Maternal-Fetal Medicine Practice Questions

Q: A pregnant lady at 32 weeks' gestation presents with a BP of 160/110 mm Hg, proteinuria, and retinal hemorrhage. What is the definitive management of choice in this case?

Termination of pregnancy. **Explanation:** The patient presents with a blood pressure of 160/110 mm Hg and proteinuria, which confirms a diagnosis of **Preeclampsia**. The presence of **retinal hemorrhage** is a "severity marker" indicating end-organ damage (Grade IV hypertensive retinopathy). This classifies the condition as **Preeclampsia with Severe Features**. **1. Why "Termination of Pregnancy" is correct:** In cases of severe preeclampsia, the definitive treatment is the delivery of the fetus and placenta, regardless of gestational age. Once end-organ damage (like retinal hemorrhage, renal failure, or HELLP syndrome) occurs, the risk of maternal complications (stroke, retinal detachment, or eclampsia) outweighs the benefits of prolonging the pregnancy. At 32 weeks, the goal is maternal safety via termination. **2. Why other options are incorrect:** * **Ritodrine (A):** This is a tocolytic used to *stop* preterm labor. It is contraindicated here because we want to deliver the patient, not prolong the pregnancy. * **Nifedipine (B):** While used to control acute BP, it is a symptomatic treatment, not a definitive cure. * **Magnesium Sulfate (C):** This is the drug of choice for seizure prophylaxis (preventing eclampsia), but it does not treat the underlying pathology. It is an *adjunct* to management, not the definitive treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Definitive treatment for Preeclampsia/Eclampsia:** Delivery (Termination of pregnancy). * **Indications for immediate delivery in Preeclampsia:** BP >160/110 despite meds, platelet count <1 lakh, deteriorating renal/liver function, placental abruption, or visual disturbances/retinal changes. * **Target BP in Severe Preeclampsia:** Maintain between 140/90 and 150/100 mm Hg to prevent hemorrhagic stroke.

Q: In a lady at 32 weeks gestation, an injection of dexamethasone is given to prevent which of the following in the newborn?

Respiratory Distress Syndrome. ### Explanation **Correct Option: A. Respiratory Distress Syndrome (RDS)** The primary goal of administering antenatal corticosteroids (like Dexamethasone or Betamethasone) between 24 and 34 weeks of gestation is to accelerate **fetal lung maturity**. Dexamethasone induces the maturation of **Type II pneumocytes**, which increases the production and release of **surfactant**. Surfactant reduces alveolar surface tension, preventing lung collapse upon expiration. This significantly reduces the incidence and severity of Respiratory Distress Syndrome (RDS), Intraventricular Hemorrhage (IVH), and Necrotizing Enterocolitis (NEC) in preterm neonates. **Why other options are incorrect:** * **B. Neonatal convulsion:** These are typically caused by metabolic disturbances (hypoglycemia, hypocalcemia), birth asphyxia, or infections, rather than a lack of steroids. * **C. Neonatal jaundice:** Steroids do not influence bilirubin metabolism or conjugation in the liver. Jaundice in preterm infants is usually due to hepatic immaturity or hemolysis. * **D. Cerebral palsy:** While steroids reduce IVH (a risk factor for brain injury), they are not primarily given to prevent cerebral palsy. Magnesium sulfate is the drug of choice for neuroprotection in pregnancies <32 weeks. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Dose:** Dexamethasone **6 mg IM every 12 hours (4 doses)** OR Betamethasone **12 mg IM every 24 hours (2 doses)**. * **Window of Efficacy:** Maximum benefit is seen if delivery occurs **after 24 hours** but **within 7 days** of the first dose. * **Rescue Dose:** A single "rescue course" can be given if the initial course was >7 days ago and the patient is still <34 weeks with an imminent risk of delivery. * **Contraindication:** Systemic maternal infection (e.g., Chorioamnionitis).

Q: Regarding autoimmune hemolytic anemia in pregnancy, all are true except?

Usually does not respond to steroids.. ### Explanation **Autoimmune Hemolytic Anemia (AIHA)** in pregnancy is a rare but serious condition characterized by the production of autoantibodies against red blood cell (RBC) antigens. **Why Option C is the Correct Answer (The "Except" Statement):** Contrary to the statement, **steroids (Corticosteroids) are the first-line treatment** for AIHA in pregnancy. Most cases are of the "warm-antibody" type (IgG), which typically shows a dramatic response to prednisone. Steroids work by decreasing antibody production and reducing the clearance of antibody-coated RBCs by the splenic macrophages. **Analysis of Other Options:** * **Option A (Direct Coombs Test):** This is the gold standard for diagnosis. A positive Direct Antiglobulin Test (DAT) confirms the presence of antibodies or complement attached to the patient's RBCs. * **Option B (Pregnancy accelerates hemolysis):** Pregnancy is known to exacerbate AIHA. The physiological changes and altered immune state can lead to increased hemolysis, often requiring higher doses of steroids or even blood transfusions. * **Option C (Fetal Microchimerism):** This is a recognized pathogenic theory. The trafficking of fetal cells into the maternal circulation (microchimerism) can trigger an immune dysregulation, leading to the production of aberrant autoantibodies against maternal RBCs. **High-Yield Clinical Pearls for NEET-PG:** * **Warm AIHA:** Most common type in pregnancy; mediated by **IgG**; responds well to steroids. * **Cold AIHA:** Mediated by **IgM**; usually does not respond to steroids; managed by avoiding cold exposure. * **Fetal Risk:** While maternal IgG can cross the placenta, significant fetal hemolysis is rare. However, there is an increased risk of preterm labor and fetal growth restriction (FGR). * **Second-line therapy:** If steroids fail, intravenous immunoglobulin (IVIG) or splenectomy (preferably in the second trimester) may be considered.

Q: Which of the following is NOT a contraindication for a cervical cerclage operation?

Pregnancy beyond 14 weeks. **Explanation:** Cervical cerclage is a surgical procedure used to treat cervical insufficiency by placing a non-absorbable suture around the cervix. The goal is to provide mechanical support and maintain the structural integrity of the cervical canal. **Why Option D is the Correct Answer:** Pregnancy beyond 14 weeks is **not** a contraindication; in fact, it is the standard timing for the procedure. An **Elective (Prophylactic) Cerclage** is typically performed between **12 and 14 weeks** of gestation, after confirming fetal viability and screening for chromosomal abnormalities (NT scan). Cerclage can also be performed as an "Urgent" or "Emergency" procedure up to 24 weeks if cervical shortening or dilation is noted. **Analysis of Incorrect Options (Contraindications):** * **Ruptured Membranes (A):** If the membranes have ruptured, the risk of ascending infection is extremely high, and the procedure will not prevent preterm birth. * **Chorioamnionitis (B):** Intrauterine infection is an absolute contraindication. Placing a stitch in an infected environment can lead to maternal sepsis. * **Vaginal Bleeding (C):** Active bleeding suggests placental abruption or labor. Cerclage in the presence of uterine activity or abruption can lead to cervical laceration or severe hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **McDonald’s Operation:** The most common technique; a purse-string suture is placed at the cervicovaginal junction. * **Shirodkar’s Operation:** A submucosal stitch placed higher up at the level of the internal os. * **Indication:** History of ≥3 unexplained second-trimester losses or preterm births. * **Suture Removal:** Usually performed at **36–37 weeks** or immediately if labor begins, to prevent cervical rupture. * **Most common complication:** Preterm Prelabor Rupture of Membranes (PPROM).

Q: A patient with a known marginal placenta presents for follow-up. On ultrasound, a 4 x 4 cm placental mass is noted invading into the urinary bladder. What is the most likely diagnosis?

Placenta percreta. ***Placenta percreta*** - This is the most severe form of the **placenta accreta spectrum**, where the placental villi penetrate through the entire uterine wall, including the **serosa**, and invade adjacent organs. - The ultrasound finding of a placental mass invading the **urinary bladder** is the classic presentation of **placenta percreta**. *Placenta previa* - This term describes the location of the placenta, where it partially or completely covers the **internal cervical os**. It does not describe the depth of invasion. - Although **placenta previa** is a significant risk factor for placenta accreta spectrum disorders, the invasion into the bladder points to a specific diagnosis of abnormal adherence, not just location. *Placenta increta* - In **placenta increta**, the placental villi invade into the **myometrium** (uterine muscle) but do not penetrate through to the serosa or adjacent organs. - This represents the intermediate form of the accreta spectrum, more severe than accreta but less severe than percreta. *Placenta accreta* - In **placenta accreta**, the placental villi are abnormally attached to the **myometrium**, but they do not invade the uterine muscle itself. This is the least invasive form of the spectrum. - The finding of invasion into the **urinary bladder** rules out simple accreta, as this requires penetration through the entire myometrium and serosa, which is characteristic of percreta.

Q: Fetal anaemia is primarily determined by Doppler assessment of which artery?

Middle cerebral artery. ***Middle cerebral artery***- The **Middle Cerebral Artery (MCA) peak systolic velocity (PSV)** is the most reliable non-invasive method for detecting moderate to severe fetal anemia.- An elevated MCA-PSV indicates increased cerebral blood flow velocity due to reduced blood viscosity (from anemia) and the **brain-sparing effect**.- *Umbilical artery*- Doppler assessment of the umbilical artery primarily evaluates **placental vascular resistance** (e.g., in fetal growth restriction) using indices like the resistive index (RI) or pulsatility index (PI).- While abnormalities like absent or reversed diastolic flow indicate severe placental insufficiency, they are not the primary diagnostic measure for fetal anemia.- *Ductus venosus*- Ductus venosus Doppler evaluates **fetal cardiac function** and is critical in assessing fetal compromise, especially in conditions leading to hydrops fetalis.- Although reverse flow can be an indicator of severe compromise and impending heart failure (potentially caused by severe anemia), it is secondary to MCA-PSV for the specific diagnosis of anemia.- *Uterine artery*- Uterine artery Doppler assesses **maternal placental perfusion** and resistance, primarily used for screening and monitoring conditions like **preeclampsia** and **fetal growth restriction**.- It measures maternal blood flow to the placenta and has no direct correlation or role in determining the severity of fetal anemia.

Q: A 29-year-old woman presents with abdominal pain, vaginal bleeding, and a history of amenorrhea for 6 weeks. Transvaginal ultrasound does not show an intrauterine gestational sac or features suggestive of ectopic pregnancy. Her serum $\beta$-hCG is 1,200 IU/L, which is below the discriminatory zone. What is the next step in management?

Repeat $\beta$-hCG after 48 hours. ***Repeat $\beta$-hCG after 48 hours*** - In a pregnancy of unknown location (PUL) with **β-hCG below the discriminatory zone** (1,500-2,000 IU/L), ultrasound cannot reliably visualize an intrauterine pregnancy - **Serial β-hCG monitoring at 48-hour intervals** is the standard approach to determine pregnancy viability and location - Expected β-hCG patterns help guide management: - **Rise >53% in 48 hours**: Suggests viable intrauterine pregnancy → repeat ultrasound when β-hCG reaches discriminatory zone - **Rise 50% in 48 hours**: Suggests spontaneous miscarriage → monitor to zero - Patient is **hemodynamically stable**, so expectant management with close monitoring is appropriate *Dilatation and curettage* - Premature intervention without knowing β-hCG trend - Reserved for cases where β-hCG plateaus or rises abnormally, suggesting either ectopic or abnormal intrauterine pregnancy - May be used for histological diagnosis (presence of chorionic villi confirms intrauterine pregnancy) *Methotrexate therapy* - Cannot be administered without **confirmed diagnosis of ectopic pregnancy** - Requires meeting specific criteria: hemodynamic stability, unruptured ectopic, β-hCG typically <5,000 IU/L, no fetal cardiac activity - Inappropriate when pregnancy location is unknown *Laparoscopy* - Too invasive as initial management for a **stable patient** - Reserved for hemodynamically unstable patients with suspected ruptured ectopic pregnancy - May be indicated later if ectopic pregnancy is confirmed and meets surgical criteria

Question 1

Which of the following is NOT a complication of placenta previa?

Accepted Answer

Rapid dilation of the cervix

Answer

Malpresentation

Answer

Premature labor

Answer

Retained placenta

Question 2

A pregnant lady at 32 weeks' gestation presents with a BP of 160/110 mm Hg, proteinuria, and retinal hemorrhage. What is the definitive management of choice in this case?

Accepted Answer

Termination of pregnancy

Answer

Ritodrine

Answer

Nifedipine

Answer

Magnesium sulfate

Question 3

In a lady at 32 weeks gestation, an injection of dexamethasone is given to prevent which of the following in the newborn?

Accepted Answer

Respiratory Distress Syndrome

Answer

Neonatal convulsion

Answer

Neonatal jaundice

Answer

Cerebral palsy

Question 4

Regarding autoimmune hemolytic anemia in pregnancy, all are true except?

Accepted Answer

Usually does not respond to steroids.

Answer

Direct Coombs test is usually positive.

Answer

Pregnancy accelerates hemolysis.

Answer

Fetal microchimerism results in aberrant antibody production.

Question 5

A 32-week pregnant patient presents with antepartum hemorrhage and unstable vitals (BP 80/60). What is the next step in management?

Accepted Answer

Blood transfusion

Answer

Careful observation

Answer

Medical induction of labor

Answer

Immediate cesarean section

Question 6

Which of the following is NOT a contraindication for a cervical cerclage operation?

Accepted Answer

Pregnancy beyond 14 weeks

Answer

Ruptured membranes

Answer

Signs of chorioamnionitis

Answer

History of vaginal bleeding

Question 7

A patient with a known marginal placenta presents for follow-up. On ultrasound, a 4 x 4 cm placental mass is noted invading into the urinary bladder. What is the most likely diagnosis?

Accepted Answer

Placenta percreta

Answer

Placenta accreta

Answer

Placenta previa

Answer

Placenta increta

Question 8

Fetal anaemia is primarily determined by Doppler assessment of which artery?

Accepted Answer

Middle cerebral artery

Answer

Umbilical artery

Answer

Uterine artery

Answer

Ductus venosus

Question 9

A 28-year-old pregnant woman at 33 weeks gestation presents for a routine prenatal visit. She reports decreased fetal movements over the past two days. She has a history of gestational diabetes, and her pregnancy has been otherwise uneventful. The doctor decides to perform antepartum fetal surveillance. Which of the following is the most appropriate initial test to assess the fetal well-being in this scenario?

Accepted Answer

Non Stress test

Answer

Biophysical profile

Answer

Amniotic fluid index

Answer

Contraction Stress test

Question 10

A 29-year-old woman presents with abdominal pain, vaginal bleeding, and a history of amenorrhea for 6 weeks. Transvaginal ultrasound does not show an intrauterine gestational sac or features suggestive of ectopic pregnancy. Her serum $\beta$-hCG is 1,200 IU/L, which is below the discriminatory zone. What is the next step in management?

Accepted Answer

Repeat $\beta$-hCG after 48 hours

Answer

Dilatation and curettage

Answer

Methotrexate therapy

Answer

Laparoscopy

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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