Maternal-Fetal Medicine Practice Questions

Q: Recurrent abortion in the first trimester is most often due to what cause?

Chromosomal abnormalities. **Explanation:** **1. Why Chromosomal Abnormalities are the Correct Answer:** Chromosomal abnormalities are the single most common cause of spontaneous pregnancy loss, especially in the **first trimester** (up to 12 weeks). In cases of recurrent pregnancy loss (RPL), parental chromosomal rearrangements (like balanced translocations) or sporadic embryonic aneuploidy account for the majority of early losses. Among these, **Autosomal Trisomy** is the most frequent specific chromosomal anomaly found in abortuses, followed by Monosomy X (Turner syndrome) and Polyploidy. **2. Analysis of Incorrect Options:** * **B. Uterine Anomaly:** Structural issues (e.g., septate uterus, cervical incompetence, or fibroids) are significant causes of recurrent abortion but are more characteristically associated with **second-trimester** losses rather than early first-trimester ones. * **C. Hormonal Disturbance:** Conditions like Luteal Phase Defect (LPD), uncontrolled Diabetes Mellitus, and Thyroid disorders can cause miscarriage. However, statistically, they occur less frequently than genetic factors in the first trimester. * **D. Infection:** While certain infections (TORCH, Mycoplasma) can cause sporadic pregnancy loss, they are **rarely** a cause of recurrent abortion, as the mother usually develops immunity after the initial exposure. **3. Clinical Pearls for NEET-PG:** * **Most common Trisomy in abortus:** Trisomy 16. * **Most common single chromosomal anomaly:** Monosomy X (45,X). * **Investigation of choice for RPL:** Karyotyping of both parents to rule out balanced translocations. * **Timing:** If the question specifies "Second Trimester," the most common cause shifts toward **Anatomical/Uterine factors** (specifically Cervical Incompetence).

Q: Which one of the following causes the greatest risk of ectopic pregnancy?

Previous ectopic pregnancy. **Explanation:** The risk of ectopic pregnancy is primarily determined by the degree of damage to the fallopian tube. **1. Why "Previous Ectopic Pregnancy" is correct:** A history of a previous ectopic pregnancy is the **strongest risk factor**, increasing the risk by approximately **10 to 15 times** compared to the general population. If a patient has had two or more prior ectopic pregnancies, the risk escalates to over 25%. This is due to underlying tubal pathology, scarring from previous surgery (salpingostomy), or persistent functional impairment of the cilia. **2. Analysis of Incorrect Options:** * **Pelvic Inflammatory Disease (PID):** While PID is the **most common** cause of ectopic pregnancy due to post-inflammatory tubal scarring and adhesions, it does not carry as high a relative risk as a prior ectopic event. * **IUD Use:** IUDs are highly effective contraceptives. They do not *cause* ectopic pregnancy; however, if a woman becomes pregnant with an IUD in situ, the **proportion** of those pregnancies being ectopic is higher. In absolute terms, IUD users have a lower risk of ectopic pregnancy than women using no contraception. * **Previous MTP:** Uncomplicated Medical Termination of Pregnancy (MTP) does not significantly increase the risk. Only if the procedure was complicated by post-abortal sepsis leading to tubal damage would the risk increase. **Clinical Pearls for NEET-PG:** * **Strongest Risk Factor:** Previous ectopic pregnancy. * **Most Common Cause:** Pelvic Inflammatory Disease (Chlamydia is the most common organism). * **Other High-Risk Factors:** Tubal reconstructive surgery, DES exposure in utero, and smoking (impairs ciliary motility). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (seen in only 50% of cases).

Q: A woman presents with amenorrhea of 2 months duration, lower abdominal pain, facial pallor, fainting, and shock. What is the most likely diagnosis?

Ruptured ectopic pregnancy. **Explanation:** The clinical presentation described is a classic medical emergency in early pregnancy. The correct diagnosis is **Ruptured Ectopic Pregnancy** based on the "Classic Triad" and signs of hemodynamic instability. **1. Why Ruptured Ectopic Pregnancy is Correct:** The patient presents with the hallmark features: **amenorrhea** (indicating pregnancy), **acute abdominal pain**, and **hypovolemic shock** (pallor, fainting, hypotension). In a ruptured ectopic pregnancy, the fallopian tube (most common site) bursts, leading to massive intraperitoneal hemorrhage (hemoperitoneum). This rapid blood loss causes the shock and fainting (syncope) described. **2. Why Other Options are Incorrect:** * **Ruptured Ovarian Cyst:** While it causes acute pain and potential hemoperitoneum, it is usually not associated with amenorrhea or a positive pregnancy status. * **Threatened Abortion:** This presents with vaginal bleeding and mild cramping, but the cervix is closed, and there is no hemodynamic collapse or signs of internal hemorrhage. * **Septic Abortion:** This involves infection of the products of conception. While it can cause shock (septic shock), it is characterized by high-grade fever, foul-smelling vaginal discharge, and exquisite uterine tenderness, rather than sudden fainting and pallor from blood loss. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Ectopic Pregnancy:** Ampulla of the Fallopian tube. * **Most common site of Rupture:** Isthmus (occurs earlier, around 6–8 weeks). * **Gold Standard Investigation:** Transvaginal Ultrasound (TVUS) + Serum $\beta$-hCG (Correlation of "Discriminatory Zone"). * **Management of Rupture:** Immediate resuscitation followed by **emergency laparotomy** (Salpingectomy). * **Kehr’s Sign:** Referred pain to the shoulder due to diaphragmatic irritation by blood—a classic sign of ruptured ectopic pregnancy.

Q: Twin pregnancy predisposes to which of the following complications?

All of the above. **Explanation:** Twin pregnancy is a high-risk condition because the presence of more than one fetus significantly increases the physiological and mechanical demands on the maternal system. * **Hydramnios (Polyhydramnios):** This occurs in approximately 10% of twin pregnancies. It is often associated with Twin-to-Twin Transfusion Syndrome (TTTS) in monochorionic twins, where the recipient twin develops polyuria. It can also result from an increased total fetal urine output due to the presence of two fetuses. * **Pregnancy-Induced Hypertension (PIH):** The risk of PIH and preeclampsia is 2–3 times higher in multifetal gestations. This is attributed to the increased placental mass (hyperplacentosis), which leads to a higher release of anti-angiogenic factors (like sFlt-1) into the maternal circulation. * **Malpresentation:** Due to the limited intrauterine space and the presence of two fetuses, the likelihood of at least one twin being in a non-cephalic position (breech or transverse) is high. Only about 40–50% of twin pregnancies present with both fetuses in the cephalic position. **Conclusion:** Since all the listed conditions are recognized complications of multifetal gestation, **Option D** is the correct answer. **High-Yield NEET-PG Pearls:** * **Most common complication:** Preterm labor/prematurity. * **Most common presentation:** Cephalic-Cephalic (Vertex-Vertex). * **Anemia:** Iron deficiency anemia is more common due to increased fetal demand. * **Postpartum Hemorrhage (PPH):** Increased risk due to uterine overdistension leading to atony.

Q: The placenta, anchored to the myometrium partially or completely without any intervening decidua, is called what?

Placenta accreta. **Explanation:** The question describes **Placenta Accreta**, a condition characterized by an abnormal adherence of the placenta to the uterine wall. The fundamental pathology is the **partial or complete absence of the decidua basalis** (specifically the Nitabuch’s layer), which normally acts as a barrier. Without this layer, the chorionic villi attach directly to the surface of the myometrium. **Analysis of Options:** * **Placenta Accreta (Correct):** Villi are attached directly to the **surface** of the myometrium without invading it. It is the most common type (approx. 75-80% of cases). * **Placenta Increta:** Villi **invade into** the myometrium. * **Placenta Percreta:** Villi **penetrate through** the entire thickness of the myometrium and may invade serosa or adjacent organs like the bladder. * **Placenta Succenturiata:** This is a morphological variation where one or more small accessory lobes of placenta are developed in the membranes at a distance from the main peripheral margin. It is not an invasive disorder. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** The most significant risk factors are a **previous Cesarean section** and **Placenta Previa**. The risk increases linearly with the number of prior C-sections. * **Clinical Presentation:** Often presents as a "retained placenta" or profuse hemorrhage during the third stage of labor when the placenta fails to separate. * **Diagnosis:** Antenatally diagnosed via Ultrasound/Color Doppler (look for "placental lacunae" or loss of the retroplacental hypoechoic zone). * **Management:** The standard treatment for confirmed placenta accreta spectrum is a planned **Cesarean Hysterectomy**.

Q: Medical treatment of ectopic pregnancy should be offered to which of the following patient profiles?

hCG level < 10,000 IU/L and mass size < 4 cm. **Explanation:** The medical management of ectopic pregnancy primarily involves the administration of **Methotrexate**, a folic acid antagonist that inhibits DNA synthesis in rapidly dividing trophoblastic cells. The success of medical therapy is highly dependent on the initial serum β-hCG levels and the size of the ectopic mass. **Why Option A is Correct:** According to standard clinical guidelines (including ACOG and RCOG), medical management is most effective and should be considered when the **serum β-hCG is < 5,000–10,000 IU/L** and the **ectopic mass size is < 4 cm**. While a lower hCG (< 5,000) is preferred for higher success rates, the threshold of < 10,000 IU/L with a mass < 4 cm represents the upper limit of acceptable criteria for offering medical treatment in a hemodynamically stable patient without fetal cardiac activity. **Analysis of Incorrect Options:** * **Option B:** While an hCG < 5,000 is a very strong indication, a mass size of < 5 cm is generally considered too large, increasing the risk of rupture and treatment failure. * **Option C:** An hCG of 7,500 is acceptable, but a mass size of 7.5 cm is a contraindication for medical management; surgical intervention is required. * **Option D:** These values are very safe for medical management, but they are overly restrictive. Patients with higher values (up to 4 cm and 10,000 IU/L) are still eligible for treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications for Methotrexate:** Hemodynamic instability (ruptured ectopic), intrauterine pregnancy, breastfeeding, and hepatic/renal/hematologic dysfunction. * **Relative Contraindications:** Fetal cardiac activity and hCG > 5,000 IU/L (increased failure rate). * **Monitoring:** hCG levels are measured on Day 4 and Day 7. A drop of **≥ 15%** between Day 4 and Day 7 indicates successful treatment. * **Dose:** Single-dose regimen is 50 mg/m² BSA.

Q: What condition is characterized by painless, heavy, recurrent bleeding of sudden onset?

Placenta previa. **Explanation:** The clinical presentation of **painless, bright red, recurrent, and sudden-onset vaginal bleeding** in the second half of pregnancy is the classic hallmark of **Placenta Previa**. This occurs because the placenta is implanted in the lower uterine segment. As the lower segment stretches and thins out in the third trimester, the placental attachments are disrupted, leading to unavoidable bleeding. Since the bleeding is primarily maternal in origin and not associated with uterine contractions or placental separation from the fundus, it remains painless. **Analysis of Incorrect Options:** * **Abruptio Placentae:** Characterized by **painful** vaginal bleeding (dark red), uterine tenderness, and often associated with hypertension. The pain is due to retroplacental hemorrhage and uterine spasm. * **Cervical Carcinoma:** While it can cause bleeding, it is usually associated with contact bleeding (post-coital) or foul-smelling discharge, rather than sudden, heavy obstetric hemorrhage. * **Circumvallate Placenta:** This is a morphological variation where the chorionic plate is smaller than the basal plate. It may cause mild antepartum hemorrhage or preterm labor, but it does not typically present with the "sudden, heavy, and recurrent" pattern seen in previa. **NEET-PG High-Yield Pearls:** * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pressed into the pelvis, suggesting a posterior placenta previa. * **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the gold standard (safer and more accurate than transabdominal). * **Contraindication:** **Never** perform a digital vaginal examination (PV) in a suspected case of placenta previa until it is ruled out by USG, as it can provoke torrential hemorrhage. * **Management:** If the patient is stable and <37 weeks, follow **Macafee’s expectant management regime**.

Q: A 21-year-old primigravida at 39 weeks gestation presents with painless antepartum hemorrhage. On examination, the uterus is soft and non-tender, with the fetal head engaged. What is the appropriate management?

Pelvic examination in the operating theatre. ### Explanation The clinical presentation of **painless, bright red antepartum hemorrhage (APH)** in a stable patient with a soft, non-tender uterus and an engaged fetal head is highly suggestive of **Placenta Previa**. **Why Option C is Correct:** In cases of suspected placenta previa, a digital vaginal examination is strictly contraindicated in the labor room because it can provoke massive, life-threatening hemorrhage by dislodging a clot or tearing the placenta. The definitive management is a **Double Set-up Examination** (pelvic examination performed in an operating theatre prepared for an immediate Cesarean section). This allows the clinician to confirm the degree of placenta previa and proceed immediately to delivery if torrential bleeding occurs. **Why Other Options are Incorrect:** * **Option A:** While resuscitation is vital, blood transfusion alone does not address the underlying cause or determine the mode of delivery. * **Option B:** A speculum examination may be used to rule out local causes (like cervical polyps), but it must be done with extreme caution and only after ultrasound has localized the placenta. It is not the definitive "management" step for delivery planning. * **Option D:** Tocolysis is used in expectant management (Macafee regime) for preterm cases (<37 weeks) to gain time for steroid administration. This patient is at **39 weeks (term)**; therefore, delivery is indicated, not prolongation of pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pushed into the pelvis, commonly seen in posterior placenta previa. * **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the gold standard for placental localization (safer and more accurate than transabdominal). * **Engagement Rule:** If the fetal head is engaged, it usually rules out major degrees (Type III or IV) of placenta previa.

Question 1

A patient at 22 weeks gestation is diagnosed with IUD which occurred at 17 weeks but did not have a miscarriage. This patient is at increased risk for which of the following?

Accepted Answer

Consumptive coagulopathy with hypofibrinogenemia

Answer

Septic abortion

Answer

Recurrent abortion

Answer

Future infertility

Question 2

Recurrent abortion in the first trimester is most often due to what cause?

Accepted Answer

Chromosomal abnormalities

Answer

Uterine anomaly

Answer

Hormonal disturbance

Answer

Infection

Question 3

Which one of the following causes the greatest risk of ectopic pregnancy?

Accepted Answer

Previous ectopic pregnancy

Answer

Pelvic inflammatory disease

Answer

IUD use

Answer

Previous MTP

Question 4

A woman presents with amenorrhea of 2 months duration, lower abdominal pain, facial pallor, fainting, and shock. What is the most likely diagnosis?

Accepted Answer

Ruptured ectopic pregnancy

Answer

Ruptured ovarian cyst

Answer

Threatened abortion

Answer

Septic abortion

Question 5

Twin pregnancy predisposes to which of the following complications?

Accepted Answer

All of the above

Answer

Hydramnios

Answer

Pregnancy-induced hypertension

Answer

Malpresentation

Question 6

The placenta, anchored to the myometrium partially or completely without any intervening decidua, is called what?

Accepted Answer

Placenta accreta

Answer

Placenta increta

Answer

Placenta succenturia

Answer

Placenta percreta

Question 7

Which of the following is FALSE regarding maternal adaptations in multiple pregnancy compared to singleton pregnancy?

Accepted Answer

Proportionately more red cell mass increase along with fluid increase, resulting in a similar Hemoglobin pattern as singleton pregnancy

Answer

Greater maternal blood volume expansion

Answer

Higher incidence of hyperemesis in twins

Answer

Higher blood volume expansion in twins

Question 8

Medical treatment of ectopic pregnancy should be offered to which of the following patient profiles?

Accepted Answer

hCG level < 10,000 IU/L and mass size < 4 cm

Answer

hCG level < 5,000 IU/L and mass size < 5 cm

Answer

hCG level < 7,500 IU/L and mass size < 7.5 cm

Answer

hCG level < 2,000 IU/L and mass size < 3 cm

Question 9

What condition is characterized by painless, heavy, recurrent bleeding of sudden onset?

Accepted Answer

Placenta previa

Answer

Cervical carcinoma

Answer

Circumvallate placenta

Answer

Abruptio placentae

Question 10

A 21-year-old primigravida at 39 weeks gestation presents with painless antepartum hemorrhage. On examination, the uterus is soft and non-tender, with the fetal head engaged. What is the appropriate management?

Accepted Answer

Pelvic examination in the operating theatre

Answer

Blood transfusion and sedatives

Answer

A speculum examination

Answer

Tocolysis and sedatives

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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