Maternal-Fetal Medicine Practice Questions

Q: Which of the following drugs is not helpful in the treatment of ectopic pregnancy?

Misoprostol. **Explanation:** The primary goal of medical management in ectopic pregnancy is to inhibit the rapidly dividing trophoblastic cells, leading to the involution of the pregnancy. **Why Misoprostol is the Correct Answer:** **Misoprostol** is a synthetic Prostaglandin E1 (PGE1) analogue. Its primary action is to induce uterine contractions and cervical ripening. While it is highly effective for medical abortion in **intrauterine pregnancies**, it has no effect on the fallopian tubes or extrauterine tissues. Therefore, it cannot terminate an ectopic pregnancy and is not used in its management. **Analysis of Incorrect Options:** * **Methotrexate (Option A):** The drug of choice for medical management. It is a folic acid antagonist that inhibits Dihydrofolate Reductase, stopping DNA synthesis in actively dividing trophoblastic cells. * **Actinomycin-D (Option C):** An antitumor antibiotic that inhibits RNA synthesis. While rarely used today due to toxicity, it was historically used as a second-line agent for ectopic pregnancy and remains a treatment for gestational trophoblastic neoplasia. * **RU486 / Mifepristone (Option D):** An anti-progestational agent. Since progesterone is essential for maintaining any pregnancy (including ectopic), RU486 can be used as an adjunct to Methotrexate to increase success rates. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Candidate for Methotrexate:** Hemodynamically stable, tubal mass <3.5 cm, no fetal cardiac activity, and baseline β-hCG <5000 mIU/mL. * **Dosing:** Most common regimen is a single dose of **50 mg/m²** IM. * **Contraindication:** Ruptured ectopic pregnancy (requires immediate surgery). * **Follow-up:** Monitor β-hCG on days 4 and 7; a drop of <15% between these days requires a second dose.

Q: Highest maternal mortality is seen in which of the following congenital heart diseases?

Eisenmenger's syndrome. **Explanation:** **Eisenmenger’s Syndrome** is associated with the highest maternal mortality rate among congenital heart diseases (CHD), ranging from **30% to 50%**. 1. **Why it is the correct answer:** Eisenmenger’s syndrome involves a long-standing left-to-right shunt that leads to severe pulmonary hypertension and eventual shunt reversal (right-to-left). During pregnancy, the normal physiological decrease in systemic vascular resistance (SVR) exacerbates the right-to-left shunt, leading to profound hypoxemia, cyanosis, and heart failure. The most critical period is the **immediate postpartum phase**, where sudden hemodynamic shifts often lead to cardiovascular collapse. 2. **Why the other options are incorrect:** * **Pulmonary Stenosis (B):** Generally well-tolerated in pregnancy unless the stenosis is severe. Mortality is low. * **Coarctation of Aorta (C):** While it carries risks like aortic dissection or rupture, the mortality rate (approx. 3-9%) is significantly lower than Eisenmenger’s. * **Ventricular Septal Defect (D):** Small to moderate VSDs are usually well-tolerated. It only becomes high-risk if it progresses to Eisenmenger’s syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Class IV (Pregnancy Contraindicated):** Includes Eisenmenger’s syndrome, severe Pulmonary Arterial Hypertension (PAH), severe systemic ventricular dysfunction (EF <30%), and severe symptomatic mitral/aortic stenosis. * **Most common CHD in pregnancy:** Atrial Septal Defect (ASD). * **Most common heart disease in pregnancy (India):** Rheumatic Heart Disease (Mitral Stenosis is the most common lesion). * **Management:** Termination of pregnancy is usually advised in the first trimester for Eisenmenger's patients due to the extreme mortality risk.

Q: What is the risk of neural tube defect in a child if either parent was born with spina bifida?

5%. **Explanation:** **1. Why Option B (5%) is correct:** Neural Tube Defects (NTDs) follow a **multifactorial inheritance** pattern, meaning they result from a combination of multiple genetic predispositions and environmental factors (like folic acid deficiency) [1]. In multifactorial inheritance, the recurrence risk is directly related to the degree of kinship [1]. If a **first-degree relative** (a parent or a previous sibling) is affected by an NTD, the risk for the offspring increases significantly from the general population risk (0.1%) to approximately **3–5%**. Standard textbooks and clinical guidelines for PG entrance exams cite 4–5% as the specific risk when one parent is affected. **2. Why other options are incorrect:** * **Option A (3%):** While 3% is sometimes cited as the lower end of the range for a previous sibling, 5% is the more definitive "high-yield" figure used in examinations for a parent or one sibling. * **Option C (10%):** This risk level is typically seen if **two** previous siblings are affected, or if one parent and one sibling are affected. * **Option D (15%):** This is an overestimation for a single first-degree relative. Risks this high are generally not seen in multifactorial inheritance unless there is a very strong family clustering (three or more affected first-degree relatives). **3. Clinical Pearls for NEET-PG:** * **Folic Acid Prophylaxis:** For the general population, the dose is **400 mcg (0.4 mg)** daily [2]. * **High-Risk Dose:** For women with a previous child with NTD or if either parent has an NTD, the dose is increased to **4 mg (4000 mcg)** daily, started at least 1 month (ideally 3 months) before conception through the first trimester. * **Screening:** Maternal Serum Alpha-Fetoprotein (MSAFP) is measured at **15–20 weeks**; elevated levels (>2.5 MoM) suggest an open NTD [3].

Q: What is the characteristic finding of ectopic pregnancy on ultrasonography?

Absence of the gestational sac within the uterus. ### Explanation The diagnosis of ectopic pregnancy relies on the correlation of clinical findings, quantitative β-hCG levels, and ultrasonography (USG). **1. Why Option A is Correct:** The **absence of an intrauterine gestational sac** in a patient with a positive pregnancy test (especially when β-hCG is above the **discriminatory zone**, typically 1,500–2,000 mIU/mL for transvaginal sonography) is the most fundamental finding. While seeing an extrauterine embryo with a heartbeat is 100% specific, it is only seen in a minority of cases. Therefore, the "empty uterus" sign is the primary red flag that necessitates a thorough search for an ectopic gestation. **2. Analysis of Incorrect Options:** * **Option B:** While a **complex adnexal mass** (the "blob sign") is the most common USG finding in ectopic pregnancy (present in ~60-80% of cases), it is not as definitive as the absence of an intrauterine sac, as it can be confused with a corpus luteum or inflammatory mass. * **Option C:** Ectopic pregnancies typically show **low resistance flow** (high diastolic flow) on color Doppler, often referred to as the **"Ring of Fire"** sign. Increased resistance is incorrect. * **Option D:** **Free fluid** (hemoperitoneum) in the Pouch of Douglas is a common finding, especially in ruptured ectopics, but it is non-specific and can occur with ruptured hemorrhagic cysts or ovulation. **Clinical Pearls for NEET-PG:** * **Pseudogestational Sac:** A midline fluid collection in the uterus (without a yolk sac or double decidual sign) seen in 10% of ectopics. Do not mistake this for a normal pregnancy. * **Double Decidual Sac Sign:** A feature of a true intrauterine pregnancy; its absence helps confirm an ectopic. * **Gold Standard:** Laparoscopy remains the gold standard for diagnosis, though USG + β-hCG is the standard initial approach. * **Most Common Site:** The **Ampulla** of the Fallopian tube.

Q: A woman undergoes chorionic villous sampling at 11 weeks gestation. The result shows two cell lines: 46, XY and 47, XY, +21. What is your next step?

Perform amniocentesis for further confirmation. **Explanation:** The presence of two different cell lines (one normal and one aneuploid) in a Chorionic Villus Sampling (CVS) specimen is known as **Confined Placental Mosaicism (CPM)**. This occurs in approximately 1–2% of CVS procedures. Because CVS samples the trophoblastic tissue (placenta) rather than the fetus itself, the mosaicism may be restricted to the placenta while the fetus remains euploid. **Why Option C is Correct:** To differentiate between CPM and true fetal mosaicism, a definitive test that samples fetal cells is required. **Amniocentesis** (typically performed after 15 weeks) is the gold standard in this scenario. Amniocytes are derived from the fetus (skin, respiratory, and urinary tracts), providing a more accurate representation of the fetal karyotype than placental villi. **Why Other Options are Incorrect:** * **Option A:** Repeating CVS would likely yield the same placental results and does not resolve the diagnostic dilemma of whether the fetus is affected. * **Option B:** Ignoring the result is negligent, as there is still a significant risk that the fetus carries the trisomy 21 cell line. * **Option D:** Diagnosing Down syndrome based solely on a mosaic CVS result may lead to the termination of a genetically normal fetus. A definitive diagnosis requires amniocentesis. **Clinical Pearls for NEET-PG:** * **CVS Timing:** 10–13 weeks. It cannot detect Neural Tube Defects (NTDs) as it doesn't measure AFP. * **Amniocentesis Timing:** 15–20 weeks. * **Confined Placental Mosaicism (CPM):** Always consider this when CVS shows mosaicism but the ultrasound is normal. * **Risk of miscarriage:** CVS (~0.5–1%) is slightly higher than or equal to mid-trimester amniocentesis (~0.1–0.5%).

Q: Which of the following is NOT a risk factor for preeclampsia?

Multigravida. ### Explanation **Correct Answer: D. Multigravida** **1. Why Multigravida is the Correct Answer:** Preeclampsia is classically a disease of **primigravidae** (first-time mothers). The underlying pathophysiology involves an immune maladaptation to paternal antigens during the first exposure. Being a **multigravida** (especially with the same partner) is actually a **protective factor**, as the maternal immune system has been previously "sensitized" to fetal/placental antigens, reducing the risk of placental dysfunction. **2. Why the Other Options are Wrong (Risk Factors):** * **A. Antiphospholipid Syndrome (APS):** This is one of the strongest high-risk factors. It causes a prothrombotic state and defective trophoblastic invasion, leading to placental ischemia. * **B. Obesity:** A BMI >30 kg/m² is a significant risk factor. Obesity is associated with chronic inflammation and insulin resistance, which trigger endothelial dysfunction—the hallmark of preeclampsia. * **C. Previous History of Preeclampsia:** This is the single most important predictor. A woman with a history of preeclampsia has a 7-10x higher risk of recurrence in subsequent pregnancies. **3. High-Yield Clinical Pearls for NEET-PG:** * **The "New Partner" Rule:** If a multigravida has a child with a **new partner**, her risk resets to that of a primigravida (due to new paternal antigens). * **High-Risk Factors (Aspirin Indicated):** History of preeclampsia, Chronic Hypertension, Type 1 or 2 Diabetes, Renal disease, and Autoimmune diseases (SLE/APS). * **Moderate Risk Factors:** Nulliparity, Obesity, Family history (mother/sister), Age ≥35, and Multifetal gestation. * **Prophylaxis:** Low-dose Aspirin (75–150 mg) started before 16 weeks of gestation is recommended for women with high-risk factors.

Question 1

Which of the following is true in twin-reversed arterial perfusion (TRAP) sequence?

Accepted Answer

The donor twin is at risk of cardiomegaly and high output heart failure.

Answer

It is caused by a large arteriovenous placental shunt.

Answer

The most effective treatment is injection of potassium chloride into the recipient twin.

Answer

Placental arterial perfusion pressure in the recipient exceeds that of the donor.

Question 2

Which of the following drugs is not helpful in the treatment of ectopic pregnancy?

Accepted Answer

Misoprostol

Answer

Methotrexate

Answer

Actinomycin-D

Answer

RU486

Question 3

All of the following interventions are recommended to prevent mother-to-child transmission of HIV, except?

Accepted Answer

Vaginal delivery

Answer

Avoid breast feeding

Answer

Highly Active Antiretroviral Therapy (HAART)

Answer

Intrapartum Zidovudine

Question 4

Which of the following is NOT a contraindication to pregnancy?

Accepted Answer

Large secundum atrial septal defect with left to right shunt

Answer

Severe pulmonary hypertension

Answer

Severe obstructive valvular lesions

Answer

Marfan syndrome with dilated aorta

Question 5

Highest maternal mortality is seen in which of the following congenital heart diseases?

Accepted Answer

Eisenmenger's syndrome

Answer

Pulmonary stenosis

Answer

Coarctation of aorta

Answer

Ventricular septal defect (VSD)

Question 6

What is the risk of neural tube defect in a child if either parent was born with spina bifida?

Accepted Answer

5%

Answer

3%

Answer

10%

Answer

15%

Question 7

What is the characteristic finding of ectopic pregnancy on ultrasonography?

Accepted Answer

Absence of the gestational sac within the uterus

Answer

A complex adnexal mass

Answer

Increased resistance on color Doppler imaging

Answer

Free fluid in the peritoneal cavity

Question 8

A woman undergoes chorionic villous sampling at 11 weeks gestation. The result shows two cell lines: 46, XY and 47, XY, +21. What is your next step?

Accepted Answer

Perform amniocentesis for further confirmation

Answer

Repeat CVS at 13 weeks gestation

Answer

No further evaluation needed

Answer

Diagnose Down syndrome and counsel the couple

Question 9

Which of the following is NOT a risk factor for preeclampsia?

Accepted Answer

Multigravida

Answer

Antiphospholipid syndrome

Answer

Obesity

Answer

Previous history of preeclampsia

Question 10

All of the following are obstetric clinical criteria for the diagnosis of Antiphospholipid Antibody Syndrome except:

Accepted Answer

One or more episodes of arterial, venous, or small vessel thrombosis in any tissue or organ.

Answer

One or more unexplained deaths of a morphologically normal fetus at or beyond 10 weeks gestation.

Answer

Severe preeclampsia or placental insufficiency necessitating delivery before 34 weeks.

Answer

Three or more unexplained consecutive abortions before 10 weeks gestation.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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