Maternal-Fetal Medicine Practice Questions

Q: Late deceleration in fetal heart rate monitoring is suggestive of:

Fetal hypoxia. **Explanation:** **Late decelerations** are characterized by a gradual decrease in fetal heart rate (FHR) that begins *after* the peak of the uterine contraction and returns to baseline only after the contraction has ended. This pattern is a hallmark sign of **uteroplacental insufficiency**. During a contraction, uterine blood flow decreases; if the placental reserve is already low, the fetus experiences a drop in $PO_2$ below the critical threshold. This triggers chemoreceptors, leading to a vagal response and myocardial depression, resulting in **fetal hypoxia** and metabolic acidosis. **Analysis of Incorrect Options:** * **B. Head Compression:** This causes **Early Decelerations**. The pressure on the fetal head increases vagal tone, causing a heart rate dip that mirrors the contraction (the nadir of the FHR coincides with the peak of the contraction). It is considered physiological. * **C. Cord Compression:** This leads to **Variable Decelerations**. These are abrupt in onset and offset and vary in timing relative to contractions. They are the most common type of deceleration seen in labor. * **D. Fetal Death:** While hypoxia can lead to death, late decelerations are a sign of a struggling, live fetus. Fetal death is confirmed by the absence of cardiac activity on ultrasound or Doppler. **High-Yield Clinical Pearls for NEET-PG:** * **VEAL CHOP Mnemonic:** **V**ariable = **C**ord; **E**arly = **H**ead; **A**ccelerations = **O**k (Oxygenated); **L**ate = **P**lacenta. * Late decelerations are categorized as **Category III** (Abnormal) if associated with absent variability, requiring immediate resuscitation or delivery. * The first step in management is "intrauterine resuscitation": Left lateral position, oxygen, IV fluids, and stopping oxytocin.

Q: What is the drug of choice for imminent eclampsia?

Magnesium sulfate. **Explanation:** **Magnesium Sulfate (MgSO₄)** is the drug of choice for both the **prevention** of seizures in imminent eclampsia and the **treatment** of seizures in established eclampsia. The underlying medical concept relies on its role as a potent neuromuscular blocker and CNS depressant. It acts by inhibiting NMDA receptors, blocking calcium influx into neurons, and decreasing acetylcholine release at the motor endplate, thereby raising the seizure threshold. Large-scale trials (like the Magpie Trial) have proven its superiority over diazepam and phenytoin in preventing the progression of pre-eclampsia to eclampsia. **Analysis of Incorrect Options:** * **Hydralazine (A) & Labetalol (B):** These are antihypertensive agents. While they are used to manage hypertensive emergencies in pregnancy (BP ≥160/110 mmHg), they do not possess anti-convulsant properties and cannot prevent seizures. Labetalol is often the first-line IV antihypertensive, but it is not the drug of choice for "imminent eclampsia." * **Methyldopa (D):** This is a centrally acting alpha-2 agonist. It is the drug of choice for **chronic hypertension** in pregnancy due to its long-term safety profile, but it is too slow-acting for acute management or seizure prophylaxis. **High-Yield Clinical Pearls for NEET-PG:** * **Pritchard Regimen:** 4g IV (loading) + 10g IM (5g in each buttock), followed by 5g IM every 4 hours. * **Therapeutic Range:** 4–7 mEq/L. * **Monitoring:** Always check for **Patellar reflex** (earliest sign of toxicity), **Respiratory rate** (>12/min), and **Urine output** (>30ml/hr). * **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (given over 10 minutes).

Q: You are called to the operating room for a patient found to have an abdominal pregnancy with an 18-week fetus and placenta attached to the omentum during surgery for suspected appendicitis. What is the best course of action?

Removal of the fetus only. **Explanation:** The management of abdominal pregnancy is a high-stakes scenario in maternal-fetal medicine. The primary challenge is the **placenta**, which lacks the contractile myometrium of the uterus to control bleeding after separation. **1. Why "Removal of the fetus only" is correct:** In abdominal pregnancies, the placenta often attaches to highly vascular organs (like the omentum, bowel, or major vessels). Attempting to detach the placenta can lead to **uncontrollable, life-threatening hemorrhage**. The standard recommendation is to ligate the umbilical cord close to the placenta and leave the placenta *in situ*. It is then allowed to undergo spontaneous resorption, which can be monitored using serial β-hCG levels and ultrasound. Methotrexate may occasionally be used to accelerate this process. **2. Why the other options are incorrect:** * **Option A:** Removing the placenta is contraindicated unless it is attached to a simple, pedicled structure (like the omentum) that can be easily ligated and removed entirely. However, as a general rule for exams, "leaving the placenta" is the safest answer to prevent surgical catastrophe. * **Option B:** While the cord is ligated, the fetus must be removed to prevent infection, lithopedion formation, or further complications. * **Option D:** Abdominal pregnancy carries a very high risk of maternal mortality and fetal anomalies (due to oligohydramnios). Expectant management until viability is rarely recommended and is extremely hazardous. **Clinical Pearls for NEET-PG:** * **Diagnosis:** Often suggested by "easily palpable fetal parts" and an "empty uterus" on ultrasound. * **Management of Placenta:** If left behind, the patient is at risk for bowel obstruction and infection. * **Most common site:** The Pouch of Douglas. * **Key Rule:** Never attempt to peel the placenta off a vital organ.

Q: Bleeding is of fetal origin in which of the following conditions?

Vasa previa. **Explanation:** In **Vasa Previa**, fetal blood vessels (unprotected by Wharton’s jelly or placental tissue) run across the internal os of the cervix, usually due to a velamentous cord insertion or succenturiate lobe. When the membranes rupture (spontaneously or artificially), these fetal vessels are lacerated. Because the blood lost comes directly from the fetal circulation, even a small amount of bleeding can lead to rapid fetal exsanguination and distress, while the mother remains hemodynamically stable. **Analysis of Incorrect Options:** * **Placenta Accreta, Increta, and Percreta:** These are spectrums of morbidly adherent placenta where the chorionic villi invade the myometrium to varying depths (Accreta: superficial; Increta: into myometrium; Percreta: through serosa). Bleeding in these conditions occurs during attempts at placental delivery and is **maternal** in origin (from the uterine spiral arteries). **High-Yield Clinical Pearls for NEET-PG:** * **The Classic Triad:** Rupture of membranes + Painless vaginal bleeding + Fetal bradycardia/distress. * **Diagnostic Test:** To differentiate fetal from maternal blood, the **Apt test** or **Ogita test** is used (based on the resistance of fetal hemoglobin to alkali denaturation). * **Antenatal Diagnosis:** Color Doppler ultrasound is the gold standard for identifying vessels crossing the os. * **Management:** If diagnosed antenatally, a planned Cesarean section is performed (usually at 34–36 weeks) to avoid labor and membrane rupture.

Q: What is the standard regimen of magnesium sulfate for the management of severe pre-eclampsia and eclampsia?

Pritchard regimen. **Explanation:** Magnesium sulfate ($MgSO_4$) is the drug of choice for preventing and treating seizures in severe pre-eclampsia and eclampsia. The **Pritchard regimen** (intramuscular) and the **Zuspan regimen** (intravenous) are the two globally recognized protocols. **Why Option B is Correct:** The **Pritchard regimen** is the standard intramuscular (IM) protocol. It consists of: * **Loading Dose:** 4g IV (20% solution) over 5–10 minutes + 10g IM (5g in each buttock as a 50% solution). * **Maintenance Dose:** 5g IM every 4 hours in alternating buttocks. It is preferred in settings where infusion pumps are unavailable, making it a high-yield topic for exams focusing on Indian clinical scenarios. **Analysis of Incorrect Options:** * **A. Menon Regimen:** This is an older "Lytic Cocktail" (Chlorpromazine, Promethazine, and Pethidine) used before $MgSO_4$ became the gold standard. It is no longer recommended due to inferior efficacy and neonatal depression. * **C. Lean Regimen:** This is a distractor; there is no standard obstetric protocol by this name. * **D. Pinard’s Regimen:** Pinard refers to a maneuver for breech extraction (bringing down a leg) or a type of stethoscope used for fetal heart sounds, not a pharmacological regimen. **High-Yield Clinical Pearls for NEET-PG:** 1. **Therapeutic Range:** 4–7 mEq/L. 2. **Toxicity Signs:** Loss of patellar reflex (first sign, 8–10 mEq/L) $\rightarrow$ Respiratory depression (12 mEq/L) $\rightarrow$ Cardiac arrest (>25 mEq/L). 3. **Prerequisites for Maintenance:** Urine output >30 ml/hr, Respiratory rate >12-14/min, and presence of Patellar reflex. 4. **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (given over 10 minutes).

Q: What is the commonest cause of perinatal mortality in twins?

Prematurity. **Explanation:** **1. Why Prematurity is Correct:** Prematurity is the single most significant factor contributing to perinatal mortality and morbidity in twin gestations. While the average singleton pregnancy lasts 40 weeks, the average twin pregnancy lasts approximately 37 weeks. About 50% of twins are born preterm (before 37 weeks), and nearly 10% are born very preterm (before 32 weeks). The complications associated with prematurity—specifically **Respiratory Distress Syndrome (RDS)**, intraventricular hemorrhage, and necrotizing enterocolitis—are the primary drivers of neonatal death in these cases. **2. Why Other Options are Incorrect:** * **Infection:** While chorioamnionitis or neonatal sepsis can occur, they are often secondary to prolonged rupture of membranes or consequences of prematurity itself, rather than the primary statistical cause of death. * **Head Injury:** Birth trauma (like intracranial hemorrhage) was more common historically due to difficult vaginal deliveries of the second twin. However, with modern obstetric management and increased C-section rates for malpresentations, it is now a rare cause of mortality. * **Malnutrition:** While **Intrauterine Growth Restriction (IUGR)** and discordant growth are common in twins (especially Monochorionic), they typically lead to morbidity rather than being the leading cause of mortality compared to the systemic failures of prematurity. **High-Yield Clinical Pearls for NEET-PG:** * **Average duration of pregnancy:** Singletons (40 weeks), Twins (37 weeks), Triplets (33 weeks), Quadruplets (29 weeks). * **Monochorionic twins** have a 3–5 times higher mortality rate than dichorionic twins due to unique complications like **Twin-to-Twin Transfusion Syndrome (TTTS)**. * The **second twin** is generally at a higher risk of hypoxia and birth trauma than the first twin. * **Most common malpresentation in twins:** Cephalic-Cephalic (approx. 40-45%).

Q: A woman presents with amenorrhea of 2 months duration, lower abdominal pain, facial pallor, fainting, and shock. What is the most likely diagnosis?

Ruptured ectopic pregnancy. **Explanation:** The clinical presentation described is a classic medical emergency in gynecology. The patient exhibits the **"Classic Triad"** of ectopic pregnancy: amenorrhea (2 months), abdominal pain, and signs of internal hemorrhage (pallor, fainting, and shock). **1. Why Ruptured Ectopic Pregnancy is Correct:** A ruptured ectopic pregnancy leads to massive **hemoperitoneum**. The 2-month period of amenorrhea corresponds to the 6–8 week window when a tubal pregnancy (most commonly in the ampulla) typically outgrows the tube and ruptures. The sudden loss of blood into the peritoneal cavity causes acute abdominal pain and **hypovolemic shock**, manifesting as pallor and syncope. **2. Why the other options are incorrect:** * **Ruptured ovarian cyst:** While it causes acute pain and sometimes hemoperitoneum (e.g., ruptured corpus luteum), it is rarely associated with 2 months of amenorrhea or profound shock unless there is massive bleeding. * **Threatened abortion:** This presents with vaginal bleeding and mild cramping, but the cervix remains closed, and there is no shock or signs of intraperitoneal hemorrhage. * **Septic abortion:** This presents with fever, foul-smelling vaginal discharge, and pelvic pain following an incomplete abortion. While shock can occur, it is **septic shock** (fever, tachycardia) rather than hemorrhagic shock. **Clinical Pearls for NEET-PG:** * **Most common site of Ectopic Pregnancy:** Fallopian tube (95%), specifically the **Ampulla**. * **Most common site of Rupture:** Isthmus (occurs early, 6–8 weeks) vs. Ampulla (8–12 weeks). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serum $\beta$-hCG (Discriminatory zone: 1500–2000 mIU/ml). * **Management of Rupture:** Immediate resuscitation and **Emergency Laparotomy** (Salpingectomy).

Q: What is the most common cause of antepartum hemorrhage (APH)?

Abruptio placenta. **Explanation:** **Antepartum Hemorrhage (APH)** is defined as bleeding from or into the genital tract occurring from the 28th week of pregnancy until the birth of the baby. **Why Abruptio Placenta is Correct:** Abruptio placenta (premature separation of a normally situated placenta) is the **most common cause** of APH, accounting for approximately **30-35%** of cases. It is clinically characterized by painful vaginal bleeding, uterine tenderness, and increased uterine tone. It is a significant cause of maternal and perinatal morbidity and is frequently associated with pregnancy-induced hypertension (PIH). **Analysis of Incorrect Options:** * **Placenta Previa:** This is the second most common cause of APH (approx. 20-25%). It is characterized by **painless, causeless, and recurrent** bleeding. The placenta is implanted in the lower uterine segment. * **Vasa Previa:** This is a rare but life-threatening condition where fetal vessels run across the internal os. While it causes APH, the bleeding is **fetal in origin**, and it is much less common than abruption. * **Placenta Accreta:** This refers to an abnormal adherence of the placenta to the myometrium. It typically causes **postpartum hemorrhage (PPH)** during the third stage of labor rather than antepartum hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of APH:** Abruptio Placenta. * **Most common cause of DIC in pregnancy:** Abruptio Placenta. * **Couvelaire Uterus:** A complication of severe concealed abruption where blood extravasates into the myometrium. * **Warning Hemorrhage:** A classic feature of Placenta Previa, not Abruption. * **Stallworthy’s Sign:** Associated with posterior placenta previa.

Question 1

Late deceleration in fetal heart rate monitoring is suggestive of:

Accepted Answer

Fetal hypoxia

Answer

Head compression

Answer

Cord compression

Answer

Fetal death

Question 2

What is the drug of choice for imminent eclampsia?

Accepted Answer

Magnesium sulfate

Answer

Hydralazine

Answer

Labetalol

Answer

Methyldopa

Question 3

You are called to the operating room for a patient found to have an abdominal pregnancy with an 18-week fetus and placenta attached to the omentum during surgery for suspected appendicitis. What is the best course of action?

Accepted Answer

Removal of the fetus only

Answer

Removal of both fetus and placenta

Answer

Laparoscopic ligation of the umbilical cord

Answer

Closely follow until viability and then deliver by laparotomy

Question 4

Bleeding is of fetal origin in which of the following conditions?

Accepted Answer

Vasa previa

Answer

Placenta accreta

Answer

Placenta percreta

Answer

Placenta increta

Question 5

What is the standard regimen of magnesium sulfate for the management of severe pre-eclampsia and eclampsia?

Accepted Answer

Pritchard regimen

Answer

Menon regimen

Answer

Lean regimen

Answer

Pinard's regimen

Question 6

What is the commonest cause of perinatal mortality in twins?

Accepted Answer

Prematurity

Answer

Infection

Answer

Head injury

Answer

Malnutrition

Question 7

A 27-year-old G2P1 woman at 34 weeks' gestation presents to the emergency department following a motor vehicle collision. Her heart rate is 130/min and blood pressure is 150/90 mm Hg. She is alert and oriented to person, place, and time. She complains of severe abdominal pain that began immediately after the collision. Physical examination reveals bruising over her abdomen, along with a hypertonic uterus and dark vaginal bleeding. A sonogram reveals a placental abruption, and the fetal heart tracing reveals some decelerations. Emergency laboratory tests reveal an International Normalized Ratio of 2.5, with elevated fibrin degradation products. Which of the following is the most appropriate first step in management?

Accepted Answer

Administer fresh frozen plasma

Answer

Administer a tocolytic

Answer

Administer a corticosteroid

Answer

Deliver the fetus immediately by LSCS

Question 8

A woman presents with amenorrhea of 2 months duration, lower abdominal pain, facial pallor, fainting, and shock. What is the most likely diagnosis?

Accepted Answer

Ruptured ectopic pregnancy

Answer

Ruptured ovarian cyst

Answer

Threatened abortion

Answer

Septic abortion

Question 9

What is the most common cause of antepartum hemorrhage (APH)?

Accepted Answer

Abruptio placenta

Answer

Placenta previa

Answer

Vasa previa

Answer

Placenta accreta

Question 10

Which of the following conditions is associated with an incoagulable state?

Accepted Answer

Abruption placentae

Answer

Acute promyelocytic leukaemia

Answer

Severe falciparum malaria

Answer

Heparin overdose

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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