Management of Medical Disorders in Pregnancy — MCQs
What is a potential risk for pregnant women who undertake long journeys with prolonged sitting?
What is the drug of choice for hypertension in pregnancy?
Under the Anaemia Mukt Bharath initiative, mild to moderate anaemia in pregnant women <34 weeks of gestation is treated using:
A pregnant woman is diagnosed with Graves' disease. The most appropriate therapy for her would be:
What is the most common fetal complication associated with gestational diabetes?
What is the definitive treatment for preeclampsia?
A G1 P0 woman at 36 weeks presents with newly diagnosed gestational diabetes. What is the most appropriate initial management?
A 32-year-old primigravida at 39 weeks of gestational age has a blood pressure reading of 150/100 mmHg obtained during a routine visit, which is an elevation from her baseline blood pressure of 120/70 mmHg. She denies any headache, visual changes, nausea, vomiting, or abdominal pain. Her repeat BP is 160/90 mmHg, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?
What is the management of eclampsia at 34 weeks of pregnancy?
Which of the following is an indication for medical management in ectopic pregnancy?
Management of Medical Disorders in Pregnancy Indian Medical PG Practice Questions and MCQs
Question 1: What is a potential risk for pregnant women who undertake long journeys with prolonged sitting?
- A. Venous thromboembolism
- B. Deep vein thrombosis (Correct Answer)
- C. Pulmonary embolism
- D. Leg swelling
Explanation: ***Deep vein thrombosis*** - **Pregnancy** is a **hypercoagulable state** due to increased levels of clotting factors (fibrinogen, factors VII, VIII, X) and decreased protein S activity. - **Prolonged sitting** during long journeys causes **venous stasis** in the lower extremities, which is a key component of **Virchow's triad** for thrombosis (stasis, hypercoagulability, endothelial injury). - **DVT** is the **direct and most specific pathological consequence** of prolonged immobilization during travel in pregnancy. - The risk of **VTE in pregnancy** is **4-5 times higher** than in non-pregnant women, with travel-related DVT being a recognized complication. *Venous thromboembolism* - VTE is an **umbrella term** that encompasses both **DVT and pulmonary embolism**. - While technically correct as a broader category, DVT is the **more specific and direct answer** to what prolonged sitting causes. - In medical education and clinical practice, identifying the **specific pathology** (DVT) is more appropriate than using the general category (VTE). *Pulmonary embolism* - PE is a **complication** of DVT, occurring when a thrombus dislodges and embolizes to the pulmonary circulation. - PE is a **secondary consequence**, not the **primary risk** from prolonged sitting itself. - The direct mechanism of prolonged sitting → venous stasis → **DVT formation** → potential embolization to lungs. *Leg swelling* - **Leg swelling** (edema) is a **symptom**, not a pathological diagnosis. - While leg edema can indicate DVT, it's also common in normal pregnancy due to increased venous pressure and fluid retention. - The question asks for a **risk** (pathological condition), not a symptom.
Question 2: What is the drug of choice for hypertension in pregnancy?
- A. Verapamil
- B. Methyldopa (Correct Answer)
- C. Furosemide
- D. Enalapril
Explanation: ***Methyldopa*** - **Methyldopa** is considered a first-line agent because of its established safety profile for both the mother and the fetus throughout pregnancy. - It acts centrally as an **alpha-2 adrenergic agonist**, reducing sympathetic outflow and thereby lowering blood pressure. *Enalapril* - **Angiotensin-converting enzyme (ACE) inhibitors** like Enalapril are contraindicated in pregnancy due to their association with **fetal renal abnormalities**, **oligohydramnios**, and **growth restriction**, especially in the second and third trimesters. - Their use can lead to **fetal hypotension** and potentially **fetal death**. *Verapamil* - **Calcium channel blockers** like Verapamil are generally considered second-line agents for hypertension in pregnancy. - While generally safer than ACE inhibitors, **Labetalol** and **Nifedipine** are often preferred among calcium channel blockers, and **Methyldopa** has a longer track record of safety. *Furosemide* - **Diuretics** like Furosemide are generally not recommended for chronic hypertension in pregnancy as they can **reduce plasma volume** and potentially impair placental perfusion. - They are primarily used in cases of **pulmonary edema** or severe fluid overload, rather than routine management of hypertension.
Question 3: Under the Anaemia Mukt Bharath initiative, mild to moderate anaemia in pregnant women <34 weeks of gestation is treated using:
- A. IM ferric carboxy maltose (FCM)
- B. IV iron sucrose for non-compliance with oral tablets
- C. 2 iron and folic acid tablets OD+IV iron sucrose
- D. 1-2 IFA tablets daily (depending on severity) (Correct Answer)
Explanation: ***1-2 IFA tablets daily (depending on severity)*** - The **Anaemia Mukt Bharat (AMB)** guidelines recommend **oral iron and folic acid (IFA)** supplementation as the primary treatment for mild to moderate anaemia in pregnant women <34 weeks gestation. - **Mild anaemia (Hb 10-10.9 g/dL):** 1 IFA tablet daily (100 mg elemental iron + 500 mcg folic acid) - **Moderate anaemia (Hb 7-9.9 g/dL):** 2 IFA tablets twice daily (total 200 mg elemental iron per day) - Oral IFA is safe, cost-effective, and addresses the underlying nutritional deficiency. *IM ferric carboxy maltose (FCM)* - **Intramuscular (IM) iron** formulations like FCM are generally reserved for cases of severe anaemia, malabsorption, or intolerance to oral iron. - For mild to moderate anaemia, IM iron is not the **first-line treatment** under AMB guidelines due to potential injection site reactions and the effectiveness of oral alternatives. *IV iron sucrose for non-compliance with oral tablets* - **Intravenous (IV) iron sucrose** is indicated for specific situations such as severe anaemia (Hb <7 g/dL), significant malabsorption, documented intolerance, or persistent non-compliance with oral iron. - However, for mild to moderate anaemia, efforts are made to ensure compliance with oral treatment before resorting to **parenteral iron**, particularly given its higher cost and need for administration in a healthcare setting. *2 iron and folic acid tablets OD+IV iron sucrose* - Combining **oral iron tablets with IV iron sucrose** is not recommended for mild to moderate anaemia under AMB guidelines. - This approach would be considered **overtreatment** for mild to moderate anaemia in the absence of severe anaemia or documented failure of oral therapy despite good compliance.
Question 4: A pregnant woman is diagnosed with Graves' disease. The most appropriate therapy for her would be:
- A. Radioiodine therapy
- B. Total thyroidectomy
- C. Carbimazole parenteral
- D. Propylthiouracil oral (Correct Answer)
Explanation: ***Propylthiouracil oral*** - **Propylthiouracil (PTU)** is the preferred antithyroid drug during the **first trimester** of pregnancy due to a lower risk of teratogenicity compared to methimazole/carbimazole [1]. - It works by inhibiting both the synthesis of thyroid hormones and the peripheral conversion of **T4 to T3**. *Radioiodine therapy* - **Radioactive iodine** is absolutely contraindicated in pregnancy as it can cross the placenta and cause **fetal hypothyroidism or athyreosis**. - It leads to permanent destruction of the thyroid gland and is not suitable for a temporary condition in a pregnant woman. *Total thyroidectomy* - While thyroidectomy can be considered for Graves' disease in pregnancy, it is generally reserved for cases where antithyroid drugs are not tolerated or ineffective, or for very large goiters causing compressive symptoms. - It carries risks associated with **surgery and anesthesia** during pregnancy, and requires **lifelong thyroid hormone replacement**. *Carbimazole parenteral* - **Carbimazole** (which is metabolized to methimazole) is generally avoided in the **first trimester** due to an increased risk of teratogenicity, particularly **aplasia cutis**, omphalocele, and choanal atresia [1]. - While it can be used in the second and third trimesters, **PTU is preferred in the first trimester**, and carbimazole is not typically administered parenterally.
Question 5: What is the most common fetal complication associated with gestational diabetes?
- A. Only a small percentage of women with gestational diabetes develop overt diabetes.
- B. There is a risk of macrosomia in babies born to mothers with gestational diabetes. (Correct Answer)
- C. Gestational diabetes is usually diagnosed in the second or third trimester.
- D. Gestational diabetes can increase the risk of congenital malformations.
Explanation: ***There is a risk of macrosomia in babies born to mothers with gestational diabetes.*** - **Macrosomia** (birth weight >4000g or >90th percentile) is a common complication due to fetal exposure to high glucose levels, stimulating excessive growth. - Increased fetal insulin from maternal hyperglycemia promotes fat accumulation and growth, leading to **shoulder dystocia**, birth trauma, and increased risk of C-section. *Only a small percentage of women with gestational diabetes develop overt diabetes.* - A significant percentage, up to **50% of women** with gestational diabetes, will develop **type 2 diabetes** later in life, often within 5-10 years postpartum, making this statement incorrect. - This persistent risk highlights the importance of postpartum screening and lifestyle modifications for these women. *Gestational diabetes is usually diagnosed in the second or third trimester.* - While screening typically occurs between **24 and 28 weeks of gestation** (second trimester), this describes when it is diagnosed, not the *most common risk* associated with the condition itself. - Early screening may occur in the first trimester for high-risk individuals, but the general screening period is later in pregnancy. *Gestational diabetes can increase the risk of congenital malformations.* - **Congenital malformations** are primarily associated with **pre-existing diabetes** (type 1 or type 2 diabetes) in the mother during the **first trimester**, when organogenesis occurs. - Gestational diabetes, diagnosed later in pregnancy, primarily leads to complications related to **fetal growth** and metabolic issues, not structural malformations.
Question 6: What is the definitive treatment for preeclampsia?
- A. Delivery of the baby (Correct Answer)
- B. Use of antihypertensive medications
- C. Dietary modifications
- D. Increased rest and monitoring
Explanation: ***Delivery of the baby*** - **Preeclampsia** is a multisystem disorder of pregnancy; its pathogenesis is directly linked to the **placenta**. - **Removal of the placenta** through delivery is the only definitive cure for preeclampsia, leading to the resolution of symptoms. *Use of antihypertensive medications* - Antihypertensive medications are used to **manage blood pressure** in preeclampsia, preventing complications like stroke. - They **do not address the underlying cause** of the disease and are not a curative treatment. *Dietary modifications* - While a healthy diet is important during pregnancy, **dietary modifications** alone cannot resolve the pathological processes of preeclampsia. - There is **no specific diet** proven to cure or prevent preeclampsia. *Increased rest and monitoring* - **Increased rest and close monitoring** are supportive measures that can help manage symptoms and detect complications. - These interventions **do not reverse the disease process** and are not a definitive treatment.
Question 7: A G1 P0 woman at 36 weeks presents with newly diagnosed gestational diabetes. What is the most appropriate initial management?
- A. Induction of labor
- B. Oral hypoglycemics
- C. Diet control (Correct Answer)
- D. Insulin
Explanation: ***Diet control (Medical Nutrition Therapy)*** - For newly diagnosed gestational diabetes, **lifestyle modifications**, primarily **dietary changes**, are the **first-line treatment** per ACOG and ADA guidelines - Medical nutrition therapy (MNT) aims to control blood glucose levels through proper nutrition and should be attempted for **1-2 weeks** before considering pharmacologic interventions - Target goals: Fasting glucose <95 mg/dL, 1-hour postprandial <140 mg/dL, 2-hour postprandial <120 mg/dL *Induction of labor* - **Induction of labor** is typically considered for gestational diabetes if there are concerns about **fetal macrosomia** (EFW >4000-4500g), **poor glycemic control despite treatment**, or other maternal-fetal complications - Generally considered at **39-40 weeks** in well-controlled GDM or earlier with complications - Not the initial management for a new diagnosis at 36 weeks without additional concerning features *Oral hypoglycemics* - **Metformin** or **glyburide** may be used as second-line agents when **dietary management fails** to achieve adequate glycemic control after 1-2 weeks - Metformin is increasingly preferred as it does not cross the placenta as readily as glyburide - They are **not the initial step** in management *Insulin* - **Insulin therapy** is indicated when **dietary modifications alone** are insufficient in maintaining target blood glucose levels - Also preferred if oral agents are contraindicated or fail to achieve glycemic targets - Represents a **secondary intervention** when primary non-pharmacological methods are inadequate
Question 8: A 32-year-old primigravida at 39 weeks of gestational age has a blood pressure reading of 150/100 mmHg obtained during a routine visit, which is an elevation from her baseline blood pressure of 120/70 mmHg. She denies any headache, visual changes, nausea, vomiting, or abdominal pain. Her repeat BP is 160/90 mmHg, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?
- A. Preeclampsia
- B. Chronic hypertension with superimposed preeclampsia
- C. Eclampsia
- D. Gestational hypertension (Correct Answer)
Explanation: ***Gestational hypertension*** - This patient presents with **new-onset hypertension** (BP > 140/90 mmHg) after 20 weeks of gestation, without **proteinuria** or signs of **end-organ damage**. - The absence of proteinuria and severe features distinguishes it from preeclampsia, making gestational hypertension the most likely diagnosis. *Preeclampsia* - Preeclampsia requires new-onset hypertension combined with **proteinuria** (≥300 mg in 24 hours or protein/creatinine ratio ≥0.3) or signs of **end-organ dysfunction**, neither of which are described here. - While hypertension is present, the **lack of proteinuria** or other severe features rules out this diagnosis. *Chronic hypertension with superimposed preeclampsia* - This diagnosis applies to women with **pre-existing hypertension** (diagnosed before pregnancy or before 20 weeks) who then develop new-onset proteinuria or worsening hypertension with severe features. - The patient's baseline blood pressure was normal (120/70 mmHg), indicating no chronic hypertension, and no proteinuria or severe features are present. *Eclampsia* - Eclampsia is defined by the occurrence of **generalized tonic-clonic seizures** in a woman with preeclampsia, which is a life-threatening obstetric emergency. - The patient described has no signs of seizures or even severe preeclampsia.
Question 9: 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 10: Which of the following is an indication for medical management in ectopic pregnancy?
- A. Ectopic mass size < 4 cm (Correct Answer)
- B. Presence of fetal heart activity in the ectopic mass
- C. Gestation age < 6 weeks
- D. hCG level > 5000 mIU/mL
Explanation: ***Ectopic mass size < 4 cm*** - A small ectopic mass size, generally less than 3.5 to 4 cm, is a **key criterion for medical management with methotrexate**, as larger masses are associated with higher risk of rupture and treatment failure. - This dimension indicates a lower risk of imminent rupture, making medical intervention a safer and effective option. *Presence of fetal heart activity in the ectopic mass* - The presence of **fetal cardiac activity** is a **contraindication** for medical management and typically necessitates **surgical intervention** due to high failure rate of methotrexate and increased risk of rupture. - Fetal viability signifies an actively growing pregnancy, which is less likely to resolve successfully with medical treatment. *Gestation age < 6 weeks* - While a low gestational age might seem favorable, there is **no specific gestational age cutoff** as an independent indication for medical management of ectopic pregnancy. - The decision depends more on **hCG levels**, mass size, and absence of fetal cardiac activity rather than gestational weeks alone. *hCG level > 5000 mIU/mL* - An hCG level **greater than 5000 mIU/mL** is generally a **contraindication** for medical management, not an indication. - For methotrexate therapy to be considered, hCG levels should typically be **below 5000 mIU/mL** (some protocols use < 10,000 mIU/mL), as higher levels are associated with **lower success rates** and increased risk of treatment failure. - Very high hCG levels generally prompt consideration for surgical intervention, especially if other risk factors are present.
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