Maternal-Fetal Medicine Practice Questions

Q: The "lambda sign" or "twin peak sign" is seen in which type of twin pregnancy?

Dichorionic diamniotic. ### Explanation The **Lambda sign** (also known as the **Twin Peak sign**) is a crucial sonographic marker used to determine chorionicity in twin pregnancies, typically between 10 and 14 weeks of gestation. **1. Why Dichorionic Diamniotic (DCDA) is correct:** In a DCDA pregnancy, each fetus has its own placenta and gestational sac. Where the two placentas meet, the intervening membrane is thick because it consists of four layers (two layers of chorion and two layers of amnion). This results in a **triangular projection of placental tissue** extending into the base of the inter-twin membrane, resembling the Greek letter lambda (λ). This sign confirms that there are two separate placentas (even if they appear fused). **2. Why the other options are incorrect:** * **Diamniotic Monochorionic (MCDA):** These twins share a single placenta. The inter-twin membrane is thin (only two layers of amnion) and joins the placenta abruptly without any intervening placental tissue. This creates a **"T-sign"** rather than a lambda sign. * **Monoamniotic Monochorionic (MCMA):** These twins share both a placenta and an amniotic sac. There is no inter-twin membrane at all; therefore, neither the lambda nor the T-sign is present. ### High-Yield Clinical Pearls for NEET-PG: * **Timing:** Chorionicity is most accurately determined in the **first trimester** (10–14 weeks). As the pregnancy progresses, the lambda sign may disappear (the "vanishing lambda sign"), making early scans vital. * **Membrane Thickness:** A membrane thickness of **>2 mm** usually indicates DCDA, while **<2 mm** suggests MCDA. * **Significance:** Determining chorionicity is the most important step in managing twin pregnancies, as monochorionic twins are at high risk for **Twin-to-Twin Transfusion Syndrome (TTTS)**.

Q: Cord blood gas and pH analysis is done in the following circumstances, except?

Antepartum hemorrhage. **Explanation:** Umbilical cord blood gas (UCBG) analysis is the objective "gold standard" for assessing the metabolic status of a newborn at the time of delivery. It is primarily indicated when there is a high suspicion of **fetal acidemia** or intrapartum hypoxia. **Why Antepartum Hemorrhage (APH) is the correct answer:** APH (e.g., placenta previa or abruptio placentae) is a clinical diagnosis and an obstetric emergency. While severe abruption can lead to fetal distress, APH itself is not a direct indication for cord gas analysis unless it results in a low APGAR score or fetal distress during labor. The analysis is performed to document the newborn's condition *after* delivery, not as a routine response to maternal bleeding. **Analysis of Incorrect Options:** * **Low 5-minute APGAR score:** This is a primary indication. A score <7 necessitates UCBG to differentiate between birth asphyxia (metabolic acidosis) and other causes of depression (e.g., maternal sedation). * **Maternal thyroid disease:** Maternal thyrotoxicosis or Graves' disease can lead to fetal/neonatal thyrotoxicosis or goiter. Cord blood is often sampled here to check fetal thyroid function (T4/TSH) and acid-base status. * **Severe Fetal Growth Restriction (FGR):** FGR fetuses have chronic placental insufficiency and reduced reserve, making them highly susceptible to intrapartum hypoxia and acidosis. **NEET-PG High-Yield Pearls:** * **Sampling:** Ideally taken from the **umbilical artery** (reflects fetal status) rather than the vein (reflects placental status). * **Normal pH:** Approximately 7.20–7.30. * **Pathological Acidemia:** Defined as a pH **<7.00** and a base deficit **≥12 mmol/L**. This threshold is strongly associated with an increased risk of neurological deficits (e.g., Cerebral Palsy). * **Indications:** Abnormal FHR patterns (Category III), operative delivery for fetal distress, and multiple gestations.

Q: With regards to acute pyelonephritis in pregnancy, all of the following are true except:

Left kidney is involved in 50% of patients.. **Explanation:** Acute pyelonephritis is one of the most common medical complications of pregnancy, occurring in approximately 1–2% of pregnancies. **Why Option A is the Correct Answer (The False Statement):** In pregnancy, the **right kidney** is involved in the majority of cases (70–80%), not the left. This is due to **dextrorotation of the uterus**, which causes mechanical compression of the right ureter at the pelvic brim. Additionally, the right ovarian vein complex, which is dilated during pregnancy, crosses the right ureter, further contributing to stasis. While bilateral involvement occurs in about 25% of cases, isolated left-sided involvement is rare. **Analysis of Other Options:** * **Option B:** **E. coli** is indeed the most common isolate, responsible for 70–80% of cases, followed by *Klebsiella pneumoniae* and *Proteus*. * **Option C:** It is more common in the **later half of pregnancy** (second and third trimesters). This is because the physiological changes—progesterone-induced ureteral smooth muscle relaxation and mechanical obstruction by the enlarging uterus—peak during this period. * **Option D:** Pyelonephritis **responds well to aminoglycosides** (like Gentamicin) often used in combination with Ampicillin or Cephalosporins. Intravenous hydration and antibiotics are the standard of care. **High-Yield Clinical Pearls for NEET-PG:** * **Physiological Hydroureter:** More prominent on the right side. * **Complication:** The most serious complication is **ARDS** (due to endotoxin-induced alveolar damage) and septic shock. * **Screening:** Asymptomatic bacteriuria must be treated in pregnancy to prevent progression to pyelonephritis (occurs in 25% of untreated cases). * **Recurrence:** Patients require suppressive antibiotic therapy (e.g., Nitrofurantoin) for the remainder of the pregnancy after an acute episode.

Q: A woman presents with right-sided lower abdominal pain and mild vaginal bleeding at 6 weeks of gestation. Her general condition is satisfactory, and a urine hCG test is positive. Transvaginal ultrasound reveals an adnexal mass measuring 30 mm in diameter without cardiac activity, and no intrauterine pregnancy is seen. What is the most appropriate management?

Intramuscular methotrexate. **Explanation:** The clinical presentation of abdominal pain, vaginal bleeding, and an empty uterus on ultrasound with a positive hCG is classic for an **Ectopic Pregnancy**. **Why Intramuscular Methotrexate is correct:** Medical management with Methotrexate (MTX) is the treatment of choice in hemodynamically stable patients who meet specific criteria. This patient is a prime candidate because: 1. **Hemodynamic stability:** Her general condition is "satisfactory." 2. **Mass size:** The adnexal mass is ≤ 3.5 cm (30 mm). 3. **Fetal Cardiac Activity:** Absent (a prerequisite for MTX). 4. **Gestational age:** Early presentation (6 weeks). **Why the other options are incorrect:** * **Laparoscopic Salpingectomy (A):** This involves removing the fallopian tube. It is indicated for ruptured ectopic pregnancy, hemodynamic instability, or when medical management fails/is contraindicated. * **Laparoscopic Salpingo-oophorectomy (B):** This involves removing both the tube and the ovary. It is rarely indicated for ectopic pregnancy unless there is extensive ovarian involvement or torsion. * **Laparoscopic Salpingotomy (C):** This is a fertility-preserving surgery where the tube is opened and the products are removed. While an option for stable patients desiring future fertility, medical management (MTX) is less invasive and preferred when the mass is < 3.5 cm. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) + Serum β-hCG. * **Discriminatory Zone:** The β-hCG level (usually 1500–2000 mIU/mL) at which an intrauterine sac should be visible on TVS. * **MTX Contraindications:** Breastfeeding, immunodeficiency, ruptured ectopic, or hepatic/renal/hematologic dysfunction. * **Most common site:** Ampulla of the Fallopian tube. * **Most common site for rupture:** Isthmus (due to narrow lumen).

Q: In gestational hypertension, hypertension should resolve by how many weeks in the postpartum period?

12 weeks. **Explanation:** **1. Why 12 Weeks is Correct:** Gestational hypertension is defined as the new onset of hypertension (Systolic BP ≥140 mmHg or Diastolic BP ≥90 mmHg) after 20 weeks of gestation in a previously normotensive woman, without proteinuria or features of end-organ dysfunction. By definition, this condition is **transient**. According to ACOG and NHBPEP guidelines, the blood pressure must return to normal by **12 weeks postpartum**. If hypertension persists beyond 12 weeks, the diagnosis is revised to **Chronic Hypertension**. **2. Why Other Options are Incorrect:** * **A (2 weeks) & B (6 weeks):** While many patients see a resolution of BP within the first few days or weeks after delivery, these timeframes are too short to be the diagnostic cutoff. Six weeks marks the end of the traditional puerperium, but the physiological changes of pregnancy can take longer to stabilize. * **C (8 weeks):** This is an arbitrary timeframe and does not align with the standardized diagnostic criteria used in international obstetric guidelines. **3. Clinical Pearls & High-Yield Facts for NEET-PG:** * **Transient Hypertension:** If BP resolves by 12 weeks postpartum, the retrospective diagnosis is "Transient Hypertension of Pregnancy." * **Chronic Hypertension:** Hypertension present *before* pregnancy or diagnosed *before* 20 weeks of gestation is termed Chronic Hypertension. * **Preeclampsia:** If gestational hypertension is accompanied by proteinuria (>300mg/24hrs) or signs of end-organ damage (e.g., thrombocytopenia, elevated liver enzymes), it is classified as Preeclampsia. * **Risk Factor:** Women with gestational hypertension have a higher risk of developing essential hypertension and cardiovascular disease later in life.

Q: A G2P1 patient on warfarin presents at 38 weeks in labor. What is the next step in management?

Stop warfarin and proceed with cesarean section.. **Explanation:** The management of a patient on warfarin in active labor is a critical scenario due to the risk of **fetal intracranial hemorrhage**. Warfarin crosses the placenta and induces a fetal anticoagulant state. During the mechanical stress of labor—specifically during passage through the birth canal—the fetus is at an extremely high risk of internal bleeding. **1. Why Option B is Correct:** When a patient presents in labor while taking warfarin, the priority is to minimize fetal trauma. **Cesarean section** is the preferred mode of delivery because it is associated with less mechanical trauma to the fetal head compared to vaginal delivery, thereby reducing the risk of intracranial hemorrhage. Warfarin should be stopped immediately to manage maternal bleeding risks, and reversal agents (like Vitamin K or PCC) may be considered for the mother. **2. Why Other Options are Incorrect:** * **Option A:** Vaginal delivery is contraindicated because the fetal coagulation factors are depleted, making the risk of birth-trauma-induced hemorrhage unacceptably high. * **Options C & D:** While heparin is the preferred anticoagulant during pregnancy (as it does not cross the placenta), switching to heparin *at the time of active labor* at 38 weeks does not reverse the **existing fetal anticoagulation** caused by the warfarin already in the fetal system. It takes several days for fetal clotting factors to normalize after stopping warfarin. **High-Yield Clinical Pearls for NEET-PG:** * **Warfarin Embryopathy:** Occurs with exposure between 6–9 weeks (features: nasal hypoplasia, stippled epiphyses). * **Switching Protocol:** Ideally, warfarin should be switched to Heparin (LMWH or UFH) at **36 weeks** of gestation to allow fetal clotting factors to recover before labor begins. * **Breastfeeding:** Warfarin is **not** excreted in breast milk and is safe for postpartum anticoagulation.

Q: What is the recommended treatment for cholera during pregnancy?

Azithromycin. **Explanation:** The primary goal in treating cholera during pregnancy is aggressive rehydration and appropriate antibiotic therapy to reduce the duration of diarrhea and the volume of stool loss. **1. Why Azithromycin is the correct answer:** According to current WHO and CDC guidelines, **Azithromycin** is the drug of choice for treating cholera in pregnant women and children. It is a Macrolide (Category B) that is safe during pregnancy, effective against *Vibrio cholerae*, and has shown lower rates of treatment failure compared to other agents in regions with emerging resistance. **2. Why the other options are incorrect:** * **Tetracycline and Doxycycline:** These are traditionally the drugs of choice for non-pregnant adults. However, they are generally **avoided in pregnancy** (Category D) because they cross the placenta and can cause permanent tooth discoloration and enamel hypoplasia in the fetus, as well as affect fetal bone growth. * **Furazolidone:** While previously used in pregnancy, it is less effective than Azithromycin and is associated with higher rates of nausea and potential hemolytic anemia in G6PD-deficient individuals. It is no longer considered first-line. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (General Population):** Doxycycline (Single 300mg dose). * **Drug of Choice (Pregnancy/Children):** Azithromycin (Single 1g dose for adults). * **Most Important Step:** Rehydration (ORS for mild/moderate; IV Ringer’s Lactate for severe dehydration) is more critical than antibiotics for survival. * **Cholera in Pregnancy:** Increases the risk of miscarriage, preterm labor, and stillbirth due to severe maternal dehydration and electrolyte imbalance.

Q: A patient presents with a history of recurrent early pregnancy loss. What investigations should be ordered?

Hemogram and blood grouping. In the evaluation of **Recurrent Pregnancy Loss (RPL)**—defined as two or more consecutive clinical pregnancy losses—the goal is to identify treatable systemic or anatomical causes. **Why "Hemogram and blood grouping" is the correct answer:** While not a direct "cause" of recurrent loss in the same way as APS or uterine anomalies, a **Hemogram and Blood Grouping** are fundamental baseline investigations in any pregnancy-related workup. 1. **Hemogram:** Identifies chronic maternal anemia or systemic illness that may complicate pregnancy. 2. **Blood Grouping:** Essential to identify **Rh-negative** status. Rh isoimmunization can lead to hydrops fetalis and late-term losses, though its role in "early" recurrent loss is limited. However, in the context of standard NEET-PG protocols, baseline maternal health assessment always precedes specialized serology. **Why the other options are incorrect:** * **B & D (Toxoplasma and Rubella):** These are part of the **TORCH** panel. It is a high-yield fact that TORCH infections cause *sporadic* pregnancy loss, not *recurrent* loss. Once a mother develops antibodies, she is generally immune, preventing subsequent losses from the same pathogen. * **A (VDRL):** While Syphilis can cause mid-trimester fetal loss or stillbirth, it is rarely a cause of recurrent early (first trimester) loss. **NEET-PG High-Yield Pearls for RPL:** * **Most common cause of sporadic loss:** Fetal chromosomal anomalies (Trisomies). * **Most common treatable cause of RPL:** Antiphospholipid Syndrome (APS). * **Standard RPL Workup includes:** Parental karyotyping, Lupus anticoagulant/Anticardiolipin antibodies, Pelvic Ultrasound (for septate uterus), and TSH/HbA1c. * **Progesterone:** Only indicated if there is proven luteal phase defect or bleeding in the current pregnancy.

Q: Which lung head ratio is associated with a good prognosis?

Greater than 1.4. **Explanation:** The **Lung-to-Head Ratio (LHR)** is a critical sonographic marker used primarily to predict the prognosis and severity of pulmonary hypoplasia in fetuses with **Congenital Diaphragmatic Hernia (CDH)**. It is calculated by measuring the area of the contralateral lung (the lung not compressed by herniated organs) at the level of the four-chamber view of the heart and dividing it by the fetal head circumference. **Why Option D is Correct:** The LHR serves as a proxy for remaining lung volume. A higher ratio indicates more lung tissue and better development. * **LHR > 1.4:** Associated with a **good prognosis**, with survival rates approaching 100%. These neonates typically have manageable pulmonary hypertension and require less aggressive ventilatory support. **Analysis of Incorrect Options:** * **Options A & B (LHR 1):** While better than 1.4. **High-Yield Clinical Pearls for NEET-PG:** * **Observed/Expected LHR (O/E LHR):** To account for gestational age, clinicians now often use the O/E LHR. An **O/E LHR < 25%** signifies severe CDH. * **Liver Position:** The presence of the liver in the thorax ("Liver-up") is the single most important additional predictor of a poor outcome in CDH. * **Timing:** LHR is most predictive when measured between **22 and 26 weeks** of gestation.

Question 1

The "lambda sign" or "twin peak sign" is seen in which type of twin pregnancy?

Accepted Answer

Dichorionic diamniotic

Answer

Diamniotic monochorionic

Answer

Monochorionic monoamniotic

Answer

None of the above

Question 2

Cord blood gas and pH analysis is done in the following circumstances, except?

Accepted Answer

Antepartum hemorrhage

Answer

Low 5-minute APGAR score

Answer

Maternal thyroid disease

Answer

Severe fetal growth restriction

Question 3

With regards to acute pyelonephritis in pregnancy, all of the following are true except:

Accepted Answer

Left kidney is involved in 50% of patients.

Answer

Most common isolate is E. coli.

Answer

More common in the later half of pregnancy.

Answer

Responds to aminoglycosides.

Question 4

A woman presents with right-sided lower abdominal pain and mild vaginal bleeding at 6 weeks of gestation. Her general condition is satisfactory, and a urine hCG test is positive. Transvaginal ultrasound reveals an adnexal mass measuring 30 mm in diameter without cardiac activity, and no intrauterine pregnancy is seen. What is the most appropriate management?

Accepted Answer

Intramuscular methotrexate

Answer

Laparoscopic salpingectomy

Answer

Laparoscopic salpingo-oophorectomy

Answer

Laparoscopic salpingotomy

Question 5

In gestational hypertension, hypertension should resolve by how many weeks in the postpartum period?

Accepted Answer

12 weeks

Answer

2 weeks

Answer

6 weeks

Answer

8 weeks

Question 6

A G2P1 patient on warfarin presents at 38 weeks in labor. What is the next step in management?

Accepted Answer

Stop warfarin and proceed with cesarean section.

Answer

Stop warfarin and proceed with vaginal delivery.

Answer

Replace warfarin with heparin and proceed with vaginal delivery.

Answer

Replace warfarin with heparin and proceed with cesarean section.

Question 7

What is the recommended treatment for cholera during pregnancy?

Accepted Answer

Azithromycin

Answer

Furazolidone

Answer

Tetracycline

Answer

Doxycycline

Question 8

A patient presents with a history of recurrent early pregnancy loss. What investigations should be ordered?

Accepted Answer

Hemogram and blood grouping

Answer

VDRL

Answer

Toxoplasma serology

Answer

Rubella screening

Question 9

Which lung head ratio is associated with a good prognosis?

Accepted Answer

Greater than 1.4

Answer

Less than 1

Answer

Less than 1.4

Answer

Greater than 1

Question 10

What is the most common route of transmission of HIV from mother to baby?

Accepted Answer

During vaginal delivery

Answer

During pregnancy (vertical transmission)

Answer

Through breast milk

Answer

Through constant touch and handling

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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