Maternal-Fetal Medicine Practice Questions

Q: Twin pregnancy should have ultrasound at 10-13 weeks to confirm which of the following? I. Number of foetus II. Viability of foetus III. Chorionicity of twins IV. Malformation in either foetus Select the correct answer using the code given below :

I, II and III only. ***I, II and III only*** - A **first-trimester ultrasound** (10-13 weeks) in a twin pregnancy is essential for confirming the **number of fetuses**, assessing their **viability** (cardiac activity), and most importantly determining the **chorionicity of twins**. - **Chorionicity determination** is crucial at this stage as it guides the entire pregnancy management - monochorionic twins require more intensive surveillance due to higher risks. - While nuchal translucency screening for chromosomal abnormalities is performed at 11-13+6 weeks, **systematic structural malformation screening is NOT the primary objective** of the first-trimester scan and is typically performed at **18-22 weeks**. *I and III only* - While confirming the **number of fetuses** and **chorionicity** is essential, this option incorrectly omits the assessment of **fetal viability**. - Confirming cardiac activity and viability of both fetuses is a fundamental component of the first-trimester ultrasound examination. *II and IV only* - This option fails to include the most critical aspects of first-trimester twin ultrasound: confirming the **number of fetuses** and determining **chorionicity**. - Additionally, **malformation screening** is NOT a primary objective at 10-13 weeks; detailed anomaly scanning is performed in the second trimester (18-22 weeks). *I, II, III and IV* - While this option correctly includes fetal number, viability, and chorionicity determination, it incorrectly adds **malformation screening** as a primary objective. - **Structural anomaly scanning** is performed during the **mid-trimester ultrasound (18-22 weeks)**, not at 10-13 weeks, when organ development is more complete and detailed anatomical survey is possible.

Q: Which of the following is the primary surveillance tool in the growth-restricted fetus?

Umbilical artery Doppler. ***Umbilical artery Doppler*** - The **umbilical artery Doppler** is the primary tool for fetal surveillance in **growth-restricted fetuses** because it directly assesses **placental resistance** and **blood flow** to the fetus. - Abnormal findings, such as **increased resistance** or **absent/reversed end-diastolic flow**, indicate **placental insufficiency** and are key indicators for intervention. *Umbilical venous pulsation* - **Umbilical venous pulsation** can be a sign of **cardiac dysfunction** in the fetus but is considered a **late and severe sign** of fetal compromise, not a primary surveillance tool. - Its presence usually indicates significant **cardiac overload** or **venous congestion**, suggesting advanced stages of fetal distress. *Uterine artery Doppler* - **Uterine artery Doppler** is primarily used for **screening** for preeclampsia and fetal growth restriction in the **second trimester**, not as a primary surveillance tool once growth restriction is established. - It assesses **placental bed development** and **maternal uterine blood flow** but doesn't directly monitor the fetal response to placental insufficiency. *Middle cerebral artery Doppler* - **Middle cerebral artery (MCA) Doppler** is used to assess for **brain-sparing effect** in growth-restricted fetuses, indicating the fetus is shunting blood to the brain due to hypoxia. - While important for evaluating the severity of compromise, it is a **secondary surveillance tool** for brain perfusion, not the primary measure of placental function.

Q: If, on amniocentesis, the alpha fetoprotein is found to be elevated in the amniotic fluid (which correlates with elevated maternal serum levels), which of the following conditions is likely to be present?

Neural tube defects. ***Neural tube defects*** - **Elevated alpha-fetoprotein (AFP)** in amniotic fluid and maternal serum is a key indicator of neural tube defects like **spina bifida** or **anencephaly**. - These defects result in an open neural tube, allowing AFP to leak directly into the amniotic fluid. *Duchenne muscular dystrophy* - This is an **X-linked recessive genetic disorder** causing progressive muscle degeneration. - While it can be detected prenatally through genetic testing, it is **not associated with elevated AFP** levels. *Cardiac septal defects* - These are **structural abnormalities of the heart** (e.g., ventricular septal defect, atrial septal defect). - They are typically diagnosed via **fetal echocardiography** and do not cause elevated AFP levels. *Galactosaemia* - This is an **autosomal recessive metabolic disorder** where the body cannot properly metabolize galactose. - It is diagnosed by detecting elevated galactose or genetic testing, and **AFP levels are unaffected**.

Q: Tongue bite occurs in eclampsia at :

Tonic stage. ***Tonic stage*** - During the **tonic stage** of an eclamptic seizure, there is a sudden, sustained contraction of all muscles, including the **masseter muscles** (jaw muscles). - This forceful, sustained jaw clenching causes the teeth to clench tightly, leading to involuntary **biting of the tongue**. - The tonic phase lasts 10-20 seconds and is the first phase of the eclamptic seizure, characterized by rigid muscle contraction. *Coma stage* - The coma stage occurs after the seizure activity has ceased, and the patient is unconscious. - While aspiration or other complications can occur during this stage, **tongue biting** specifically happens during the active tonic phase of the seizure, not afterward. *Clonic stage* - The clonic stage follows the tonic stage and is characterized by rhythmic, jerking movements of the limbs and body. - Although there is muscle activity, the severe, **sustained jaw clenching** that causes tongue bite is specific to the tonic phase. - In the clonic phase, the jaw may rhythmically open and close, but the initial tongue bite has already occurred. *Postictal stage* - The postictal stage is the period of recovery immediately following a seizure. - The patient may be confused, drowsy, or unresponsive, but the active seizure movements, including **tongue biting**, have already occurred in the tonic phase.

Q: Intrahepatic cholestasis of pregnancy presents with which of the following features ? 1. Pruritus after 28 weeks gestation, especially in palms and soles 2. Serum bilirubin levels > 5 mg% 3. Raised levels of serum bile acids 4. Features subside within two weeks postpartum Select the correct answer using the code given below :

1, 3 and 4. ***1, 3 and 4*** - **Intrahepatic cholestasis of pregnancy (ICP)** is characterized by **pruritus** without skin lesions, which typically begins in the **late second or third trimester (after 28 weeks gestation)**. The itching is often most severe on the **palms and soles**. - A hallmark of ICP is **elevated serum bile acid levels** (typically >10 μmol/L). The condition and its symptoms **subside rapidly** after delivery, usually **within 1-2 weeks postpartum**, as hormonal influences resolve. *1, 2 and 3* - This option incorrectly includes the feature of **serum bilirubin levels > 5 mg%**. While bilirubin levels can be mildly elevated in ICP, they typically remain below this threshold, and values **above 5 mg%** would suggest a more severe or alternative cause of **liver dysfunction**. - The other features (**pruritus after 28 weeks, raised serum bile acids**) are indeed characteristic of ICP. *1, 2 and 4* - This option also incorrectly includes **serum bilirubin levels > 5 mg%**, which is uncharacteristic for ICP and would warrant further investigation for other liver pathologies. - The presence of pruritus and the resolution postpartum are correct features. *2, 3 and 4* - This option incorrectly includes **serum bilirubin levels > 5 mg%** and does not include **pruritus as a primary symptom**, which is the most common presenting complaint of ICP. - While raised bile acids and postpartum resolution are correct, the absence of pruritus as a core feature and the high bilirubin level make this option incorrect.

Q: A 29-year-old female with 3 months amenorrhoea presents to gynaecology OPD with complaints of something coming out of her vagina. On clinical evaluation she was found to have single live pregnancy with second degree uterine prolapse. Which one of the following is the best management plan for her ?

Pessary treatment. ***Pessary treatment*** - **Symptomatic uterine prolapse during pregnancy** (patient complaining of "something coming out") requires **active management**, not just reassurance. - **Pessary insertion** is the **first-line treatment** for symptomatic uterine prolapse in pregnancy, providing mechanical support and immediate symptom relief. - **Ring pessary or Hodge pessary** can be safely used to support the prolapsed uterus until natural ascension occurs in the second trimester. - Combined with **bed rest** and **knee-chest position**, pessaries effectively manage symptoms while allowing pregnancy to continue. - The pessary can typically be removed after **16-20 weeks** when the gravid uterus naturally rises out of the pelvis. *Reassurance* - While it's true that the growing uterus will naturally ascend in the second trimester (reducing the prolapse), **reassurance alone is inadequate** for a patient with **active symptoms**. - Reassurance would be appropriate for **asymptomatic** or **mild prolapse**, but this patient has second-degree prolapse with troublesome symptoms requiring intervention. - Leaving symptomatic prolapse untreated risks complications like **cervical edema, ulceration, infection**, and increased patient distress. *Cerclage operation* - **Cervical cerclage** addresses **cervical insufficiency** to prevent preterm birth, not uterine prolapse. - It does not provide mechanical support for a prolapsed uterus and is not indicated in this clinical scenario. *Cervical amputation* - **Cervical amputation (trachelectomy)** is a radical procedure for **cervical cancer** or severe cervical pathology. - It would be **contraindicated in ongoing pregnancy** and carries significant risks of pregnancy loss. - Completely inappropriate for managing uterine prolapse.

Q: Which of the following are the clinical features of molar pregnancy ? 1. History of amenorrhea and vaginal bleeding 2. Patient has excessive vomiting 3. History of expulsion of grape-like vesicles Select the correct answer using the code given below :

1, 2 and 3. ***1, 2 and 3*** - **All three are clinical features of molar pregnancy (hydatidiform mole)** - **Amenorrhea and vaginal bleeding**: Classic presentation seen in most cases. Vaginal bleeding typically occurs in the first or early second trimester and is the most common presenting symptom - **Excessive vomiting (hyperemesis gravidarum)**: Occurs in approximately 25-30% of cases due to abnormally high levels of **hCG** produced by the proliferating trophoblastic tissue, much higher than in normal pregnancy - **Expulsion of grape-like vesicles**: This is a **pathognomonic (definitive) sign** of molar pregnancy. While it may not be the initial presenting symptom and often occurs during spontaneous expulsion or evacuation, it is a characteristic clinical feature when present - **Other features**: Uterine size larger than dates, absent fetal heart sounds, pre-eclampsia before 20 weeks, and markedly elevated serum hCG levels *1 and 2 only* - This option incorrectly excludes the **expulsion of grape-like vesicles**, which is a definitive clinical feature of molar pregnancy - While vesicle expulsion may occur later in the clinical course, the question asks about clinical features, not just initial presenting symptoms *2 and 3 only* - This option omits **amenorrhea and vaginal bleeding**, which are the most common and important presenting symptoms - Vaginal bleeding occurs in 80-90% of molar pregnancies and is typically the chief complaint *1 and 3 only* - This option incorrectly excludes **excessive vomiting**, which is a well-recognized clinical feature occurring in 25-30% of cases - Hyperemesis gravidarum associated with molar pregnancy can be severe due to extremely elevated hCG levels

Q: A patient, who is 2 months pregnant, reports to a hospital with complaints of increased vaginal bleeding and pain in lower abdomen. Internal examination reveals dilated internal os of cervix and products of conception are felt through it. What is her likely clinical diagnosis?

Inevitable abortion. ***Inevitable abortion*** - This diagnosis is characterized by **vaginal bleeding**, **lower abdominal pain**, and a **dilated cervix** with **products of conception palpable through the cervical os**. - The dilation of the internal os and products protruding through it indicate that the abortion process **cannot be halted** and will inevitably proceed to completion, distinguishing it from a threatened abortion. - In inevitable abortion, the products may be felt through the dilated os but have not yet been fully expelled from the uterus. *Threatened abortion* - While there is vaginal bleeding and a viable intrauterine pregnancy, the **cervix remains closed**, and there is no expulsion of fetal tissue. - The symptoms are milder, and with appropriate management, the pregnancy can often continue successfully. *Incomplete abortion* - This involves the **partial expulsion of the products of conception**, meaning some tissue has already passed out of the uterus, but some remains inside. - The key difference is that in incomplete abortion, **part of the products have been expelled**, with retained tissue remaining in the uterus, often requiring intervention (such as surgical evacuation) to remove the retained tissue. - The patient would typically report passage of tissue. *Septic abortion* - This is a serious complication involving an **infection of the uterus** during an abortion, presenting with **fever, chills, foul-smelling or purulent vaginal discharge**, in addition to bleeding and pain. - The clinical picture provided (bleeding, pain, dilated os, palpable products of conception) does not include signs of infection such as fever or other systemic symptoms of sepsis.

Q: A 24-year-old primigravida comes to ANC clinic at 8 months amenorrhoea. Her BP is found to be 160/100 mm Hg. Lab findings reveal thrombocytopenia, increased SGOT/SGPT and LDH. What is her diagnosis?

HELLP syndrome. ***HELLP syndrome*** - **HELLP syndrome** is characterized by **hemolysis**, **elevated liver enzymes** (SGOT/SGPT, LDH), and **low platelet count (thrombocytopenia)**, all of which are present in this patient with severe hypertension. - It is a severe form of **preeclampsia** and requires prompt recognition and management due to high maternal and fetal morbidity and mortality. *Eclampsia* - Eclampsia involves the occurrence of **new-onset grand mal seizures** in a woman with preeclampsia, which is not mentioned in the patient's presentation. - While preeclampsia (high BP) is present, the defining feature of eclampsia (seizures) is absent. *Hepatitis B* - **Hepatitis B** infection can cause elevated liver enzymes, but it typically presents with symptoms such as **abdominal pain, nausea, jaundice**, and may not involve hypertension or thrombocytopenia. - The combination of severe hypertension and thrombocytopenia makes hepatitis B an unlikely primary diagnosis in this context. *Obstetric cholestasis* - **Obstetric cholestasis** is characterized by **pruritus (itching)**, especially on the palms and soles, and elevated bile acids, often with only mildly elevated liver enzymes. - It does not typically cause **severe hypertension** or **thrombocytopenia**.

Question 1

Twin pregnancy should have ultrasound at 10-13 weeks to confirm which of the following?
I. Number of foetus
II. Viability of foetus
III. Chorionicity of twins
IV. Malformation in either foetus

Select the correct answer using the code given below :

Accepted Answer

I, II and III only

Answer

I and III only

Answer

II and IV only

Answer

I, II, III and IV

Question 2

Which of the following is the primary surveillance tool in the growth-restricted fetus?

Accepted Answer

Umbilical artery Doppler

Answer

Umbilical venous pulsation

Answer

Uterine artery Doppler

Answer

Middle cerebral artery Doppler

Question 3

Which of the following are the predictive factors for Fetal Growth Restriction (FGR)?
I. Low level of maternal 1^st trimester Beta hCG
II. Abnormal uterine artery Doppler at 20-24 weeks of pregnancy
III. Fetal echogenic bowel on ultrasound
IV. Maternal medical disorder

Select the correct answer using the code given below :

Accepted Answer

I, II and IV

Answer

I, III and IV

Answer

I, II and III

Answer

II, III and IV

Question 4

If, on amniocentesis, the alpha fetoprotein is found to be elevated in the amniotic fluid (which correlates with elevated maternal serum levels), which of the following conditions is likely to be present?

Accepted Answer

Neural tube defects

Answer

Duchenne muscular dystrophy

Answer

Cardiac septal defects

Answer

Galactosaemia

Question 5

Tongue bite occurs in eclampsia at :

Accepted Answer

Tonic stage

Answer

Coma stage

Answer

Clonic stage

Answer

Postictal stage

Question 6

Intrahepatic cholestasis of pregnancy presents with which of the following features ?

1. Pruritus after 28 weeks gestation, especially in palms and soles
2. Serum bilirubin levels > 5 mg%
3. Raised levels of serum bile acids
4. Features subside within two weeks postpartum

Select the correct answer using the code given below :

Accepted Answer

1, 3 and 4

Answer

1, 2 and 3

Answer

1, 2 and 4

Answer

2, 3 and 4

Question 7

A 29-year-old female with 3 months amenorrhoea presents to gynaecology OPD with complaints of something coming out of her vagina. On clinical evaluation she was found to have single live pregnancy with second degree uterine prolapse. Which one of the following is the best management plan for her ?

Accepted Answer

Pessary treatment

Answer

Reassurance

Answer

Cerclage operation

Answer

Cervical amputation

Question 8

Which of the following are the clinical features of molar pregnancy ?

1. History of amenorrhea and vaginal bleeding
2. Patient has excessive vomiting
3. History of expulsion of grape-like vesicles

Select the correct answer using the code given below :

Accepted Answer

1, 2 and 3

Answer

1 and 3 only

Answer

2 and 3 only

Answer

1 and 2 only

Question 9

A patient, who is 2 months pregnant, reports to a hospital with complaints of increased vaginal bleeding and pain in lower abdomen. Internal examination reveals dilated internal os of cervix and products of conception are felt through it. What is her likely clinical diagnosis?

Accepted Answer

Inevitable abortion

Answer

Threatened abortion

Answer

Incomplete abortion

Answer

Septic abortion

Question 10

A 24-year-old primigravida comes to ANC clinic at 8 months amenorrhoea. Her BP is found to be 160/100 mm Hg. Lab findings reveal thrombocytopenia, increased SGOT/SGPT and LDH. What is her diagnosis?

Accepted Answer

HELLP syndrome

Answer

Eclampsia

Answer

Hepatitis B

Answer

Obstetric cholestasis

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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