Hypertensive Disorders in Pregnancy — MCQs

10 questions

A 25-year-old lady, Neethu, in her 22nd week of pregnancy develops hypertension and mild proteinuria. Due to the baby's gestational age, her obstetrician chooses to carefully monitor the mother for any sign of developing complications rather than to immediately deliver the baby. Which of the following complications account for the most maternal deaths in preeclampsia?

A pregnant woman at 36 weeks gestation is found to have high blood pressure recording and a urine protein of 3+. Concomitant presence of which of the following symptoms would make you suspect imminent eclampsia? 1. Headache 2. Blurred vision 3. Persistent pedal oedema 4. Epigastric pain

A 32-year-old female at 36 weeks of pregnancy presents with BP 170/100 mmHg, visual disturbances, headache, urine protein 3+. What will be the next step?

What is the management of eclampsia at 34 weeks of pregnancy?

Pregnancy-associated risk factors for pre-eclampsia include all except which of the following?

A lady with 36-week pregnancy with previous C-section comes with low BP, tachycardia, and on USG fluid present in peritoneum. What is the diagnosis and next management?

Which of the following is not a feature of HELLP syndrome?

A female of 36 weeks' gestation presents with severe hypertension, blurring of vision, and headache. Her blood pressure readings are 180/120 mmHg and 174/110 mmHg after 20 minutes. What is the most appropriate management for this patient?

Cardiac diseases in pregnancy which have major risk of maternal mortality are: 1. Pulmonary hypertension 2. Aortic coarctation with valvular involvement 3. Atrial septal defect 4. Mitral stenosis Select the correct answer using the code given below:

Q10

Pregnancy is contraindicated in which cardiac disease?

Hypertensive Disorders in Pregnancy Indian Medical PG Practice Questions and MCQs

Question 1: A 25-year-old lady, Neethu, in her 22nd week of pregnancy develops hypertension and mild proteinuria. Due to the baby's gestational age, her obstetrician chooses to carefully monitor the mother for any sign of developing complications rather than to immediately deliver the baby. Which of the following complications account for the most maternal deaths in preeclampsia?

A. Cerebral hemorrhage and acute respiratory distress syndrome (Correct Answer)
B. Cerebral edema and laryngeal edema
C. Convulsions and renal tubular necrosis
D. Hemolysis and hepatic infection

Explanation: ***Cerebral hemorrhage and acute respiratory distress syndrome*** - **Cerebral hemorrhage** is the leading cause of maternal death in preeclampsia/eclampsia, accounting for approximately 20-30% of maternal deaths, often resulting from uncontrolled severe hypertension leading to rupture of cerebral vessels. - **Acute Respiratory Distress Syndrome (ARDS)** is another major cause of maternal mortality in severe preeclampsia, developing due to endothelial dysfunction, capillary leak, and pulmonary edema leading to significant respiratory compromise. *Cerebral edema and laryngeal edema* - While **cerebral edema** can occur in severe preeclampsia and contribute to neurological complications, **cerebral hemorrhage** is the more direct and fatal cerebrovascular complication. - **Laryngeal edema** is rare in preeclampsia and not considered a primary cause of maternal death; it may occur with aggressive fluid resuscitation or as part of airway management complications. *Convulsions and renal tubular necrosis* - **Convulsions (eclampsia)** are a serious complication, but they are not the direct cause of death; rather, **cerebral hemorrhage** following eclamptic seizures or from uncontrolled hypertension is the actual fatal event. - **Acute tubular necrosis** can lead to acute kidney injury, but with modern dialysis and supportive care, renal failure is rarely a direct cause of maternal death compared to acute cerebrovascular or respiratory events. *Hemolysis and hepatic infection* - **Hemolysis** is a component of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a severe form of preeclampsia, but hemolysis itself is not typically the direct cause of death; associated complications like hepatic rupture or cerebral hemorrhage are the fatal events. - **Hepatic infection** is not a complication of preeclampsia; preeclampsia can lead to hepatic dysfunction, subcapsular hematoma, or hepatic rupture in HELLP syndrome, but not infection.

Question 2: A pregnant woman at 36 weeks gestation is found to have high blood pressure recording and a urine protein of 3+. Concomitant presence of which of the following symptoms would make you suspect imminent eclampsia? 1. Headache 2. Blurred vision 3. Persistent pedal oedema 4. Epigastric pain

A. 1,2,3,4
B. 2 and 4 only
C. 1,2,3
D. 1 and 2 only (Correct Answer)

Explanation: ***1 and 2 only*** - **Headache** (severe, persistent, frontal or occipital) and **blurred vision** (scotomas, photophobia, or visual field defects) are the classic **neurological symptoms** indicating cerebral irritation and vasospasm that directly precede eclamptic seizures. - These symptoms reflect **imminent CNS involvement** and are the strongest predictors of impending seizure, requiring urgent intervention (magnesium sulfate prophylaxis, delivery planning). - While other symptoms indicate severe pre-eclampsia, these neurological signs specifically herald **imminent eclampsia**. *2 and 4 only* - **Blurred vision** is indeed a key warning sign, and **epigastric pain** (right upper quadrant pain) is an important symptom of severe pre-eclampsia indicating hepatic capsule distension or subcapsular hematoma. - However, this option misses **headache**, which is one of the most critical neurological warning signs of imminent seizure. Epigastric pain indicates hepatic involvement (severe disease) but is not as directly predictive of immediate seizure onset as the combination of headache and visual disturbances. *1,2,3,4* - While headache, blurred vision, and epigastric pain are all features of severe pre-eclampsia, **persistent pedal edema** is extremely common in normal pregnancy and pre-eclampsia (present in >80% of cases) and is **not a specific indicator of imminent eclampsia**. - Generalized edema alone does not indicate imminent seizure risk and is too non-specific to be grouped with the acute neurological warning signs. *1,2,3* - **Headache** and **blurred vision** are the correct neurological indicators of imminent eclampsia. - However, **persistent pedal edema** is very common in pre-eclampsia and not specific for imminent eclamptic seizure risk. It does not have the same predictive value as severe headache or acute visual disturbances for identifying patients at immediate risk of convulsion.

Question 3: A 32-year-old female at 36 weeks of pregnancy presents with BP 170/100 mmHg, visual disturbances, headache, urine protein 3+. What will be the next step?

A. IV labetalol and delivery at 37 weeks
B. IV labetalol, dexamethasone, and immediate termination of pregnancy
C. IV labetalol, dexamethasone, and conservative management
D. IV labetalol, magnesium sulfate (MgSO4), expedite delivery (Correct Answer)

Explanation: ***IV labetalol, magnesium sulfate (MgSO4), expedite delivery*** - The patient presents with **severe preeclampsia** (BP > 160/110 mmHg, visual disturbances, headache, proteinuria) at 36 weeks, requiring **antihypertensive therapy** (labetalol) and seizure prophylaxis (**magnesium sulfate**). - Given the severe features and gestational age, **expedited delivery** is indicated to prevent maternal and fetal complications, as expectant management beyond severe preeclampsia at this stage offers minimal benefit and increased risk. *IV labetalol and delivery at 37 weeks* - While IV labetalol is appropriate for **blood pressure control**, delaying delivery to 37 weeks might not be optimal given the **severe features of preeclampsia** at 36 weeks, increasing risks for both mother and fetus. - The plan is incomplete without mentioning **seizure prophylaxis** with magnesium sulfate, which is crucial for severe preeclampsia. *IV labetalol, dexamethasone, and immediate termination of pregnancy* - **Dexamethasone** is used for **fetal lung maturity** in preterm deliveries and is not indicated for immediate termination unless the fetus is preterm and lung maturity is a concern. At 36 weeks, lung maturity is usually established. - While immediate termination might be considered, the phrase "immediate termination" implies C-section without considering vaginal delivery and overlooks the need for **seizure prophylaxis**. *IV labetalol, dexamethasone, and conservative management* - **Dexamethasone** is not a primary treatment for severe preeclampsia itself but rather for **fetal lung maturation** in preterm deliveries, which is less critical at 36 weeks. - **Conservative management** is generally inappropriate for **severe preeclampsia** at 36 weeks, as it increases maternal and fetal risk; delivery is the definitive treatment.

Question 4: What is the management of eclampsia at 34 weeks of pregnancy?

A. Continue convulsions and wait for 37 weeks to complete.
B. Wait for spontaneous labor.
C. Continue blood pressure management.
D. Administer antihypertensives, anticonvulsants, and consider termination of pregnancy. (Correct Answer)

Explanation: **Administer antihypertensives, anticonvulsants, and consider termination of pregnancy.** - In eclampsia, emergent management includes immediate administration of **magnesium sulfate** as an anticonvulsant and **antihypertensives** (e.g., labetalol, hydralazine, nifedipine) to control blood pressure. - Given the gestational age of 34 weeks and the occurrence of eclampsia, **delivery of the fetus** is often indicated to resolve the maternal condition, regardless of fetal lung maturity. *Continue convulsions and wait for 37 weeks to complete.* - Allowing **convulsions to continue** is extremely dangerous for both mother and fetus, increasing risks of aspiration, trauma, hypoxemia, and placental abruption. - Eclampsia is a severe complication of pregnancy that necessitates immediate intervention and **should not be passively observed** until full term. *Wait for spontaneous labor.* - **Delaying delivery** while waiting for spontaneous labor in eclampsia significantly prolongs the mother's exposure to the severe complications of the condition. - Eclampsia is an ** obstetric emergency** where prompt delivery, often via induction or C-section, is the definitive cure. *Continue blood pressure management.* - While **blood pressure management** is a crucial component of eclampsia treatment, it is insufficient on its own. - Eclampsia specifically involves **seizures**, which require anticonvulsant therapy (magnesium sulfate) in addition to antihypertensives, and the ultimate treatment is delivery.

Question 5: Pregnancy-associated risk factors for pre-eclampsia include all except which of the following?

A. Rh incompatibility (Correct Answer)
B. Fetal structural abnormalities
C. Trisomy 13
D. Multiple pregnancy

Explanation: ***Rh incompatibility*** - **Rh incompatibility** is a risk factor for **hemolytic disease of the newborn** and not typically a direct risk factor for **pre-eclampsia**. - Its pathophysiology involves an immune response against fetal red blood cells, distinct from the placental dysfunction seen in pre-eclampsia. *Multiple pregnancy* - **Multiple pregnancies** significantly increase the risk of pre-eclampsia due to a larger placental mass and increased demands on the maternal cardiovascular system. - The elevated placental burden leads to greater production of anti-angiogenic factors, contributing to the development of the disorder. *Fetal structural abnormalities* - While not all **fetal structural abnormalities** increase pre-eclampsia risk, those associated with **poor placental development** or dysfunction, like certain genetic syndromes, can elevate the risk. - This connection is related to impaired placental development and function, similar to severe cases of pre-eclampsia without overt fetal anomalies. *Trisomy 13* - **Trisomy 13** (Patau syndrome) is strongly associated with an increased risk of severe and early-onset **pre-eclampsia**. - The presence of this chromosomal abnormality often leads to significant placental dysfunction and shallow trophoblast invasion, which are hallmarks of pre-eclampsia.

Question 6: A lady with 36-week pregnancy with previous C-section comes with low BP, tachycardia, and on USG fluid present in peritoneum. What is the diagnosis and next management?

A. Abruptio and C-section
B. Ectopic pregnancy and abortion
C. Impending dehiscence and Laparoscopy
D. Uterine scar rupture with Laparotomy (Correct Answer)

Explanation: ***Uterine scar rupture with Laparotomy*** - The presentation of **low blood pressure**, **tachycardia**, and **free fluid in the peritoneum** in a 36-week pregnant woman with a **previous C-section** is highly indicative of uterine scar rupture given the signs of **hemorrhagic shock**. - **Laparotomy** (emergency abdominal surgery) is the immediate and definitive management to repair the ruptured uterus, control bleeding, and deliver the fetus. *Abruptio and C-section* - **Placental abruption** typically presents with painful vaginal bleeding, uterine tenderness, and fetal distress, which are not explicitly mentioned as the primary symptoms here. - While a **C-section** would be indicated for abruption, the presence of free fluid in the peritoneum and hemodynamic instability in a woman with a prior C-section points more towards rupture. *Ectopic pregnancy and abortion* - An **ectopic pregnancy** is ruled out by the 36-week gestational age; these occur much earlier in pregnancy. - An **abortion** refers to the termination of pregnancy and does not cause these specific signs and symptoms at 36 weeks. *Impending dehiscence and Laparoscopy* - **Impending dehiscence** (separation of the uterine scar without complete rupture) would likely cause localized pain but typically not the severe signs of **hypovolemic shock** and free peritoneal fluid seen here. - **Laparoscopy** is a minimally invasive procedure and would not be appropriate for the emergency management of a potentially life-threatening hemorrhage from uterine rupture.

Question 7: Which of the following is not a feature of HELLP syndrome?

A. Raised liver enzyme
B. Hemolytic anemia
C. Eosinophilia (Correct Answer)
D. Thrombocytopenia

Explanation: ***Eosinophilia*** - **Eosinophilia** (an increase in eosinophils) is not a characteristic feature of **HELLP syndrome**. - HELLP syndrome is defined by specific hematologic and liver abnormalities, not changes in eosinophil count. *Thrombocytopenia* - **Thrombocytopenia** (platelet count < 100,000/µL) is a defining feature of **HELLP syndrome**. - It results from increased platelet consumption due to microangiopathic hemolysis. *Raised liver enzyme* - **Raised liver enzymes** (AST or ALT ≥ 70 IU/L) are a crucial diagnostic criterion for **HELLP syndrome**, indicating hepatocellular injury. - This elevation reflects liver damage and is often associated with epigastric or right upper quadrant pain. *Hemolytic anemia* - **Hemolytic anemia** (evidenced by an abnormal peripheral blood smear, elevated bilirubin, or low haptoglobin) is another key component of **HELLP syndrome**. - This involves the destruction of red blood cells, leading to anemia and often contributing to the elevated liver enzymes and thrombocytopenia.

Question 8: A female of 36 weeks' gestation presents with severe hypertension, blurring of vision, and headache. Her blood pressure readings are 180/120 mmHg and 174/110 mmHg after 20 minutes. What is the most appropriate management for this patient?

A. Admit the patient, start antihypertensives, administer MgSO4, and plan for delivery. (Correct Answer)
B. Admit the patient and monitor her condition.
C. Discharge the patient with oral antihypertensives and schedule a follow-up.
D. Admit the patient, initiate antihypertensive therapy, and continue the pregnancy until term.

Explanation: ***Admit the patient, start antihypertensives, administer MgSO4, and plan for delivery.*** - The patient's symptoms (**severe hypertension**, **blurring of vision**, **headache**) at **36 weeks' gestation** indicate severe preeclampsia, necessitating immediate admission and management to prevent complications. - **Antihypertensives** are crucial to control severe hypertension, **magnesium sulfate (MgSO4)** prevents eclamptic seizures, and **delivery** is the definitive treatment for severe preeclampsia, especially near term. *Admit the patient and monitor her condition.* - While admission is correct, merely monitoring is insufficient given the patient's severe symptoms and high blood pressure readings, which indicate an urgent need for active management. - Delaying treatment could lead to serious maternal or fetal complications such as **eclampsia** or **placental abruption**. *Discharge the patient with oral antihypertensives and schedule a follow-up.* - Discharging a patient with severe preeclampsia is highly inappropriate and dangerous, as it puts both the mother and fetus at significant risk. - Oral antihypertensives alone are insufficient to manage severe preeclampsia acutely, and close monitoring and definitive treatment are required. *Admit the patient, initiate antihypertensive therapy, and continue the pregnancy until term.* - Although admitting the patient and starting antihypertensives are correct initial steps, continuing the pregnancy until term is generally not advisable with **severe preeclampsia** at **36 weeks' gestation**. - The risks associated with continuing the pregnancy often outweigh the benefits, and delivery is usually indicated to resolve the condition and prevent further progression.

Question 9: Cardiac diseases in pregnancy which have major risk of maternal mortality are: 1. Pulmonary hypertension 2. Aortic coarctation with valvular involvement 3. Atrial septal defect 4. Mitral stenosis Select the correct answer using the code given below:

A. 1 and 4
B. 2 and 3
C. 1 and 2 (Correct Answer)
D. 3 and 4

Explanation: ***1 and 2*** - **Pulmonary hypertension** is classified as WHO Class IV (highest risk) with maternal mortality rates of 30-50%. It represents a contraindication to pregnancy due to the inability to accommodate increased cardiac output and hemodynamic changes. - **Aortic coarctation with valvular involvement** is also high-risk (WHO Class III-IV) due to increased risk of aortic dissection, rupture, heart failure, and stroke from the hemodynamic stress of pregnancy, particularly when complicated by valvular disease. - This combination represents the two conditions with the **highest and most consistently documented maternal mortality risk**. *1 and 4* - **Pulmonary hypertension** carries extremely high risk as noted above. - **Mitral stenosis** risk is severity-dependent: severe MS (valve area <1.0 cm²) is WHO Class III-IV with significant mortality risk (5-15%), while mild-moderate MS is lower risk with proper management. - While this combination includes high-risk conditions, **aortic coarctation with valvular involvement** (option 2) generally carries higher and more consistent risk than mitral stenosis, particularly compared to non-severe MS cases. *2 and 3* - **Aortic coarctation with valvular involvement** is high-risk as described above. - **Atrial septal defect (ASD)** is typically WHO Class II (low risk) and well-tolerated during pregnancy unless complicated by Eisenmenger syndrome or pulmonary hypertension. - This pairing incorrectly combines a high-risk condition with a generally low-risk condition. *3 and 4* - **Atrial septal defect (ASD)** is generally low-risk (WHO Class II) in uncomplicated cases. - **Mitral stenosis** varies by severity, but even severe MS carries lower mortality risk than pulmonary hypertension or complicated aortic coarctation. - This option incorrectly identifies conditions that do not consistently represent the **major/highest** maternal mortality risk compared to pulmonary hypertension and aortic coarctation with valvular involvement.

Question 10: Pregnancy is contraindicated in which cardiac disease?

A. Mitral stenosis
B. Primary pulmonary hypertension (Correct Answer)
C. VSD
D. Mitral regurgitation

Explanation: ***Primary pulmonary hypertension*** - Pregnancy in **primary pulmonary hypertension (PPH)** is an **absolute contraindication** (WHO Class IV cardiac disease) with a maternal mortality rate of 30-50%, often due to right heart failure precipitated by the physiological changes of pregnancy. - The increased **cardiac output**, blood volume, systemic vasodilation, and elevated pulmonary vascular resistance during gestation can severely worsen pulmonary arterial pressures. - The hemodynamic changes of pregnancy, labor, and postpartum period are poorly tolerated in PPH, making it one of the highest-risk cardiac conditions. *Mitral stenosis* - While pregnancy can exacerbate **mitral stenosis**, leading to pulmonary edema, it is not an absolute contraindication for pregnancy with careful management. - Severe mitral stenosis (WHO Class III) is a relative contraindication, but maternal mortality is significantly lower (around 1%) compared to primary pulmonary hypertension. *VSD* - **Ventricular septal defect (VSD)** generally carries a low risk during pregnancy, especially if it is small and not associated with pulmonary hypertension or heart failure. - Close monitoring is required to prevent complications like paradoxical embolism, but it is rarely a contraindication. *Mitral regurgitation* - **Mitral regurgitation** is often well-tolerated in pregnancy because the systemic vasodilation typical of pregnancy reduces afterload, which can actually decrease the severity of regurgitation. - It is one of the better-tolerated valvular heart diseases during gestation.

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