Maternal-Fetal Medicine Practice Questions

Q: A 38-week pregnant woman delivered a baby without upper limbs. What is a possible cause?

Amniotic band. **Explanation:** The correct answer is **Amniotic Band Syndrome (ABS)**. This condition occurs due to the premature rupture of the amnion, leading to the formation of fibrous, sticky bands. These bands can entangle, constrict, or amputate developing fetal parts, most commonly the distal limbs and digits. When these bands encircle a limb early in gestation, they can lead to complete **congenital amputation** or transverse limb defects, explaining the absence of upper limbs in this neonate. **Analysis of Incorrect Options:** * **B. True knot of umbilical cord:** While a true knot can lead to fetal distress or intrauterine fetal death (IUFD) due to compromised blood flow, it does not cause structural limb defects or amputations. * **C. Genetic abnormality:** While certain genetic syndromes (like Roberts syndrome) can cause limb reduction defects (phocomelia), they are usually symmetrical and associated with other dysmorphic features. Amniotic band syndrome is typically **asymmetrical and sporadic**, making it a more classic cause for isolated limb absence in a non-syndromic presentation. **High-Yield Clinical Pearls for NEET-PG:** * **Pathogenesis:** The most widely accepted theory is the **Torpin Theory** (Exogenous theory), which suggests that amnion rupture leads to "entrapment" by fibrous bands. * **Clinical Presentation:** Look for "constriction rings" on limbs, pseudo-syndactyly (fused fingers), or asymmetric amputations. * **Associated Defects:** ABS is also linked to craniofacial clefts and body wall defects (e.g., gastroschisis) if the bands involve the head or abdomen. * **Risk Factors:** It is generally a **sporadic event** with a very low recurrence risk in subsequent pregnancies.

Q: An **AG2 P1L1** (gravida 2, para 1, living 1) female, with a previous history of lower segment cesarean section (LSCs), presents at 36 weeks of gestation with breech presentation. What is the next step in management?

External cephalic version (ECV) at 37 weeks. ### Explanation **Correct Option: A. External cephalic version (ECV) at 37 weeks** The primary goal in managing a breech presentation is to achieve a cephalic presentation to allow for a trial of labor. According to RCOG and ACOG guidelines, a **previous lower segment cesarean section (LSCS) is NOT a contraindication to ECV**. The success rate of ECV in women with a prior scar is similar to those without one, and the risk of uterine rupture is extremely low (<0.5%). ECV is ideally performed at **37 weeks** in multiparous women to minimize the risk of preterm labor while ensuring the fetus is mature enough if an emergency delivery is required. **Why other options are incorrect:** * **B. Planned cesarean section at 38 weeks:** While a repeat CS is an option, it is not the *next* step. Guidelines recommend offering ECV first to provide the patient the opportunity for a Vaginal Birth After Cesarean (VBAC). * **C. Immediate cesarean section:** There is no evidence of fetal distress or active labor. At 36 weeks, the fetus is late-preterm; immediate delivery without indication increases neonatal morbidity. * **D. Induction of labor:** Inducing labor in a breech presentation, especially with a scarred uterus, is contraindicated due to the high risk of cord prolapse and difficult after-coming head delivery. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisites for ECV:** Reactive NST, adequate liquor (AFI >5), and no uterine anomalies. * **Contraindications to ECV:** Placenta previa, multifetal gestation, ruptured membranes, or any indication for a CS regardless of presentation. * **Success Rate:** Approximately 50% in nulliparous and 60% in multiparous women. * **Tocolysis:** Use of beta-mimetics (e.g., Ritodrine or Terbutaline) during ECV increases the success rate by relaxing the myometrium.

Q: A 24-year-old woman presents with primary infertility and acute abdominal pain. Her vital signs are: blood pressure 90/60 mm Hg, pulse rate 102 bpm. Her hematocrit is 28%. Which of the following is a feature of ectopic pregnancy?

Pain referred to the supraclavicular region. ### Explanation The clinical presentation of acute abdominal pain, hypotension (90/60 mm Hg), tachycardia (102 bpm), and a low hematocrit (28%) in a woman of reproductive age strongly suggests a **ruptured ectopic pregnancy** with resulting hemoperitoneum and hypovolemic shock. **Why Option D is Correct:** The correct answer is **pain referred to the supraclavicular region (Laffon’s sign)**. When an ectopic pregnancy ruptures, blood accumulates in the peritoneal cavity. As the patient lies down, this blood tracks up to the subdiaphragmatic space, irritating the **phrenic nerve (C3-C5)**. Since the supraclavicular nerves share the same spinal origin (C3-C4), the brain perceives this irritation as pain in the shoulder/neck area. This is a classic example of **referred pain**. **Analysis of Incorrect Options:** * **Option A:** In hypovolemic shock, blood pressure **decreases** (orthostatic hypotension) rather than elevates when assuming an erect position. * **Option B:** **Pulsus paradoxus** (an exaggerated drop in systolic BP >10 mmHg during inspiration) is characteristic of cardiac tamponade or severe asthma, not ectopic pregnancy. * **Option C:** **Murphy’s sign** is indicative of acute cholecystitis. While right upper quadrant pain can occur in Fitz-Hugh-Curtis syndrome (PID), it is not a classic feature of ruptured ectopic pregnancy. **NEET-PG High-Yield Pearls:** * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serum β-hCG (Correlation with the "Discriminatory Zone" of 1500–2000 mIU/mL). * **Cullen’s Sign:** Periumbilical bluish discoloration indicating hemoperitoneum (rare but high-yield). * **Management:** Hemodynamically unstable patients (like the one in this vignette) require **immediate laparotomy**, not laparoscopy or medical management.

Q: Which of the following is the earliest conclusive evidence of intrauterine death?

Intra-aortic gas. **Explanation:** The diagnosis of intrauterine fetal death (IUFD) relies on specific radiological and clinical signs. The correct answer is **Intra-aortic gas (Robert’s Sign)**. **1. Why Intra-aortic gas is correct:** Robert’s Sign refers to the presence of gas (primarily nitrogen) in the fetal heart and large vessels (like the aorta). It is the **earliest radiological sign** of fetal death, appearing as early as **6 to 12 hours** after the event. It occurs due to the release of gases from decomposing fetal blood. **2. Why the other options are incorrect:** * **Spalding Sign (Option D):** This is the overlapping of fetal skull bones due to liquefaction of the brain and loss of intracranial pressure. While highly characteristic, it typically takes **4 to 7 days** to develop. * **Increased curvature of the spine (Option C):** Also known as **Hartley’s Sign**, this occurs due to the loss of fetal muscle tone, leading to an exaggerated flexion of the spine. It is a late sign and less specific than gas formation. * **Shrinking of the body (Option A):** This is a non-specific, late finding associated with maceration and absorption of amniotic fluid. **Clinical Pearls for NEET-PG:** * **Gold Standard:** Today, the definitive diagnosis of IUFD is the **demonstration of absent fetal cardiac activity on Ultrasound (USG)**. * **Spalding Sign:** Requires a living mother and a dead fetus; it is not valid if the labor has started (as molding can cause overlapping). * **Deuel’s Halo Sign:** Another radiological sign where a translucent halo appears around the fetal head due to edema of the scalp tissues. * **Rollover Test:** Used for predicting pre-eclampsia, not IUFD (common distractor).

Q: All of the following strategies are effective in preventing mother-to-child transmission of HIV, except?

Vaginal cleansing before delivery. **Explanation:** The goal of preventing mother-to-child transmission (PMTCT) of HIV is to reduce the viral load in the mother and minimize the infant's exposure to infected maternal fluids. **Why Option B is the Correct Answer:** **Vaginal cleansing** (using antiseptic solutions like chlorhexidine) before or during labor has been studied extensively and has **not** been shown to reduce the risk of HIV transmission. While it may reduce the risk of other neonatal infections (like Group B Strep), it does not impact the cell-associated or cell-free HIV virus present in birth canal secretions. **Analysis of Other Options:** * **A. Zidovudine (AZT):** Antiretroviral therapy (ART) is the cornerstone of PMTCT. AZT administered to the mother during pregnancy/labor and to the infant post-exposure significantly reduces viral replication and transmission risk. * **C. Stopping Breastfeeding:** HIV is secreted in breast milk. In developed settings, complete avoidance of breastfeeding (replacement feeding) is recommended to eliminate postnatal transmission. (Note: In resource-limited settings, WHO recommends exclusive breastfeeding with maternal ART). * **D. Elective Cesarean Section:** Performing a C-section before the onset of labor or rupture of membranes avoids the infant's contact with vaginal secretions and blood, reducing transmission risk, especially if the maternal viral load is >1,000 copies/mL. **High-Yield Clinical Pearls for NEET-PG:** * **Most common timing of transmission:** Intrapartum (during labor and delivery). * **Current Protocol (WHO/NACO):** All pregnant women living with HIV should be started on **Lifelong ART (TDF + 3TC + EFV/DTG)** regardless of CD4 count or clinical stage. * **Infant Prophylaxis:** Nevirapine (NVP) is typically given to the infant for 6 weeks. * **Best Indicator:** Maternal viral load at the time of delivery is the strongest predictor of transmission risk.

Q: A pregnant woman presents with a blood pressure of 150/100 mmHg and proteinuria after 20 weeks of gestation. What is the most likely diagnosis?

Pre-eclampsia. **Explanation:** The correct diagnosis is **Pre-eclampsia**. According to the standard diagnostic criteria, pre-eclampsia is defined as the new onset of hypertension (**BP ≥140/90 mmHg**) occurring **after 20 weeks of gestation** accompanied by significant **proteinuria** (≥300 mg/24h or ≥1+ on dipstick). In this case, the patient’s BP of 150/100 mmHg and the presence of proteinuria after the 20-week mark perfectly satisfy these criteria. **Analysis of Incorrect Options:** * **Gestational Hypertension:** This refers to hypertension (≥140/90) developing after 20 weeks of gestation **without** proteinuria or other systemic features of pre-eclampsia. * **Renal Hypertension:** This is typically a form of chronic hypertension that exists prior to pregnancy or is diagnosed before 20 weeks of gestation. While it causes proteinuria, the timing in this clinical vignette points toward a pregnancy-induced pathology. * **Eclampsia:** This is the occurrence of generalized tonic-clonic **seizures** in a woman with pre-eclampsia that cannot be attributed to other causes. Since no seizures were mentioned, this diagnosis is incorrect. **High-Yield Clinical Pearls for NEET-PG:** * **Timing is Key:** Hypertension before 20 weeks is "Chronic Hypertension"; after 20 weeks it is "Gestational Hypertension" or "Pre-eclampsia." * **New Criteria:** If proteinuria is absent, pre-eclampsia can still be diagnosed if there is new-onset hypertension plus evidence of end-organ dysfunction (thrombocytopenia, renal insufficiency, impaired liver function, or visual/cerebral symptoms). * **Drug of Choice:** Magnesium Sulfate ($MgSO_4$) is the drug of choice for seizure prophylaxis and control in eclampsia (Pritchard Regimen). * **Definitive Treatment:** Delivery of the fetus and placenta remains the only definitive cure.

Q: What is the most common cause of direct obstetric deaths?

Hemorrhage. **Explanation:** The correct answer is **Hemorrhage**. Globally and in India, hemorrhage remains the leading cause of direct maternal mortality. **1. Why Hemorrhage is Correct:** Direct obstetric deaths result from obstetric complications of the pregnant state (pregnancy, labor, and puerperium). **Obstetric Hemorrhage**, specifically **Postpartum Hemorrhage (PPH)**, is the most common cause. It is characterized by rapid blood loss (often >500ml in vaginal delivery or >1000ml in C-section) leading to hypovolemic shock and death if not managed within the "Golden Hour." The primary etiology is uterine atony. **2. Analysis of Incorrect Options:** * **Anemia:** While a major contributor to maternal mortality in India, it is classified as an **indirect cause** (a pre-existing disease aggravated by pregnancy). It often acts as a predisposing factor that makes a woman less likely to survive a hemorrhage. * **Obstructed Labor:** This is a significant cause of morbidity (e.g., fistulas) and mortality, but it ranks lower than hemorrhage and sepsis in modern statistics due to better access to emergency cesarean sections. * **Infection (Sepsis):** Puerperal sepsis is the second or third most common direct cause, but it typically follows a more subacute course compared to the rapid fatality of hemorrhage. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of Maternal Mortality (Global & India):** Hemorrhage (Direct). * **Most common cause of Indirect Maternal Death:** Anemia (followed by Heart Disease). * **Most common cause of PPH:** Uterine Atony. * **The "Big Three" Direct Causes:** 1. Hemorrhage, 2. Sepsis, 3. Hypertensive disorders (Eclampsia). * **MMR Definition:** Number of maternal deaths per 1,00,000 live births.

Question 1

A pregnant woman at 34 weeks gestation presents with antepartum hemorrhage and a blood pressure of 80/something. What is the initial management?

Accepted Answer

Blood transfusion

Answer

Examination in OT and termination of pregnancy

Answer

Observation

Answer

Lower segment caesarean section

Question 2

A 38-week pregnant woman delivered a baby without upper limbs. What is a possible cause?

Accepted Answer

Amniotic band

Answer

True knot of umbilical cord

Answer

Genetic abnormality

Answer

None of the above

Question 3

Increased gestational period is associated with which congenital anomaly?

Accepted Answer

Anencephaly

Answer

Spina bifida

Answer

Meningomyelocele

Answer

Omphalocele

Question 4

An **AG2 P1L1** (gravida 2, para 1, living 1) female, with a previous history of lower segment cesarean section (LSCs), presents at 36 weeks of gestation with breech presentation. What is the next step in management?

Accepted Answer

External cephalic version (ECV) at 37 weeks

Answer

Planned cesarean section at 38 weeks

Answer

Immediate cesarean section

Answer

Induction of labor

Question 5

A 24-year-old woman presents with primary infertility and acute abdominal pain. Her vital signs are: blood pressure 90/60 mm Hg, pulse rate 102 bpm. Her hematocrit is 28%. Which of the following is a feature of ectopic pregnancy?

Accepted Answer

Pain referred to the supraclavicular region

Answer

Elevated blood pressure on assuming an erect position

Answer

Pulsus paradoxus

Answer

Tenderness below the right subcostal margin (Murphy's sign)

Question 6

A 32-year-old G2P1001 at 20 weeks gestational age presents to the emergency room complaining of constipation and abdominal pain for the past 24 hours. The patient also admits to bouts of nausea and emesis since eating a very spicy meal the evening before. She denies a history of any medical problems. During her last pregnancy, the patient underwent an elective cesarean section at term to deliver a fetus in the breech presentation. The emergency room doctor reports that the patient has a low-grade fever of 100°F, with a normal pulse and blood pressure. She is minimally tender to deep palpation with hypoactive bowel sounds and no rebound tenderness. Her WBC is 13,000, and electrolytes are normal. What is the appropriate next step in the management of this patient?

Accepted Answer

The patient should be sent to radiology for an upright abdominal x-ray.

Answer

The patient should be discharged with reassurance and instructions to give herself a soapsuds enema and follow a high-fiber diet with laxative use as needed.

Answer

The patient should be prepped for the operating room immediately to have an emergent appendectomy.

Answer

The patient should be reassured that her symptoms are due to the spicy meal consumed the evening before and should be given Pepto-Bismol to alleviate the symptoms.

Question 7

Which of the following is the earliest conclusive evidence of intrauterine death?

Accepted Answer

Intra-aortic gas

Answer

Shrinking of the body

Answer

Increased curvature of the spine

Answer

Spalding sign

Question 8

All of the following strategies are effective in preventing mother-to-child transmission of HIV, except?

Accepted Answer

Vaginal cleansing before delivery

Answer

Zidovudine to mother and baby

Answer

Stopping breastfeeding

Answer

Elective cesarean section

Question 9

A pregnant woman presents with a blood pressure of 150/100 mmHg and proteinuria after 20 weeks of gestation. What is the most likely diagnosis?

Accepted Answer

Pre-eclampsia

Answer

Gestational hypertension

Answer

Renal hypertension

Answer

Eclampsia

Question 10

What is the most common cause of direct obstetric deaths?

Accepted Answer

Hemorrhage

Answer

Anemia

Answer

Obstructed labor

Answer

Infection

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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