Prenatal Care — MCQs

Prenatal Care Indian Medical PG Practice Questions and MCQs

Question 421: Weight gain in pregnancy depends on all of the following except?

A. Smoking (Correct Answer)
B. Pre-pregnancy weight
C. Ethnicity
D. Maternal age

Explanation: **Explanation:** The total weight gain during pregnancy is influenced by several physiological, demographic, and socioeconomic factors. However, **Smoking (Option A)** is the correct answer because it is primarily associated with **Intrauterine Growth Restriction (IUGR)** and lower birth weight of the neonate, rather than being a primary determinant of the mother's total gestational weight gain (GWG) patterns in the same way biological factors are. **Analysis of Options:** * **Pre-pregnancy weight (Option B):** This is the most significant predictor of weight gain. According to IOM (Institute of Medicine) guidelines, women with a lower pre-pregnancy BMI are advised to gain more weight (12.5–18 kg), while obese women are advised to gain less (5–9 kg). * **Ethnicity (Option C):** Studies show significant variations in weight gain patterns across different ethnic groups due to genetic predispositions, cultural dietary habits, and metabolic differences. * **Maternal Age (Option D):** Adolescent pregnancies (younger age) are often associated with higher weight gain as the mother is still growing herself, whereas advanced maternal age can influence weight gain through different metabolic profiles and associated comorbidities. **NEET-PG High-Yield Pearls:** 1. **Average Weight Gain:** In a healthy pregnancy with a normal BMI, the average weight gain is **11 kg** (range 10–12.5 kg). 2. **Distribution:** 1 kg in the 1st trimester, and approximately 5 kg each in the 2nd and 3rd trimesters (0.4–0.5 kg/week). 3. **Components:** The fetus, placenta, and liquor account for only about **1/3rd** of the total weight gain; the rest is due to maternal fat stores, blood volume expansion, and reproductive organ hypertrophy. 4. **IOM Guidelines:** Always calculate weight gain targets based on the **Pre-pregnancy BMI**.

Question 422: Increased acetylcholinesterase in amniotic fluid indicates which of the following?

A. Open neural tube defects (Correct Answer)
B. Oesophageal atresia
C. Down syndrome
D. Edwards syndrome

Explanation: **Explanation:** **Acetylcholinesterase (AChE)** is an enzyme found primarily in neural tissues. In a normal pregnancy, it is not present in significant amounts in the amniotic fluid. However, in cases of **Open Neural Tube Defects (ONTDs)**, such as anencephaly or open spina bifida, the fetal neural tissue is directly exposed to the amniotic fluid. This allows AChE to leak from the exposed nerves into the fluid. While **Alpha-fetoprotein (AFP)** is the primary screening marker for ONTDs, it can be elevated in several other conditions (e.g., abdominal wall defects). **Amniotic fluid AChE is a more specific confirmatory test** for open neural tube defects because its presence specifically indicates the exposure of neural elements. **Analysis of Incorrect Options:** * **B. Oesophageal atresia:** This condition is associated with polyhydramnios and may show elevated maternal serum AFP (due to failure of the fetus to swallow and digest AFP), but it does not involve neural tissue exposure, so AChE will not be elevated. * **C. Down syndrome (Trisomy 21):** This is characterized by **decreased** maternal serum AFP and is typically screened using the Quadruple marker test (low AFP, low Estriol, high hCG, and high Inhibin-A). * **D. Edwards syndrome (Trisomy 18):** This condition typically presents with **decreased** levels of all maternal serum markers (AFP, hCG, and Estriol). **High-Yield Clinical Pearls for NEET-PG:** * **Sequence of Screening:** Elevated Maternal Serum AFP (MSAFP) $\rightarrow$ Ultrasound $\rightarrow$ Amniocentesis for Amniotic Fluid AFP $\rightarrow$ **AChE (Confirmatory).** * **False Positives:** Blood contamination during amniocentesis can cause a false-positive AChE result; however, the electrophoretic "fast-moving" band is specific to neural AChE. * **Closed NTDs:** AChE and AFP levels remain **normal** in closed neural tube defects (e.g., spina bifida occulta) because the defect is covered by skin.

Question 423: Palmer's sign in pregnancy refers to which of the following?

A. Rhythmic contractions of the uterus (Correct Answer)
B. Pulsations in the lateral fornix
C. Discoloration of the vagina
D. None of the above

Explanation: **Explanation:** **Palmer’s sign** is a presumptive sign of pregnancy characterized by **regular, rhythmic, and painless contractions of the uterus** that can be felt during a bimanual examination as early as 4 to 8 weeks of gestation. These contractions occur due to the increased vascularity and muscular hypertrophy of the uterine wall in early pregnancy. **Analysis of Options:** * **Option A (Correct):** Palmer’s sign specifically refers to these early rhythmic contractions. They are distinct from Braxton-Hicks contractions, which occur later in pregnancy (usually after 28 weeks). * **Option B (Incorrect):** Pulsations felt in the lateral fornices due to increased vascularity of the uterine artery is known as **Osiander’s sign**. * **Option C (Incorrect):** Bluish or purplish discoloration of the vagina and cervix due to pelvic congestion is known as **Chadwick’s sign** (or Jacquemier’s sign). * **Option D (Incorrect):** As Option A is the established clinical definition. **High-Yield Clinical Pearls for NEET-PG:** * **Hegar’s Sign:** Softening of the lower uterine segment (isthmus), typically felt between 6–10 weeks. * **Goodell’s Sign:** Softening of the cervix (feels like the lips instead of the tip of the nose). * **Piskacek’s Sign:** Asymmetrical enlargement of the uterus if implantation occurs near one of the cornua. * **Ladins Sign:** Softening of the uterus in the anterior midline at the junction of the uterus and cervix.

Question 424: Which of the following sonographic findings confirms an intrauterine pregnancy?

A. An echogenic rim along one side of the decidua.
B. Two concentric echogenic rings surrounding the sac.
C. A sac positioned eccentrically within the endometrium.
D. All of the above. (Correct Answer)

Explanation: To confirm an intrauterine pregnancy (IUP) and differentiate it from a "pseudogestational sac" (often seen in ectopic pregnancies), sonographers look for specific signs of the early gestational sac. **Explanation of the Correct Answer:** The correct answer is **D (All of the above)** because these three findings collectively describe the **Double Decidual Sac Sign (DDSS)**, which is the earliest reliable sonographic sign of an IUP before a yolk sac is visible. * **Option A (Intraseptal Sign):** This refers to the echogenic rim (decidua capsularis) seen along one side of the uterine cavity. * **Option B (Double Decidual Sign):** This consists of two concentric echogenic rings. The inner ring is the **decidua capsularis** (surrounding the chorion) and the outer ring is the **decidua parietalis** (lining the uterine cavity). The presence of these two layers confirms the sac is embedded within the endometrium, not just fluid in the cavity. * **Option C (Eccentric Position):** A true gestational sac is implanted within the decidua, making it **eccentrically located** relative to the midline uterine cavity. In contrast, a pseudogestational sac is typically centrally located. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest Sign of IUP:** The Double Decidual Sac Sign (seen at ~4.5–5 weeks). * **Definitive Sign of IUP:** Visualization of a **Yolk Sac** within the gestational sac (seen at ~5–5.5 weeks via TVS). * **Mean Sac Diameter (MSD):** A yolk sac should be seen when the MSD is **>8 mm** (TVS); an embryo should be seen when the MSD is **>25 mm**. * **Pseudogestational Sac:** A collection of fluid/blood in the uterine cavity in 10-15% of ectopic pregnancies; it lacks the double decidual rings and is centrally located.

Question 425: At what gestational age is a gestational sac typically visualized by transvaginal sonography (TVS)?

A. 5 weeks (Correct Answer)
B. 6 weeks
C. 7 weeks
D. 8 weeks

Explanation: **Explanation:** The visualization of early pregnancy milestones via ultrasonography follows a predictable chronological sequence based on the **Gestational Age (GA)** and **Serum β-hCG levels**. 1. **Why 5 weeks is correct:** The **Gestational Sac (GS)** is the first definitive sonographic sign of pregnancy. Using **Transvaginal Sonography (TVS)**, it typically becomes visible at **4.5 to 5 weeks** of gestation. At this stage, the mean sac diameter is approximately 2–3 mm, and the corresponding "Discriminatory Zone" of serum β-hCG is usually between **1,500 and 2,000 mIU/mL**. 2. **Why the other options are incorrect:** * **6 weeks:** By this time, the **Yolk Sac** (appears at 5.5 weeks) and the **Fetal Pole** with cardiac activity (appears at 6 weeks) should be visible via TVS. * **7–8 weeks:** These are late for the initial appearance of the sac. By 7-8 weeks, the embryo is well-defined, and Transabdominal Sonography (TAS) would easily identify the pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of 4-5-6 (TVS):** Gestational Sac at 4–5 weeks, Yolk Sac at 5.5 weeks, and Embryo with Heartbeat at 6 weeks. * **TAS vs. TVS:** Transabdominal markers usually lag behind TVS by **1 week**. (e.g., GS is seen at 6 weeks via TAS). * **Discriminatory Zone:** If β-hCG is >2,000 mIU/mL and no intrauterine sac is seen on TVS, ectopic pregnancy must be highly suspected. * **Double Decidual Sign:** This is the characteristic appearance of a true gestational sac, helping to differentiate it from a "pseudogestational sac" seen in ectopic pregnancies.

Question 426: Which of the following is NOT an indication for blood transfusion?

A. Moderate anemia at 24-30 weeks gestation (Correct Answer)
B. Severe anemia at 36 weeks gestation
C. Blood loss anemia
D. Refractory anemia

Explanation: In the management of anemia during pregnancy, the decision to transfuse blood is guided by the severity of anemia, the gestational age, and the clinical status of the patient. **Why Option A is the Correct Answer:** Moderate anemia (Hemoglobin 7–10.9 g/dL) at 24–30 weeks gestation is **not** an indication for blood transfusion. At this stage of pregnancy, there is sufficient time (at least 10–16 weeks) before delivery to correct hemoglobin levels using oral or parenteral iron therapy. Blood transfusion is an invasive procedure with risks (alloimmunization, infections, reactions) and is reserved for cases where rapid correction is mandatory. **Analysis of Incorrect Options:** * **B. Severe anemia at 36 weeks gestation:** Severe anemia (Hb <7 g/dL) near term is a high-risk state. Since there is insufficient time for iron therapy to take effect before labor, transfusion is indicated to prevent heart failure and postpartum hemorrhage complications. * **C. Blood loss anemia:** Acute blood loss (e.g., APH or PPH) leading to hemodynamic instability requires immediate volume and oxygen-carrying capacity replacement via transfusion. * **D. Refractory anemia:** If anemia fails to respond to standard iron or vitamin therapy (often due to underlying bone marrow issues or chronic disease), transfusion may be necessary to maintain safe hemoglobin levels. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Classification:** Mild (10–10.9 g/dL), Moderate (7–9.9 g/dL), Severe (<7 g/dL), Very Severe (<4 g/dL). * **Cut-off for Transfusion:** Generally, Hb <7 g/dL at any gestation or Hb <8–9 g/dL near term (36+ weeks) are indications. * **Target Hb:** The goal of therapy in pregnancy is to maintain Hb >11 g/dL. * **Parenteral Iron:** Preferred over oral iron if the patient is non-compliant or has malabsorption, provided they are <36 weeks pregnant.

Question 427: Which congenital malformation of the fetus can be diagnosed in the first trimester by ultrasound?

A. Anencephaly (Correct Answer)
B. Iniencephaly
C. Microcephaly
D. Holoprosencephaly

Explanation: **Explanation:** **Anencephaly** is the correct answer because it is one of the most reliable major structural malformations detectable during the late first trimester (11–13+6 weeks). The diagnosis is based on the absence of the cranial vault (acrania) and the presence of the "Mickey Mouse" sign or "Frog-eye" appearance, where the orbits are prominent due to the lack of frontal bone. By 11 weeks, ossification of the skull is usually sufficient to identify its absence on ultrasound. **Analysis of Incorrect Options:** * **Iniencephaly:** While it is a severe neural tube defect involving retroflexion of the head and spinal defects, it is much rarer than anencephaly and often diagnosed later when spinal curvature becomes more apparent. * **Microcephaly:** This is a diagnosis of exclusion that typically cannot be confirmed until the late second or third trimester. It relies on serial measurements of the head circumference (HC) falling significantly below the mean (usually >3 SD), which is not evident in the first trimester. * **Holoprosencephaly:** While severe (alobar) forms can sometimes be suspected in the first trimester by the "monoventricle" appearance, it is less consistently diagnosed than anencephaly. Many cases are only confirmed in the second trimester when the midline structures of the brain are expected to be fully developed. **High-Yield Clinical Pearls for NEET-PG:** * **Acrania-Anencephaly Sequence:** Acrania (absent skull with brain present) precedes anencephaly (degeneration of brain tissue due to exposure to amniotic fluid). * **Screening Window:** The 11–13+6 week scan (NT scan) is the primary window for early detection of major structural anomalies. * **Prevention:** Periconceptional Folic Acid (400 mcg/day for low risk; 4 mg/day for high risk) reduces the incidence of Neural Tube Defects (NTDs). * **Biochemical Marker:** Maternal Serum Alpha-Fetoprotein (MSAFP) is significantly elevated in open NTDs like anencephaly.

Question 428: A multigravida with a history of medical termination of pregnancy due to fetus with anencephaly presents for routine antenatal check-up. How is anencephaly best diagnosed in the current pregnancy?

A. Maternal Alpha-fetoprotein measurement
B. Amniotic fluid beta-hCG measurement
C. Ultrasound (USG) (Correct Answer)
D. X-ray

Explanation: **Explanation:** **Anencephaly** is a lethal neural tube defect (NTD) characterized by the absence of the cranial vault and cerebral hemispheres. 1. **Why Ultrasound (USG) is the Correct Answer:** USG is the **gold standard** and the investigation of choice for diagnosing anencephaly. It can detect the defect as early as **11–14 weeks** (late first trimester). Key sonographic signs include the **"Frog-eye appearance"** (due to prominent orbits and absence of the calvarium) and the **"Mickey Mouse sign"** in early gestation. It is non-invasive, highly sensitive (nearly 100%), and provides immediate results. 2. **Why Other Options are Incorrect:** * **Maternal Serum Alpha-fetoprotein (MSAFP):** While MSAFP is elevated in 80-90% of open NTDs, it is a **screening tool**, not a diagnostic one. High levels require confirmation via USG. * **Amniotic fluid beta-hCG:** This has no clinical role in the diagnosis of neural tube defects. Amniotic fluid **Acetylcholinesterase (AChE)** is the biochemical marker used for confirmation if USG is inconclusive, not hCG. * **X-ray:** Historically used to see the absence of the skull vault, it is now **obsolete** due to radiation risks to the fetus and the superior resolution of USG. **High-Yield Clinical Pearls for NEET-PG:** * **Prevention:** For a woman with a previous history of a child with NTD (like this patient), the recommended dose of **Folic Acid is 4 mg/day**, starting at least 1 month pre-conception through the first trimester. (Standard dose for low-risk is 400 mcg/day). * **Associated Finding:** Anencephaly is frequently associated with **polyhydramnios** because the fetus lacks the swallowing reflex. * **Screening Window:** MSAFP screening is typically performed between **15–20 weeks** of gestation.

Question 429: Self breast examination by females is advisable to be done at which of the following times?

A. Premenstrual period
B. During menses
C. 7-10 days after menses (Correct Answer)
D. Ovulatory period

Explanation: **Explanation:** The ideal time for a female to perform a **Self Breast Examination (SBE)** is **7–10 days after the onset of menstruation** (the early follicular phase). **Why Option C is correct:** During the menstrual cycle, breast tissue undergoes physiological changes due to hormonal fluctuations. In the luteal phase (premenstrual period), high levels of **progesterone** cause increased vascularity, water retention, and acinar proliferation. This results in breast engorgement, tenderness, and "nodularity" (lumpiness). By 7–10 days after menses begins, estrogen and progesterone levels are at their lowest, fluid retention has subsided, and the breast tissue is at its **softest and least tender**, making it much easier to palpate discrete masses and reducing the likelihood of false positives. **Why other options are incorrect:** * **A & B (Premenstrual & During menses):** The breasts are often swollen, tender, and naturally "lumpy" due to hormonal congestion. This makes the examination uncomfortable and can lead to the misidentification of normal physiological thickening as a pathological lump. * **D (Ovulatory period):** Estrogen peaks during ovulation, which can begin the process of breast vascularity and sensitivity in many women, making it less ideal than the post-menstrual phase. **NEET-PG High-Yield Pearls:** * **Post-menopausal women:** Should perform SBE on a **fixed date** every month (e.g., the 1st of every month) to maintain consistency. * **Lactating women:** Should perform SBE after the breast has been emptied (post-feed or post-expression). * **Clinical Significance:** While SBE is no longer recommended as a primary screening tool for mortality reduction by some international bodies (like the ACS), it remains a vital tool for **"Breast Awareness"** in the Indian context to detect early changes. * **Technique:** Use the pads of the middle three fingers, moving in a vertical strip or circular pattern, including the **Axillary Tail of Spence**.

Question 430: Abnormal alpha-fetoprotein levels are seen in which of the following conditions?

A. Trisomy 18
B. Twin pregnancy
C. Neural tube defect
D. All of the above (Correct Answer)

Explanation: **Explanation:** Alpha-fetoprotein (AFP) is a glycoprotein synthesized by the fetal yolk sac and later by the fetal liver. It is a crucial marker used in maternal serum screening (Triple/Quadruple tests) to detect fetal anomalies. The term "abnormal" refers to levels that are either significantly higher or lower than the median (MoM - Multiples of the Median). 1. **Neural Tube Defects (NTDs):** Conditions like anencephaly and spina bifida involve an open defect in the fetal skin/spine. This allows AFP to leak into the amniotic fluid and subsequently into the maternal circulation, leading to **elevated** Maternal Serum AFP (MSAFP). 2. **Twin Pregnancy:** AFP levels are directly proportional to the number of fetuses. In multiple gestations, the combined production of AFP results in **elevated** MSAFP levels. 3. **Trisomy 18 (and Trisomy 21):** Chromosomal abnormalities are typically associated with **decreased** MSAFP levels. In Trisomy 18 (Edwards Syndrome), AFP, hCG, and estriol are all characteristically low. Since all three conditions result in AFP levels deviating from the normal range, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Causes of Increased MSAFP:** NTDs, abdominal wall defects (Omphalocele, Gastroschisis), Multiple pregnancy, Fetal demise, and Renal anomalies (Finnish-type nephrosis). * **Causes of Decreased MSAFP:** Trisomy 21 (Down Syndrome), Trisomy 18, Gestational Trophoblastic Disease, and Maternal Obesity. * **Most Common Cause of Abnormal AFP:** Incorrect gestational age (dating error). Always re-check the dates via ultrasound if AFP is abnormal. * **Timing:** Optimal screening is performed between **15–20 weeks** of gestation.

Practice by Chapter

Preconception Counseling

Practice Questions

Pregnancy Diagnosis and Dating

Practice Questions

Routine Antenatal Assessments

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Maternal Physiological Changes

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Nutrition in Pregnancy

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Screening Tests in Pregnancy

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Fetal Growth Assessment

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High-Risk Pregnancy Identification

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Antenatal Complications Management

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Psychosocial Aspects of Pregnancy

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