Maternal-Fetal Medicine Practice Questions

Q: Nitabuch's layer is absent in which of the following conditions?

Placenta accreta. **Explanation:** **Nitabuch’s layer** is a fibrinoid layer located between the **decidua basalis** and the **chorionic villi** (specifically the syncytiotrophoblast). Its primary physiological role is to prevent the over-invasion of trophoblastic tissue into the myometrium. **1. Why Placenta Accreta is correct:** In **Placenta Accreta**, there is a partial or complete absence of the **decidua basalis**. Because Nitabuch’s layer is a derivative of the decidua, its absence leads to the direct attachment of chorionic villi to the underlying myometrium. This lack of a cleavage plane results in a placenta that is morbidly adherent and fails to separate after delivery, often leading to life-threatening postpartum hemorrhage (PPH). **2. Why other options are incorrect:** * **Placenta Previa:** This refers to the abnormal *location* of the placenta (implanted in the lower uterine segment). While previa is a major risk factor for accreta, the layer itself is present unless co-existing with an adherence defect. * **Placenta Membranacea:** A rare condition where the entire fetal sac is covered by functional villi (placenta diffusa). The placenta is thin but the decidual layers are generally intact. * **Circumvallate Placenta:** A morphological variation where the chorionic plate is smaller than the basal plate, causing the membranes to double back. It involves the peripheral anatomy, not the absence of the fibrinoid layer. **High-Yield Clinical Pearls for NEET-PG:** * **Rohr’s Stria:** A similar fibrinoid layer found more superficially, at the bottom of the intervillous space and surrounding the attachment of anchoring villi. * **Risk Factors for Accreta:** Previous Cesarean section (most common) and Placenta Previa. * **Management:** The gold standard for morbidly adherent placenta (Accreta, Increta, Percreta) is often a planned **Cesarean Hysterectomy**.

Q: USG examination of a 28-week pregnant primigravida shows vasa previa. All of the following are true regarding this condition, EXCEPT:

Fetal mortality rate of 20% with undiagnosed cases. **Explanation:** **Vasa Previa** is a high-stakes obstetric emergency where fetal vessels (unprotected by Wharton’s jelly) run through the membranes across the internal os. **Why Option B is the Correct Answer (The Exception):** The statement in Option B underestimates the severity of the condition. In **undiagnosed cases** of vasa previa, the fetal mortality rate is significantly higher, ranging from **50% to 95%**. This occurs because when membranes rupture (ARM or SRM), the fetal vessels tear, leading to rapid fetal exsanguination. Since the total fetal blood volume is small (approx. 80-100 ml/kg), even a small amount of bleeding is catastrophic. **Analysis of Other Options:** * **Option A:** The incidence is approximately **1:1500 to 1:2500** pregnancies, making it a rare but critical diagnosis. * **Option C:** Vasa previa is strongly associated with placental abnormalities such as **low-lying placenta**, **succenturiate lobes** (vessels connecting the lobes), and **velamentous insertion of the cord**. * **Option D:** **Elective Cesarean section** (usually at 34–36 weeks) is the definitive management to avoid labor and membrane rupture, which would otherwise lead to fetal death. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Rupture of membranes + Painless vaginal bleeding + Fetal distress/bradycardia. * **Diagnostic Test:** Antenatal **Color Doppler USG** is the gold standard. * **Apt’s Test/Ogita Test:** Used to differentiate fetal hemoglobin from maternal blood in vaginal bleeding. * **Management:** If diagnosed antenatally, the survival rate exceeds 95%. If diagnosed intrapartum, immediate CS is mandatory.

Q: Cervical incompetence is when the cervix measures less than?

2.5 cm. **Explanation:** Cervical incompetence (or cervical insufficiency) is the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions. The diagnosis is primarily based on a history of painless second-trimester miscarriages or via Transvaginal Ultrasound (TVS). **Why 2.5 cm is the correct answer:** In clinical practice and according to standard guidelines (ACOG/RCOG), a cervical length of **less than 2.5 cm (25 mm)** before 24 weeks of gestation is the established threshold for diagnosing a "short cervix." This measurement is a significant predictor of preterm birth, as a shorter cervix lacks the structural integrity to support the growing fetus and increasing intrauterine pressure. **Analysis of Incorrect Options:** * **A (1 cm) and B (1.5 cm):** While these measurements definitely indicate cervical shortening, they represent extreme cases. Waiting for the cervix to reach 1 cm or 1.5 cm before diagnosing incompetence would delay critical interventions like cerclage, increasing the risk of imminent pregnancy loss. * **C (2 cm):** Although 2 cm is clinically concerning, the standardized diagnostic cutoff for intervention and risk assessment in asymptomatic high-risk women is 2.5 cm. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Transvaginal Ultrasound (TVS) is superior to transabdominal ultrasound for measuring cervical length. * **The "Funneling" Sign:** This refers to the protrusion of amniotic membranes into the internal os, often taking a 'T, Y, V, or U' shape (Mnemonic: **TRUST** - **T**hinning, **R**eaching **U** **S**haped **T**erminal). * **Treatment:** The definitive management is **Cervical Cerclage** (e.g., McDonald’s or Shirodkar’s technique), typically performed between 14–18 weeks of gestation. * **Best Time for Screening:** In women with a history of preterm birth, cervical length is monitored between 16 and 24 weeks.

Q: A 37-year-old primigravida at 30 weeks' gestation has noted increasing pedal edema, headaches, confusion, and decreased urine output for the past 2 weeks. She now exhibits seizure activity and then lapses into a coma. On physical examination, her temperature is 36.8°C, pulse is 82/min, respirations are 24/min, and blood pressure is 145/95 mm Hg. Her heart rate is regular, and lung fields are clear. The abdomen is soft, and bowel sounds are present. There is pitting edema to the thighs. No vaginal bleeding is noted, and the cervix is not effaced. Laboratory findings show hemoglobin, 11.9 g/dL; hematocrit, 35.8%; platelet count, 63,500/mm³; WBC count, 8180/mm³; glucose, 151 mg/dL; total protein, 6.1 g/dL; albumin, 3.2 g/dL; total bilirubin, 2.3 mg/dL; AST, 88 U/L; ALT, 103 U/L; alkaline phosphatase, 253 U/L; and prothrombin time, 32 seconds (INR 2.8). Urinalysis shows specific gravity of 1.024, pH 6, 4+ proteinuria, 1+ glucosuria, and no blood. An ultrasound examination shows a viable 30-week fetus. What condition is most likely present in this patient?

HELLP syndrome. ### Explanation The patient presents with a classic progression of **Preeclampsia** (hypertension, edema, 4+ proteinuria) to **Eclampsia** (seizures and coma). However, the laboratory findings specifically point towards **HELLP syndrome**, a severe complication of preeclampsia. **1. Why HELLP Syndrome is Correct:** HELLP is an acronym for: * **H (Hemolysis):** Suggested by elevated total bilirubin (2.3 mg/dL). * **EL (Elevated Liver enzymes):** AST (88 U/L) and ALT (103 U/L) are significantly elevated. * **LP (Low Platelets):** The count is 63,500/mm³ (threshold is <100,000/mm³). The patient also shows signs of **DIC** (prolonged PT/INR), which is a common sequela of HELLP syndrome. **2. Why Other Options are Incorrect:** * **Abruptio placentae:** While associated with preeclampsia, it typically presents with painful vaginal bleeding and a woody-hard uterus, neither of which are present here. * **Budd-Chiari syndrome:** This involves hepatic vein thrombosis. While it causes hepatomegaly and ascites, it does not explain the proteinuria, hypertension, or seizure activity. * **Dilated cardiomyopathy:** Peripartum cardiomyopathy presents with signs of congestive heart failure (orthopnea, rales, S3 gallop). This patient’s lung fields are clear. **3. NEET-PG High-Yield Pearls:** * **Mississippi Classification:** Class 1 HELLP is the most severe (platelets <50,000/mm³). * **Treatment of Choice:** Immediate stabilization (Magnesium sulfate for seizures, antihypertensives) followed by **delivery**, regardless of gestational age, if HELLP is diagnosed. * **Differential:** Always differentiate HELLP from **Acute Fatty Liver of Pregnancy (AFLP)**; AFLP typically features hypoglycemia and more profound coagulation abnormalities.

Q: A 22-week pregnant patient, gravida 3 with a history of a second-trimester abortion, presents with abdominal pain. Ultrasound reveals internal os tunneling and a cervical length of 21 mm. What is the ideal management?

McDonald's suture. ### Explanation The patient presents with signs of **Cervical Insufficiency** (also known as cervical incompetence), characterized by painless cervical shortening and "tunneling" or "funneling" of the internal os. Given her history of a second-trimester abortion and the current ultrasound findings at 22 weeks, surgical intervention is indicated to prevent preterm birth. **Why McDonald’s Suture is Correct:** The **McDonald’s suture** is a type of cervical cerclage performed transvaginally. It involves a purse-string suture placed at the cervicovaginal junction to reinforce the cervix. In this case, it is considered an **"Ultrasound-indicated" or "Rescue" cerclage** because the cervical length is <25 mm before 24 weeks of gestation in a patient with a suggestive history. It is the standard treatment for cervical insufficiency to provide mechanical support to the internal os. **Analysis of Incorrect Options:** * **A & B (Dinoprost and Misoprost):** These are prostaglandins used to *induce* labor or abortion by causing cervical ripening and uterine contractions. They are contraindicated here as the goal is to maintain the pregnancy. * **C (Fothergill’s Suture):** This is part of the Manchester operation used for treating **pelvic organ prolapse** (uterine descent) in women who wish to preserve their uterus. It is not used for cervical insufficiency in pregnancy. **Clinical Pearls for NEET-PG:** * **Timing:** Cerclage is ideally performed between **12–14 weeks** (prophylactic) but can be done up to **24 weeks** (rescue). * **Shirodkar Cerclage:** An alternative technique where the suture is placed higher (submucosal), requiring bladder reflection. * **Contraindications to Cerclage:** Chorioamnionitis, active bleeding, ruptured membranes, or fetal anomalies incompatible with life. * **Removal:** The suture is typically removed at **36–37 weeks** or at the onset of labor to allow for vaginal delivery.

Q: Mr. and Mrs. Annadurai have a 2-month-old baby with Down syndrome. Karyotype of Mrs. Annadurai shows a translocation variety of Down syndrome. Which of the following investigations will you advise to the parents before their next pregnancy?

Karyotyping. ### Explanation **Why Karyotyping is the Correct Answer:** The scenario describes a case of **Translocation Down Syndrome**. Unlike Trisomy 21 (nondisjunction), which is usually sporadic and related to maternal age, translocation Down syndrome can be inherited from a phenotypically normal parent who is a **balanced translocation carrier**. If Mrs. Annadurai has a translocation variety, there is a significant risk of recurrence in future pregnancies. To provide accurate genetic counseling and determine the specific recurrence risk (e.g., 10–15% if the mother is a carrier of a 14;21 translocation, or 100% if a parent carries a 21;21 translocation), **Karyotyping of both parents** is the essential first step before the next pregnancy. This identifies if either parent is a carrier of the balanced translocation. **Why Other Options are Incorrect:** * **Triple Test (A), Alpha-fetoprotein (B), and Beta-hCG (D):** These are components of **maternal serum screening** performed *during* pregnancy (typically between 15–20 weeks). While they help screen for Down syndrome in a current fetus, they cannot identify a parental carrier state or provide pre-conceptional risk assessment. **Clinical Pearls for NEET-PG:** * **Trisomy 21 Etiology:** 95% are due to Nondisjunction (risk increases with maternal age); 3–4% are due to Robertsonian Translocation (independent of maternal age); 1% are Mosaicism. * **Recurrence Risk:** If a previous child had Trisomy 21 (nondisjunction), the recurrence risk is ~1%. If a parent is a translocation carrier, the risk is significantly higher. * **Most Common Translocation:** The most frequent translocation in Down syndrome is **t(14;21)**. * **Pre-conceptional Counseling:** Always prioritize parental karyotyping when a structural chromosomal abnormality is identified in a proband (the affected child).

Q: A 37-week pregnant female presents with grade 3 placenta previa, vaginal bleeding, and uterine contractions. What is the most appropriate management?

Emergency lower segment Cesarean section. **Explanation:** The management of placenta previa depends on the **gestational age**, the **severity of bleeding**, and the **presence of labor**. **1. Why Option D is Correct:** The patient is at **37 weeks (term)** and is symptomatic with **vaginal bleeding and uterine contractions**. In placenta previa, uterine contractions cause cervical effacement and dilatation, which leads to further separation of the placenta and life-threatening hemorrhage. Since the pregnancy has reached term and the patient is in active labor/bleeding, immediate delivery is mandatory. For **Grade 3 (total/major)** placenta previa, vaginal delivery is contraindicated; therefore, an **Emergency Lower Segment Cesarean Section (LSCS)** is the definitive management to save both mother and fetus. **2. Why Other Options are Incorrect:** * **Option A & B:** These are components of **Macafee and Johnson’s expectant management**. This protocol is only indicated if the fetus is preterm (<37 weeks), bleeding is not life-threatening, and the patient is not in labor. * **Option C:** "Wait and watch" is dangerous in the presence of active contractions and major placenta previa at term, as it risks sudden, massive maternal hemorrhage and fetal distress. **Clinical Pearls for NEET-PG:** * **Macafee Protocol Goal:** To carry the pregnancy to 37 weeks (term). * **Contraindication:** Never perform a **per-vaginal (PV) examination** in a suspected case of placenta previa outside the operating theater ("Double Setup"), as it can provoke torrential bleeding. * **Stallworthy’s Sign:** A drop in fetal heart rate when the fetal head is pressed into the pelvis (common in posterior placenta previa). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) is more accurate than transabdominal ultrasound for locating the placental edge.

Question 1

Nitabuch's layer is absent in which of the following conditions?

Accepted Answer

Placenta accreta

Answer

Placenta previa

Answer

Placenta membranacea

Answer

Circumvallate placenta

Question 2

A healthy, 44-year-old woman, gravida 2, para 1, has a screening ultrasound at 18 weeks' gestation that shows no fetal anomalies. At 32 weeks' gestation, she experiences decreased fetal movement, and ultrasound reveals fetal growth restriction with relative sparing of the fetal head. The placenta appears normally positioned in the lateral fundus but seems small, and the amniotic fluid index is reduced. Maternal blood pressure is normal. Which of the following conditions is most likely present?

Accepted Answer

Uteroplacental insufficiency

Answer

Congenital Treponema pallidum infection

Answer

Galactosemia

Answer

Preeclampsia

Question 3

USG examination of a 28-week pregnant primigravida shows vasa previa. All of the following are true regarding this condition, EXCEPT:

Accepted Answer

Fetal mortality rate of 20% with undiagnosed cases

Answer

Incidence is 1:1500

Answer

Associated with low-lying placenta

Answer

Caesarean section is indicated

Question 4

Cervical incompetence is when the cervix measures less than?

Accepted Answer

2.5 cm

Answer

1 cm

Answer

1.5 cm

Answer

2 cm

Question 5

A 37-year-old primigravida at 30 weeks' gestation has noted increasing pedal edema, headaches, confusion, and decreased urine output for the past 2 weeks. She now exhibits seizure activity and then lapses into a coma. On physical examination, her temperature is 36.8°C, pulse is 82/min, respirations are 24/min, and blood pressure is 145/95 mm Hg. Her heart rate is regular, and lung fields are clear. The abdomen is soft, and bowel sounds are present. There is pitting edema to the thighs. No vaginal bleeding is noted, and the cervix is not effaced. Laboratory findings show hemoglobin, 11.9 g/dL; hematocrit, 35.8%; platelet count, 63,500/mm³; WBC count, 8180/mm³; glucose, 151 mg/dL; total protein, 6.1 g/dL; albumin, 3.2 g/dL; total bilirubin, 2.3 mg/dL; AST, 88 U/L; ALT, 103 U/L; alkaline phosphatase, 253 U/L; and prothrombin time, 32 seconds (INR 2.8). Urinalysis shows specific gravity of 1.024, pH 6, 4+ proteinuria, 1+ glucosuria, and no blood. An ultrasound examination shows a viable 30-week fetus. What condition is most likely present in this patient?

Accepted Answer

HELLP syndrome

Answer

Abruptio placentae

Answer

Budd-Chiari syndrome

Answer

Dilated cardiomyopathy

Question 6

A 22-week pregnant patient, gravida 3 with a history of a second-trimester abortion, presents with abdominal pain. Ultrasound reveals internal os tunneling and a cervical length of 21 mm. What is the ideal management?

Accepted Answer

McDonald's suture

Answer

Dinoprost and bed rest

Answer

Misoprost and bed rest

Answer

Fothergill's suture

Question 7

Mr. and Mrs. Annadurai have a 2-month-old baby with Down syndrome. Karyotype of Mrs. Annadurai shows a translocation variety of Down syndrome. Which of the following investigations will you advise to the parents before their next pregnancy?

Accepted Answer

Karyotyping

Answer

Triple test

Answer

Alpha-fetoprotein

Answer

Beta-human chorionic gonadotropin (hCG)

Question 8

What is the normal beat-to-beat variability in a Non-Stress Test (NST) on a term fetus?

Accepted Answer

10-25 beats per minute

Answer

5-10 beats per minute

Answer

greater than 25 beats per minute

Answer

any variability above a baseline of 110 bpm is normal

Question 9

Which of the following is NOT typically performed in the management of Intrauterine Growth Restriction (IUGR)?

Accepted Answer

Amniocentesis

Answer

Non-stress test

Answer

Oxytocin challenge test

Answer

Ultrasound of the abdomen

Question 10

A 37-week pregnant female presents with grade 3 placenta previa, vaginal bleeding, and uterine contractions. What is the most appropriate management?

Accepted Answer

Emergency lower segment Cesarean section

Answer

Dexamethasone and nifedipine

Answer

Bed rest and sedation

Answer

Wait and watch

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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