Maternal-Fetal Medicine Practice Questions

Q: All of the following are predictors of preeclampsia except?

Shake test. **Explanation:** The **Shake Test** (also known as the Foam Stability Index) is a bedside test used to assess **fetal lung maturity**, not to predict preeclampsia. It involves mixing amniotic fluid with 95% ethanol and shaking it; the persistence of a ring of bubbles at the air-liquid interface indicates the presence of sufficient surfactant to prevent Respiratory Distress Syndrome (RDS). **Analysis of Predictors of Preeclampsia:** * **Roll-over Test:** This is a clinical screening test performed between 28–32 weeks of gestation. A rise in diastolic blood pressure of **>15 mmHg** when the patient moves from a left lateral to a supine position indicates a positive test and increased risk for preeclampsia. * **Serum Uric Acid:** Hyperuricemia (due to decreased renal clearance) is one of the earliest biochemical markers of preeclampsia. While it has low sensitivity for prediction, it is a strong indicator of disease severity and fetal prognosis. * **Weight Gain:** Excessive weight gain (>2 kg/month or >0.5 kg/week) in the second trimester is often due to occult edema and fluid retention, serving as an early clinical warning sign before the onset of hypertension and proteinuria. **Clinical Pearls for NEET-PG:** * **Gold Standard for Prediction:** Uterine Artery Doppler (noting the presence of a **diastolic notch** at 20–24 weeks) is a highly specific predictor. * **Biochemical Markers:** Low levels of **PAPP-A** and **PlGF** (Placental Growth Factor), and high levels of **sFlt-1**, are modern predictive markers. * **Prophylaxis:** In patients with positive predictive tests, low-dose **Aspirin (150 mg)** started before 16 weeks reduces the risk of early-onset preeclampsia.

Q: Gas in the aorta after intrauterine fetal death (IUFD) is which sign?

Robert sign. **Explanation:** The correct answer is **Robert sign**. This sign refers to the presence of gas (usually carbon dioxide) within the fetal heart or large vessels, most commonly the **aorta**. It is one of the earliest radiological signs of intrauterine fetal death (IUFD), appearing as early as 12 hours after death. The gas is produced by the decomposition of fetal blood and is typically visualized on an X-ray or ultrasound. **Analysis of Incorrect Options:** * **Spalding sign:** This is the most famous radiological sign of IUFD. it refers to the **overlapping of fetal skull bones** caused by the liquefaction of the brain and loss of intracranial pressure. It usually takes 4–7 days after death to appear. * **Ball sign:** This refers to the **hyperflexion of the fetal spine**, resulting in a "balled-up" appearance. It occurs due to the loss of fetal muscle tone after death. * **Blair-Hartley sign:** This refers to the **constriction of the fetal thorax** or a "collapsed" chest wall, another secondary sign of maceration and loss of internal structural integrity. **NEET-PG High-Yield Pearls:** * **Earliest Sign:** Robert sign (12 hours) is seen earlier than Spalding sign (days). * **Gold Standard:** Today, the diagnosis of IUFD is confirmed via **Ultrasonography (USG)** by demonstrating the absence of fetal heart activity. * **Deuel’s Halo Sign:** Another sign of IUFD where a radiolucent halo appears around the fetal head due to edema of the scalp (subcutaneous fat). * **Clinical context:** Always check for maternal coagulation profile (Fibrinogen levels) if a dead fetus is retained for >4 weeks to monitor for Disseminated Intravascular Coagulation (DIC).

Q: All are true in HELLP syndrome except?

Develops only in cases of maternal hypertension. **Explanation:** HELLP syndrome is a severe multisystem complication, traditionally considered a variant of preeclampsia. The acronym stands for **H**emolysis, **E**levated **L**iver enzymes, and **L**ow **P**latelets. **Why Option D is the correct answer (the false statement):** While HELLP syndrome is strongly associated with preeclampsia, it **does not develop only in cases of maternal hypertension.** Approximately **15–20%** of patients with HELLP syndrome are normotensive and do not exhibit proteinuria at the time of diagnosis. This makes it a "great masquerader," as the absence of hypertension can lead to a dangerous delay in diagnosis. **Analysis of other options (True statements):** * **A. Hemolysis:** This is a hallmark feature, characterized by microangiopathic hemolytic anemia. Peripheral smears show **schistocytes** (fragmented RBCs) and helmet cells. Lab markers include elevated LDH (>600 U/L) and indirect bilirubin. * **B. Elevated Liver Enzymes:** This occurs due to periportal necrosis and hepatic sinusoids being obstructed by fibrin deposits. AST and ALT are typically elevated to ≥70 U/L. * **C. Low Platelets:** Thrombocytopenia (Platelets <100,000/mm³) results from increased platelet consumption and activation. **NEET-PG High-Yield Pearls:** * **Mississippi Classification:** Classifies HELLP based on the nadir of the platelet count (Class 1: <50k, Class 2: 50k–100k, Class 3: 100k–150k). * **Clinical Presentation:** The most common symptom is **epigastric or right upper quadrant pain** (due to Glisson’s capsule stretch). * **Definitive Treatment:** Delivery of the fetus (usually after 34 weeks or if maternal/fetal condition deteriorates). * **Complication:** Beware of **hepatic subcapsular hematoma**; sudden hypotension in a HELLP patient suggests rupture.

Q: A patient who is G3P2L2 with two previous lower segment cesarean sections presents to the OPD with placenta near the internal os. What is the greatest risk for this patient?

Adherent placenta. **Explanation:** The correct answer is **Adherent placenta** (Placenta Accreta Spectrum - PAS). **1. Why Adherent Placenta is correct:** The patient has two major risk factors for PAS: **previous cesarean sections** and **placenta previa** (placenta near the internal os). In a scarred uterus, the decidua basalis is often deficient. This allows the chorionic villi to invade directly into the myometrium. According to the Silver and Landon criteria, the risk of placenta accreta increases exponentially with the number of prior C-sections. For a patient with two previous C-sections and placenta previa, the risk of an adherent placenta is approximately **35–40%**. **2. Why other options are incorrect:** * **Placental abruption:** While previa is a risk factor for bleeding, the specific combination of a prior scar and overlying placenta is the classic triad for *invasion* (accreta), not premature *separation* (abruption). * **Vasa previa:** This involves fetal vessels crossing the internal os, usually associated with velamentous cord insertion or succenturiate lobes, not specifically with previous C-section scars. * **Preterm birth:** While common in previa due to iatrogenic delivery or bleeding, it is a *consequence* of the pathology, whereas adherent placenta is the primary *pathological risk* associated with the scar. **3. NEET-PG High-Yield Pearls:** * **Most important risk factor for PAS:** Previous C-section + Placenta Previa. * **Risk progression:** 1 prior C-section + previa (~11% risk); 2 prior C-sections + previa (~40% risk); 3 prior C-sections + previa (~61% risk). * **Gold Standard Diagnosis:** Antenatal Ultrasound/Color Doppler (look for "placental lacunae" and loss of the retroplacental hypoechoic zone). * **Management:** Planned multidisciplinary cesarean hysterectomy is often the treatment of choice.

Q: Which type of twins has the highest mortality?

Siamese twins. **Explanation:** The correct answer is **Siamese twins (Conjoined twins)**. **1. Why Siamese Twins have the highest mortality:** Conjoined twins represent the most extreme and rarest form of monozygotic twinning, occurring due to the incomplete division of the embryonic disc after day 13 of fertilization. They carry the highest mortality rate (up to 75-90%) due to several factors: * **Structural anomalies:** Shared vital organs (e.g., heart, liver, or brain) often make survival or surgical separation impossible. * **Prematurity:** Most are born preterm. * **Stillbirth:** Approximately 40-60% are stillborn. * **Obstetric complications:** High risk of birth trauma and dystocia during delivery. **2. Analysis of Incorrect Options:** * **Monoamniotic Monochorionic (MoMo):** While high-risk (mortality ~10-20%), the primary risks are cord entanglement and Twin-to-Twin Transfusion Syndrome (TTTS). Mortality is significantly lower than in conjoined twins. * **Diamniotic Dichorionic (DiDi):** These have the lowest risk among twins because each fetus has its own placenta and sac, preventing cord accidents and vascular shunting. * **Binovular twins:** Another term for Dizygotic (fraternal) twins. These are always dichorionic/diamniotic and carry the best prognosis. **3. NEET-PG High-Yield Pearls:** * **Timing of Division:** * 0–72 hours: Dichorionic Diamniotic (DiDi) * 4–8 days: Monochorionic Diamniotic (MoDi) — *Most common type of MZ twins.* * 8–13 days: Monochorionic Monoamniotic (MoMo) * >13 days: Conjoined twins. * **Most common type of conjoined twins:** Thoracopagus (joined at the chest). * **Diagnosis:** Best made via ultrasound in the first trimester (look for the "Lambda sign" in DiDi vs. "T-sign" in MoDi).

Q: A non-stress test (NST) of a multigravida who is diabetic shows late decelerations. Which of the following is NOT true about late decelerations?

Caused by head compression. **Explanation:** The correct answer is **A (Caused by head compression)** because head compression is the physiological cause of **Early Decelerations**, not late decelerations. Early decelerations are mediated by a vagal response and are considered benign. **Understanding Late Decelerations:** Late decelerations are a sign of **uteroplacental insufficiency**. They occur when the oxygen reserve in the intervillous space is so low that the transient decrease in blood flow during a contraction leads to fetal hypoxemia and myocardial depression. * **Option B & D (Incorrect):** These describe the classic morphology of a late deceleration. The nadir (lowest point) of the fetal heart rate occurs **after the apex** (peak) of the uterine contraction. The deceleration is "late" because it lags behind the contraction. * **Option C (Incorrect):** This is the primary underlying etiology. Conditions like maternal diabetes, hypertension, or post-term pregnancy can lead to placental insufficiency, manifesting as late decelerations on a Non-Stress Test (NST). **High-Yield Clinical Pearls for NEET-PG:** * **Early Decelerations:** "Mirror image" of the contraction; caused by **Head Compression** (Benign). * **Variable Decelerations:** Abrupt onset; vary in timing; caused by **Umbilical Cord Compression** (Most common type). * **Late Decelerations:** Gradual onset; nadir after the peak of contraction; caused by **Uteroplacental Insufficiency** (Ominous/Non-reassuring). * **Management:** For persistent late decelerations, the immediate steps include lateral decubitus positioning, oxygen supplementation, IV fluids, and potentially urgent delivery if the pattern persists.

Q: What is the normal range of Amniotic Fluid Index (AFI)?

5 to 24 cm. The **Amniotic Fluid Index (AFI)** is a semi-quantitative assessment used to monitor fetal well-being. It is calculated by dividing the uterus into four quadrants using the umbilicus and the linea nigra as landmarks, then summing the vertical depth (in cm) of the largest pocket of fluid in each quadrant. ### **Explanation of Options** * **Correct Answer (D) 5 to 24 cm:** In clinical practice, an AFI between **5 cm and 24 cm** is considered the normal physiological range. * **AFI 24 cm** (or 25 cm in some texts) is the threshold for **Polyhydramnios**. * **Option A & C (2 cm):** The value "2 cm" refers to the **Single Deepest Pocket (SDP)** or Maximum Vertical Pocket (MVP) method. An SDP 8 cm indicates polyhydramnios. * **Option B (5 to 8 cm):** This range is too narrow. While an AFI of 5–8 cm is sometimes termed "borderline" or "low-normal," it is not the standard definition of the entire normal range. ### **High-Yield Clinical Pearls for NEET-PG** * **Gold Standard:** While AFI is commonly used, the **Single Deepest Pocket (SDP)** is often considered superior in twin pregnancies and for reducing unnecessary interventions in post-term pregnancies. * **Peak Volume:** Amniotic fluid volume peaks at approximately **34–36 weeks** (roughly 800–1000 mL) and gradually declines thereafter. * **Common Associations:** * **Oligohydramnios:** Renal agenesis (Potter sequence), PROM, and Placental insufficiency. * **Polyhydramnios:** Gestational diabetes, Tracheoesophageal fistula, and Anencephaly.

Q: A 31-year-old woman presents with abdominal pain and vaginal spotting, which began 2 days ago and has been worsening. The spotting started this morning. Her last menstrual period was 6 weeks ago. She has no medical problems, takes no medications, and has no known drug allergies. Her vital signs are: temperature 37°C (98.6°F), blood pressure 90/50 mm Hg, pulse 110/min, and respirations 14/min. Abdominal examination reveals significant lower abdominal tenderness. Speculum examination shows scant blood in the vagina with a closed cervical os. Bimanual examination demonstrates significant left adnexal tenderness. Urine hCG is positive, and serum hCG is 5,000 mIU/mL. Pelvic ultrasound shows a normal uterus with a left adnexal mass surrounded by free fluid. In MOST cases, the disease process of this patient affects which of the following anatomic structures?

Fallopian tube. **Explanation:** The patient presents with the classic triad of **ectopic pregnancy**: amenorrhea (LMP 6 weeks ago), abdominal pain, and vaginal bleeding. Her clinical presentation—hypotension (90/50 mmHg), tachycardia (110/min), and free fluid on ultrasound—strongly suggests a **ruptured ectopic pregnancy**, a surgical emergency. **Why the Fallopian Tube is Correct:** In approximately **95–98%** of ectopic pregnancies, the blastocyst implants within the **fallopian tube**. Within the tube, the **ampulla** is the most common site (70%), followed by the isthmus (12%), fimbriae (11%), and interstitium (2%). The lack of a gestational sac in the uterus despite a serum hCG above the discriminatory zone (>2,000–3,500 mIU/mL) and an adnexal mass confirms the diagnosis. **Why Other Options are Incorrect:** * **A. Cervix:** Cervical pregnancies are rare (<1%) and typically present with painless vaginal bleeding and a "hourglass" shaped uterus. * **C. Ovary:** Ovarian pregnancies occur in only 1–3% of cases. They are often confused with hemorrhagic corpus luteum cysts. * **D. Peritoneal cavity:** Primary abdominal pregnancy is extremely rare (approx. 1%). While the "free fluid" (hemoperitoneum) is located in the peritoneal cavity, it is a *consequence* of the tubal rupture, not the primary site of the disease process. **NEET-PG High-Yield Pearls:** * **Most common site overall:** Ampulla of the Fallopian tube. * **Most dangerous site:** Interstitial/Cornual (due to late presentation and risk of massive hemorrhage from the uterine artery). * **Risk Factors:** Previous ectopic (strongest), PID (most common), tubal surgery, and smoking. * **Management:** If hemodynamically unstable (as in this case), the treatment of choice is **emergency laparotomy/laparoscopy**. If stable and hCG <5,000, medical management with **Methotrexate** may be considered.

Q: Administration of antiretroviral therapy during the peripartum period decreases the risk of vertical transmission by what percentage?

65%. The correct answer is **65% (Option C)**. ### **Explanation** The risk of vertical transmission of HIV from an untreated mother to her child is approximately **25–30%**. The landmark **PACTG 076 trial** established that the administration of Zidovudine (AZT) during the antepartum, intrapartum, and neonatal periods reduces the risk of transmission by approximately **two-thirds (66-67%)**, bringing the transmission rate down to about 8%. In the context of standard medical examinations like NEET-PG, **65%** is the recognized value for this reduction. ### **Analysis of Options** * **Option A (30%):** This represents the baseline risk of transmission in an untreated patient (without any interventions). * **Option B (50%):** This is an underestimate. Monotherapy or short-course prophylaxis provides a more significant reduction than 50%. * **Option D (75%):** While modern Highly Active Antiretroviral Therapy (HAART) combined with a viral load 95% reduction), the specific historical benchmark for peripartum ART efficacy is 65-67%. ### **NEET-PG High-Yield Pearls** * **Most common route of transmission:** Intrapartum (during labor and delivery) is the period of highest risk. * **PPTCT Protocol (India):** All HIV-positive pregnant women should be started on **Lifelong ART** (TDF + 3TC + EFV/DTG) regardless of CD4 count or clinical stage. * **Mode of Delivery:** If the viral load is **>1000 copies/mL** at 36 weeks, a **Pre-labor Cesarean Section** is recommended to further reduce risk. * **Breastfeeding:** In India, exclusive breastfeeding for 6 months is recommended if the mother is on ART, though replacement feeding is preferred only if it is AFASS (Affordable, Feasible, Acceptable, Sustainable, and Safe).

Question 1

Routine pelvic examination is contraindicated in which of the following conditions?

Accepted Answer

Placenta previa

Answer

Carcinoma cervix

Answer

Cord prolapse

Answer

Pregnancy-induced hypertension

Question 2

All of the following are predictors of preeclampsia except?

Accepted Answer

Shake test

Answer

Roll over test

Answer

Serum uric acid

Answer

Weight gain > 2kg per month

Question 3

Gas in the aorta after intrauterine fetal death (IUFD) is which sign?

Accepted Answer

Robert sign

Answer

Spalding sign

Answer

Ball sign

Answer

Blair-Hartley sign

Question 4

All are true in HELLP syndrome except?

Accepted Answer

Develops only in cases of maternal hypertension

Answer

Hemolysis

Answer

Elevated liver enzymes

Answer

Low platelets

Question 5

A patient who is G3P2L2 with two previous lower segment cesarean sections presents to the OPD with placenta near the internal os. What is the greatest risk for this patient?

Accepted Answer

Adherent placenta

Answer

Placental abruption

Answer

Vasa previa

Answer

Preterm birth

Question 6

Which type of twins has the highest mortality?

Accepted Answer

Siamese twins

Answer

Monoamniotic monochorionic

Answer

Diamniotic dichorionic

Answer

Binovular twins

Question 7

A non-stress test (NST) of a multigravida who is diabetic shows late decelerations. Which of the following is NOT true about late decelerations?

Accepted Answer

Caused by head compression

Answer

Fetal heart rate begins to slow down after the contraction's apex

Answer

Suggestive of placental insufficiency

Answer

Occurs after the apex of the contraction

Question 8

What is the normal range of Amniotic Fluid Index (AFI)?

Accepted Answer

5 to 24 cm

Answer

2 to 8 cm

Answer

5 to 8 cm

Answer

2 to 24 cm

Question 9

A 31-year-old woman presents with abdominal pain and vaginal spotting, which began 2 days ago and has been worsening. The spotting started this morning. Her last menstrual period was 6 weeks ago. She has no medical problems, takes no medications, and has no known drug allergies. Her vital signs are: temperature 37°C (98.6°F), blood pressure 90/50 mm Hg, pulse 110/min, and respirations 14/min. Abdominal examination reveals significant lower abdominal tenderness. Speculum examination shows scant blood in the vagina with a closed cervical os. Bimanual examination demonstrates significant left adnexal tenderness. Urine hCG is positive, and serum hCG is 5,000 mIU/mL. Pelvic ultrasound shows a normal uterus with a left adnexal mass surrounded by free fluid. In MOST cases, the disease process of this patient affects which of the following anatomic structures?

Accepted Answer

Fallopian tube

Answer

Cervix

Answer

Ovary

Answer

Peritoneal cavity

Question 10

Administration of antiretroviral therapy during the peripartum period decreases the risk of vertical transmission by what percentage?

Accepted Answer

65%

Answer

30%

Answer

50%

Answer

75%

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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