Maternal-Fetal Medicine Practice Questions

Q: What is the recommended daily dose of folic acid for treating megaloblastic anemia during pregnancy?

1 mg. **Explanation:** **1. Why Option C (1 mg) is Correct:** Megaloblastic anemia in pregnancy is most commonly caused by **folic acid deficiency**. While the physiological requirement for folate increases during pregnancy, the therapeutic dose required to treat established megaloblastic anemia is **1 mg of folic acid daily**. This dose is sufficient to induce a reticulocyte response and restore hemoglobin levels, provided there is no concurrent Vitamin B12 deficiency or malabsorption. **2. Why Other Options are Incorrect:** * **Option A (400 mg):** This is an erroneously high value. The standard prophylactic dose for low-risk pregnancies is 400 **micrograms** (0.4 mg), not milligrams. * **Option B (5 mg):** This is the high-dose prophylaxis recommended for women at **high risk of Neural Tube Defects (NTDs)** (e.g., previous child with NTD, maternal diabetes, or anti-epileptic drug use). While often used in clinical practice for anemia, 1 mg is the standard textbook recommendation for treatment. * **Option D (2 mg):** This is not a standard recommended dose in international or national guidelines for the treatment of nutritional anemia. **3. High-Yield Clinical Pearls for NEET-PG:** * **Prophylaxis (Low Risk):** 400 mcg (0.4 mg) daily, starting 1 month preconception until 12 weeks of gestation. * **Prophylaxis (High Risk):** 5 mg daily to prevent NTD recurrence. * **Iron + Folic Acid (IFA) Program:** Under the *Anemia Mukt Bharat* guidelines, pregnant women receive **60 mg elemental iron + 500 mcg (0.5 mg) folic acid** daily for 180 days. * **Diagnosis:** Megaloblastic anemia is characterized by a **Mean Corpuscular Volume (MCV) > 100 fL** and hypersegmented neutrophils on peripheral smear. Always rule out Vitamin B12 deficiency before starting high-dose folate to avoid masking neurological symptoms.

Q: What is the most valuable diagnostic test in a case of suspected ectopic pregnancy?

Transvaginal ultrasound. **Explanation:** The diagnosis of ectopic pregnancy relies on the "Discriminatory Zone" concept—the level of serum beta-hCG at which an intrauterine pregnancy (IUP) should be visible. **1. Why Transvaginal Ultrasound (TVS) is the correct answer:** TVS is the **most valuable diagnostic tool** because it provides direct anatomical evidence. It can confirm an IUP (ruling out ectopic via the principle of exclusivity, except in rare heterotopic cases) or visualize an adnexal mass/gestational sac. TVS is superior to transabdominal ultrasound as it can detect an IUP at lower hCG levels (1,500–2,000 mIU/mL). Finding an empty uterus with an adnexal mass in a patient with a positive pregnancy test is highly diagnostic. **2. Why other options are incorrect:** * **Serial beta-hCG levels:** While crucial for monitoring viability and determining the discriminatory zone, a single or serial level cannot pinpoint the *location* of the pregnancy. It is a supportive biochemical test, not a definitive diagnostic one. * **Progesterone measurement:** Levels <5 ng/mL suggest a non-viable pregnancy but do not distinguish between a miscarriage and an ectopic pregnancy. It is rarely used in modern clinical practice. * **Culdocentesis:** Historically used to detect hemoperitoneum (ruptured ectopic), it has been largely replaced by the non-invasive and more accurate TVS. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Laparoscopy (allows for both diagnosis and immediate surgical management). * **Most common site:** Ampulla of the Fallopian tube. * **Arias-Stella Reaction:** Hypersecretory endometrium seen on biopsy; it is suggestive of pregnancy but not specific to ectopic. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases).

Q: Raised beta-hCG levels are seen in which of the following conditions?

Rh incompatibility. **Explanation:** The correct answer is **Rh incompatibility**. **1. Why Rh Incompatibility is Correct:** In Rh-isoimmunization, maternal antibodies cross the placenta and cause fetal hemolysis. To compensate for the resulting fetal anemia, the placenta undergoes **hypertrophic changes (placentomegaly)**. The increased mass of the cytotrophoblasts and syncytiotrophoblasts leads to an overproduction of human chorionic gonadotropin (hCG). Therefore, raised maternal serum beta-hCG levels are a characteristic finding in severe Rh-isoimmunization and hydrops fetalis. **2. Analysis of Incorrect Options:** * **Diabetes Mellitus:** While DM is associated with large placentas, beta-hCG levels are typically **normal** or only slightly altered; they are not a diagnostic or characteristic marker for the condition. * **Preeclampsia:** This condition is associated with placental ischemia and "placental aging." While some studies show elevated hCG in severe cases due to trophoblastic hyperproliferation, it is **not** the classic association compared to Rh incompatibility in standard textbooks. * **Ectopic Pregnancy:** This is a high-yield distractor. In ectopic pregnancy, beta-hCG levels are **lower than expected** for the period of gestation and fail to show the normal doubling (at least 66% increase) every 48 hours. **3. NEET-PG High-Yield Pearls:** * **Conditions with Raised beta-hCG:** Molar pregnancy (highest levels), Multiple pregnancy, Rh-isoimmunization, Down Syndrome (Triple/Quadruple screen), and Choriocarcinoma. * **Conditions with Low beta-hCG:** Ectopic pregnancy, Threatened/Spontaneous abortion, and Edwards Syndrome (Trisomy 18). * **Doubling Time:** In a healthy intrauterine pregnancy, beta-hCG doubles every 48–72 hours until it peaks at 8–11 weeks.

Q: Fundal height is more than the period of gestation in all conditions except:

Intrauterine death (IUD). **Explanation:** In clinical obstetrics, the symphysis-fundal height (SFH) is a crucial screening tool. When the **fundal height is less than the period of gestation**, it indicates a decrease in the contents of the uterus (fetus, placenta, or liquor). **1. Why Intrauterine Death (IUD) is the Correct Answer:** In IUD, the cessation of fetal growth, the loss of fetal muscle tone (leading to collapse of the fetal body), and the subsequent absorption of amniotic fluid (liquor) cause the uterus to shrink. Consequently, the fundal height becomes **less than** the expected period of gestation. **2. Analysis of Incorrect Options (Conditions where SFH > Gestational Age):** * **Twin Pregnancy:** The presence of two fetuses and two placentas increases the total intrauterine volume. * **Hydatidiform Mole:** This is characterized by the rapid proliferation of chorionic villi and the accumulation of concealed hemorrhage, often making the uterus "doughy" and larger than dates. * **Hydramnios (Polyhydramnios):** An excessive accumulation of amniotic fluid directly increases the uterine size beyond what is expected for the fetal age. **Clinical Pearls for NEET-PG:** * **Other causes of SFH > Dates:** Large for gestational age (LGA) fetus, uterine fibroids, and maternal obesity or full bladder during examination. * **Other causes of SFH 2 cm** between SFH and gestational age warrants further investigation via ultrasound. * **McDonald's Rule:** SFH in cm = Gestational age in weeks (applicable between 20–36 weeks).

Q: A 15 cm x 15 cm ovarian cyst has been diagnosed in an 8-week pregnant lady. Further management includes:

Laparotomy at 14-16 weeks. ### Explanation The management of an adnexal mass in pregnancy depends on the size of the cyst, its sonographic features, and the gestational age. **Why Option B is Correct:** A 15 cm ovarian cyst is considered large (typically >6–10 cm) and carries a high risk of **torsion, rupture, or labor obstruction**. The ideal time for surgical intervention is the **early second trimester (14–16 weeks)**. * By this time, the **luteo-placental shift** is complete (the placenta has taken over progesterone production from the corpus luteum), significantly reducing the risk of miscarriage. * The uterus is not yet large enough to technically obstruct the surgical field, making the procedure safer than in the third trimester. **Why Other Options are Incorrect:** * **Option A:** Observation is reserved for simple cysts <6 cm, which often resolve spontaneously. A 15 cm cyst is unlikely to resolve and poses an immediate risk of torsion. * **Option C & D:** Delaying surgery until term or postpartum increases the risk of emergency complications (torsion/rupture) throughout the pregnancy and may necessitate an emergency laparotomy, which carries higher maternal and fetal morbidity than an elective mid-trimester procedure. **High-Yield Clinical Pearls for NEET-PG:** * **Most common ovarian cyst in pregnancy:** Corpus luteum cyst (usually regresses by 12–14 weeks). * **Most common benign neoplasm in pregnancy:** Mature cystic teratoma (Dermoid). * **Indications for surgery:** Size >10 cm, solid components/papillary projections on ultrasound (suspicion of malignancy), or acute complications (torsion). * **Laparoscopy vs. Laparotomy:** While laparotomy is the traditional answer, laparoscopy is now considered safe in the second trimester if performed by an expert.

Q: Which of the following is NOT a cause of Disseminated Intravascular Coagulation (DIC)?

Fat emboli. **Explanation:** Disseminated Intravascular Coagulation (DIC) in obstetrics is primarily triggered by the release of **thromboplastin** (tissue factor) into the maternal circulation, leading to widespread activation of the coagulation cascade and subsequent consumption of clotting factors. **Why Fat Emboli is the Correct Answer:** While **Fat Embolism Syndrome (FES)** is a life-threatening condition typically associated with long bone fractures or orthopedic trauma, it is **not** a recognized cause of DIC in the obstetric context. FES primarily causes respiratory distress, petechial rashes, and neurological symptoms due to mechanical obstruction of capillaries and free fatty acid toxicity, rather than a systemic consumptive coagulopathy. **Analysis of Incorrect Options:** * **Abruption Placentae:** This is the **most common** cause of DIC in pregnancy. The retroplacental clot releases massive amounts of tissue thromboplastin into the maternal bloodstream. * **Amniotic Fluid Embolism (AFE):** This is the **most severe** cause. Amniotic fluid contains high concentrations of procoagulant factors and tissue factor, triggering an "anaphylactoid syndrome" and sudden, profound DIC. * **Intrauterine Fetal Demise (IUD):** If a dead fetus is retained for more than 3–4 weeks ("Dead Fetus Syndrome"), the gradual release of degenerating fetal tissue products into the maternal circulation leads to chronic DIC. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of DIC in pregnancy:** Abruptio Placentae. * **Earliest lab finding in DIC:** Decreased platelet count and presence of Schistocytes (fragmented RBCs) on peripheral smear. * **Best screening test:** FDPs (Fibrin Degradation Products) or D-dimer (elevated). * **Confirmatory/Most specific finding:** Low Fibrinogen levels (<150 mg/dL). * **Management:** Always treat the underlying cause (e.g., delivery) and replace blood products (FFP, Cryoprecipitate).

Question 1

An ovarian cyst is detected in a pregnant woman; what is the recommended management?

Accepted Answer

Removal by laparotomy in the second trimester

Answer

Immediate removal by laparotomy

Answer

Wait and watch

Answer

Removal at the time of cesarean section

Question 2

What is the recommended daily dose of folic acid for treating megaloblastic anemia during pregnancy?

Accepted Answer

1 mg

Answer

400 mg

Answer

5 mg

Answer

2 mg

Question 3

What is the most valuable diagnostic test in a case of suspected ectopic pregnancy?

Accepted Answer

Transvaginal ultrasound

Answer

Serial beta-hCG levels

Answer

Progesterone measurement

Answer

Culdocentesis

Question 4

Raised beta-hCG levels are seen in which of the following conditions?

Accepted Answer

Rh incompatibility

Answer

Diabetes Mellitus

Answer

Preeclampsia

Answer

Ectopic pregnancy

Question 5

Which of the following statements is true regarding the management of labor in an HIV-positive mother?

Accepted Answer

Routine suctioning of the newborn should be avoided.

Answer

Cesarean delivery is the preferred method of delivery.

Answer

Early artificial rupture of membranes should be performed to detect meconium, as these patients are at high risk of fetal distress.

Answer

If instrumental delivery is required, vacuum extraction is preferable to forceps.

Question 6

Fundal height is more than the period of gestation in all conditions except:

Accepted Answer

Intrauterine death (IUD)

Answer

Twin pregnancy

Answer

Hydatidiform mole

Answer

Hydramnios

Question 7

What is the highest risk factor for ectopic pregnancy?

Accepted Answer

Previous surgery for ectopic pregnancy

Answer

Intrauterine device

Answer

Salpingitis

Answer

Salpingitis isthmica nodosa

Question 8

A 28-week pregnant woman (G2P1) detected with major placenta previa on ultrasound (transvaginal scan) should have a confirmatory scan performed at which gestational age?

Accepted Answer

32 weeks

Answer

34 weeks

Answer

36 weeks

Answer

Onset of labor

Question 9

A 15 cm x 15 cm ovarian cyst has been diagnosed in an 8-week pregnant lady. Further management includes:

Accepted Answer

Laparotomy at 14-16 weeks

Answer

Only follow-up without surgical intervention

Answer

Cesarean delivery and ovariotomy at term

Answer

Surgery after delivery

Question 10

Which of the following is NOT a cause of Disseminated Intravascular Coagulation (DIC)?

Accepted Answer

Fat emboli

Answer

Abruption placentae

Answer

Amniotic fluid embolism

Answer

Intrauterine fetal demise (IUD)

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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