Maternal-Fetal Medicine Practice Questions

Q: Which of the following conditions typically improves during pregnancy?

Rheumatoid arthritis. **Explanation:** **Rheumatoid Arthritis (RA)** is the correct answer because approximately **75–90% of patients** experience significant clinical improvement or even complete remission during pregnancy. This improvement is primarily attributed to the **shift from a Th1 (pro-inflammatory) to a Th2 (anti-inflammatory) cytokine profile**, increased levels of circulating progesterone, and the presence of fetal-maternal HLA disparity, which induces a state of maternal immune tolerance. However, it is important to note that up to 90% of these patients will experience a **flare-up in the postpartum period**. **Analysis of Incorrect Options:** * **Multiple Sclerosis (MS):** While the relapse rate often decreases during the second and third trimesters, MS does not "typically improve" in the same predictable manner as RA. Furthermore, there is a significantly high risk of relapse in the first 3 months postpartum. * **Systemic Lupus Erythematosus (SLE):** Pregnancy is generally a period of **exacerbation** for SLE. It can trigger new flares (especially lupus nephritis) and is associated with increased risks of preeclampsia, fetal loss, and Neonatal Lupus (due to Anti-Ro/SSA and Anti-La/SSB antibodies). * **Myasthenia Gravis:** The course is highly unpredictable. One-third improve, one-third worsen, and one-third remain stable. It is not characterized by typical improvement. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice for RA in pregnancy:** Sulfasalazine and Hydroxychloroquine are considered safe. **Methotrexate and Leflunomide are strictly contraindicated** (teratogenic). * **Postpartum Flare:** RA is notorious for flaring up 6–12 weeks after delivery. * **SLE & Pregnancy:** Patients should ideally be in remission for at least 6 months before conceiving to ensure the best maternal and fetal outcomes.

Q: True about intrauterine fetal death (IUD)?

Overlapping of skull bones. **Explanation:** Intrauterine Fetal Death (IUFD) is characterized by specific radiological signs that occur due to the cessation of circulation and subsequent degenerative changes in the fetus. **1. Why Option C is Correct:** **Spalding’s Sign** refers to the **overlapping of fetal skull bones**. It occurs due to the liquefaction of the brain matter and loss of intracranial pressure following fetal death. This sign typically appears 4–7 days after death. It is a classic radiological marker for IUFD, provided the mother is not in labor (as molding during labor can also cause overlapping). **2. Analysis of Incorrect Options:** * **Option A (Gas bubbles in great vessels):** This is known as **Robert’s Sign**. While it is a sign of IUFD, it is caused by the liberation of gas (CO2) from blood decomposition. However, it is an early sign (appearing within 12 hours) and is less commonly tested or specific compared to Spalding's sign in clinical scenarios. * **Option B (Halo’s Sign):** This refers to the elevation of the scalp fat layer due to edema, creating a "halo" appearance. While associated with IUFD (Deuel’s halo sign), it is non-specific and can also be seen in cases of fetal hydrops or maternal diabetes. * **Option D (Decreased amniotic fluid):** While oligohydramnios may be associated with the cause of death (e.g., renal agenesis or placental insufficiency), it is not a diagnostic radiological sign of the death itself. **Clinical Pearls for NEET-PG:** * **Earliest Sign of IUFD:** Robert’s Sign (Gas in the heart/great vessels). * **Most Common Sign:** Spalding’s Sign. * **Confirmatory Test of Choice:** Real-time Ultrasound showing absence of fetal cardiac activity. * **Spalding’s Sign Mimic:** Can be false-positive in a live fetus during active labor due to molding or in cases of severe dehydration.

Q: As per WHO, anemia is considered to exist in pregnancy if the hemoglobin level is below what value?

11 gm%. **Explanation:** The correct answer is **11 gm%**. According to the **World Health Organization (WHO)**, anemia in pregnancy is defined as a hemoglobin (Hb) concentration of **< 11 g/dL** (or a hematocrit < 33%). This threshold is lower than that for non-pregnant women (12 g/dL) due to the physiological changes of pregnancy. During gestation, there is a disproportionate increase in plasma volume (approx. 50%) compared to red cell mass (approx. 20-30%), leading to **hemodilution**, often referred to as "physiological anemia of pregnancy." **Analysis of Options:** * **11 gm% (Correct):** The WHO standard for anemia throughout pregnancy. However, note that the CDC and some guidelines suggest < 10.5 g/dL specifically during the second trimester. * **12 gm% (Incorrect):** This is the WHO cutoff for anemia in **non-pregnant, non-lactating adult women**. * **13 gm% (Incorrect):** This is the WHO cutoff for anemia in **adult men**. * **14 gm% (Incorrect):** This represents a normal, healthy hemoglobin level and is never used as a diagnostic cutoff for anemia. **High-Yield Clinical Pearls for NEET-PG:** 1. **ICMR/Government of India Classification:** While WHO uses < 11 g/dL, the National Iron Plus Initiative (NIPI) in India classifies severity as: * **Mild:** 10 – 10.9 g/dL * **Moderate:** 7 – 9.9 g/dL * **Severe:** < 7 g/dL * **Very Severe:** < 4 g/dL 2. **Most Common Cause:** Iron deficiency anemia (IDA) is the most common cause of anemia in pregnancy worldwide. 3. **Prophylaxis:** Under the *Anemia Mukt Bharat* strategy, pregnant women should receive **60 mg elemental iron and 500 mcg folic acid** daily for 180 days, starting from the second trimester.

Q: A pregnant female at 16 weeks of gestation presents with bleeding. Ultrasound reveals a fibroid. What is the most appropriate management?

Conservative management. **Explanation:** The correct management for a fibroid diagnosed during pregnancy is **Conservative Management (Option A)**. **Why it is correct:** Most fibroids are asymptomatic during pregnancy and do not require intervention. Surgical removal of a fibroid (myomectomy) during pregnancy is strictly contraindicated due to the high risk of profuse hemorrhage from the increased pelvic vascularity and the significant risk of miscarriage or preterm labor. If a patient experiences pain (often due to **Red Degeneration**), the standard of care is bed rest, hydration, and analgesics (NSAIDs like Ibuprofen, though avoided near term). **Why other options are incorrect:** * **Laparoscopic myomectomy (Option B):** Myomectomy is generally deferred until 3–6 months postpartum. Surgery during pregnancy is only considered in extreme, rare cases of pedunculated fibroid torsion that fails to respond to conservative treatment. * **Curettage (Option C):** This is a procedure to remove the uterine lining or products of conception; it has no role in the management of a fibroid and would lead to pregnancy loss. * **Hysterectomy (Option D):** This is an invasive, definitive surgery that results in the loss of the fetus and future fertility. It is only a last resort for life-threatening postpartum hemorrhage. **NEET-PG High-Yield Pearls:** * **Most common change** in fibroid during pregnancy: No change in size (though 20-30% may increase). * **Most common complication:** Red Degeneration (Necrobiosis), typically occurring in the 2nd trimester. * **Red Degeneration Diagnosis:** Clinical (pain, fever, tenderness); MRI shows a characteristic peripheral rim of high signal intensity on T1-weighted images. * **Mode of delivery:** Fibroids are not an absolute indication for C-section unless they are large, lower-segment fibroids obstructing the birth canal (Previa fibroid).

Q: The clinical diagnosis of threatened abortion is presumed when a bloody vaginal discharge appears through a closed cervical os during which period of pregnancy?

First half of pregnancy. **Explanation:** **1. Why Option A is Correct:** The definition of **Threatened Abortion** is clinically specific: it refers to vaginal bleeding occurring before the **20th week of gestation** (the first half of pregnancy) in the presence of a **closed cervical os**. At this stage, the fetus is still viable, and the pregnancy may continue. The "first half of pregnancy" is the standard medical threshold because, after 20 weeks (or 24 weeks in some jurisdictions), the fetus reaches the age of viability, and any bleeding or complications are categorized under different clinical entities like antepartum hemorrhage or preterm labor. **2. Why Other Options are Incorrect:** * **Option B & C:** Bleeding in the second half of pregnancy or the third trimester is classified as **Antepartum Hemorrhage (APH)**. Common causes include Abruptio Placentae or Placenta Previa. The term "abortion" is never used for complications occurring after the point of viability. * **Option D:** Since the terminology changes based on gestational age, "All" is incorrect. **3. NEET-PG High-Yield Pearls:** * **Cervical Os Status:** In Threatened Abortion, the internal os is always **closed**. If the os is open with bleeding, it is classified as an Inevitable or Incomplete abortion. * **Prognosis:** Approximately 50% of threatened abortions proceed to actual miscarriage. However, if fetal heart activity is documented on ultrasound, the chance of pregnancy continuation is >90%. * **Management:** The mainstay of treatment is **expectant management** and bed rest (though evidence for bed rest is limited). Progesterone supplementation is often used if a corpus luteum deficiency is suspected. * **Differential Diagnosis:** Always rule out ectopic pregnancy and molar pregnancy in any patient presenting with first-trimester bleeding.

Q: What is the risk of subsequent preterm delivery in a woman with a history of two previous preterm deliveries before 34 weeks of gestation?

40%. The risk of recurrent preterm birth (PTB) is one of the most significant predictors in obstetric history. The risk increases progressively with each subsequent preterm delivery. ### **Explanation of the Correct Answer** The risk of preterm delivery in a primigravida is approximately **10-15%**. However, once a woman has a history of PTB, the risk for the next pregnancy rises sharply: * **After 1 previous PTB:** The risk increases to approximately **15–25%**. * **After 2 previous PTBs:** The risk escalates significantly to about **40%**. * **After 3 previous PTBs:** The risk can exceed **60%**. The risk is also inversely proportional to the gestational age of the previous delivery; the earlier the previous PTB (especially before 34 weeks), the higher the risk of recurrence. ### **Analysis of Incorrect Options** * **A (15%):** This is the baseline risk for a woman with no prior history or the risk after one prior term delivery followed by one preterm delivery. * **B (20%):** This represents the approximate risk after only **one** previous preterm delivery. * **C (30%):** While higher than the baseline, this underestimates the cumulative risk associated with two consecutive early preterm births. ### **High-Yield Clinical Pearls for NEET-PG** 1. **Best Predictor:** A history of previous spontaneous PTB is the strongest risk factor for future PTB. 2. **Prophylaxis:** For women with a history of spontaneous PTB, **Progesterone** (17-OHP caproate or vaginal progesterone) is indicated starting from 16–24 weeks to reduce recurrence. 3. **Cervical Length:** In women with a history of PTB, a cervical length of **<25 mm** on TVS (between 16–24 weeks) is a strong predictor and may warrant **Cervical Cerclage**. 4. **Inter-pregnancy Interval:** An interval of less than **6 months** significantly increases the risk of subsequent PTB.

Q: Which of the following types of ovarian tumors most frequently causes complications during pregnancy?

Teratoma. **Explanation:** **1. Why Teratoma is the Correct Answer:** Mature cystic teratoma (Dermoid cyst) is the most common germ cell tumor and the most frequent ovarian neoplasm encountered during pregnancy. Its high complication rate is primarily due to its **propensity for torsion**. Because teratomas contain heavy sebaceous material and hair, they are often buoyant and have a long pedicle, making them prone to twisting. Torsion most commonly occurs during the **first trimester** (as the uterus rises) or the **puerperium** (as the uterus rapidly involutes, creating space in the pelvis). Rupture, though rare, can lead to chemical peritonitis. **2. Analysis of Incorrect Options:** * **B. Mucinous cystadenoma:** While these can occur in pregnancy and grow to massive sizes, they are less common than teratomas and have a lower incidence of acute torsion. * **C. Serous cystadenocarcinoma:** Malignant ovarian tumors are rare during pregnancy (only 2–5% of cases). Serous cystadenocarcinoma is more common in postmenopausal women. * **D. Brenner’s tumor:** These are rare fibroepithelial tumors, usually asymptomatic and small, and are typically incidental findings in older women rather than pregnancy-related complications. **3. NEET-PG High-Yield Clinical Pearls:** * **Most common ovarian tumor in pregnancy:** Mature Cystic Teratoma. * **Most common complication:** Torsion (followed by rupture and labor obstruction). * **Management:** If an ovarian mass is >5–6 cm or symptomatic, the ideal time for surgical intervention (Laparoscopy/Laparotomy) is the **second trimester (16–20 weeks)** to minimize miscarriage risk and avoid the technical difficulty of a large third-trimester uterus. * **Emergency:** Acute torsion at any gestation requires immediate surgical intervention regardless of the trimester.

Q: A 10 cm ovarian cyst is detected incidentally in an 8-week pregnant woman. What is the appropriate management?

Second trimester surgery. **Explanation:** The management of an adnexal mass in pregnancy depends on the size of the cyst, gestational age, and ultrasound characteristics. **Why Option C is Correct:** The **second trimester (ideally 14–18 weeks)** is the "surgical window" for elective procedures in pregnancy. By this time, organogenesis is complete (reducing teratogenic risk), and the placenta has taken over progesterone production from the corpus luteum (reducing miscarriage risk). A 10 cm cyst is unlikely to resolve spontaneously and carries a high risk of **torsion, rupture, or labor obstruction**. Surgery is indicated for asymptomatic cysts >6–10 cm that persist into the second trimester. **Why Other Options are Incorrect:** * **Option A:** Surgery in the first trimester is avoided unless there is an emergency (e.g., acute torsion) because it increases the risk of miscarriage and may inadvertently remove a corpus luteum necessary for pregnancy maintenance. * **Option B:** CT scans are generally contraindicated in pregnancy due to ionizing radiation. MRI or Doppler Ultrasound are the preferred imaging modalities for assessing malignancy. * **Option D:** Waiting until a Cesarean section increases the risk of complications (torsion or rupture) during the second and third trimesters. Furthermore, most women with ovarian cysts can still have a vaginal delivery. **High-Yield Clinical Pearls for NEET-PG:** * **Most common ovarian mass in pregnancy:** Corpus luteum cyst (usually resolves by 14 weeks). * **Most common pathological cyst in pregnancy:** Mature cystic teratoma (Dermoid). * **Indications for surgery:** Size >10 cm, solid components/septations (suggesting malignancy), or acute complications (torsion). * **Laparoscopy** is safe in pregnancy but requires careful trocar placement and low intra-abdominal pressure (8–12 mmHg).

Question 1

Which of the following conditions typically improves during pregnancy?

Accepted Answer

Rheumatoid arthritis

Answer

Multiple sclerosis

Answer

Systemic lupus erythematosus (SLE)

Answer

Myasthenia gravis

Question 2

True about intrauterine fetal death (IUD)?

Accepted Answer

Overlapping of skull bones

Answer

Gas bubbles in great vessels

Answer

Halo's sign +ve

Answer

Decreased amniotic fluid volume

Question 3

As per WHO, anemia is considered to exist in pregnancy if the hemoglobin level is below what value?

Accepted Answer

11 gm%

Answer

14 gm%

Answer

12 gm%

Answer

13 gm%

Question 4

A pregnant female at 16 weeks of gestation presents with bleeding. Ultrasound reveals a fibroid. What is the most appropriate management?

Accepted Answer

Conservative management

Answer

Laparoscopic myomectomy

Answer

Curettage

Answer

Hysterectomy

Question 5

The clinical diagnosis of threatened abortion is presumed when a bloody vaginal discharge appears through a closed cervical os during which period of pregnancy?

Accepted Answer

First half of pregnancy

Answer

Second half of pregnancy

Answer

Third trimester

Answer

All

Question 6

Which of the following statements regarding the transmission of HIV to an infant from an infected mother are true?

Accepted Answer

Start zidovudine during labor, 25% chance of vertical transmission, and avoid breastfeeding.

Answer

Start zidovudine during labor, 25% chance of vertical transmission, and vaccinate infant with OPV and MMR.

Answer

Start zidovudine during labor, avoid breastfeeding, and Cesarean section causes less transmission.

Answer

Start zidovudine during labor, vaccinate infant with OPV and MMR, and Cesarean section causes less transmission.

Question 7

What is the risk of subsequent preterm delivery in a woman with a history of two previous preterm deliveries before 34 weeks of gestation?

Accepted Answer

40%

Answer

15%

Answer

20%

Answer

30%

Question 8

A 19-year-old primigravida presents with vaginal bleeding, an enlarged-for-dates uterus, and absent fetal heart sounds. Ultrasound findings are consistent with this presentation. What is the most likely diagnosis?

Accepted Answer

Hydatidiform mole

Answer

Sarcoma botryoides

Answer

Tuberculous endometritis

Answer

Adenocarcinoma of the uterus

Question 9

Which of the following types of ovarian tumors most frequently causes complications during pregnancy?

Accepted Answer

Teratoma

Answer

Mucinous cystadenoma

Answer

Serous cystadenocarcinoma

Answer

Brenner's tumor

Question 10

A 10 cm ovarian cyst is detected incidentally in an 8-week pregnant woman. What is the appropriate management?

Accepted Answer

Second trimester surgery

Answer

Immediate removal by laparotomy

Answer

CT scan to rule out malignancy and secondaries

Answer

Remove at the time of cesarean section

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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