Pregnancy Medicine — MCQs
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A 25-year-old woman at 33 weeks gestation with gestational hypertension controlled on labetalol presents with sudden onset severe occipital headache, visual disturbance, and vomiting. BP is 188/118 mmHg. She has brisk reflexes with 3 beats of clonus. Urinalysis shows 2+ protein. CTG shows baseline 145 bpm with normal variability. While urgent bloods are being processed, what is the most important immediate pharmacological intervention?
A 34-year-old woman presents for pre-pregnancy counselling. She has well-controlled epilepsy on lamotrigine 200 mg twice daily and has been seizure-free for 3 years. She is keen to optimize her pregnancy planning. Apart from folic acid supplementation, what advice regarding her lamotrigine is most appropriate?
A 32-year-old woman at 24 weeks gestation undergoes OGTT following detection of glycosuria at routine antenatal visit. Results show: fasting glucose 6.8 mmol/L, 2-hour glucose 9.2 mmol/L. She has BMI 28 kg/m² and no other risk factors. She is referred to the joint diabetes and antenatal clinic. What dietary advice should be the initial focus of management?
A 40-year-old woman at 31 weeks gestation with chronic hypertension on methyldopa 500 mg three times daily presents with BP 156/102 mmHg. She reports new-onset headache and epigastric discomfort. Blood tests show: platelets 178 × 10⁹/L, ALT 38 IU/L, AST 42 IU/L, uric acid 0.38 mmol/L, creatinine 88 μmol/L, LDH 520 IU/L. PCR is 45 mg/mmol. Blood film shows occasional schistocytes. What is the most likely diagnosis?
A 36-year-old woman in her fourth pregnancy attends at 11 weeks gestation for booking. Her previous pregnancies include: one uncomplicated vaginal delivery at term, one early pregnancy loss at 8 weeks, and one late miscarriage at 21 weeks due to cervical insufficiency treated with emergency cerclage which was unsuccessful. She is otherwise healthy. What is the most appropriate management of her current pregnancy?
A 27-year-old primigravida attends her booking appointment at 9 weeks gestation. She is taking no regular medications. Her blood tests reveal: Hb 102 g/L, MCV 72 fL, ferritin 8 μg/L. She is asymptomatic. What is the most appropriate initial management?
A 31-year-old woman with diet-controlled gestational diabetes at 35 weeks gestation attends for growth scan. Estimated fetal weight is on the 45th centile. Her fasting glucose averages 5.3 mmol/L and 1-hour post-prandial readings average 8.2 mmol/L over the past week. She has been compliant with dietary advice. What is the most appropriate management?
A 38-year-old woman at 26 weeks gestation presents with blood pressure 152/98 mmHg at routine antenatal clinic. She is asymptomatic. Her booking BP at 10 weeks was 118/72 mmHg. Urinalysis shows trace protein. Blood tests show: platelets 245 × 10⁹/L, ALT 28 IU/L, creatinine 68 μmol/L. PCR is 18 mg/mmol. What is the most appropriate initial classification and management?
What is the recommended timing for the routine anomaly ultrasound scan in pregnancy according to UK antenatal screening guidelines?
A 35-year-old woman in her second pregnancy is admitted at 34 weeks gestation with blood pressure 162/108 mmHg and 3+ proteinuria on dipstick. Blood tests show: platelets 95 × 10⁹/L, ALT 78 IU/L, AST 82 IU/L, creatinine 115 μmol/L. She is commenced on labetalol and magnesium sulphate. Four hours later she develops right upper quadrant pain and her blood pressure rises to 178/115 mmHg despite treatment. What is the most likely diagnosis requiring urgent consideration?
Pregnancy Medicine UK Medical PG Practice Questions and MCQs
Question 111: A 25-year-old woman at 33 weeks gestation with gestational hypertension controlled on labetalol presents with sudden onset severe occipital headache, visual disturbance, and vomiting. BP is 188/118 mmHg. She has brisk reflexes with 3 beats of clonus. Urinalysis shows 2+ protein. CTG shows baseline 145 bpm with normal variability. While urgent bloods are being processed, what is the most important immediate pharmacological intervention?
- A. Intravenous labetalol boluses to reduce BP to below 160/110 mmHg
- B. Intravenous magnesium sulphate 4g loading dose over 5-10 minutes (Correct Answer)
- C. Oral nifedipine 10 mg immediate release
- D. Intravenous hydralazine 5 mg bolus
- E. Intravenous dexamethasone 12 mg for fetal lung maturation
Explanation: ***Intravenous magnesium sulphate 4g loading dose over 5-10 minutes*** - This patient presents with **severe pre-eclampsia** (BP ≥160/110 mmHg, 2+ proteinuria, and severe symptoms) and features of **impending eclampsia**, specifically severe headache, visual disturbance, hyperreflexia, and clonus. - **Magnesium sulphate** is the gold standard for **seizure prophylaxis** in severe pre-eclampsia and eclampsia, and its immediate administration is crucial to prevent maternal seizures, which are life-threatening. *Intravenous labetalol boluses to reduce BP to below 160/110 mmHg* - While **acute blood pressure control** is vital to reduce the risk of **maternal stroke** and other complications, the most immediate life-saving intervention when impending eclampsia is suspected (due to clonus) is seizure prophylaxis. - **IV labetalol** is a first-line agent for severe hypertension in pregnancy, but stabilization of the central nervous system with magnesium takes immediate precedence in the setting of neurologic triggers like **clonus**. *Oral nifedipine 10 mg immediate release* - **Oral nifedipine** is an appropriate antihypertensive for acute BP management in pregnancy, but **immediate-release** formulations should be used with caution due to the risk of precipitous hypotension. - Crucially, it does not address the underlying **cerebral irritability** or the immediate threat of eclamptic seizures, which is the primary concern given the patient's neurological signs. *Intravenous hydralazine 5 mg bolus* - **Intravenous hydralazine** is an alternative for acute hypertensive crisis in pregnancy, typically used if labetalol is contraindicated or ineffective. - However, similar to other antihypertensives, its administration is secondary to the immediate need for **magnesium sulphate** for the prevention of impending eclampsia in this critical scenario. *Intravenous dexamethasone 12 mg for fetal lung maturation* - **Corticosteroids** like dexamethasone are essential for promoting **fetal lung maturity** at 33 weeks gestation, especially when preterm delivery is anticipated. - While important for fetal outcome, it is not the **most immediate pharmacological intervention** for the mother's acute, life-threatening condition of impending eclampsia.
Question 112: A 34-year-old woman presents for pre-pregnancy counselling. She has well-controlled epilepsy on lamotrigine 200 mg twice daily and has been seizure-free for 3 years. She is keen to optimize her pregnancy planning. Apart from folic acid supplementation, what advice regarding her lamotrigine is most appropriate?
- A. Continue current dose and arrange for lamotrigine levels to be monitored monthly during pregnancy (Correct Answer)
- B. Attempt to wean off lamotrigine before conception as seizure-free for 3 years
- C. Switch to levetiracetam which has a better safety profile in pregnancy
- D. Reduce lamotrigine dose by 50% before conception to minimize fetal exposure
- E. Continue current dose with plan to increase dose if seizures occur during pregnancy
Explanation: ***Continue current dose and arrange for lamotrigine levels to be monitored monthly during pregnancy*** - **Lamotrigine clearance** increases significantly during pregnancy, primarily due to **estrogen-induced glucuronidation**, which can lead to subtherapeutic levels and a risk of seizure recurrence. - **Therapeutic drug monitoring** is crucial to maintain effective **seizure control**, which is paramount for both maternal well-being and fetal safety, given lamotrigine's relatively **low teratogenic risk**. *Attempt to wean off lamotrigine before conception as seizure-free for 3 years* - Discontinuing effective antiepileptic medication carries a significant risk of **seizure relapse**, which can result in **maternal injury** and fetal hypoxia during pregnancy. - While seizure-free for 3 years is positive, the risks of stopping a proven medication before or during pregnancy typically outweigh the benefits, especially with a relatively safe drug like lamotrigine. *Switch to levetiracetam which has a better safety profile in pregnancy* - Both **lamotrigine and levetiracetam** are considered among the safest antiepileptic drugs in pregnancy, with comparable **low risks of teratogenicity**. - Switching from a well-controlled, effective regimen to another medication unnecessarily introduces a risk of **seizure breakthrough** and is generally not recommended unless there is a clear clinical indication. *Reduce lamotrigine dose by 50% before conception to minimize fetal exposure* - Arbitrarily reducing the dose increases the risk of **breakthrough seizures**, which can lead to more severe maternal and fetal complications than controlled medication exposure. - The goal is to use the **lowest effective dose** to prevent seizures, and the current dose has proven effective for 3 years. *Continue current dose with plan to increase dose if seizures occur during pregnancy* - This approach is reactive and potentially dangerous; waiting for a seizure to occur means the patient has already experienced a loss of **seizure control**. - Proactive **therapeutic drug monitoring** allows for timely dose adjustments based on serum levels, preventing seizures before they manifest.
Question 113: A 32-year-old woman at 24 weeks gestation undergoes OGTT following detection of glycosuria at routine antenatal visit. Results show: fasting glucose 6.8 mmol/L, 2-hour glucose 9.2 mmol/L. She has BMI 28 kg/m² and no other risk factors. She is referred to the joint diabetes and antenatal clinic. What dietary advice should be the initial focus of management?
- A. Low glycaemic index carbohydrate diet with carbohydrates distributed evenly throughout the day (Correct Answer)
- B. Strict carbohydrate restriction to less than 100g per day
- C. High protein, low fat diet with limited carbohydrate intake at breakfast
- D. Mediterranean-style diet with unrestricted complex carbohydrates
- E. Calorie restriction of 1500 kcal per day to achieve weight loss
Explanation: ***Low glycaemic index carbohydrate diet with carbohydrates distributed evenly throughout the day*** - For a patient with **gestational diabetes (GDM)**, the initial focus is on diet modification including **low glycaemic index (GI)** foods and steady distribution to prevent glucose spikes. - NICE guidelines suggest avoiding long gaps between meals and distributing **carbohydrates** across three meals and snacks to maintain stable **blood glucose levels**. *Strict carbohydrate restriction to less than 100g per day* - Severe **carbohydrate restriction** is discouraged during pregnancy as it can lead to **ketonuria**, which may negatively impact fetal neurodevelopment. - Carbohydrates should still comprise approximately **40-50%** of total energy intake for adequate fetal growth. *High protein, low fat diet with limited carbohydrate intake at breakfast* - While some patients experience higher **post-prandial glucose** spikes after breakfast, initial advice focuses on general **low GI** distribution rather than strictly limiting breakfast carbohydrates. - The primary goal of medical nutrition therapy is achieving **glycaemic targets** through balanced portions rather than just increasing protein intake. *Mediterranean-style diet with unrestricted complex carbohydrates* - Although a Mediterranean-style diet is healthy, **carbohydrate portions** must still be controlled and distributed even if they are complex to manage **2-hour postprandial glucose**. - "Unrestricted" intake is inappropriate in GDM as even healthy complex carbohydrates can exceed **metabolic capacity** and raise blood sugar levels. *Calorie restriction of 1500 kcal per day to achieve weight loss* - **Weight loss** is not recommended during pregnancy; management should focus on **weight maintenance** or slow gain regardless of initial BMI. - Excessive **caloric restriction** risks nutritional deficiencies for the fetus and mother, and is not the primary mechanism for treating GDM.
Question 114: A 40-year-old woman at 31 weeks gestation with chronic hypertension on methyldopa 500 mg three times daily presents with BP 156/102 mmHg. She reports new-onset headache and epigastric discomfort. Blood tests show: platelets 178 × 10⁹/L, ALT 38 IU/L, AST 42 IU/L, uric acid 0.38 mmol/L, creatinine 88 μmol/L, LDH 520 IU/L. PCR is 45 mg/mmol. Blood film shows occasional schistocytes. What is the most likely diagnosis?
- A. Severe pre-eclampsia superimposed on chronic hypertension
- B. Chronic hypertension with inadequate blood pressure control
- C. HELLP syndrome
- D. Microangiopathic haemolytic anaemia secondary to severe pre-eclampsia (Correct Answer)
- E. Thrombotic thrombocytopenic purpura
Explanation: ***Microangiopathic haemolytic anaemia secondary to severe pre-eclampsia*** - The presence of **schistocytes** on blood film and an **elevated LDH** (520 IU/L) directly indicates **microangiopathic haemolytic anaemia (MAHA)**. - This finding, combined with **new-onset headache**, **epigastric discomfort**, **proteinuria (PCR 45 mg/mmol)**, and **worsening hypertension** in a patient with chronic hypertension, points to **severe pre-eclampsia** as the underlying cause. *Severe pre-eclampsia superimposed on chronic hypertension* - While the patient exhibits clear signs of **severe pre-eclampsia superimposed on chronic hypertension**, this diagnosis is less specific than identifying the established **MAHA** indicated by the blood film and LDH. - Superimposed pre-eclampsia is broadly correct but does not highlight the critical and specific hematological complication observed. *Chronic hypertension with inadequate blood pressure control* - This diagnosis fails to account for the **new-onset proteinuria (PCR 45 mg/mmol)** and the development of **severe symptoms** like headache and epigastric discomfort. - Inadequate control of chronic hypertension alone does not explain the **biochemical evidence of hemolysis**, such as elevated LDH and schistocytes. *HELLP syndrome* - The full diagnostic criteria for HELLP syndrome are not met: the **platelet count (178 × 10⁹/L)** is not below 100 × 10⁹/L, and the **liver enzymes (ALT 38, AST 42 IU/L)** are not significantly elevated (typically >70 IU/L). - Although hemolysis is present, the absence of severe thrombocytopenia and marked liver enzyme elevation means HELLP syndrome is not the most precise diagnosis at this stage. *Thrombotic thrombocytopenic purpura* - TTP typically presents with a pentad including **severe thrombocytopenia** (often <20 × 10⁹/L), **fever**, and pronounced **neurological symptoms**, none of which are definitively present or severe enough in this case. - The clinical context of late pregnancy with **hypertension** and **proteinuria** makes severe pre-eclampsia with MAHA a far more likely diagnosis than TTP.
Question 115: A 36-year-old woman in her fourth pregnancy attends at 11 weeks gestation for booking. Her previous pregnancies include: one uncomplicated vaginal delivery at term, one early pregnancy loss at 8 weeks, and one late miscarriage at 21 weeks due to cervical insufficiency treated with emergency cerclage which was unsuccessful. She is otherwise healthy. What is the most appropriate management of her current pregnancy?
- A. Arrange elective cervical cerclage at 12-14 weeks gestation (Correct Answer)
- B. Perform serial transvaginal ultrasound cervical length measurements from 14 weeks and insert cerclage if cervix shortens
- C. Prescribe vaginal progesterone from 16 weeks and monitor cervical length fortnightly
- D. Advise pelvic rest and reduced activity, with hospital admission if symptoms develop
- E. Arrange cervical assessment at 16 weeks and consider cerclage only if cervical length <25 mm
Explanation: ***Arrange elective cervical cerclage at 12-14 weeks gestation*** - This patient has a clear history of **cervical insufficiency**, demonstrated by a prior mid-trimester loss at 21 weeks and a failed rescue cerclage, making a **history-indicated (elective) cerclage** the treatment of choice. - **Elective cerclage** is ideally performed between **12 and 14 weeks** gestation to provide structural support before the cervix begins to shorten or dilate. *Perform serial transvaginal ultrasound cervical length measurements from 14 weeks and insert cerclage if cervix shortens* - This approach, known as **ultrasound-indicated cerclage**, is typically reserved for women with a less definitive history or an isolated history of **spontaneous preterm birth**. - Given the high-risk history of a mid-trimester loss despite intervention, waiting for **cervical shortening** to appear on ultrasound poses an unnecessary risk of another failure. *Prescribe vaginal progesterone from 16 weeks and monitor cervical length fortnightly* - **Vaginal progesterone** is primarily indicated for women with a history of spontaneous preterm birth and a **short cervix** (<25mm), but it is not the primary treatment for established cervical insufficiency. - In cases of mechanical cervical weakness, **progesterone alone** is less effective than a surgical cerclage in preventing recurrent mid-trimester loss. *Advise pelvic rest and reduced activity, with hospital admission if symptoms develop* - **Pelvic rest** and activity restriction have not been clinically proven to improve outcomes or prevent pregnancy loss in patients with **cervical insufficiency**. - Relying on symptom development is dangerous, as cervical insufficiency is characteristically **painless** and can lead to rapid, irreversible membrane prolapse. *Arrange cervical assessment at 16 weeks and consider cerclage only if cervical length <25 mm* - Monitoring for a **cervical length <25 mm** is appropriate for women at moderate risk, but this patient's history of a failed emergency cerclage warrants a more **proactive surgical intervention**. - Waiting until 16 weeks to assess the cervix may be too late for an elective procedure if the **cervical changes** occur early in the second trimester.
Question 116: A 27-year-old primigravida attends her booking appointment at 9 weeks gestation. She is taking no regular medications. Her blood tests reveal: Hb 102 g/L, MCV 72 fL, ferritin 8 μg/L. She is asymptomatic. What is the most appropriate initial management?
- A. Prescribe ferrous sulphate 200 mg once daily and recheck FBC at 28 weeks
- B. Prescribe ferrous sulphate 200 mg twice daily and recheck FBC in 2-4 weeks (Correct Answer)
- C. Arrange urgent haematology referral for investigation of microcytic anaemia
- D. Prescribe ferrous fumarate 210 mg twice daily and recheck FBC at 20-24 weeks
- E. Advise dietary iron supplementation only as anaemia is mild
Explanation: ***Prescribe ferrous sulphate 200 mg twice daily and recheck FBC in 2-4 weeks***- The patient has **iron deficiency anaemia** (IDA) defined in the **first trimester** as Hb <110 g/L; her low **ferritin** (8 μg/L) and low **MCV** confirm the diagnosis.- Guidelines recommend **oral iron supplementation** with monitoring of the Full Blood Count (FBC) within **2–4 weeks** to ensure an adequate rise in **hemoglobin** (typically 10-20 g/L over 2 weeks).*Prescribe ferrous sulphate 200 mg once daily and recheck FBC at 28 weeks*- While once-daily dosing may be used for prophylaxis, **established anaemia** requires higher therapeutic doses to replenish stores quickly.- Waiting until **28 weeks** to recheck the FBC is inappropriate as it delays the identification of non-responders and risks worsening anaemia as pregnancy progresses.*Arrange urgent haematology referral for investigation of microcytic anaemia*- An **urgent haematology referral** is not indicated for a clear case of nutritional IDA with low ferritin in a pregnant patient.- Management should be initiated in **primary care** or the booking clinic, as microcytosis in this context is most likely due to iron deficiency.*Prescribe ferrous fumarate 210 mg twice daily and recheck FBC at 20-24 weeks*- Although ferrous fumarate is an acceptable alternative to ferrous sulphate, the **recheck interval** is too long.- Monitoring must occur within **2–4 weeks** of initiation to confirm treatment efficacy and patient **compliance** before mid-pregnancy.*Advise dietary iron supplementation only as anaemia is mild*- **Dietary modifications** alone are insufficient to correct established IDA in pregnancy due to the high **fetal and placental demands** for iron.- Pharmacological **iron replacement** is necessary when the ferritin is significantly depleted and Hb is below trimester-specific thresholds.
Question 117: A 31-year-old woman with diet-controlled gestational diabetes at 35 weeks gestation attends for growth scan. Estimated fetal weight is on the 45th centile. Her fasting glucose averages 5.3 mmol/L and 1-hour post-prandial readings average 8.2 mmol/L over the past week. She has been compliant with dietary advice. What is the most appropriate management?
- A. Continue dietary management alone and plan delivery at 40-41 weeks
- B. Commence metformin and continue monitoring with plan for delivery at 38-39 weeks (Correct Answer)
- C. Commence insulin therapy and arrange weekly growth scans
- D. Commence metformin and plan for delivery at 40-41 weeks if well controlled
- E. Continue dietary management and offer induction at 38-39 weeks
Explanation: ***Commence metformin and continue monitoring with plan for delivery at 38-39 weeks*** - This patient's **1-hour post-prandial glucose** averages 8.2 mmol/L, which exceeds the **NICE target** of ody
Question 118: A 38-year-old woman at 26 weeks gestation presents with blood pressure 152/98 mmHg at routine antenatal clinic. She is asymptomatic. Her booking BP at 10 weeks was 118/72 mmHg. Urinalysis shows trace protein. Blood tests show: platelets 245 × 10⁹/L, ALT 28 IU/L, creatinine 68 μmol/L. PCR is 18 mg/mmol. What is the most appropriate initial classification and management?
- A. Gestational hypertension; commence labetalol and review in antenatal day unit in 48 hours (Correct Answer)
- B. Mild pre-eclampsia; admit for observation and commence antihypertensive therapy
- C. Gestational hypertension; arrange twice-weekly BP monitoring and weekly bloods as outpatient
- D. Chronic hypertension; commence nifedipine and routine antenatal care
- E. White coat hypertension; reassure and continue routine antenatal care
Explanation: ***Gestational hypertension; commence labetalol and review in antenatal day unit in 48 hours*** - This patient has **new-onset hypertension** (≥140/90 mmHg) at 26 weeks gestation with **no significant proteinuria** (PCR 18 mg/mmol is below the threshold of 30 mg/mmol), confirming the diagnosis of gestational hypertension. - **Labetalol** is a first-line antihypertensive in pregnancy, and commencing treatment for BP 152/98 mmHg with close follow-up in an antenatal day unit within 48 hours is appropriate to monitor for effectiveness and progression. *Mild pre-eclampsia; admit for observation and commence antihypertensive therapy* - Pre-eclampsia requires evidence of **significant proteinuria** (e.g., PCR ≥30 mg/mmol) or **maternal organ dysfunction**, neither of which are present in this case (PCR 18 mg/mmol, normal platelets and liver enzymes). - Admission for observation is typically reserved for more severe hypertension (≥160/110 mmHg) or if there are signs and symptoms of severe pre-eclampsia. *Gestational hypertension; arrange twice-weekly BP monitoring and weekly bloods as outpatient* - While the classification of gestational hypertension is correct, a BP of 152/98 mmHg warrants immediate **antihypertensive therapy** rather than just monitoring, to reduce maternal and fetal risks. - Current guidelines recommend initiating treatment for persistently elevated blood pressure (e.g., ≥140/90 mmHg) in pregnancy. *Chronic hypertension; commence nifedipine and routine antenatal care* - **Chronic hypertension** is defined as hypertension present before pregnancy or diagnosed before **20 weeks gestation**. - This patient had a normal booking BP of 118/72 mmHg at 10 weeks, ruling out chronic hypertension. *White coat hypertension; reassure and continue routine antenatal care* - **White coat hypertension** can only be diagnosed if home or ambulatory blood pressure monitoring confirms normal readings outside the clinic, which has not been done here. - Given the sustained elevated blood pressure in the clinic, simply reassuring the patient without further investigation or management would be inappropriate and potentially harmful.
Question 119: What is the recommended timing for the routine anomaly ultrasound scan in pregnancy according to UK antenatal screening guidelines?
- A. 16-18 weeks gestation
- B. 18-20 weeks gestation
- C. 18-20+6 weeks gestation (Correct Answer)
- D. 20-22 weeks gestation
- E. 22-24 weeks gestation
Explanation: ***18-20+6 weeks gestation*** - According to the **NHS Fetal Anomaly Screening Programme (FASP)**, the routine mid-trimester scan should be ideally performed between **18+0 and 20+6 weeks** gestation. - This window provides the best balance for **optimal visualization** of fetal structures and sufficient time for further diagnostic testing if an anomaly is identified. *16-18 weeks gestation* - Performing the scan this early may result in incomplete visualization as certain organs, particularly the **fetal heart and brain structures**, are not yet sufficiently developed. - It is outside the recommended **national screening guidelines** for a routine anomaly assessment. *18-20 weeks gestation* - While this range is partially correct, it excludes the critical **extra six days** (up to 20+6) defined in the formal protocol. - Accuracy in gestation terminology is vital for **clinical coding** and ensuring patients are seen within the legal and medical framework. *20-22 weeks gestation* - This range extends beyond the primary target window, which can limit the timeframe for **follow-up invasive testing** like amniocentesis. - Scanning primarily after 20 weeks may reduce the time available for parents to make **informed decisions** regarding the pregnancy. *22-24 weeks gestation* - At this late stage, **fetal bone ossification** can create shadows that make it more difficult to view internal structures like the heart. - This timeframe is significantly beyond the **UK screening standard** and is typically only used for specific follow-up scans or late-booking patients.
Question 120: A 35-year-old woman in her second pregnancy is admitted at 34 weeks gestation with blood pressure 162/108 mmHg and 3+ proteinuria on dipstick. Blood tests show: platelets 95 × 10⁹/L, ALT 78 IU/L, AST 82 IU/L, creatinine 115 μmol/L. She is commenced on labetalol and magnesium sulphate. Four hours later she develops right upper quadrant pain and her blood pressure rises to 178/115 mmHg despite treatment. What is the most likely diagnosis requiring urgent consideration?
- A. Acute fatty liver of pregnancy
- B. HELLP syndrome with subcapsular liver haematoma (Correct Answer)
- C. Acute cholecystitis
- D. Hepatic infarction secondary to severe pre-eclampsia
- E. Placental abruption with referred pain
Explanation: ***HELLP syndrome with subcapsular liver haematoma*** - The patient exhibits core features of **HELLP syndrome**, including **thrombocytopenia** (platelets 95 × 10⁹/L) and **elevated transaminases** (ALT 78, AST 82) alongside severe pre-eclampsia (BP 162/108 mmHg, 3+ proteinuria). - New-onset **right upper quadrant (RUQ) pain** and worsening hypertension despite treatment are red flags for a **subcapsular liver haematoma**, a serious complication of HELLP syndrome with high risk of **hepatic rupture**. *Acute fatty liver of pregnancy* - This condition typically presents with significant **hypoglycemia**, severe **coagulopathy** (elevated PT/INR), and **jaundice**, which are not the primary features highlighted in this case. - While it causes liver enzyme elevation and can occur in late pregnancy, the **thrombocytopenia** and acute worsening with RUQ pain fit HELLP better. *Acute cholecystitis* - This would present with **RUQ pain**, often radiating to the back or shoulder, and possibly fever or a positive **Murphy’s sign**, but it cannot account for the low **platelets**, severe **proteinuria**, or elevated liver enzymes (other than a mild, secondary elevation). - It is a local gallbladder pathology and does not explain the systemic features of **pre-eclampsia** and HELLP syndrome. *Hepatic infarction secondary to severe pre-eclampsia* - Hepatic infarction is an extremely rare complication and typically associated with **massively elevated transaminases** (often in the thousands), much higher than the values seen here (ALT 78, AST 82). - While it can cause RUQ pain, the full clinical picture of **thrombocytopenia** and elevated liver enzymes in the context of severe pre-eclampsia points more strongly to HELLP syndrome with its complications. *Placental abruption with referred pain* - **Placental abruption** typically presents with painful **vaginal bleeding**, uterine tenderness, and fetal distress rather than isolated right upper quadrant pain. - While it is a serious complication of severe **hypertension**, it does not explain the specific **biochemical abnormalities** of **thrombocytopenia** and elevated liver enzymes as well as HELLP syndrome does.
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