Maternal-Fetal Medicine Practice Questions

Q: Theca-lutein cysts are characteristic of which condition?

Molar pregnancy. **Explanation:** **Theca-lutein cysts** are functional ovarian cysts that occur due to supraphysiological stimulation of the ovaries by high levels of **human chorionic gonadotropin (hCG)**. 1. **Why Molar Pregnancy is Correct:** In Hydatidiform mole (molar pregnancy) and Choriocarcinoma, there is a massive proliferation of trophoblastic tissue leading to extremely high serum hCG levels. hCG shares a common alpha-subunit with LH; at high concentrations, it mimics LH action, causing luteinization and cystic enlargement of the theca interna cells. These cysts are typically bilateral, multiloculated, and regress spontaneously once the source of hCG is removed (e.g., suction evacuation). 2. **Why Other Options are Incorrect:** * **Ectopic Pregnancy:** While hCG is present, the levels are usually lower than in a normal intrauterine pregnancy, making theca-lutein cysts highly unlikely. * **Missed Abortion:** In this condition, the products of conception have died, and hCG levels are rapidly declining, which would not provide the stimulus needed for cyst formation. * **Preeclampsia:** This is a hypertensive disorder of pregnancy. While it can be associated with large placentas (like in twins or moles), it is not the primary cause of theca-lutein cysts. **High-Yield NEET-PG Pearls:** * **Hyperreactio Luteinalis:** This is the term used when theca-lutein cysts occur in a normal singleton pregnancy (rare). * **Associations:** Apart from molar pregnancy, these cysts are seen in **Multiple gestations**, **Rh-isoimmunization**, and **Ovulation induction** (Ovarian Hyperstimulation Syndrome). * **Management:** They are benign and usually managed **conservatively**. Surgery is only indicated in cases of torsion or rupture with hemorrhage.

Q: An obstetrician sees a pregnant patient who was exposed to rubella virus at eighteen weeks of pregnancy. She does not remember getting a rubella vaccination. What is the best immediate course of action?

Order a rubella antibody titer to determine immune status. **Explanation:** The management of rubella exposure in pregnancy depends on the mother’s immune status and the gestational age at exposure. **Why Option B is Correct:** The immediate priority is to determine if the mother is already immune. A **Rubella IgG antibody titer** should be ordered. If the patient is IgG positive, she is immune, and the fetus is at no risk. If she is IgG negative (susceptible), a second sample is taken 2–3 weeks later to check for seroconversion (IgM or rising IgG), which would indicate an acute infection. **Why Other Options are Incorrect:** * **Option A:** Termination is not indicated without confirming maternal infection and assessing fetal risk. Furthermore, the risk of **Congenital Rubella Syndrome (CRS)** decreases significantly after 16 weeks; exposure at 18 weeks carries a much lower risk (approx. 10–15%) compared to the first trimester. * **Option C:** This is factually incorrect. Rubella is most dangerous in the **first trimester** (up to 85% risk of CRS). While the risk decreases after 16 weeks, it does not become "not a problem" specifically after 30 weeks. * **Option D:** The rubella vaccine is a **Live Attenuated Vaccine (RA 27/3 strain)** and is strictly **contraindicated during pregnancy** due to the theoretical risk of fetal infection. **High-Yield Clinical Pearls for NEET-PG:** * **Gregg’s Triad (CRS):** Cataracts, Sensorineural hearing loss (most common), and Cardiac defects (PDA/Peripheral Pulmonary Artery Stenosis). * **Vaccination Timing:** If a woman is found to be non-immune during pregnancy, she should be vaccinated in the **immediate postpartum period**. She must avoid pregnancy for **28 days (1 month)** after vaccination. * **Diagnosis:** The presence of **Rubella IgM** in a newborn is diagnostic of congenital infection, as IgM does not cross the placenta.

Q: Which one of the following is categorized as a high-risk pregnancy?

Twins pregnancy. **Explanation:** A **high-risk pregnancy** is defined as one in which the mother, the fetus, or the newborn is at an increased risk of morbidity or mortality due to factors complicating the pregnancy. **Why "Twins Pregnancy" is Correct:** Multiple gestations (twins, triplets, etc.) are inherently high-risk because they significantly increase the risk of both maternal and fetal complications. * **Maternal risks:** Preeclampsia (3x higher risk), gestational diabetes, anemia, and postpartum hemorrhage (due to uterine overdistension). * **Fetal risks:** Preterm birth (the most common complication), intrauterine growth restriction (IUGR), malpresentation, and specific risks like Twin-to-Twin Transfusion Syndrome (TTTS) in monochorionic twins. **Analysis of Incorrect Options:** * **Birth order 3:** Generally, the "Grand Multipara" (Para 4 or more) is considered high-risk due to risks of placenta previa, malpresentation, and atonic PPH. A third pregnancy is typically considered a "safe" parity. * **Maternal height 150 cm:** In the Indian context, a "short-statured" mother is defined as having a height **<145 cm** (or 140 cm in some guidelines). 150 cm is above the threshold for increased risk of Cephalopelvic Disproportion (CPD). * **Blood group AB positive:** This is the "universal recipient" and does not pose an immunological risk. High-risk blood groups include **Rh-negative** (risk of isoimmunization) or rare blood groups where cross-matching may be difficult during emergencies. **NEET-PG High-Yield Pearls:** * **Primi-elderly:** Age >30 years (some texts say >35). * **Short Stature:** Height <145 cm (associated with contracted pelvis). * **Anemia in Pregnancy:** Hb <11 g/dL (WHO). * **Previous LSCS:** Always categorized as high-risk due to the risk of scar dehiscence or morbidly adherent placenta.

Q: An Rh-negative woman married to a heterozygous Rh-positive man has three children. What is the probability that all three of their children are Rh-positive?

1:8. ### Explanation **1. Why the Correct Answer (C) is Right:** The inheritance of the Rh factor follows Mendelian genetics. In this scenario: * **Mother:** Rh-negative (Genotype: **dd**) * **Father:** Heterozygous Rh-positive (Genotype: **Dd**) Using a Punnett square for each pregnancy: * Possible offspring genotypes: **Dd** (Rh-positive) or **dd** (Rh-negative). * The probability of having an Rh-positive child in **each** pregnancy is **1/2 (50%)**. Since each pregnancy is an independent event, the probability of all three children being Rh-positive is calculated using the multiplication rule: **1/2 (1st child) × 1/2 (2nd child) × 1/2 (3rd child) = 1/8.** **2. Why Other Options are Wrong:** * **Option A (1:2):** This is the probability for a *single* child to be Rh-positive, not all three. * **Option B (1:4):** This would be the probability if only *two* children were Rh-positive. * **Option D (Zero):** This would only be possible if the father were also Rh-negative (dd). **3. Clinical Pearls for NEET-PG:** * **Rh Incompatibility:** Occurs only when the mother is Rh-negative and the fetus is Rh-positive. * **Homozygous Father:** If the father were homozygous Rh-positive (DD), **100%** of the children would be Rh-positive. * **Anti-D Prophylaxis:** Administered at 28 weeks of gestation and within 72 hours of delivery to prevent sensitization. * **Kleihauer-Betke Test:** Used to quantify fetal-maternal hemorrhage to determine the required dose of Rh-immunoglobulin. * **Critical Titer:** An Indirect Coombs Test (ICT) titer of **1:16** is generally considered the critical threshold requiring further fetal surveillance (e.g., MCA-PSV Doppler).

Q: A pregnant woman at 18 weeks gestation is found to have an abdominal pregnancy with the fetus and placenta attached to the omentum. What is the best course of action?

Removal of the fetus only. **Explanation:** In abdominal pregnancy, the management of the placenta is the most critical decision. Unlike an intrauterine pregnancy, there is no uterine contraction to constrict blood vessels after placental separation. **Why "Removal of the fetus only" is correct:** When the placenta is attached to a highly vascular or vital organ (like the omentum, bowel, or large vessels), attempting to remove it can lead to **uncontrollable, life-threatening hemorrhage**. The standard surgical recommendation is to ligate the umbilical cord close to the placenta and leave the placenta *in situ*. The placenta will eventually undergo spontaneous resorption, a process that can be monitored using serial β-hCG levels and ultrasound. **Analysis of Incorrect Options:** * **Option A:** Removing the placenta carries a high risk of massive bleeding because the site lacks the "living ligatures" (myometrial fibers) found in the uterus. * **Option B:** While the cord is ligated, the fetus must be removed to prevent infection, lithopedion formation, or maternal inflammatory response. Ligation alone is insufficient. * **Option C:** Waiting for viability is extremely dangerous. Abdominal pregnancies are associated with high maternal mortality (up to 7-8 times higher than tubal ectopic) and a high risk of sudden placental abruption or organ rupture. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Suggested by "painful fetal movements," easily palpable fetal parts, and an empty uterus on ultrasound. * **Placental Management:** If the placenta is left behind, **Methotrexate** is generally **avoided** as it causes rapid placental necrosis, leading to infection and abscess formation. * **Classification:** Primary abdominal pregnancy (rare) vs. Secondary (more common, usually following tubal abortion/rupture). * **Criteria:** Studdiford’s Criteria are used to diagnose primary abdominal pregnancy.

Q: A primigravida at 37 weeks of gestation presents with central placenta previa and heavy vaginal bleeding. The fetal heart rate is normal. What is the best management option for this patient?

Cesarean section. **Explanation:** The management of placenta previa is guided by the degree of placenta encroachment on the internal os and the clinical stability of the mother and fetus. **Why Option B is Correct:** In **central (Type IV/Total) placenta previa**, the placenta completely covers the internal cervical os. Vaginal delivery is physically impossible because the placenta precedes the fetus; any cervical dilation will cause massive, life-threatening maternal hemorrhage. Furthermore, the patient is at **37 weeks (term)** and presenting with **heavy bleeding**. At term, the goal is delivery. Even if the fetal heart rate is currently normal, the severity of the bleeding in a central previa necessitates an immediate **Cesarean section** to save the mother and the fetus. **Why Other Options are Incorrect:** * **Option A:** Expectant management (Macafee-Johnson protocol) is only indicated if the fetus is preterm (<37 weeks), the bleeding is mild/settled, and there is no fetal distress. This patient is at term with heavy bleeding. * **Options C & D:** Induction of labor and vaginal delivery are contraindicated in central placenta previa. Attempting vaginal delivery would lead to catastrophic hemorrhage. Vaginal delivery is only considered in low-lying placenta (Type I) or some cases of marginal previa (Type II anterior) where the head can compress the placental edge. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) is safer and more accurate than transabdominal ultrasound for locating the placenta. * **Vaginal Examination:** A "per-vaginal" (PV) examination is **strictly contraindicated** in suspected placenta previa (can cause torrential hemorrhage) unless performed as a "Double Setup Examination" in the OT. * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pressed into the pelvis, seen in posterior placenta previa.

Q: Bleeding that follows partial or complete placental separation and dilation of the cervical os in the first 20 weeks is termed as what?

Incomplete abortion. ### Explanation **Correct Answer: C. Incomplete abortion** **1. Why it is correct:** An **incomplete abortion** is defined as the partial expulsion of the products of conception before 20 weeks of gestation. Pathophysiologically, it involves the separation of the placenta (either partially or completely) from the uterine wall. Because some products remain inside the uterus while others have passed, the **cervical os remains dilated** to allow for the passage of tissue. This leads to persistent bleeding and cramp-like pain. **2. Why the other options are incorrect:** * **A. Threatened abortion:** In this condition, the pregnancy is potentially viable. While bleeding occurs, the **cervical os remains closed**, and there is no expulsion of tissue. * **B. Complete abortion:** Here, all products of conception have been expelled. Consequently, the **cervical os closes**, the uterus is well-contracted (small for dates), and bleeding diminishes significantly. * **D. Preterm labor:** This refers to the onset of labor (regular contractions and cervical changes) **after 20 weeks** (or 28 weeks depending on regional definitions) but before 37 completed weeks. The question specifically mentions the first 20 weeks. **3. NEET-PG High-Yield Pearls:** * **Cervical Os Status:** This is the most critical clinical differentiator. The os is **closed** in Threatened and Complete abortions; it is **open** in Inevitable and Incomplete abortions. * **Ultrasonography (USG) findings:** In an incomplete abortion, USG shows "retained products of conception" (RPOCs) and an endometrial thickness usually >15 mm. * **Management:** The treatment of choice for incomplete abortion is **Dilation and Evacuation (D&E)** or medical management with Misoprostol to ensure the uterus is empty and to prevent hemorrhage or sepsis. * **Definition of Abortion:** Termination of pregnancy before **20 weeks** (WHO) or a fetal weight less than **500g**.

Q: What is the tocolytic of choice in HELLP syndrome?

Atosiban. **Explanation:** The management of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) often necessitates delivery; however, if the pregnancy is extremely preterm and tocolysis is required to complete a course of corticosteroids for fetal lung maturity, **Atosiban** is the preferred choice. **Why Atosiban is correct:** Atosiban is an oxytocin receptor antagonist. Its primary advantage in HELLP syndrome is its **minimal side-effect profile**, particularly regarding the cardiovascular and hepatic systems. Unlike other tocolytics, it does not cause significant hypotension, tachycardia, or fluid overload, making it the safest option in a patient already physiologically compromised by endothelial dysfunction and potential coagulopathy. **Analysis of Incorrect Options:** * **Nifedipine (Calcium Channel Blocker):** While a first-line tocolytic in routine preterm labor, it can cause hypotension and may interfere with magnesium sulfate (increasing the risk of neuromuscular blockade). In HELLP, it may also mask or complicate the management of severe hypertension. * **Magnesium Sulfate:** While used in HELLP syndrome for **seizure prophylaxis** (neuroprotection), it is a very weak tocolytic and is not used primarily to arrest labor. * **Salbutamol (Beta-mimetics):** These are contraindicated in HELLP/Preeclampsia due to risks of maternal tachycardia, hyperglycemia, and, most critically, **pulmonary edema**, which is a known complication of severe preeclampsia. **NEET-PG High-Yield Pearls:** * **Drug of Choice for Tocolysis (General):** Nifedipine is generally the first-line tocolytic for preterm labor. * **Tocolytic in Heart Disease/Diabetes:** Atosiban is the preferred choice. * **HELLP Definitive Treatment:** Delivery of the fetus (usually after 34 weeks or if maternal/fetal condition deteriorates). * **Steroids in HELLP:** Dexamethasone is often used to increase platelet counts, though its effect on overall prognosis is debated.

Question 1

Theca-lutein cysts are characteristic of which condition?

Accepted Answer

Molar pregnancy

Answer

Ectopic pregnancy

Answer

Missed abortion

Answer

Preeclampsia

Question 2

An obstetrician sees a pregnant patient who was exposed to rubella virus at eighteen weeks of pregnancy. She does not remember getting a rubella vaccination. What is the best immediate course of action?

Accepted Answer

Order a rubella antibody titer to determine immune status

Answer

Terminate the pregnancy

Answer

Reassure the patient because rubella is not a problem until after the thirtieth week

Answer

Administer rubella vaccine

Question 3

Which one of the following is categorized as a high-risk pregnancy?

Accepted Answer

Twins pregnancy

Answer

Birth order 3

Answer

Maternal height 150 cm

Answer

Blood group AB positive

Question 4

An Rh-negative woman married to a heterozygous Rh-positive man has three children. What is the probability that all three of their children are Rh-positive?

Accepted Answer

1:8

Answer

1:2

Answer

1:4

Answer

Zero

Question 5

A pregnant woman at 18 weeks gestation is found to have an abdominal pregnancy with the fetus and placenta attached to the omentum. What is the best course of action?

Accepted Answer

Removal of the fetus only

Answer

Removal of both fetus and placenta

Answer

Laparoscopic ligation of umbilical cord

Answer

Close follow-up until viability and then delivery by laparotomy

Question 6

A primigravida at 37 weeks of gestation presents with central placenta previa and heavy vaginal bleeding. The fetal heart rate is normal. What is the best management option for this patient?

Accepted Answer

Cesarean section

Answer

Expectant management

Answer

Induction and vaginal delivery

Answer

Induction and forceps delivery

Question 7

Bleeding that follows partial or complete placental separation and dilation of the cervical os in the first 20 weeks is termed as what?

Accepted Answer

Incomplete abortion

Answer

Threatened abortion

Answer

Complete abortion

Answer

Preterm labor

Question 8

A woman presents with amenorrhea for 8 weeks, acute abdominal pain, and vaginal discharge. Which is the most appropriate investigation to rule out ectopic pregnancy?

Accepted Answer

Laparoscopy

Answer

Urine pregnancy test

Answer

Ultrasound (USG)

Answer

Hysteroscopy

Question 9

What is the tocolytic of choice in HELLP syndrome?

Accepted Answer

Atosiban

Answer

Nifedipine

Answer

Magnesium sulfate

Answer

Salbutamol

Question 10

Rh isoimmunization is typically identified in which trimester?

Accepted Answer

30-32 weeks

Answer

10-12 weeks

Answer

36 weeks

Answer

Immediately after delivery

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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