Maternal-Fetal Medicine Practice Questions

Q: Malformations of which of the following fetal organ systems are most commonly associated with a single umbilical artery?

Genitourinary. **Explanation:** **Single Umbilical Artery (SUA)**, also known as a 2-vessel cord, occurs when one of the two umbilical arteries is absent (usually the left). While most cases are isolated, approximately 20–30% are associated with structural anomalies or chromosomal trisomies (especially Trisomy 18 and 13). **Why Genitourinary is correct:** Among the associated structural malformations, **Genitourinary (GU) anomalies** are the most frequently documented. The common embryological origin and proximity of the umbilical arteries to the developing urogenital system explain this link. Common GU findings include renal agenesis, multicystic dysplastic kidney, and hydronephrosis. **Analysis of Incorrect Options:** * **Cardiovascular (B):** These are the second most common anomalies associated with SUA (e.g., VSD). While highly significant, they statistically follow GU anomalies in frequency in most large-scale screening studies. * **Central Nervous System (A) & Skeletal (D):** While anomalies like holoprosencephaly or limb defects can occur with SUA (particularly in the context of aneuploidy), they are significantly less common than GU or cardiac defects. **High-Yield Clinical Pearls for NEET-PG:** * **Incidence:** ~1% of singleton pregnancies; higher in twin gestations and diabetic mothers. * **Management:** If SUA is detected on a mid-trimester scan, a **detailed targeted anomaly scan (Level II)** and **fetal echocardiography** are mandatory. * **Prognosis:** If the SUA is an isolated finding (no other anomalies), the prognosis is generally excellent, though there is a slightly increased risk of **Intrauterine Growth Restriction (IUGR)**. * **Vessel Anatomy:** The normal cord contains **two arteries** (carrying deoxygenated blood from fetus to placenta) and **one vein** (carrying oxygenated blood to the fetus).

Q: Which of the following is not used in the management of DIC in pregnancy?

Epsilon-aminocaproic acid and heparin. **Explanation:** Disseminated Intravascular Coagulation (DIC) in pregnancy is a secondary pathological process characterized by widespread activation of the coagulation cascade, leading to the consumption of clotting factors and platelets. **1. Why Option A is the Correct Answer:** * **Epsilon-aminocaproic acid (EACA):** This is an antifibrinolytic agent. In DIC, while there is excessive fibrinolysis, it is a secondary response to widespread clotting. Inhibiting fibrinolysis with EACA can lead to catastrophic, irreversible widespread thrombosis and organ failure. It is generally **contraindicated** in DIC. * **Heparin:** While heparin is used in some chronic DIC cases (like retained dead fetus), it is **avoided** in acute obstetric DIC (e.g., Abruptio Placentae, Postpartum Hemorrhage) because it can aggravate active life-threatening bleeding. **2. Why the other options are incorrect:** * **Option B (Blood Transfusion):** This is a cornerstone of management. DIC involves the consumption of RBCs and clotting factors; therefore, Whole Blood, Packed RBCs, Fresh Frozen Plasma (FFP), and Cryoprecipitate are essential to replace what is lost. * **Option C (Intravenous Fluids):** Maintaining hemodynamic stability and renal perfusion is critical in DIC to prevent Acute Tubular Necrosis (ATN). Crystalloids are the first line of resuscitation. **Clinical Pearls for NEET-PG:** * **Definitive Treatment:** The most important step in managing obstetric DIC is the **removal of the underlying cause** (e.g., delivery of the fetus/placenta). * **Most Common Cause:** Abruptio placentae is the most common cause of DIC in pregnancy. * **Diagnosis:** Look for low Fibrinogen (<150 mg/dL), elevated D-dimer/FDPs, and prolonged PT/APTT. * **Rule of Thumb:** In obstetric DIC, "Replace what is lost and empty the uterus." Avoid anticoagulants and antifibrinolytics unless specifically indicated in rare, non-bleeding scenarios.

Q: Which of the following laboratory findings is known as a biochemical marker of pre-eclampsia?

Serum uric acid. **Explanation:** **Serum uric acid** is considered a classic biochemical marker for pre-eclampsia. The underlying pathophysiology involves reduced renal perfusion and a decrease in the glomerular filtration rate (GFR). Specifically, pre-eclampsia causes functional changes in the renal tubules, leading to **decreased clearance and increased reabsorption of uric acid**. Hyperuricemia often precedes the clinical onset of hypertension and proteinuria, and its levels correlate significantly with the severity of the disease and adverse perinatal outcomes. **Analysis of Incorrect Options:** * **A & C (Low platelets & Elevated liver enzymes):** While these are critical components of the **HELLP syndrome** (a severe complication of pre-eclampsia), they are considered diagnostic criteria for "pre-eclampsia with severe features" rather than primary biochemical markers used for early identification or screening of the disease process itself. * **B (Raised serum Na):** Sodium levels are generally not used as markers for pre-eclampsia. In fact, due to the activation of the Renin-Angiotensin-Aldosterone System (RAAS) and subsequent edema, there is often water retention, but serum sodium typically remains within the normal range. **High-Yield Clinical Pearls for NEET-PG:** * **Hyperuricemia (>4.5 mg/dL)** is one of the earliest laboratory signs of pre-eclampsia. * **Soluble fms-like tyrosine kinase-1 (sFlt-1)** and **Placental Growth Factor (PlGF)** ratio is the modern "gold standard" biochemical marker for predicting pre-eclampsia. * The most common cause of death in pre-eclampsia is **Cerebral Hemorrhage**, while the most common cause of death in HELLP syndrome is **Hepatic Rupture**.

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

Disseminated intravascular coagulation (DIC). **Explanation:** Intrauterine Fetal Demise (IUFD) refers to fetal death occurring after 20 weeks of gestation but before birth. **Why B is Correct:** The primary complication associated with a retained dead fetus is **Disseminated Intravascular Coagulation (DIC)**. When a fetus dies and is retained in the uterus for more than 3–4 weeks, thromboplastin-like substances are released from the degenerating fetal tissues and placenta into the maternal circulation. This triggers the extrinsic coagulation pathway, leading to the consumption of clotting factors (especially fibrinogen) and platelets, ultimately resulting in a consumptive coagulopathy. **Why Incorrect Options are Wrong:** * **A. Hypertension:** IUFD does not cause hypertension. While Preeclampsia is a common *cause* of IUFD, the death of the fetus itself often leads to a decrease in blood pressure as the placental hormonal influence diminishes. * **C. Increase in fundal height:** In IUFD, the fundal height **decreases** or remains stationary. This is due to the cessation of fetal growth, the absorption of amniotic fluid (liquor), and the collapse of the fetal skull bones (Spalding’s sign). * **D. Increased uterine tone:** IUFD is typically associated with a "silent" or flaccid uterus. Increased uterine tone (hypertonicity) is more characteristic of Abruptio Placentae. **High-Yield Clinical Pearls for NEET-PG:** * **Spalding’s Sign:** Overlapping of fetal skull bones (seen on X-ray/USG 4–7 days after death). * **Robert’s Sign:** Appearance of gas in the fetal large vessels or heart (earliest radiological sign, seen within 12 hours). * **Investigation of Choice:** Ultrasound (demonstrates absence of fetal heart activity). * **Management:** If fibrinogen levels drop below 150 mg/dL, it indicates impending DIC, and the uterus must be evacuated immediately after stabilizing the patient.

Q: What is the single most sensitive marker of intrauterine growth restriction on ultrasonography?

Abdominal Circumference (AC). **Explanation:** **Abdominal Circumference (AC)** is the single most sensitive ultrasound parameter for diagnosing Intrauterine Growth Restriction (IUGR). The physiological basis lies in the fact that the fetal liver is the first organ to be affected by chronic placental insufficiency. IUGR leads to a depletion of fetal glycogen stores in the liver and a reduction in subcutaneous fat. Since the AC measurement primarily reflects the size of the liver and the thickness of the abdominal wall fat, it decreases significantly before other skeletal parameters are affected. **Analysis of Options:** * **Amniotic Fluid Index (AFI):** While oligohydramnios (low AFI) is a common association and a sign of fetal distress in IUGR, it is a non-specific marker and can occur due to various other causes (e.g., PROM, renal anomalies). * **Femur Length (FL) & Biparietal Diameter (BPD):** These are markers of skeletal growth. In "Asymmetrical IUGR" (the most common type), the fetus exhibits "brain-sparing," meaning the head and long bones continue to grow while the body remains small. Therefore, BPD and FL remain relatively preserved until the late stages of growth restriction. **Clinical Pearls for NEET-PG:** * **Most sensitive single parameter:** Abdominal Circumference (AC). * **Most sensitive ratio:** HC/AC ratio (Head Circumference/Abdominal Circumference). This ratio is elevated in asymmetrical IUGR. * **Earliest sign of IUGR on Doppler:** Increased resistance/pulsatility index in the **Umbilical Artery**. * **Gold Standard for Monitoring:** Umbilical Artery Doppler is the best tool for managing IUGR and deciding the timing of delivery.

Q: What is the most common association of renal failure in obstetrics?

Pregnancy-induced hypertension (PIH). **Explanation:** Acute Kidney Injury (AKI) in pregnancy is a serious complication, and **Pregnancy-Induced Hypertension (PIH)**, specifically pre-eclampsia and eclampsia, remains the most common cause of renal failure in the obstetric population. **1. Why PIH is the Correct Answer:** The pathophysiology of PIH involves widespread endothelial dysfunction and vasospasm. In the kidneys, this manifests as **Glomerular Endotheliosis** (swelling of endothelial cells and loss of capillary lumen), which leads to a decreased Glomerular Filtration Rate (GFR), proteinuria, and eventually, acute renal failure. While modern management has reduced its incidence, it still accounts for the majority of obstetric AKI cases globally. **2. Analysis of Incorrect Options:** * **Sepsis:** A significant cause of AKI, particularly in the first trimester (due to septic abortion) or postpartum (puerperal sepsis). However, statistically, it follows PIH in overall frequency. * **Abruptio Placentae:** This is the most common cause of **Acute Tubular Necrosis (ATN)** and **Bilateral Renal Cortical Necrosis** in pregnancy due to severe hypovolemia and DIC. While it is a "classic" cause of severe AKI, it is less frequent than PIH. * **HELLP Syndrome:** While HELLP is a severe variant of PIH and frequently involves renal impairment, it is a subset of the broader category of hypertensive disorders of pregnancy. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of AKI in 1st trimester:** Septic abortion. * **Most common cause of AKI in 3rd trimester:** PIH (Pre-eclampsia/Eclampsia). * **Renal Cortical Necrosis:** Classically associated with Abruptio Placentae; it often leads to permanent renal failure. * **Glomerular Endotheliosis:** The pathognomonic renal lesion of pre-eclampsia.

Q: A pregnant woman is found to have excessive accumulation of amniotic fluid. Polyhydramnios is likely to be associated with all of the following conditions, except:

Bilateral renal agenesis. **Explanation:** The volume of amniotic fluid is a dynamic balance between production (primarily fetal urine) and clearance (primarily fetal swallowing). **Polyhydramnios** occurs when there is either excessive production or impaired clearance of fluid. **Why Bilateral Renal Agenesis is the Correct Answer:** In **Bilateral Renal Agenesis** (Potter’s Syndrome), the fetal kidneys fail to develop. Since fetal urine is the primary source of amniotic fluid from the second trimester onwards, its absence leads to **Oligohydramnios** (deficiency of fluid), not polyhydramnios. This is a classic "except" question where the condition leads to the exact opposite pathology. **Analysis of Incorrect Options:** * **Twin Pregnancy:** Polyhydramnios can occur due to increased fetal surface area or, more specifically, in **Twin-to-Twin Transfusion Syndrome (TTTS)**, where the recipient twin develops polyuria and subsequent polyhydramnios. * **Anencephaly:** This neural tube defect causes polyhydramnios via two mechanisms: (1) failure of the fetal swallowing reflex and (2) transudation of fluid from the exposed meninges into the amniotic sac. * **Esophageal Atresia:** This creates a mechanical obstruction in the fetal gastrointestinal tract, preventing the fetus from swallowing and absorbing amniotic fluid, leading to accumulation. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Polyhydramnios is defined as an Amniotic Fluid Index (AFI) **> 25 cm** or a Single Deepest Pocket (SDP) **> 8 cm**. * **Maternal Cause:** The most common maternal cause of polyhydramnios is **Maternal Diabetes Mellitus** (due to fetal osmotic diuresis). * **Potter Sequence:** Bilateral renal agenesis → Oligohydramnios → Pulmonary hypoplasia, limb deformities, and flattened facies.

Q: Which of the following is the drug of choice in pregnancy-induced hypertension?

Methyldopa. **Explanation:** **Alpha-methyldopa** is considered the traditional drug of choice for the management of chronic hypertension and pregnancy-induced hypertension (PIH). It is a centrally acting alpha-2 adrenergic agonist that reduces sympathetic outflow. Its preference in pregnancy stems from its long-standing safety profile, lack of teratogenicity, and the fact that it does not compromise uteroplacental blood flow. **Analysis of Options:** * **B. Diltiazem:** This is a calcium channel blocker (CCB). While certain CCBs like Nifedipine are commonly used in pregnancy, Diltiazem is not a first-line agent for PIH due to less clinical data compared to Methyldopa or Labetalol. * **C. Metoprolol:** While beta-blockers can be used, Metoprolol is generally avoided in the first trimester due to risks of fetal bradycardia and potential growth restriction (IUGR). **Labetalol** (a combined alpha/beta-blocker) is the preferred beta-blocker in pregnancy. * **D. Enalapril:** ACE inhibitors and ARBs are **strictly contraindicated** in pregnancy (Category X). They are associated with fetal renal dysgenesis, oligohydramnios, and skull hypoplasia. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (Chronic/Long-term):** Methyldopa. * **Drug of Choice (Acute Hypertensive Crisis/Emergency):** Intravenous **Labetalol** (fastest acting) or Hydralazine. * **Oral Labetalol** is increasingly replacing Methyldopa in modern guidelines due to a faster onset and fewer side effects (like sedation/depression). * **Prophylaxis:** Low-dose Aspirin (75–150 mg) is started before 16 weeks for women at high risk of preeclampsia. * **Magnesium Sulfate ($MgSO_4$):** The drug of choice for seizure prophylaxis and control in Eclampsia.

Question 1

What is true regarding the delivery of an HIV-positive woman?

Accepted Answer

Vaginal delivery has a higher risk of HIV transmission to the child compared to Cesarean section.

Answer

Vaginal delivery has a lower risk of HIV transmission to the child compared to Cesarean section.

Answer

The use of instrumentation during delivery has no risk of increased HIV infection transmission.

Answer

Vertical transmission of HIV is less likely in cases of preterm birth.

Question 2

Malformations of which of the following fetal organ systems are most commonly associated with a single umbilical artery?

Accepted Answer

Genitourinary

Answer

Central nervous system

Answer

Cardiovascular

Answer

Skeletal

Question 3

Which of the following is not used in the management of DIC in pregnancy?

Accepted Answer

Epsilon-aminocaproic acid and heparin

Answer

Blood transfusion

Answer

Intravenous fluids

Answer

None of the above

Question 4

Which of the following laboratory findings is known as a biochemical marker of pre-eclampsia?

Accepted Answer

Serum uric acid

Answer

Low platelets

Answer

Raised serum Na

Answer

Elevated liver enzymes

Question 5

Which of the following is seen in intrauterine fetal demise?

Accepted Answer

Disseminated intravascular coagulation (DIC)

Answer

Hypertension

Answer

Increase in fundal height of uterus

Answer

Increased uterine tone

Question 6

What is the single most sensitive marker of intrauterine growth restriction on ultrasonography?

Accepted Answer

Abdominal Circumference (AC)

Answer

Amniotic Fluid Index (AFI)

Answer

Femur Length (FL)

Answer

Biparietal Diameter (BPD)

Question 7

In multiple pregnancy, fetal reduction is typically performed using which of the following agents?

Accepted Answer

Potassium chloride (KCl)

Answer

Mifepristone

Answer

Prostaglandin F2-alpha (PGF2-alpha)

Answer

Methotrexate

Question 8

What is the most common association of renal failure in obstetrics?

Accepted Answer

Pregnancy-induced hypertension (PIH)

Answer

Sepsis

Answer

Abruptio placentae

Answer

HELLP syndrome

Question 9

A pregnant woman is found to have excessive accumulation of amniotic fluid. Polyhydramnios is likely to be associated with all of the following conditions, except:

Accepted Answer

Bilateral renal agenesis

Answer

Twin pregnancy

Answer

Anencephaly

Answer

Esophageal atresia

Question 10

Which of the following is the drug of choice in pregnancy-induced hypertension?

Accepted Answer

Methyldopa

Answer

Diltiazem

Answer

Metoprolol

Answer

Enalapril

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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