Pregnancy Medicine — MCQs
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A 29-year-old woman at 16 weeks gestation attends her antenatal appointment. She has a BMI of 32 kg/m². Her mother developed type 2 diabetes at age 45. Her booking glucose was 4.8 mmol/L and HbA1c was 38 mmol/mol. She asks about her risk of developing gestational diabetes. What is the most appropriate advice regarding oral glucose tolerance testing?
A 33-year-old woman at 37 weeks gestation with gestational diabetes on insulin therapy presents for routine antenatal assessment. Her blood glucose levels have been well controlled. Fetal ultrasound shows estimated fetal weight on 95th centile with abdominal circumference above the 95th centile. Amniotic fluid index is 26 cm. What is the most appropriate next step in management?
A 28-year-old primigravida is diagnosed with pre-eclampsia at 34 weeks gestation. Her blood pressure is controlled on labetalol. Blood tests show: platelets 92 × 10⁹/L, ALT 105 U/L, bilirubin 18 μmol/L, LDH 620 U/L, creatinine 88 μmol/L. Blood film shows fragmented red cells. What syndrome has developed and what is the most appropriate management?
A 36-year-old woman with insulin-treated gestational diabetes at 32 weeks gestation reports reduced fetal movements for the past 8 hours. Her blood glucose has been well controlled with fasting values 4.8-5.1 mmol/L. CTG is normal. What is the most appropriate further assessment?
A 41-year-old woman with chronic hypertension on amlodipine 5 mg daily becomes pregnant. At her booking visit at 8 weeks, her blood pressure is 136/88 mmHg. What is the most appropriate management of her antihypertensive medication?
A 32-year-old woman attends pre-pregnancy counselling. She takes sodium valproate 800 mg twice daily for epilepsy, which is well controlled with no seizures for 3 years. What is the most appropriate advice regarding her medication in pregnancy?
A 35-year-old woman with diet-controlled gestational diabetes at 38 weeks gestation declines induction of labour. She requests expectant management. What is the most appropriate counselling regarding this decision?
A 27-year-old woman at 14 weeks gestation attends antenatal clinic. She mentions she has a cat at home. She has no previous immunity to toxoplasmosis. What advice should be given regarding toxoplasmosis prevention?
A 31-year-old woman presents at 25 weeks gestation with blood pressure 172/115 mmHg. She has no symptoms and urinalysis shows trace protein. Blood tests show: platelets 165 × 10⁹/L, ALT 35 U/L, creatinine 72 μmol/L. What is the most appropriate immediate antihypertensive management?
A 29-year-old woman presents to antenatal clinic at 36 weeks gestation with blood pressure 138/92 mmHg. This is her first elevated reading. Urinalysis shows no protein. She is asymptomatic. Blood tests show: platelets 198 × 10⁹/L, ALT 28 U/L, creatinine 65 μmol/L. What is the most appropriate classification and management?
Pregnancy Medicine UK Medical PG Practice Questions and MCQs
Question 121: A 29-year-old woman at 16 weeks gestation attends her antenatal appointment. She has a BMI of 32 kg/m². Her mother developed type 2 diabetes at age 45. Her booking glucose was 4.8 mmol/L and HbA1c was 38 mmol/mol. She asks about her risk of developing gestational diabetes. What is the most appropriate advice regarding oral glucose tolerance testing?
- A. She should have OGTT now at 16 weeks gestation
- B. She should have OGTT at 24-28 weeks gestation only (Correct Answer)
- C. She requires OGTT at both 16 weeks and 24-28 weeks gestation
- D. She does not require OGTT as her booking tests were normal
- E. She should have random glucose testing at each antenatal visit instead
Explanation: ***She should have OGTT at 24-28 weeks gestation only*** - According to **NICE guidelines**, patients with risk factors such as a **BMI >30 kg/m²** or a **first-degree relative with diabetes** should be offered a 75g 2-hour **OGTT** at 24–28 weeks gestation. - This patient qualifies for screening due to her high BMI and family history, but since she has no history of **previous gestational diabetes**, early testing at 16 weeks is not required. *She should have OGTT now at 16 weeks gestation* - Early OGTT (at booking or 16 weeks) is specifically reserved for women who have had **gestational diabetes in a previous pregnancy**. - Testing at 16 weeks is not the standard protocol for patients whose only risk factors are **obesity** or **family history** without a prior GDM diagnosis. *She requires OGTT at both 16 weeks and 24-28 weeks gestation* - Dual testing at both time points is indicated for women with **prior gestational diabetes** to detect early recurrence or development of type 2 diabetes. - For a primigravida or someone with no history of the condition, a single test at **24–28 weeks** is sufficient to catch the peak of insulin resistance typically seen in GDM. *She does not require OGTT as her booking tests were normal* - Normal **booking glucose** (4.8 mmol/L) and **HbA1c** (38 mmol/mol) only rule out pre-existing type 2 diabetes; they do not predict the development of **gestational diabetes**, which often manifests later in pregnancy. - Risk factors like a **BMI of 32 kg/m²** and a **first-degree relative with diabetes** mandate formal screening regardless of initial normal results. *She should have random glucose testing at each antenatal visit instead* - **Random glucose testing** and **urinalysis for glycosuria** are not sufficiently sensitive or specific to be used as primary screening or diagnostic tools for gestational diabetes. - The gold standard for diagnosing gestational diabetes in high-risk groups remains the **oral glucose tolerance test (OGTT)** performed at the appropriate gestational age.
Question 122: A 33-year-old woman at 37 weeks gestation with gestational diabetes on insulin therapy presents for routine antenatal assessment. Her blood glucose levels have been well controlled. Fetal ultrasound shows estimated fetal weight on 95th centile with abdominal circumference above the 95th centile. Amniotic fluid index is 26 cm. What is the most appropriate next step in management?
- A. Perform amniocentesis to assess fetal lung maturity
- B. Increase insulin dose and reassess in one week
- C. Arrange elective caesarean section at 38 weeks
- D. Offer induction of labour at 37-38 weeks (Correct Answer)
- E. Continue expectant management until 40 weeks with weekly monitoring
Explanation: ***Offer induction of labour at 37-38 weeks*** - For women with **gestational diabetes mellitus (GDM)** on **insulin therapy**, guidelines recommend offering delivery (induction or elective C-section) between **37+0 and 38+6** weeks. - The presence of **macrosomia** (EFW >95th centile) and **polyhydramnios** (AFI 26 cm) increases the risk of **shoulder dystocia** and stillbirth, making delivery at 37-38 weeks the safest management.*Perform amniocentesis to assess fetal lung maturity* - This procedure is no longer routinely recommended because **corticosteroids** and modern neonatal care have reduced the need for lung maturity testing. - At **37 weeks**, the fetus is considered late-term, and the risks of continued macrocosmic growth outweigh the benefits of testing for lung maturity.*Increase insulin dose and reassess in one week* - The patient already has **well-controlled blood glucose**, and maternal glucose levels do not immediately reverse existing **fetal macrosomia** or polyhydramnios. - Delaying delivery to adjust medication at 37 weeks increases the risk of **stillbirth** without significant benefit to fetal size.*Arrange elective caesarean section at 38 weeks* - **Elective caesarean section** is generally only specifically indicated for GDM if the estimated fetal weight is **>4.5 kg** to prevent shoulder dystocia. - Unless there are specific contraindications to vaginal birth, **induction of labour** is the first-line recommendation for delivery initiation.*Continue expectant management until 40 weeks with weekly monitoring* - Expectant management beyond 38+6 weeks in insulin-dependent GDM is associated with an increased risk of **intrauterine fetal death**. - Monitoring does not mitigate the mechanical risks associated with **macrosomia** and polyhydramnios that are already present.
Question 123: A 28-year-old primigravida is diagnosed with pre-eclampsia at 34 weeks gestation. Her blood pressure is controlled on labetalol. Blood tests show: platelets 92 × 10⁹/L, ALT 105 U/L, bilirubin 18 μmol/L, LDH 620 U/L, creatinine 88 μmol/L. Blood film shows fragmented red cells. What syndrome has developed and what is the most appropriate management?
- A. Acute fatty liver of pregnancy; deliver immediately regardless of fetal maturity
- B. HELLP syndrome; give corticosteroids and plan delivery within 24-48 hours (Correct Answer)
- C. Thrombotic thrombocytopenic purpura; commence plasmapheresis urgently
- D. Severe pre-eclampsia; continue conservative management with twice-daily blood tests
- E. Disseminated intravascular coagulation; give fresh frozen plasma and deliver immediately
Explanation: ***HELLP syndrome; give corticosteroids and plan delivery within 24-48 hours*** - The patient exhibits the classic triad of **Hemolysis** (fragmented red cells, elevated LDH), **Elevated Liver enzymes** (ALT 105 U/L), and **Low Platelets** (92 × 10⁹/L), which precisely defines **HELLP syndrome**. - At 34 weeks gestation, management involves stabilizing the mother, administering **corticosteroids** (e.g., betamethasone) for fetal lung maturity, and planning delivery within a **24-48 hour window**. *Acute fatty liver of pregnancy; deliver immediately regardless of fetal maturity* - **Acute fatty liver of pregnancy (AFLP)** typically presents with more profound **hypoglycemia**, prolonged coagulation times (e.g., PT/APTT), and sometimes more severe **hyperbilirubinemia** than seen here. - Although AFLP also requires urgent delivery, the specific combination of **hemolysis** and **elevated LDH** strongly points towards HELLP syndrome rather than AFLP. *Thrombotic thrombocytopenic purpura; commence plasmapheresis urgently* - **Thrombotic thrombocytopenic purpura (TTP)** often includes features like **fever**, significant **neurological symptoms**, and severe **renal failure**, which are not described in this pre-eclamptic patient. - While both conditions can cause **schistocytes** (fragmented red cells), the clinical context of hypertension and pregnancy-related liver dysfunction makes **HELLP syndrome** the more fitting diagnosis. *Severe pre-eclampsia; continue conservative management with twice-daily blood tests* - The development of **HELLP syndrome** signifies a severe manifestation of pre-eclampsia that requires active intervention, not conservative management, due to the high risk of maternal complications like **liver rupture** or placental abruption. - Continuing conservative management is inappropriate once there is laboratory evidence of progressive **hemolysis**, **thrombocytopenia**, and **hepatic dysfunction** at 34 weeks. *Disseminated intravascular coagulation; give fresh frozen plasma and deliver immediately* - **Disseminated intravascular coagulation (DIC)** is characterized by widespread activation of the clotting cascade, leading to consumption of clotting factors and platelets, typically resulting in prolonged **PT**, **aPTT**, and decreased **fibrinogen**. - While DIC can complicate HELLP, the primary diagnosis based on the presented labs is HELLP; **fresh frozen plasma** is primarily used for bleeding or severe coagulopathy in DIC, not as initial management for HELLP itself.
Question 124: A 36-year-old woman with insulin-treated gestational diabetes at 32 weeks gestation reports reduced fetal movements for the past 8 hours. Her blood glucose has been well controlled with fasting values 4.8-5.1 mmol/L. CTG is normal. What is the most appropriate further assessment?
- A. Perform ultrasound for biophysical profile (Correct Answer)
- B. Admit for continuous CTG monitoring for 24 hours
- C. Reassure and discharge home with routine follow-up
- D. Arrange umbilical artery Doppler assessment
- E. Advise kick counting and return if further episodes
Explanation: ***Perform ultrasound for biophysical profile*** - In **high-risk pregnancies**, such as those complicated by **insulin-treated gestational diabetes**, a **normal CTG** alone is insufficient to exclude fetal compromise after reports of **reduced fetal movements (RFM)**. - The **biophysical profile** (BPP) provides a comprehensive assessment of **fetal well-being**, including fetal tone, movement, breathing, and **amniotic fluid volume**, which is crucial in managing high-risk pregnancies and mitigating the risk of **stillbirth**. *Admit for continuous CTG monitoring for 24 hours* - While **continuous CTG monitoring** is valuable for confirmed fetal distress or during labor, a currently **normal CTG** does not immediately necessitate 24-hour admission without further diagnostic information. - This approach would delay obtaining comprehensive data on **fetal growth** or **amniotic fluid volume** that a detailed ultrasound can provide. *Reassure and discharge home with routine follow-up* - **Reduced fetal movements** in a patient with **insulin-treated gestational diabetes** is a significant warning sign that mandates further investigation and should never be simply reassured. - Discharging without a thorough assessment of **fetal well-being** and **placental function** would be unsafe and could lead to adverse **fetal outcomes**. *Arrange umbilical artery Doppler assessment* - **Umbilical artery Doppler** is primarily used to evaluate **placental function** and **fetal blood flow**, particularly in cases of suspected **fetal growth restriction** or placental insufficiency. - While it provides important information, it is not as comprehensive as a **biophysical profile** for assessing overall **fetal well-being** (e.g., fetal tone, breathing, movement, and amniotic fluid) following an episode of RFM. *Advise kick counting and return if further episodes* - **Kick counting** is generally not recommended as a primary standalone management strategy for **reduced fetal movements**, especially in **high-risk pregnancies**. - Relying solely on maternal perception via kick counts can cause unnecessary anxiety and may delay critical assessment and intervention, as current guidelines emphasize prompt evaluation of any **subjective change** in fetal movement.
Question 125: A 41-year-old woman with chronic hypertension on amlodipine 5 mg daily becomes pregnant. At her booking visit at 8 weeks, her blood pressure is 136/88 mmHg. What is the most appropriate management of her antihypertensive medication?
- A. Stop amlodipine and commence labetalol 200 mg twice daily
- B. Continue amlodipine at current dose throughout pregnancy
- C. Stop amlodipine and monitor blood pressure; restart treatment if BP ≥140/90 mmHg (Correct Answer)
- D. Increase amlodipine to 10 mg daily to ensure optimal control
- E. Switch to methyldopa 250 mg three times daily
Explanation: ***Stop amlodipine and monitor blood pressure; restart treatment if BP 140/90 mmHg*** - According to guidelines (e.g., **NICE**), if **chronic hypertension** is well-controlled (BP <140/90 mmHg) at booking, stopping treatment is a valid strategy due to the physiological **BP drop** in early pregnancy. - This approach minimizes **fetal drug exposure** while ensuring treatment is re-introduced only if blood pressure exceeds the target threshold of **140/90 mmHg**. *Stop amlodipine and commence labetalol 200 mg twice daily* - Switching to **labetalol** is unnecessary if the patient's blood pressure is already **below 140/90 mmHg** and a drug-free period is feasible. - While labetalol is a **first-line** agent in pregnancy, initiating it immediately when current control is good and observation is possible is not the primary management step. *Continue amlodipine at current dose throughout pregnancy* - **Amlodipine** has less comprehensive **safety data** in pregnancy compared to established first-line antihypertensives like labetalol or nifedipine. - Standard practice is to review medications with limited pregnancy data and consider switching to those with a more robust safety profile, or discontinuing if possible. *Increase amlodipine to 10 mg daily to ensure optimal control* - Increasing the dose is inappropriate because her current blood pressure (136/88 mmHg) is already within the **target range** for chronic hypertension during pregnancy. - Doubling the dose would unnecessarily increase **fetal exposure** and potential maternal side effects without a clinical indication for tighter control. *Switch to methyldopa 250 mg three times daily* - **Methyldopa** is considered a safe option in pregnancy, but an immediate switch is not required if the patient's blood pressure is well-controlled and **monitoring without medication** is a viable initial strategy. - Like labetalol, it should be reserved for when blood pressure consistently reaches or exceeds the treatment threshold of **140/90 mmHg**.
Question 126: A 32-year-old woman attends pre-pregnancy counselling. She takes sodium valproate 800 mg twice daily for epilepsy, which is well controlled with no seizures for 3 years. What is the most appropriate advice regarding her medication in pregnancy?
- A. Continue current dose and add high-dose folic acid 5 mg daily
- B. Gradually reduce to minimum effective dose and take folic acid 5 mg daily
- C. Switch to lamotrigine or levetiracetam before conception if possible (Correct Answer)
- D. Stop sodium valproate immediately and monitor seizure activity
- E. Continue sodium valproate but arrange monthly fetal ultrasound scans
Explanation: ***Switch to lamotrigine or levetiracetam before conception if possible*** - **Sodium valproate** is highly **teratogenic**, associated with a significant risk of **congenital malformations** (e.g., neural tube defects) and **neurodevelopmental delays** (e.g., lower IQ) in offspring. - Current guidelines (e.g., NICE, MHRA) strongly recommend avoiding **valproate** in women of childbearing potential, advocating for a switch to safer alternatives like **lamotrigine** or **levetiracetam** *prior to conception* if seizure control can be maintained.*Continue current dose and add high-dose folic acid 5 mg daily* - While **high-dose folic acid (5 mg)** is crucial to reduce the risk of **neural tube defects**, it does not mitigate the overall high **teratogenic risk** of **sodium valproate** for other congenital anomalies and neurodevelopmental problems. - Continuing valproate at a high dose is generally contraindicated for planned pregnancy due to unacceptable risks, even with folic acid supplementation.*Gradually reduce to minimum effective dose and take folic acid 5 mg daily* - Although the **teratogenic risk** of **sodium valproate** is dose-dependent, even reduced doses still carry a significantly higher risk compared to safer alternative **antiepileptic drugs**. - The primary goal in pre-conception counseling for women on **valproate** is to optimize medication to the safest effective regimen *before* pregnancy, which typically involves switching to a less teratogenic drug rather than just reducing the dose.*Stop sodium valproate immediately and monitor seizure activity* - **Abrupt cessation** of **antiepileptic drugs** like **sodium valproate** is dangerous and can precipitate **seizures** or **status epilepticus**, posing severe risks to the mother. - Any changes to antiepileptic medication, especially discontinuation, must be **gradual** and carefully supervised by a specialist to ensure continued **seizure control**.*Continue sodium valproate but arrange monthly fetal ultrasound scans* - **Fetal ultrasound scans** can detect some **structural malformations** but cannot prevent them, nor can they assess the risk of **neurodevelopmental disorders** associated with valproate exposure. - The most critical period for **teratogenesis** is in the **first trimester**, and continuing **valproate** without seeking a safer alternative is not considered appropriate management.
Question 127: A 35-year-old woman with diet-controlled gestational diabetes at 38 weeks gestation declines induction of labour. She requests expectant management. What is the most appropriate counselling regarding this decision?
- A. Agree to expectant management with twice-weekly CTG and growth scans until 42 weeks
- B. Explain increased risk of stillbirth and birth trauma; offer induction at 39 weeks if she declines 38 weeks (Correct Answer)
- C. Respect her decision and arrange routine care with induction offered at 41 weeks
- D. Arrange senior obstetric review and consider application for court order
- E. Insist on induction by 38+6 weeks due to mandatory guidelines
Explanation: ***Explain increased risk of stillbirth and birth trauma; offer induction at 39 weeks if she declines 38 weeks***- Counselling must include the increased risk of **stillbirth** (which rises after 38 weeks in GDM) and **birth trauma/shoulder dystocia** related to **macrosomia**.- NICE guidelines recommend offering induction between **37+0 and 38+6 weeks**; if declined, a balanced discussion should follow to explore alternative plans like induction at 39 weeks.*Agree to expectant management with twice-weekly CTG and growth scans until 42 weeks*- Waiting until **42 weeks** is not recommended in GDM due to the significant rise in **perinatal mortality** and placental insufficiency.- **Twice-weekly CTG** has not been proven to reliably prevent stillbirth in the context of prolonged GDM pregnancy.*Respect her decision and arrange routine care with induction offered at 41 weeks*- Routine care (induction at 41 weeks) is for low-risk pregnancies; **gestational diabetes** classifies the pregnancy as high-risk, requiring earlier intervention.- Delaying to 41 weeks without highlighting specific **GDM-associated risks** fails the requirement for informed consent and clinical safety.*Arrange senior obstetric review and consider application for court order*- Competent pregnant women have the **autonomy** to refuse any medical intervention, including induction of labour.- A **court order** is inappropriate and unethical as the patient has the right to make decisions about her own body even if they carry risk.*Insist on induction by 38+6 weeks due to mandatory guidelines*- Guidelines are **recommendations**, not mandatory laws, and must be adapted to individual patient preferences through **shared decision-making**.- "Insisting" undermines the **patient-provider relationship** and ignores the ethical principle of respect for patient autonomy.
Question 128: A 27-year-old woman at 14 weeks gestation attends antenatal clinic. She mentions she has a cat at home. She has no previous immunity to toxoplasmosis. What advice should be given regarding toxoplasmosis prevention?
- A. Rehome the cat until after delivery
- B. Avoid handling the cat and have someone else clean the litter tray daily
- C. Wear gloves when cleaning the litter tray, which should be done every 3-4 days (Correct Answer)
- D. Arrange monthly toxoplasmosis serology screening throughout pregnancy
- E. Keep the cat indoors and wear gloves for all contact with the animal
Explanation: ***Wear gloves when cleaning the litter tray, which should be done every 3-4 days*** - **Toxoplasma gondii** oocysts excreted in cat feces typically require **1 to 5 days** to sporulate and become infectious, so frequent cleaning reduces risk. - Using **gloves** and performing thorough hand hygiene are key protective measures for non-immune pregnant women who must handle litter. *Rehome the cat until after delivery* - **Rehoming** is considered an unnecessary and extreme measure that causes undue stress to the owner and the animal. - The risk of transmission can be effectively managed through **hygiene practices** and proper fecal disposal without removing the pet. *Avoid handling the cat and have someone else clean the litter tray daily* - General handling of cats (petting) poses **no significant risk** of toxoplasmosis; the primary concern is contact with infectious feces. - While having someone else clean the tray is ideal, it is the **litter management**, not the presence of the cat, that requires specific avoidance. *Arrange monthly toxoplasmosis serology screening throughout pregnancy* - Routine **serological screening** for toxoplasmosis is not recommended in standard UK antenatal care due to low prevalence. - Emphasis is placed on **primary prevention** (hygiene/diet) rather than repeated diagnostic testing in asymptomatic women. *Keep the cat indoors and wear gloves for all contact with the animal* - Protective clothing like gloves is only necessary for high-risk activities like **gardening** or cleaning **litter trays**, not for normal interaction. - Keeping a cat indoors may reduce its hunting of infected prey, but it is an **overly restrictive** recommendation compared to hygiene basics.
Question 129: A 31-year-old woman presents at 25 weeks gestation with blood pressure 172/115 mmHg. She has no symptoms and urinalysis shows trace protein. Blood tests show: platelets 165 × 10⁹/L, ALT 35 U/L, creatinine 72 μmol/L. What is the most appropriate immediate antihypertensive management?
- A. Oral labetalol 200 mg stat, then 200 mg twice daily (Correct Answer)
- B. Oral nifedipine MR 20 mg twice daily
- C. Intravenous labetalol 20 mg bolus followed by infusion
- D. Oral methyldopa 250 mg three times daily
- E. Intravenous hydralazine 5 mg bolus, repeated every 30 minutes
Explanation: ***Oral labetalol 200 mg stat, then 200 mg twice daily***- Severe hypertension (BP ≥160/110 mmHg) in an **asymptomatic pregnant woman** requires prompt but controlled blood pressure reduction, for which **oral labetalol** is a first-line agent to prevent maternal complications like stroke.- The **stat dose** followed by regular dosing ensures a rapid initial effect without causing a sudden, dangerous drop in blood pressure that could compromise **fetal perfusion**.*Oral nifedipine MR 20 mg twice daily*- While **oral nifedipine** (modified-release) is an acceptable alternative for hypertension in pregnancy, **labetalol** is often preferred as a first-line agent for initial severe hypertension management as per guidelines.- The MR formulation might not provide the **immediate rapid blood pressure control** needed for severe hypertension, and this regimen lacks an initial stat dose.*Intravenous labetalol 20 mg bolus followed by infusion*- **Intravenous antihypertensives**, such as IV labetalol, are reserved for **hypertensive emergencies** or crises where there is evidence of impending organ damage (e.g., severe headache, visual changes, pulmonary edema) or eclampsia.- Since the patient is **asymptomatic**, rapid reduction via IV medications can lead to **placental hypoperfusion** and potential **fetal distress**, making oral agents a safer initial choice.*Oral methyldopa 250 mg three times daily*- **Methyldopa** is a safe and commonly used antihypertensive in pregnancy, especially for chronic hypertension, but it has a **slow onset of action** (typically 24-48 hours).- This slow action makes it unsuitable for the **immediate management** of severe hypertension (172/115 mmHg) where a more rapid blood pressure reduction is required to prevent acute complications.*Intravenous hydralazine 5 mg bolus, repeated every 30 minutes*- **Intravenous hydralazine** is a potent direct vasodilator often used in the management of **hypertensive emergencies** or **eclampsia** when other agents are insufficient or contraindicated.- Its use in an **asymptomatic patient** with severe hypertension is generally not recommended as a first-line immediate therapy due to the risk of **precipitous drops in blood pressure** and reflex tachycardia.
Question 130: A 29-year-old woman presents to antenatal clinic at 36 weeks gestation with blood pressure 138/92 mmHg. This is her first elevated reading. Urinalysis shows no protein. She is asymptomatic. Blood tests show: platelets 198 × 10⁹/L, ALT 28 U/L, creatinine 65 μmol/L. What is the most appropriate classification and management?
- A. Gestational hypertension; arrange follow-up within 48 hours with blood tests (Correct Answer)
- B. White coat hypertension; reassure and arrange 24-hour ambulatory monitoring
- C. Mild pre-eclampsia; admit for observation and commence labetalol
- D. Gestational hypertension; arrange follow-up in 7 days with blood pressure check
- E. Chronic hypertension; commence labetalol and routine antenatal care
Explanation: ***Gestational hypertension; arrange follow-up within 48 hours with blood tests*** - **Gestational hypertension** is defined as new-onset hypertension (BP ≥140/90 mmHg or persistent elevation) presenting after **20 weeks of gestation** without significant **proteinuria** or signs of end-organ dysfunction. - Given the advanced **36 weeks gestation** and it being the first elevated reading, prompt follow-up within **48 hours** with blood tests is crucial to monitor for progression to **pre-eclampsia** and reassess maternal and fetal well-being. *White coat hypertension; reassure and arrange 24-hour ambulatory monitoring* - While **24-hour ambulatory monitoring** can identify **white coat hypertension**, a single elevated reading at **36 weeks gestation** necessitates a more cautious approach due to the immediate risk of developing **pre-eclampsia**. - Reassurance alone is inappropriate; the priority is to rule out or manage potential **gestational hypertension** or **pre-eclampsia** rather than immediately attributing it to white coat effect. *Mild pre-eclampsia; admit for observation and commence labetalol* - This patient lacks the key diagnostic criteria for **pre-eclampsia**, specifically significant **proteinuria** and any signs of end-organ dysfunction or adverse features. - Her normal **platelets**, **ALT**, and **creatinine** values indicate no current biochemical evidence of pre-eclampsia, thus admission and immediate medication are not warranted. *Gestational hypertension; arrange follow-up in 7 days with blood pressure check* - A **7-day follow-up** interval is too long for a first elevated **blood pressure** reading at **36 weeks gestation**, as clinical conditions can rapidly deteriorate in late pregnancy. - National guidelines recommend more frequent monitoring, typically within **48-72 hours**, to promptly detect any worsening of hypertension or development of **proteinuria**, which would indicate pre-eclampsia. *Chronic hypertension; commence labetalol and routine antenatal care* - **Chronic hypertension** is defined as hypertension that predates pregnancy or develops before **20 weeks of gestation**, neither of which applies to this patient who presents with her first elevated reading at 36 weeks. - While **labetalol** is an appropriate antihypertensive in pregnancy, pharmacological treatment is typically initiated for consistently sustained readings ≥140/90 mmHg, and after proper classification, not for a single reading of 138/92 mmHg.
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