Maternal-Fetal Medicine Practice Questions

Q: Abortion in the second trimester is mostly due to:

Incompetent cervix. **Explanation:** The majority of spontaneous abortions (miscarriages) occur in the first trimester, primarily due to chromosomal abnormalities. However, once a pregnancy reaches the **second trimester (13–28 weeks)**, the etiology shifts from genetic factors to anatomical and maternal factors. **1. Why "Incompetent Cervix" is correct:** Cervical insufficiency (incompetent cervix) is the most common cause of mid-trimester pregnancy loss. It is characterized by the painless dilation of the cervix, leading to the prolapse of membranes and subsequent expulsion of a premature but often morphologically normal fetus. This occurs because the cervix fails to remain closed against the increasing intrauterine pressure as the fetus grows. **2. Analysis of Incorrect Options:** * **Defective Genes (Chromosomal Abnormalities):** This is the leading cause of **first-trimester** abortions (approx. 50–60%). While they can cause second-trimester loss, their frequency decreases significantly as the pregnancy advances. * **Tuberculosis:** While genital TB is a major cause of primary and secondary infertility (due to tubal blockage or endometrial scarring), it is a rare cause of spontaneous abortion compared to anatomical defects. * **Trauma:** Though a common concern for patients, physical trauma is rarely the cause of abortion unless it is severe enough to cause placental abruption or direct uterine injury. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) showing a cervical length **<25 mm** or "funneling" of the internal os before 24 weeks. * **Treatment:** Cervical Cerclage (e.g., **McDonald’s or Shirodkar’s procedure**), typically performed between 14–18 weeks of gestation. * **Classic History:** Repeated, painless, mid-trimester abortions preceded by spontaneous rupture of membranes.

Q: Intrahepatic cholestasis of pregnancy typically occurs in which trimester?

Third trimester. **Explanation:** **Intrahepatic Cholestasis of Pregnancy (ICP)** is a reversible type of hormone-influenced cholestasis. The correct answer is the **Third Trimester** because this is when serum estrogen and progesterone levels reach their peak. High levels of estrogen (specifically estriol) and progesterone metabolites interfere with the transport of bile acids across the canalicular membrane, leading to their accumulation in the systemic circulation. * **Why Third Trimester is Correct:** Approximately 80% of cases occur after 30 weeks of gestation. The increasing hormonal load and the stretching of the gallbladder lead to decreased bile flow (cholestasis). * **Why other options are incorrect:** * **First Trimester:** Hormonal levels are not yet high enough to cause significant cholestasis. * **Second Trimester:** While possible in late second trimester, it is statistically much less common than the third. * **Postpartum:** ICP is characterized by the **rapid resolution** of symptoms (usually within 48 hours) after delivery as hormone levels plummet. **Clinical Pearls for NEET-PG:** 1. **Hallmark Symptom:** Pruritus, which is typically worse at night and characteristically involves the **palms and soles**. There is **no primary rash**. 2. **Diagnostic Gold Standard:** Elevated **Total Serum Bile Acids (TSBA)** >10 µmol/L. 3. **Fetal Risk:** Increased risk of sudden intrauterine fetal death (IUFD), meconium-stained liquor, and preterm labor. 4. **Management:** **Ursodeoxycholic Acid (UDCA)** is the drug of choice to reduce pruritus and improve biochemical parameters. Delivery is usually recommended by 37–38 weeks to prevent stillbirth.

Q: A 30-year-old primigravida presents with a blood pressure of 160/96 mm Hg. Her BUN is 14 mg/dL and creatinine is 1.0 mg/dL. Urinalysis shows no proteinuria. Complete blood count and liver function tests are within normal limits. What is the first best drug to be given to this patient?

Labetalol. ### Explanation **Diagnosis:** The patient is a primigravida with a blood pressure of 160/96 mm Hg, normal renal/liver function, and no proteinuria. This presentation is consistent with **Gestational Hypertension** (if >20 weeks) or **Chronic Hypertension** (if <20 weeks). Regardless of the specific classification, the immediate clinical goal is the safe management of hypertension in pregnancy. **Why Labetalol is Correct:** Labetalol is a combined alpha- and beta-adrenergic blocker and is considered a **first-line antihypertensive agent** in pregnancy. It is preferred due to its rapid onset of action, excellent safety profile, and lack of significant teratogenic effects. It effectively lowers blood pressure without causing significant reflex tachycardia or compromising uteroplacental blood flow. **Analysis of Incorrect Options:** * **Furosemide (A):** Diuretics are generally avoided in pregnancy as they can cause volume depletion and potentially decrease placental perfusion. They are only used in specific cases like pulmonary edema. * **Lisinopril (C) & Losartan (D):** ACE inhibitors and ARBs are **absolutely contraindicated** in pregnancy (Category D/X). They are associated with fetal renal dysgenesis, oligohydramnios, skull hypoplasia, and intrauterine growth restriction (IUGR). **Clinical Pearls for NEET-PG:** * **First-line drugs for Hypertension in Pregnancy:** Oral Labetalol, Methyldopa (safest long-term), and Nifedipine (long-acting). * **Management of Hypertensive Crisis (BP ≥160/110):** IV Labetalol, IV Hydralazine, or Oral Nifedipine. * **Drugs to Avoid:** ACE inhibitors, ARBs, Sodium Nitroprusside (cyanide toxicity), and Spironolactone. * **Target BP:** Aim to maintain systolic between 140–150 mmHg and diastolic between 90–100 mmHg to prevent maternal cerebrovascular accidents without compromising fetal circulation.

Q: Which of the following medications does NOT affect the fetus?

Magnesium sulfate. **Explanation:** The correct answer is **Magnesium Sulfate (MgSO₄)**. In the context of obstetric pharmacology, MgSO₄ is the drug of choice for seizure prophylaxis in pre-eclampsia and management of eclampsia. It is considered safe for the fetus because it does not have teratogenic effects. While it crosses the placenta, it typically only causes minor, transient neonatal effects (such as decreased heart rate variability or mild hypotonia) at therapeutic levels. It is also used for **fetal neuroprotection** in preterm births <32 weeks. **Why the other options are incorrect:** * **Lytic Cocktail (Pethidine, Chlorpromazine, Promethazine):** Historically used for eclampsia, these drugs cross the placenta and cause significant **neonatal respiratory depression** and sedation. * **Warfarin:** A potent teratogen. Exposure during the first trimester (6–9 weeks) leads to **Fetal Warfarin Syndrome** (stippled epiphyses, nasal hypoplasia). In later trimesters, it can cause fetal intracranial hemorrhage. * **Phenytoin:** An anticonvulsant associated with **Fetal Hydantoin Syndrome**, characterized by craniofacial anomalies (cleft lip/palate), phalangeal hypoplasia, and growth retardation. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic range of MgSO₄:** 4–7 mEq/L. * **First sign of toxicity:** Loss of patellar reflex (8–10 mEq/L). * **Antidote:** 10% Calcium Gluconate (10 mL IV over 10 minutes). * **Safe Antihypertensives in Pregnancy:** Labetalol (1st line), Methyldopa, Nifedipine, and Hydralazine. * **Contraindicated Antihypertensives:** ACE inhibitors and ARBs (cause fetal renal dysgenesis and oligohydramnios).

Q: What is the easiest method for determining zygosity?

Placental examination. **Explanation:** Determining zygosity in multiple gestations is crucial for risk stratification. **Placental examination** is considered the **easiest and most practical method** for determining zygosity, particularly in the clinical setting immediately following delivery. 1. **Why Placental Examination is Correct:** By examining the placenta and the intervening membranes, clinicians can determine chorionicity. If the twins are **Monochorionic**, they are definitively **Monozygotic** (identical). If they are **Dichorionic**, they can be either dizygotic or monozygotic (if cleavage occurred early). While DNA fingerprinting is the "gold standard" for accuracy, placental examination provides an immediate, non-invasive, and highly reliable clinical assessment of zygosity in most cases. 2. **Analysis of Incorrect Options:** * **Sex of Fetus (B):** While different-sex twins are always dizygotic, same-sex twins can be either monozygotic or dizygotic. Therefore, sex alone is insufficient for a definitive diagnosis. * **Blood Grouping (A):** Different blood groups confirm dizygosity, but identical blood groups do not guarantee monozygosity, as dizygotic twins can share the same blood type by chance. * **Amniotic Fluid Examination (D):** This is primarily used for genetic testing or lung maturity and does not provide a direct structural assessment of zygosity. **NEET-PG High-Yield Pearls:** * **Gold Standard:** DNA Fingerprinting (most accurate). * **Best Ultrasound Sign:** The **"Twin Peak" or "Lambda" (λ) sign** indicates Dichorionic twins; the **"T-sign"** indicates Monochorionic twins. * **Timing of Cleavage:** * 0–72 hours: Dichorionic Diamniotic (DCDA) * 4–8 days: Monochorionic Diamniotic (MCDA) — *Most common type of MZ twins.* * 8–13 days: Monochorionic Monoamniotic (MCMA) * >13 days: Conjoined twins

Q: Which of the following is NOT a feature of mild pre-eclampsia?

Mild Intrauterine Growth Restriction (IUGR). **Explanation:** In modern obstetric practice (based on ACOG and NHBPEP guidelines), pre-eclampsia is classified into two categories: **Pre-eclampsia without severe features** (formerly "Mild") and **Pre-eclampsia with severe features**. **Why Option C is the Correct Answer:** Intrauterine Growth Restriction (IUGR) is considered a sign of placental insufficiency and significant fetal compromise. According to standard diagnostic criteria, the presence of **fetal growth restriction** automatically upgrades the diagnosis to **Severe Pre-eclampsia**. Therefore, IUGR is never a feature of "mild" pre-eclampsia; its presence indicates a more advanced disease state requiring closer monitoring and potential delivery. **Analysis of Incorrect Options:** * **Options A & B:** Mild pre-eclampsia is defined by a Blood Pressure $\geq$ 140/90 mm Hg but **$<$ 160/110 mm Hg**. Thus, a Diastolic BP < 100 mm Hg and a Systolic BP < 160 mm Hg are consistent with the mild category. * **Option D:** "Premonitory symptoms" include headache, visual disturbances, epigastric pain, and oliguria. These are markers of end-organ damage. Their **absence** is a hallmark of mild pre-eclampsia; if these symptoms appear, it is classified as severe. **High-Yield Clinical Pearls for NEET-PG:** * **Proteinuria:** In mild cases, it is $\geq$ 300 mg/24 hours or 1+ on dipstick. Massive proteinuria (> 5g) is no longer used to define severity in current ACOG guidelines, but is still frequently tested in exams. * **Edema:** Pedal edema is common in normal pregnancy and is **no longer** a diagnostic criterion for pre-eclampsia. * **The "Severe" Checklist:** BP $\geq$ 160/110, Platelets 1.1 mg/dL, or Pulmonary Edema.

Q: Which cardiac lesion in pregnant women has the worst prognosis?

Eisenmenger syndrome. ### Explanation **Eisenmenger Syndrome** is associated with the highest maternal mortality rate (30–50%), making it the cardiac lesion with the worst prognosis in pregnancy. **1. Why Eisenmenger Syndrome is the Correct Answer:** Eisenmenger syndrome involves a reversed (right-to-left) shunt due to severe pulmonary hypertension. During pregnancy, the systemic vascular resistance (SVR) naturally decreases. This drop in SVR exacerbates the right-to-left shunt, leading to profound hypoxemia, cyanosis, and sudden cardiovascular collapse. The most critical period is the **immediate postpartum phase**, where shifts in fluid and pressure can lead to fatal right-sided heart failure. **2. Why the Other Options are Incorrect:** * **Mitral Stenosis (A):** This is the most common rheumatic heart lesion in pregnancy. While it carries significant risk (especially of pulmonary edema due to tachycardia), the mortality rate is much lower (approx. 1–5% in NYHA Class I/II) compared to Eisenmenger. * **Coarctation of the Aorta (B):** While it poses risks like aortic dissection or rupture, it is generally manageable with strict blood pressure control. * **Tetralogy of Fallot (D):** If uncorrected, it carries risk, but if surgically corrected prior to pregnancy, women usually tolerate pregnancy well. Even uncorrected, the mortality is lower than in pulmonary hypertensive conditions. **3. NEET-PG High-Yield Pearls:** * **Absolute Contraindications to Pregnancy:** Eisenmenger syndrome, severe Pulmonary Arterial Hypertension (PAH), Marfan syndrome with aortic root dilation (>4cm), and severe symptomatic Aortic Stenosis. * **Most Common Heart Disease in Pregnancy:** Mitral Stenosis (Rheumatic). * **Most Common Congenital Heart Disease in Pregnancy:** ASD (Atrial Septal Defect). * **Highest Risk Period:** The third stage of labor and the first 48 hours postpartum (due to "autotransfusion" from the uterus).

Q: A 32-week pregnant female presents with sudden onset of painless vaginal bleeding. Ultrasonography reveals placenta previa. What is the expectant method of management for this patient?

Macafee & Johnson's method. **Explanation:** The correct answer is **C. Macafee & Johnson’s method.** In cases of placenta previa, the primary goal of management is to prolong the pregnancy until fetal lung maturity is achieved (ideally 37 weeks), provided the mother and fetus remain stable. This conservative approach is known as **Macafee & Johnson’s regimen**. It is indicated when the pregnancy is <37 weeks, bleeding is not life-threatening, and the fetus is alive and stable. The patient is kept on bed rest, monitored for further bleeding, and administered corticosteroids (e.g., Dexamethasone) to accelerate fetal lung maturity. **Analysis of Incorrect Options:** * **A. Brandt-Andrews method:** This is a technique used for the active management of the third stage of labor to deliver the placenta by applying controlled cord traction while guarding the uterus. * **B. Crede’s method:** An obsolete and potentially dangerous technique of delivering the placenta by squeezing the uterine fundus. It is no longer recommended due to the risk of uterine inversion. * **D. Liley’s regimen:** This refers to the **Liley Chart**, which was historically used to manage Rh-isoimmunization by plotting bilirubin levels in amniotic fluid (measured by $\Delta OD_{450}$) against gestational age. **Clinical Pearls for NEET-PG:** * **Cardinal Sign:** Painless, causeless, and recurrent vaginal bleeding is the hallmark of placenta previa. * **Contraindication:** A **digital vaginal examination (PV)** is strictly contraindicated in suspected placenta previa until the diagnosis is ruled out by USG, as it can provoke torrential hemorrhage (the "Stallworthy's sign"). * **Termination:** If the patient is >37 weeks or in active labor/distress, the Macafee regimen is abandoned in favor of delivery (usually Cesarean section).

Question 1

Abortion in the second trimester is mostly due to:

Accepted Answer

Incompetent cervix

Answer

Defective genes

Answer

Tuberculosis

Answer

Trauma

Question 2

Intrahepatic cholestasis of pregnancy typically occurs in which trimester?

Accepted Answer

Third trimester

Answer

First trimester

Answer

Second trimester

Answer

Postpartum period

Question 3

IUGR is defined when:

Accepted Answer

Birth weight is below the tenth percentile for the gestational age

Answer

Birth weight is below the 20th percentile for the gestational age

Answer

Birth weight is below the 30th percentile for the gestational age

Answer

Weight of baby is less than 1000 gm

Question 4

A 30-year-old primigravida presents with a blood pressure of 160/96 mm Hg. Her BUN is 14 mg/dL and creatinine is 1.0 mg/dL. Urinalysis shows no proteinuria. Complete blood count and liver function tests are within normal limits. What is the first best drug to be given to this patient?

Accepted Answer

Labetalol

Answer

Furosemide

Answer

Lisinopril

Answer

Losartan

Question 5

Which of the following medications does NOT affect the fetus?

Accepted Answer

Magnesium sulfate

Answer

Lytic cocktail

Answer

Warfarin

Answer

Phenytoin

Question 6

What is the easiest method for determining zygosity?

Accepted Answer

Placental examination

Answer

Blood grouping

Answer

Sex of fetus

Answer

Amniotic fluid examination

Question 7

Which of the following is NOT a feature of mild pre-eclampsia?

Accepted Answer

Mild Intrauterine Growth Restriction (IUGR)

Answer

Diastolic BP < 100 mm Hg

Answer

Systolic BP < 160 mm Hg

Answer

No premonitory symptoms

Question 8

Which cardiac lesion in pregnant women has the worst prognosis?

Accepted Answer

Eisenmenger syndrome

Answer

Mitral stenosis

Answer

Co-arctation of aorta

Answer

Tetralogy of Fallot's

Question 9

A woman at 32 weeks of gestation presents with labor pains. On examination, her cervix is dilated and uterine contractions are palpable. What is the appropriate management?

Accepted Answer

Isoxsuprine hydrochloride

Answer

Dilatation and Evacuation

Answer

Termination of pregnancy

Answer

Wait and watch

Question 10

A 32-week pregnant female presents with sudden onset of painless vaginal bleeding. Ultrasonography reveals placenta previa. What is the expectant method of management for this patient?

Accepted Answer

Macafee & Johnson's method

Answer

Brand-Andrews method

Answer

Crede's method

Answer

Lilley's regimen

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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