Maternal-Fetal Medicine Practice Questions

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: 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: Oligohydramnios is defined by an Amniotic Fluid Index (AFI) of:

Less than 5 cm. **Explanation:** Amniotic fluid volume is a critical indicator of fetal well-being and placental function. The **Amniotic Fluid Index (AFI)** is calculated using the Phelan technique, where the vertical depth of the largest pocket in each of the four uterine quadrants is measured and summed. **1. Why Option B is Correct:** The standard diagnostic threshold for **Oligohydramnios** is an **AFI of less than 5 cm** (or a Single Deepest Pocket < 2 cm). This value represents the 5th percentile for gestational age and is clinically significant as it correlates with increased risks of cord compression, fetal distress, and meconium aspiration. **2. Analysis of Incorrect Options:** * **Option A (< 8 cm):** While an AFI between 5 cm and 8 cm is often termed "borderline" or "low-normal," it does not meet the formal diagnostic criteria for oligohydramnios. * **Option C (< 2 cm):** This is an extremely low value. While an AFI < 2 cm certainly indicates oligohydramnios, the *definition* starts at the 25 cm** or a Single Deepest Pocket > 8 cm. * **Common Causes of Oligohydramnios:** Renal agenesis (Potter sequence), Premature Rupture of Membranes (PROM), and Uteroplacental insufficiency (IUGR). * **Gold Standard:** The most accurate method to measure amniotic fluid is the dye-dilution technique, but it is invasive and rarely used clinically. * **Management:** In isolated term oligohydramnios, induction of labor is generally preferred over expectant management.

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: $[Weight (g) \times 100] / [Length (cm)]^3$).

Q: Which of the following is not teratogenic for fetal development?

Herpes. **Explanation:** The correct answer is **Herpes (HSV-2)**. In the context of teratogenicity—which refers to agents causing structural malformations during organogenesis (typically the first trimester)—Herpes Simplex Virus is generally not considered a classic teratogen. While HSV can cause devastating neonatal infection, it is usually transmitted **perinatally** (during passage through the birth canal) rather than transplacentally during early development. **Why the other options are incorrect:** * **Rubella:** A classic member of the TORCH complex. Infection in the first trimester leads to **Congenital Rubella Syndrome**, characterized by the triad of cataracts, sensorineural deafness, and cardiac defects (PDA). * **Alcohol:** The most common preventable cause of teratogenicity. It leads to **Fetal Alcohol Syndrome (FAS)**, presenting with microcephaly, smooth philtrum, thin upper lip, and intellectual disability. * **Tetracycline:** A well-known pharmacological teratogen. It crosses the placenta and chelates calcium, leading to **permanent yellow-brown discoloration of deciduous teeth** and inhibition of bone growth. **High-Yield Clinical Pearls for NEET-PG:** * **TORCH Agents:** Remember that while Rubella, CMV, and Toxoplasmosis are classic teratogens, **HSV and HIV** are primarily transmitted during delivery (vertical transmission). * **Rule of Thumb:** Teratogens act most severely during the **3rd to 8th week** of gestation (organogenesis). * **Tetracycline Timing:** It affects teeth if taken after the 14th week of gestation when deciduous teeth begin to calcify. * **Safe Antibiotics in Pregnancy:** Penicillins, Cephalosporins, and Erythromycin are generally preferred over Tetracyclines or Fluoroquinolones.

Q: What is the ratio of placental weight to fetal weight at term?

1:6. **Explanation:** The **placental-fetal weight ratio** is a critical indicator of placental efficiency and fetal growth. At full term (37–40 weeks), the average weight of a healthy placenta is approximately **500 grams**, while the average weight of a newborn is approximately **3000 grams (3 kg)**. Dividing the fetal weight by the placental weight (3000/500) yields a ratio of **1:6**. **Analysis of Options:** * **Option C (1:6) - Correct:** This is the physiological norm at term. It represents the optimal balance where the placenta has reached its functional peak to support the metabolic demands of a full-grown fetus. * **Options A (1:4) and B (1:5):** These ratios are typically seen earlier in pregnancy (around 32–34 weeks). In early gestation, the placenta is disproportionately large compared to the fetus to establish the necessary surface area for nutrient exchange. * **Option D (1:7):** This ratio may be seen in cases of placental insufficiency or fetal macrosomia, where the placenta is relatively small compared to the fetus, potentially compromising oxygenation. **High-Yield Clinical Pearls for NEET-PG:** * **Early Pregnancy:** At 17 weeks, the placenta and fetus weigh roughly the same (Ratio 1:1). * **Placental Weight:** It is generally **1/6th** of the baby's weight at birth. * **Clinical Significance:** An increased ratio (e.g., 1:10) is seen in gestational diabetes or fetal hydrops (large placenta). A decreased ratio is often associated with Intrauterine Growth Restriction (IUGR). * **Dimensions:** A term placenta is discoid, 15–20 cm in diameter, and 3 cm thick at its center.

Q: Alpha-fetoprotein (AFP) is raised in all except:

Trisomy 21 (Down syndrome). **Explanation:** Alpha-fetoprotein (AFP) is a glycoprotein synthesized initially by the fetal yolk sac and later by the fetal liver. It is the fetal equivalent of albumin. Monitoring maternal serum AFP (MSAFP) is a crucial screening tool for fetal anomalies. **Why Trisomy 21 is the correct answer:** In **Trisomy 21 (Down syndrome)**, MSAFP levels are characteristically **decreased** (usually <0.5 MoM), not raised. This is thought to be due to a decrease in the functional mass of the fetal liver or a delay in its maturation. In a triple or quadruple screen for Down syndrome, you typically see "Low AFP, Low Estriol, and High hCG/Inhibin-A." **Analysis of incorrect options (Conditions where AFP is raised):** * **Polycystic Kidney Disease:** Any fetal renal anomaly (including congenital nephrosis or polycystic kidneys) leads to increased protein excretion into the amniotic fluid, raising AFP levels. * **Esophageal Atresia:** AFP is normally swallowed by the fetus and degraded in the GI tract. In esophageal or duodenal atresia, the fetus cannot swallow amniotic fluid, leading to AFP accumulation. * **Intrauterine Death (IUD):** Fetal death leads to the breakdown of fetal tissues and skin, causing a massive leakage of AFP into the amniotic fluid and subsequently into the maternal circulation. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of raised MSAFP:** Incorrect gestational age (under-dating). * **Highest levels of AFP:** Seen in **Anencephaly** and **Open Neural Tube Defects (ONTD)** due to direct exposure of fetal vessels to amniotic fluid. * **Other causes of raised AFP:** Omphalocele, Gastroschisis, Multiple gestations, and Patau syndrome (Trisomy 13). * **Causes of decreased AFP:** Trisomy 21, Trisomy 18 (Edwards syndrome), Gestational Trophoblastic Disease (Molar pregnancy), and Maternal Obesity.

Q: Singer's alkali denaturation test is performed for?

Vasa previa. **Explanation:** The **Singer’s alkali denaturation test** (also known as the Apt test) is used to differentiate between **fetal hemoglobin (HbF)** and **adult hemoglobin (HbA)**. The test relies on the principle that fetal hemoglobin is resistant to denaturation by strong alkalis (like Potassium Hydroxide), whereas adult hemoglobin is not. 1. **Why Vasa Previa is Correct:** In vasa previa, the bleeding originates from the fetal vessels crossing the internal os. When vaginal bleeding occurs, it is critical to determine if the blood is maternal or fetal. In the Singer test, the blood is mixed with 1% KOH; if the solution remains **pink**, it indicates the presence of HbF (fetal blood), confirming the diagnosis of vasa previa. If it turns yellow-brown, it is maternal blood. 2. **Why Incorrect Options are Wrong:** * **Rh Incompatibility:** This is managed by Kleihauer-Betke (KB) test (to quantify feto-maternal hemorrhage) or Indirect Coombs Test, not Singer’s test. * **Abruptio Placenta:** The bleeding here is primarily maternal in origin (retroplacental hemorrhage). * **Preterm Labor:** This is a clinical diagnosis based on uterine contractions and cervical changes; biochemical tests like Fetal Fibronectin (fFN) are used, not hemoglobin denaturation tests. **High-Yield Clinical Pearls for NEET-PG:** * **Apt Test vs. Kleihauer-Betke (KB) Test:** Apt test is a qualitative bedside test for vaginal blood; KB test is a quantitative acid-elution test used on maternal peripheral blood to calculate the dose of Anti-D. * **Vasa Previa Triad:** Rupture of membranes + Painless vaginal bleeding + Fetal bradycardia/distress. * **HbF Resistance:** HbF is resistant to both **alkali** (Singer/Apt test) and **acid** (KB test).

Question 1

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 2

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 3

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 4

Oligohydramnios is defined by an Amniotic Fluid Index (AFI) of:

Accepted Answer

Less than 5 cm

Answer

Less than 8 cm

Answer

Less than 2 cm

Answer

Less than 1 cm

Question 5

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

Accepted Answer

Phenothiazine

Answer

Nicotine

Answer

Alcohol

Answer

Propranolol

Question 6

Which of the following is not teratogenic for fetal development?

Accepted Answer

Herpes

Answer

Rubella

Answer

Alcohol

Answer

Tetracycline

Question 7

What is the ratio of placental weight to fetal weight at term?

Accepted Answer

1:6

Answer

1:4

Answer

1:5

Answer

1:7

Question 8

Alpha-fetoprotein (AFP) is raised in all except:

Accepted Answer

Trisomy 21 (Down syndrome)

Answer

Polycystic kidney disease

Answer

Intrauterine device (IUD) use

Answer

Esophageal atresia

Question 9

A pregnant woman at 39 weeks gestation with a singleton fetus in cephalic presentation develops chickenpox. She has no other pregnancy complications. What is the best method to prevent neonatal infection?

Accepted Answer

Continue the pregnancy for at least one week.

Answer

Administer varicella zoster immune globulin (VZIG) to the neonate soon after birth.

Answer

Administer varicella zoster vaccine to the neonate soon after birth.

Answer

Induce labor immediately.

Question 10

Singer's alkali denaturation test is performed for?

Accepted Answer

Vasa previa

Answer

Rh incompatibility

Answer

Abruptio placenta

Answer

Preterm labor

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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