Maternal-Fetal Medicine Practice Questions

Q: A 30-week pregnant woman presents for an antenatal check-up complaining of mild dyspnea and palpitations. On examination, pedal edema is present. An ejection systolic murmur is noted. ECG shows sinus tachycardia, left axis deviation, and occasional premature ventricular beats. Echocardiogram reveals a small pleural effusion and mild mitral regurgitation. No other relevant findings are present. What is the next line of treatment?

No treatment needed. **Explanation:** The correct answer is **C. No treatment needed**. This question tests the ability to distinguish between physiological cardiovascular changes in pregnancy and pathological heart disease. During pregnancy, blood volume increases by 40–50%, leading to a hyperdynamic circulation. The findings described in the clinical vignette are **normal physiological adaptations** at 30 weeks: * **Symptoms:** Mild dyspnea and palpitations are common due to the enlarging uterus and increased cardiac output. * **Physical Signs:** Dependent pedal edema occurs due to IVC compression. An **ejection systolic murmur** (Grade I/II) is heard in up to 90% of pregnant women due to increased flow across the pulmonary and aortic valves. * **ECG Changes:** Left axis deviation occurs as the diaphragm elevates and shifts the heart's position. Sinus tachycardia and isolated PVCs are common. * **Echocardiogram:** Mild mitral or tricuspid regurgitation and trace pericardial/pleural effusions can be seen due to volume overload and are not necessarily indicative of failure. **Why incorrect options are wrong:** * **Option A:** Diuretics are not indicated as the edema is physiological, not due to congestive heart failure. * **Option B:** Endocarditis prophylaxis is no longer recommended for physiological murmurs or uncomplicated vaginal/cesarean deliveries. * **Option D:** Termination is contraindicated. These findings do not meet the criteria for NYHA Class III/IV heart failure or life-threatening conditions (like Eisenmenger syndrome or severe MS). **Clinical Pearls for NEET-PG:** * **Diastolic murmurs** in pregnancy are **always pathological** and require investigation. * The most common heart disease in pregnancy in India is **Rheumatic Heart Disease (Mitral Stenosis)**. * Cardiac output peaks at **30–34 weeks** and immediately **post-partum** (due to autotransfusion). These are the periods of maximum risk for heart failure.

Q: A patient at 36 weeks of gestation presents with abdominal pain, uterine tenderness, and vaginal bleeding. Her vital signs are stable, and fetal heart tracing is regular. Which of the following steps is NOT required?

Tocolysis to arrest labor. ### Explanation The clinical presentation of abdominal pain, uterine tenderness, and vaginal bleeding in the third trimester is a classic triad for **Abruptio Placentae** (premature separation of the placenta). **1. Why Tocolysis (Option D) is NOT required:** In the management of placental abruption, **tocolysis is strictly contraindicated**. The primary goal is delivery, as the retroplacental clot acts as a uterine irritant, often leading to labor anyway. Attempting to arrest labor with tocolytics in the presence of abruption can lead to worsening hemorrhage, concealment of bleeding, and delay in definitive management, potentially resulting in maternal shock or fetal demise. **2. Why the other options are part of management:** * **Amniotomy/Prostaglandins (Option A):** Vaginal delivery is the preferred route if the fetus is stable. Amniotomy (rupturing membranes) is a priority as it reduces intrauterine pressure, decreases the entry of thromboplastin into maternal circulation (reducing DIC risk), and often accelerates labor. * **Blood Products (Option B):** Abruption is an obstetric emergency with a high risk of sudden, massive hemorrhage and Consumptive Coagulopathy (DIC). Cross-matching and arranging blood products is a mandatory safety step. * **IV Crystalloids/Colloids (Option C):** Aggressive fluid resuscitation is essential to maintain maternal hemodynamic stability and ensure adequate placental perfusion. **Clinical Pearls for NEET-PG:** * **Most common cause of DIC in pregnancy:** Abruptio Placentae. * **Couvelaire Uterus:** A complication of severe abruption where blood extravasates into the myometrium, giving it a bluish/purplish appearance. * **Management Rule:** If the fetus is alive and stable, aim for vaginal delivery (Amniotomy + Oxytocin). If there is fetal distress or maternal instability, proceed to immediate Cesarean Section.

Q: A G1 P0 patient presents with blood pressure of 160/102 mmHg, 3+ proteinuria, and right upper quadrant discomfort at 36 weeks gestation. Following induction of labor, she delivers vaginally and experiences 1500mL blood loss. Her serum creatinine rises from 0.98 mg/dL pre-delivery to 1.42 mg/dL post-delivery. What is the most likely diagnosis?

Acute tubular necrosis. ### Explanation **Correct Answer: D. Acute tubular necrosis (ATN)** The patient presents with **Severe Preeclampsia** (BP 160/102, 3+ proteinuria, RUQ pain) complicated by a massive **Postpartum Hemorrhage (PPH)** of 1500 mL. The core clinical event is the sudden rise in serum creatinine (from 0.98 to 1.42 mg/dL) following significant blood loss. In the context of obstetric hemorrhage and hypovolemia, the most common cause of acute kidney injury (AKI) is **Acute Tubular Necrosis**. The ischemic insult to the renal tubules caused by profound hypotension (from PPH) leads to the rise in creatinine. **Why other options are incorrect:** * **A. Severe preeclampsia:** While the patient meets the criteria for severe preeclampsia, this is the *underlying condition*, not the specific diagnosis for the post-delivery renal deterioration. * **B. Postpartum hemorrhage:** This is the *precipitating event* (the cause), but it does not describe the resulting renal pathology. * **C. Subcapsular liver hematoma:** Although RUQ pain in preeclampsia suggests liver involvement (Glisson’s capsule stretch), it does not explain the acute rise in creatinine following delivery and blood loss. **Clinical Pearls for NEET-PG:** * **Renal Failure in Pregnancy:** The most common cause of AKI in the third trimester is preeclampsia/HELLP syndrome, but the most common cause of *ischemic* AKI (ATN) is obstetric hemorrhage (Abruptio placentae or PPH). * **Creatinine Norms:** Remember that normal serum creatinine in pregnancy is lower (0.4–0.8 mg/dL) due to increased GFR. A value of 1.42 mg/dL represents significant renal impairment. * **Management:** The priority in ATN is fluid resuscitation and maintaining renal perfusion. Most cases are reversible if the primary cause is managed.

Q: A woman with mitral stenosis but no pulmonary hypertension is in labor at 39 weeks of gestation. She has dyspnea on exertion and a pulse rate of 80 bpm. There are no basal crepitations in the lungs. The cervix is 4 cm dilated, and she is having 1-2 uterine contractions in 10 minutes. Which of the following steps is best avoided in her management?

Use of ergometrine in the third stage of labor. In patients with **Mitral Stenosis (MS)**, the primary goal of management is to avoid sudden increases in preload and heart rate to prevent pulmonary edema. ### **Why Ergometrine is Avoided (Correct Answer)** Ergometrine (and Syntometrine) causes **vasoconstriction and a sudden shift of blood** from the peripheral circulation to the central compartment (autotransfusion). In MS, the narrowed mitral valve cannot handle this sudden increase in venous return (preload), leading to a rapid rise in left atrial pressure and a high risk of **acute pulmonary edema**. Therefore, it is strictly contraindicated in cardiac patients. ### **Analysis of Other Options** * **A. Active Management of the Third Stage of Labor (AMTSL):** This is recommended to prevent Postpartum Hemorrhage (PPH). However, in cardiac patients, the uterotonic of choice is **Oxytocin** (slow infusion), not ergometrine. * **B. Augmentation of labor with oxytocin:** This is acceptable if labor is slow. Oxytocin should be given in a concentrated form via an infusion pump to avoid fluid overload. * **C. Epidural analgesia:** This is highly beneficial in MS. It reduces pain-induced tachycardia and decreases preload (via sympathetic blockade), which helps prevent pulmonary congestion. ### **Clinical Pearls for NEET-PG** * **Most common cardiac lesion in pregnancy:** Mitral Stenosis (Rheumatic). * **Most critical period:** Immediately postpartum (due to autotransfusion from the involuting uterus and relief of IVC compression). * **Management of choice for PPH in MS:** Oxytocin (slow IV) or Misoprostol. Avoid Ergometrine and Carboprost (the latter increases pulmonary artery pressure). * **Position:** Labor in the **left lateral position** to optimize venous return and cardiac output.

Q: You have initiated magnesium sulfate therapy for a patient with eclampsia. Later you notice the respiratory rate is 6/minute and the tendon reflexes are not elicitable. What is the next appropriate step?

Administer calcium gluconate 10 ml over 10 minutes. ### Explanation This clinical scenario describes **Magnesium Sulfate ($MgSO_4$) toxicity**. $MgSO_4$ is the drug of choice for controlling seizures in eclampsia, but it has a narrow therapeutic index. **1. Why Option B is Correct:** The patient is exhibiting classic signs of magnesium toxicity: **loss of deep tendon reflexes (patellar reflex)**, which occurs at serum levels of 7–10 mEq/L, and **respiratory depression** (RR 12 mEq/L. * **Mechanism:** Magnesium acts as a calcium antagonist at the neuromuscular junction. * **Antidote:** **10 ml of 10% Calcium Gluconate** administered IV over 10 minutes is the immediate treatment. Calcium antagonizes the membrane effects of magnesium, reversing respiratory depression and cardiac toxicity. **2. Why Other Options are Incorrect:** * **Option A (Naloxone):** This is an opioid antagonist used for opioid overdose. It has no role in reversing magnesium-induced neuromuscular blockade. * **Option C (Atropine):** This is an anticholinergic used for symptomatic bradycardia or organophosphate poisoning. It does not counteract magnesium. * **Option D (Sodium Bicarbonate):** Used for metabolic acidosis or specific toxicities (like TCAs), but not for $MgSO_4$ toxicity. **3. High-Yield Clinical Pearls for NEET-PG:** * **Monitoring $MgSO_4$:** Always check three parameters before every dose: 1. **Patellar Reflex:** Must be present (First sign of toxicity is loss of reflex). 2. **Respiratory Rate:** Must be >12–14/min. 3. **Urine Output:** Must be >30 ml/hr or >100 ml/4hr (Magnesium is excreted solely by kidneys). * **Therapeutic Range:** 4–7 mEq/L. * **Sequence of Toxicity:** Loss of reflexes $\rightarrow$ Respiratory depression $\rightarrow$ Cardiac arrest (>25 mEq/L). * **Pritchard Regimen:** 4g IV + 10g IM (loading), followed by 5g IM every 4 hours (maintenance).

Q: A woman has had two previous anencephalic babies. What is the risk of having a third one?

10%. **Explanation:** Neural Tube Defects (NTDs), such as anencephaly and spina bifida, follow a **multifactorial inheritance** pattern. This means they result from a combination of multiple genetic predispositions and environmental factors (like folic acid deficiency). In multifactorial inheritance, the recurrence risk increases significantly with each previously affected sibling. * **Why 10% is correct:** In the general population, the risk of NTD is approximately 0.1–0.2%. After **one** affected child, the recurrence risk rises to **2–5%**. After **two** affected children, the risk increases further to approximately **10%**. This is a classic high-yield statistic for postgraduate exams. **Analysis of Incorrect Options:** * **0%:** Incorrect, as genetic and environmental predispositions persist in subsequent pregnancies. * **25%:** This risk is characteristic of **Autosomal Recessive** disorders (e.g., Thalassemia). While some rare syndromes involving NTDs exist, isolated anencephaly does not follow this pattern. * **50%:** This risk is characteristic of **Autosomal Dominant** disorders (if one parent is affected). **Clinical Pearls for NEET-PG:** 1. **Prevention:** For a woman with a previous history of NTD, the recommended dose of **Folic Acid is 4 mg/day**, started at least 1 month (ideally 3 months) prior to conception and continued through the first trimester. 2. **Low-risk prophylaxis:** For women without a history, the standard dose is **400 mcg (0.4 mg)/day**. 3. **Screening:** Maternal Serum Alpha-Fetoprotein (MSAFP) is elevated in open NTDs. Diagnosis is confirmed via targeted ultrasound (Level II scan) at 18–20 weeks.

Question 1

A 30-week pregnant woman presents for an antenatal check-up complaining of mild dyspnea and palpitations. On examination, pedal edema is present. An ejection systolic murmur is noted. ECG shows sinus tachycardia, left axis deviation, and occasional premature ventricular beats. Echocardiogram reveals a small pleural effusion and mild mitral regurgitation. No other relevant findings are present. What is the next line of treatment?

Accepted Answer

No treatment needed

Answer

Start diuretics

Answer

Start endocarditis prophylaxis

Answer

Terminate pregnancy as features are diagnostic of heart failure

Question 2

A patient at 36 weeks of gestation presents with abdominal pain, uterine tenderness, and vaginal bleeding. Her vital signs are stable, and fetal heart tracing is regular. Which of the following steps is NOT required?

Accepted Answer

Tocolysis to arrest labor

Answer

Amniotomy or prostaglandins to induce labor

Answer

Arrange for blood products

Answer

Intravenous crystalloids and colloids

Question 3

A G1 P0 patient presents with blood pressure of 160/102 mmHg, 3+ proteinuria, and right upper quadrant discomfort at 36 weeks gestation. Following induction of labor, she delivers vaginally and experiences 1500mL blood loss. Her serum creatinine rises from 0.98 mg/dL pre-delivery to 1.42 mg/dL post-delivery. What is the most likely diagnosis?

Accepted Answer

Acute tubular necrosis

Answer

Severe preeclampsia

Answer

Postpartum hemorrhage

Answer

Subcapsular liver hematoma

Question 4

A woman with mitral stenosis but no pulmonary hypertension is in labor at 39 weeks of gestation. She has dyspnea on exertion and a pulse rate of 80 bpm. There are no basal crepitations in the lungs. The cervix is 4 cm dilated, and she is having 1-2 uterine contractions in 10 minutes. Which of the following steps is best avoided in her management?

Accepted Answer

Use of ergometrine in the third stage of labor

Answer

Active management of the third stage of labor

Answer

Augmentation of labor with oxytocin

Answer

Use of epidural analgesia for pain relief

Question 5

A 36-year-old multigravida at 34 weeks gestation, with a history of two previous lower segment caesarean sections (LSCS), presents with an unstable lie. What is the most likely diagnosis in this case?

Accepted Answer

Placenta previa

Answer

Oligohydramnios

Answer

Pelvic tumor

Answer

Uterine anomalies

Question 6

A 25-year-old nulliparous woman at 35 weeks' gestation presents with contractions, headache, and visual disturbances. Her pregnancy has been uncomplicated. Her temperature is 37 C, blood pressure is 160/110 mm Hg, pulse is 88/minute, and respirations are 12/minute. Examination reveals a cervix that is 2 cm dilated and 75% effaced, with contractions occurring every 2 minutes. Fetal heart rate is in the 140s and reactive. Urinalysis shows 3+ proteinuria. Laboratory values: leukocytes 9,400/mm3, hematocrit 35%, platelets 101,000/mm3, AST 200 U/L, and ALT 300 U/L. What is the most appropriate next step in management?

Accepted Answer

Administer magnesium sulfate

Answer

Administer oxytocin

Answer

Discharge the patient

Answer

Encourage ambulation

Question 7

For diagnosing chronic hypertension in pregnancy, hypertension is considered present prior to what gestational age?

Accepted Answer

20 weeks

Answer

8 weeks

Answer

14 weeks

Answer

24 weeks

Question 8

A 28-year-old woman (Gravida 2, Para 1, Abortus 0) at 36 weeks of gestation has a history of a prior stillbirth at 37 weeks. What is the optimal timing for delivery in this current pregnancy?

Accepted Answer

39 weeks of gestation

Answer

Immediately

Answer

37 weeks of gestation

Answer

38 weeks of gestation

Question 9

You have initiated magnesium sulfate therapy for a patient with eclampsia. Later you notice the respiratory rate is 6/minute and the tendon reflexes are not elicitable. What is the next appropriate step?

Accepted Answer

Administer calcium gluconate 10 ml over 10 minutes

Answer

Administer naloxone at 0.01 mg/kg over 5 minutes

Answer

Administer 0.4 mg atropine IV

Answer

Administer 5 mEq/kg sodium bicarbonate IV over 10 minutes

Question 10

A woman has had two previous anencephalic babies. What is the risk of having a third one?

Accepted Answer

10%

Answer

0%

Answer

25%

Answer

50%

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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