Maternal-Fetal Medicine Practice Questions

Q: Which of the following is more common in multiparous women than primiparous women, EXCEPT?

Pregnancy-induced hypertension (PIH). **Explanation:** The correct answer is **Pregnancy-induced hypertension (PIH)**. **1. Why PIH is the correct answer:** Pregnancy-induced hypertension (specifically Preeclampsia) is classically considered a **"disease of theories"** and a **"disease of primigravidae."** The underlying pathophysiology involves an abnormal immune response to paternal antigens and defective trophoblastic invasion of spiral arteries. In subsequent pregnancies with the same partner, the maternal immune system develops a "protective" tolerance, significantly reducing the risk. Therefore, PIH is more common in primiparous women, making it the exception in this list. **2. Analysis of incorrect options:** * **Anemia:** Multiparous women are at a higher risk for iron-deficiency and folate-deficiency anemia due to depleted nutritional stores from repeated pregnancies and short interpregnancy intervals. * **Placenta Previa:** The risk of placenta previa increases with parity. This is attributed to permanent atherosclerotic changes in the pelvic vessels and scarring of the endometrium from previous implantations, which may lead the placenta to seek a better-vascularized site in the lower uterine segment (the "placental migration" theory). **Clinical Pearls for NEET-PG:** * **Preeclampsia Risk Factors:** While primiparity is a major risk factor, multiparous women can still develop PIH if there is a **change in paternity**, a long interpregnancy interval (>10 years), or underlying medical conditions (e.g., DM, HTN, SLE). * **Multiparous Risks:** High parity is also associated with Malpresentations, Postpartum Hemorrhage (PPH) due to uterine atony, and Abruptio Placentae. * **Primiparous Risks:** Apart from PIH, primigravidae are more prone to prolonged labor (due to an unyielding birth canal) and instrumental deliveries.

Q: What is the normal length of the umbilical cord?

30-100 cm. **Explanation:** The umbilical cord is the vital conduit between the fetus and the placenta. In a term pregnancy, the **average length is approximately 50–55 cm**, but the **normal physiological range is widely accepted as 30–100 cm**. 1. **Why Option C is Correct:** The length of the cord is determined by both genetic factors and fetal movement in utero. A range of **30–100 cm** covers the vast majority of normal pregnancies. Cords within this range allow for adequate fetal movement without increasing the risk of entanglement or traction during delivery. 2. **Analysis of Incorrect Options:** * **Option A (40-50 cm):** While this represents the average, it is too narrow to be defined as the "normal range." * **Option B (60-120 cm):** This shifts toward the "long cord" category. Cords exceeding 100 cm are pathologically long. * **Option D (25-40 cm):** This range is too short. A cord less than 30 cm is clinically defined as a "short cord." **High-Yield Clinical Pearls for NEET-PG:** * **Short Cord ( 100 cm):** Associated with cord prolapse, cord entanglement (nuchal cord), true knots, and fetal thromboembolism. * **Structure:** Contains **two arteries and one vein** (the left vein persists; the right vein disappears). * **Wharton’s Jelly:** The specialized connective tissue that prevents compression of the umbilical vessels. * **False Knots:** These are simply redundant foldings of the umbilical vessels and have no clinical significance, unlike **True Knots** (found in ~1% of deliveries).

Q: What laboratory parameters are monitored in a patient with pre-eclampsia?

All of the above. In pre-eclampsia, the underlying pathophysiology involves widespread **endothelial dysfunction** and vasospasm, leading to multi-organ involvement. Monitoring laboratory parameters is crucial to assess the severity of the disease and detect complications like HELLP syndrome. **Explanation of the Correct Answer:** * **Uric Acid:** Hyperuricemia is one of the earliest laboratory markers of pre-eclampsia. It occurs due to decreased renal clearance (secondary to reduced GFR and increased tubular reabsorption). A rising uric acid level correlates with disease severity and poor fetal outcomes. * **Platelet Count:** Thrombocytopenia (Platelets <1,00,000/mm³) is a hallmark of severe pre-eclampsia. It results from increased platelet activation, aggregation, and consumption due to endothelial damage. * **Liver Function Tests (LFTs):** Elevated transaminases (ALT/AST) indicate hepatic ischemia or periportal hemorrhage. This is a critical component of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). Since all these parameters are essential for monitoring maternal stability and disease progression, **Option D** is the correct answer. **Clinical Pearls for NEET-PG:** * **Gold Standard for Proteinuria:** 24-hour urine protein (>300 mg) is the traditional gold standard, though the Protein:Creatinine ratio (≥0.3) is now more commonly used in clinical practice. * **HELLP Syndrome:** Always look for the triad of schistocytes on peripheral smear (hemolysis), AST/ALT >70 IU/L, and platelets 1.1 mg/dL or doubling of baseline indicates severe features. * **Management Tip:** Magnesium Sulfate ($MgSO_4$) is the drug of choice for seizure prophylaxis in severe pre-eclampsia and eclampsia.

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

Q: Fetal anaemia is monitored by?

MCA-PSV. ***MCA-PSV*** - **Middle Cerebral Artery-Peak Systolic Velocity (MCA-PSV)** is a non-invasive Doppler ultrasound method to assess for fetal anemia. It measures the peak velocity of blood flow in the fetal middle cerebral artery. - In anemic fetuses, blood viscosity decreases, leading to increased cardiac output and higher cerebral blood flow velocity. A value greater than **1.5 Multiples of the Median (MoM)** for gestational age is highly predictive of moderate to severe fetal anemia. *Maternal blood* - Maternal blood testing, such as the **Indirect Coombs Test (ICT)**, is used to detect maternal antibodies against fetal red blood cells, indicating maternal sensitization and risk of fetal hemolysis. - While a rising titer suggests an increased risk, it does not directly quantify the severity of anemia in the fetus itself; it serves as a screening tool to identify pregnancies needing closer surveillance. *Fetal blood* - Fetal blood sampling, performed via **cordocentesis**, is the gold standard for diagnosing and quantifying the degree of fetal anemia by directly measuring fetal hemoglobin. - However, it is an invasive procedure with significant risks (e.g., fetal loss, hemorrhage) and is reserved for confirming severe anemia indicated by non-invasive tests like MCA-PSV, or for therapeutic intervention like intrauterine transfusion. *Amniocentesis* - Historically, amniocentesis was used to measure the level of bilirubin in the amniotic fluid (spectrophotometry at ΔOD450) as an indirect marker of hemolysis. - This invasive method has been largely replaced by the non-invasive, safer, and more accurate MCA-PSV Doppler assessment for monitoring fetal anemia.

Q: Which findings are most suggestive of tubal pregnancy?

Adnexal mass with empty uterus and fluid in pelvis. ***Adnexal mass with empty uterus and fluid in pelvis***- The visualization of an **adnexal mass** (corresponding to the tubal gestation) and an **empty uterus** confirms the diagnosis of an ectopic pregnancy.- The presence of **free fluid in the pelvis** (hemoperitoneum) is highly suggestive of a ruptured or leaking tubal pregnancy, representing the most urgent presentation.*Ovarian mass with single layer of endometrium*- An **ovarian mass** suggests pathology involving the ovary itself, such as an ovarian ectopic pregnancy or a cyst, rather than the most common site, the fallopian tube.- The **single layer of endometrium** (thin decidual reaction) may occur in ectopic pregnancy due to insufficient hormonal stimulus but is not sufficient evidence for a tubal location.*Adnexal mass with empty uterus*- While this constellation of findings definitely suggests an **ectopic pregnancy**, it is often indicative of an early and **unruptured** tubal pregnancy.- Lacking **free fluid (blood)** in the pelvis makes this option less suggestive of advanced or complicated tubal pregnancy compared to the correct option.*Trilayer endometrium without adnexal mass*- A **trilayer endometrium** is a typical ultrasound finding during the proliferative phase, or it may be seen in a developing intrauterine pregnancy (IUP).- The absence of an **adnexal mass** essentially excludes the possibility of a tubal ectopic pregnancy.

Question 1

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 2

Which of the following is more common in multiparous women than primiparous women, EXCEPT?

Accepted Answer

Pregnancy-induced hypertension (PIH)

Answer

Anemia

Answer

Placenta previa

Answer

None of the above

Question 3

What is the normal length of the umbilical cord?

Accepted Answer

30-100 cm

Answer

40-50 cm

Answer

60-120 cm

Answer

25-40 cm

Question 4

What laboratory parameters are monitored in a patient with pre-eclampsia?

Accepted Answer

All of the above

Answer

Uric acid

Answer

Platelet count

Answer

Liver function tests

Question 5

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 6

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 7

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 8

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

Question 9

Fetal anaemia is monitored by?

Accepted Answer

MCA-PSV

Answer

Amniocentesis

Answer

Maternal blood

Answer

Fetal blood

Question 10

Which findings are most suggestive of tubal pregnancy?

Accepted Answer

Adnexal mass with empty uterus and fluid in pelvis

Answer

Trilayer endometrium without adnexal mass

Answer

Ovarian mass with single layer of endometrium

Answer

Adnexal mass with empty uterus

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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