Maternal-Fetal Medicine Practice Questions

Q: What is the safe drug for antihypertensive crisis during pregnancy?

Hydralazine. **Explanation:** The management of hypertension in pregnancy is categorized into chronic management and the management of an **acute hypertensive crisis** (defined as BP ≥160/110 mmHg). **Why Hydralazine is correct:** Hydralazine is a potent direct-acting peripheral vasodilator. It is considered a first-line agent for **hypertensive emergencies** in pregnancy because of its rapid onset of action (5–20 minutes) when administered intravenously. It effectively reduces systemic vascular resistance, ensuring rapid stabilization of blood pressure to prevent maternal intracranial hemorrhage. **Analysis of Incorrect Options:** * **Enalapril (Option A):** ACE inhibitors are strictly **contraindicated** in pregnancy (Category X). They are teratogenic and can cause fetal renal dysgenesis, oligohydramnios, and skull hypoplasia. * **Methyldopa (Option C):** While Methyldopa is the **drug of choice for chronic hypertension** in pregnancy, it is unsuitable for a crisis. It has a slow onset of action (4–6 hours) and works via a central mechanism, making it ineffective for immediate BP reduction. * **Option D:** Incorrect because Methyldopa cannot be used for an acute crisis. **High-Yield Clinical Pearls for NEET-PG:** 1. **First-line drugs for Hypertensive Crisis:** IV Labetalol (most common/preferred), IV Hydralazine, and Oral Nifedipine (rapid release). 2. **Drug of Choice (DOC) for Chronic Hypertension:** Methyldopa (safest long-term profile). 3. **DOC for Eclampsia/Preeclampsia Seizures:** Magnesium Sulfate ($MgSO_4$). 4. **Avoid in Pregnancy:** ACE inhibitors, ARBs, Sodium Nitroprusside (risk of fetal cyanide poisoning), and Diuretics (may compromise placental perfusion).

Q: What is the cut-off value of cervical length at 24 weeks of gestation for the prediction of preterm delivery?

2.5 cm. **Explanation:** The assessment of cervical length via **Transvaginal Sonography (TVS)** is a critical screening tool for predicting spontaneous preterm birth (PTB). **1. Why 2.5 cm is the Correct Answer:** In clinical practice and major guidelines (such as ACOG and Fetal Medicine Foundation), a cervical length of **<25 mm (2.5 cm)** before 24 weeks of gestation is the standard threshold used to identify women at high risk for preterm delivery. This value corresponds to the 10th percentile for cervical length at this gestational age. A cervix shorter than this indicates "cervical effacement" or insufficiency, necessitating interventions like vaginal progesterone or cervical cerclage to reduce the risk of prematurity. **2. Analysis of Incorrect Options:** * **0.5 cm (Option A):** This represents extreme shortening or near-complete effacement, usually seen in imminent labor or advanced cervical incompetence, rather than a screening cut-off. * **1.5 cm (Option B):** While 1.5 cm is a "high-risk" threshold (often used to decide on cerclage in twin pregnancies or specific high-risk scenarios), it is not the standard screening cut-off for the general population. * **3.5 cm (Option D):** This is considered a normal, healthy cervical length. A length >30 mm has a high negative predictive value, meaning preterm birth is highly unlikely. **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Transvaginal Ultrasound (TVS) is superior to transabdominal ultrasound for measuring cervical length. * **Funneling:** The protrusion of the amniotic sac into the internal os (forming a U or V shape) is an additional sign of cervical incompetence. * **Management:** If cervical length is <25 mm in a singleton pregnancy, the first-line management is typically **Vaginal Progesterone**. * **Timing:** Screening is most effective when performed between **18 and 24 weeks** of gestation.

Q: A 31-year-old woman presents with abdominal pain and vaginal spotting. The pain started 2 days ago and has been worsening, with spotting occurring this morning. Her last menstrual period was 6 weeks ago. Vital signs show a temperature of 37°C, blood pressure of 90/50 mm Hg, pulse of 110/minute, and respirations of 14/minute. Physical examination reveals significant lower abdominal tenderness, scant blood in the vagina with a closed cervical os, and significant left adnexal tenderness on bimanual examination. Urine hCG is positive, and serum hCG is 5,000 mIU/mL. Pelvic ultrasound shows a normal uterus with a left adnexal mass surrounded by free fluid. Which of the following is the most likely diagnosis?

Ectopic pregnancy. **Explanation:** The clinical presentation of **amenorrhea (6 weeks), abdominal pain, and vaginal spotting** in a woman of reproductive age is a classic triad for **Ectopic Pregnancy**. The diagnosis is confirmed by the following findings: 1. **Hemodynamic Instability:** Hypotension (90/50 mmHg) and tachycardia (110 bpm) suggest a **ruptured ectopic pregnancy** leading to hemoperitoneum. 2. **Biochemical Markers:** A positive urine hCG and a serum hCG of 5,000 mIU/mL indicate pregnancy. 3. **Imaging:** Ultrasound reveals an empty uterus (despite hCG being well above the discriminatory zone of 1,500–2,000 mIU/mL) and a left adnexal mass with free fluid (blood), localized to the site of tenderness. **Incorrect Options:** * **Appendicitis:** While it causes RLQ pain, it does not explain the positive hCG, vaginal spotting, or adnexal mass. * **Ovarian Cancer:** Usually presents in older women with chronic symptoms (bloating, weight loss) rather than acute pain and a positive pregnancy test. * **Pelvic Inflammatory Disease (PID):** Can cause adnexal tenderness and pain, but it typically presents with fever, purulent cervical discharge, and a negative pregnancy test. **NEET-PG High-Yield Pearls:** * **Discriminatory Zone:** The serum hCG level at which an intrauterine gestational sac should be visible on TVS (usually 1,500–2,000 mIU/mL). If the uterus is empty above this level, suspect ectopic pregnancy. * **Most Common Site:** The **Ampulla** of the fallopian tube. * **Management:** Hemodynamically unstable patients (like this one) require **emergency laparotomy**, not medical management with Methotrexate. * **Arias-Stella Reaction:** Hypersecretory endometrium seen on biopsy in ectopic pregnancy (due to hormonal stimulation without an intrauterine sac).

Q: What is the best diagnostic modality for unruptured tubal pregnancy?

Vaginal ultrasound. **Explanation:** The diagnosis of an unruptured tubal pregnancy relies on the visualization of an extrauterine gestational sac. **Transvaginal Ultrasound (TVS)** is the gold standard and the best diagnostic modality because it offers high resolution and can detect an intrauterine pregnancy as early as 4.5 to 5 weeks. The characteristic findings on TVS include an empty uterus, a "tubal ring" sign (hyperechoic ring around the extrauterine sac), or a complex adnexal mass. **Analysis of Options:** * **Serum hCG estimation (Option B):** While essential for confirming pregnancy and interpreting ultrasound findings (via the "Discriminatory Zone"), a single hCG value cannot localize the pregnancy. It is a biochemical marker, not a definitive diagnostic modality for tubal location. * **Serum Progesterone estimation (Option C):** Low progesterone (<5 ng/mL) suggests a non-viable pregnancy but does not differentiate between a miscarriage and an ectopic pregnancy. * **Culdocentesis (Option D):** This involves aspirating fluid from the Pouch of Douglas. It is used to detect hemoperitoneum in **ruptured** ectopic pregnancies. It has largely been replaced by TVS and is not the investigation of choice for unruptured cases. **High-Yield Clinical Pearls for NEET-PG:** * **Discriminatory Zone:** The level of β-hCG at which an intrauterine gestational sac should be visible on TVS is **1500–2000 mIU/mL**. If hCG is above this and the uterus is empty, ectopic pregnancy is highly suspected. * **Gold Standard for Diagnosis:** While TVS is the best initial/diagnostic modality, **Laparoscopy** remains the "Gold Standard" for definitive confirmation. * **Most common site:** The **Ampulla** is the most common site for tubal pregnancy. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases).

Q: A 37-week pregnant female presents with grade 3 placenta previa, bleeding per vaginum, and uterine contractions. What is the most appropriate management for this patient?

Emergency LSCS. **Explanation:** The management of placenta previa is primarily determined by the **gestational age**, the **severity of bleeding**, and the **stability of the mother and fetus**. 1. **Why Emergency LSCS is correct:** This patient is at **37 weeks (term)** and is presenting with **active bleeding** and **uterine contractions**. In placenta previa, contractions cause further cervical effacement and dilatation, leading to massive, life-threatening hemorrhage due to the separation of the placenta from the lower uterine segment. Since the pregnancy has reached term and there is active bleeding, immediate delivery via **Emergency Lower Segment Cesarean Section (LSCS)** is the definitive management to ensure maternal and fetal safety. Grade 3 (totalis/partial) placenta previa is a contraindication for vaginal delivery. 2. **Why other options are incorrect:** * **A. Dexamethasone and nifedipine:** These are components of "Expectant Management" (Macafee-Johnson protocol). Dexamethasone is used for fetal lung maturity (usually <34 weeks), and nifedipine is a tocolytic. They are contraindicated here because the patient is at term and actively bleeding. * **B & C. Bed rest, sedation, and Wait and watch:** These are passive approaches. Waiting in the presence of active bleeding and contractions at 37 weeks risks maternal shock and fetal demise. **High-Yield Clinical Pearls for NEET-PG:** * **Macafee-Johnson Protocol:** Indicated only if the fetus is preterm (<37 weeks), bleeding is not life-threatening, and the mother is hemodynamically stable. * **Double Setup Examination:** Historically used to diagnose previa in the OT; however, it is now largely replaced by **Transvaginal Sonography (TVS)**, which is the gold standard for diagnosis. * **Vaginal Examination:** Strictly contraindicated in suspected placenta previa (can cause torrential hemorrhage) until previa is ruled out by ultrasound.

Q: The risk factors for placental abruption include the following, except:

Diabetes mellitus. **Explanation:** Placental abruption (abruptio placentae) is the premature separation of a normally situated placenta from the uterine wall. The primary pathophysiology involves **rupture of maternal spiral arteries** in the decidua basalis, leading to retroplacental hemorrhage. **Why Diabetes Mellitus is the correct answer:** Diabetes mellitus (both pre-gestational and gestational) is **not** a direct risk factor for placental abruption. While diabetes is associated with other placental complications like placentomegaly and placental insufficiency, it does not predispose the patient to premature separation. In fact, the risk of abruption is primarily linked to conditions causing vascular damage or sudden uterine decompression. **Analysis of Incorrect Options:** * **History of previous abruption:** This is the **strongest risk factor**. A woman with a history of abruption has a 10–15 fold increased risk in subsequent pregnancies. * **Hypertension:** This is the **most common cause** of abruption. Both chronic hypertension and preeclampsia cause vascular vasospasm and endothelial damage, leading to hemorrhage. * **Preterm Rupture of Membranes (PROM):** Sudden decompression of the uterus (also seen in polyhydramnios) causes a rapid decrease in intrauterine pressure, which can shear the placenta away from the uterine wall. **Clinical Pearls for NEET-PG:** * **Most common cause:** Hypertension (Preeclampsia). * **Strongest risk factor:** Previous history of abruption. * **Other high-yield risk factors:** Smoking, Cocaine use (causes acute vasospasm), Trauma, and Short umbilical cord. * **Classic Triad:** Painful vaginal bleeding, uterine tenderness (woody hard uterus), and fetal distress. * **Couvelaire Uterus:** A complication where blood extravasates into the myometrium, seen during C-section.

Question 1

What is the safe drug for antihypertensive crisis during pregnancy?

Accepted Answer

Hydralazine

Answer

Enalapril

Answer

Methyldopa

Answer

Both Hydralazine and Methyldopa

Question 2

Increased acidosis and hypoxemia in a fetus is associated with which of the following findings?

Accepted Answer

Increased fetal diastolic flow in the middle cerebral artery with absent diastolic flow in the aorta

Answer

Normal Doppler waveform

Answer

Presence of the 'notch' in the uterine artery

Answer

Absent umbilical artery

Question 3

A woman presents with chickenpox at 8 weeks of gestation. What is the best method to exclude fetal varicella syndrome?

Accepted Answer

Perform an ultrasound scan at 20 weeks.

Answer

Perform amniocentesis at 15 weeks and test for VZV DNA in the amniotic fluid.

Answer

Perform an ultrasound scan immediately.

Answer

Perform chorionic villus sampling and test for VZV DNA.

Question 4

What is the cut-off value of cervical length at 24 weeks of gestation for the prediction of preterm delivery?

Accepted Answer

2.5 cm

Answer

0.5 cm

Answer

1.5 cm

Answer

3.5 cm

Question 5

A 31-year-old woman presents with abdominal pain and vaginal spotting. The pain started 2 days ago and has been worsening, with spotting occurring this morning. Her last menstrual period was 6 weeks ago. Vital signs show a temperature of 37°C, blood pressure of 90/50 mm Hg, pulse of 110/minute, and respirations of 14/minute. Physical examination reveals significant lower abdominal tenderness, scant blood in the vagina with a closed cervical os, and significant left adnexal tenderness on bimanual examination. Urine hCG is positive, and serum hCG is 5,000 mIU/mL. Pelvic ultrasound shows a normal uterus with a left adnexal mass surrounded by free fluid. Which of the following is the most likely diagnosis?

Accepted Answer

Ectopic pregnancy

Answer

Appendicitis

Answer

Ovarian cancer

Answer

Pelvic inflammatory disease

Question 6

What is the best diagnostic modality for unruptured tubal pregnancy?

Accepted Answer

Vaginal ultrasound

Answer

Serum hCG estimation

Answer

Serum Progesterone estimation

Answer

Culdocentesis

Question 7

A 37-week pregnant female presents with grade 3 placenta previa, bleeding per vaginum, and uterine contractions. What is the most appropriate management for this patient?

Accepted Answer

Emergency LSCS

Answer

Dexamethasone and nifedipine

Answer

Bed rest and sedation

Answer

Wait and watch

Question 8

The risk factors for placental abruption include the following, except:

Accepted Answer

Diabetes mellitus

Answer

History of placental abruption in previous pregnancy

Answer

Hypertension

Answer

Preterm rupture of membranes

Question 9

Which of the following statements is true regarding heart disease in pregnancy?

Accepted Answer

In Mitral Stenosis, surgery is better avoided during pregnancy.

Answer

Mitral Regurgitation has a definite indication for termination of pregnancy.

Answer

Aortic stenosis in old age is due to Bicuspid valve.

Answer

Termination of pregnancy is advised in NYHA class II.

Question 10

Which of the following findings are highly predictive of placenta accreta?

Accepted Answer

Less than 1 mm between uterine serosa - bladder interface and retroplacental vessels; large placental lakes.

Answer

Large intraplacental lakes; fundal placenta.

Answer

Less than 1 mm between uterine serosa - bladder interface and retroplacental vessels; lateral placenta.

Answer

None of the above.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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