Maternal-Fetal Medicine Practice Questions

Q: Which of the following is NOT a sonographic finding of fetal syphilis?

Lymphadenopathy. **Explanation:** Congenital syphilis is caused by the transplacental transmission of *Treponema pallidum*. The sonographic findings of fetal syphilis are primarily a reflection of fetal inflammatory response, severe anemia, and hepatic dysfunction. **Why Lymphadenopathy is the correct answer:** While lymphadenopathy is a classic physical exam finding in **neonates** with early congenital syphilis (presenting as generalized swelling or "snuffles"), it is **not** a detectable or characteristic finding on **prenatal ultrasound**. Fetal sonography focuses on organomegaly and fluid distribution rather than discrete fetal lymph node visualization. **Analysis of Incorrect Options:** * **Hepatomegaly (Option A):** This is the **most common** and often the earliest sonographic sign of fetal syphilis. It results from direct treponemal infiltration of the liver and extramedullary hematopoiesis. * **Placentomegaly (Option C):** A thick, enlarged placenta (typically >4-5 cm in the second/third trimester) is a hallmark of syphilis. It occurs due to villous edema and inflammation (villitis). * **Ascites/Hydrops (Option D):** As the disease progresses, hepatic dysfunction (leading to hypoalbuminemia) and severe anemia lead to fetal hydrops, characterized by ascites, pleural effusion, and skin edema. **NEET-PG High-Yield Pearls:** * **Triad of Fetal Syphilis:** Hepatomegaly, Placentomegaly, and Polyhydramnios. * **Screening:** All pregnant women should be screened at the first prenatal visit with non-treponemal tests (VDRL/RPR). * **Treatment of Choice:** Parenteral **Penicillin G** is the only treatment documented to be effective for preventing maternal transmission to the fetus and treating fetal infection. * **Jarisch-Herxheimer Reaction:** Pregnant women treated for syphilis must be monitored for this reaction, as it can precipitate preterm labor or fetal distress.

Q: Hyperemesis gravidarum is typically most severe at which gestational age?

9 weeks. **Explanation:** **Hyperemesis Gravidarum (HG)** is a severe form of nausea and vomiting in pregnancy characterized by weight loss, ketonuria, and electrolyte imbalances. The severity and timing of HG are directly correlated with the serum levels of **Human Chorionic Gonadotropin (hCG)**. 1. **Why 9 Weeks is Correct:** Serum hCG levels begin to rise shortly after implantation, doubling every 48–72 hours. These levels reach their **peak between 8 and 12 weeks** of gestation (averaging around 9–10 weeks). Because the pathogenesis of HG is linked to the high concentration of hCG (and its stimulatory effect on the TSH receptor), symptoms are most intense during this peak. 2. **Why Other Options are Incorrect:** * **6 Weeks:** This is typically when "morning sickness" begins (onset), but hCG levels have not yet reached their maximum concentration. * **28 and 36 Weeks:** These represent the third trimester. In most cases, HG resolves by 16–20 weeks as hCG levels plateau and decline. Persistent vomiting in late pregnancy should prompt investigation for other causes like HELLP syndrome, acute fatty liver of pregnancy, or gastrointestinal issues. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Multiple gestations and Molar pregnancies (due to excessively high hCG levels). * **Wernicke’s Encephalopathy:** A rare but serious complication of HG due to **Vitamin B1 (Thiamine)** deficiency. Always replenish Thiamine before giving IV Dextrose. * **Electrolyte Imbalance:** Most common pattern is **Hypokalemic Hypochloremic Metabolic Alkalosis**. * **First-line Pharmacotherapy:** Pyridoxine (Vitamin B6) ± Doxylamine.

Q: Which of the following congenital malformations will most predictably result in oligohydramnios?

Renal agenesis. ### Explanation The volume of amniotic fluid is a dynamic balance between production and removal. From the second trimester onwards, **fetal urine** becomes the primary source of amniotic fluid, while **fetal swallowing** is the primary route of removal. **Why Renal Agenesis is Correct:** In cases of **bilateral renal agenesis** (Potter’s Syndrome), there is a complete failure of fetal urine production. Since the primary source of amniotic fluid is absent, severe **oligohydramnios** (Amniotic Fluid Index < 5 cm) inevitably occurs. This lack of fluid leads to secondary complications like pulmonary hypoplasia and limb deformities due to uterine compression. **Why Other Options are Incorrect:** * **Anencephaly:** This condition typically results in **polyhydramnios**. The absence of the swallowing reflex (due to neural defects) and the transudation of fluid from the exposed meninges lead to an accumulation of fluid. * **Pyloric Stenosis:** While it involves a gastrointestinal obstruction, it occurs late or postnatally and does not significantly impair fetal swallowing in utero. Therefore, it is not a classic cause of polyhydramnios or oligohydramnios. * **Tracheoesophageal Fistula (TEF):** This often results in **polyhydramnios**. If the fistula prevents the fetus from effectively swallowing and absorbing amniotic fluid through the GI tract, the fluid accumulates in the gestational sac. **NEET-PG Clinical Pearls:** * **Potter’s Sequence:** Remember the mnemonic **POTTER** (Pulmonary hypoplasia, Oligohydramnios, Twisted face, Twisted skin, Extremity defects, Renal agenesis). * **Amniotic Fluid Index (AFI):** Normal range is 5–25 cm. 25 cm is polyhydramnios. * **Drug Link:** Maternal intake of **ACE inhibitors** or **NSAIDs** in the second/third trimester can also cause oligohydramnios by reducing fetal renal perfusion.

Q: Nausea and vomiting are common in pregnancy. Hyperemesis gravidarum is a serious and potentially fatal problem. Which of the following findings should alert the physician to the diagnosis of hyperemesis gravidarum early in its course?

Ketonuria. ### Explanation **Hyperemesis Gravidarum (HG)** is a severe form of nausea and vomiting in pregnancy characterized by persistent vomiting, weight loss (>5% of pre-pregnancy weight), and dehydration. **1. Why Ketonuria is the Correct Answer:** The hallmark of HG is a state of **starvation metabolism**. When a patient cannot retain oral intake, the body exhausts its glycogen stores and begins breaking down fats for energy. This process produces ketone bodies (acetone, acetoacetate, and beta-hydroxybutyrate), which are excreted in the urine. **Ketonuria** is the earliest objective laboratory finding that differentiates HG from simple morning sickness and indicates the need for hospitalization and IV fluid resuscitation. **2. Analysis of Incorrect Options:** * **A. ECG evidence of hypokalemia:** While hypokalemia occurs due to loss of gastric secretions and decreased intake, ECG changes (like U-waves or T-wave flattening) are **late signs** of severe electrolyte depletion, not early diagnostic markers. * **B. Metabolic acidosis:** HG typically causes **Metabolic Alkalosis** (due to loss of hydrochloric acid from the stomach). Metabolic acidosis only occurs in terminal stages due to starvation ketosis or renal failure, making it an incorrect early finding. * **C. Jaundice:** This is a **late and grave sign** indicating hepatic involvement (centrilobular necrosis). It is not used for early diagnosis. **3. NEET-PG High-Yield Pearls:** * **Most common electrolyte abnormality:** Hypokalemic hypochloremic metabolic alkalosis. * **Hormonal link:** Strongly associated with peak levels of **hCG** and Estrogen (often seen in molar pregnancies and multiple gestations). * **Wernicke’s Encephalopathy:** A dreaded complication caused by **Vitamin B1 (Thiamine) deficiency**; always supplement Thiamine before giving Dextrose-containing fluids. * **First-line Drug:** Pyridoxine (Vit B6) +/- Doxylamine.

Q: Diagnosis of Down syndrome at 11 weeks gestation can be assessed by:

Chorionic villous biopsy. **Explanation:** The diagnosis of Down syndrome (Trisomy 21) requires a **definitive genetic analysis** (karyotyping or FISH) to identify the extra chromosome 21. 1. **Why Chorionic Villous Biopsy (CVS) is correct:** CVS is an invasive diagnostic procedure performed between **10 and 13 weeks** of gestation. It involves taking a sample of placental tissue (chorionic villi), which shares the same genetic makeup as the fetus. Since the question specifies **11 weeks**, CVS is the gold-standard diagnostic tool available at this specific gestational age. 2. **Why other options are incorrect:** * **Ultrasonography:** While USG can detect "soft markers" like increased Nuchal Translucency (NT) at 11–13 weeks, it is a **screening tool**, not a diagnostic one. It suggests a risk but cannot confirm the diagnosis. * **Amniocentesis:** This is a definitive diagnostic test, but it is typically performed between **15 and 20 weeks**. Performing it before 15 weeks (early amniocentesis) is avoided due to higher risks of clubfoot (talipes) and pregnancy loss. * **Doppler Ultrasound:** This is used to assess blood flow in maternal and fetal vessels (e.g., Uterine or Umbilical artery) to monitor fetal well-being and growth restriction; it has no role in the primary diagnosis of chromosomal aneuploidies. **High-Yield Clinical Pearls for NEET-PG:** * **First Trimester Screening (Combined Test):** Includes NT scan + PAPP-A + β-hCG (performed between 11–13+6 weeks). * **Definitive Diagnosis:** CVS (10–13 weeks) or Amniocentesis (>15 weeks). * **NIPT (Non-Invasive Prenatal Testing):** Analyzes cell-free fetal DNA in maternal blood; it is the most sensitive screening test but still requires confirmation via CVS or Amniocentesis.

Q: A 25-year-old woman, G2 P1 with a prior cesarean delivery, is in labor. The fetal heart rate monitor shows the tracing seen in the image. What is your diagnosis?

Uterine rupture. ***Uterine rupture*** - **Sudden prolonged fetal bradycardia** in a woman with **prior cesarean delivery** attempting **VBAC** (vaginal birth after cesarean) is highly suggestive of uterine rupture. - The **previous cesarean scar** creates a weak point in the uterine wall that can rupture during labor, causing immediate fetal compromise and maternal hemorrhage. *Cord compression* - Typically presents with **variable decelerations** that correlate with uterine contractions, not sudden prolonged bradycardia. - The fetal heart rate pattern would show **abrupt drops** followed by **rapid return to baseline** between contractions. *Fetal anemia* - Characterized by a **sinusoidal fetal heart rate pattern** with smooth, wave-like oscillations of 5-15 beats per minute. - Would not present as **sudden prolonged bradycardia** but rather as a continuous undulating pattern. *Amniotic fluid embolism* - Primarily causes **sudden maternal cardiovascular collapse** with hypotension, respiratory distress, and coagulopathy. - The fetal heart rate changes are **secondary to maternal compromise**, not the primary presenting feature.

Q: Which one of the following is NOT a feature of severe pre-eclampsia?

Thrombocytosis. **Explanation:** Pre-eclampsia is defined as new-onset hypertension (≥140/90 mmHg) and proteinuria (or organ dysfunction) after 20 weeks of gestation. The distinction between pre-eclampsia and **severe pre-eclampsia** is critical for management decisions. **Why Thrombocytosis is the correct answer:** In severe pre-eclampsia, the underlying pathophysiology involves widespread endothelial damage and microangiopathic hemolytic anemia. This leads to **Thrombocytopenia** (platelet count <100,000/mm³), not thrombocytosis. Low platelets occur due to increased consumption and destruction of platelets within the damaged vasculature. **Analysis of Incorrect Options (Features of Severe Pre-eclampsia):** * **BP 160/110 mmHg:** A systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg on two occasions at least 4 hours apart is a diagnostic criterion for severe features. * **Visual Disturbances:** New-onset cerebral or visual disturbances (e.g., photopsia, scotomata, blurred vision) indicate cerebral edema or occipital lobe ischemia, marking severe disease. * **Oliguria:** Reduced urine output ( 1.1 mg/dL) signifies significant renal impairment. **NEET-PG High-Yield Pearls:** * **HELLP Syndrome:** A severe variant characterized by **H**emolysis, **E**levated **L**iver enzymes, and **L**ow **P**latelets. * **Drug of Choice:** Magnesium Sulfate ($MgSO_4$) is the gold standard for preventing and treating eclamptic seizures. * **Definitive Treatment:** Delivery of the fetus and placenta is the only cure for pre-eclampsia. * **Proteinuria:** While proteinuria is a diagnostic feature of pre-eclampsia, the *amount* of proteinuria (formerly >5g) is no longer used to define "severe" features in current ACOG guidelines, though it remains a clinical marker.

Q: A pregnant female with chronic hypertension whose blood pressure is controlled with antihypertensives should ideally be delivered at which gestational age?

37-39 weeks. **Explanation:** The management of chronic hypertension in pregnancy focuses on balancing the risks of intrauterine growth restriction (IUGR) and placental abruption against the risks of neonatal prematurity. **Why Option B is Correct:** According to ACOG and standard obstetric guidelines, women with **chronic hypertension** that is **well-controlled** with medication and who do not develop superimposed preeclampsia should be delivered between **37 0/7 and 39 6/7 weeks** of gestation. Delivery during this window (early term to full term) minimizes the risk of stillbirth while ensuring fetal lung maturity and reducing neonatal morbidity associated with late-preterm birth. **Analysis of Incorrect Options:** * **Option A (38-39 weeks):** While delivery in this window is acceptable, it is too narrow. The guidelines specifically allow for delivery starting at 37 weeks. * **Option C (36-37 weeks):** This is the timing for chronic hypertension that is **difficult to control** or associated with mild complications. For well-controlled cases, delivering before 37 weeks unnecessarily increases the risk of respiratory distress syndrome (RDS). * **Option D (35-36 weeks):** This range is generally reserved for severe complications, such as superimposed preeclampsia with severe features or fetal growth restriction with abnormal dopplers. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Chronic hypertension is BP ≥140/90 mmHg predating pregnancy or diagnosed before 20 weeks of gestation. * **Drug of Choice:** Labetalol is generally the first-line antihypertensive; Methyldopa and Nifedipine are also used. **ACE inhibitors and ARBs are strictly contraindicated** due to fetal renal dysgenesis. * **Superimposed Preeclampsia:** If a patient with chronic hypertension develops preeclampsia, delivery is usually indicated at **37 weeks** (without severe features) or **immediately upon diagnosis after 34 weeks** (with severe features).

Question 1

Which of the following is NOT a sonographic finding of fetal syphilis?

Accepted Answer

Lymphadenopathy

Answer

Hepatomegaly

Answer

Placentomegaly

Answer

Ascites/hydrops

Question 2

Hyperemesis gravidarum is typically most severe at which gestational age?

Accepted Answer

9 weeks

Answer

6 weeks

Answer

28 weeks

Answer

36 weeks

Question 3

Which of the following congenital malformations will most predictably result in oligohydramnios?

Accepted Answer

Renal agenesis

Answer

Anencephaly

Answer

Pyloric stenosis

Answer

Tracheoesophageal fistula

Question 4

Highest transmission of hepatitis B from mother to fetus occurs if the mother is infected during which period?

Accepted Answer

3rd trimester

Answer

1st trimester

Answer

2nd trimester

Answer

At the time of implantation

Question 5

Nausea and vomiting are common in pregnancy. Hyperemesis gravidarum is a serious and potentially fatal problem. Which of the following findings should alert the physician to the diagnosis of hyperemesis gravidarum early in its course?

Accepted Answer

Ketonuria

Answer

Electrocardiographic evidence of hypokalemia

Answer

Metabolic acidosis

Answer

Jaundice

Question 6

Diagnosis of Down syndrome at 11 weeks gestation can be assessed by:

Accepted Answer

Chorionic villous biopsy

Answer

Ultrasonography

Answer

Aminocentesis

Answer

Doppler ultrasound

Question 7

A 30-week pregnant female presents for antenatal Doppler assessment. The findings are shown. What is the recommended management?

Accepted Answer

Admit the patient, provide steroid cover, monitor with Non-stress test (NST) and repeat Doppler, and plan for delivery at 32-34 weeks or earlier if Doppler findings worsen.

Answer

Urgent lower segment cesarean section (LSCS)

Answer

The findings are normal for 30 weeks of pregnancy; the patient can be followed up on an outpatient basis.

Answer

Admit the patient, provide steroid cover, and continue follow-up until 37-38 weeks.

Question 8

A 25-year-old woman, G2 P1 with a prior cesarean delivery, is in labor. The fetal heart rate monitor shows the tracing seen in the image. What is your diagnosis?

Accepted Answer

Uterine rupture

Answer

Cord compression

Answer

Fetal anemia

Answer

Amniotic fluid embolism

Question 9

Which one of the following is NOT a feature of severe pre-eclampsia?

Accepted Answer

Thrombocytosis

Answer

BP 160/110 mmHg

Answer

Visual disturbances

Answer

Oliguria

Question 10

A pregnant female with chronic hypertension whose blood pressure is controlled with antihypertensives should ideally be delivered at which gestational age?

Accepted Answer

37-39 weeks

Answer

38-39 weeks

Answer

36-37 weeks

Answer

35-36 weeks

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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