Maternal-Fetal Medicine Practice Questions

Q: Which of the following is a side effect of magnesium sulfate?

Hypotonia. **Explanation:** Magnesium sulfate ($MgSO_4$) is the drug of choice for seizure prophylaxis in pre-eclampsia and control in eclampsia. Its primary mechanism involves blocking neuromuscular transmission by decreasing the amount of acetylcholine released at the motor endplate. **Why Hypotonia is correct:** As a neuromuscular blocker and CNS depressant, magnesium causes generalized muscle relaxation. In the mother, this manifests as a loss of deep tendon reflexes (the first sign of toxicity). If it crosses the placenta, it can cause **neonatal hypotonia** (floppy baby syndrome) and respiratory depression, especially if administered shortly before delivery. **Analysis of Incorrect Options:** * **Anuria:** $MgSO_4$ is excreted almost exclusively by the kidneys. While renal failure leads to magnesium toxicity, the drug itself does not cause anuria. In fact, monitoring urine output ($>30$ ml/hr) is mandatory to prevent toxicity. * **Coma:** While severe toxicity can lead to CNS depression and somnolence, "Coma" is an extreme end-stage manifestation. Hypotonia and loss of reflexes are much more characteristic and common side effects. * **Pulmonary Edema:** This is a known complication of pre-eclampsia and can be exacerbated by fluid overload during $MgSO_4$ administration, but it is not a direct pharmacological side effect of the magnesium ion itself. **NEET-PG High-Yield Pearls:** * **Monitoring Parameters:** 1. Patellar reflex (earliest sign of toxicity: loss of reflex at 7–10 mEq/L); 2. Respiratory rate ($>12$/min); 3. Urine output ($>100$ ml/4 hours). * **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (administered over 10 minutes). * **Therapeutic Range:** 4–7 mEq/L. Respiratory paralysis occurs at $>12$ mEq/L and cardiac arrest at $>25$ mEq/L.

Q: Which of the following is NOT an unequivocal evidence of heart disease in pregnancy?

Systolic murmur. **Explanation:** In pregnancy, physiological changes such as increased blood volume, decreased blood viscosity, and a hyperdynamic circulation often lead to the development of **functional (innocent) murmurs**. **1. Why Systolic Murmur is the Correct Answer:** A **systolic murmur** (specifically a soft, mid-systolic ejection murmur) is found in up to 90% of healthy pregnant women. It is caused by increased flow across the pulmonary and aortic valves. Because it is a common physiological finding, it is **not** unequivocal evidence of organic heart disease. **2. Why the other options are wrong (Evidence of Organic Disease):** * **Diastolic Murmur (Option B):** Diastolic murmurs are **always pathological** in pregnancy. They usually indicate underlying conditions like Mitral Stenosis (the most common rheumatic heart lesion in pregnancy) or Aortic Regurgitation. * **Diastolic/Systolic Thrills (Options C & D):** The presence of a **thrill** (a palpable murmur) signifies a high-grade turbulence that is never physiological. A systolic thrill usually indicates severe valvular stenosis or a Ventricular Septal Defect (VSD). **High-Yield Clinical Pearls for NEET-PG:** * **Burwell’s Criteria:** Organic heart disease is diagnosed if any of the following are present: 1. Diastolic, presystolic, or continuous murmur. 2. Cardiac enlargement (clinically or via X-ray). 3. Loud systolic murmur associated with a **thrill**. 4. Severe arrhythmia (e.g., Atrial Fibrillation). * **Most common heart disease in pregnancy (India):** Rheumatic Heart Disease (Mitral Stenosis is the most common lesion). * **Most common congenital heart disease:** ASD (Atrial Septal Defect). * **Dangerous Period:** The risk of heart failure is highest at **28–32 weeks** (peak blood volume), during **labor**, and immediately **postpartum** (due to autotransfusion from the uterus).

Q: Which of the following tests is not used for the detection of specific aneuploidy?

Microarray. **Explanation:** The core of this question lies in distinguishing between **numerical** chromosomal abnormalities (aneuploidy) and **structural** sub-microscopic abnormalities (copy number variants). **Why Microarray is the correct answer:** Chromosomal Microarray (CMA) is designed to detect **microdeletions and microduplications** (Copy Number Variations - CNVs) that are too small to be seen under a microscope. While it can detect unbalanced rearrangements, it is **not** the primary tool for specific aneuploidy detection because it cannot detect balanced translocations or triploidy effectively. In clinical practice, if a specific aneuploidy (like Trisomy 21) is suspected, rapid molecular tests or karyotyping are preferred. **Why the other options are incorrect:** * **FISH (Fluorescent In Situ Hybridization):** Uses fluorescent probes to bind to specific chromosomes (13, 18, 21, X, Y). It is a rapid gold-standard test for detecting specific aneuploidies in interphase nuclei. * **QF-PCR (Quantitative Fluorescent PCR):** Amplifies polymorphic microsatellite markers. It is the fastest method (24–48 hours) specifically used to diagnose common autosomal and sex chromosome aneuploidies. * **Karyotyping:** The traditional "gold standard" that provides a visual representation of all chromosomes. It identifies both numerical (aneuploidy) and large structural abnormalities (>5-10 Mb). **Clinical Pearls for NEET-PG:** * **Rapid Aneuploidy Testing:** FISH and QF-PCR are the preferred methods for quick results (e.g., following an abnormal prenatal screen). * **Microarray Indication:** It is the **first-line investigation** for a fetus with one or more structural ultrasound abnormalities but a normal karyotype. * **Karyotyping Limitation:** It requires cell culture (takes 2–3 weeks), whereas molecular methods (QF-PCR/FISH) do not. * **Triploidy:** QF-PCR is superior to Microarray in detecting triploidy.

Q: A pregnant woman presents with a major degree placenta previa and a malformed fetus. What is the best management approach?

Cesarean section. **Explanation:** The management of placenta previa is primarily dictated by the degree of the previa and the maternal hemodynamic status, rather than the condition of the fetus. **1. Why Cesarean Section is Correct:** In cases of **major degree placenta previa** (Grade III and IV), the placenta completely or partially covers the internal os. This creates a physical barrier to vaginal delivery and, more importantly, poses a massive risk of life-threatening maternal hemorrhage if the cervix begins to dilate or if any attempt at vaginal delivery is made. Even if the fetus is malformed or dead, the **maternal safety** takes precedence. A Cesarean section is mandatory to bypass the obstruction and control bleeding, regardless of fetal viability or anomalies. **2. Why Incorrect Options are Wrong:** * **Oxytocin drip & Rupture of membranes (ARM):** These are methods to induce or augment labor. In major placenta previa, uterine contractions and cervical dilatation will cause placental separation from the lower uterine segment, leading to torrential, uncontrollable bleeding. ARM is only considered in minor degrees (Grade I or II-anterior). * **Instillation of Prostaglandin E2:** This is used for cervical ripening and induction. Similar to oxytocin, inducing labor in a major previa is contraindicated due to the risk of maternal exsanguination. **Clinical Pearls for NEET-PG:** * **Macafee’s Regimen:** Expectant management used to gain fetal maturity, but only if the mother is stable and bleeding has stopped. * **Double Set-up Examination:** Only performed in the OT (ready for immediate CS) for cases of minor/doubtful placenta previa to decide the mode of delivery. * **Rule of Thumb:** In placenta previa, "The life of the mother is always more important than the condition of the fetus." Major degree = Mandatory CS.

Q: A 25-year-old pregnant woman diagnosed with Rheumatic Heart Disease and Mitral Stenosis at 16 years of age presents at 6 weeks of gestation with a mitral valve area of 1.4 sq cm. She is currently in NYHA class 2 and on antiarrhythmic drugs. What is the risk of maternal mortality?

1.5 cm²) or **moderate** (Valve area 1.0–1.5 cm²) and the patient is asymptomatic or mildly symptomatic (NYHA Class I or II). * For mWHO Class II, the risk of maternal mortality is extremely low, typically **<1%**. Although she is on antiarrhythmics, her valve area (1.4 cm²) and functional status (NYHA II) do not place her in a high-risk category. 2. **Why incorrect options are wrong:** * **Options B, C, and D (5% to 50%):** These high mortality rates are associated with **mWHO Class IV** conditions. These include Severe Mitral Stenosis (Valve area <1.0 cm²), Pulmonary Arterial Hypertension (Eisenmenger syndrome), and severe systemic ventricular dysfunction (EF <30%). In such cases, mortality can range from 10% to 50%, and pregnancy is generally contraindicated. **High-Yield Clinical Pearls for NEET-PG:** * **Most common heart disease in pregnancy (India):** Rheumatic Heart Disease (RHD). * **Most common lesion in RHD:** Mitral Stenosis. * **Critical MS:** Valve area **<1.0 cm²**. This is mWHO Class IV and carries a high risk of pulmonary edema and mortality. * **Most dangerous period:** The immediate postpartum period (first 24–48 hours) due to "autotransfusion" from the involuting uterus and relief of IVC compression, leading to sudden fluid overload. * **Management:** Beta-blockers are the mainstay for rate control in MS to allow adequate diastolic filling.

Q: When shoulder pain develops in a case of tubal pregnancy, what does it indicate?

Severe internal bleeding. **Explanation:** The correct answer is **D. Severe internal bleeding.** In the context of a ruptured ectopic pregnancy, shoulder tip pain is a classic clinical sign known as **Danforth’s Sign**. This occurs due to massive intraperitoneal hemorrhage (hemoperitoneum). The blood accumulates in the subdiaphragmatic space, causing irritation of the **phrenic nerve** (C3, C4, C5). Because the phrenic nerve shares the same spinal cord segments as the supraclavicular nerves, the pain is referred to the shoulder (dermatomes C3-C4). This indicates a surgical emergency and significant blood loss. **Analysis of Incorrect Options:** * **A. Tubal abortion:** While this involves the expulsion of the products of conception through the fimbrial end and can cause bleeding, it is often gradual and may form a pelvic hematocele rather than the massive, rapid bleeding required to reach the diaphragm. * **B. Tubal mole:** This occurs when the ovum dies but remains in the tube, surrounded by layers of blood clot. It is usually a contained process and does not typically cause massive intraperitoneal hemorrhage. * **C. Broad ligament hematoma:** This occurs in an extraperitoneal rupture (between the leaves of the broad ligament). Since the blood is contained within the ligament and does not enter the general peritoneal cavity to touch the diaphragm, it will not cause shoulder pain. **High-Yield Clinical Pearls for NEET-PG:** * **Kehr’s Sign:** Similar referred shoulder pain, but classically associated with a **ruptured spleen**. * **Cullen’s Sign:** Periumbilical ecchymosis (bluish discoloration) indicating intraperitoneal hemorrhage; seen in ruptured ectopic pregnancy or acute pancreatitis. * **Golden Rule:** Any woman of reproductive age presenting with amenorrhea, abdominal pain, and fainting/syncope should be evaluated for ruptured ectopic pregnancy until proven otherwise.

Q: Maternal Alpha-fetoprotein is increased in which of the following conditions?

Neural tube defects. **Explanation:** **Alpha-fetoprotein (AFP)** is a glycoprotein synthesized by the fetal yolk sac and later by the fetal liver. It is the fetal equivalent of albumin. In a normal pregnancy, small amounts of AFP leak into the maternal circulation through the placenta. **Why Neural Tube Defects (NTDs) cause increased AFP:** In conditions like **Anencephaly** and **Open Spina Bifida**, there is a defect in the fetal skin or neural coverings. This allows AFP to leak directly from the fetal cerebrospinal fluid or exposed capillaries into the amniotic fluid, and subsequently into the maternal serum. Therefore, Maternal Serum AFP (MSAFP) is a primary screening tool for open NTDs. **Analysis of Incorrect Options:** * **Diabetes Mellitus:** Maternal diabetes is actually associated with **decreased** levels of MSAFP. The exact mechanism is unclear but may relate to delayed fetal growth or placental factors. * **Fetal Cardiac Defects:** These do not typically cause a breach in fetal integument; hence, AFP levels remain normal. * **Rubella Infection:** While intrauterine infections can cause various anomalies, they are not classically associated with elevated AFP. **High-Yield Clinical Pearls for NEET-PG:** * **Causes of Increased MSAFP:** Open NTDs, Multiple pregnancy (most common cause of "unexplained" elevation), Omphalocele, Gastroschisis, Renal anomalies (Finnish-type nephrosis), and Fetal demise. * **Causes of Decreased MSAFP:** Down Syndrome (Trisomy 21), Trisomy 18, Maternal Obesity, and Gestational Trophoblastic Disease. * **Screening Window:** MSAFP is ideally measured between **15–20 weeks** (Second Trimester). * **Next Step:** If MSAFP is elevated, the first step is a **Targeted Ultrasound** to confirm gestational age and rule out multiple pregnancies or visible defects.

Q: Placenta succenturiata may lead to all of the following except?

Preterm delivery. **Explanation:** **Placenta Succenturiata** is a morphological variation where one or more small accessory lobes of placental tissue are located in the membranes at a distance from the main placental mass. These lobes are connected to the main placenta by fetal vessels (vasa previa risk). **Why Option A is the correct answer:** Preterm delivery is **not** typically caused by a succenturiate lobe. Preterm labor is generally associated with conditions like uterine overdistension (polyhydramnios, twins), infections, or cervical insufficiency. While placental abnormalities like placenta previa or abruption can lead to preterm birth, a succenturiate lobe itself does not trigger early labor. **Analysis of Incorrect Options:** * **B. Postpartum Hemorrhage (PPH):** If the accessory lobe is retained in the uterus after the main placenta is delivered, it prevents effective uterine contraction, leading to atonic PPH. * **C. Missing Lobe:** Upon inspection of the delivered placenta, a "gap" in the membranes with torn vessels extending from the main mass suggests a missing succenturiate lobe remains inside the uterus. * **D. Sepsis and Subinvolution:** A retained accessory lobe acts as a nidus for infection (**Sepsis/Endometritis**) and prevents the uterus from returning to its non-pregnant size (**Subinvolution**). **High-Yield NEET-PG Pearls:** 1. **Vasa Previa:** The most dangerous complication occurs when the connecting vessels run across the internal os. Rupture of these vessels leads to fetal exsanguination (Benckiser’s hemorrhage). 2. **Management:** Always inspect the membranes for torn vessels; if a lobe is suspected to be missing, manual exploration of the uterus is mandatory. 3. **Diagnosis:** Often made via antenatal color Doppler ultrasound.

Question 1

A G2P1L1 woman with a previous lower segment cesarean section (LSCS) presents at 37 weeks gestation with a blood pressure of 150/100 mm Hg. The cardiotocography (CTG) is reactive, and her per vaginum (P/V) findings are: os closed, cervix partially effaced, soft, midline, vertex at -2 station, and the pelvis is adequate. Urine protein by dipstick is 1+. What is the management?

Accepted Answer

Induction of labor.

Answer

Start antihypertensives and follow up after 1 week.

Answer

Cesarean section.

Answer

Do not start antihypertensives but follow up after 1 week.

Question 2

Which of the following is a side effect of magnesium sulfate?

Accepted Answer

Hypotonia

Answer

Anuria

Answer

Coma

Answer

Pulmonary edema

Question 3

Which of the following is NOT an unequivocal evidence of heart disease in pregnancy?

Accepted Answer

Systolic murmur

Answer

Diastolic murmur

Answer

Diastolic thrill and murmur

Answer

Systolic thrill and murmur

Question 4

Which of the following tests is not used for the detection of specific aneuploidy?

Accepted Answer

Microarray

Answer

FISH

Answer

Karyotyping

Answer

QF-PCR

Question 5

A pregnant woman presents with a major degree placenta previa and a malformed fetus. What is the best management approach?

Accepted Answer

Cesarean section

Answer

Oxytocin drip

Answer

Rupture of membranes

Answer

Instillation of Prostaglandin E2

Question 6

A 25-year-old pregnant woman diagnosed with Rheumatic Heart Disease and Mitral Stenosis at 16 years of age presents at 6 weeks of gestation with a mitral valve area of 1.4 sq cm. She is currently in NYHA class 2 and on antiarrhythmic drugs. What is the risk of maternal mortality?

Accepted Answer

<1%

Answer

50%

Answer

15%

Answer

5%

Question 7

When shoulder pain develops in a case of tubal pregnancy, what does it indicate?

Accepted Answer

Severe internal bleeding

Answer

Tubal abortion

Answer

Development of a tubal mole

Answer

Development of a broad ligament hematoma

Question 8

Maternal Alpha-fetoprotein is increased in which of the following conditions?

Accepted Answer

Neural tube defects

Answer

Diabetes mellitus

Answer

Fetal cardiac defects

Answer

Rubella infection

Question 9

Which of the following is the most appropriate imaging modality to detect an abnormally located placenta?

Accepted Answer

Transvaginal Ultrasound (TVS)

Answer

Magnetic Resonance Imaging (MRI)

Answer

Doppler Ultrasound

Answer

Transabdominal Ultrasound (TAS)

Question 10

Placenta succenturiata may lead to all of the following except?

Accepted Answer

Preterm delivery

Answer

Postpartum hemorrhage

Answer

Missing lobe

Answer

Sepsis and subinvolution

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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