Maternal-Fetal Medicine Practice Questions

Q: Which type of hepatitis is prevalent in pregnancy?

Hepatitis E. **Explanation:** **Hepatitis E Virus (HEV)** is the correct answer because it is the most common cause of acute viral hepatitis during pregnancy in developing countries, including India. While other hepatitis viruses occur in pregnant women, Hepatitis E is uniquely "prevalent" in terms of its clinical significance and the severity of outbreaks linked to contaminated water. * **Why Hepatitis E is the correct answer:** HEV is a feco-oral RNA virus. In the general population, it is usually self-limiting. However, in pregnant women (especially during the 2nd and 3rd trimesters), it carries a disproportionately high morbidity and mortality rate (up to 20–25%). This is attributed to high viral loads, altered immune responses (Th2 shift), and a high incidence of Fulminant Hepatic Failure (FHF). * **Why other options are incorrect:** * **Hepatitis A:** Also feco-oral, but rarely causes fulminant failure or significant outbreaks specifically targeting the pregnant population. * **Hepatitis B:** While it is the most common cause of *chronic* hepatitis and carries a high risk of vertical transmission, it does not typically cause the acute, epidemic-style prevalence or high maternal mortality associated with HEV in endemic zones. * **Hepatitis C:** Primarily transmitted parenterally; it rarely causes acute hepatitis during pregnancy and is not considered "prevalent" in the context of pregnancy-specific complications. **High-Yield Clinical Pearls for NEET-PG:** 1. **Mortality:** HEV has the highest maternal mortality rate among all viral hepatitides (20%). 2. **Transmission:** Vertical transmission of HEV is high (up to 100%), often leading to neonatal hypoglycemia and hypothermia. 3. **Diagnosis:** Detection of IgM anti-HEV is the gold standard for acute infection. 4. **Complications:** HEV in pregnancy is strongly associated with Disseminated Intravascular Coagulation (DIC) and Postpartum Hemorrhage (PPH).

Q: A patient with heart disease delivers. What should be given postpartum?

Furosemide. **Explanation:** The immediate postpartum period is the most critical time for a patient with heart disease. Following the delivery of the placenta, there is a massive "autotransfusion" of approximately 500–800 mL of blood from the uteroplacental circulation back into the systemic circulation. Additionally, the relief of inferior vena cava compression by the gravid uterus further increases venous return. **Why Furosemide is the Correct Answer:** This sudden increase in preload (volume overload) can lead to acute heart failure and pulmonary edema in a compromised heart. **Furosemide (Lasix)**, a potent loop diuretic, is administered to rapidly decrease this intravascular volume and prevent cardiac decompensation. **Analysis of Incorrect Options:** * **Methergine (Methylergonovine):** This is strictly **contraindicated** in cardiac patients. It causes peripheral vasoconstriction and can lead to sudden hypertension, coronary artery vasospasm, and acute heart failure. * **IVF fluids (1000 ml):** Rapid fluid administration is dangerous as it exacerbates the volume overload already occurring due to autotransfusion, increasing the risk of pulmonary edema. * **ACE Inhibitors:** While used in chronic heart failure management, they are not the immediate priority in the acute postpartum transition to prevent volume overload. **Clinical Pearls for NEET-PG:** * **Most dangerous time:** The first **24–48 hours postpartum** is the period of highest risk for cardiac failure. * **Uterotonic of choice:** **Oxytocin** (in dilute infusion) is the safest uterotonic for cardiac patients. Avoid bolus doses as they cause hypotension. * **Antibiotic Prophylaxis:** No longer routinely recommended for most cardiac lesions during delivery unless there is an active infection (as per recent AHA/ACOG guidelines), except for high-risk conditions like prosthetic valves.

Q: Abruptio placentae can be classified on the basis of which of the following?

Clinical findings. Abruptio placentae is primarily a **clinical diagnosis**. The most widely accepted classification system used in clinical practice is the **Sher’s Classification**, which categorizes the severity of placental abruption based on **clinical findings** such as vaginal bleeding, uterine tenderness, fetal distress, and maternal hemodynamic stability. ### Why "Clinical Findings" is Correct: The management of abruption depends on the degree of clinical compromise. Sher’s Classification grades abruption as: * **Grade 0:** Asymptomatic (diagnosed retrospectively by finding a retroplacental clot). * **Grade 1:** Mild (slight bleeding, no fetal distress). * **Grade 2:** Moderate (tense/tender uterus, fetal distress present). * **Grade 3:** Severe (maternal shock, fetal death, often associated with coagulopathy). ### Why Other Options are Incorrect: * **A. Anatomic locations:** This refers to the classification of *Placenta Previa* (e.g., Type I-IV), not abruption. * **B. Pathological features:** While coagulopathy (DIC) is a complication of Grade 3 abruption, it is a consequence rather than the primary basis for classification. * **D. Investigations (Ultrasound):** Ultrasound has low sensitivity (~25-50%) for detecting abruption. A negative ultrasound does **not** rule out abruption; therefore, it is not used as the basis for classification. ### High-Yield Clinical Pearls: * **Classic Triad:** Painful vaginal bleeding, uterine tenderness/hypertonicity, and fetal distress. * **Couvelaire Uterus:** A pathological finding where blood extravasates into the myometrium (port-wine appearance); it is not a reason for hysterectomy unless the uterus is atonic. * **Most common cause of DIC in pregnancy:** Abruptio placentae. * **Risk Factor:** Hypertension (most common), trauma, and cocaine use.

Q: What is the most common explanation for fetal tachycardia?

Maternal fever from amnionitis. **Explanation:** Fetal tachycardia is defined as a baseline fetal heart rate (FHR) greater than **160 beats per minute (bpm)** for at least 10 minutes. **Why Option B is Correct:** The most common cause of fetal tachycardia is **maternal fever**, often resulting from **chorioamnionitis (amnionitis)**. As maternal body temperature rises, the heat is transferred to the fetus. This increases the fetal metabolic rate and oxygen demand, leading to a compensatory increase in heart rate. In the context of labor, a rising FHR baseline is frequently the earliest clinical sign of intrauterine infection, often appearing before maternal pyrexia is fully manifest. **Analysis of Incorrect Options:** * **Option A:** While sympathomimetic drugs (e.g., Terbutaline, Ritodrine) cause tachycardia, and parasympatholytic drugs (e.g., Atropine) can increase FHR by blocking vagal tone, these are pharmacological interventions and not the most common clinical explanation encountered in labor wards. * **Option C & D:** Fetal cardiac defects and arrhythmias (like supraventricular tachycardia) are significant causes of persistent, extreme tachycardia (>200 bpm), but they are statistically rare compared to maternal infectious processes. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Normal FHR is 110–160 bpm. * **Early Sign:** Fetal tachycardia is often the first sign of **fetal hypoxia** (due to sympathetic stimulation) before it progresses to bradycardia. * **Other Causes:** Maternal hyperthyroidism, fetal anemia, and fetal prematurity (due to an immature parasympathetic system). * **Management:** If tachycardia is due to amnionitis, management involves hydration, antipyretics, and broad-spectrum antibiotics.

Q: Which one of the following medical disorders leads to delayed fetal lung maturity?

Diabetes. **Explanation:** The correct answer is **Diabetes**. Fetal lung maturity is primarily determined by the production of pulmonary surfactant (phospholipids like lecithin). In pregnancies complicated by maternal diabetes, maternal hyperglycemia leads to **fetal hyperinsulinemia**. High levels of fetal insulin act as a potent antagonist to the action of cortisol on the type II pneumocytes. This inhibits the synthesis of surfactant proteins and phospholipids, specifically delaying the appearance of **Phosphatidylglycerol (PG)**. Consequently, infants of diabetic mothers are at a higher risk of Respiratory Distress Syndrome (RDS) even at relatively mature gestational ages. **Analysis of Incorrect Options:** * **Heart Disease:** Chronic maternal hypoxia or circulatory compromise (as seen in heart disease) acts as a form of chronic fetal stress. Stress triggers the premature release of endogenous fetal glucocorticoids, which actually **accelerates** lung maturity. * **Thalassemia Minor:** This is generally an asymptomatic carrier state and does not significantly alter the intrauterine environment or fetal hormonal milieu to delay lung maturation. * **Epilepsy:** While the medications used (anti-epileptics) may have teratogenic risks, the disorder itself does not interfere with the biochemical pathways of surfactant production. **High-Yield Clinical Pearls for NEET-PG:** * **Accelerated Lung Maturity:** Seen in conditions causing **chronic placental insufficiency** or fetal stress (e.g., Preeclampsia, Chronic Hypertension, IUGR, Premature Rupture of Membranes, and Maternal Smoking). * **Delayed Lung Maturity:** Primarily associated with **Diabetes Mellitus** and **Rh Isoimmunization**. * **Gold Standard:** The presence of **Phosphatidylglycerol (PG)** in amniotic fluid is the most reliable indicator of lung maturity in diabetic pregnancies, as the L/S ratio can sometimes be falsely reassuring.

Q: Maternal serum alpha-fetoprotein concentration is elevated in all of the following conditions except:

Fetal Down's syndrome. **Explanation:** Maternal Serum Alpha-Fetoprotein (MSAFP) is a glycoprotein produced initially by the yolk sac and later by the fetal liver. It serves as a crucial biomarker in prenatal screening and oncology. **Why Fetal Down’s Syndrome is the Correct Answer:** In pregnancies affected by **Down’s Syndrome (Trisomy 21)**, the MSAFP levels are characteristically **decreased** (usually <0.5 MoM), not elevated. This is often accompanied by low unconjugated estriol (uE3) and elevated levels of Beta-hCG and Inhibin-A (the "Quadruple Test" pattern). The exact mechanism for decreased AFP in Down's syndrome is thought to be related to reduced fetal liver synthesis or delayed maturity of the liver. **Why the other options are incorrect:** * **Hepatoma (Hepatocellular Carcinoma) & Hepatoblastoma:** AFP is a classic tumor marker for primary liver malignancies. It is re-expressed by malignant hepatocytes, leading to significantly elevated serum levels. * **Endodermal Sinus Tumor (Yolk Sac Tumor):** This is a highly malignant germ cell tumor. Since the yolk sac is the primary embryological producer of AFP, these tumors secrete high amounts of AFP, making it a specific marker for diagnosis and monitoring recurrence. **High-Yield Clinical Pearls for NEET-PG:** * **Causes of Elevated MSAFP:** Neural tube defects (Anencephaly, Spina bifida), abdominal wall defects (Omphalocele, Gastroschisis), multiple gestations, and fetal demise. * **Most Common Cause of Elevated MSAFP:** Underestimation of gestational age (wrong dates). * **Causes of Low MSAFP:** Down’s syndrome, Trisomy 18 (Edwards syndrome), gestational trophoblastic disease, and maternal obesity. * **Rule of Thumb:** If the question mentions "Open" defects (NTD), think **High AFP**; if it mentions "Chromosomal" defects (Down's), think **Low AFP**.

Q: Which of the following is NOT associated with an increased risk of thromboembolism in pregnancy?

Blood group O. **Explanation:** Pregnancy is a naturally prothrombotic state due to an increase in clotting factors (I, VII, VIII, IX, X) and a decrease in protein S levels. Understanding the specific risk factors for Venous Thromboembolism (VTE) is crucial for NEET-PG. **Why Blood Group O is the Correct Answer:** Individuals with **Non-O blood groups (A, B, and AB)** have a significantly higher risk (approx. 2–4 times) of thromboembolism compared to those with Blood Group O. This is because Non-O individuals have higher plasma concentrations of **von Willebrand factor (vWF)** and **Factor VIII**, which are stabilized by the A and B antigens. Therefore, Blood Group O is actually "protective" against VTE rather than a risk factor. **Analysis of Other Options:** * **Anemia:** Severe anemia (especially sickle cell disease or acute blood loss requiring transfusion) is associated with an increased risk of VTE due to hyperkinetic circulation and potential endothelial injury. * **Rising Parity:** The risk of VTE increases with parity. Women who are **multiparous (Parity ≥3)** are at a higher risk compared to primigravida women. * **Antithrombin (AT) Deficiency:** This is the **most thrombophilic** of the hereditary thrombophilias. While Factor V Leiden is the most common, AT deficiency carries the highest absolute risk of a thromboembolic event during pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common VTE in pregnancy:** Deep Vein Thrombosis (DVT), usually occurring in the **left leg** (80%) due to compression of the left common iliac vein by the right axial artery (May-Thurner phenomenon). * **Highest risk period:** The **postpartum period** (especially the first 6 weeks) carries a higher daily risk of VTE than pregnancy itself. * **Gold Standard Diagnosis:** Compression Duplex Ultrasound for DVT; CT Pulmonary Angiography (CTPA) or V/Q scan for Pulmonary Embolism.

Question 1

Which type of hepatitis is prevalent in pregnancy?

Accepted Answer

Hepatitis E

Answer

Hepatitis A

Answer

Hepatitis B

Answer

Hepatitis C

Question 2

A patient with heart disease delivers. What should be given postpartum?

Accepted Answer

Furosemide

Answer

Ace inhibitors

Answer

Methergine

Answer

IVF fluids 1000 ml over the next 4 hours

Question 3

Abruptio placentae can be classified on the basis of which of the following?

Accepted Answer

Clinical findings

Answer

Anatomic locations of placenta

Answer

Pathological features including blood coagulation profile

Answer

Investigations using ultrasound

Question 4

Which type of hepatitis causes more morbidity in pregnant females?

Accepted Answer

Hepatitis E

Answer

Hepatitis A

Answer

Hepatitis B

Answer

Hepatitis C

Question 5

What is the most common explanation for fetal tachycardia?

Accepted Answer

Maternal fever from amnionitis

Answer

Maternal administration of parasympathetic or sympathomimetic drugs

Answer

Fetal cardiac defects

Answer

Cardiac arrhythmias

Question 6

Which one of the following medical disorders leads to delayed fetal lung maturity?

Accepted Answer

Diabetes

Answer

Heart disease

Answer

Thalassemia minor

Answer

Epilepsy

Question 7

Maternal serum alpha-fetoprotein concentration is elevated in all of the following conditions except:

Accepted Answer

Fetal Down's syndrome

Answer

Hepatoma

Answer

Hepatoblastoma

Answer

Endodermal sinus tumor

Question 8

Which of the following cannot be used to lower mother-to-child HIV transmission?

Accepted Answer

Omitting ergometrine

Answer

Elective Cesarean section

Answer

Antiretroviral therapy (ART)

Answer

Intrapartum nevirapine

Question 9

A pregnant patient in her first trimester presents with an amoebic liver abscess. What is the preferred treatment?

Accepted Answer

Aspiration

Answer

Metronidazole

Answer

Diloxanide furoate

Answer

Chloroquine

Question 10

Which of the following is NOT associated with an increased risk of thromboembolism in pregnancy?

Accepted Answer

Blood group O

Answer

Anemia

Answer

Increased risk with rising parity

Answer

Antithrombin deficiency

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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