Maternal-Fetal Medicine — MCQs
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Spalding sign is seen in ?
A woman presents to you at 36 weeks of gestation with complaints of breathlessness and excessive abdominal distension. Fetal movements are normal. On examination, fetal parts are not easily felt and fetal heartbeat is heard but it is muffled. Her symphysis fundal height is 41 cm. Her abdomen is tense but not tender. What is the most likely diagnosis?
A 22-year-old primigravida visits ANC OPD with 20 weeks POG. On examination uterine height reveals a 16-week size. USG shows reduced liquor. What will be the diagnosis?
The major contributor to amniotic fluid after 20 weeks of gestation is:
Which of the following is the MOST significant physiological change that occurs during pregnancy?
What maternal condition is commonly associated with congenital heart defects in the fetus?
A 40 year old G2P1 woman with 18 weeks of amenorrhea comes with a dilated cervix. The cervical length is 15 mm. In spite of explaining the risks, she insisted on cerclage. Which of the following is a contraindication for cervical cerclage?
In a case of DCDA twins at 38 weeks, with the first twin in breech presentation, and the mother having a blood pressure of 140/96 and 1+ proteinuria, what is the preferred management?
Which of the following statement is correct about acute fatty liver of pregnancy?
A baby born at 34 weeks gestation weighs 3kg. Which of the following conditions is this child most likely to develop in the immediate postnatal period?
Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs
Question 1211: Spalding sign is seen in ?
- A. Drowning
- B. Mummification
- C. Maceration (Correct Answer)
- D. Starvation
Explanation: ***Maceration*** - **Spalding sign** is a classic radiological finding in **intrauterine fetal death**, characterized by the **overlapping of fetal skull bones** due to liquefaction of the brain and loss of structural support. - This sign typically appears **7-10 days after fetal demise** and is a hallmark of **maceration**, the aseptic autolysis of a dead fetus retained in utero in the presence of amniotic fluid. - Maceration involves softening and peeling of skin, reddish discoloration, and progressive tissue breakdown in a **moist intrauterine environment**. *Mummification* - **Mummification** is an alternative form of fetal death in utero that occurs in **dry conditions** (typically in twin pregnancies where one twin dies and amniotic fluid is absent). - The fetus becomes **desiccated, shriveled, and preserved** rather than undergoing liquefaction. - Spalding sign is **not seen** in mummification because the skull remains intact without liquefactive changes. *Drowning* - **Drowning** is death by suffocation in a liquid medium and is unrelated to intrauterine fetal pathology. - Not associated with Spalding sign, which is specific to retained dead fetus in utero. *Starvation* - **Starvation** refers to severe nutritional deprivation leading to wasting and organ failure. - Not associated with specific radiological signs of fetal death like Spalding sign.
Question 1212: A woman presents to you at 36 weeks of gestation with complaints of breathlessness and excessive abdominal distension. Fetal movements are normal. On examination, fetal parts are not easily felt and fetal heartbeat is heard but it is muffled. Her symphysis fundal height is 41 cm. Her abdomen is tense but not tender. What is the most likely diagnosis?
- A. Abruptio placenta
- B. Hydrocephalus of fetus
- C. Polyhydramnios (Correct Answer)
- D. Oligohydramnios
Explanation: ***Polyhydramnios*** - The patient's symptoms of **breathlessness**, **excessive abdominal distension**, a **symphysis fundal height of 41 cm at 36 weeks** (indicating a significantly larger than expected uterus), and **muffled fetal heart tones** are classic signs of polyhydramnios. - **Difficulty feeling fetal parts** is also consistent with excess amniotic fluid, which cushions the fetus and makes palpation harder. *Abruptio placenta* - This condition typically presents with sudden onset of **painful vaginal bleeding**, uterine tenderness, and fetal distress, none of which are described here. - While the abdomen might be tense due to uterine contractions or concealed bleeding, the lack of pain and bleeding makes this diagnosis unlikely. *Hydrocephalus of fetus* - Fetal hydrocephalus would primarily manifest as an **abnormally large fetal head** upon ultrasound, potentially leading to a higher fundal height. - However, it wouldn't directly explain the generalized excessive abdominal distension or the difficulty in feeling fetal parts due to fluid, though it could be a cause of polyhydramnios itself, it is not the most likely primary diagnosis from the given options directly addressing the symptoms. *Oligohydramnios* - This condition is characterized by **too little amniotic fluid**, which would result in a **smaller than expected symphysis fundal height** and an easily palpable fetus. - The patient's symptoms, particularly the excessive distension and high fundal height, directly contradict the features of oligohydramnios.
Question 1213: A 22-year-old primigravida visits ANC OPD with 20 weeks POG. On examination uterine height reveals a 16-week size. USG shows reduced liquor. What will be the diagnosis?
- A. Bilateral renal agenesis (Correct Answer)
- B. Bartter’s syndrome
- C. Liddle syndrome
- D. Fetal anemia
Explanation: ***Renal agenesis*** - **Bilateral renal agenesis** leads to **oligohydramnios** because the fetal kidneys are the primary producers of amniotic fluid after 16 weeks of gestation. - The reduced amniotic fluid (liquor) is consistent with the decreased uterine size (16-week size at 20 weeks POG) and is a hallmark of this condition, often resulting in **Potter sequence**. *Bartter’s syndrome* - This is a rare, inherited renal tubulopathy characterized by significant electrolyte disturbances (hypokalemia, metabolic alkalosis, hypercalciuria) due to impaired ion transport. - While it affects kidney function, it does not typically cause severe **oligohydramnios** or **renal agenesis** and would not explain the small uterine size in this scenario. *Liddle syndrome* - This is a rare genetic disorder characterized by early-onset hypertension, hypokalemia, and metabolic alkalosis, due to constitutive activation of the epithelial sodium channel (ENaC) in the collecting ducts. - It does not involve structural kidney abnormalities or significantly impact amniotic fluid volume during pregnancy to cause the described findings. *Fetal anemia* - Fetal anemia can lead to complications such as **hydrops fetalis**, which would typically cause **polyhydramnios** or a uterine size larger than expected due to fluid accumulation, not oligohydramnios or a smaller uterine size. - Reduced liquor and a small uterine size are not characteristic presentations of fetal anemia.
Question 1214: The major contributor to amniotic fluid after 20 weeks of gestation is:
- A. Fetal urine (Correct Answer)
- B. Fetal skin
- C. Ultrafiltrate of maternal plasma
- D. Fluid from fetal lungs
Explanation: ***Fetal urine*** - After **20 weeks of gestation**, the **fetal kidneys** are fully functional, and fetal urination becomes the primary source of amniotic fluid. - This contribution is crucial for the **volume of amniotic fluid** and plays a vital role in **fetal lung development** by allowing the fetus to "breathe" the fluid. *Ultrafiltrate of maternal plasma* - While an ultrafiltrate of maternal plasma contributes to the early amniotic fluid volume, its significance diminishes as the **fetal kidneys mature** past 20 weeks. - This source primarily provides water and dissolved solutes, but not a substantial volume. *Fluid from fetal lungs* - Fluid produced by the fetal lungs also contributes to amniotic fluid, but its volume is considerably smaller than that from **fetal urine**, especially after 20 weeks. - It mainly includes pulmonary surfactants and other specific proteins important for lung maturation. *Fetal skin* - Before **keratinization** of the fetal skin (around 20-22 weeks), the skin is permeable and allows for transepidermal fluid transport, contributing to amniotic fluid. - However, once **keratinization** is complete, the skin becomes impermeable, and its contribution to amniotic fluid becomes negligible.
Question 1215: Which of the following is the MOST significant physiological change that occurs during pregnancy?
- A. Increase total protein
- B. Increase GFR
- C. Increase residual volume
- D. Increase cardiac output (Correct Answer)
Explanation: ***Increase cardiac output*** - **Cardiac output** significantly increases during pregnancy, starting in the first trimester and peaking in the third trimester. This is to meet the increased metabolic demands of the growing fetus, placenta, and maternal organs. - This increase is primarily due to an increase in **stroke volume** and **heart rate**, crucial for maintaining adequate uteroplacental perfusion. *Increase total protein* - While total blood volume increases during pregnancy, **plasma volume** increases disproportionately more than red blood cell mass, leading to hemodilution. - This hemodilution generally causes a *decrease* in total serum protein concentration and albumin levels, rather than an increase. *Increase residual volume* - **Residual volume** (the volume of air remaining in the lungs after maximal exhalation) actually *decreases* during pregnancy. - This decrease is due to the upward displacement of the diaphragm by the gravid uterus and an increase in inspiratory capacity, not an increase in residual volume. *Increase GFR* - **Glomerular filtration rate (GFR)** does significantly increase during pregnancy, often by 30-50% by the second trimester, in response to increased renal blood flow. - While important, the increase in GFR is a consequence of the systemic hemodynamic changes (including increased cardiac output) and is not as *overall* physiologically significant as the **fundamental increase in cardiac output** that drives many other physiological adaptations.
Question 1216: What maternal condition is commonly associated with congenital heart defects in the fetus?
- A. Gestational Diabetes Mellitus (GDM)
- B. Pregestational Diabetes Mellitus (DM) (Correct Answer)
- C. Maternal use of Valproate
- D. Maternal use of ACE inhibitors
Explanation: ***Pregestational Diabetes Mellitus (DM)*** - **Pre-existing diabetes** in the mother is one of the **most significant** risk factors for various **congenital anomalies**, including **congenital heart defects** due to its teratogenic effects during critical periods of fetal development. - Poor glycemic control during the **first trimester** is particularly harmful, leading to increased rates of **septal defects (VSD, ASD)**, **transposition of the great arteries**, **coarctation of aorta**, and other cardiac malformations. - The risk increases with **HbA1c levels**, with poor control conferring up to a **3-5 fold increased risk** of congenital heart defects. *Gestational Diabetes Mellitus (GDM)* - While GDM can lead to fetal complications like **macrosomia** and an increased risk of childhood obesity, it is **not associated with major congenital malformations** compared to pregestational diabetes. - The onset of GDM typically occurs **after 20 weeks**, well after the primary period of **organogenesis** (weeks 3-8) when most cardiac defects are established. *Maternal use of Valproate* - **Valproate**, an antiepileptic drug, is a known teratogen associated with **multiple congenital anomalies** including **neural tube defects** (e.g., spina bifida), **facial dysmorphism**, and **congenital heart defects** (VSD, ASD, pulmonary stenosis). - However, while valproate does increase the risk of cardiac anomalies, **pregestational diabetes** is considered a **more common** and clinically significant association with congenital heart defects in routine obstetric practice. *Maternal use of ACE inhibitors* - **ACE inhibitors** are associated with issues such as **renal dysfunction**, **oligohydramnios**, **hypocalvaria**, and **fetal growth restriction** when used during the second and third trimesters. - Their primary teratogenic effects are on the **renal system** rather than cardiac development, making them less commonly associated with **congenital heart defects** compared to pregestational diabetes.
Question 1217: A 40 year old G2P1 woman with 18 weeks of amenorrhea comes with a dilated cervix. The cervical length is 15 mm. In spite of explaining the risks, she insisted on cerclage. Which of the following is a contraindication for cervical cerclage?
- A. Advanced maternal age
- B. Ruptured membranes (Correct Answer)
- C. Fetal fibronectin positive
- D. Prolapse of membranes into the vagina
Explanation: ***Ruptured membranes*** - **Ruptured membranes** are an **absolute contraindication** to cervical cerclage because the protective barrier against infection is lost. - Placing a cerclage after membrane rupture would trap bacteria within the uterus, leading to serious complications such as **chorioamnionitis** and **sepsis**. - Once membranes rupture, the focus shifts to prevention of infection and preparation for delivery rather than cervical reinforcement. *Prolapse of membranes into the vagina* - This represents a **relative contraindication** rather than an absolute one; cerclage can still be attempted in selected cases with appropriate technique. - While bulging or prolapsed membranes make the procedure more technically challenging and increase risks of membrane rupture, the membranes can sometimes be reduced back before cerclage placement. - This scenario requires careful patient counseling about increased risks, but is not an absolute contraindication if the patient insists and understands the complications. *Advanced maternal age* - **Advanced maternal age** (40 years in this case) is **not a contraindication** for cerclage at all. - The decision for cerclage is based on cervical findings and obstetric history showing cervical insufficiency, not on maternal age. - Age may be a risk factor for other pregnancy complications, but does not preclude cerclage if indicated. *Fetal fibronectin positive* - A **positive fetal fibronectin** test indicates increased risk of preterm labor but is **not a contraindication** to cerclage. - It may prompt closer monitoring or influence timing of intervention, but doesn't rule out cerclage if there's a strong indication based on cervical insufficiency. - Prophylactic or rescue cerclage can still be performed despite positive fetal fibronectin if clinically indicated.
Question 1218: In a case of DCDA twins at 38 weeks, with the first twin in breech presentation, and the mother having a blood pressure of 140/96 and 1+ proteinuria, what is the preferred management?
- A. Plan induction of labor at 40 weeks
- B. Induce labor immediately and deliver if necessary
- C. Induce labor only if preeclampsia worsens
- D. Perform cesarean section (Correct Answer)
Explanation: ***Perform cesarean section*** - The combination of **DCDA twins** at **38 weeks**, the **first twin in breech presentation**, and maternal **preeclampsia** (BP 140/96, 1+ proteinuria) necessitates prompt delivery via cesarean section. - A **breech presentation** for the first twin significantly increases the risk of complications during vaginal delivery, making a **cesarean section** the safest and preferred route to prevent birth trauma, cord prolapse, and potential fetal distress. - At **38 weeks gestation** with **preeclampsia**, delivery is indicated as the definitive treatment, and cesarean section addresses both the obstetric indication (breech first twin) and maternal condition. *Plan induction of labor at 40 weeks* - This option is inappropriate due to the presence of **preeclampsia** and the **breech presentation** of the first twin, both of which indicate the need for earlier intervention. - Waiting until 40 weeks would expose the mother and fetuses to increased risks associated with prolonged preeclampsia and potential complications from breech vaginal delivery. *Induce labor immediately and deliver if necessary* - While prompt delivery is warranted due to preeclampsia at term, attempting **induction of labor** with a **breech presenting first twin** carries substantial risks for both twins. - **Vaginal delivery of a breech first twin** is generally discouraged in multiple gestations due to increased rates of fetal entrapment, cord prolapse, and other obstetrical emergencies, making cesarean section the safer choice. *Induce labor only if preeclampsia worsens* - This approach fails to address the immediate risks posed by the **breech presenting first twin** and the existing **preeclampsia** at term gestation. - Delaying intervention until the preeclampsia worsens could lead to severe maternal complications such as eclampsia, HELLP syndrome, or placental abruption, and increased fetal compromise.
Question 1219: Which of the following statement is correct about acute fatty liver of pregnancy?
- A. Mostly seen in last trimester (Correct Answer)
- B. May be associated with decreased uric acid
- C. Occurs in 1 in 1000 pregnancies
- D. Not related to the gender of the fetus
Explanation: ***Mostly seen in last trimester*** - **Acute fatty liver of pregnancy (AFLP)** typically manifests in the **third trimester** (weeks 28-40) of gestation or in the immediate postpartum period. - This timing is due to the increased metabolic demands on the liver during late pregnancy, which can exacerbate underlying defects in mitochondrial fatty acid oxidation. *Occurs in 1 in 1000 pregnancies* - AFLP is a **rare** obstetric complication, occurring in approximately **1 in 7,000 to 1 in 16,000** pregnancies, not 1 in 1000. - The incidence of 1 in 1000 would make it far too common and is incorrect. *Not related to the gender of the fetus* - AFLP has been observed to have a higher incidence in pregnancies involving a **male fetus**. - This association is thought to be related to differences in fetal steroid metabolism or the demands placed on maternal liver function by the male fetus. *May be associated with decreased uric acid* - AFLP is typically associated with **elevated serum uric acid levels** (hyperuricemia), not decreased levels. - Other typical findings include elevated liver enzymes, bilirubin, and sometimes severe hypoglycemia.
Question 1220: A baby born at 34 weeks gestation weighs 3kg. Which of the following conditions is this child most likely to develop in the immediate postnatal period?
- A. APH
- B. Diabetes
- C. Anemia (Correct Answer)
- D. None of the options
Explanation: ***Anemia*** - A 3kg baby at 34 weeks is **large for gestational age (LGA)** and often associated with maternal diabetes, leading to initial **polycythemia** due to chronic intrauterine hypoxia and increased erythropoietin production. - After birth, the excess red blood cells undergo rapid **hemolysis**, resulting in **anemia** in the immediate postnatal period as a recognized complication of LGA babies. *APH* - **Antepartum hemorrhage (APH)** is a maternal obstetric complication involving bleeding before delivery, not a condition that develops in the newborn. - This is a **maternal complication** that occurs during pregnancy, not a neonatal condition that the baby would present with after birth. *Diabetes* - While **maternal diabetes** is often the cause of fetal macrosomia, the newborn does not develop diabetes itself in the immediate postnatal period. - These babies are instead at risk for **hypoglycemia**, **respiratory distress**, and **polycythemia** due to fetal hyperinsulinemia, but not diabetes as a presenting condition. *None of the options* - This is incorrect because **anemia** is indeed a valid condition that LGA babies can develop through the **polycythemia-hemolysis cycle**. - While other complications like **hypoglycemia** are more statistically common, anemia remains a recognized sequela among LGA babies in the immediate postnatal period.
Practice by Chapter
Fetal Assessment Techniques
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Hypertensive Disorders in Pregnancy
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Intrauterine Growth Restriction
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Multiple Gestation
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Rh Isoimmunization and Other Blood Group Incompatibilities
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Intrauterine Fetal Therapy
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Prenatal Diagnosis and Genetic Counseling
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Placental Abnormalities
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Preterm Labor and Delivery
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Management of Medical Disorders in Pregnancy
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