Maternal-Fetal Medicine Practice Questions

Q: A 22-year-old pregnant woman presents with fever, and is treated with antibiotics. The fever is not controlled. Further investigation reveals septic pelvic thrombophlebitis. What is the recommended next course of treatment?

Continue antibiotics and start heparin. **Explanation:** **Septic Pelvic Thrombophlebitis (SPT)** is a rare but serious complication of postpartum or post-abortal infections (like endometritis). It occurs when pelvic infection leads to venous stasis and endothelial injury, causing a clot to form in the pelvic veins (most commonly the ovarian veins). **Why Option B is Correct:** The standard management for SPT is the **"Heparin Challenge."** SPT is typically a diagnosis of exclusion in a patient who has persistent fever despite 48–72 hours of broad-spectrum antibiotic therapy. The pathophysiology involves both infection and thrombosis; therefore, the treatment must address both. **Continuing broad-spectrum antibiotics** treats the underlying infection, while **starting intravenous Heparin** prevents further clot propagation. A rapid clinical response (defervescence within 48–72 hours of starting heparin) confirms the diagnosis. **Why Other Options are Incorrect:** * **Option A:** Stopping antibiotics is dangerous as the thrombus is "septic" (infected). Antibiotics are essential to clear the bacteremia. * **Option C:** Surgical embolectomy is reserved for massive pulmonary emboli and is not the primary treatment for pelvic venous thrombosis. * **Option D:** Hysterectomy is only indicated if there is extensive uterine necrosis or a non-responsive uterine abscess, not for isolated SPT. **Clinical Pearls for NEET-PG:** * **Enigma of SPT:** It is often called the "diagnosis of exclusion" for unexplained postpartum fever. * **Most Common Site:** The **Right Ovarian Vein** is involved in ~90% of cases (due to its length and lack of valves). * **Imaging:** Contrast-enhanced CT or MRI is the gold standard for visualizing the thrombus. * **Duration:** Heparin is usually continued for 7–10 days, though some protocols suggest longer if a large clot is visualized.

Q: During pregnancy, there is a reduced risk of which of the following conditions?

Relapse of multiple sclerosis. **Explanation:** The correct answer is **A. Relapse of multiple sclerosis.** **Why it is correct:** Pregnancy is a state of **physiologic immunosuppression** characterized by a shift from a Th1 (pro-inflammatory) to a **Th2 (anti-inflammatory) cytokine profile**. This shift occurs to prevent maternal rejection of the fetal semi-allograft. Since Multiple Sclerosis (MS) is a Th1-mediated autoimmune disease, the high levels of estrogen and progesterone during pregnancy (especially in the third trimester) lead to a significant **reduction in the rate of relapses**. However, it is important to note that the risk of relapse increases significantly in the first 3–6 months postpartum (the "rebound effect"). **Why the other options are incorrect:** * **Bell’s Palsy:** The incidence of Bell’s palsy is actually **increased** during pregnancy, particularly in the third trimester and the immediate postpartum period, likely due to perineural edema or viral reactivation. * **Meningioma:** These tumors often express **progesterone receptors**. The high progesterone levels in pregnancy can cause rapid enlargement or symptomatic worsening of a pre-existing meningioma. * **Chorea:** Known as **Chorea Gravidarum**, this is a rare movement disorder that can be triggered or exacerbated by pregnancy, often associated with a history of Rheumatic fever or SLE/Antiphospholipid syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Autoimmune diseases that improve in pregnancy:** Multiple Sclerosis, Rheumatoid Arthritis (RA), and Psoriasis (due to Th2 shift). * **Autoimmune diseases that may worsen/flare:** Systemic Lupus Erythematosus (SLE) – specifically renal flares. * **Neurological conditions that worsen:** Epilepsy (increased seizure frequency due to hemodilution of drugs), Myasthenia Gravis (variable, but risk of crisis in labor), and Carpal Tunnel Syndrome (due to edema).

Q: Which condition is associated with the highest maternal mortality?

Pulmonary Hypertension. **Explanation:** **Pulmonary Hypertension (PH)**, particularly when associated with Eisenmenger syndrome, carries the highest risk of maternal mortality, with rates historically reported between **30% and 50%**. The physiological changes of pregnancy—specifically the increase in cardiac output and the profound drop in systemic vascular resistance (SVR)—are poorly tolerated. In PH, the fixed pulmonary vascular resistance prevents the right ventricle from increasing output, leading to right heart failure. Furthermore, any drop in SVR can trigger a fatal right-to-left shunt, causing intractable cyanosis and sudden death, most commonly during labor or the early postpartum period. **Analysis of Incorrect Options:** * **Aortic Stenosis (A):** While severe symptomatic aortic stenosis is high-risk (WHO Class IV), the mortality rate (approx. 5-10%) is significantly lower than in Pulmonary Hypertension. * **Ventricular Septal Defect (B):** Small to moderate VSDs are generally well-tolerated in pregnancy (WHO Class II) unless they lead to Eisenmenger syndrome (which then falls under the PH category). * **Tetralogy of Fallot (C):** Repaired ToF carries a low risk. Even unrepaired patients have a lower mortality rate (approx. 2-10%) compared to the extreme risks of PH, provided they do not have severe pulmonary hypertension. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Classification:** Pulmonary Hypertension, Eisenmenger Syndrome, and severe Mitral Stenosis are categorized as **WHO Class IV** (pregnancy is contraindicated). * **Timing of Death:** In cardiac patients, the most dangerous period is the **immediate postpartum (third stage of labor)** due to the "autotransfusion" of blood from the contracting uterus, causing sudden volume overload. * **Management:** The gold standard advice for women with PH is **pre-conception counseling and permanent contraception**. If pregnancy occurs, early termination is medically recommended.

Q: During pregnancy, HIV transmission from mother to child occurs mostly during which period?

During labour and delivery. **Explanation:** The risk of Mother-to-Child Transmission (MTCT) of HIV occurs throughout pregnancy, but the timing is heavily skewed toward the peripartum period. **Why "During Labour and Delivery" is correct:** Approximately **60–75%** of vertical transmission occurs during labour and delivery. This is primarily due to **micro-transfusions** of maternal blood into the fetal circulation during uterine contractions and direct fetal contact with infected **cervicovaginal secretions** and blood in the birth canal. This "ascending infection" or direct exposure is the most significant window for transmission in untreated women. **Why the other options are incorrect:** * **First and Second Trimesters (A & B):** While the virus can cross the placenta early in pregnancy, the risk is relatively low (approx. 5–10%) because the placental barrier is more robust and there is less direct exchange of bodily fluids. * **Third Trimester (C):** Transmission risk increases as the placenta ages and thins, but it still accounts for only a minority of cases compared to the intense exposure during the intrapartum period. **High-Yield Clinical Pearls for NEET-PG:** * **Transmission Rates:** Without intervention, the risk of MTCT is 25–40%. With effective Antiretroviral Therapy (ART) and viral suppression, this risk drops to ** 1000 copies/ml** or unknown near term. * **Prophylaxis:** Nevirapine or Zidovudine is typically administered to the infant for 6–12 weeks post-delivery depending on the risk category.

Q: Which of the following placental anomalies is characterized by an abnormal attachment of the umbilical cord?

Battledore placenta (Marginal insertion). ### Explanation **Correct Answer: B. Battledore placenta (Marginal insertion)** The umbilical cord normally inserts into the center of the placental mass (eccentric or central insertion) [3]. In a **Battledore placenta**, the cord is attached at or within 2 cm of the **placental margin** [1]. The name is derived from its resemblance to a "battledore" (a historical badminton racket). While often clinically insignificant, it can be associated with preterm labor, fetal distress, or progress to a velamentous insertion. **Analysis of Incorrect Options:** * **A. Succenturiate lobe:** This is an anomaly of **placental morphology**, not cord attachment [2]. It involves one or more small accessory lobes of placental tissue situated at a distance from the main placental mass, connected by fetal vessels running through the membranes [2]. * **C. Horseshoe placenta:** This is a rare morphological variant where the placenta is shaped like a horseshoe, often associated with placenta previa. It does not specifically define an anomaly of cord attachment. **High-Yield Clinical Pearls for NEET-PG:** 1. **Velamentous Insertion:** A more severe attachment anomaly where the cord inserts into the **fetal membranes** (chorioamniotic membranes) rather than the placental mass itself [1]. The vessels run unprotected by Wharton’s jelly. 2. **Vasa Previa:** Often associated with velamentous insertion or succenturiate lobes; fetal vessels cross the internal os [1]. This is a surgical emergency due to the risk of fetal exsanguination upon rupture of membranes. 3. **Placenta Membranacea:** A rare condition where the entire chorionic sac is covered by functional villi, resulting in a thin, membranous placenta [2].

Q: The management of eclampsia includes all except?

Prolongation of pregnancy. **Explanation:** The definitive treatment for eclampsia is the **delivery of the fetus and placenta**, as the pathology originates from placental dysfunction. Once a patient develops eclampsia (generalized tonic-clonic seizures), it is considered an obstetric emergency. **1. Why "Prolongation of pregnancy" is the correct answer (The Exception):** In eclampsia, the goal is stabilization followed by prompt delivery, regardless of gestational age. **Prolongation of pregnancy is contraindicated** because it increases the risk of life-threatening maternal complications such as placental abruption, hepatic rupture, renal failure, and maternal death. Expectant management is only sometimes considered in *pre-eclampsia* far from term, but never in *eclampsia*. **2. Analysis of Incorrect Options:** * **Control of convulsions:** This is the immediate priority. **Magnesium Sulfate (MgSO₄)** is the drug of choice (Pritchard’s or Zuspan’s regimen) to arrest and prevent further seizures. * **Control of blood pressure:** Severe hypertension (≥160/110 mmHg) must be managed to prevent intracranial hemorrhage. Common agents include Labetalol, Hydralazine, or Nifedipine. * **Delivery of the fetus:** This is the only "cure." Once the mother is stabilized (airway secured, seizures controlled, BP lowered), delivery should be initiated. **Clinical Pearls for NEET-PG:** * **Drug of Choice:** MgSO₄ is superior to Diazepam or Phenytoin for eclampsia. * **Therapeutic Range of MgSO₄:** 4–7 mEq/L. * **Toxicity Check:** Always monitor patellar reflex (first to disappear), respiratory rate (>12/min), and urine output (>30ml/hr). * **Antidote:** Calcium Gluconate (10ml of 10% solution IV). * **Mode of Delivery:** Eclampsia is not an absolute indication for Cesarean section; vaginal delivery is preferred if the cervix is favorable and the maternal-fetal status is stable.

Q: What is the drug of choice for the treatment of malaria due to P. Vivax in a 25-year-old pregnant female?

Chloroquine. **Explanation:** The drug of choice for treating uncomplicated **Plasmodium vivax** malaria in pregnancy is **Chloroquine**. It is considered safe in all trimesters of pregnancy and effectively clears the erythrocytic stages of the parasite. **Why the other options are incorrect:** * **Primaquine (Option B):** While Primaquine is used for the radical cure (preventing relapse) of *P. vivax* in non-pregnant patients, it is **strictly contraindicated** in pregnancy. It can cross the placenta and cause life-threatening hemolysis in a fetus with unknown G6PD status. Radical cure is deferred until after delivery. * **Sulfadoxine-pyrimethamine (Option C):** This is primarily used for Intermittent Preventive Treatment (IPTp) or in combination for *P. falciparum*. It is not the first-line treatment for *P. vivax*. * **Quinine (Option D):** Quinine is typically reserved for severe malaria or chloroquine-resistant cases. While safe in pregnancy, it is not the first-line choice for uncomplicated *P. vivax* due to its side-effect profile (cinchonism, hypoglycemia). **High-Yield Clinical Pearls for NEET-PG:** * **Treatment Strategy:** In pregnancy, treat the acute attack of *P. vivax* with Chloroquine and initiate **weekly Chloroquine prophylaxis** (300 mg base) until delivery to prevent relapses. * **Radical Cure:** Primaquine can only be administered **postpartum**, provided the mother and infant (if breastfeeding) are screened for G6PD deficiency. * **P. falciparum in Pregnancy:** According to WHO/NVBDCP guidelines, Artemisinin-based Combination Therapy (**ACT**) is the drug of choice for *P. falciparum* in all trimesters (except Artesunate + Sulfadoxine-Pyrimethamine, which is avoided in the first trimester).

Question 1

A 22-year-old pregnant woman presents with fever, and is treated with antibiotics. The fever is not controlled. Further investigation reveals septic pelvic thrombophlebitis. What is the recommended next course of treatment?

Accepted Answer

Continue antibiotics and start heparin

Answer

Stop antibiotics and start heparin

Answer

Surgical embolectomy

Answer

Hysterectomy

Question 2

During pregnancy, there is a reduced risk of which of the following conditions?

Accepted Answer

Relapse of multiple sclerosis

Answer

Bell's palsy

Answer

Meningioma

Answer

Chorea

Question 3

Which condition is associated with the highest maternal mortality?

Accepted Answer

Pulmonary Hypertension

Answer

Aortic Stenosis

Answer

Ventricular Septal Defect

Answer

Tetralogy of Fallot

Question 4

A patient with Stage 1A2 cervical cancer is detected at 26 weeks of gestation. What is the next appropriate management step?

Accepted Answer

Classical Cesarean section followed by Wertheim's hysterectomy at 30-32 weeks gestation

Answer

Lower segment Cesarean section followed by extrafascial hysterectomy at 28 weeks gestation

Answer

Immediate concurrent chemoradiotherapy

Answer

Medical termination of pregnancy

Question 5

Two weeks later, the results of the patient's prenatal labs come back. Her blood type is A, with an anti-D antibody titer of 1:4. What is the most appropriate next step in the management of this patient?

Accepted Answer

Repeat titer in 4 weeks

Answer

Schedule an amniocentesis for amniotic fluid bilirubin at 16 weeks

Answer

Repeat titer in 28 weeks

Answer

Schedule PUBS to determine fetal hematocrit at 20 weeks

Question 6

During pregnancy, HIV transmission from mother to child occurs mostly during which period?

Accepted Answer

During labour and delivery

Answer

First trimester

Answer

Second trimester

Answer

Third trimester

Question 7

Which of the following placental anomalies is characterized by an abnormal attachment of the umbilical cord?

Accepted Answer

Battledore placenta (Marginal insertion)

Answer

Succenturiate lobe (Lobate placenta)

Answer

Horseshoe placenta

Answer

None of the above

Question 8

An elderly multiparous woman with intrauterine fetal death was admitted with strong labor pains. The patient suddenly goes into shock with cyanosis, respiratory disturbances, and pulmonary edema. What is the most likely clinical diagnosis?

Accepted Answer

Amniotic fluid embolism

Answer

Rupture of uterus

Answer

Congestive heart failure

Answer

Concealed accidental hemorrhage

Question 9

The management of eclampsia includes all except?

Accepted Answer

Prolongation of pregnancy

Answer

Control of convulsions

Answer

Control of blood pressure

Answer

Delivery of the fetus

Question 10

What is the drug of choice for the treatment of malaria due to P. Vivax in a 25-year-old pregnant female?

Accepted Answer

Chloroquine

Answer

Primaquine

Answer

Sulfadoxine-pyrimethamine

Answer

Quinine

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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