Maternal-Fetal Medicine Practice Questions

Q: Which among the following is decreased in twin pregnancy compared to singleton pregnancy?

Systemic vascular resistance. In a twin pregnancy, the maternal body undergoes exaggerated physiological adaptations compared to a singleton pregnancy to meet the increased metabolic demands of two fetuses. **Explanation of the Correct Answer:** **Systemic Vascular Resistance (SVR)** is significantly **decreased** in twin pregnancies. This is due to the high-flow, low-resistance circuit of the dual placentae and the profound vasodilatory effects of increased progesterone and nitric oxide. While SVR drops in all pregnancies, the decline is more pronounced in multifetal gestations to accommodate a much higher cardiac output (which increases by an additional 20% over singleton levels). **Why the other options are incorrect:** * **Blood loss at delivery:** This is **increased**. The larger placental site and the risk of uterine atony due to overdistension of the uterus make postpartum hemorrhage (PPH) much more common in twins. * **Blood pressure at term:** This is typically **increased** or remains similar. Twin pregnancies carry a significantly higher risk (3–4 times) of developing gestational hypertension and preeclampsia compared to singletons. * **Blood volume expansion:** This is **increased**. While singleton pregnancies see a 40–50% increase, twin pregnancies experience a 50–60% increase in plasma volume to support dual uteroplacental perfusion. **High-Yield Clinical Pearls for NEET-PG:** * **Anemia:** Because plasma volume expansion exceeds the rise in red cell mass more severely in twins, **physiologic anemia** is more profound. * **Cardiac Output:** Reaches its peak earlier and is higher in twins. * **Uterine Volume:** Can reach up to 10 liters or more, leading to increased diaphragmatic splinting and respiratory discomfort.

Q: All of the following are true about anencephaly except?

Preterm delivery is a norm. **Explanation:** Anencephaly is a lethal neural tube defect characterized by the absence of the cranial vault and cerebral hemispheres. **Why Option C is the correct answer (The False Statement):** Contrary to common belief, **post-term pregnancy (prolonged pregnancy)** is more common in anencephaly than preterm delivery. This occurs because the fetal pituitary-adrenal axis is defective or absent. The lack of fetal cortisol and precursors for estrogen synthesis leads to a failure in the initiation of labor, often resulting in a pregnancy that continues beyond 42 weeks unless medical intervention occurs. **Analysis of Incorrect Options:** * **A. Face presentation:** Due to the absence of the vertex (calvarium), the head cannot engage normally. The face becomes the leading part, making face presentation a common clinical finding. * **B. Increased alpha-fetoprotein (AFP):** Anencephaly is an open neural tube defect. This allows AFP to leak from the fetal circulation into the amniotic fluid and maternal serum, leading to significantly elevated levels. * **D. Polyhydramnios:** This occurs due to two reasons: (1) the fetus lacks the swallowing reflex due to neurological deficit, and (2) transudation of fluid from the exposed meninges (cerebrospinal fluid) into the amniotic sac. **High-Yield Clinical Pearls for NEET-PG:** * **Screening:** Elevated Maternal Serum AFP (MSAFP) at 15–20 weeks. * **Diagnosis:** Ultrasound is the gold standard (shows "Frog-eye appearance" or "Mickey Mouse sign" in early scans). * **Prevention:** 4 mg of Folic acid daily (pre-conceptionally) for women with a previous history; 400 mcg for low-risk pregnancies. * **Associated finding:** "Shoulder dystocia" can occur because these fetuses often have large trunks despite the absent cranial vault.

Q: What is the clinical diagnosis when a pregnant woman presents with bloody vaginal discharge through a closed cervical os during the first 20 weeks?

Threatened abortion. ### Explanation **Correct Answer: A. Threatened Abortion** **Medical Concept:** Threatened abortion is defined as vaginal bleeding occurring before the 20th week of gestation where the **cervical os remains closed**. It is a clinical diagnosis indicating that the pregnancy is at risk, but the products of conception have not been expelled. The hallmark features are painless or mildly painful bleeding with a closed internal os and a viable fetus on ultrasound. **Why the other options are incorrect:** * **B. Complete Abortion:** In this case, all products of conception have been expelled. The cervix has usually closed *after* the event, the uterus is smaller than the period of gestation, and ultrasound shows an empty cavity. * **C. Incomplete Abortion:** This involves the partial expulsion of products. Crucially, the **cervical os is open**, and some tissue remains within the uterus, often leading to heavy bleeding and crampy pain. * **D. Preterm Labor:** This refers to the onset of labor (regular contractions and cervical changes) occurring after the age of viability (typically >20–24 weeks) but before 37 weeks. The question specifies the first 20 weeks. **NEET-PG High-Yield Pearls:** * **Management:** The mainstay of treatment for threatened abortion is **expectant management** and bed rest (though evidence for bed rest is limited). Progesterone supplementation is often used if a deficiency is suspected. * **Prognosis:** Approximately 50% of threatened abortions progress to actual loss; however, if fetal heart activity is seen on USG, there is a >90% chance of the pregnancy continuing. * **Cervical Os Status:** This is the "deciding factor" in abortion questions. * **Closed Os:** Threatened or Missed abortion. * **Open Os:** Inevitable or Incomplete abortion.

Q: Which of the following is NOT a feature of postdated pregnancy?

Polyhydramnios. **Explanation:** Postdated pregnancy (defined as a pregnancy extending beyond 42 weeks) is characterized by a progressive decline in placental function. The correct answer is **Polyhydramnios** because postdated pregnancies are actually associated with **Oligohydramnios** (decreased amniotic fluid). **Why Polyhydramnios is the correct choice (the "NOT" feature):** As the placenta ages (placental insufficiency), fetal perfusion decreases. This leads to reduced fetal renal blood flow, resulting in decreased fetal urine output—the primary source of amniotic fluid in late pregnancy. Therefore, oligohydramnios is a hallmark of postterm pregnancy, not polyhydramnios. **Analysis of incorrect options:** * **Cord compression:** Due to the reduction in amniotic fluid (oligohydramnios), the umbilical cord is no longer cushioned, making it highly susceptible to compression during contractions or fetal movement. * **Fetal distress:** Placental insufficiency leads to chronic hypoxia. This, combined with cord compression, significantly increases the risk of non-reassuring fetal heart rate patterns and fetal distress. * **Intrauterine growth restriction (IUGR):** While many postterm fetuses are macrosomic, a subset experiences "Dysmaturity Syndrome" (Clifford’s Syndrome) due to placental failure, leading to loss of subcutaneous fat and growth restriction. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Postterm is ≥42 weeks; Late-term is 41 weeks to 41 weeks 6 days. * **Most common cause:** Inaccurate dating (wrong dates). * **Amniotic Fluid Index (AFI):** An AFI <5 cm or a single deepest pocket <2 cm is a critical indicator for induction in postterm cases. * **Meconium Aspiration Syndrome (MAS):** Risk increases significantly post-42 weeks due to increased meconium passage in utero (triggered by vagal stimulation from cord compression).

Q: All of the following are to be monitored during Magnesium sulfate prophylaxis in impending eclampsia, EXCEPT:

Serum magnesium level. **Explanation:** Magnesium sulfate ($MgSO_4$) is the drug of choice for seizure prophylaxis in pre-eclampsia and control in eclampsia. It is primarily excreted by the kidneys and has a narrow therapeutic index. Therefore, monitoring for **magnesium toxicity** is mandatory. **Why Serum Magnesium Level is the Correct Answer:** Routine monitoring of serum magnesium levels is **not required** during prophylaxis. Clinical monitoring of bedside parameters is sufficient and more practical. Serum levels are only indicated if the patient has renal impairment (Serum Creatinine >1.0 mg/dL), if clinical signs of toxicity appear, or if seizures recur despite treatment. The therapeutic range is 4–7 mEq/L, while toxicity begins when levels exceed 7–10 mEq/L. **Why the other options are monitored (Clinical Monitoring):** Clinical signs of toxicity follow a predictable sequence, which must be monitored every 2–4 hours: * **Patellar reflex (A):** Loss of deep tendon reflexes (knee jerk) is the **earliest sign** of toxicity (occurs at 7–10 mEq/L). $MgSO_4$ must be stopped if the reflex is absent. * **Respiratory Rate (B):** Magnesium causes neuromuscular blockade. Respiratory depression (RR 30 ml/hr or 100 ml/4 hours) ensures the drug does not accumulate to toxic levels. **High-Yield Clinical Pearls for NEET-PG:** * **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (administered slowly over 10 minutes). * **Pritchard Regimen:** 4g IV + 10g IM (loading), followed by 5g IM every 4 hours (maintenance). * **Zuspan Regimen:** 4g IV (loading), followed by 1-2g/hr IV infusion (maintenance). * **Therapeutic Range:** 4–7 mEq/L (or 4.8–8.4 mg/dL). * **Cardiac Arrest:** Occurs at levels >25 mEq/L.

Q: A 28-year-old female with a history of 8 weeks of amenorrhea complains of vaginal bleeding and lower abdominal pain. On USG examination, there is a gestational sac with absent fetal parts. What is the diagnosis?

Incomplete abortion. **Explanation:** The clinical presentation of vaginal bleeding and abdominal pain following amenorrhea, combined with the ultrasound finding of a gestational sac with absent fetal parts, points toward an **Incomplete Abortion**. **1. Why Incomplete Abortion is correct:** In an incomplete abortion, the products of conception (POC) have partially expelled from the uterus. On ultrasound, this typically manifests as an irregular gestational sac, a collapsed sac, or heterogeneous echogenic material (retained products) within the uterine cavity. The absence of fetal parts in a sac that previously contained them, or a disorganized sac at 8 weeks, confirms that the pregnancy is no longer viable and is in the process of expulsion. **2. Why other options are incorrect:** * **Ectopic Pregnancy:** While it presents with pain and bleeding, the ultrasound would typically show an empty uterus and an adnexal mass. A gestational sac *inside* the uterus (as stated in the question) makes this less likely. * **Threatened Abortion:** In this condition, bleeding occurs but the pregnancy remains viable. Ultrasound would show a well-formed gestational sac with a visible fetal pole and cardiac activity (at 8 weeks). * **Corpus Luteum Cyst:** This is a functional physiological cyst of pregnancy. While it may cause mild pain, it does not cause vaginal bleeding or the presence of a non-viable gestational sac. **High-Yield Clinical Pearls for NEET-PG:** * **Cervical Os Status:** In Incomplete and Inevitable abortions, the internal os is **open**. In Threatened and Missed abortions, the os is **closed**. * **Management:** Incomplete abortion is managed by medical evacuation (Misoprostol) or surgical evacuation (D&E/MVA). * **USG Hallmark:** The "Snowstorm appearance" is specific to Molar pregnancy, while an "Empty sac" >25mm MSD (Mean Sac Diameter) defines a Blighted Ovum (Anembryonic pregnancy).

Q: Magnesium sulfate has no role in the prevention of which of the following?

Respiratory distress syndrome in a premature baby. **Explanation:** Magnesium sulfate ($MgSO_4$) is the drug of choice in obstetric practice for seizure prophylaxis and neuroprotection, but it does not have a direct role in fetal lung maturation. 1. **Why Option B is Correct:** Respiratory Distress Syndrome (RDS) is prevented by the administration of **antenatal corticosteroids** (such as Betamethasone or Dexamethasone), which stimulate surfactant production. $MgSO_4$ does not affect surfactant synthesis and therefore has no role in preventing RDS. 2. **Why Options A & C are Incorrect:** $MgSO_4$ is the gold standard for both the **prevention** of seizures in women with severe pre-eclampsia (prophylaxis) and the **control/prevention of recurrence** in eclampsia (treatment). It acts by increasing the seizure threshold and causing cerebral vasodilation. 3. **Why Option D is Incorrect:** $MgSO_4$ is administered for **fetal neuroprotection** in anticipated preterm births (usually <32 weeks). It reduces the risk of cerebral palsy and severe motor dysfunction in the neonate by stabilizing neuronal membranes and reducing oxidative stress. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** $MgSO_4$ is an NMDA receptor antagonist and a calcium channel blocker. * **Therapeutic Range:** 4–7 mEq/L. * **Toxicity Signs:** Loss of patellar reflex (earliest sign, 8–10 mEq/L) → Respiratory depression (12–15 mEq/L) → Cardiac arrest (>25 mEq/L). * **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (administered slowly). * **Excretion:** Exclusively via kidneys; hence, dose adjustment is mandatory in renal failure.

Q: What is the fetal anomaly characterized by the absence of the cranium?

Anencephaly. ### Explanation **Correct Answer: C. Anencephaly** **Anencephaly** is the most common lethal neural tube defect (NTD). It results from the failure of the **cephalic (rostral) end of the neural tube** to close between the 23rd and 26th day of conception. This failure leads to the absence of the cranial vault (acrania) and the cerebral hemispheres. The exposed brain tissue undergoes degeneration, leaving behind a vascular mass called the *area cerebrovasculosa*. On ultrasound, this presents as the characteristic **"Frog-eye appearance"** due to prominent orbits and the absence of the calvarium. **Analysis of Incorrect Options:** * **A. Cephalocele:** This is a protrusion of the cranial contents through a defect in the skull (usually occipital). Unlike anencephaly, the rest of the cranium is present. * **B. Holoprosencephaly:** This is a failure of the prosencephalon (forebrain) to divide into two cerebral hemispheres. While it involves brain malformation and facial defects (like cyclopia), the skull vault is typically present. * **C. Dandy-Walker Malformation:** This involves the posterior fossa, characterized by agenesis of the cerebellar vermis, cystic dilation of the fourth ventricle, and an enlarged posterior fossa. The cranium itself is intact. **NEET-PG High-Yield Pearls:** * **Screening:** Elevated **Maternal Serum Alpha-Fetoprotein (MSAFP)** is a classic marker for open NTDs like anencephaly. * **Prevention:** Periconceptional intake of **Folic Acid (400 mcg/day)** reduces the risk by 70%. For women with a previous affected pregnancy, the dose is increased to **4 mg/day**. * **Associated Finding:** **Polyhydramnios** is frequently seen in the third trimester because the fetus lacks the swallowing reflex due to neurological impairment.

Q: When the death of one fetus in a multiple pregnancy occurs early in pregnancy, how may it manifest?

Vanishing twin. ### Explanation The correct answer is **B. Vanishing twin**. **1. Why "Vanishing Twin" is correct:** When a fetus dies **early in pregnancy** (typically during the first trimester), the gestational sac and fetal tissues are often completely reabsorbed by the mother or the surviving twin. On a follow-up ultrasound, the previously documented twin simply "disappears," leaving a single viable fetus. This phenomenon occurs in approximately 20–30% of pregnancies conceived via assisted reproductive techniques. **2. Why the other options are incorrect:** * **A. Fetus papyraceus:** This occurs when fetal death happens in the **second trimester** (usually after 14 weeks). The fetus is too large to be fully reabsorbed; instead, the amniotic fluid is absorbed, and the dead fetus becomes flattened, mummified, and parchment-like due to mechanical compression by the growing survivor. * **C. Fetus compressus:** This is a similar stage to fetus papyraceus. It refers to a fetus that has died and been compressed, but the term "papyraceus" is more specifically used when it is flattened to a paper-thin state. * **D. Fetus acardiacus (TRAP Sequence):** This is a rare complication of monochorionic twinning where one twin has a rudimentary or absent heart and is perfused by the "pump twin" through large artery-to-artery anastomoses. It is a developmental malformation, not a manifestation of early fetal death/reabsorption. **3. Clinical Pearls for NEET-PG:** * **Timing is Key:** Early 1st Trimester = Vanishing Twin; 2nd Trimester = Fetus Papyraceus. * **Prognosis:** If a twin "vanishes" in the 1st trimester, the prognosis for the surviving twin is usually excellent. * **Monochorionic Risk:** Death of a twin in the **2nd or 3rd trimester** in a monochorionic pregnancy carries a high risk of neurological damage (periventricular leukomalacia) or death for the survivor due to acute hemodynamic shifts.

Q: Which of the following is true about magnesium sulfate (MgSO4)?

Magnesium sulfate is used in the management of eclampsia.. **Explanation:** **Magnesium Sulfate (MgSO₄)** is the drug of choice for both the prophylaxis and treatment of seizures in eclampsia (Pritchard or Zuspan regimens). It acts primarily by blocking NMDA receptors, increasing the seizure threshold, and causing cerebral vasodilation. **Analysis of Options:** * **Option B (Correct):** MgSO₄ is the gold standard for managing eclamptic seizures and preventing progression from pre-eclampsia to eclampsia. * **Option A (Incorrect):** While not the *first-line* choice today (calcium channel blockers are preferred), MgSO₄ **is** a tocolytic. It acts as a calcium antagonist, relaxing uterine smooth muscle to delay preterm labor. * **Option C (Incorrect):** MgSO₄ crosses the placenta. In cases of maternal toxicity or prolonged high-dose infusion, it can cause **neonatal respiratory depression**, hypotonia ("floppy infant syndrome"), and suppressed reflexes. * **Option D (Incorrect):** MgSO₄ is **strictly contraindicated in Myasthenia Gravis**. It inhibits the release of acetylcholine at the neuromuscular junction, which can precipitate a life-threatening myasthenic crisis. **High-Yield Clinical Pearls for NEET-PG:** 1. **Therapeutic Range:** 4–7 mEq/L. 2. **Monitoring:** Always check for **Patellar reflex** (first to disappear at 8–10 mEq/L), **Respiratory rate** (>12/min), and **Urine output** (>30 ml/hr, as it is renally excreted). 3. **Antidote:** 10 ml of 10% **Calcium Gluconate** IV (administered slowly). 4. **Neuroprotection:** MgSO₄ is also used for fetal neuroprotection in imminent preterm births <32 weeks to reduce the risk of cerebral palsy.

Question 1

Which among the following is decreased in twin pregnancy compared to singleton pregnancy?

Accepted Answer

Systemic vascular resistance

Answer

Blood loss at delivery

Answer

Blood pressure at term

Answer

Blood volume expansion

Question 2

All of the following are true about anencephaly except?

Accepted Answer

Preterm delivery is a norm

Answer

Face presentation

Answer

Increased alpha-fetoprotein

Answer

Polyhydramnios

Question 3

What is the clinical diagnosis when a pregnant woman presents with bloody vaginal discharge through a closed cervical os during the first 20 weeks?

Accepted Answer

Threatened abortion

Answer

Complete abortion

Answer

Incomplete abortion

Answer

Preterm labor

Question 4

Which of the following is NOT a feature of postdated pregnancy?

Accepted Answer

Polyhydramnios

Answer

Cord compression

Answer

Fetal distress

Answer

Intrauterine growth restriction (IUGR)

Question 5

All of the following are to be monitored during Magnesium sulfate prophylaxis in impending eclampsia, EXCEPT:

Accepted Answer

Serum magnesium level

Answer

Patellar reflex

Answer

Respiratory Rate

Answer

Urine output

Question 6

A 28-year-old female with a history of 8 weeks of amenorrhea complains of vaginal bleeding and lower abdominal pain. On USG examination, there is a gestational sac with absent fetal parts. What is the diagnosis?

Accepted Answer

Incomplete abortion

Answer

Ectopic pregnancy

Answer

Threatened abortion

Answer

Corpus luteum cyst

Question 7

Magnesium sulfate has no role in the prevention of which of the following?

Accepted Answer

Respiratory distress syndrome in a premature baby

Answer

Seizures in severe pre-eclampsia

Answer

Recurrent seizures in eclampsia

Answer

Neuroprotection

Question 8

What is the fetal anomaly characterized by the absence of the cranium?

Accepted Answer

Anencephaly

Answer

Cephalocele

Answer

Holoprosencephaly

Answer

Dandy-Walker Malformation

Question 9

When the death of one fetus in a multiple pregnancy occurs early in pregnancy, how may it manifest?

Accepted Answer

Vanishing twin

Answer

Fetus papyraceus

Answer

Fetus compressus

Answer

Fetus acardiacus

Question 10

Which of the following is true about magnesium sulfate (MgSO4)?

Accepted Answer

Magnesium sulfate is used in the management of eclampsia.

Answer

Magnesium sulfate is not a tocolytic.

Answer

Magnesium sulfate does not cause neonatal respiratory depression.

Answer

Magnesium sulfate can be given in myasthenia gravis.

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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