Maternal-Fetal Medicine Practice Questions

Q: Which of the following is NOT a complication of fibroid in pregnancy?

Malignant transformation. **Explanation:** The correct answer is **Malignant transformation**. While uterine fibroids (leiomyomas) are the most common benign tumors of the uterus, their transformation into leiomyosarcoma is extremely rare (incidence <0.3%). Crucially, there is no evidence that pregnancy increases this risk. In fact, most fibroids either remain stable or undergo "Red Degeneration" during pregnancy due to rapid growth and outstripping of blood supply, but they do not become malignant. **Why the other options are complications:** * **Abortion (C):** Fibroids, especially submucosal or large intramural ones, can distort the uterine cavity, interfere with implantation, or cause decidual irritation, leading to early pregnancy loss. * **Preterm labor (A):** Large fibroids act as space-occupying lesions, leading to uterine overdistension and increased uterine irritability, which triggers premature contractions. * **Postpartum hemorrhage (B):** Fibroids interfere with the effective contraction and retraction of the uterine myometrium after delivery (uterine atony), which is the most common cause of PPH in these patients. **High-Yield Clinical Pearls for NEET-PG:** * **Red Degeneration (Carneous Degeneration):** The most common complication of fibroid *during* pregnancy (usually 2nd trimester). It presents with acute abdominal pain, fever, and leukocytosis. Management is strictly **conservative** (analgesics and bed rest). * **Most common effect of pregnancy on fibroid:** Most fibroids (approx. 60-70%) show no significant change in size; however, if they do change, they usually enlarge during the first trimester. * **Myomectomy during pregnancy:** Generally contraindicated due to the risk of uncontrollable hemorrhage, except in cases of a pedunculated fibroid undergoing torsion.

Q: Fetal middle cerebral artery Doppler is most useful in the evaluation of which of the following conditions?

Fetal anemia. **Explanation:** The **Middle Cerebral Artery (MCA) Doppler** is the gold standard non-invasive screening tool for **fetal anemia** (most commonly due to Rh isoimmunization or Parvovirus B19 infection). **Why Fetal Anemia is Correct:** In anemic fetuses, the blood viscosity decreases and the cardiac output increases to maintain oxygen delivery. This results in an increased velocity of blood flow. The specific parameter measured is the **Peak Systolic Velocity (PSV)**. An MCA-PSV value **>1.5 Multiples of Median (MoM)** for the corresponding gestational age indicates a high risk of moderate-to-severe fetal anemia, necessitating further intervention like cordocentesis or intrauterine transfusion. **Analysis of Incorrect Options:** * **A & B (IUGR and Preeclampsia):** While Doppler is used here, the **Umbilical Artery (UA)** and **Uterine Artery** are the primary vessels evaluated. In IUGR, MCA Doppler is used to look for the "Brain Sparing Effect" (vasodilation leading to *decreased* resistance), but it is not the *most* specific use compared to its role in anemia. * **D (Fetal Metabolic Disorders):** These are typically diagnosed via genetic testing or biochemical analysis of amniotic fluid, not by Doppler flow studies. **High-Yield Clinical Pearls for NEET-PG:** * **Brain Sparing Effect:** In hypoxia (IUGR), blood is shunted to the brain, leading to **decreased Pulsatility Index (PI)** in the MCA. * **Cerebroplacental Ratio (CPR):** Calculated as MCA-PI / UA-PI. A low CPR (<1.0) is a sensitive marker for adverse perinatal outcomes in IUGR. * **Ductus Venosus:** The best vessel to assess for immediate fetal cardiac failure or impending demise (look for reversed 'a' wave).

Q: Which umbilical artery Doppler finding most significantly predicts intrauterine fetal death?

Reversal of diastolic flow. **Explanation:** Umbilical artery (UA) Doppler is a vital tool for monitoring fetuses with Fetal Growth Restriction (FGR). It reflects placental vascular resistance; as resistance increases, the diastolic flow progressively decreases. **1. Why "Reversal of Diastolic Flow" is correct:** Reversed End-Diastolic Velocity (REVDV) represents the most advanced stage of placental insufficiency. It occurs when more than 70% of the placental vascular bed is obliterated. During diastole, the high resistance in the placenta causes blood to actually flow backward toward the fetal heart. This finding is a critical "pre-terminal" sign, indicating extreme fetal hypoxia and acidosis, and is the strongest predictor of impending intrauterine fetal death (IUFD). **2. Analysis of Incorrect Options:** * **Absent Diastolic Flow (AEDV):** This occurs when approximately 60-70% of the placental bed is damaged. While a serious sign of fetal compromise, it precedes reversal and carries a lower immediate risk of IUFD compared to REVDV. * **Absent Systolic Flow:** This is not a recognized clinical stage in UA Doppler. If systolic flow were absent, it would imply a complete lack of cardiac output, which is incompatible with life. * **Presence of Diastolic Notch:** This is a characteristic finding in **Uterine Artery** Doppler (maternal side), indicating a failure of trophoblastic invasion and a risk for pre-eclampsia/FGR, but it does not predict immediate fetal death. **Clinical Pearls for NEET-PG:** * **Sequence of Deterioration:** Reduced Diastolic Flow → Absent Diastolic Flow (AEDV) → Reversed Diastolic Flow (REVDV). * **Management:** REVDV in a viable fetus (>32 weeks) is usually an indication for immediate delivery via Cesarean section. * **Ductus Venosus:** If UA Doppler shows REVDV, the next step is often checking the Ductus Venosus; reversal of the 'a' wave here is the final sign before fetal demise.

Q: A primigravida at 36 weeks of gestation presents with generalized pruritus, which is more intense on the soles. What is the most likely diagnosis?

Intrahepatic cholestasis of pregnancy. ### Explanation **1. Why Intrahepatic Cholestasis of Pregnancy (ICP) is Correct:** ICP is the most common pregnancy-specific liver disorder, typically occurring in the **third trimester**. It is characterized by **generalized pruritus** that classically starts or is most intense on the **palms and soles**, worsening at night. Pathophysiologically, it involves the failure of bile acid excretion, leading to elevated serum bile acids. Crucially, there is **no primary skin rash** (only secondary excoriations) and no jaundice in most cases. **2. Why the Other Options are Incorrect:** * **HELLP Syndrome:** Presents with Hemolysis, Elevated Liver enzymes, and Low Platelets. It is usually associated with preeclampsia (hypertension/proteinuria) and presents with epigastric pain, not isolated pruritus. * **Viral Hepatitis:** The most common cause of jaundice in pregnancy. It presents with prodromal symptoms like fever, nausea, vomiting, and significantly elevated transaminases, rather than isolated pruritus of the soles. * **Acute Fatty Liver of Pregnancy (AFLP):** A medical emergency occurring in the late third trimester. It presents with acute liver failure symptoms (hypoglycemia, jaundice, encephalopathy, and DIC). Pruritus is not a hallmark feature. **3. High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Elevated **Serum Bile Acids** (>10 µmol/L) is the most sensitive biochemical marker. * **Treatment:** **Ursodeoxycholic acid (UDCA)** is the drug of choice (improves pruritus and liver functions). * **Fetal Risk:** ICP is associated with increased risks of **meconium-stained amniotic fluid**, preterm labor, and **sudden intrauterine fetal death (IUFD)**. * **Management:** Delivery is usually recommended by **37 weeks** to prevent late-term fetal complications.

Q: Which of the following is the most common predisposing factor for placenta accreta?

Placenta previa. **Explanation:** **Placenta accreta** occurs due to a defect in the **decidua basalis**, specifically the absence of the Nitabuch layer, which allows chorionic villi to invade the myometrium directly. **Why Placenta Previa is the correct answer:** While several factors can cause decidual deficiency, **placenta previa** is statistically the most significant predisposing factor. When the placenta implants in the lower uterine segment, the decidua is naturally thinner and less vascularized than in the upper segment, facilitating abnormal adherence. The risk is synergistically increased if a patient has both placenta previa and a previous uterine scar. **Analysis of Incorrect Options:** * **Previous Cesarean Section (C):** This is a major risk factor, but it is the *combination* of a previous C-section with a current placenta previa that poses the highest risk. In isolation, placenta previa remains the most common clinical association found in accreta cases. * **Recent Curettage (B) & Myomectomy (A):** These involve uterine trauma that can lead to localized decidual defects. While they are recognized risk factors, they are statistically less common causes of placenta accreta compared to the implantation site issues seen in placenta previa. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Correlation:** If a patient has placenta previa and 1 previous C-section, the risk of accreta is ~11%. With 4 or more C-sections and previa, the risk jumps to **>60%**. * **Management:** The gold standard management for confirmed placenta accreta is a **planned cesarean hysterectomy**. * **Diagnosis:** Antenatal diagnosis is primarily via **Color Doppler Ultrasound** (showing loss of retroplacental clear zone and bladder wall irregularities).

Q: Macrosomia is seen in all of the following conditions EXCEPT:

Hydrocephalus. **Explanation:** **Macrosomia** is defined as a birth weight >4000g or >4500g (regardless of gestational age) or a birth weight above the 90th percentile for gestational age. It refers to a generalized increase in body size and fat deposition. **Why Hydrocephalus is the Correct Answer:** Hydrocephalus involves an abnormal accumulation of cerebrospinal fluid (CSF) within the brain's ventricles, leading to an **enlarged head circumference (macrocephaly)**. While the head is disproportionately large, the overall body weight does not necessarily exceed the 90th percentile. Therefore, hydrocephalus causes macrocephaly, not true macrosomia. **Analysis of Incorrect Options:** * **Diabetes Mellitus:** Maternal hyperglycemia leads to fetal hyperglycemia, which stimulates the fetal pancreas to produce excess **insulin**. Since insulin is a potent anabolic hormone (fetal growth factor), it causes excessive deposition of fat and glycogen, leading to macrosomia. * **Obesity:** Maternal obesity is one of the most common risk factors for macrosomia due to increased nutrient availability and insulin resistance. * **Post-maturity:** Pregnancies exceeding 42 weeks allow for a longer period of intrauterine growth. If the placenta remains functional, the fetus continues to gain weight, often resulting in macrosomia. **High-Yield Clinical Pearls for NEET-PG:** * **Beckwith-Wiedemann Syndrome:** A classic high-yield cause of macrosomia characterized by the triad of macrosomia, macroglossia, and omphalocele. * **Infant of Diabetic Mother (IDM):** These infants are "large and plump" but have small brains (except for the heart and adrenals, most organs are enlarged). * **Complications:** Macrosomia increases the risk of shoulder dystocia, Erb’s palsy, and neonatal hypoglycemia.

Q: On Doppler studies, which finding is an ominous sign for an Intrauterine Growth Restriction (IUGR) fetus?

Reverse diastolic flow. **Explanation:** In the management of Intrauterine Growth Restriction (IUGR), Umbilical Artery (UA) Doppler is the gold standard for monitoring fetal well-being and placental resistance. **1. Why Reverse Diastolic Flow (REDF) is the correct answer:** As placental insufficiency worsens, the resistance in the umbilical artery increases. Initially, this leads to a decrease in end-diastolic flow. When more than 70% of the placental vascular bed is obliterated, the flow during diastole stops (Absent End Diastolic Velocity - AEDV). The most critical and **ominous** stage is **Reversed End Diastolic Velocity (REDF)**, where blood actually flows back toward the fetus during diastole. This indicates imminent fetal compromise, severe hypoxia, and acidosis, usually necessitating immediate delivery. **2. Why other options are incorrect:** * **A. Increased S/D ratio:** This is an early sign of increased placental resistance. While abnormal, it is not "ominous" as it precedes AEDV and REDV. * **B. Diastolic notch:** A notch in the **Uterine Artery** waveform (not Umbilical) at 20–24 weeks is a screening marker for the *risk* of developing pre-eclampsia or IUGR, but it is not a sign of acute fetal jeopardy. **Clinical Pearls for NEET-PG:** * **Sequence of Doppler changes:** Increased S/D ratio → AEDV → REDV → Abnormal Ductus Venosus (DV) flow (a-wave reversal). * **Ductus Venosus:** Reversal of the 'a-wave' in the DV is the most specific predictor of fetal death within 48–72 hours. * **Brain Sparing Effect:** Identified by a *decrease* in the Pulsatility Index (PI) of the Middle Cerebral Artery (MCA), indicating blood shunting to the fetal brain.

Question 1

Which of the following is NOT a complication of fibroid in pregnancy?

Accepted Answer

Malignant transformation

Answer

Preterm labor

Answer

Postpartum hemorrhage

Answer

Abortion

Question 2

At which gestational age is the Shirodkar stitch typically performed during pregnancy?

Accepted Answer

14-16 weeks

Answer

6 weeks

Answer

12 weeks

Answer

20-24 weeks

Question 3

Fetal middle cerebral artery Doppler is most useful in the evaluation of which of the following conditions?

Accepted Answer

Fetal anemia

Answer

Intrauterine growth restriction

Answer

Preeclampsia

Answer

Fetal metabolic disorders

Question 4

Which umbilical artery Doppler finding most significantly predicts intrauterine fetal death?

Accepted Answer

Reversal of diastolic flow

Answer

Absent diastolic flow

Answer

Absent systolic flow

Answer

Presence of diastolic notch

Question 5

A 20-year-old primigravida at 30 weeks of gestation has polyhydramnios. What advice should be given?

Accepted Answer

Oral indomethacin

Answer

Bed rest

Answer

Artificial rupture of membranes

Answer

Restriction of oral fluids

Question 6

A primigravida at 36 weeks of gestation presents with generalized pruritus, which is more intense on the soles. What is the most likely diagnosis?

Accepted Answer

Intrahepatic cholestasis of pregnancy

Answer

HELLP syndrome

Answer

Viral hepatitis

Answer

Acute fatty liver of pregnancy

Question 7

Which of the following is the most common predisposing factor for placenta accreta?

Accepted Answer

Placenta previa

Answer

Myomectomy

Answer

Recent curettage

Answer

Previous cesarean section

Question 8

For maturity estimation, amniotic fluid cells are stained with which of the following?

Accepted Answer

Nile blue sulphate

Answer

Methylene blue

Answer

Mucicarmine

Answer

Sudan black

Question 9

Macrosomia is seen in all of the following conditions EXCEPT:

Accepted Answer

Hydrocephalus

Answer

Diabetes mellitus

Answer

Obesity

Answer

Post maturity

Question 10

On Doppler studies, which finding is an ominous sign for an Intrauterine Growth Restriction (IUGR) fetus?

Accepted Answer

Reverse diastolic flow

Answer

Increased S/D ratio

Answer

Diastolic notch

Answer

All of the above

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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