Maternal-Fetal Medicine Practice Questions

Q: An ectopic pregnancy is shed as?

Decidua vera. In an ectopic pregnancy, the hormonal changes (rising progesterone) stimulate the transformation of the endometrium into **decidua**, despite the embryo being implanted outside the uterine cavity. ### Why Decidua Vera is Correct The endometrium undergoes a "decidual reaction" to prepare for implantation. In a normal intrauterine pregnancy, the decidua is divided into three layers: 1. **Decidua Basalis:** Where the blastocyst implants. 2. **Decidua Capsularis:** Covers the blastocyst. 3. **Decidua Vera (Parietalis):** Lines the remainder of the uterine cavity. In an **ectopic pregnancy**, there is no blastocyst inside the uterus to create the basalis or capsularis layers. Therefore, the entire uterine lining transforms uniformly into **Decidua Vera**. When the ectopic pregnancy fails and hormone levels fall, this lining sloughs off and is shed, often as a single intact piece known as a **decidual cast**. ### Why Other Options are Incorrect * **Decidua Basalis & Capsularis:** These layers only form in response to the physical presence and implantation of the embryo within the uterus. Since the embryo is extrauterine, these specific layers do not exist. * **Decidua Rubra:** This is not a standard anatomical term for the decidual layers; it is likely a distractor derived from "Lochia Rubra" (the bloody discharge seen postpartum). ### NEET-PG Clinical Pearls * **Arias-Stella Reaction:** This is the characteristic histological change seen in the endometrium during ectopic pregnancy, featuring hypersecretory glands and nuclear hypertrophy. * **Decidual Cast:** If a patient presents with abdominal pain and passes a fleshy mass per vaginum, it is often a decidual cast. This must be differentiated from a miscarriage (which would contain chorionic villi). * **Key Distinction:** The absence of chorionic villi on histopathology of the shed tissue is a strong indicator of ectopic pregnancy.

Q: In which of the following conditions, the medical treatment of ectopic pregnancy is contraindicated?

Presence of fetal heart activity. **Explanation:** Medical management of ectopic pregnancy, primarily using **Methotrexate (MTX)**, is reserved for hemodynamically stable patients who meet specific criteria. The presence of **fetal heart activity (Option C)** is a major contraindication because it indicates a high trophoblastic load and a more advanced pregnancy, which significantly increases the risk of treatment failure and tubal rupture. **Analysis of Options:** * **Presence of fetal heart activity (Correct):** This is an absolute contraindication for medical management. MTX is less effective when there is active cardiac motion, necessitating surgical intervention. * **Sac size is 3 cm (Incorrect):** Medical management is generally indicated if the gestational sac diameter is **< 3.5 cm or 4 cm**. A 3 cm sac falls within the acceptable range for MTX. * **Blood in pelvis is 70 mL (Incorrect):** While significant hemoperitoneum (suggesting rupture) is a contraindication, a small amount of free fluid (usually **< 100 mL**) in the pouch of Douglas is common and does not preclude medical treatment. * **Previous ectopic pregnancy (Incorrect):** A history of ectopic pregnancy is not a contraindication. In fact, medical management is often preferred in these cases to avoid further surgical scarring of the fallopian tubes. **NEET-PG High-Yield Pearls:** * **Ideal Candidate for MTX:** Hemodynamically stable, Serum β-hCG < 5000 mIU/mL, Sac size < 3.5 cm, and No fetal cardiac activity. * **Absolute Contraindications:** Ruptured ectopic pregnancy, hemodynamic instability, breastfeeding, immunodeficiency, and significant renal/hepatic/pulmonary disease. * **Dosing:** Most common is the single-dose regimen (50 mg/m² IM). * **Monitoring:** β-hCG levels are measured on Day 4 and Day 7. A drop of **≥ 15%** between Day 4 and 7 indicates successful treatment.

Q: In a normal Non-Stress Test (NST), what is the time period for observing two or three accelerations that peak at 15 bpm or more above the baseline?

20 minutes. ### Explanation **1. Why Option C (20 minutes) is Correct:** A Non-Stress Test (NST) evaluates fetal well-being by observing the fetal heart rate (FHR) response to fetal movement. A **Reactive (Normal) NST** is defined by the presence of **two or more accelerations** within a **20-minute window**. An acceleration is defined as a peak of at least **15 beats per minute (bpm)** above the baseline, lasting for at least **15 seconds** (the "15x15" rule). This indicates a functional fetal autonomic nervous system and adequate oxygenation. **2. Why the Other Options are Incorrect:** * **A (3 minutes) & B (15 minutes):** These durations are too short. Fetal sleep cycles can last up to 40 minutes; therefore, a short observation window might result in a false-positive "non-reactive" result simply because the fetus is sleeping. * **D (60 minutes):** While an NST can be extended to 40 or 60 minutes if the initial 20-minute period is non-reactive (to account for fetal sleep), the standard diagnostic window for defining a reactive test is 20 minutes. **3. High-Yield Clinical Pearls for NEET-PG:** * **The "15x15" Rule:** For pregnancies >32 weeks, accelerations must be ≥15 bpm for ≥15 seconds. For **preterm fetuses (<32 weeks)**, the criteria are lower: **10 bpm for 10 seconds**. * **Non-Reactive NST:** If criteria are not met within 40 minutes, the test is non-reactive. The next step is usually a **Biophysical Profile (BPP)** or a **Contraction Stress Test (CST)**. * **Most Common Cause of Non-Reactive NST:** Fetal sleep cycle. * **Vibroacoustic Stimulation (VAS):** Can be used to "wake" the fetus and shorten the time to a reactive result.

Q: What is the most common type of twins following assisted reproductive technology?

Dizygotic twins. **Explanation:** The correct answer is **Dizygotic twins (C)**. **Why Dizygotic twins is correct:** Assisted Reproductive Technology (ART), specifically ovulation induction and In-Vitro Fertilization (IVF), significantly increases the rate of multiple gestations. The primary mechanism is the **transfer of multiple embryos** into the uterus during IVF or the **stimulation of multiple follicles** during ovulation induction (using drugs like Clomiphene citrate or Gonadotropins). Since these twins arise from two separate ova fertilized by two separate sperm, they are dizygotic (fraternal). While ART also slightly increases the risk of monozygotic twinning compared to natural conception, dizygotic twins remain overwhelmingly more common in this population. **Why the other options are incorrect:** * **Monozygotic twins (A):** These occur from the splitting of a single fertilized ovum. While the incidence is higher in IVF (approx. 2–5%) compared to natural conception (0.4%), they are still far less frequent than dizygotic twins in ART. * **Acardiac twin (B):** This is a rare, severe complication of Monochorionic Diamniotic (MCDA) twins known as Twin Reversed Arterial Perfusion (TRAP) sequence. It is a specific pathology, not a "type" of twinning common to ART. * **Conjoined twins (D):** These are a rare complication of monozygotic twinning where the embryo divides very late (after day 13). They are extremely rare and not the standard outcome of ART. **High-Yield Clinical Pearls for NEET-PG:** * **Natural Twinning Rate:** Approximately 1 in 80 pregnancies (Hellin’s Law). * **Most common type of Monozygotic twins:** Monochorionic Diamniotic (MCDA) — division occurs at 4–8 days (Blastocyst stage). * **Vanishing Twin Syndrome:** Frequent in ART, where one twin is resorbed in the first trimester. * **Risk Factor:** The single most important risk factor for dizygotic twinning is the use of ovulation-inducing drugs.

Q: All the conditions mentioned below are associated with decreased fetal heart rate except?

Fetal movement. **Explanation:** The fetal heart rate (FHR) is a dynamic indicator of fetal well-being, regulated by the autonomic nervous system. To answer this question, one must distinguish between factors that cause **accelerations** versus those that cause **decelerations** or bradycardia. **1. Why Fetal Movement is the Correct Answer:** Fetal movement is associated with a **transient increase** in fetal heart rate, known as an **acceleration**. An acceleration is defined as a rise in FHR of at least 15 beats per minute (bpm) above the baseline, lasting for at least 15 seconds. This is a reassuring sign indicating a functional fetal sympathetic nervous system and the absence of acidemia. Therefore, it does not decrease the heart rate. **2. Analysis of Incorrect Options:** * **Chronic Hypoxia (B):** Prolonged oxygen deprivation leads to myocardial depression and increased vagal tone, resulting in a decrease in baseline FHR or late decelerations. * **Cord Compression (C):** This causes umbilical vein/artery occlusion, triggering a baroreceptor-mediated reflex that results in **variable decelerations** (abrupt decreases in FHR). * **Head Compression (D):** During labor, pressure on the fetal head increases intracranial pressure, stimulating the vagus nerve. This results in **early decelerations**, which are symmetrical decreases in FHR mirroring uterine contractions. **NEET-PG High-Yield Pearls:** * **Reactive Non-Stress Test (NST):** Defined by $\geq$ 2 accelerations in 20 minutes. * **Early Decelerations:** "Mirror images" of contractions; caused by head compression (vagal reflex); clinically benign. * **Late Decelerations:** Occur after the peak of contraction; caused by **uteroplacental insufficiency**; always pathological. * **Variable Decelerations:** Most common type; caused by **cord compression**; managed by changing maternal position.

Q: Macrosomia is defined as a fetal weight greater than which of the following?

4.5 kg. **Explanation:** **Fetal Macrosomia** is defined by the American College of Obstetricians and Gynecologists (ACOG) as a birth weight of **more than 4,500 grams (4.5 kg)**, regardless of gestational age. This threshold is chosen because the risks of maternal and neonatal morbidity (such as shoulder dystocia and birth trauma) increase significantly above this weight. * **Option D (4.5 kg) is Correct:** While some older texts used 4 kg as a cutoff, current clinical guidelines (ACOG) strictly define macrosomia as >4.5 kg. In clinical practice, a weight >4 kg is often termed "Large for Gestational Age" (LGA), but "Macrosomia" is the specific diagnosis for the 4.5 kg threshold. * **Options A & B (3 kg and 3.5 kg):** These represent normal average birth weights. The average birth weight for a term neonate is approximately 3.2 kg to 3.5 kg. * **Option C (4 kg):** This is the threshold for LGA (weight >90th percentile for gestational age). While often used interchangeably in casual clinical settings, it is not the formal definition of macrosomia for boards. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Cause:** Maternal Diabetes Mellitus (Gestational or Pre-gestational). * **Complications:** Shoulder dystocia (most feared), Erb’s palsy, postpartum hemorrhage (due to uterine atony), and perineal tears. * **Management:** Elective Cesarean Section is recommended if the estimated fetal weight is **>5 kg** in non-diabetic women or **>4.5 kg** in diabetic women. * **Ponderal Index:** Used to differentiate between symmetrical and asymmetrical growth; macrosomic infants of diabetic mothers often show asymmetrical growth (increased fat deposition on shoulders/abdomen).

Question 1

An ectopic pregnancy is shed as?

Accepted Answer

Decidua vera

Answer

Decidua basalis

Answer

Decidua capsularis

Answer

Decidua rubra

Question 2

A 28-year-old pregnant lady at 23 weeks of gestation presents to the emergency room with headache, blurring of vision, vomiting, and convulsion. On examination, her blood pressure is 195/150 mm Hg, and she has ankle edema and urinary proteinuria. Intravenous magnesium sulfate was administered and she recovered smoothly. During discharge, which of the following medications will be justified for her management?

Accepted Answer

Metoprolol

Answer

Nifedipine

Answer

Methyldopa

Answer

Olmesartan

Question 3

A patient with systemic lupus erythematosus desires pregnancy. What should her physician advise her regarding pregnancy in lupus patients?

Accepted Answer

There may be an increase in spontaneous abortions and prematurity.

Answer

There is no increased risk to the fetus.

Answer

There may be an increase in cardiovascular malformations.

Answer

There may be an increase in nervous system malformations.

Question 4

In which of the following conditions, the medical treatment of ectopic pregnancy is contraindicated?

Accepted Answer

Presence of fetal heart activity

Answer

Sac size is 3 cm

Answer

Blood in pelvis is 70 mL

Answer

Previous ectopic pregnancy

Question 5

In a normal Non-Stress Test (NST), what is the time period for observing two or three accelerations that peak at 15 bpm or more above the baseline?

Accepted Answer

20 minutes

Answer

3 minutes

Answer

15 minutes

Answer

60 minutes

Question 6

At 29 weeks gestational age, it becomes apparent that the fetus has developed hydrops. All of the following are characteristics of fetal hydrops except?

Accepted Answer

Small placenta

Answer

Polyhydramnios

Answer

Pericardial effusion

Answer

Subcutaneous edema

Question 7

What is the most common type of twins following assisted reproductive technology?

Accepted Answer

Dizygotic twins

Answer

Monozygotic twins

Answer

Acardiac twin

Answer

Conjoined twins

Question 8

Fetal growth restriction is defined as estimated fetal weight is below the ______ for their gestational age?

Accepted Answer

10th percentile

Answer

3rd percentile

Answer

5th percentile

Answer

15th percentile

Question 9

All the conditions mentioned below are associated with decreased fetal heart rate except?

Accepted Answer

Fetal movement

Answer

Chronic hypoxia

Answer

Cord compression

Answer

Head compression

Question 10

Macrosomia is defined as a fetal weight greater than which of the following?

Accepted Answer

4.5 kg

Answer

3 kg

Answer

3.5 kg

Answer

4 kg

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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