Maternal-Fetal Medicine Practice Questions

Q: A woman delivered a child after a normal prenatal period. One hour postpartum, she experienced a stroke. What is the probable cause?

Amniotic fluid embolism. **Explanation:** The correct answer is **Amniotic Fluid Embolism (AFE)**. AFE is a rare but catastrophic obstetric emergency characterized by the entry of amniotic fluid, fetal cells, or debris into the maternal circulation. It typically occurs during labor or in the immediate postpartum period (usually within the first hour). The pathophysiology involves a systemic inflammatory response syndrome (SIRS) rather than a simple mechanical obstruction. This leads to a classic triad of **hypotension, hypoxia, and coagulopathy (DIC)**. Neurological manifestations, including seizures or **embolic stroke**, are recognized complications due to paradoxical embolism or severe cerebral hypoxia/hypoperfusion. **Why other options are incorrect:** * **APLAS (B):** While APLAS is a prothrombotic state that can cause strokes, it is a chronic condition usually associated with recurrent pregnancy loss or preeclampsia. It does not typically present as an acute, catastrophic event specifically within one hour of a normal delivery without prior history. * **Choriocarcinoma (C):** This is a gestational trophoblastic neoplasm. While it can metastasize to the brain and cause hemorrhage/stroke, it typically presents weeks to months after delivery, often with persistent vaginal bleeding and elevated β-hCG levels. * **Sheehan’s Syndrome (D):** This refers to postpartum pituitary necrosis due to severe obstetric hemorrhage. It presents with failure to lactate or amenorrhea in the weeks/months following delivery, not an acute stroke. **Clinical Pearls for NEET-PG:** * **AFE Diagnosis:** Primarily clinical; "Diagnosis of exclusion." * **Key finding on autopsy:** Squamous cells or fetal debris in the maternal pulmonary vasculature. * **Management:** Supportive (A-B-C) and aggressive management of DIC. * **Risk Factors:** Advanced maternal age, multiparity, and placental abruption.

Q: Which of the following is NOT associated with teenage pregnancy?

Post-dated pregnancy is more common. **Explanation:** Teenage pregnancy (defined as pregnancy in girls aged 10–19) is considered a high-risk condition due to both biological immaturity and socio-economic factors. **Why "Post-dated pregnancy" is the correct answer:** Teenage pregnancies are significantly more associated with **Preterm Labor** (delivery before 37 weeks) rather than post-dated pregnancy. This is attributed to factors such as an immature uterine blood supply, a developing cervix, and a higher prevalence of genitourinary infections. Therefore, post-dated pregnancy is **not** a characteristic feature of teenage gestation. **Analysis of Incorrect Options:** * **Cesarean section is more common:** While some studies show varying rates, the incidence of C-sections is generally higher in teenagers due to **Cephalopelvic Disproportion (CPD)**. This occurs because the maternal bony pelvis may not be fully developed or fused, making it too small for the fetal head. * **Eclampsia is more common:** Young age (nulliparity) is a major risk factor for Hypertensive Disorders of Pregnancy. Teenagers have a significantly higher predisposition to **Pre-eclampsia and Eclampsia** compared to women in their 20s. * **Maternal mortality rate is higher:** The MMR is elevated in this group due to the higher frequency of complications like obstructed labor (CPD), eclampsia, and unsafe abortions, combined with late booking or poor antenatal care. **High-Yield Clinical Pearls for NEET-PG:** * **Most common complication:** Anemia (Iron deficiency). * **Fetal outcomes:** Higher risk of Low Birth Weight (LBW) and Intrauterine Growth Restriction (IUGR). * **Psychosocial:** Increased risk of postpartum depression and repeat pregnancy within two years. * **Key takeaway:** If a question asks for the "most common" obstetric complication in teens, think **Anemia** or **Pre-eclampsia**. If it asks for the "least likely" timing, think **Post-dated**.

Q: Which one of the following congenital malformations of the fetus can be diagnosed in the first trimester by ultrasound?

Anencephaly. **Explanation:** The correct answer is **Anencephaly**. **1. Why Anencephaly is the correct answer:** Anencephaly is a lethal neural tube defect characterized by the absence of the cranial vault (acrania) and cerebral hemispheres. With high-resolution transvaginal sonography (TVS), it can be reliably diagnosed in the late first trimester (11–14 weeks). The hallmark ultrasound findings are the **"Mickey Mouse sign"** (the appearance of preserved facial structures and orbits without a calvarium) and the **"Frog-eye appearance"** in the coronal plane. By 11 weeks, ossification of the skull should be complete; its absence confirms the diagnosis. **2. Why the other options are incorrect:** * **Inencephaly:** While a severe neural tube defect involving extreme retroflexion of the head, it is much rarer than anencephaly and often requires second-trimester imaging for a definitive diagnosis of the spinal involvement. * **Microcephaly:** This is a diagnosis of "growth" rather than "structure." It is typically diagnosed in the late second or third trimester because the head circumference must fall significantly below the mean (usually >3 SD) over time. * **Holoprosencephaly:** Although severe alobar forms can sometimes be suspected in the first trimester, it is traditionally a second-trimester diagnosis when the development of the midline structures (thalamus, falx cerebri) can be clearly assessed. **Clinical Pearls for NEET-PG:** * **Acrania-Anencephaly Sequence:** Acrania (absent skull with brain present) precedes anencephaly (brain degeneration due to exposure to amniotic fluid). * **Biochemical Marker:** Maternal Serum Alpha-Fetoprotein (MSAFP) is significantly **elevated** in open neural tube defects. * **Prevention:** 400 mcg of Folic acid daily (pre-conceptionally) reduces risk; 4 mg daily is required for women with a previous affected pregnancy.

Q: For fetal lung maturation, which of the following corticosteroids cannot be used?

Methylprednisolone. **Explanation:** The primary goal of administering corticosteroids in cases of anticipated preterm birth (24 to 34 weeks) is to accelerate fetal lung maturity and reduce the incidence of Respiratory Distress Syndrome (RDS), Intraventricular Hemorrhage (IVH), and Necrotizing Enterocolitis (NEC). **Why Methylprednisolone is the Correct Answer:** To be effective for fetal lung maturation, a corticosteroid must cross the placenta in its active form. **Methylprednisolone**, along with Hydrocortisone and Prednisolone, is extensively metabolized and inactivated by the placental enzyme **11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2)**. Consequently, these drugs do not reach the fetus in sufficient concentrations to induce surfactant production. **Analysis of Other Options:** * **Betamethasone (Option A) & Dexamethasone (Option B):** These are the only two recommended steroids for fetal lung maturity. They are fluorinated compounds that are poor substrates for 11β-HSD2, allowing them to cross the placenta easily and bind to fetal glucocorticoid receptors. * **Hydrocortisone (Option C):** Like Methylprednisolone, it is inactivated by the placenta and is not used for fetal lung maturation. However, in the context of this specific question format, Methylprednisolone is the classic "distractor" used in exams to differentiate between maternal and fetal indications. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Regimens:** * Betamethasone: 12 mg IM, 2 doses, 24 hours apart (Drug of choice). * Dexamethasone: 6 mg IM, 4 doses, 12 hours apart. * **Timing:** Maximum benefit is seen if delivery occurs between 24 hours and 7 days after the first dose. * **Indication:** All women at risk of preterm delivery between **24 and 34 weeks** of gestation. * **Mechanism:** Steroids increase the synthesis of **Surfactant** (specifically Dipalmitoylphosphatidylcholine) by Type II pneumocytes.

Q: What is the most important factor in the management of preeclampsia?

Severity of hypertension. **Explanation:** The management of preeclampsia is primarily dictated by the **severity of hypertension** and the **gestational age** of the fetus. The degree of blood pressure elevation is the most critical factor because it directly correlates with the risk of life-threatening maternal complications, such as cerebrovascular accidents (hemorrhagic stroke), placental abruption, and hypertensive encephalopathy. Management protocols (e.g., the decision to initiate antihypertensives like Labetalol or Hydralazine and the timing of delivery) are triggered by specific blood pressure thresholds (≥160/110 mmHg). **Analysis of Incorrect Options:** * **Proteinuria:** While essential for the classic diagnosis of preeclampsia, the *amount* of proteinuria does not correlate with clinical outcomes and is no longer used to define "severity" or guide management decisions according to ACOG and NHBPEP guidelines. * **Convulsions:** This defines **Eclampsia**. While critical, management aims to prevent this stage. Once convulsions occur, the diagnosis changes, and the management shifts to emergency seizure control (Magnesium Sulfate). * **Pedal Edema:** This is common in normal pregnancies and is no longer included in the diagnostic criteria for preeclampsia due to its lack of specificity. **Clinical Pearls for NEET-PG:** * **Target BP:** In severe preeclampsia, the goal is to maintain systolic BP between 140–150 mmHg and diastolic BP between 90–100 mmHg. * **Drug of Choice (DOC):** For seizure prophylaxis in preeclampsia with severe features is **Magnesium Sulfate** (Pritchard Regimen). * **Definitive Treatment:** Delivery of the fetus and placenta remains the only cure for preeclampsia. * **New Criteria:** Preeclampsia can now be diagnosed *without* proteinuria if other "severe features" (thrombocytopenia, renal insufficiency, liver dysfunction, or visual symptoms) are present.

Q: A 35-week multigravida presents with epigastric pain, headache, visual symptoms, and proteinuria of 3+. What is the next step in management?

Start magnesium sulfate therapy. ### Explanation **Correct Answer: D. Start magnesium sulfate therapy** The patient presents with **Severe Preeclampsia** (35 weeks gestation, proteinuria, and "imminent symptoms" like epigastric pain, headache, and visual disturbances). These symptoms indicate cerebral and hepatic involvement, signaling an extremely high risk of progressing to **Eclampsia** (seizures). In any case of severe preeclampsia or eclampsia, the **immediate priority is stabilization**. Magnesium sulfate ($MgSO_4$) is the drug of choice for seizure prophylaxis and treatment. According to standard protocols (Pritchard or Zuspan), stabilization with $MgSO_4$ and blood pressure control must occur *before* proceeding to delivery, regardless of the planned mode of birth. **Why other options are incorrect:** * **A & C:** While delivery is the definitive treatment for preeclampsia, it should only be initiated *after* the mother is stabilized with $MgSO_4$. The mode of delivery (C-section vs. Induction) depends on obstetric indications (e.g., Bishop’s score, fetal distress); severe preeclampsia itself is not an absolute indication for a Cesarean section. * **B:** While steroids are indicated for fetal lung maturity before 34 weeks, this patient is at **35 weeks**. Furthermore, in the presence of "imminent symptoms," stabilization and delivery take precedence over waiting 48 hours for steroid efficacy. **Clinical Pearls for NEET-PG:** * **Drug of Choice for Seizures:** Magnesium sulfate (Superior to Diazepam/Phenytoin). * **Therapeutic Range:** 4–7 mEq/L. * **First Sign of Toxicity:** Loss of Patellar Reflex (Knee jerk) at 7–10 mEq/L. * **Antidote:** 10 ml of 10% Calcium Gluconate (administered IV over 10 mins). * **Management Goal:** In severe preeclampsia >34 weeks, stabilize and deliver. If <34 weeks and stable, conservative management can be considered.

Q: What is the single best prognostic indicator of successful treatment with single-dose Methotrexate?

Serum b-hCG level. **Explanation:** The primary goal of medical management in ectopic pregnancy is to inhibit the rapidly dividing trophoblastic cells. **Serum β-hCG level** is the single most important predictor of treatment success with Methotrexate (MTX). 1. **Why Serum β-hCG is the best indicator:** MTX is a folic acid antagonist that inhibits DNA synthesis. Its efficacy is directly related to the metabolic activity and volume of the trophoblastic tissue. Higher baseline β-hCG levels reflect a higher trophoblastic load and a greater risk of treatment failure or tubal rupture. Success rates are >90% when β-hCG is 3.5–4 cm is a relative contraindication, it is less predictive of success than the biochemical activity (hCG). * **Absence of fetal cardiac activity (C):** The presence of cardiac activity is a contraindication to MTX because it indicates advanced development and a high failure rate, but among patients who meet the criteria, the baseline hCG level remains the superior prognostic tool. * **Pain abdomen (D):** This is a clinical symptom. While severe pain may suggest rupture (a contraindication), it is subjective and not a quantitative prognostic indicator. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Candidate for MTX:** Hemodynamically stable, β-hCG 15% decline** between Day 4 and Day 7 indicates successful treatment. * **Contraindications:** Breastfeeding, immunodeficiency, or significant hepatic/renal/pulmonary disease.

Question 1

A woman delivered a child after a normal prenatal period. One hour postpartum, she experienced a stroke. What is the probable cause?

Accepted Answer

Amniotic fluid embolism

Answer

Antiphospholipid antibody syndrome (APLAS)

Answer

Choriocarcinoma

Answer

Sheehan's syndrome

Question 2

Which of the following is NOT associated with teenage pregnancy?

Accepted Answer

Post-dated pregnancy is more common

Answer

Cesarean section is more common

Answer

Eclampsia is more common

Answer

Maternal mortality rate is higher

Question 3

Which one of the following congenital malformations of the fetus can be diagnosed in the first trimester by ultrasound?

Accepted Answer

Anencephaly

Answer

Inencephaly

Answer

Microcephaly

Answer

Holoprosencephaly

Question 4

For fetal lung maturation, which of the following corticosteroids cannot be used?

Accepted Answer

Methylprednisolone

Answer

Betamethasone

Answer

Dexamethasone

Answer

Hydrocortisone

Question 5

What is the classical presentation of placenta previa?

Accepted Answer

Posterior

Answer

Answer

Central

Answer

Lateral

Question 6

What is the most important factor in the management of preeclampsia?

Accepted Answer

Severity of hypertension

Answer

Proteinuria

Answer

Convulsions

Answer

Pedal edema

Question 7

A 35-week multigravida presents with epigastric pain, headache, visual symptoms, and proteinuria of 3+. What is the next step in management?

Accepted Answer

Start magnesium sulfate therapy

Answer

Immediate cesarean section

Answer

Betamethasone for fetal lung maturity

Answer

Induction of labor for vaginal delivery

Question 8

A 4-month pregnant lady on regular treatment with valproate asks for advice regarding continuing the drug during pregnancy. What is the best course of action?

Accepted Answer

Change to carbamazepine

Answer

Immediately stop valproate and start lamotrigine

Answer

Continue valproate and monitor blood levels

Answer

Slowly taper the dose of valproate

Question 9

What is the single best prognostic indicator of successful treatment with single-dose Methotrexate?

Accepted Answer

Serum b-hCG level

Answer

Gestational sac size

Answer

Absence of fetal cardiac activity

Answer

Pain abdomen

Question 10

A young lady presents with acute abdominal pain and a history of 1 1/2 months of amenorrhea. On ultrasound examination, there is a collection of fluid in the pouch of Douglas and an empty gestational sac. What is the most likely diagnosis?

Accepted Answer

Ectopic pregnancy

Answer

Pelvic hematocele

Answer

Threatened abortion

Answer

Twisted ovarian cyst

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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