimester, characterized by intense pruritus (typically on palms and soles) and elevated serum bile acids. **Why Ursodeoxycholic Acid (UDCA) is the Correct Choice:** UDCA is the **first-line treatment of choice** for ICP. It is a naturally occurring hydrophilic bile acid that works by: 1. **Displacing** more toxic, hydrophobic endogenous bile acids from the enterohepatic circulation. 2. **Stimulating** the expression of bile acid transporters, thereby reducing serum bile acid levels. 3. **Improving symptoms:** It effectively reduces maternal pruritus and improves liver function tests. 4. **Fetal Protection:** Most importantly, it may reduce the risk of adverse neonatal outcomes like stillbirth and preterm birth. **Analysis of Incorrect Options:** * **A. Cholestyramine:** An anion-exchange resin that binds bile acids in the gut. While it may reduce pruritus, it is less effective than UDCA and can cause Vitamin K deficiency, increasing the risk of postpartum hemorrhage. * **C. Corticosteroids (Dexamethasone):** Previously used to suppress fetoplacental estrogen production, but studies have shown they are not effective in relieving pruritus or improving biochemical markers in ICP. * **D. Antihistamines:** These may provide mild symptomatic relief for itching (sedative effect) but do not address the underlying pathology or lower bile acid levels. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnostic Marker:** Elevated **Serum Bile Acids (>10 µmol/L)** is the most sensitive biochemical marker. * **Fetal Risk:** The risk of sudden intrauterine fetal death (IUFD) increases significantly when bile acids exceed **40–100 µmol/L**. * **Management:** Active management (delivery) is usually recommended between **36 0/7 to 39 0/7 weeks**, depending on bile acid levels. * **Recurrence:** ICP has a high recurrence rate (60–70%) in subsequent pregnancies.

Question 858: 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?

A. Aspirin alone
B. Aspirin and heparin (Correct Answer)
C. Low molecular weight heparin (LMWH)
D. Warfarin for 6 months

Explanation: **Explanation:** The patient has **Antiphospholipid Antibody Syndrome (APS)** with a history of prior thrombotic events (DVT) and a current acute DVT. In pregnancy, APS significantly increases the risk of recurrent thrombosis and adverse obstetric outcomes (miscarriage, preeclampsia, IUGR). **Why Option B is Correct:** The standard of care for a pregnant woman with **thrombotic APS** is the combination of **Low-Dose Aspirin (LDA) and Heparin** (typically Low Molecular Weight Heparin). Aspirin inhibits platelet aggregation, while heparin provides systemic anticoagulation. For patients with a history of thrombosis, "therapeutic" or "intermediate" doses of heparin are often required throughout pregnancy and for 6 weeks postpartum to prevent life-threatening recurrent emboli. **Why Other Options are Incorrect:** * **A. Aspirin alone:** This is insufficient for thrombotic APS. Aspirin alone may be considered in asymptomatic APL-positive patients, but not in those with a history of DVT. * **C. LMWH alone:** While LMWH is the mainstay of anticoagulation, clinical trials and guidelines (like RCOG/ACOG) show superior outcomes in preventing pregnancy loss when combined with Aspirin. * **D. Warfarin:** Warfarin is **teratogenic** (causing fetal warfarin syndrome/chondrodysplasia punctata), especially between 6–12 weeks of gestation. It is generally avoided in pregnancy unless the patient has a mechanical heart valve. **High-Yield Clinical Pearls for NEET-PG:** 1. **Diagnosis of APS:** Requires at least one clinical criteria (Vascular thrombosis or specific Pregnancy morbidity) AND one laboratory criteria (Lupus anticoagulant, Anti-cardiolipin, or Anti-β2 glycoprotein-I antibodies) positive on two occasions 12 weeks apart. 2. **Obstetric APS Management:** * *Recurrent early loss:* LDA + Prophylactic Heparin. * *Prior Thrombosis:* LDA + Therapeutic Heparin. 3. **Postpartum:** Anticoagulation must continue for at least 6 weeks after delivery, as the risk of DVT is highest during the puerperium.

Question 859: A pregnant mother is treated with oral anticoagulant. What is the likely congenital malformation that may result in the fetus?

A. Long bones limb defect
B. Cranial malformation
C. Cardiovascular malformation
D. Chondrodysplasia punctata (Correct Answer)

Explanation: **Explanation:** The correct answer is **Chondrodysplasia punctata**. This condition is the hallmark of **Fetal Warfarin Syndrome (Warfarin Embryopathy)**, which occurs when oral anticoagulants (specifically Vitamin K antagonists like Warfarin) are administered during the first trimester (6–9 weeks of gestation). **Why it is correct:** Warfarin crosses the placenta and interferes with the γ-carboxylation of proteins required for bone and cartilage formation (such as osteocalcin). This leads to **Chondrodysplasia punctata**, characterized by "stippled epiphyses" (calcific punctate deposits in the ends of bones) on X-ray. Other classic features include **nasal hypoplasia** (depressed nasal bridge) and midface hypoplasia. **Why the other options are incorrect:** * **A. Long bones limb defect:** While Warfarin affects bone development, it typically causes stippling and shortening rather than gross limb reduction defects (which are more characteristic of Thalidomide). * **B. Cranial malformation:** Though CNS anomalies (like microcephaly or hydrocephalus) can occur if Warfarin is used in the 2nd or 3rd trimester due to fetal hemorrhage, they are not the primary "stippled" malformation associated with early exposure. * **C. Cardiovascular malformation:** These are more commonly associated with Lithium (Ebstein’s anomaly) or uncontrolled maternal diabetes, rather than oral anticoagulants. **High-Yield Clinical Pearls for NEET-PG:** * **Critical Period:** Exposure between **6–9 weeks** gestation is most teratogenic for bone defects. * **Safe Alternative:** **Heparin** (both UFH and LMWH) is the anticoagulant of choice in pregnancy because it is a large molecule and **does not cross the placenta**. * **Late Pregnancy Risk:** Warfarin in the 3rd trimester increases the risk of fetal intracranial hemorrhage during labor.

Question 860: Which of the following statements is NOT true regarding the amniotic fluid index (AFI)?

A. It is calculated by adding the vertical depths of the largest pocket in each of four equal uterine quadrants.
B. Fluid restriction may lead to a lower AFI.
C. Significant hydramnios is defined by an AFI greater than 24 cm.
D. There is a steady increase in AFI after 36 weeks of gestation. (Correct Answer)

Explanation: **Explanation:** The correct answer is **D**. In normal pregnancy, amniotic fluid volume (AFV) reaches its peak of approximately 800–1000 mL at **34–36 weeks** of gestation. After this peak, there is a **steady physiological decline** in the volume, reaching about 400 mL by 42 weeks. Therefore, the statement that AFI increases after 36 weeks is incorrect. **Analysis of other options:** * **Option A:** This describes the **Phelan’s technique**. The uterus is divided into four quadrants using the umbilicus and the linea nigra as landmarks. The sum of the deepest vertical pockets (devoid of fetal parts or cord) in each quadrant gives the AFI. * **Option B:** Maternal hydration status directly influences amniotic fluid. **Dehydration** increases maternal plasma osmolality, leading to decreased fetal urine production and a lower AFI. Conversely, oral or IV hydration can increase AFI. * **Option C:** Polyhydramnios (hydramnios) is classically defined as an **AFI > 24 cm** or a single deepest pocket (SDP) > 8 cm. **High-Yield Clinical Pearls for NEET-PG:** * **Normal AFI range:** 5 cm to 24 cm. * **Oligohydramnios:** AFI < 5 cm or SDP < 2 cm. * **Gold Standard for AFV:** Dye dilution technique (though rarely used clinically; ultrasound is the standard). * **Potter’s Sequence:** Associated with severe oligohydramnios (secondary to renal agenesis), leading to pulmonary hypoplasia and limb deformities. * **Commonest cause of Polyhydramnios:** Idiopathic (60%), followed by Maternal Diabetes.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

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Multiple Gestation

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Rh Isoimmunization and Other Blood Group Incompatibilities

Practice Questions

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

Practice Questions

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