Maternal-Fetal Medicine Practice Questions

Q: A 24-week pregnancy scan revealed frontal facial fetal defects suggestive of Moebius syndrome. Which of the following could account for the teratogenic effects?

Misoprostol. **Explanation:** **Misoprostol** is a synthetic prostaglandin E1 (PGE1) analogue. When used in the first trimester for failed medical abortion, it can cause uterine contractions leading to **vascular disruption** in the developing fetus. This vascular insult (specifically involving the subclavian artery or cranial vessels) results in **Moebius Syndrome**, characterized by congenital paralysis of the 6th (abducens) and 7th (facial) cranial nerves, often associated with limb reduction defects and orofacial malformations. **Analysis of Incorrect Options:** * **Mifepristone (A):** An anti-progestogen used for medical abortion. While it terminates pregnancy by blocking progesterone receptors, it is not specifically linked to the vascular disruption sequence seen in Moebius syndrome. * **Dinoprostone (C):** A PGE2 analogue used primarily for cervical ripening and induction of labor at term. It is not typically associated with first-trimester teratogenicity leading to Moebius syndrome. * **Methotrexate (D):** A folate antagonist. Teratogenicity (Fetal Methotrexate Syndrome) typically presents with "cloverleaf skull," craniosynostosis, wide-set eyes, and limb defects, rather than the specific cranial nerve palsies of Moebius syndrome. **NEET-PG High-Yield Pearls:** * **Moebius Syndrome Triad:** Facial paralysis (mask-like facies), impaired lateral eye movement, and limb deformities (e.g., clubfoot). * **Vascular Disruption Sequence:** The same mechanism (Misoprostol) can also cause **Poland Syndrome** (unilateral absence of pectoralis major and syndactyly). * **Safe Use:** Misoprostol is highly effective for PPH prophylaxis and medical abortion, but patients must be counseled on the teratogenic risks if the pregnancy continues.

Q: Which of the following is the drug of choice for Toxoplasmosis in pregnancy?

Spiramycin. **Explanation:** **Toxoplasmosis in pregnancy** is a critical topic for NEET-PG due to its potential for congenital transmission. The management depends on whether the fetus is infected. **Why Spiramycin is the Correct Answer:** Spiramycin is a macrolide antibiotic and is the **drug of choice for primary prophylaxis** in a pregnant woman with documented acute Toxoplasmosis where fetal infection is not yet confirmed. Its primary mechanism is to concentrate in the placenta, thereby reducing the risk of vertical transmission from mother to fetus by approximately 60%. Importantly, it does not cross the placenta in significant amounts, making it safe for the fetus but ineffective if the fetus is already infected. **Analysis of Incorrect Options:** * **A. Metronidazole:** This is an antiprotozoal/antibiotic used for Trichomoniasis, Bacterial Vaginosis, and anaerobic infections; it has no role in treating Toxoplasmosis. * **B & C. Pyrimethamine and Sulfadiazine:** This combination is the **treatment of choice if fetal infection is confirmed** (via positive amniotic fluid PCR) or if the mother is infected late in the third trimester. However, Pyrimethamine is potentially teratogenic (folate antagonist) and is generally avoided in the first trimester. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad of Congenital Toxoplasmosis:** Chorioretinitis, Hydrocephalus, and Intracranial calcifications (typically diffuse/scattered). * **Transmission Risk:** The risk of transmission increases with gestational age (highest in the 3rd trimester), but the **severity** of fetal damage is greatest if infected in the 1st trimester. * **Diagnosis:** Sabin-Feldman Dye test is the gold standard (though rarely used now); IgM and IgG avidity tests are used clinically. * **Folinic Acid (Leucovorin):** Always co-administer with Pyrimethamine to prevent bone marrow suppression.

Q: On sonography, a multigravida is found to have oligohydramnios. Which among the following will be associated with this condition?

Renal agenesis. **Explanation:** **Understanding the Concept:** Amniotic fluid volume is a dynamic balance between production and removal. After 12–14 weeks of gestation, **fetal urine** becomes the primary source of amniotic fluid, while **fetal swallowing** is the major route of its removal. **Why Renal Agenesis is Correct:** In cases of **Renal Agenesis** (Potter’s Sequence), the kidneys fail to develop, leading to a total absence of fetal urine production. Since the primary source of fluid is missing, it results in severe **oligohydramnios** (Amniotic Fluid Index < 5 cm or Single Deepest Pocket < 2 cm). **Analysis of Incorrect Options:** * **Oesophageal Atresia:** This condition prevents the fetus from swallowing amniotic fluid. Since the removal mechanism is blocked while urine production continues, it leads to **polyhydramnios**. * **Spina Bifida:** Open neural tube defects (NTDs) cause **polyhydramnios** due to the transudation of cerebrospinal fluid into the amniotic sac and impaired fetal swallowing. * **Chorioangioma of Placenta:** This is a vascular tumor of the placenta. Large chorioangiomas (>5 cm) act as arteriovenous shunts, leading to high-output cardiac failure in the fetus, increased fetal urine production, and subsequent **polyhydramnios**. **NEET-PG High-Yield Pearls:** * **Most common cause of oligohydramnios:** Premature Rupture of Membranes (PROM). * **Most common fetal anomaly associated with oligohydramnios:** Renal anomalies (e.g., Posterior Urethral Valves, Polycystic Kidney Disease). * **Potter’s Sequence:** Oligohydramnios → Pulmonary hypoplasia, flattened facies, and limb deformities (clubfoot). * **Drug-induced oligohydramnios:** ACE inhibitors and NSAIDs (due to decreased fetal renal perfusion).

Q: A multiparous woman at 38 weeks of gestation, with a history of previous lower segment cesarean section (LSCS), presents in shock. What is the most likely differential diagnosis?

All of the above. **Explanation:** The clinical presentation of a multiparous woman in late pregnancy with a history of a previous uterine scar (LSCS) presenting in shock constitutes an obstetric emergency. The correct answer is **"All of the above"** because each of these conditions can lead to massive hemorrhage and hypovolemic shock. 1. **Uterine Rupture:** This is the most critical suspicion in a patient with a previous LSCS. The scarred uterus is a weak point; rupture can lead to massive intraperitoneal hemorrhage, fetal distress, and rapid maternal collapse (shock). 2. **Abruptio Placentae:** Multiparous women are at higher risk for placental abruption. Severe "concealed" or "revealed" hemorrhage can lead to shock, often out of proportion to visible blood loss, and may trigger DIC. 3. **Placenta Previa:** A previous LSCS is a major risk factor for placenta previa and the morbidly adherent placenta spectrum (Placenta Accreta). Sudden, painless, profuse bleeding can lead to immediate hemorrhagic shock. **Why "All of the above" is correct:** In a NEET-PG context, when a patient presents in shock during the third trimester, you must consider all causes of **Antepartum Hemorrhage (APH)** and **Uterine Rupture**. While the previous scar points strongly toward rupture, it also significantly increases the risk of abnormal placentation (Previa/Accreta). **Clinical Pearls for NEET-PG:** * **Scar Tenderness:** The earliest sign of impending uterine rupture in a patient with a previous LSCS. * **Couvelaire Uterus:** Associated with severe Abruptio Placentae (extravasation of blood into the myometrium). * **Classic Triad of Rupture:** Sudden abdominal pain, cessation of uterine contractions, and recession of the presenting part (Station becomes higher). * **Management:** Immediate resuscitation (ABC), large-bore IV lines, and emergency laparotomy/delivery.

Q: What is the most sensitive test for acute fetal distress?

Loss of beat-to-beat variation of heart rate. **Explanation:** **1. Why Option B is Correct:** Beat-to-beat variability (short-term variability) is the most sensitive indicator of fetal well-being. It reflects the continuous interaction between the fetal sympathetic and parasympathetic nervous systems. In the presence of **acute fetal distress (hypoxia/acidosis)**, the fetal brain and autonomic nervous system are the first to be affected, leading to a "flat" or diminished baseline variability. The **loss of beat-to-beat variation** is often the earliest sign of fetal compromise, preceding late decelerations. **2. Why Other Options are Incorrect:** * **Option A (Fresh meconium):** While meconium-stained liquor can be a sign of fetal distress, it is often a non-specific finding (seen in post-term pregnancies or breech presentation) and is less sensitive than heart rate changes. * **Option C (Increased fetal movements):** Fetal distress is typically associated with *decreased* or absent fetal movements (the "alarm signal"). While a sudden burst of hyperactive movement can occasionally precede fetal demise, it is not a standardized clinical test. * **Option D (Type 1 dips):** Also known as early decelerations, these are caused by fetal head compression during labor. They are considered physiological (benign) and are not indicative of fetal distress. **Clinical Pearls for NEET-PG:** * **Normal Variability:** 6 to 25 beats per minute. * **Most Specific Sign:** Late decelerations (Type II dips) are highly specific for uteroplacental insufficiency but may appear later than loss of variability. * **Gold Standard for Confirmation:** If CTG is non-reassuring, **Fetal Scalp Blood pH** is the most definitive test (pH < 7.20 indicates acidosis). * **Sinusoidal Pattern:** Indicates severe fetal anemia (e.g., Rh isoimmunization).

Q: What is the pathognomonic feature of abdominal pregnancy?

Fetus appears lateral to the lumbar spine on X-ray. **Explanation:** Abdominal pregnancy is a rare but serious form of ectopic pregnancy where the fetus develops within the peritoneal cavity. **Why Option A is correct:** The pathognomonic radiological sign of an abdominal pregnancy is the **fetus appearing lateral to or overlapping the maternal lumbar spine** on a lateral X-ray (the **"Spalding’s Sign"** is different; this is specifically about fetal position relative to the spine). In a normal intrauterine pregnancy, the thick muscular wall of the uterus keeps the fetus centered and anterior to the spine. In an abdominal pregnancy, the lack of a uterine wall allows the fetus to fall posteriorly or laterally, often overlapping the maternal vertebrae on a lateral view. **Analysis of Incorrect Options:** * **B. Small uterus:** While the uterus is indeed smaller than the period of gestation (as it is empty), this is a common finding in all ectopic pregnancies and is not pathognomonic. * **C. Fetus easily palpable:** While "fetal parts felt easily" is a classic clinical sign due to the absence of the uterine wall, it is subjective and can be confused with a very thin uterine wall or a ruptured uterus. * **D. Positive pregnancy test:** This only confirms pregnancy, not the location. **NEET-PG High-Yield Pearls:** * **Clinical Sign:** Failure of the uterus to contract after oxytocin administration (since the fetus is extrauterine). * **Diagnosis:** Ultrasound is the primary modality, but **MRI** is the gold standard for assessing placental attachment to abdominal organs. * **Management:** The placenta is usually left in situ (if attached to vital organs) to avoid massive hemorrhage; methotrexate may be used postoperatively to accelerate its involution.

Question 1

Which of the following is NOT an absolute maternal indication for termination of pregnancy?

Accepted Answer

Parous woman with grade III and IV cardiac lesions

Answer

Eisenmenger's syndrome

Answer

Primary pulmonary hypertension

Answer

Pulmonary veno-occlusive disease

Question 2

A 24-week pregnancy scan revealed frontal facial fetal defects suggestive of Moebius syndrome. Which of the following could account for the teratogenic effects?

Accepted Answer

Misoprostol

Answer

Mifepristone

Answer

Dinoprostone

Answer

Methotrexate

Question 3

Which drug is given as a single dose to prevent mother-to-child HIV transmission?

Accepted Answer

Nevirapine

Answer

Didanosine

Answer

Acyclovir

Answer

Nelfinavir

Question 4

Which of the following is the drug of choice for Toxoplasmosis in pregnancy?

Accepted Answer

Spiramycin

Answer

Metronidazole

Answer

Pyrimethamine

Answer

Sulfadiazine

Question 5

On sonography, a multigravida is found to have oligohydramnios. Which among the following will be associated with this condition?

Accepted Answer

Renal agenesis

Answer

Oesophageal atresia

Answer

Spina bifida

Answer

Cholangioma of placenta

Question 6

What is the most common type of anemia in pregnancy?

Accepted Answer

Microcytic hypochromic anemia

Answer

Megaloblastic anemia

Answer

Microcytic normochromic anemia

Answer

Normochromic normocytic anemia

Question 7

A multiparous woman at 38 weeks of gestation, with a history of previous lower segment cesarean section (LSCS), presents in shock. What is the most likely differential diagnosis?

Accepted Answer

All of the above

Answer

Placenta previa

Answer

Abruptio placenta

Answer

Uterine rupture

Question 8

What is the most sensitive test for acute fetal distress?

Accepted Answer

Loss of beat-to-beat variation of heart rate

Answer

Fresh meconium on induction of labor

Answer

Increased fetal movements

Answer

Type 1 dips in the second stage

Question 9

What is the pathognomonic feature of abdominal pregnancy?

Accepted Answer

Fetus appears lateral to the lumbar spine on X-ray

Answer

Small uterus

Answer

Fetus easily palpable

Answer

Positive pregnancy test

Question 10

Which of the following pregnancy complications is associated with polycythemia vera?

Accepted Answer

Stillbirth

Answer

Coagulopathy

Answer

Placental abruption

Answer

Placenta previa

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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