Maternal-Fetal Medicine Practice Questions

Q: Which of the following tumors are unique to pregnancy?

Luteoma. **Explanation:** **Luteoma of Pregnancy** (Pregnancy Luteoma) is a non-neoplastic, tumor-like ovarian lesion that is **unique to pregnancy**. It is not a true neoplasm but rather a hyperplastic reaction of ovarian stromal cells to Human Chorionic Gonadotropin (hCG). These lesions are typically asymptomatic, solid, often bilateral, and multinodular. They characteristically regress spontaneously during the postpartum period as hCG levels fall. **Why the other options are incorrect:** * **Serous and Mucinous Cystadenomas:** These are true epithelial ovarian neoplasms. While they can be found during pregnancy, they are not *unique* to it; they occur frequently in non-pregnant women across various age groups. * **Teratoma:** This is a germ cell tumor. Mature cystic teratomas (Dermoid cysts) are the most common ovarian tumors diagnosed during pregnancy, but they originate from germ cells and exist independently of the gestational state. **High-Yield Clinical Pearls for NEET-PG:** * **Virilization:** Luteomas are hormonally active. Maternal virilization occurs in about 25% of cases, and there is a high risk (up to 60-70%) of virilization in female fetuses. * **Management:** Since they are benign and regress spontaneously, the management is **conservative observation**. Surgery is only indicated to rule out malignancy or if complications like torsion occur. * **Differential Diagnosis:** Must be distinguished from **Hyperreactio Luteinalis** (multiple theca lutein cysts), which is also pregnancy-related but presents as cystic enlargement rather than solid nodules.

Q: Grade 2 abruptio placenta is characterized by?

Fetal distress. **Explanation:** Abruptio placentae is the premature separation of a normally situated placenta. To standardize clinical management, the **Sher and Linthicum classification** is used to grade the severity based on clinical findings. **Why Fetal Distress is the Correct Answer:** In **Grade 2 (Moderate) Abruption**, the separation involves approximately 1/4th to 2/3rd of the placental surface. This significant loss of surface area leads to uteroplacental insufficiency. The classic presentation includes uterine tenderness, increased uterine tone, and most characteristically, **evidence of fetal distress** (abnormal heart rate patterns or fetal tachycardia). While the mother may show signs of tachycardia or orthostatic hypotension, she is not yet in profound shock. **Analysis of Incorrect Options:** * **A & B (Pronounced shock & Severe bleeding):** These are hallmarks of **Grade 3 (Severe) Abruption**. In Grade 2, bleeding is mild to moderate, and maternal hemodynamics are usually maintained despite compensated tachycardia. * **C (Coagulation defect):** Consumptive coagulopathy (DIC) is a severe complication typically reserved for **Grade 3** cases, often associated with intrauterine fetal death (IUFD). **NEET-PG High-Yield Pearls:** * **Grade 0:** Asymptomatic; diagnosed retrospectively by finding a retroplacental clot after delivery. * **Grade 1:** Mild; no fetal distress, no maternal shock. * **Grade 3:** Severe; characterized by **maternal shock, fetal death (IUFD), and often DIC.** * **Couvelaire Uterus:** A complication where blood extravasates into the myometrium (port-wine appearance); it is a clinical diagnosis made during laparotomy. * **Most common risk factor:** Maternal hypertension (Chronic or PIH).

Q: Funneling in cervicogram is seen in which of the following conditions?

Cervical incompetence. **Explanation:** **Cervical incompetence** (now often termed cervical insufficiency) is the correct answer. It is characterized by the painless dilation and effacement of the cervix, typically during the second trimester, leading to recurrent pregnancy loss or preterm birth. **Funneling** refers to the protrusion of the amniotic membranes into the internal os as it begins to open, while the external os remains closed. On ultrasound (cervicogram), this creates a characteristic "V" or "U" shaped appearance. **Analysis of Options:** * **A. During labor:** While the cervix dilates and effaces during labor, this is a physiological process driven by uterine contractions. The term "funneling" specifically describes the pre-labor pathological changes seen in an incompetent cervix. * **C. Cervical ectopic pregnancy:** This condition involves the implantation of the blastocyst within the cervical canal. It typically presents with a "hourglass" shaped uterus and a closed internal os, rather than the progressive funneling of membranes. * **D. During TVS:** Transvaginal sonography is the **modality** used to diagnose funneling, not a condition itself. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** TVS is the gold standard. A cervical length **<25 mm** before 24 weeks is a significant risk factor. * **The "Trust" Rule:** The sequence of cervical changes in funneling follows the mnemonic **T-Y-U-V** (T = normal, Y = early funneling, U = advanced funneling, V = imminent loss). * **Management:** The primary treatment is **Cervical Cerclage** (e.g., McDonald or Shirodkar techniques), usually performed between 12–14 weeks of gestation. * **Clinical Sign:** On physical exam, "bulging membranes" or "hourglass membranes" may be visible at the external os.

Q: What is the best test to diagnose lung maturity in a neonate born to a diabetic mother?

Phosphatidylglycerol. **Explanation:** The assessment of fetal lung maturity (FLM) in diabetic pregnancies requires specific markers because maternal hyperglycemia can lead to delayed surfactant production, even if the fetus is at term. **1. Why Phosphatidylglycerol (PG) is the correct answer:** Phosphatidylglycerol is the "final marker" of lung maturation. It typically appears in amniotic fluid around 35–36 weeks of gestation. In diabetic mothers, high levels of fetal insulin (hyperinsulinism) can inhibit the enzymes responsible for surfactant synthesis. This can lead to **Respiratory Distress Syndrome (RDS)** even with a "mature" L/S ratio. However, the presence of **Phosphatidylglycerol** is not affected by insulin levels. Therefore, its presence is the most reliable indicator that the lungs are mature and the risk of RDS is near zero, making it the gold standard for diabetic pregnancies. **2. Why other options are incorrect:** * **Lecithin/Sphingomyelin (L/S) ratio:** While an L/S ratio > 2.0 generally indicates maturity in normal pregnancies, it is notoriously **unreliable in diabetic mothers**. These fetuses can develop RDS despite an L/S ratio > 2.0 (false maturity). * **Ultrasonography:** While USG can estimate gestational age and detect certain markers (like placental grading or distal femoral epiphysis), it cannot biochemically confirm functional lung maturity. **High-Yield Clinical Pearls for NEET-PG:** * **Hyperinsulinemia** is the primary culprit; it antagonizes the action of cortisol on type II pneumocytes. * **L/S Ratio:** Measured via amniocentesis. 2.0 is mature; 1.5–1.9 is intermediate; 30,000–50,000/µL suggests maturity.

Q: For the prevention of preterm labor in a patient with a history of preterm delivery, which of the following is used?

Progesterone. **Explanation:** **1. Why Progesterone is Correct:** Progesterone is essential for maintaining "uterine quiescence." It inhibits the production of pro-inflammatory cytokines and prostaglandins, thereby preventing cervical ripening and uterine contractions. In women with a **documented history of spontaneous preterm birth (sPTB)**, progesterone supplementation (typically 17-OHP caproate or vaginal progesterone) has been shown to significantly reduce the risk of recurrence. It is the standard of care for secondary prevention of preterm labor. **2. Why Other Options are Incorrect:** * **A. Calcium supplements:** While calcium is vital for maternal bone health and may play a role in reducing the risk of pre-eclampsia, it has no proven role in preventing preterm labor. * **B. Ecosprin (Low-dose Aspirin):** This is used primarily for the prevention of **Pre-eclampsia** and Fetal Growth Restriction (FGR) in high-risk patients. It does not prevent preterm labor directly. * **C. Steroids (Corticosteroids):** These are used for **fetal lung maturity** once preterm labor is *imminent* (between 24–34 weeks). They do not prevent the onset of labor; they reduce neonatal morbidity (RDS, IVH, NEC) after the birth. **3. High-Yield Clinical Pearls for NEET-PG:** * **Screening:** In patients with a history of sPTB, **Transvaginal Ultrasound (TVS)** for cervical length (CL) is performed. If CL <25 mm before 24 weeks, it is a strong predictor of preterm birth. * **Management:** * **History of sPTB:** Progesterone is indicated. * **Short Cervix (<25mm) + History of sPTB:** Consider **Cervical Cerclage** (McDonald or Shirodkar). * **Short Cervix (<25mm) + No History:** Vaginal progesterone is the preferred treatment. * **Tocolytics:** (e.g., Nifedipine, Atosiban) are used to delay delivery for 48 hours to allow steroid action, not for long-term prevention.

Q: A pregnant woman in her 32nd week of gestation is given magnesium sulfate for pre-eclampsia. What is the earliest clinical indication of hypermagnesemia?

Loss of deep tendon reflexes. **Explanation:** Magnesium sulfate ($MgSO_4$) is the drug of choice for seizure prophylaxis in pre-eclampsia and control in eclampsia. It acts as a CNS depressant and a neuromuscular blocker by inhibiting acetylcholine release at the motor endplate. Because it is excreted solely by the kidneys, toxicity (hypermagnesemia) is a significant risk, especially in patients with renal impairment. **Why Option A is Correct:** The **loss of deep tendon reflexes (patellar reflex/knee jerk)** is the **earliest clinical sign** of magnesium toxicity. It occurs when serum magnesium levels reach **7–10 mEq/L** (Normal therapeutic range is 4–7 mEq/L). The loss of reflexes serves as a crucial "warning sign" that precedes more severe life-threatening complications. **Analysis of Incorrect Options:** * **B. Flaccid paralysis:** This occurs at higher levels (usually >10–12 mEq/L) as neuromuscular blockade intensifies, leading to generalized muscle weakness. * **C. Respiratory arrest:** This is a late and fatal sign, typically occurring when levels exceed **12–15 mEq/L** due to paralysis of the diaphragm and intercostal muscles. * **D. Hypotension:** While $MgSO_4$ causes vasodilation, hypotension is an inconsistent finding and not the primary clinical marker used to monitor for toxicity. **NEET-PG High-Yield Pearls:** * **Monitoring:** Always monitor **Respiratory Rate** (>12/min), **Urine Output** (>30 ml/hr), and **Patellar Reflex** during administration. * **Antidote:** The immediate management for toxicity is **10 ml of 10% Calcium Gluconate** IV (administered over 10 minutes). * **Cardiac Arrest:** Occurs at levels >25 mEq/L. * **Therapeutic Level:** 4.8–8.4 mg/dL (or 4–7 mEq/L).

Q: What is the most common cause of cervical insufficiency?

Idiopathic. **Explanation:** Cervical insufficiency (formerly known as cervical incompetence) is characterized by the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions. **1. Why Idiopathic is correct:** While there are several known mechanical and congenital risk factors, the **most common cause of cervical insufficiency is idiopathic**. In many patients, no specific history of trauma or structural anomaly is identified. It is often attributed to a functional deficiency in the cervical collagen-to-elastin ratio or biochemical changes in the connective tissue that lead to premature ripening. **2. Analysis of Incorrect Options:** * **Previous Dilatation and Curettage (D&C):** This is a common **acquired** cause. Forceful mechanical dilatation of the internal os can lead to structural damage, but statistically, it occurs less frequently than idiopathic cases. * **Exposure to Diethylstilbestrol (DES):** This is a **congenital** cause. DES exposure in utero leads to structural uterine anomalies (e.g., T-shaped uterus) and cervical hypoplasia. However, DES is now rarely encountered in modern clinical practice. * **Conization:** Cold knife conization or LEEP (Loop Electrosurgical Excision Procedure) removes a significant portion of the cervical stroma, weakening its structural integrity. While a significant risk factor, it is not the most common cause. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Clinical history of recurrent painless second-trimester mid-trimester losses. * **USG Finding:** "Funneling" of the internal os and a cervical length **<25 mm** before 24 weeks. * **Treatment:** Cervical Cerclage (McDonald or Shirodkar technique), typically performed between **12–14 weeks** of gestation. * **Emergent Procedure:** "Rescue cerclage" is performed when the cervix is already dilated with bulging membranes.

Q: Pelvic examination is not indicated in which of the following conditions?

Placenta previa. In cases of **Placenta Previa**, the placenta is implanted in the lower uterine segment, covering or near the internal os. Performing a digital pelvic examination (PV) can inadvertently detach the placenta or traumatize the highly vascularized placental bed, leading to **sudden, torrential, and life-threatening hemorrhage**. Therefore, a PV examination is strictly contraindicated unless performed in an "Operation Theatre" under double setup (prepared for immediate Cesarean section). The gold standard for diagnosis is a Transvaginal Ultrasound (TVS), which is safe and accurate. **Explanation of Incorrect Options:** * **Contracted Pelvis:** Pelvic examination (Clinical Pelvimetry) is essential here to assess the pelvic diameters (e.g., diagonal conjugate, ischial spines) and determine the feasibility of vaginal delivery. * **Hydatidiform Mole:** While diagnosis is primarily via USG ("snowstorm appearance") and beta-hCG levels, a PV examination is not contraindicated and may reveal a "doughy" uterus or the presence of theca lutein cysts. * **Ectopic Pregnancy:** A bimanual examination is a standard clinical step to check for cervical motion tenderness (Chandelier sign) and adnexal masses, though it must be performed gently to avoid rupturing the sac. **High-Yield Clinical Pearls for NEET-PG:** * **Warning Hemorrhage:** The first episode of bleeding in placenta previa is usually painless, causeless, and recurrent. * **Rule of Thumb:** In any patient presenting with antepartum hemorrhage (APH), **always** perform a speculum examination to rule out local causes, but **never** perform a digital PV until placenta previa is ruled out by ultrasound. * **Stallworthy’s Sign:** Posterior placenta previa can interfere with the engagement of the fetal head, a classic clinical finding.

Q: Which syndrome is most commonly associated with cystic hygroma in first-trimester ultrasound?

Trisomy 21. **Explanation:** Cystic hygroma is a congenital malformation of the lymphatic system characterized by fluid-filled sacs, most commonly occurring in the neck. Its clinical significance and association with chromosomal anomalies vary significantly depending on the **gestational age** at which it is detected. **1. Why Trisomy 21 is the Correct Answer:** In the **first trimester** (11–14 weeks), the most common chromosomal abnormality associated with cystic hygroma is **Trisomy 21 (Down Syndrome)**. Large-scale screening studies have shown that while cystic hygroma is a non-specific marker of aneuploidy, Trisomy 21 has the highest prevalence among affected fetuses during this early window. **2. Analysis of Incorrect Options:** * **Turner Syndrome (45,X):** This is the most common association in the **second trimester**. While Turner syndrome presents with very large, septated cystic hygromas and hydrops, it is statistically less frequent than Trisomy 21 in first-trimester screenings. * **Trisomy 18 (Edwards) & Trisomy 13 (Patau):** These are frequently associated with increased nuchal translucency and cystic hygroma, but their overall incidence is lower than Trisomy 21. They usually present with other structural anomalies (e.g., choroid plexus cysts, holoprosencephaly, or polydactyly). **High-Yield Clinical Pearls for NEET-PG:** * **First Trimester Association:** Trisomy 21 > Turner Syndrome > Trisomy 18. * **Second Trimester Association:** Turner Syndrome (most common). * **Prognosis:** If the karyotype is normal and the hygroma resolves by 18 weeks, the prognosis is generally good. However, persistent hygroma is associated with a high risk of cardiac defects (most commonly Coarctation of the Aorta in Turner syndrome). * **Management:** Detection of a cystic hygroma in the first trimester warrants immediate counseling for invasive prenatal testing (CVS or Amniocentesis) and a detailed fetal echocardiogram.

Question 1

Which of the following tumors are unique to pregnancy?

Accepted Answer

Luteoma

Answer

Serous cystadenoma

Answer

Mucinous cystadenoma

Answer

Teratoma

Question 2

Grade 2 abruptio placenta is characterized by?

Accepted Answer

Fetal distress

Answer

Pronounced shock

Answer

Severe bleeding

Answer

Coagulation defect

Question 3

Funneling in cervicogram is seen in which of the following conditions?

Accepted Answer

Cervical incompetence

Answer

During labor

Answer

Cervical ectopic pregnancy

Answer

During transvaginal sonography (TVS)

Question 4

What is the best test to diagnose lung maturity in a neonate born to a diabetic mother?

Accepted Answer

Phosphatidylglycerol

Answer

Sphingomyelin/Lecithin ratio

Answer

Ultrasonography

Answer

None of the above

Question 5

For the prevention of preterm labor in a patient with a history of preterm delivery, which of the following is used?

Accepted Answer

Progesterone

Answer

Calcium supplements

Answer

Ecosprin

Answer

Steroids

Question 6

A pregnant woman in her 32nd week of gestation is given magnesium sulfate for pre-eclampsia. What is the earliest clinical indication of hypermagnesemia?

Accepted Answer

Loss of deep tendon reflexes

Answer

Flaccid paralysis

Answer

Respiratory arrest

Answer

Hypotension

Question 7

What is the most common cause of cervical insufficiency?

Accepted Answer

Idiopathic

Answer

Previous dilatation and curettage

Answer

Exposure to diethylstilbestrol (DES)

Answer

Conization

Question 8

Pelvic examination is not indicated in which of the following conditions?

Accepted Answer

Placenta previa

Answer

Contracted pelvis

Answer

Hydatidiform mole

Answer

Ectopic pregnancy

Question 9

Which syndrome is most commonly associated with cystic hygroma in first-trimester ultrasound?

Accepted Answer

Trisomy 21

Answer

Trisomy 18

Answer

Trisomy 13

Answer

Turner syndrome

Question 10

A 38-year-old woman, gravida 3, para 2, at 32 weeks' gestation presents with vaginal bleeding. She reports passing two quarter-sized clots of blood this morning. She denies contractions, gushes of fluid, or fetal distress. Her obstetrical history includes two low-transverse cesarean deliveries due to non-reassuring fetal heart rate tracings. An ultrasound reveals a complete placenta previa. For which of the following conditions is this patient at highest risk?

Accepted Answer

Placenta accreta

Answer

Dystocia

Answer

Intrauterine fetal demise (IUFD)

Answer

Preeclampsia

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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