Gestational diabetes — MCQs

10 questions

A 37-year-old woman at 28 weeks gestation presents with sudden onset dyspnea and chest pain. She has a history of previous DVT. D-dimer is elevated. What is the most appropriate anticoagulant if PE is confirmed?

A 35-year-old woman at 32 weeks gestation presents with severe headache, visual changes, and RUQ pain. BP is 175/110 mmHg. Blood tests show AST 200 U/L, platelets 70,000/μL. What is the most appropriate management?

A 33-year-old woman at 36 weeks gestation presents with severe abdominal pain and vaginal bleeding. Her previous pregnancy was delivered by cesarean section. Fetal heart rate shows bradycardia. What is the most likely diagnosis?

A 37-year-old woman at 30 weeks gestation presents with sudden onset dyspnea and pleuritic chest pain. She has a swollen left calf. What is the most appropriate initial investigation?

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 34-year-old woman at 32 weeks gestation presents with severe headache and visual disturbances. BP is $165/105\mathrm{mmHg}$. Proteinuria is $3+$. Blood tests show normal platelets and liver enzymes. What is the most likely diagnosis?

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?

Q10

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?

Gestational diabetes UK Medical PG Practice Questions and MCQs

Question 1: A 37-year-old woman at 28 weeks gestation presents with sudden onset dyspnea and chest pain. She has a history of previous DVT. D-dimer is elevated. What is the most appropriate anticoagulant if PE is confirmed?

A. Warfarin
B. Dabigatran
C. Rivaroxaban
D. Low molecular weight heparin (Correct Answer)
E. Unfractionated heparin

Explanation: ***Low molecular weight heparin*** - **Low molecular weight heparin (LMWH)** is the preferred anticoagulant for treating **pulmonary embolism (PE)** during pregnancy because it **does not cross the placenta**, minimizing risk to the fetus. - It is effective, has a predictable dose-response, and requires less monitoring than unfractionated heparin. *Warfarin* - **Warfarin** is a **teratogen** (Category X) and is strictly contraindicated during the first trimester due to the risk of **fetal warfarin syndrome**. - It carries a risk of fetal hemorrhage and central nervous system abnormalities even in later trimesters, making it generally avoided in pregnancy. *Dabigatran* - **Dabigatran** is a direct thrombin inhibitor (DOAC) with limited data on safety during pregnancy, and its molecular weight suggests some placental transfer is possible. - Due to lack of robust safety data, **DOACs** are generally not recommended for use in pregnant women for treating VTE. *Rivaroxaban* - **Rivaroxaban** is a Factor Xa inhibitor (DOAC) also generally avoided in pregnancy due to insufficient data on fetal safety and potential placental transfer. - There is a theoretical risk of fetal bleeding, and **LMWH** remains the standard of care. *Unfractionated heparin* - **Unfractionated heparin (UFH)** is safe in pregnancy as it does not cross the placenta, similar to LMWH. - However, **LMWH** is preferred due to its greater bioavailability, longer half-life, and lower risk of **heparin-induced thrombocytopenia (HIT)** and **osteoporosis** with long-term use.

Question 2: A 35-year-old woman at 32 weeks gestation presents with severe headache, visual changes, and RUQ pain. BP is 175/110 mmHg. Blood tests show AST 200 U/L, platelets 70,000/μL. What is the most appropriate management?

A. Antihypertensive treatment
B. Magnesium sulfate
C. Immediate delivery (Correct Answer)
D. Corticosteroids
E. Observation

Explanation: ***Immediate delivery*** - The patient's symptoms (severe headache, visual changes, RUQ pain, BP 175/110 mmHg) and lab results (**AST 200 U/L**, **platelets 70,000/μL**) meet the criteria for **HELLP syndrome**, a severe manifestation of preeclampsia. - **Immediate delivery** is the definitive management for **HELLP syndrome**, as removing the placenta resolves the underlying pathology and prevents life-threatening maternal complications like stroke, DIC, and liver rupture, especially given the severe presentation at 32 weeks gestation. *Antihypertensive treatment* - While crucial for preventing **hemorrhagic stroke** by managing the severe hypertension (BP 175/110 mmHg), antihypertensive treatment (e.g., **labetalol**, **hydralazine**) only addresses a symptom. - It is a supportive measure and not the definitive treatment for the underlying pathophysiology of **HELLP syndrome**, which requires removal of the placenta. *Magnesium sulfate* - **Magnesium sulfate** is essential for **seizure prophylaxis** to prevent **eclampsia** in patients with severe preeclampsia and HELLP syndrome, addressing a critical maternal complication. - However, it does not resolve the underlying liver dysfunction or hematological abnormalities of **HELLP syndrome**; therefore, it is an important stabilizing measure but not the primary definitive management. *Corticosteroids* - Corticosteroids like **betamethasone** are primarily administered before 34 weeks for **fetal lung maturity**, but they require 24-48 hours to be effective. - In severe maternal conditions like **HELLP syndrome**, delaying delivery for corticosteroid administration can pose significant risks to the mother and is often contraindicated when immediate delivery is indicated. *Observation* - **Observation** is dangerous and contraindicated in cases of severe preeclampsia with **HELLP syndrome** due to the imminent risk of life-threatening maternal complications, including **eclampsia**, **placental abruption**, and **maternal stroke**. - This clinical scenario requires **active management**, which includes stabilization and **definitive delivery**, rather than passive monitoring.

Question 3: A 33-year-old woman at 36 weeks gestation presents with severe abdominal pain and vaginal bleeding. Her previous pregnancy was delivered 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. Preterm labor
E. Vasa previa

Explanation: ***Uterine rupture*** - The combination of acute, severe abdominal pain, vaginal bleeding, and profound fetal **bradycardia** in a woman with a history of a previous **Cesarean section** is highly indicative of uterine rupture. - A prior uterine scar is a significant risk factor for rupture, which leads to immediate fetal compromise due to placental detachment or expulsion into the abdomen, along with maternal hemorrhage. *Placental abruption* - While placental abruption can present with vaginal bleeding, abdominal pain, and fetal distress, the pain is often described as constant with a **board-like abdomen**, and the primary cause is typically not a prior uterine incision leading to mechanical failure. - Although fetal bradycardia is common, the patient's history of a Cesarean section points to a mechanical failure of the uterus rather than primary abruption. *Placenta previa* - Placenta previa characteristically causes **painless vaginal bleeding**, often recurrent, and usually does not present with severe acute abdominal pain. - Fetal distress in previa is typically due to significant maternal blood loss, not a sudden uterine catastrophe. *Preterm labor* - Preterm labor involves rhythmic, painful uterine **contractions** leading to cervical changes, not the constant, severe, tearing-like pain indicative of a uterine tear. - While severe pain and fetal bradycardia can occur in complicated labor, the underlying cause in this scenario is specifically suggested by the previous **uterine scar** and the acute, severe presentation. *Vasa previa* - Vasa previa involves the rupture of **fetal blood vessels** within the membranes over the cervix, causing **painless vaginal bleeding** of fetal origin and rapid fetal distress. - It does not explain the severe maternal abdominal pain associated with a major uterine insult and is not directly related to a prior Cesarean scar.

Question 4: A 37-year-old woman at 30 weeks gestation presents with sudden onset dyspnea and pleuritic chest pain. She has a swollen left calf. What is the most appropriate initial investigation?

A. D-dimer
B. Chest X-ray
C. Compression ultrasound of leg (Correct Answer)
D. V/Q scan
E. CTPA

Explanation: ***Compression ultrasound of leg*** - In a pregnant patient with symptomatic DVT/PE suspicion, identifying a **proximal DVT** via CUS is crucial as it confirms venous thromboembolism (VTE) and often allows **anticoagulation initiation** without further imaging that involves radiation (CTPA or V/Q scan). - CUS is **non-invasive**, readily available, and carries **no risk of fetal radiation**, making it the safest and most appropriate initial diagnostic test for VTE in pregnancy in this clinical context. *D-dimer* - The **D-dimer** test is unreliable in pregnancy because levels naturally increase throughout gestation, especially in the third trimester (30 weeks here), leading to **high false-positive rates** and poor diagnostic specificity. - While useful in low-risk non-pregnant patients (PERC rule), its lack of negative predictive value in this high-risk scenario makes it an inappropriate *initial* diagnostic step. *Chest X-ray* - A **Chest X-ray (CXR)** is primarily used to exclude alternative diagnoses, such as **pneumonia** or **pneumothorax**, that could mimic PE symptoms. - It is generally **not diagnostic** for PE itself, as findings are often non-specific or normal, and therefore does not confirm the need for anticoagulation. *V/Q scan* - A **V/Q scan** involves ionizing radiation and is typically considered for confirming PE only if the CUS is negative and clinical suspicion remains high. - While it has **lower fetal radiation exposure** compared to CTPA, it is deferred until non-invasive CUS results are known. *CTPA* - **CT Pulmonary Angiography (CTPA)** is highly sensitive for PE but exposes the mother (especially the breasts) to higher radiation doses compared to a V/Q scan. - It is usually reserved for cases where the **CXR is abnormal** or when the V/Q scan is **non-diagnostic**, following an initial assessment with CUS.

Question 5: 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 6: A 34-year-old woman at 32 weeks gestation presents with severe headache and visual disturbances. BP is $165/105\mathrm{mmHg}$. Proteinuria is $3+$. Blood tests show normal platelets and liver enzymes. What is the most likely diagnosis?

A. Gestational hypertension
B. Severe pre-eclampsia (Correct Answer)
C. HELLP syndrome
D. Eclampsia
E. Chronic hypertension

Explanation: ***Severe pre-eclampsia*** - The presence of **hypertension** ($165/105\mathrm{mmHg}$) and significant **proteinuria ($3+$)** in a woman at 32 weeks gestation (after 20 weeks) indicates pre-eclampsia. - The additional presence of **severe symptoms** like **headache** and **visual disturbances**, along with **severe-range blood pressure** ($\geq 160/110\mathrm{mmHg}$), confirms the diagnosis of **severe pre-eclampsia**. *Gestational hypertension* - *Gestational hypertension* is characterized by new-onset **hypertension** after 20 weeks gestation in the absence of **proteinuria** or any **severe features**. - The patient's **$3+$ proteinuria** and **severe symptoms** (headache, visual disturbances) directly exclude this diagnosis. *HELLP syndrome* - **HELLP syndrome** is a severe form of pre-eclampsia defined by **Hemolysis**, **Elevated Liver enzymes**, and **Low Platelets** (thrombocytopenia). - The clinical vignette explicitly states that the patient's **platelets and liver enzymes are normal**, thereby ruling out HELLP syndrome. *Eclampsia* - **Eclampsia** is diagnosed by the occurrence of **generalized tonic-clonic seizures** or unexplained coma in a patient with pre-eclampsia. - While the patient has severe pre-eclampsia, the absence of **seizures** in the presentation means she has not yet progressed to eclampsia. *Chronic hypertension* - **Chronic hypertension** is hypertension diagnosed before pregnancy or before **20 weeks gestation**, or hypertension that persists beyond 12 weeks postpartum. - The **new-onset proteinuria** and severe symptoms arising after 20 weeks gestation are characteristic of a pregnancy-specific hypertensive disorder, specifically **pre-eclampsia**, rather than isolated chronic hypertension.

Question 7: 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 8: 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 9: 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 10: 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.

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