Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 81: Which parameter on umbilical artery Doppler indicates imminent fetal demise?

A. Increased S/D ratio
B. Absent diastolic flow
C. Reversal of flow (Correct Answer)
D. Normal S/D ratio

Explanation: **Explanation:** The umbilical artery Doppler is a critical tool for assessing placental vascular resistance and fetal well-being in cases of Fetal Growth Restriction (FGR). **1. Why "Reversal of Flow" is correct:** As placental insufficiency worsens, the resistance in the umbilical artery increases. Eventually, the pressure in the fetal systemic circulation becomes lower than the pressure in the placenta during diastole. This causes blood to flow backward toward the fetal heart (**Reversed End-Diastolic Velocity - REDV**). This represents extreme placental compromise (usually >70% of the placental bed is non-functional) and is a pre-terminal sign indicating **imminent fetal demise** or severe acidemia. Delivery is usually indicated urgently if the fetus is viable. **2. Analysis of Incorrect Options:** * **Increased S/D ratio:** This is the earliest sign of increased placental resistance. While it indicates placental insufficiency, it is not an immediate marker of fetal death. * **Absent diastolic flow (AEDV):** This occurs when resistance is high enough that flow stops during diastole. It is a serious sign and precedes reversal, but the risk of immediate demise is significantly higher once the flow reverses. * **Normal S/D ratio:** This indicates healthy placental perfusion and low resistance, which is the expected finding in a normal pregnancy. **3. High-Yield Clinical Pearls for NEET-PG:** * **Sequence of Deterioration:** Increased S/D ratio → Absent End Diastolic Velocity (AEDV) → Reversed End Diastolic Velocity (REDV). * **Ductus Venosus:** If REDV is noted in the umbilical artery, the next step is often checking the Ductus Venosus. **Reversal of the 'a' wave** in the Ductus Venosus is the most definitive predictor of imminent fetal heart failure. * **Management:** AEDV usually warrants delivery by 34 weeks; REDV usually warrants delivery by 32 weeks (after steroid cover).

Question 82: Betamethasone in pregnancy is given to prevent which of the following complications?

A. Prematurity
B. Neonatal convulsions
C. Cerebral palsy
D. Respiratory distress syndrome (Correct Answer)

Explanation: **Explanation:** **Betamethasone** is a corticosteroid administered to pregnant women at risk of preterm delivery (between 24 and 34 weeks of gestation) to accelerate fetal lung maturity. **Why Respiratory Distress Syndrome (RDS) is the correct answer:** The primary mechanism of Betamethasone is the induction of **Type II pneumocytes** in the fetal lungs. This stimulation increases the production and release of **surfactant**, which reduces alveolar surface tension. Adequate surfactant prevents alveolar collapse upon expiration, thereby significantly reducing the incidence and severity of RDS, intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC). **Analysis of Incorrect Options:** * **A. Prematurity:** Betamethasone does not prevent preterm labor or birth; it only improves the neonatal outcomes associated with being born early. Tocolytics are used to delay prematurity. * **B. Neonatal convulsions:** These are typically caused by metabolic disturbances (hypoglycemia/hypocalcemia) or birth asphyxia, not steroid deficiency. * **C. Cerebral palsy:** While steroids reduce IVH (a risk factor for CP), they are not the primary preventive agent. **Magnesium sulfate** is the drug of choice for neuroprotection to reduce the risk of cerebral palsy in imminent preterm births. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Dose:** 12 mg intramuscularly, 2 doses, 24 hours apart. * **Drug of Choice:** Betamethasone is preferred over Dexamethasone because it has a longer half-life and is associated with a lower risk of periventricular leukomalacia. * **Time to Benefit:** Maximum benefit occurs 24 hours after the first dose and lasts for up to 7 days. * **Indication:** All women between **24–34 weeks** at risk of delivery within 7 days. (Recent guidelines extend this to 36 weeks 6 days in specific "late preterm" scenarios).

Question 83: Painless, heavy, and recurrent bleeding of sudden onset during pregnancy is seen in which of the following conditions?

A. Cervical carcinoma
B. Circumvallate placenta
C. Placenta previa (Correct Answer)
D. Abruptio placentae

Explanation: ### Explanation **Placenta Previa** is the correct answer because it is the classic cause of **painless, bright red, and recurrent** vaginal bleeding in the second half of pregnancy. The bleeding occurs when the lower uterine segment stretches and thins out, causing the placenta to detach from its attachment site. Since there is no retroplacental clot formation or uterine tension, the bleeding is painless and typically of sudden onset. **Analysis of Incorrect Options:** * **Abruptio Placentae:** Characterized by **painful** vaginal bleeding associated with uterine tenderness and a "woody hard" uterus. The bleeding is often dark and may be concealed. * **Cervical Carcinoma:** While it can cause bleeding during pregnancy, it is typically **post-coital** or "spotting" rather than heavy, sudden-onset obstetric hemorrhage. * **Circumvallate Placenta:** This is a morphological variation where the fetal membranes double back. While it can cause intermittent bleeding and preterm labor, it is not the classic presentation for sudden, heavy, painless hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** 1. **The Golden Rule:** Never perform a per-vaginal (PV) examination in a case of antepartum hemorrhage (APH) until Placenta Previa is ruled out by ultrasound, as it can trigger torrential bleeding (Stallworthy’s sign). 2. **Stallworthy’s Sign:** A drop in fetal heart rate when the fetal head is pressed into the pelvic inlet, suggestive of posterior placenta previa. 3. **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the gold standard for diagnosing placental localization (safer and more accurate than transabdominal). 4. **Management:** If the patient is stable and <37 weeks, **MacAfee’s expectant management** is followed. If unstable or at term, delivery (usually Cesarean) is indicated.

Question 84: An 8th-month primigravida presented with severe pruritus and mild icterus. Her serum bilirubin was 3 mg/dL, with elevated AST, ALT, and alkaline phosphatase. Her renal function tests and coagulation profile were within normal limits. What is the most likely diagnosis?

A. HELLP syndrome
B. Hepatorenal syndrome
C. Obstetric cholestasis (Correct Answer)
D. Viral hepatitis

Explanation: ### Explanation **Correct Answer: C. Obstetric cholestasis** **Why it is correct:** Obstetric cholestasis (Intrahepatic Cholestasis of Pregnancy - ICP) typically presents in the **third trimester** with **severe pruritus**, characteristically involving the palms and soles, which worsens at night. While jaundice is present in only 10–20% of cases (mild icterus), the biochemical hallmark is an elevation in **serum bile acids**. Laboratory findings typically show mild elevations in AST/ALT (usually <500 U/L) and a significant rise in **Alkaline Phosphatase (ALP)**—though ALP is less specific as it is also produced by the placenta. The absence of hypertension, proteinuria, or coagulopathy in this patient strongly points toward ICP. **Why the other options are incorrect:** * **HELLP Syndrome:** This is a complication of severe preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets. The patient in the question has a normal coagulation profile and no mention of hypertension or thrombocytopenia. * **Hepatorenal Syndrome:** This involves functional renal failure in the setting of advanced cirrhosis or fulminant liver failure. The patient’s renal function tests (RFTs) are explicitly stated as normal. * **Viral Hepatitis:** While it can cause jaundice and elevated transaminases, the primary presenting symptom of viral hepatitis is usually prodromal (fever, malaise, nausea) rather than intense pruritus. AST/ALT levels in viral hepatitis are typically much higher (>1000 U/L). **High-Yield Clinical Pearls for NEET-PG:** * **Most sensitive marker:** Elevated **Serum Bile Acids** (>10 µmol/L). * **Treatment of choice:** **Ursodeoxycholic acid (UDCA)**; it improves pruritus and liver function. * **Fetal Risk:** Increased risk of sudden intrauterine fetal death (IUFD), meconium-stained liquor, and preterm birth. * **Delivery Timing:** Delivery is usually recommended between **37 0/7 and 38 6/7 weeks** of gestation to prevent late-term stillbirth.

Question 85: Maximum cardiac output during pregnancy is typically observed at which gestational age?

A. 20 weeks
B. 30 weeks
C. 34 weeks (Correct Answer)
D. 36 weeks

Explanation: **Explanation:** The correct answer is **34 weeks**. During pregnancy, the maternal cardiovascular system undergoes significant physiological adaptations to meet the metabolic demands of the fetus. Cardiac output (CO) begins to increase as early as 5 weeks gestation, primarily due to an increase in stroke volume and later, an increase in heart rate. **Why 34 weeks is correct:** Cardiac output increases progressively throughout the first and second trimesters, reaching its peak (approximately 30–50% above pre-pregnancy levels) between **32 and 34 weeks** of gestation. After this point, it typically plateaus until the onset of labor. **Analysis of Incorrect Options:** * **A (20 weeks):** While CO is significantly elevated by this stage, it has not yet reached its maximum plateau. * **B (30 weeks):** This is close to the peak, but the maximum physiological rise is traditionally cited at the 34-week mark. * **D (36 weeks):** By 36 weeks, the CO has usually plateaued or may even appear slightly decreased in the supine position due to **aortocaval compression** by the gravid uterus, which reduces venous return. **High-Yield Clinical Pearls for NEET-PG:** * **Maximum CO overall:** The absolute peak of cardiac output occurs **immediately postpartum** (up to 60–80% increase) due to the "autotransfusion" of blood from the involuting uterus and the relief of caval compression. * **Labor:** CO increases by an additional 15% in the first stage and 50% in the second stage of labor. * **Clinical Significance:** Patients with underlying heart disease (e.g., Mitral Stenosis) are at the highest risk of heart failure at **32–34 weeks** and during the **immediate postpartum period**.

Question 86: The placenta is anchored to the myometrium partially or completely without any intervening decidua. What is this condition called?

A. Placenta accreta
B. Placenta increta (Correct Answer)
C. Placenta succenturiate
D. Placenta percreta

Explanation: **Explanation:** The question describes a spectrum of **Morbidly Adherent Placenta (MAP)**, where there is an abnormal adherence of the placenta to the uterine wall due to the partial or total absence of the **Decidua Basalis** (specifically the Nitabuch’s layer). **Why Option B is Correct:** * **Placenta Increta:** In this condition, the chorionic villi invade **into the myometrium**. The key distinction is the depth of penetration; it goes beyond the surface but does not breach the serosa. **Why Other Options are Incorrect:** * **Placenta Accreta (Option A):** This is the mildest form where villi are attached directly **to the surface** of the myometrium without invading it. While it is the most common type (approx. 75-80%), it does not involve deep muscular penetration. * **Placenta Percreta (Option D):** This is the most severe form where villi penetrate **through the entire myometrium** and may breach the uterine serosa, potentially invading adjacent organs like the urinary bladder. * **Placenta Succenturiate (Option C):** This is a morphological variation where one or more small accessory lobes of placenta are developed at a distance from the main placental mass, connected by fetal vessels. It is not a disorder of invasion. **NEET-PG High-Yield Pearls:** 1. **Risk Factors:** The most significant risk factors are a **previous Cesarean section** and **Placenta Previa**. The risk increases linearly with the number of prior C-sections. 2. **Diagnosis:** Antenatal diagnosis is primarily via **Color Doppler Ultrasound** (showing loss of retroplacental hypoechoic zone). 3. **Management:** The standard management for confirmed MAP is a planned **Cesarean Hysterectomy**. 4. **Mnemonic (A-I-P):** * **A**ccreta: **A**ttached to myometrium. * **I**ncreta: **I**nto the myometrium. * **P**ercreta: **P**enetrates through the myometrium.

Question 87: What ultrasound findings suggest cervical incompetence?

A. Shortened cervical length
B. Funneling of the internal os
C. Widening of the internal os
D. All of the above (Correct Answer)

Explanation: **Cervical Incompetence** (also known as Cervical Insufficiency) is the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions. It is a structural weakness that leads to painless cervical dilatation and subsequent preterm birth or mid-trimester miscarriage. ### **Explanation of Ultrasound Findings** Transvaginal Ultrasound (TVS) is the gold standard for diagnosing cervical changes. The correct answer is **D** because all three findings are progressive markers of cervical failure: 1. **Shortened Cervical Length:** A cervical length of **<25 mm** before 24 weeks of gestation is the most significant predictor of preterm birth. 2. **Funneling of the Internal Os:** This occurs when the internal os opens but the external os remains closed. It is often described by the shapes **T, Y, V, and U** (mnemonic: **"Trust Your Vaginal Ultrasound"**), where 'U' represents the most advanced stage of funneling. 3. **Widening of the Internal Os:** As the cervix weakens, the internal os dilates, often allowing the fetal membranes to prolapse into the cervical canal (the "hourglass" membranes sign). ### **Why other options are incorrect** Options A, B, and C are individual components of the same pathological process. Selecting only one would be incomplete, as they often occur concurrently or sequentially during the "shortening and funneling" process. ### **NEET-PG High-Yield Pearls** * **Gold Standard Diagnosis:** History-based (recurrent mid-trimester losses) or TVS-based (cervical length <25 mm). * **McDonald’s and Shirodkar’s Operations:** These are the two common types of cervical cerclage. * **Best Time for Cerclage:** Usually performed between **12–14 weeks** of gestation. * **The "Stress Test":** Applying fundal pressure during ultrasound can elicit funneling that is not visible at rest, helping in early diagnosis.

Question 88: What is the best method for the diagnosis of lung maturity?

A. Lecithin/Sphingomyelin (L/S) ratio in amniotic fluid
B. Phosphatidyl glycerol estimation in amniotic fluid (Correct Answer)
C. Bilirubin in amniotic fluid
D. Amniotic fluid creatinine

Explanation: **Explanation:** The assessment of fetal lung maturity (FLM) depends on the presence of pulmonary surfactants in the amniotic fluid. **Why Phosphatidylglycerol (PG) is the best method:** Phosphatidylglycerol is a minor constituent of surfactant that appears late in gestation (usually after 35–36 weeks). Its presence is the **most reliable and specific indicator** of lung maturity. Unlike the L/S ratio, PG estimation is **not affected by contamination** with blood, meconium, or vaginal secretions, making it the "gold standard" for accuracy in complicated pregnancies. **Analysis of Incorrect Options:** * **Lecithin/Sphingomyelin (L/S) ratio:** Historically the most common test. A ratio >2:1 indicates maturity. However, it is highly sensitive to contamination (blood/meconium) and has a higher false-positive rate in diabetic pregnancies compared to PG. * **Bilirubin in amniotic fluid:** Measured via spectrophotometry ($\Delta OD_{450}$), this is used to assess the severity of **Rh-isoimmunization** and fetal hemolysis, not lung maturity. * **Amniotic fluid creatinine:** This reflects **fetal renal maturity** and muscle mass. While levels >2 mg/dL correlate with a gestational age of >37 weeks, it is not a direct or reliable measure of pulmonary surfactant. **High-Yield Clinical Pearls for NEET-PG:** * **Most sensitive/earliest test:** L/S ratio. * **Most specific test (Best):** Phosphatidylglycerol (PG). * **Rapid bedside test:** Shake test (Bubble stability test). * **Diabetes Mellitus:** PG is particularly useful here because the L/S ratio can be >2:1 while the lungs are still immature (delayed maturation). * **Lamellar Body Count (LBC):** A modern, rapid automated test; a count >30,000-50,000/µL indicates maturity.

Question 89: Which of the following genital infections carries the highest risk for preterm delivery?

A. Trichomonas vaginitis
B. Monilial vaginitis
C. Bacterial vaginitis (Correct Answer)
D. Human papilloma virus

Explanation: **Explanation:** **Bacterial Vaginosis (BV)** is the most significant genital infection associated with adverse pregnancy outcomes, particularly **preterm labor (PTL)** and **preterm premature rupture of membranes (PPROM)**. The underlying mechanism involves a shift in vaginal flora from protective *Lactobacilli* to anaerobic organisms (e.g., *Gardnerella vaginalis*, *Mobiluncus*). These bacteria produce inflammatory cytokines, prostaglandins, and phospholipase A2, which stimulate uterine contractions and weaken fetal membranes, leading to cervical ripening and preterm delivery. **Analysis of Options:** * **Bacterial Vaginosis (Correct):** It increases the risk of preterm birth by approximately 2-fold. It is also linked to late miscarriages and postpartum endometritis. * **Trichomonas vaginitis:** While associated with some adverse outcomes, the correlation with preterm delivery is significantly weaker than BV. Interestingly, treating asymptomatic Trichomoniasis in pregnancy has not been proven to reduce preterm birth rates. * **Monilial (Candidiasis) vaginitis:** This is very common in pregnancy due to high estrogen levels but is considered a commensal overgrowth. It does **not** increase the risk of preterm labor. * **Human Papilloma Virus (HPV):** This is a viral infection primarily associated with cervical dysplasia and genital warts. It does not have a recognized causal link with preterm delivery. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis for BV:** Nugent Scoring (Gram stain). * **Clinical Diagnosis:** Amsel’s Criteria (requires 3 out of 4: Thin white discharge, pH >4.5, +ve Whiff test, and **Clue cells**). * **Treatment in Pregnancy:** Oral Clindamycin or Metronidazole is recommended to symptomatic patients to alleviate symptoms, though it may not always prevent preterm birth once the inflammatory cascade has begun.

Question 90: Presence of a gas shadow in the head and great vessels suggestive of intrauterine death. This is called?

A. Chadwick's sign
B. Osiander's sign
C. Robe's sign (Correct Answer)
D. Spalding sign

Explanation: **Explanation:** The presence of gas shadows within the fetal heart, great vessels, or head on an X-ray is known as **Robert’s sign** (often referred to as Robe’s sign in exams). This is a radiological sign of intrauterine fetal death (IUFD). **1. Why Robert’s Sign is Correct:** Robert’s sign occurs due to the fermentation of blood and tissue breakdown following fetal demise, leading to the release of gas (primarily nitrogen) into the fetal circulatory system. It is one of the earliest radiological signs of IUFD, appearing as early as 12 hours after death. **2. Analysis of Incorrect Options:** * **Chadwick’s Sign:** A presumptive sign of pregnancy characterized by a bluish discoloration of the cervix, vagina, and labia due to increased vascularity (venous congestion). It typically appears around 6–8 weeks of gestation. * **Osiander’s Sign:** An early sign of pregnancy felt during a vaginal examination, characterized by increased pulsations felt in the lateral vaginal fornices due to hypertrophy of the uterine arteries. * **Spalding Sign:** A radiological sign of IUFD characterized by the overlapping of fetal skull bones due to the liquefaction of the brain and loss of intracranial pressure. It usually takes 4–7 days after fetal death to develop. **3. High-Yield Clinical Pearls for NEET-PG:** * **Earliest Sign of IUFD on Ultrasound:** Absence of fetal cardiac activity (Gold Standard). * **Earliest Radiological (X-ray) Sign of IUFD:** Robert’s sign (12 hours). * **Spalding Sign:** Requires significant maceration; not seen immediately. * **Deuel’s Halo Sign:** Edema of the fetal scalp causing a "halo" appearance on X-ray, also suggestive of IUFD. * **Hyperflexion of the Spine:** Another late radiological sign of IUFD due to loss of fetal muscle tone.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

Practice Questions

Multiple Gestation

Practice Questions

Rh Isoimmunization and Other Blood Group Incompatibilities

Practice Questions

Intrauterine Fetal Therapy

Practice Questions

Prenatal Diagnosis and Genetic Counseling

Practice Questions

Placental Abnormalities

Practice Questions

Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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