Maternal-Fetal Medicine Practice Questions

Q: Which of the following is NOT an explanation for decreased variability of the fetal heart rate tracing?

Fetal stimulation. **Explanation:** Fetal heart rate (FHR) variability represents the fine-tuning of the fetal cardiac output by the interplay between the sympathetic and parasympathetic nervous systems. It is the single most important indicator of an intact neurological pathway and fetal oxygenation. **Why Fetal Stimulation is the correct answer:** Fetal stimulation (e.g., scalp stimulation or vibroacoustic stimulation) is used to provoke a response in a fetus with a non-reactive or quiet trace. It typically causes **increased variability** and **accelerations**, confirming fetal well-being and the absence of acidosis. Therefore, it does not cause decreased variability. **Why the other options are incorrect:** * **Fetal sleep state:** This is the most common cause of transiently decreased variability. Fetal "quiet sleep" cycles usually last 20–40 minutes; if variability is low, the clinician should wait or stimulate the fetus to rule out sleep. * **Prematurity:** Variability is dependent on the maturation of the autonomic nervous system. In very preterm fetuses (especially <28 weeks), the parasympathetic system is underdeveloped, leading to naturally lower baseline variability. * **Barbiturate ingestion:** Central nervous system (CNS) depressants, including barbiturates, benzodiazepines, and opioids (like pethidine), cross the placenta and suppress fetal brain activity, leading to a "flat" or diminished variability trace. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Normal variability is **6–25 bpm**. * **Minimal variability:** ≤5 bpm; **Absent:** Undetectable; **Marked:** >25 bpm. * **Sinusoidal Pattern:** A specific type of absent variability indicating severe fetal anemia (e.g., Rh isoimmunization) or acute hypoxia. * **Management:** If decreased variability persists >40 minutes despite stimulation, consider fetal hypoxia, acidosis, or drug effects.

Q: Which maternal condition is associated with the following fetal anomaly?

Diabetes Mellitus (DM). ***Diabetes Mellitus (DM)*** - **Caudal regression syndrome** (sacral agenesis) is the pathognomonic fetal anomaly associated with **pre-gestational diabetes mellitus** (Type 1 or Type 2 DM). - **Pre-conception hyperglycemia** during organogenesis leads to **neural crest cell disruption**, affecting sacral and lower lumbar vertebrae development. *Gestational Diabetes Mellitus (GDM)* - GDM typically causes **fetal macrosomia** and **metabolic complications** rather than structural anomalies like caudal regression syndrome. - Onset occurs after **20 weeks gestation**, well after the critical period for **organogenesis** when structural defects develop. *Intake of ACE inhibitors* - ACE inhibitors cause **renal tubular dysgenesis** and **oligohydramnios**, leading to **Potter sequence** with facial deformities. - Associated with **intrauterine growth restriction (IUGR)** and **renal failure**, not spinal defects like sacral agenesis. *Intake of sodium valproate* - Sodium valproate is associated with **neural tube defects** such as **spina bifida** and **anencephaly**. - Also causes **valproate syndrome** with characteristic facial dysmorphism and **cognitive impairment**, distinct from caudal regression syndrome.

Q: On a routine first-trimester ultrasound at 6 weeks, the gestational sac is seen separate from the endometrium and more than 1 cm away from the most lateral edge of the uterine cavity. The "interstitial line sign" is observed. What is your diagnosis?

Interstitial pregnancy. **Explanation:** The correct diagnosis is **Interstitial pregnancy**, a specific type of ectopic pregnancy where the blastocyst implants within the proximal, intramural portion of the fallopian tube as it traverses the muscular uterine wall. **Why it is correct:** The diagnosis is confirmed by three classic sonographic criteria: 1. **Empty uterine cavity:** The gestational sac is seen separate from the endometrium. 2. **Eccentric location:** The sac is located more than 1 cm from the most lateral edge of the uterine cavity. 3. **Interstitial line sign:** This is a highly specific high-yield finding where a thin echogenic line extends from the endometrial canal to the center of the ectopic gestational sac, representing the interstitial portion of the fallopian tube. **Why the other options are incorrect:** * **Angular pregnancy:** The embryo implants in the lateral angle of the uterine cavity, *medial* to the uterotubal junction. Unlike interstitial pregnancy, it is surrounded by myometrium and can potentially progress to a viable term delivery, though with higher risks. * **Cornual pregnancy:** This term is often used interchangeably but strictly refers to a pregnancy in the horn of a **bicornuate or unicornuate uterus**. * **Isthmic pregnancy:** This refers to an ectopic pregnancy in the narrow, extra-uterine portion of the fallopian tube (isthmus), not within the uterine wall. **Clinical Pearls for NEET-PG:** * **Risk of Rupture:** Interstitial pregnancies often rupture later (12–14 weeks) than other tubal pregnancies because the myometrium allows for more expansion. * **Hemorrhage:** Rupture can lead to catastrophic, life-threatening hemorrhage due to the proximity of the **uterine and ovarian artery anastomosis** (Sampson’s artery). * **Management:** While methotrexate can be used in stable cases, surgical management often requires cornual resection or hysterectomy.

Q: Placental villi invading through the serosa of the uterus falls under which category?

Placenta percreta. **Explanation:** The question describes a spectrum of **Morbidly Adherent Placenta (MAP)**, where there is an abnormal attachment of the placenta to the uterine wall due to the absence or deficiency of the **Nitabuch’s layer** (decidua basalis). **Why Option D is Correct:** * **Placenta Percreta:** This is the most severe form. The chorionic villi penetrate through the entire thickness of the myometrium and breach the **uterine serosa**. In some cases, it may even invade adjacent organs, most commonly the urinary bladder. **Why Other Options are Incorrect:** * **A. Placenta Previa:** This refers to the abnormal *location* of the placenta (implanted in the lower uterine segment), not the depth of invasion. * **B. Placenta Accreta:** The villi are attached directly to the myometrium but do not invade it. This is the most common type (approx. 75-80%). * **C. Placenta Increta:** The villi invade deep **into** the myometrium but do not reach or pass through the serosa. **NEET-PG High-Yield Pearls:** 1. **Risk Factors:** The single most important risk factor is a **previous Cesarean Section** combined with **Placenta Previa**. The risk increases linearly with the number of prior C-sections. 2. **Diagnosis:** Antenatal diagnosis is primarily via **Ultrasound/Color Doppler**. Look for "placental lacunae" (Swiss cheese appearance) and loss of the retroplacental clear zone. 3. **Management:** The gold standard management for confirmed percreta is a **planned Cesarean Hysterectomy**. 4. **Complication:** The most common and life-threatening complication is massive postpartum hemorrhage (PPH).

Q: The McAfee and Johnson regimen is used for which of the following conditions?

Placenta previa. **Explanation:** The **McAfee and Johnson regimen** (also known as the expectant management of placenta previa) is the gold standard for managing asymptomatic or hemodynamically stable patients with placenta previa before 37 weeks of gestation. **Why it is correct:** The primary goal of this regimen is to prolong pregnancy to achieve fetal lung maturity while ensuring maternal safety. It is indicated when the fetus is preterm ( 10 g/dL. * Rh-immunoglobulin if the mother is Rh-negative. **Why other options are incorrect:** * **Eclampsia:** Managed using the **Pritchard regimen** or **Zuspan regimen** (Magnesium Sulfate) to control seizures. * **Placental Abruption:** Usually requires definitive management (delivery) rather than expectant management, as it poses an immediate risk of DIC and fetal distress. * **Placenta Accreta:** This is a surgical emergency typically managed by planned cesarean hysterectomy; expectant management is not the standard "McAfee" protocol. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisite:** The first step in suspected placenta previa is a **Transvaginal Ultrasound (TVS)**; per-vaginal examination is strictly contraindicated (can cause torrential hemorrhage). * **Termination:** Expectant management is terminated at **37 weeks** or if heavy bleeding/fetal distress occurs. * **Stallworthy’s Sign:** A clinical sign where the fetal head is displaced anteriorly or posteriorly due to a low-lying placenta.

Q: A non-stress test (NST) performed on a 36-week pregnant diabetic female is non-reactive. What is the recommended next step?

Proceed to biophysical profile assessment. **Explanation:** The **Non-Stress Test (NST)** is a screening tool used to assess fetal well-being by observing the fetal heart rate (FHR) response to fetal movement. A **non-reactive NST** (defined as fewer than two accelerations of at least 15 bpm lasting 15 seconds over a 20-minute period) is a sensitive but non-specific finding. It may indicate fetal hypoxia, but it is frequently caused by a **fetal sleep cycle** (which can last up to 40 minutes) or maternal drug use. **Why Option D is correct:** Because a non-reactive NST has a high false-positive rate, it must be followed by a more specific backup test to confirm fetal compromise. The **Biophysical Profile (BPP)** or a **Contraction Stress Test (CST)** are the standard next steps. The BPP evaluates acute (NST, breathing, movement, tone) and chronic (amniotic fluid volume) markers of fetal health, providing a more accurate assessment of whether the fetus is truly in distress. **Why incorrect options are wrong:** * **Options A & B:** Immediate delivery (Induction or LSCS) is premature without confirming fetal distress. Delivering a 36-week fetus unnecessarily increases the risk of respiratory distress syndrome and prematurity-related complications. * **Option C:** While acoustic stimulation can be used to "wake" a fetus, the standard protocol after a confirmed non-reactive 40-minute NST is to proceed to a BPP or CST rather than simply repeating the same test an hour later. **Clinical Pearls for NEET-PG:** * **Most common cause of a non-reactive NST:** Fetal sleep cycle. * **BPP Components:** Tone, Movement, Breathing, NST, and Amniotic Fluid (Mnemonic: **T**he **M**any **B**abies **N**eed **A**ir). * **Modified BPP:** Consists of NST + Amniotic Fluid Index (AFI). * **High-yield:** A BPP score of 8-10 is normal; 4 or less is an indication for delivery.

Q: A 30-year-old woman presents with amenorrhoea of 6 weeks duration and a lump in the right iliac fossa. What is the investigation of choice?

Ultrasound abdomen. **Explanation:** The clinical presentation of **amenorrhoea (6 weeks)** combined with a **lump in the right iliac fossa** in a woman of reproductive age is highly suspicious for an **Ectopic Pregnancy** or a **Corpus Luteum cyst**. **Why Ultrasound (USG) is the Investigation of Choice:** Ultrasound (specifically Transvaginal Sonography/TVS) is the gold standard first-line investigation for early pregnancy complications. It is non-invasive, cost-effective, and lacks ionizing radiation, making it safe for the fetus. It can accurately confirm intrauterine pregnancy, identify an adnexal mass (like a tubal pregnancy), and detect free fluid in the Pouch of Douglas (suggestive of rupture). **Analysis of Incorrect Options:** * **Laparoscopy (Option B):** While it is the **Gold Standard for diagnosis** and treatment of ectopic pregnancy, it is an invasive surgical procedure. It is reserved for cases where USG is inconclusive or the patient is hemodynamically unstable. * **Shielded CT scan (Option C):** CT involves high doses of ionizing radiation. Even with shielding, it is contraindicated in early pregnancy due to the risk of teratogenicity and is less sensitive than USG for pelvic structures. * **X-ray (Option D):** X-rays have no role in diagnosing early pregnancy or soft tissue pelvic masses and pose a radiation risk. **High-Yield Clinical Pearls for NEET-PG:** * **Discriminatory Zone:** The level of serum β-hCG at which an intrauterine gestational sac should be visible on USG (TVS: 1500–2000 mIU/ml; TAS: 6500 mIU/ml). * **Classic Triad of Ectopic Pregnancy:** Amenorrhoea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Most common site of Ectopic Pregnancy:** Ampulla of the Fallopian tube.

Q: A woman in her first pregnancy reports that she smokes one pack of cigarettes a day. An ultrasound is ordered in the thirty-second week of the pregnancy to evaluate for which of the following?

Fetal size. **Explanation:** **1. Why "Fetal size" is the correct answer:** Cigarette smoking during pregnancy is a well-established risk factor for **Fetal Growth Restriction (FGR)**. Nicotine and carbon monoxide in tobacco smoke cause systemic vasoconstriction and increase carboxyhemoglobin levels, leading to chronic placental insufficiency and reduced oxygen delivery to the fetus. This typically results in "asymmetric" growth restriction. Since the risk of FGR increases as the pregnancy progresses, a 32-week ultrasound is specifically indicated to assess fetal biometry (size) and estimated fetal weight to ensure the fetus is growing appropriately for its gestational age. **2. Why the other options are incorrect:** * **Amniotic fluid volume:** While oligohydramnios can be associated with placental insufficiency, it is usually a secondary finding. The primary concern with smoking is the direct impact on fetal weight and size. * **Fetal abnormalities:** Smoking is not a major teratogen associated with structural malformations detectable at 32 weeks. Screening for structural anomalies is ideally performed during the "Level II" anomaly scan at 18–20 weeks. * **Fetal motion:** Fetal movement is a marker of acute fetal well-being (biophysical profile). While important, it is not the specific pathology linked to the chronic vascular effects of smoking. **Clinical Pearls for NEET-PG:** * **Dose-Response Relationship:** The reduction in birth weight is directly proportional to the number of cigarettes smoked (approx. 15–20g reduction per cigarette per day). * **Smoking & Placenta:** Smoking increases the risk of **Placenta Previa** and **Abruptio Placentae**. * **Postnatal Risks:** Maternal smoking is a significant risk factor for **Sudden Infant Death Syndrome (SIDS)** and childhood respiratory infections.

Question 1

Which of the following is NOT an explanation for decreased variability of the fetal heart rate tracing?

Accepted Answer

Fetal stimulation

Answer

Fetal sleep state

Answer

Prematurity

Answer

Barbiturate ingestion

Question 2

Which maternal condition is associated with the following fetal anomaly?

Accepted Answer

Diabetes Mellitus (DM)

Answer

Gestational Diabetes Mellitus (GDM)

Answer

Intake of ACE inhibitors

Answer

Intake of sodium valproate

Question 3

On a routine first-trimester ultrasound at 6 weeks, the gestational sac is seen separate from the endometrium and more than 1 cm away from the most lateral edge of the uterine cavity. The "interstitial line sign" is observed. What is your diagnosis?

Accepted Answer

Interstitial pregnancy

Answer

Angular pregnancy

Answer

Cornual pregnancy

Answer

Isthmic pregnancy

Question 4

Placental villi invading through the serosa of the uterus falls under which category?

Accepted Answer

Placenta percreta

Answer

Placenta previa

Answer

Placenta accreta

Answer

Placenta increta

Question 5

The McAfee and Johnson regimen is used for which of the following conditions?

Accepted Answer

Placenta previa

Answer

Eclampsia

Answer

Placental abruption

Answer

Placenta accreta

Question 6

A non-stress test (NST) performed on a 36-week pregnant diabetic female is non-reactive. What is the recommended next step?

Accepted Answer

Proceed to biophysical profile assessment

Answer

Induction of labor

Answer

Lower segment cesarean section (LSCS)

Answer

Repeat non-stress test (NST) after 1 hour

Question 7

A 35-week pregnant female presents to the emergency department with complaints of headache and blurred vision. Her blood pressure is 170/110 mm Hg. How should this patient be managed?

Accepted Answer

Admit, start magnesium sulfate and antihypertensives, and terminate the pregnancy

Answer

Admit and observe

Answer

Admit, control blood pressure, and continue pregnancy until term

Answer

Start antihypertensives and follow up in the outpatient department

Question 8

A pregnant woman at 32 weeks gestation presents for routine antenatal checkup. Examination reveals pedal edema and her blood pressure on repeated recordings is 150/100 mm Hg. Her urine protein is 2+. Which of the following will be the first-line drug of choice in this patient?

Accepted Answer

Nifedipine

Answer

Metoprolol

Answer

Methyldopa

Answer

Losartan

Question 9

A 30-year-old woman presents with amenorrhoea of 6 weeks duration and a lump in the right iliac fossa. What is the investigation of choice?

Accepted Answer

Ultrasound abdomen

Answer

Laparoscopy

Answer

Shielded CT scan

Answer

X-ray

Question 10

A woman in her first pregnancy reports that she smokes one pack of cigarettes a day. An ultrasound is ordered in the thirty-second week of the pregnancy to evaluate for which of the following?

Accepted Answer

Fetal size

Answer

Amniotic fluid volume

Answer

Fetal abnormalities

Answer

Fetal motion

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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