Maternal-Fetal Medicine Practice Questions

Q: Which of the following signs is observed in intrauterine fetal demise?

Roberts sign. **Explanation:** **Robert’s Sign** is a classic radiological finding in **Intrauterine Fetal Demise (IUFD)**. It refers to the presence of gas (usually nitrogen) in the fetal heart and large blood vessels (like the aorta). This occurs due to the decomposition of fetal blood and is typically visible on an X-ray or ultrasound within 12 to 24 hours after fetal death. It is often the earliest radiological sign of IUFD. **Analysis of Incorrect Options:** * **Von Braun-Fernwald’s Sign:** This is a sign of **early pregnancy** (around 5–8 weeks) characterized by an irregular softening and enlargement of the uterine fundus at the site of implantation. * **Goodell’s Sign:** This refers to the **softening of the cervix**, a clinical sign of pregnancy usually detectable by the 6th week of gestation. * **Osiander’s Sign:** This is the feeling of **increased pulsations** in the lateral vaginal fornices due to increased vascularity of the uterus during early pregnancy (around 8 weeks). **High-Yield Clinical Pearls for NEET-PG:** * **Spalding’s Sign:** Another crucial sign of IUFD; it refers to the **overlapping of fetal skull bones** due to the liquefaction of the brain and loss of alignment. It usually appears 4–7 days after death. * **Deuel’s Halo Sign:** An X-ray finding in IUFD where an edematous scalp separates from the skull, creating a "halo" appearance. * **Confirmatory Test:** While these radiological signs are historically important, the **gold standard** for diagnosing IUFD today is the **absence of fetal cardiac activity on Real-Time Ultrasonography.**

Q: All the following are used in hypertensive emergencies in preeclampsia except?

Methyldopa. In a hypertensive emergency during pregnancy (defined as BP ≥160/110 mmHg), the goal is to rapidly lower blood pressure to prevent maternal stroke and encephalopathy. **Why Methyldopa is the correct answer (the "Except"):** Methyldopa is a centrally acting alpha-2 agonist. While it is the **drug of choice for chronic hypertension** in pregnancy, it is **not used in emergencies**. This is because it has a slow onset of action (4–6 hours) and a peak effect that takes up to 24 hours. In an acute crisis, drugs with a rapid onset (minutes) are required. **Explanation of incorrect options (Drugs used in emergencies):** * **Labetalol (IV):** A combined alpha and beta-blocker. It is often the first-line agent due to its rapid onset (5–10 mins) and favorable safety profile. * **Hydralazine (IV):** A direct vasodilator. It was traditionally the gold standard for acute hypertensive crisis in pregnancy. It is effective but may cause reflex tachycardia and headache. * **Nifedipine (Oral):** A calcium channel blocker (short-acting/immediate-release). It is highly effective, easy to administer orally, and has a rapid onset (10–20 mins). **High-Yield Clinical Pearls for NEET-PG:** 1. **Drug of Choice (DOC) for Chronic HTN in pregnancy:** Methyldopa. 2. **DOC for Hypertensive Emergency in pregnancy:** IV Labetalol (per ACOG/FOGSI). 3. **DOC for Eclampsia (Seizures):** Magnesium Sulfate ($MgSO_4$) – *Note: $MgSO_4$ is an anticonvulsant, not an antihypertensive.* 4. **Contraindicated Antihypertensives:** ACE inhibitors and ARBs (due to fetal renal dysgenesis and oligohydramnios) and Sodium Nitroprusside (risk of fetal cyanide poisoning, used only as a last resort).

Q: What is the best investigation to diagnose ectopic pregnancy?

Laparoscopy. **Explanation:** The diagnosis of ectopic pregnancy relies on a combination of clinical, biochemical, and radiological findings. However, **Laparoscopy** remains the **Gold Standard** and the best investigation for a definitive diagnosis. 1. **Why Laparoscopy is Correct:** Laparoscopy allows for direct visualization of the fallopian tubes, ovaries, and pelvic cavity. It provides a definitive diagnosis by confirming the presence of a gestational sac outside the uterine cavity and simultaneously offers the opportunity for immediate surgical management (e.g., salpingectomy or salpingostomy). 2. **Why other options are incorrect:** * **Urine Pregnancy Test:** This is a screening tool used to confirm pregnancy (by detecting hCG) but cannot differentiate between an intrauterine and an ectopic pregnancy. * **Ultrasound (USG):** Transvaginal Sonography (TVS) is the **investigation of choice** (first-line) and the most common way to diagnose ectopic pregnancy non-invasively. However, it may sometimes yield indeterminate results (e.g., Pregnancy of Unknown Location), making it less definitive than direct visualization via laparoscopy. * **Hysteroscopy:** This involves visualizing the *inside* of the uterine cavity. While it can confirm the absence of an intrauterine pregnancy, it cannot visualize the adnexa where most ectopic pregnancies occur. **Clinical Pearls for NEET-PG:** * **Gold Standard/Best Investigation:** Laparoscopy. * **Investigation of Choice (First-line):** Transvaginal Ultrasound (TVS). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Discriminatory Zone:** The level of serum β-hCG (usually 1500–2000 mIU/mL) at which a normal intrauterine pregnancy should be visible on TVS. If hCG is above this level and the uterus is empty, ectopic pregnancy is highly suspected. * **Most common site:** Ampulla of the Fallopian tube.

Q: What is the recommended treatment for an ovarian tumor diagnosed during the first trimester of pregnancy?

Ovarian cystectomy in the second trimester. **Explanation:** The management of an adnexal mass in pregnancy depends on the gestational age and the risk of malignancy or complications (torsion/rupture). **Why Option D is correct:** The **second trimester (specifically 14–20 weeks)** is the "golden window" for surgical intervention. By this time, the placenta has taken over progesterone production, so the removal of the corpus luteum (if necessary) will not cause a miscarriage. Additionally, the uterus is not yet large enough to obstruct the surgical field, and the risk of preterm labor is significantly lower than in the third trimester. **Why other options are incorrect:** * **Option A:** Surgery in the third trimester is technically difficult due to the large gravid uterus and carries a high risk of triggering preterm labor. * **Options B & C:** Ignoring the tumor is dangerous. Large or persistent tumors (>5–6 cm) carry a 10–15% risk of **ovarian torsion**, rupture, or labor dystocia. Furthermore, while most masses are benign (e.g., dermoid cysts), the risk of malignancy must be addressed. **NEET-PG High-Yield Pearls:** * **Most common ovarian tumor in pregnancy:** Mature cystic teratoma (Dermoid cyst). * **Most common complication:** Torsion (most frequent during the 1st trimester or early postpartum). * **Indications for surgery:** Mass >6 cm, solid components on USG, or symptoms of torsion/rupture. * **Laparoscopy vs. Laparotomy:** Laparoscopy is now considered safe in pregnancy when performed by experts, preferably in the second trimester.

Q: All are complications of fibroid in pregnancy except:

Placenta previa. **Explanation:** The correct answer is **Placenta previa**. In medical entrance exams like NEET-PG, it is crucial to distinguish between conditions *caused* by a fibroid and conditions that are merely coincidental. While fibroids are associated with an increased risk of placental abruption (due to impaired implantation over a submucosal fibroid), they do not cause placenta previa. Placenta previa is primarily related to factors like previous scarring (C-sections) or multiparity. **Analysis of Options:** * **Red Degeneration (Option A):** This is the most common complication of fibroids during the **second trimester**. It occurs due to rapid growth leading to venous obstruction and infarction. It presents with acute pain, fever, and localized tenderness. * **Obstructed Labor (Option B):** Large subserosal or intramural fibroids located in the lower uterine segment or cervix can physically block the birth canal, preventing the descent of the fetal head and necessitating a Cesarean section. * **PPH (Option C):** Fibroids interfere with the effective contraction and retraction of uterine muscle fibers after delivery (uterine atony), which is a major cause of Postpartum Hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **Most common change** in fibroid during pregnancy: No change (though 20-30% increase in size). * **Most common degeneration** in pregnancy: Red degeneration (Necrobiosis). * **Management of Red Degeneration:** Always conservative (bed rest, analgesics like NSAIDs). Surgery (Myomectomy) is contraindicated during pregnancy due to high risk of hemorrhage. * **Malpresentations:** Fibroids increase the risk of breech or transverse lie due to distortion of the uterine cavity.

Q: Stillbirth is defined as the birth of a dead newborn child after how many completed weeks of gestation?

28. **Explanation:** The definition of **Stillbirth** varies globally based on the criteria used (WHO vs. National guidelines). In the context of the Indian healthcare system and the National Health Mission (NHM), stillbirth is defined as a baby born with no signs of life at or after **28 completed weeks of gestation**. **1. Why 28 weeks is correct:** In India, the legal and clinical threshold for "viability" (the ability of the fetus to survive outside the womb) is traditionally considered 28 weeks. Any fetal death occurring after this period but before birth is classified as a stillbirth. This aligns with the International Classification of Diseases (ICD-10) recommendation for international reporting. **2. Analysis of Incorrect Options:** * **20 weeks (Option A):** This is the threshold used in many developed countries (like the USA) where neonatal intensive care is more advanced. In India, fetal loss before 20–22 weeks is generally classified as an **Abortion (Miscarriage)**. * **37 weeks (Option B):** This marks the beginning of **Term** pregnancy. A fetal death between 28 and 37 weeks is a preterm stillbirth, while after 37 weeks, it is a term stillbirth. * **40 weeks (Option D):** This is the expected date of delivery (EDD). Death at this stage is a post-term or term stillbirth. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Definition:** For international comparison, WHO defines stillbirth as fetal death at **≥28 weeks** or birth weight **≥1000g**. * **Fresh vs. Macerated:** A "Fresh Stillbirth" (death <24 hours before delivery) suggests intrapartum complications, while a "Macerated Stillbirth" (peeling skin, skull collapse) suggests the fetus died in utero days before delivery. * **Spalding’s Sign:** Overlapping of skull bones on X-ray, a classic sign of fetal death (usually appears 4–7 days after death).

Q: The theorized function of the Hyl anastomosis is equalization of which of the following pressure gradients?

Pressure gradient between umbilical arteries. **Explanation:** The **Hyrtl anastomosis** (often referred to as the Hyl anastomosis in some texts) is a unique vascular shunt located on the fetal surface of the placenta, typically within 1–2 cm of the umbilical cord insertion. It represents a transverse connection between the two umbilical arteries. **Why the correct answer is right:** The primary physiological function of the Hyrtl anastomosis is to act as a **pressure-equalizing valve** between the two umbilical arteries. This ensures that blood flow is distributed evenly to all lobes of the placenta, even if one umbilical artery is partially compressed or if there is asymmetrical resistance in the placental vascular beds. It prevents "backflow" and maintains a stable hemodynamic environment for fetal-maternal exchange. **Analysis of Incorrect Options:** * **Option A:** Oxygen diffusion occurs at the level of the terminal villi in the intervillous space, governed by Fick’s law, not by macro-vascular shunts like the Hyrtl anastomosis. * **Option B:** Osmotic gradients across membranes regulate amniotic fluid volume and electrolyte balance; they are unrelated to the arterial shunts of the umbilical cord. * **Option C:** Spiral arteries are maternal vessels located in the decidua basalis. The Hyrtl anastomosis is a fetal structure located on the chorionic plate. **Clinical Pearls for NEET-PG:** * **Location:** It is the only connection between the two umbilical arteries before they branch into the chorionic villi. * **Safety Mechanism:** In cases of a **Single Umbilical Artery (SUA)**, this anastomosis is absent, which is associated with an increased risk of IUGR and congenital anomalies. * **Flow Direction:** Blood usually flows from the artery with higher pressure to the one with lower pressure, ensuring the entire placenta is perfused even during uterine contractions.

Q: A gravida 3 female with a history of two prior second-trimester abortions associated with painless cervical dilatation presents with Level II ultrasound findings. What is the most appropriate management?

Apply McDonald suture. ***Apply McDonald suture*** - History of two prior **second-trimester abortions** with **painless cervical dilatation** indicates **cervical incompetence**, requiring **cervical cerclage**. - **McDonald cerclage** is the standard procedure for cervical incompetence, using a **purse-string suture** around the cervix to provide mechanical support. *Administer progesterone* - **Progesterone** is used as adjunctive therapy for **short cervix** but is not the definitive treatment for **cervical incompetence**. - It may help maintain pregnancy but cannot provide the **mechanical support** needed to prevent cervical dilatation. *Apply Fothergill suture* - **Fothergill suture** refers to the **Manchester operation** for **uterovaginal prolapse**, not cervical incompetence. - This procedure involves **amputation of the cervix** and **cardinal ligament shortening**, which is inappropriate for pregnancy management. *Wait and watch* - **Expectant management** is inappropriate given the clear history of **recurrent second-trimester losses** due to cervical incompetence. - **Level II ultrasound** likely shows **cervical funneling** or **short cervix**, indicating active cervical changes requiring immediate intervention.

Question 1

A 37-week pregnant woman presents with bleeding per vagina. Investigations reveal a severe degree of placenta previa. What is the appropriate management?

Accepted Answer

Immediate Cesarean section

Answer

Blood transfusion

Answer

Conservative management

Answer

Medical induction of labor

Question 2

Which of the following steps are useful in the perinatal prevention of mother-to-child transmission?

Accepted Answer

Antiretroviral prophylaxis

Answer

Cleaning the mother's vagina with antiseptic lotion

Answer

Elective Cesarean section

Answer

Avoiding breastfeeding

Question 3

Which of the following signs is observed in intrauterine fetal demise?

Accepted Answer

Roberts sign

Answer

Von Braun-Fernwalds sign

Answer

Goodell's sign

Answer

Osiander's sign

Question 4

All the following are used in hypertensive emergencies in preeclampsia except?

Accepted Answer

Methyldopa

Answer

Nifedipine

Answer

Labetalol

Answer

Hydralazine

Question 5

What is the best investigation to diagnose ectopic pregnancy?

Accepted Answer

Laparoscopy

Answer

Urine pregnancy test

Answer

Ultrasound (USG)

Answer

Hysteroscopy

Question 6

What is the recommended treatment for an ovarian tumor diagnosed during the first trimester of pregnancy?

Accepted Answer

Ovarian cystectomy in the second trimester

Answer

Surgery in the third trimester

Answer

No surgery is needed

Answer

Ignore the tumor

Question 7

All are complications of fibroid in pregnancy except:

Accepted Answer

Placenta previa

Answer

Red degeneration

Answer

Obstructed labor

Answer

PPH

Question 8

Stillbirth is defined as the birth of a dead newborn child after how many completed weeks of gestation?

Accepted Answer

28

Answer

20

Answer

37

Answer

40

Question 9

The theorized function of the Hyl anastomosis is equalization of which of the following pressure gradients?

Accepted Answer

Pressure gradient between umbilical arteries

Answer

Oxygen diffusion across villi

Answer

Osmotic gradient across fetal membranes

Answer

Pressure gradient between spiral arteries

Question 10

A gravida 3 female with a history of two prior second-trimester abortions associated with painless cervical dilatation presents with Level II ultrasound findings. What is the most appropriate management?

Accepted Answer

Apply McDonald suture

Answer

Administer progesterone

Answer

Apply Fothergill suture

Answer

Wait and watch

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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