Pregnancy Medicine — MCQs
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A 25-year-old woman presents to antenatal clinic at 32 weeks gestation with blood pressure of 146/96 mmHg. This is her first pregnancy and all previous blood pressure readings have been normal. Urinalysis shows no proteinuria. Blood tests show: Hb 118 g/L, platelets 245 × 10⁹/L, ALT 22 U/L, creatinine 62 μmol/L. She is asymptomatic. What is the most appropriate diagnosis and initial management?
A 38-year-old woman with gestational diabetes on metformin and insulin is reviewed at 34 weeks gestation. Growth scans show estimated fetal weight on 92nd centile with amniotic fluid index of 26 cm (polyhydramnios). Her glucose control shows fasting values 4.9-5.4 mmol/L and 1-hour post-prandial values 7.2-8.5 mmol/L. What modification to her management plan would be most appropriate?
A 27-year-old primigravida attends her booking appointment at 12 weeks gestation. She has a history of epilepsy controlled on lamotrigine 200 mg twice daily with no seizures for 3 years. She took folic acid 400 mcg daily from 6 weeks gestation when pregnancy was confirmed. On examination, her BP is 112/68 mmHg and BMI is 24 kg/m². What is the most appropriate advice regarding her antiepileptic medication and additional supplementation?
A 33-year-old woman undergoes OGTT at 28 weeks gestation following detection of glycosuria at routine antenatal visit. Results show: fasting glucose 5.8 mmol/L and 2-hour glucose 9.2 mmol/L. Her BMI is 28 kg/m². She is referred to the diabetes in pregnancy clinic. What is the most appropriate initial management approach?
A 31-year-old woman is admitted at 36 weeks gestation with severe pre-eclampsia. Blood pressure is 168/116 mmHg despite oral labetalol 200 mg three times daily. Blood tests show: platelets 98 × 10⁹/L, ALT 125 U/L, creatinine 118 μmol/L, and proteinuria 4.2 g/24 hours. She reports mild epigastric discomfort. CTG is reassuring. What is the most appropriate immediate management plan?
A 29-year-old woman in her first pregnancy attends the antenatal day unit at 39 weeks gestation with reduced fetal movements for 12 hours. She has gestational diabetes managed with metformin 1000 mg twice daily. Cardiotocography shows a baseline rate of 150 bpm with good variability, two accelerations in 20 minutes, and no decelerations. Her blood pressure is 132/84 mmHg. Urinalysis shows 1+ protein. What is the most appropriate next step in management?
What is the recommended frequency of ultrasound fetal growth surveillance for women diagnosed with gestational diabetes managed with insulin or oral hypoglycaemic agents according to current NICE guidelines?
A 34-year-old woman presents at 23 weeks gestation for her first antenatal visit. She was previously healthy with no medical history. On examination, her blood pressure is 124/78 mmHg, BMI is 22 kg/m², and urinalysis shows no proteinuria. She smokes 10 cigarettes daily. Which additional investigation is most appropriate to perform at this visit given the late booking?
A 28-year-old primigravida at 19 weeks gestation attends routine antenatal clinic. She mentions she has been reading about vitamin supplementation in pregnancy online and asks whether she should take vitamin D supplements. She has no medical problems, works indoors, and follows a vegetarian diet. She has medium-brown skin tone. What is the most appropriate advice?
A 37-year-old woman with twin pregnancy is seen at 20 weeks gestation. Her booking BP was 124/78 mmHg. Current BP is 148/96 mmHg. Urinalysis is negative for protein. Blood tests are all within normal limits including uric acid and liver function. She is asymptomatic. She attends again 4 days later and BP is 146/94 mmHg. Urine PCR is 22 mg/mmol. What is the most appropriate management strategy?
Pregnancy Medicine UK Medical PG Practice Questions and MCQs
Question 101: A 25-year-old woman presents to antenatal clinic at 32 weeks gestation with blood pressure of 146/96 mmHg. This is her first pregnancy and all previous blood pressure readings have been normal. Urinalysis shows no proteinuria. Blood tests show: Hb 118 g/L, platelets 245 × 10⁹/L, ALT 22 U/L, creatinine 62 μmol/L. She is asymptomatic. What is the most appropriate diagnosis and initial management?
- A. Pre-eclampsia; admit for observation and commence antihypertensive therapy
- B. Gestational hypertension; arrange repeat BP in 1 week with community midwife
- C. White coat hypertension; arrange 24-hour ambulatory blood pressure monitoring
- D. Gestational hypertension; admit for observation and twice-daily BP monitoring
- E. Gestational hypertension; commence labetalol and review in 48-72 hours (Correct Answer)
Explanation: ***Gestational hypertension; commence labetalol and review in 48-72 hours*** - **Gestational hypertension** is diagnosed when new-onset hypertension (≥140/90 mmHg) occurs after **20 weeks of gestation** without **proteinuria** or biochemical organ dysfunction. - In this case, the blood pressure of 146/96 mmHg warrants **oral antihypertensive therapy** (first-line **labetalol**) with follow-up within 48-72 hours to ensure stabilization and monitor for progression to pre-eclampsia. *Pre-eclampsia; admit for observation and commence antihypertensive therapy* - A diagnosis of **pre-eclampsia** requires hypertension plus **proteinuria** or other features such as **low platelets**, elevated liver enzymes, or renal impairment, which are absent here. - Admission is generally reserved for **severe hypertension** (≥160/110 mmHg) or clinical/biochemical features of organ involvement. *Gestational hypertension; arrange repeat BP in 1 week with community midwife* - Waiting one week is inappropriate because current guidelines recommend **reviewing blood pressure** within 48-72 hours when starting medication to assess response. - This delay increases the risk of complications if the blood pressure rises further or if the condition evolves into **pre-eclampsia**. *White coat hypertension; arrange 24-hour ambulatory blood pressure monitoring* - While ambulatory monitoring can diagnose **white coat hypertension**, new-onset hypertension at **32 weeks gestation** is clinically significant and should be treated as gestational hypertension first. - Managing the risk of **maternofetal complications** takes priority over excluding white coat effects in a late-gestation patient with no previous hypertensive history. *Gestational hypertension; admit for observation and twice-daily BP monitoring* - **Admission** is not routinely required for mild-to-moderate gestational hypertension if the patient is **asymptomatic** and blood results are within normal limits. - This patient can be managed safely in the **outpatient setting** with maternal education on symptoms of pre-eclampsia and scheduled clinic reviews.
Question 102: A 38-year-old woman with gestational diabetes on metformin and insulin is reviewed at 34 weeks gestation. Growth scans show estimated fetal weight on 92nd centile with amniotic fluid index of 26 cm (polyhydramnios). Her glucose control shows fasting values 4.9-5.4 mmol/L and 1-hour post-prandial values 7.2-8.5 mmol/L. What modification to her management plan would be most appropriate?
- A. Increase insulin doses to improve post-prandial control (Correct Answer)
- B. Reduce metformin dose to prevent polyhydramnios
- C. Arrange immediate delivery by caesarean section
- D. Add glibenclamide to improve overall glycaemic control
- E. Continue current management and arrange amniocentesis
Explanation: ***Increase insulin doses to improve post-prandial control*** - The patient's **1-hour post-prandial glucose** values (up to 8.5 mmol/L) exceed the standard target of **<7.8 mmol/L**, indicating suboptimal control. - The presence of **macrosomia** (fetal weight >90th centile) and **polyhydramnios** are complications of maternal hyperglycemia, necessitating stricter insulin titration to prevent further fetal overgrowth. *Reduce metformin dose to prevent polyhydramnios* - Reducing **metformin** would lead to higher maternal blood glucose levels, potentially worsening **polyhydramnios** and fetal macrosomia. - Metformin is used to sensitize tissues to insulin and lowering it would be counter-therapeutic in the context of poor glycemic control. *Arrange immediate delivery by caesarean section* - **Immediate delivery** at 34 weeks is premature; the aim is usually to optimize control and aim for delivery between **37-38 weeks** in complicated gestational diabetes. - A **caesarean section** is not automatically indicated solely based on macrosomia unless the estimated fetal weight exceeds specific thresholds (usually >4.5kg) or there are other obstetric indications. *Add glibenclamide to improve overall glycaemic control* - **Glibenclamide** (a sulfonylurea) is generally not the first-line preference when a patient is already failing on a combination of **insulin and metformin**. - Adjusting the **insulin dose** provides more precise and flexible control over glucose spikes compared to adding a fixed-dose oral hypoglycemic agent. *Continue current management and arrange amniocentesis* - **Amniocentesis** is not indicated here as the cause of polyhydramnios is clearly identified as **fetal polyuria** secondary to maternal hyperglycemia. - Continuing current management is inappropriate because the fetal growth and fluid status demonstrate that existing **glycemic targets** are not being met.
Question 103: A 27-year-old primigravida attends her booking appointment at 12 weeks gestation. She has a history of epilepsy controlled on lamotrigine 200 mg twice daily with no seizures for 3 years. She took folic acid 400 mcg daily from 6 weeks gestation when pregnancy was confirmed. On examination, her BP is 112/68 mmHg and BMI is 24 kg/m². What is the most appropriate advice regarding her antiepileptic medication and additional supplementation?
- A. Continue current lamotrigine dose and increase folic acid to 5 mg daily (Correct Answer)
- B. Reduce lamotrigine dose and continue folic acid 400 mcg daily
- C. Continue current lamotrigine dose, explain higher folic acid was needed pre-conception but too late now
- D. Stop lamotrigine and switch to levetiracetam immediately
- E. Continue current lamotrigine dose, start vitamin K supplementation
Explanation: ***Continue current lamotrigine dose and increase folic acid to 5 mg daily*** - Women on **antiepileptic drugs (AEDs)** are at higher risk of neural tube defects and should receive a higher dose of **5 mg folic acid** throughout pregnancy. - **Lamotrigine** is among the safest AEDs during pregnancy, and the dose should be maintained at a level that provides effective **seizure control** to prevent maternal and fetal harm. *Reduce lamotrigine dose and continue folic acid 400 mcg daily* - Reducing the dose of AEDs in a seizure-free patient risks **breakthrough seizures**, which can cause fetal hypoxia or maternal injury. - The standard dose of **400 mcg folic acid** is insufficient for women taking AEDs; they require the high-dose **5 mg** protocol. *Continue current lamotrigine dose, explain higher folic acid was needed pre-conception but too late now* - Although the critical period for **neural tube closure** is the first trimester, high-dose folic acid is still recommended throughout pregnancy for patients on AEDs for overall fetal health. - It is never "too late" to optimize nutritional support and follow clinical guidelines for high-risk pregnancies. *Stop lamotrigine and switch to levetiracetam immediately* - Switching medications during pregnancy is generally avoided as it risks losing **seizure control** during the transition period. - Both **lamotrigine** and **levetiracetam** are considered first-line options in pregnancy due to lower teratogenic risk compared to sodium valproate. *Continue current lamotrigine dose, start vitamin K supplementation* - **Vitamin K** supplementation is indicated in the final month for women taking **enzyme-inducing** AEDs (e.g., carbamazepine, phenytoin) to prevent neonatal hemorrhage. - **Lamotrigine** is not an enzyme-inducing drug, so routine Vitamin K supplementation for the mother is not specifically required for this reason.
Question 104: A 33-year-old woman undergoes OGTT at 28 weeks gestation following detection of glycosuria at routine antenatal visit. Results show: fasting glucose 5.8 mmol/L and 2-hour glucose 9.2 mmol/L. Her BMI is 28 kg/m². She is referred to the diabetes in pregnancy clinic. What is the most appropriate initial management approach?
- A. Commence metformin 500 mg twice daily immediately
- B. Initiate insulin therapy with close monitoring
- C. Provide dietary advice and self-monitoring, review in 1 week (Correct Answer)
- D. Repeat OGTT in 2 weeks to confirm diagnosis
- E. Commence metformin 500 mg once daily and provide dietary advice
Explanation: ***Provide dietary advice and self-monitoring, review in 1 week*** - According to **NICE guidelines**, the initial management for gestational diabetes (GDM) with a fasting glucose **below 7.0 mmol/L** is a trial of **diet and exercise** for 1–2 weeks. - Patients must be taught **self-monitoring of blood glucose** (fasting and 1-hour postprandial) to assess if lifestyle changes alone can reach glycemic targets before considering pharmacotherapy. *Commence metformin 500 mg twice daily immediately* - **Metformin** is typically indicated only if glycemic targets are not met after a trial of **lifestyle modification** or if the initial fasting glucose is significantly elevated (e.g., ≥7.0 mmol/L). - Immediate pharmacotherapy is generally reserved for more severe presentations or when there are signs of **fetal complications**. *Initiate insulin therapy with close monitoring* - **Insulin** is usually the first-line medication only if the fasting glucose is **≥7.0 mmol/L** at diagnosis, or if there are signs of **fetal macrosomia** or polyhydramnios. - For this patient with a fasting glucose of 5.8 mmol/L, insulin is premature as **lifestyle modifications** have not yet been attempted. *Repeat OGTT in 2 weeks to confirm diagnosis* - A single abnormal **OGTT** (fasting ≥5.6 mmol/L or 2-hour ≥7.8 mmol/L for GDM) is sufficient to diagnose **gestational diabetes**; repeating the test would cause unnecessary delay. - The presence of **glycosuria** combined with these specific biochemical results confirms the diagnosis, warranting immediate management. *Commence metformin 500 mg once daily and provide dietary advice* - While providing **dietary advice** is correct, commencing **metformin** at this stage bypasses the recommended initial step of **lifestyle-only intervention**. - Guidelines emphasize assessing the efficacy of **dietary changes** and increased physical activity for at least 1 week before introducing oral hypoglycemic agents.
Question 105: A 31-year-old woman is admitted at 36 weeks gestation with severe pre-eclampsia. Blood pressure is 168/116 mmHg despite oral labetalol 200 mg three times daily. Blood tests show: platelets 98 × 10⁹/L, ALT 125 U/L, creatinine 118 μmol/L, and proteinuria 4.2 g/24 hours. She reports mild epigastric discomfort. CTG is reassuring. What is the most appropriate immediate management plan?
- A. Continue current management with repeat bloods in 24 hours
- B. Commence magnesium sulphate and plan delivery within 24-48 hours (Correct Answer)
- C. Add nifedipine and increase monitoring frequency
- D. Immediate delivery by caesarean section
- E. Start intravenous labetalol infusion and review in 6 hours
Explanation: ***Commence magnesium sulphate and plan delivery within 24-48 hours***- The patient presents with **severe pre-eclampsia** at 36 weeks, indicated by refractory hypertension, **thrombocytopenia** (platelets 98 x 10⁹/L), elevated **ALT** (125 U/L), **renal dysfunction** (creatinine 118 μmol/L), and **epigastric discomfort**, suggesting multi-organ involvement.- **Magnesium sulphate** is crucial for eclamptic seizure prophylaxis in severe pre-eclampsia, and delivery is the definitive treatment. Planning delivery within 24-48 hours is appropriate for stabilization given the **reassuring CTG** and 36 weeks gestation.*Continue current management with repeat bloods in 24 hours*- Delaying active management is inappropriate given the **severity of pre-eclampsia** and progressive **end-organ dysfunction** (thrombocytopenia, elevated ALT, renal impairment).- This approach would significantly increase the risk of serious maternal complications such as **eclampsia** or **HELLP syndrome** progression without intervention.*Add nifedipine and increase monitoring frequency*- While **nifedipine** could help with blood pressure control, it does not address the underlying pathology or the need for seizure prophylaxis and definitive treatment (delivery) in severe pre-eclampsia with multi-organ involvement.- Increased monitoring alone is insufficient for this clinical picture; active steps towards managing the disease progression are essential, not just symptom control.*Immediate delivery by caesarean section*- Although delivery is the definitive management, immediate caesarean section is not universally required, especially with a **reassuring CTG** and time for maternal optimization. - Often, a planned induction of labour can be considered if there are no immediate maternal or fetal indications for emergent operative delivery.*Start intravenous labetalol infusion and review in 6 hours*- Intravenous labetalol can manage acute severe hypertension, but it's a symptomatic treatment and does not prevent the progression of **pre-eclampsia** or address the need for delivery.- Reviewing in 6 hours without a concrete plan for **seizure prophylaxis** and **delivery** is inadequate given the patient's multi-system deterioration.
Question 106: A 29-year-old woman in her first pregnancy attends the antenatal day unit at 39 weeks gestation with reduced fetal movements for 12 hours. She has gestational diabetes managed with metformin 1000 mg twice daily. Cardiotocography shows a baseline rate of 150 bpm with good variability, two accelerations in 20 minutes, and no decelerations. Her blood pressure is 132/84 mmHg. Urinalysis shows 1+ protein. What is the most appropriate next step in management?
- A. Reassure and discharge home with routine follow-up
- B. Admit for induction of labour within 24 hours
- C. Perform protein:creatinine ratio and arrange review within 24 hours (Correct Answer)
- D. Repeat CTG in 4 hours and discharge if normal
- E. Arrange urgent ultrasound for fetal biometry and Doppler studies
Explanation: ***Perform protein:creatinine ratio and arrange review within 24 hours*** - The presence of **1+ protein** on urinalysis at 39 weeks gestation requires quantification via **spot protein:creatinine ratio (PCR)** to screen for **preeclampsia**. - Although her blood pressure is currently within normal limits (132/84 mmHg), the combination of **gestational diabetes** and new-onset proteinuria necessitates further investigation and clinical review within **24 hours**. *Reassure and discharge home with routine follow-up* - Routine follow-up is inadequate because **new-onset proteinuria** in late pregnancy is a red flag that must be quantified to exclude **preeclampsia**. - Failure to investigate clinical changes in a **high-risk patient** (gestational diabetes at term) could result in missing a significant hypertensive disorder of pregnancy. *Admit for induction of labour within 24 hours* - Immediate **induction of labour** is not yet indicated as the **CTG is reassuring** and the diagnosis of preeclampsia hasn't been confirmed. - While delivery is often the definitive management for preeclampsia at term, **quantification of proteinuria** and assessment of bloods (FBC, LFTs, U&Es) are needed before deciding on the mode and timing of delivery. *Repeat CTG in 4 hours and discharge if normal* - Repeating the **CTG** only addresses the symptom of **reduced fetal movements**, which is already reassuring with the current baseline and accelerations. - It fails to address the abnormal **urinalysis finding**, which is the more pressing clinical concern regarding maternal safety at this stage. *Arrange urgent ultrasound for fetal biometry and Doppler studies* - **Biometry and Doppler studies** are typically used to assess fetal growth and placental function in chronic conditions or persistent reduced movements. - In this acute setting with a **normal CTG** at 39 weeks, the focus should be on ruling out **preeclampsia** rather than performing an urgent ultrasound for growth.
Question 107: What is the recommended frequency of ultrasound fetal growth surveillance for women diagnosed with gestational diabetes managed with insulin or oral hypoglycaemic agents according to current NICE guidelines?
- A. Every 2 weeks from diagnosis
- B. Every 4 weeks from diagnosis (Correct Answer)
- C. Every 4 weeks from 28 weeks gestation
- D. Every 2 weeks from 32 weeks gestation
- E. At 28, 32 and 36 weeks gestation
Explanation: ***Every 4 weeks from diagnosis*** - For women with **gestational diabetes** managed with **insulin or oral hypoglycaemic agents**, NICE guidelines recommend ultrasound monitoring for **fetal growth** and **amniotic fluid volume** every 4 weeks. - This scanning frequency is designed to monitor for **macrosomia** and **polyhydramnios**, which are common complications when pharmacological intervention is required. *Every 2 weeks from diagnosis* - Monitoring every **two weeks** is considered overly intensive for standard gestational diabetes and is not supported by current NICE evidence for routine surveillance. - Such frequent scanning would increase **resource utilization** without proven clinical benefits in improving neonatal outcomes compared to the 4-week interval. *Every 4 weeks from 28 weeks gestation* - While 28 weeks is a common starting point for growth scans, the guideline specifically anchors the surveillance schedule to the **time of diagnosis**. - Using a fixed gestational age rather than the **diagnosis date** may lead to inappropriate gaps in monitoring if a woman is diagnosed early or late in the second trimester. *Every 2 weeks from 32 weeks gestation* - This frequency and timing are more commonly associated with high-risk conditions like **fetal growth restriction (FGR)** or specific placental pathologies. - For diabetes, the risk is typically **accelerated growth**, which is adequately monitored with the standard **4-week interval**. *At 28, 32 and 36 weeks gestation* - This fixed schedule does not account for the timing of **diagnosis** or the initiation of **pharmacological treatment**, which are the primary triggers for increased surveillance. - In contrast, women managed with **diet and lifestyle** alone are only required to have a single growth scan at **36 weeks**.
Question 108: A 34-year-old woman presents at 23 weeks gestation for her first antenatal visit. She was previously healthy with no medical history. On examination, her blood pressure is 124/78 mmHg, BMI is 22 kg/m², and urinalysis shows no proteinuria. She smokes 10 cigarettes daily. Which additional investigation is most appropriate to perform at this visit given the late booking?
- A. Oral glucose tolerance test
- B. Quadruple test for fetal anomalies
- C. Detailed anomaly ultrasound scan (Correct Answer)
- D. First trimester combined screening test
- E. Cervical length ultrasound
Explanation: ***Detailed anomaly ultrasound scan*** - The **fetal anomaly scan** is routinely performed between **18 and 20+6 weeks**; however, it should still be offered at **23 weeks** to detect major structural abnormalities. - It is the most appropriate next step for a **late booking** patient as it assesses fetal anatomy, placenta position, and amniotic fluid volume. *Oral glucose tolerance test* - An **OGTT** is typically performed between **24 and 28 weeks** gestation unless there are specific high-risk factors like previous **gestational diabetes** or a BMI >30. - While the patient smokes, she lacks the primary risk factors for early screening, and the scan takes priority at this specific encounter. *Quadruple test for fetal anomalies* - The **quadruple test** (screening for Down syndrome) is validated for use only up to **20 weeks and 0 days** gestation. - At **23 weeks**, the patient is outside the clinical window for this biochemical screening test to be accurate or useful. *First trimester combined screening test* - This test, which includes **nuchal translucency** and biochemical markers (PAPP-A and hCG), must be performed between **11 and 14 weeks**. - Since the patient is at **23 weeks**, the opportunity for this screening method has long passed. *Cervical length ultrasound* - **Cervical length** screening is not a routine part of antenatal care for low-risk, asymptomatic patients with no history of **preterm labor**. - This patient has no clinical indications, such as previous **mid-trimester loss** or cervical surgery, to warrant this specific investigation.
Question 109: A 28-year-old primigravida at 19 weeks gestation attends routine antenatal clinic. She mentions she has been reading about vitamin supplementation in pregnancy online and asks whether she should take vitamin D supplements. She has no medical problems, works indoors, and follows a vegetarian diet. She has medium-brown skin tone. What is the most appropriate advice?
- A. Vitamin D supplementation is not necessary unless she develops symptoms of deficiency
- B. She should take 400 IU (10 micrograms) vitamin D daily throughout pregnancy and while breastfeeding (Correct Answer)
- C. She should have serum vitamin D levels checked and only supplement if deficient
- D. She should take 800 IU (20 micrograms) vitamin D daily due to her darker skin tone
- E. Vitamin D supplementation should only be taken during winter months when sun exposure is limited
Explanation: ***She should take 400 IU (10 micrograms) vitamin D daily throughout pregnancy and while breastfeeding*** - **NICE and RCOG guidelines** recommend universal supplementation of **10 micrograms (400 IU)** daily for all pregnant and breastfeeding women to ensure adequate bone health for mother and fetus. - This patient is at high risk due to her **medium-brown skin tone**, **vegetarian diet**, and **indoor work**, making daily supplementation essential. *Vitamin D supplementation is not necessary unless she develops symptoms of deficiency* - **Vitamin D deficiency** is often asymptomatic; waiting for clinical symptoms like **osteomalacia** or muscle weakness can lead to preventable maternal and neonatal complications. - Guidelines emphasize **preventative supplementation** rather than reactive treatment to avoid the risks of **neonatal hypocalcemia**. *She should have serum vitamin D levels checked and only supplement if deficient* - **Routine screening** of serum vitamin D levels is not recommended in uncomplicated pregnancies as it is not **cost-effective** and doesn't change the standard management. - Regardless of initial levels, the baseline safety and efficacy of **low-dose supplementation** justify its universal use. *She should take 800 IU (20 micrograms) vitamin D daily due to her darker skin tone* - While women with darker skin are at higher risk of deficiency, the **standard recommended dose** for general prevention remains **400 IU (10 micrograms)**. - Higher doses (e.g., 800-2000 IU) are generally reserved for women with **biochemically proven deficiency** or specific high-risk medical conditions. *Vitamin D supplementation should only be taken during winter months when sun exposure is limited* - In the UK and similar latitudes, **UVB radiation** is insufficient for skin synthesis of Vitamin D for most of the year, but pregnancy increases **metabolic demands** year-round. - To maintain consistent **calcium homeostasis**, continuous supplementation throughout the entire pregnancy and **breastfeeding** period is advised.
Question 110: A 37-year-old woman with twin pregnancy is seen at 20 weeks gestation. Her booking BP was 124/78 mmHg. Current BP is 148/96 mmHg. Urinalysis is negative for protein. Blood tests are all within normal limits including uric acid and liver function. She is asymptomatic. She attends again 4 days later and BP is 146/94 mmHg. Urine PCR is 22 mg/mmol. What is the most appropriate management strategy?
- A. Diagnose gestational hypertension, commence labetalol, and arrange twice-weekly BP monitoring with weekly blood tests (Correct Answer)
- B. Diagnose mild pre-eclampsia, admit for observation and commence antihypertensive therapy
- C. Reassure that mild BP elevation is normal in twin pregnancy and continue routine antenatal care
- D. Repeat BP measurement in 1 week and commence treatment only if persistently elevated
- E. Arrange 24-hour ambulatory blood pressure monitoring to confirm diagnosis before treatment
Explanation: ***Diagnose gestational hypertension, commence labetalol, and arrange twice-weekly BP monitoring with weekly blood tests*** - **Gestational hypertension** is defined as new hypertension (BP ≥140/90 mmHg) presenting after **20 weeks of gestation** without significant proteinuria (PCR <30 mg/mmol). - NICE guidelines recommend initiating **antihypertensive treatment** (e.g., labetalol) when BP is persistently ≥140/90 mmHg to reduce the risk of progressing to **severe hypertension**. *Diagnose mild pre-eclampsia, admit for observation and commence antihypertensive therapy* - **Pre-eclampsia** requires the presence of hypertension plus **significant proteinuria** (PCR ≥30 mg/mmol) or other maternal organ dysfunction, which are absent here. - Admission is generally reserved for **severe hypertension** (≥160/110 mmHg) or clinical concerns of rapid deterioration, not for stable gestational hypertension. *Reassure that mild BP elevation is normal in twin pregnancy and continue routine antenatal care* - Elevated blood pressure is never considered "normal" and requires clinical intervention to prevent **maternal and fetal complications**. - **Twin pregnancies** are at a higher risk for hypertensive disorders, making active management and regular surveillance even more critical. *Repeat BP measurement in 1 week and commence treatment only if persistently elevated* - The diagnosis is already confirmed since the patient had elevated readings on two separate occasions (initial visit and 4 days later). - Delaying treatment increases the risk of **maternal stroke** and progression to **eclampsia** or HELLP syndrome. *Arrange 24-hour ambulatory blood pressure monitoring to confirm diagnosis before treatment* - While **ABPM** can rule out white-coat hypertension, it should not delay management when clinic readings are consistently elevated in a **high-risk pregnancy**. - Standard clinical protocol for **pregnancy-induced hypertension** prioritizes prompt initiation of monitoring and treatment once the threshold of 140/90 mmHg is met.
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