Gestational diabetes — MCQs

10 questions

A 28-year-old woman at 34 weeks gestation presents with sudden onset severe headache and seizures. Her BP is 180/120 mmHg. What is the most appropriate immediate treatment?

A 37-year-old woman presents with fatigue, joint pain, and a photosensitive rash. She is anti-Ro positive and planning pregnancy. What is the recommended fetal monitoring?

A 33-year-old woman at 30 weeks gestation presents with sudden onset dyspnea and chest pain. She has a swollen left leg. D-dimer is elevated. What is the most appropriate investigation?

A 36-year-old woman at 34 weeks gestation develops sudden onset severe abdominal pain and vaginal bleeding. Her previous delivery was by cesarean section. Fetal heart rate shows bradycardia. What is the most likely diagnosis?

A 34-year-old woman at 28 weeks gestation presents with severe itching, particularly on palms and soles. Bile acids are elevated. What is the most likely diagnosis?

A 41-year-old woman presents with fatigue, weight gain, and dry skin. TSH is 18 mU/L free T4 is low. She is planning pregnancy. What is the target TSH level during pregnancy?

A 37-year-old woman at 34 weeks gestation presents with severe hypertension and visual disturbances. Blood tests show elevated liver enzymes and low platelets. What is the definitive treatment?

A 29-year-old woman at 36 weeks gestation presents with severe hypertension and proteinuria. Fetal monitoring shows signs of compromise. What is the most appropriate management?

A 34-year-old woman presents with fatigue, joint pain, and photosensitive rash. She has positive anti-Ro antibodies and is planning pregnancy. What is the main fetal risk?

Q10

A 43-year-old woman presents with fatigue, cold intolerance, and weight gain 6 months after childbirth. TSH is 15 mU/L, free T4 low. What is the most likely diagnosis?

Gestational diabetes UK Medical PG Practice Questions and MCQs

Question 1: A 28-year-old woman at 34 weeks gestation presents with sudden onset severe headache and seizures. Her BP is 180/120 mmHg. What is the most appropriate immediate treatment?

A. Labetalol IV
B. Magnesium sulfate IV (Correct Answer)
C. Immediate cesarean section
D. Diazepam IV
E. Mannitol IV

Explanation: ***Magnesium sulfate IV***- **Magnesium sulfate** is the first-line and definitive treatment for the prevention and cessation of seizures in women with **eclampsia**.- It acts by stabilizing neuronal membranes and reducing neuromuscular irritability, providing effective seizure control superior to traditional *anticonvulsants*.*Labetalol IV*- Labetalol is an **antihypertensive** used to manage severe *hypertension* (BP 160/110 mmHg) in preeclampsia/eclampsia, but it does not treat or prevent the underlying seizures.- Control of blood pressure is secondary to achieving **seizure cessation** and prevention with magnesium sulfate in the immediate management protocol.*Immediate cesarean section*- Delivery is the definitive cure for eclampsia and severe preeclampsia, but immediate **maternal stabilization**, including seizure control (MgSO4) and blood pressure management, must precede delivery unless other emergent obstetric indications exist.- A planned delivery is necessary once the patient is stable, but the *seizures* must be controlled first, making MgSO4 the most **immediate** necessary step.*Diazepam IV*- While an effective general anticonvulsant, **diazepam** is generally reserved as a *second-line agent* if seizures persist despite adequate administration of magnesium sulfate.- Magnesium sulfate is preferred because it is more effective for eclamptic seizures and carries a lower risk of fetal respiratory depression and **neonatal hypotonia** compared to benzodiazepines.*Mannitol IV*- **Mannitol** is an osmotic diuretic primarily used to reduce increased *intracranial pressure* (ICP) or treat cerebral edema.- It is not the primary immediate agent for *seizure control* in eclampsia, which requires **magnesium sulfate**.

Question 2: A 37-year-old woman presents with fatigue, joint pain, and a photosensitive rash. She is anti-Ro positive and planning pregnancy. What is the recommended fetal monitoring?

A. Monthly ultrasounds
B. Serial fetal echocardiograms (Correct Answer)
C. Amniocentesis
D. Chorionic villus sampling
E. No additional monitoring

Explanation: ***Serial fetal echocardiograms***- Anti-Ro (SSA) antibodies cross the placenta and target the **fetal cardiac conduction system**, causing **congenital heart block (CHB)**, a serious complication.- Serial monitoring with fetal echocardiograms (starting around 16–18 weeks gestation) is crucial to detect early signs of CHB, allowing for timely treatment with maternal **fluorinated steroids**.*Monthly ultrasounds*- Standard monthly ultrasounds primarily monitor fetal growth and amniotic fluid volume but are often insufficient to reliably detect subtle changes in **fetal heart rhythm** characteristic of early CHB.- A dedicated **fetal echocardiogram** uses specialized techniques to visualize cardiac structures and assess the conduction system comprehensively.*Amniocentesis*- This is an invasive procedure used for **prenatal diagnosis of genetic and chromosomal disorders** by analyzing amniotic fluid, not for routine monitoring of cardiac function or rhythm.- The primary goal in an anti-Ro positive pregnancy is surveillance for development of CHB, which does not require genetic testing.*Chorionic villus sampling*- CVS is an invasive procedure typically performed in the first trimester (10–13 weeks) for **genetic and chromosomal analysis**.- It is not indicated for the surveillance or diagnosis of **fetal conduction abnormalities** caused by maternal autoantibodies, which usually manifest later in the second trimester (16–26 weeks).*No additional monitoring*- This approach is dangerous because **Anti-Ro antibodies** confer a 1–2% risk of the fetus developing **congenital heart block**, requiring specialized cardiac surveillance to prevent adverse outcomes.- Lack of appropriate surveillance can lead to late diagnosis of CHB, potentially resulting in **fetal hydrops** or the need for an immediate **pacemaker** after birth.

Question 3: A 33-year-old woman at 30 weeks gestation presents with sudden onset dyspnea and chest pain. She has a swollen left leg. D-dimer is elevated. What is the most appropriate investigation?

A. Chest X-ray
B. V/Q scan
C. CT pulmonary angiogram
D. Compression ultrasound of leg (Correct Answer)
E. Arterial blood gas

Explanation: ***Compression ultrasound of leg***- Given the clinical triad of sudden onset **dyspnea**, **chest pain**, a **swollen left leg**, and an elevated **D-dimer** in a pregnant woman, there is a high suspicion for **pulmonary embolism (PE)** secondary to **deep vein thrombosis (DVT)**.- **Compression ultrasound** is the most appropriate initial investigation as it is non-invasive and uses no ionizing radiation, making it safe in pregnancy. Confirming **DVT** in the leg allows for immediate initiation of **anticoagulation** for **venous thromboembolism (VTE)** without necessarily needing further chest imaging, thereby minimizing fetal radiation exposure.*Chest X-ray*- A **chest X-ray (CXR)** is often performed to rule out other causes of dyspnea (e.g., pneumonia, pneumothorax) and to assess if a subsequent **V/Q scan** would be interpretable (i.e., normal CXR is ideal for V/Q scan).- While important for initial assessment, a **CXR** is not diagnostic for **DVT** or **PE** itself and cannot confirm the presence of VTE to guide specific therapy.*V/Q scan*- A **ventilation-perfusion (V/Q) scan** uses less radiation than a **CT pulmonary angiogram (CTPA)** and is generally preferred in pregnancy if pulmonary imaging is deemed necessary.- However, if **DVT** is confirmed by ultrasound, treatment for **VTE** can be initiated without the need for immediate pulmonary imaging, especially given the clinical picture strongly pointing towards DVT as the source.*CT pulmonary angiogram*- A **CT pulmonary angiogram (CTPA)** is highly sensitive and specific for diagnosing **PE** and is preferred in cases where **V/Q scan** is inconclusive or unavailable, or in hemodynamically unstable patients.- However, **CTPA** delivers higher doses of ionizing radiation to both the **mother (breasts)** and the **fetus** compared to a V/Q scan or a non-radiating ultrasound, making the latter a safer initial diagnostic step in pregnancy when DVT is suspected.*Arterial blood gas*- An **arterial blood gas (ABG)** is useful for assessing the severity of respiratory compromise in patients with suspected **PE**, typically showing **hypoxemia** and **respiratory alkalosis** due to hyperventilation.- However, an **ABG** is not a diagnostic tool for **DVT** or **PE** itself and cannot confirm the presence or location of the thrombus to guide specific anticoagulant therapy.

Question 4: A 36-year-old woman at 34 weeks gestation develops sudden onset severe abdominal pain and vaginal bleeding. Her previous delivery was by cesarean section. Fetal heart rate shows bradycardia. What is the most likely diagnosis?

A. Placental abruption
B. Uterine rupture (Correct Answer)
C. Placenta previa
D. Vasa previa
E. Preterm labor

Explanation: ***Uterine rupture***- The presence of **sudden, severe abdominal pain**, **vaginal bleeding**, and profound **fetal bradycardia** in a woman with a history of **previous Cesarean section** is highly classic for uterine rupture, a catastrophic obstetrical emergency.- The prior CS scar is the most common predisposing factor, and the severe pain, often followed by retraction of the fetal presenting part, results from the tearing of the myometrium, leading to acute fetal compromise and maternal hemorrhage.*Placental abruption*- While it causes painful bleeding and potential fetal distress, placental abruption pain is typically sustained, associated with a **rigid (tender, hypertonic) uterus**, and is usually not described as a catastrophic tear.- Although fetal bradycardia can occur, the combination of **severe pain** and a **prior CS scar** makes rupture the more immediate concern.*Placenta previa*- Placenta previa typically presents as **painless bright red vaginal bleeding** and usually does not cause **severe abdominal pain** unless complicated by coexisting abruption, which is less common.- Fetal distress is less frequent in *previa* unless bleeding is massive enough to cause maternal shock, unlike the acute compromise suggested by profound bradycardia here.*Vasa previa*- This condition is characterized by **fetal vessel rupture** (often after membrane rupture) and primarily causes fetal blood loss, leading to rapid **fetal compromise** (bradycardia/sinusoidal trace).- *Vasa previa* bleeding is usually not associated with the severe maternal **abdominal pain** or the massive maternal hemorrhage expected with uterine rupture or abruption.*Preterm labor*- Preterm labor pain is characterized by **rhythmic uterine contractions** that lead to cervical change, not the **sudden, severe, non-contractile pain** associated with tissue tearing.- While preterm labor can sometimes be accompanied by some bleeding (bloody show), it does not typically result in the immediate, catastrophic **fetal bradycardia** seen here, which suggests acute compromise.

Question 5: A 34-year-old woman at 28 weeks gestation presents with severe itching, particularly on palms and soles. Bile acids are elevated. What is the most likely diagnosis?

A. Atopic dermatitis
B. Intrahepatic cholestasis of pregnancy (Correct Answer)
C. HELLP syndrome
D. Acute fatty liver of pregnancy
E. Scabies

Explanation: ***Intrahepatic cholestasis of pregnancy*** - The presentation of severe, generalized **pruritus**, especially on the **palms and soles**, during the third trimester is highly characteristic of this condition. - The definitive diagnosis relies on elevated serum **bile acids** (>10 µmol/L) in the absence of other primary liver pathology.*Atopic dermatitis* - This condition is characterized by an **eczematous rash** (papules, plaques) and is generally not localized solely to the palms and soles as isolated, severe pruritus. - It is a primary dermatological condition and does not result in the diagnostic elevation of serum **bile acids** seen in cholestasis.*HELLP syndrome* - HELLP is a life-threatening complication characterized by **H**emolysis, **E**levated **L**iver enzymes, and **L**ow **P**latelets, causing severe systemic illness (e.g., abdominal pain, nausea). - While it involves liver pathology, severe isolated pruritus and elevated bile acids are defining features of ICP, not **HELLP**.*Acute fatty liver of pregnancy* - AFLP is a fulminant process presenting with nausea, vomiting, **hypoglycemia**, coagulopathy, and **hepatic failure** (often requiring intensive care). - The clinical picture here is limited to isolated pruritus and elevated bile acids, which does not fit the severe systemic compromise or **acute liver failure** seen in AFLP.*Scabies* - Scabies is a skin infestation resulting in intensely pruritic papules and **burrows**, typically found in the finger web spaces, wrists, and belt line. - This diagnosis would not account for the significant elevation of **bile acids** found on laboratory testing, which indicates a hepatobiliary issue.

Question 6: A 41-year-old woman presents with fatigue, weight gain, and dry skin. TSH is 18 mU/L free T4 is low. She is planning pregnancy. What is the target TSH level during pregnancy?

A. <1.0 mU/L
B. <2.5 mU/L (Correct Answer)
C. <4.0 mU/L
D. <6.0 mU/L
E. <10.0 mU/L

Explanation: ***<2.5 mU/L***- This TSH target is specific for women with **hypothyroidism** who are planning pregnancy or are in the **first trimester** of pregnancy.- Maintaining TSH consistently below this level is critical to ensure optimal maternal and fetal thyroid hormone status, which is essential for early **fetal neurodevelopment**.*<1.0 mU/L*- This level is generally too suppressive for routine hypothyroidism management during pregnancy and risks iatrogenic hyperthyroidism.- Such suppression is typically reserved for aggressive management of **differentiated thyroid cancer**.*<4.0 mU/L*- While this may be an acceptable upper TSH limit for non-pregnant adults, it is too high for the first trimester of pregnancy.- The presence of **human chorionic gonadotropin (hCG)** suppresses TSH, lowering the physiological upper threshold in early gestation.*<6.0 mU/L*- This target is significantly above established guidelines for optimal thyroid function during pregnancy and would indicate **suboptimal replacement therapy**.- Failure to treat TSH aggressively during the first trimester increases the risk of adverse outcomes like miscarriage and preterm delivery.*<10.0 mU/L*- A TSH target this high indicates severe, untreated, or significantly **undertreated hypothyroidism**, which poses a high risk to both the mother and the fetus.- The goal throughout all trimesters is to keep TSH within the low-normal, **trimester-specific reference ranges**, which are much stricter than this value.

Question 7: A 37-year-old woman at 34 weeks gestation presents with severe hypertension and visual disturbances. Blood tests show elevated liver enzymes and low platelets. What is the definitive treatment?

A. Antihypertensive therapy
B. Corticosteroids
C. Magnesium sulfate
D. Delivery (Correct Answer)
E. Plasma exchange

Explanation: ***Delivery***- The patient's presentation with severe hypertension, visual disturbances, elevated liver enzymes, and low platelets at 34 weeks gestation is characteristic of **severe preeclampsia with HELLP syndrome**.- The **definitive treatment** for preeclampsia and its severe complications like HELLP syndrome is the **delivery** of the fetus and placenta, which resolves the underlying placental dysfunction.*Antihypertensive therapy*- **Antihypertensive medications** are crucial for managing **severe hypertension** to prevent maternal complications such as stroke, but they do not treat the underlying cause of preeclampsia.- These therapies are supportive measures used to stabilize the mother, often *prior to* and *during* delivery, but are not curative.*Corticosteroids*- **Corticosteroids** (e.g., dexamethasone) may be given to accelerate **fetal lung maturity** if gestation is less than 34 weeks and, in some cases of HELLP syndrome, can transiently improve platelet counts.- They are an adjunctive treatment and do not serve as the definitive or curative intervention for the maternal disease process.*Magnesium sulfate*- **Magnesium sulfate** is administered for the prevention and treatment of **eclampsia** (seizures) in women with severe preeclampsia or HELLP syndrome.- While vital for maternal neurological protection, it does not address the fundamental placental pathology that necessitates delivery.*Plasma exchange*- **Plasma exchange** is generally reserved for severe **thrombotic microangiopathies** such as **Thrombotic Thrombocytopenic Purpura (TTP)**, which has a similar presentation to HELLP syndrome but different pathophysiology.- It is not the standard or definitive treatment for HELLP syndrome, which typically resolves rapidly after **delivery**.

Question 8: A 29-year-old woman at 36 weeks gestation presents with severe hypertension and proteinuria. Fetal monitoring shows signs of compromise. What is the most appropriate management?

A. Antihypertensive therapy
B. Magnesium sulfate
C. Immediate delivery (Correct Answer)
D. Corticosteroids
E. Bed rest

Explanation: ***Immediate delivery*** - Given the presentation of **severe preeclampsia** (evidenced by severe hypertension and proteinuria) at 36 weeks, coupled with signs of **fetal compromise**, immediate delivery is the definitive and most appropriate management. - Delivery is the only definitive cure for preeclampsia, and at 36 weeks, the risks of continuation far outweigh the risks of prematurity, especially when **fetal well-being** is immediately threatened. *Antihypertensive therapy* - Antihypertensives (e.g., Labetalol, Hydralazine) are essential to prevent **maternal stroke** and intracerebral hemorrhage. - However, this therapy is supportive, not curative, and does not address the underlying pathology or the urgent need to relieve **fetal compromise**. *Magnesium sulfate* - **Magnesium sulfate** is mandatory for seizure prophylaxis (**eclampsia prevention**) in women with severe preeclampsia. - While critical for maternal stability, initiating this alone without proceeding to delivery is insufficient when the fetus is suffering **distress** at a viable gestation. *Corticosteroids* - Antenatal corticosteroids (e.g., betamethasone) are primarily used to promote **fetal lung maturity** when delivery is expected before 34 weeks gestation. - At 36 weeks, the fetus is considered **near term**, and the 24–48 hour delay required for corticosteroids to be effective is clinically unacceptable in the setting of severe maternal disease and **fetal compromise**. *Bed rest* - **Bed rest** is outdated and ineffective management for severe preeclampsia and may increase the risk of maternal **thromboembolism**. - It offers no therapeutic benefit and is dangerous when the patient requires immediate intervention due to severe hypertension and **fetal distress**.

Question 9: A 34-year-old woman presents with fatigue, joint pain, and photosensitive rash. She has positive anti-Ro antibodies and is planning pregnancy. What is the main fetal risk?

A. Neural tube defects
B. Congenital heart block (Correct Answer)
C. Growth restriction
D. Preterm labor
E. Cleft palate

Explanation: ***Congenital heart block***- The presence of **anti-Ro (SSA)** and **anti-La (SSB) antibodies** in a pregnant woman poses a significant risk for **Neonatal Lupus Erythematosus (NLE)**, specifically **congenital heart block**, due to transplacental antibody transfer.- These maternal antibodies target and damage the fetal cardiac conduction system, particularly the **AV node**, leading to **irreversible third-degree heart block** in the fetus.*Neural tube defects*- These developmental anomalies are primarily linked to deficiencies such as **folate deficiency** or exposure to certain teratogenic medications like **valproate**.- There is no direct or established causal relationship between maternal **anti-Ro antibodies** and the development of neural tube defects.*Growth restriction*- Fetal growth restriction (FGR) is more commonly associated with **active maternal systemic lupus erythematosus (SLE) disease** or concomitant **antiphospholipid syndrome (APS)**, leading to placental insufficiency.- While FGR can occur in pregnancies with autoimmune conditions, it is not the classic, directly antibody-mediated fetal risk specifically associated with **anti-Ro antibodies**.*Preterm labor*- Preterm labor is a general complication that can arise in pregnancies complicated by autoimmune diseases, often driven by factors like **active maternal inflammation**, placental dysfunction, or infections.- It is not the primary or specific fetal pathology directly caused by the transplacental passage and binding of **anti-Ro antibodies**.*Cleft palate*- **Cleft palate** and other craniofacial malformations are typically multifactorial, involving genetic predispositions or exposure to specific teratogenic agents (e.g., **phenytoin**).- Maternal **anti-Ro antibodies** are predominantly associated with fetal cardiac, dermatologic (rash), and hepatic manifestations, not structural defects like cleft palate.

Question 10: A 43-year-old woman presents with fatigue, cold intolerance, and weight gain 6 months after childbirth. TSH is 15 mU/L, free T4 low. What is the most likely diagnosis?

A. Postpartum thyroiditis (Correct Answer)
B. Hashimoto's thyroiditis
C. Postpartum depression
D. Sheehan syndrome
E. De Quervain's thyroiditis

Explanation: ***Postpartum thyroiditis*** - This condition involves transient inflammation of the thyroid gland, typically presenting 4–8 months after childbirth in the hypothyroid phase, matching the patient's 6-month timing and symptoms. - The lab findings (high **TSH** and low **Free T4**) confirm **primary hypothyroidism**, resulting from the destructive thyroiditis. *Hashimoto's thyroiditis* - While PPT is considered a variant of Hashimoto's, the term Hashimoto's generally refers to chronic autoimmune thyroiditis leading to permanent hypothyroidism. - The specific context of new onset symptoms 6 months after delivery makes **Postpartum thyroiditis** the more accurate and focused diagnosis. *Postpartum depression* - Although symptoms like fatigue and weight changes overlap, the definitive biochemical findings of **primary hypothyroidism** (High TSH, Low Free T4) necessitate a thyroid diagnosis. - **Postpartum depression** is a diagnosis of exclusion that should only be considered after ruling out organic causes like thyroid dysfunction. *Sheehan syndrome* - Sheehan syndrome is caused by **pituitary necrosis** following severe obstetrical hemorrhage, leading to **secondary hypothyroidism**. - Secondary hypothyroidism is characterized by **low or inappropriately normal TSH** alongside low Free T4, contradicting this patient's high TSH. *De Quervain's thyroiditis* - This condition is typically characterized by a **painful** and often tender thyroid gland, following a recent viral upper respiratory infection. - While it can cause transient hypothyroidism, the lack of a painful gland and clear viral prodrome makes this diagnosis less likely than PPT in the postpartum setting.

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