Pregnancy Medicine — MCQs
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A 34-year-old woman with gestational diabetes at 30 weeks gestation has consistently elevated fasting glucose readings of 5.8-6.2 mmol/L despite maximal dietary modifications. Her post-prandial readings are within target. She is already taking metformin 2 g daily in divided doses. What is the most appropriate next step in management?
What is the recommended folic acid supplementation dose for women with a previous child affected by neural tube defect who are planning pregnancy?
A 26-year-old primigravida attends her 20-week anomaly scan. The sonographer reports that the placenta is covering the internal cervical os. The woman is asymptomatic with no vaginal bleeding. What is the most appropriate management plan?
A 33-year-old woman attends her booking appointment at 12 weeks gestation. Her BMI is 34 kg/m². She has no previous history of gestational diabetes but her mother has type 2 diabetes. When should oral glucose tolerance testing be offered?
A 30-year-old woman at 28 weeks gestation presents with headache and visual disturbances. Her blood pressure is 156/98 mmHg. Urinalysis shows 2+ protein. Blood results show: platelets 145 × 10⁹/L, ALT 42 U/L, creatinine 78 μmol/L. She reports normal fetal movements. What is the most appropriate initial management?
A 37-year-old woman presents at 19 weeks gestation with blood pressure 146/94 mmHg. This is repeated 4 hours later and is 148/96 mmHg. She is asymptomatic and urine dipstick shows no proteinuria. Blood tests including renal function, liver function, and full blood count are normal. Her booking BP at 8 weeks was 156/98 mmHg. What is the most appropriate initial management of her blood pressure?
A 35-year-old woman at 24 weeks gestation is referred after screening OGTT shows fasting glucose 4.8 mmol/L and 2-hour value 10.2 mmol/L. She has a BMI of 42 kg/m² and previous macrosomia (birthweight 4.6 kg). She begins dietary management and home glucose monitoring. One week later, her glucose diary shows fasting values 5.1-5.5 mmol/L and 1-hour post-prandial values 7.2-8.4 mmol/L. Ultrasound shows estimated fetal weight on 78th centile with normal liquor volume. What is the most appropriate management?
A 40-year-old woman with pre-existing type 2 diabetes presents for pre-pregnancy counselling. She is currently on metformin 1000 mg twice daily and sitagliptin 100 mg once daily. Her HbA1c is 58 mmol/mol (7.5%). She is also on atorvastatin 20 mg daily for hyperlipidaemia. What is the most appropriate advice regarding her medications before conception?
A 32-year-old woman in her second pregnancy attends for routine antenatal care at 26 weeks gestation. Her oral glucose tolerance test shows fasting glucose 4.9 mmol/L and 2-hour glucose 11.8 mmol/L. She is started on dietary management and glucose monitoring. After 1 week of optimal dietary compliance, her glucose levels show: fasting 5.2-5.4 mmol/L (all values), 1-hour post-prandial 6.8-7.2 mmol/L. What is the most appropriate management?
A 25-year-old primigravida at 38 weeks gestation presents to the antenatal day unit with severe headache and visual disturbances. Her blood pressure is 172/114 mmHg. Blood tests show: platelets 82 × 10⁹/L, ALT 156 U/L, AST 178 U/L, bilirubin 28 μmol/L, creatinine 124 μmol/L, urea 8.2 mmol/L. Urine protein:creatinine ratio is 68 mg/mmol. What is the most appropriate immediate management?
Pregnancy Medicine UK Medical PG Practice Questions and MCQs
Question 131: A 34-year-old woman with gestational diabetes at 30 weeks gestation has consistently elevated fasting glucose readings of 5.8-6.2 mmol/L despite maximal dietary modifications. Her post-prandial readings are within target. She is already taking metformin 2 g daily in divided doses. What is the most appropriate next step in management?
- A. Add glibenclamide to the current regimen
- B. Replace metformin with insulin therapy
- C. Add short-acting insulin before meals
- D. Add intermediate or long-acting insulin at bedtime (Correct Answer)
- E. Continue current management and increase monitoring frequency
Explanation: ***Add intermediate or long-acting insulin at bedtime*** - Persistent **elevated fasting glucose** (above 5.3 mmol/L) in gestational diabetes, despite maximal dietary modifications and **metformin**, necessitates the addition of insulin. - **Intermediate or long-acting insulin** given at bedtime effectively targets **nocturnal hepatic glucose production**, which is the primary contributor to high morning fasting glucose readings. *Add glibenclamide to the current regimen* - While **glibenclamide** can be used in pregnancy, **insulin** is generally preferred for tighter and more predictable glycemic control in gestational diabetes, especially for **fasting hyperglycemia**. - Insulin offers more precise titration and is considered superior in achieving glycemic targets without the potential risks associated with sulfonylureas like increased risk of neonatal hypoglycemia. *Replace metformin with insulin therapy* - There is no indication to discontinue **metformin** as it is well-tolerated and likely contributing to the patient's **in-target post-prandial glucose levels**. - **Metformin** can be continued alongside insulin, often reducing the overall insulin requirement and improving **insulin sensitivity**. *Add short-acting insulin before meals* - **Short-acting (bolus) insulin** is indicated for managing **post-prandial hyperglycemia**, but the patient's post-prandial readings are already within target. - Adding short-acting insulin would not address the specific issue of **elevated fasting glucose** and could potentially lead to hypoglycemia if post-prandial levels are already controlled. *Continue current management and increase monitoring frequency* - Persistently elevated **fasting glucose** increases the risk of adverse maternal and fetal outcomes, including **fetal macrosomia**, shoulder dystocia, and neonatal hypoglycemia. - Continuing current management without escalation is not appropriate when glycemic targets are not met; a change in **pharmacological therapy** is required to improve control.
Question 132: What is the recommended folic acid supplementation dose for women with a previous child affected by neural tube defect who are planning pregnancy?
- A. 400 micrograms daily from before conception until 12 weeks gestation
- B. 1 mg daily from before conception until 12 weeks gestation
- C. 5 mg daily from before conception until 12 weeks gestation (Correct Answer)
- D. 5 mg daily throughout pregnancy
- E. 400 micrograms daily throughout pregnancy
Explanation: ***5 mg daily from before conception until 12 weeks gestation*** - Women at **high risk**, such as those with a **previous pregnancy affected by a neural tube defect (NTD)**, require a higher dose of **5 mg (5000 mcg)** to effectively reduce recurrence risk. - This supplementation must begin **at least one month before conception** and continue until the **12th week of gestation**, covering the critical window of **neural tube closure**. *400 micrograms daily from before conception until 12 weeks gestation* - This is the standard dose recommended for **low-risk women** in the general population to prevent primary NTDs. - It is insufficient for women with high-risk factors like **diabetes**, **BMI ≥30**, or an **affected previous sibling**. *1 mg daily from before conception until 12 weeks gestation* - While higher than the standard dose, **1 mg** is not the globally recognized evidence-based guideline for secondary prevention of NTDs. - Clinical guidelines specifically mandate the **5 mg dose** to achieve the necessary protective serum folate levels in high-risk scenarios. *5 mg daily throughout pregnancy* - Although the 5 mg dose is correct, the requirement specifically focuses on the first trimester during **organogenesis**. - Continuing 5 mg after **12 weeks** does not offer additional protection against NTDs as the **neural tube** is already closed by this stage. *400 micrograms daily throughout pregnancy* - This provides the baseline dose but fails to address the **increased risk profile** of a woman with a previous history of NTD. - While folic acid is beneficial for erythropoiesis in later pregnancy, the **pre-conception high-dose loading** is the vital intervention for this patient.
Question 133: A 26-year-old primigravida attends her 20-week anomaly scan. The sonographer reports that the placenta is covering the internal cervical os. The woman is asymptomatic with no vaginal bleeding. What is the most appropriate management plan?
- A. Admit for bed rest until 28 weeks gestation
- B. Arrange repeat transvaginal ultrasound at 32 weeks
- C. Schedule elective caesarean section at 37 weeks
- D. Advise pelvic rest and arrange rescan at 36 weeks for delivery planning (Correct Answer)
- E. Prescribe vaginal progesterone to reduce bleeding risk
Explanation: ***Advise pelvic rest and arrange rescan at 36 weeks for delivery planning***- For a placenta covering the **internal os** at the 20-week anomaly scan, it is standard practice to advise **pelvic rest** (avoidance of intercourse) and perform follow-up scans.- While initial rescanning often occurs at 32 weeks, a rescan at **36 weeks** is crucial for final delivery planning as many cases resolve due to the development of the **lower uterine segment**.*Admit for bed rest until 28 weeks gestation*- **Hospitalization** and bed rest are not indicated for asymptomatic patients with placenta previa detected in the second trimester.- Modern guidelines do not support routine **prophylactic bed rest**, as it increases the risk of **venous thromboembolism** without improving outcomes.*Arrange repeat transvaginal ultrasound at 32 weeks*- Although a 32-week scan is part of the monitoring pathway, the definitive timing for final delivery planning in asymptomatic women is later in the third trimester.- This option alone is incomplete compared to the comprehensive management that includes **pelvic rest** and late-term planning.*Schedule elective caesarean section at 37 weeks*- Scheduling a delivery at 20 weeks is **premature** because approximately 90% of low-lying placentas migrate away from the os as the pregnancy progresses.- Management hinges on the placental position confirmed during the **third-trimester** follow-up scans.*Prescribe vaginal progesterone to reduce bleeding risk*- **Vaginal progesterone** is used for the prevention of preterm birth in women with a short cervix, not for managing placenta previa.- There is no clinical evidence that progesterone reduces the risk of **antepartum hemorrhage** associated with abnormal placental implantation.
Question 134: A 33-year-old woman attends her booking appointment at 12 weeks gestation. Her BMI is 34 kg/m². She has no previous history of gestational diabetes but her mother has type 2 diabetes. When should oral glucose tolerance testing be offered?
- A. At booking and repeated at 28 weeks if normal
- B. At 24-28 weeks gestation only (Correct Answer)
- C. At 16 weeks and again at 28 weeks
- D. At booking, 20 weeks, and 28 weeks
- E. Monthly from 20 weeks until delivery
Explanation: ***At 24-28 weeks gestation only*** - According to **NICE guidelines**, an **Oral Glucose Tolerance Test (OGTT)** is recommended at **24-28 weeks** for women with one or more risk factors, such as a **BMI ≥30 kg/m²** or a **first-degree relative with diabetes**. - This patient has risk factors (BMI 34 kg/m² and mother with type 2 diabetes) but **no history of previous gestational diabetes**, meaning early screening at booking is not indicated. *At booking and repeated at 28 weeks if normal* - This protocol is strictly reserved for women who have had **gestational diabetes (GDM) in a previous pregnancy** to screen for early-onset GDM or pre-existing diabetes. - The patient in this scenario has **no history of previous GDM**, making initial screening at booking inappropriate. *At 16 weeks and again at 28 weeks* - Screening at **16 weeks** is not a standard recommendation for patients whose only risk factors are **obesity** and **family history** without a prior GDM history. - The physiological **insulin resistance** that defines GDM typically becomes clinically significant and detectable during the **late second trimester**. *At booking, 20 weeks, and 28 weeks* - Frequent screening at these specific intervals is not supported by current evidence-based guidelines and could increase **healthcare costs** and patient burden unnecessarily. - The standard **24-28 week window** provides the optimal balance for diagnostic sensitivity and clinical utility in moderate-risk profiles. *Monthly from 20 weeks until delivery* - Monthly OGTT testing is not recommended as it is an **invasive, time-consuming procedure** that does not offer additional diagnostic benefit over a single correctly timed test. - Once a patient tests negative at **28 weeks**, repeat screening is generally only performed if new clinical signs such as **polyhydramnios** or **fetal macrosomia** develop.
Question 135: A 30-year-old woman at 28 weeks gestation presents with headache and visual disturbances. Her blood pressure is 156/98 mmHg. Urinalysis shows 2+ protein. Blood results show: platelets 145 × 10⁹/L, ALT 42 U/L, creatinine 78 μmol/L. She reports normal fetal movements. What is the most appropriate initial management?
- A. Admit for observation and commence oral labetalol (Correct Answer)
- B. Arrange urgent delivery within 24 hours
- C. Prescribe magnesium sulphate prophylaxis immediately
- D. Discharge with twice-weekly blood pressure monitoring
- E. Commence intravenous hydralazine stat
Explanation: ***Admit for observation and commence oral labetalol***- The patient's presentation with new-onset hypertension (BP 156/98 mmHg), proteinuria (2+), headache, and visual disturbances at 28 weeks gestation is diagnostic of **pre-eclampsia with severe features**, necessitating **hospital admission** for close maternal and fetal monitoring.- **Oral labetalol** is a first-line antihypertensive medication commonly used to manage blood pressure in pre-eclampsia to prevent further progression and complications, aiming for a target SBP <150 mmHg and DBP <100 mmHg.*Arrange urgent delivery within 24 hours*- **Urgent delivery** is not indicated as the initial management at **28 weeks gestation** unless there are signs of severe maternal or fetal compromise such as uncontrolled hypertension, eclampsia, HELLP syndrome, placental abruption, or non-reassuring fetal status.- For pre-eclampsia with severe features before 34 weeks, **expectant management** is typically pursued, involving close monitoring, blood pressure control, and administration of **antenatal corticosteroids** to promote fetal lung maturity.*Prescribe magnesium sulphate prophylaxis immediately*- **Magnesium sulphate** is primarily indicated for the prevention of seizures in women with **severe pre-eclampsia** (e.g., BP ≥160/110 mmHg, significant end-organ dysfunction) or actual eclampsia, or when delivery is imminent.- While the patient is symptomatic, her blood pressure (156/98 mmHg) and lab values (platelets 145 × 10⁹/L, ALT 42 U/L, creatinine 78 μmol/L) do not meet all criteria for immediate magnesium sulphate initiation as the very first step, especially before optimizing blood pressure control.*Discharge with twice-weekly blood pressure monitoring*- **Discharge** is inappropriate for a patient presenting with **symptomatic pre-eclampsia** at 28 weeks gestation, as this condition carries a significant risk of rapid deterioration.- Inpatient management is crucial to monitor for worsening hypertension, proteinuria, development of **HELLP syndrome**, **eclampsia**, or fetal distress, ensuring timely intervention.*Commence intravenous hydralazine stat*- **Intravenous hydralazine** is reserved for the acute management of **hypertensive crisis** in pregnancy, defined as sustained SBP ≥160 mmHg or DBP ≥110 mmHg, to prevent maternal stroke.- The patient's blood pressure of 156/98 mmHg, while elevated, does not meet the threshold for a hypertensive crisis requiring *stat* intravenous antihypertensive therapy, making oral agents a more appropriate initial choice.
Question 136: A 37-year-old woman presents at 19 weeks gestation with blood pressure 146/94 mmHg. This is repeated 4 hours later and is 148/96 mmHg. She is asymptomatic and urine dipstick shows no proteinuria. Blood tests including renal function, liver function, and full blood count are normal. Her booking BP at 8 weeks was 156/98 mmHg. What is the most appropriate initial management of her blood pressure?
- A. No treatment required as BP <150/100 mmHg
- B. Start labetalol and aim for BP <140/90 mmHg
- C. Start labetalol and aim for BP <135/85 mmHg (Correct Answer)
- D. Arrange 24-hour ambulatory blood pressure monitoring before starting treatment
- E. Start methyldopa and aim for BP <130/80 mmHg
Explanation: ***Start labetalol and aim for BP <135/85 mmHg*** - The patient has **chronic hypertension**, diagnosed by elevated blood pressure (156/98 mmHg) before **20 weeks gestation** at her booking appointment. - Current guidelines recommend initiating antihypertensive treatment (first-line **labetalol**) for chronic hypertension in pregnancy when BP is ≥140/90 mmHg, with a target BP of **<135/85 mmHg** to optimize maternal and fetal outcomes. *No treatment required as BP <150/100 mmHg* - While a higher threshold like 150/100 mmHg may apply to certain forms of hypertension in pregnancy, **chronic hypertension** typically warrants treatment at a lower threshold of **≥140/90 mmHg**. - The patient's current repeated readings of 146/94 mmHg and 148/96 mmHg are consistently above this treatment threshold, indicating that intervention is necessary. *Start labetalol and aim for BP <140/90 mmHg* - Although **labetalol** is an appropriate first-line medication, a target blood pressure of **<140/90 mmHg** is generally considered insufficient for optimal management of chronic hypertension in pregnancy. - Current recommendations, such as those from NICE, advocate for a stricter target of **<135/85 mmHg** to significantly reduce the risk of severe hypertension and complications like **superimposed pre-eclampsia**. *Arrange 24-hour ambulatory blood pressure monitoring before starting treatment* - **Ambulatory blood pressure monitoring (ABPM)** is typically used to confirm a diagnosis of hypertension or rule out **white-coat hypertension**. - In this case, the patient has established **chronic hypertension** with consistent elevated readings at 8 weeks and 19 weeks, making ABPM an unnecessary delay to appropriate and timely treatment. *Start methyldopa and aim for BP <130/80 mmHg* - While **methyldopa** is a safe and acceptable alternative for hypertension in pregnancy, **labetalol** is often preferred as a first-line agent due to efficacy and tolerability. - Aiming for a target blood pressure as low as **<130/80 mmHg** is generally considered **too aggressive** in pregnancy and could potentially compromise **uteroplacental perfusion**, negatively impacting fetal growth and well-being.
Question 137: A 35-year-old woman at 24 weeks gestation is referred after screening OGTT shows fasting glucose 4.8 mmol/L and 2-hour value 10.2 mmol/L. She has a BMI of 42 kg/m² and previous macrosomia (birthweight 4.6 kg). She begins dietary management and home glucose monitoring. One week later, her glucose diary shows fasting values 5.1-5.5 mmol/L and 1-hour post-prandial values 7.2-8.4 mmol/L. Ultrasound shows estimated fetal weight on 78th centile with normal liquor volume. What is the most appropriate management?
- A. Continue dietary management alone as most values are acceptable
- B. Start metformin for post-prandial glucose control (Correct Answer)
- C. Start insulin for post-prandial glucose control
- D. Start metformin and insulin combination therapy
- E. Arrange repeat ultrasound in 1 week before deciding on treatment
Explanation: ***Start metformin for post-prandial glucose control*** - According to **NICE guidelines**, if blood glucose targets (fasting <5.3 mmol/L or 1-hour post-prandial <7.8 mmol/L) are not met within 1-2 weeks of lifestyle changes, **metformin** should be initiated as first-line therapy. - This patient’s 1-hour readings (up to **8.4 mmol/L**) exceed the recommended threshold, and given her high **BMI** and history of **macrosomia**, pharmacological intervention is necessary to minimize risks. *Continue dietary management alone as most values are acceptable* - While some values are within range, the recurrent readings above **7.8 mmol/L** indicate that lifestyle modifications alone are insufficient to maintain **glycemic control**. - Delaying treatment in a patient with a high risk of **fetal macrosomia** and therapeutic failure on diet increases the risk of adverse obstetric outcomes. *Start insulin for post-prandial glucose control* - **Insulin** is typically reserved as a first-line agent if the fasting glucose is significantly elevated (e.g., >7.0 mmol/L) at diagnosis or if metformin is **contraindicated**. - Since the patient is only mildly above target and just starting pharmacotherapy, **metformin** is the preferred initial step before escalating to insulin. *Start metformin and insulin combination therapy* - **Combination therapy** is typically implemented only when targets are not met despite being on the maximum tolerated dose of **metformin**. - Starting both simultaneously is premature as the majority of patients achieve adequate control with **metformin monotherapy** initially. *Arrange repeat ultrasound in 1 week before deciding on treatment* - Management decisions in **gestational diabetes** are primarily driven by the **maternal glucose diary** rather than awaiting evidence of fetal overgrowth. - Waiting for ultrasound changes (like **polyhydramnios** or increased abdominal circumference) means the fetus has already been exposed to the harmful effects of **hyperglycemia**.
Question 138: A 40-year-old woman with pre-existing type 2 diabetes presents for pre-pregnancy counselling. She is currently on metformin 1000 mg twice daily and sitagliptin 100 mg once daily. Her HbA1c is 58 mmol/mol (7.5%). She is also on atorvastatin 20 mg daily for hyperlipidaemia. What is the most appropriate advice regarding her medications before conception?
- A. Continue all current medications as diabetes control is acceptable
- B. Stop sitagliptin and atorvastatin, continue metformin, start folic acid 5 mg daily
- C. Stop sitagliptin and atorvastatin, start insulin therapy, start folic acid 5 mg daily (Correct Answer)
- D. Continue metformin and sitagliptin, stop atorvastatin, start folic acid 5 mg daily
- E. Stop all medications and aim for dietary control only
Explanation: ***Stop sitagliptin and atorvastatin, start insulin therapy, start folic acid 5 mg daily*** - **Sitagliptin** (DPP-4 inhibitor) and **atorvastatin** (statin) are generally contraindicated or not recommended in pregnancy due to potential **teratogenic risks** (atorvastatin) or insufficient safety data (sitagliptin). - The current **HbA1c of 7.5% (58 mmol/mol)** is above the recommended preconception target of **<6.5% (<48 mmol/mol)**. **Insulin** is the safest and most effective medication to achieve tight glycemic control in pregnancy, and high-dose **folic acid (5 mg)** is essential to reduce the risk of **neural tube defects** in diabetic pregnancies. *Continue all current medications as diabetes control is acceptable* - The **HbA1c of 7.5% (58 mmol/mol)** is considered suboptimal for preconception; the target should ideally be **<6.5% (<48 mmol/mol)** to minimize risks of congenital malformations. - **Atorvastatin** is contraindicated in pregnancy due to its **teratogenic potential**, and **sitagliptin** lacks sufficient safety data, making their continuation unsafe. *Stop sitagliptin and atorvastatin, continue metformin, start folic acid 5 mg daily* - While **metformin** is generally considered safe in pregnancy, it is unlikely to be sufficient as a sole agent to reduce an **HbA1c of 7.5%** to the strict preconception target, especially after discontinuing sitagliptin. - Guidelines recommend transitioning to **insulin therapy** when oral agents are insufficient to achieve optimal glycemic control before and during pregnancy, ensuring fetal safety. *Continue metformin and sitagliptin, stop atorvastatin, start folic acid 5 mg daily* - **Sitagliptin** should be discontinued prior to conception due to limited and insufficient safety data regarding its use during pregnancy, favoring agents with established safety profiles. - Although stopping the statin and initiating high-dose folic acid are correct steps, the recommendation to continue **sitagliptin** makes this option inappropriate for preconception counseling. *Stop all medications and aim for dietary control only* - A patient requiring **dual oral antihyperglycemic agents** with an **HbA1c of 7.5%** indicates that dietary control alone is insufficient to manage her diabetes effectively. - Discontinuing all medications without initiating a safe and effective alternative like **insulin** would lead to uncontrolled **hyperglycemia**, significantly increasing the risk of **miscarriage**, **fetal anomalies**, and other adverse pregnancy outcomes.
Question 139: A 32-year-old woman in her second pregnancy attends for routine antenatal care at 26 weeks gestation. Her oral glucose tolerance test shows fasting glucose 4.9 mmol/L and 2-hour glucose 11.8 mmol/L. She is started on dietary management and glucose monitoring. After 1 week of optimal dietary compliance, her glucose levels show: fasting 5.2-5.4 mmol/L (all values), 1-hour post-prandial 6.8-7.2 mmol/L. What is the most appropriate management?
- A. Continue dietary management and review in 2 weeks (Correct Answer)
- B. Start metformin 500 mg once daily
- C. Start insulin therapy
- D. Refer to specialist diabetes team for urgent review
- E. Increase monitoring frequency to 6 times daily
Explanation: ***Continue dietary management and review in 2 weeks***- The patient's blood glucose levels are currently within the **NICE target ranges** (fasting <5.6 mmol/L and 1-hour post-prandial <7.8 mmol/L).- Since her fasting levels (5.2-5.4 mmol/L) and post-prandial levels (6.8-7.2 mmol/L) are well-controlled on **dietary modification**, no pharmacological intervention is required at this time.*Start metformin 500 mg once daily*- **Metformin** is indicated only if blood glucose targets are not met within 1–2 weeks of dietary changes and exercise.- Starting medication unnecessarily increases the risk of side effects like **gastrointestinal upset** without clinical benefit since she is meeting her targets.*Start insulin therapy*- **Insulin therapy** is typically reserved for women with very high fasting glucose at diagnosis or those who do not respond to metformin and diet.- It is not indicated here as the patient is achieving **euglycemia** through lifestyle modifications alone.*Refer to specialist diabetes team for urgent review*- While a specialist team oversees **gestational diabetes (GDM)**, an **urgent review** is not needed when glucose profiles are stable and within range.- Routine follow-up is sufficient for patients who demonstrate excellent **glycemic control** and compliance.*Increase monitoring frequency to 6 times daily*- Current monitoring is sufficient to confirm that her **dietary compliance** is effectively managing her GDM.- Increasing frequency adds **unnecessary burden** to the patient without changing the clinical management plan, given her stable readings.
Question 140: A 25-year-old primigravida at 38 weeks gestation presents to the antenatal day unit with severe headache and visual disturbances. Her blood pressure is 172/114 mmHg. Blood tests show: platelets 82 × 10⁹/L, ALT 156 U/L, AST 178 U/L, bilirubin 28 μmol/L, creatinine 124 μmol/L, urea 8.2 mmol/L. Urine protein:creatinine ratio is 68 mg/mmol. What is the most appropriate immediate management?
- A. Commence oral labetalol and arrange induction of labour within 48 hours
- B. Give intravenous labetalol, magnesium sulfate prophylaxis, and plan delivery within 24-48 hours (Correct Answer)
- C. Give intravenous hydralazine and arrange emergency caesarean section
- D. Give intravenous magnesium sulfate and arrange induction of labour within 24 hours
- E. Stabilise with antihypertensives and conservative management for 1 week
Explanation: ***Give intravenous labetalol, magnesium sulfate prophylaxis, and plan delivery within 24-48 hours***- The patient presents with **severe pre-eclampsia** (BP >160/110, headache, visual changes, proteinuria) and features suggestive of **HELLP syndrome** (thrombocytopenia, elevated liver enzymes).- Immediate **intravenous labetalol** is crucial for rapid blood pressure control to prevent maternal cerebrovascular events, while **magnesium sulfate** provides **eclampsia prophylaxis**. Delivery within 24-48 hours is indicated at 38 weeks gestation after maternal stabilization.*Commence oral labetalol and arrange induction of labour within 48 hours*- **Oral labetalol** is too slow to achieve adequate and rapid blood pressure control in **severe hypertension** and does not address the immediate risk of **eclampsia**.- It lacks the crucial component of **magnesium sulfate** for seizure prevention in a patient with symptomatic severe pre-eclampsia.*Give intravenous hydralazine and arrange emergency caesarean section*- While **intravenous hydralazine** can be used for hypertension, an **emergency caesarean section** is not the immediate first step unless there is acute fetal distress or maternal compromise unresponsive to medical management.- The primary goal is maternal stabilization through **antihypertensives** and **seizure prophylaxis** before definitive delivery planning.*Give intravenous magnesium sulfate and arrange induction of labour within 24 hours*- This option correctly identifies the need for **magnesium sulfate** but critically omits immediate **intravenous antihypertensive therapy** for the severe blood pressure of 172/114 mmHg.- Failure to rapidly control severe hypertension significantly increases the risk of maternal **stroke** and other cardiovascular complications.*Stabilise with antihypertensives and conservative management for 1 week*- **Conservative management** for an additional week is highly inappropriate and dangerous in a patient at 38 weeks with **severe pre-eclampsia** and features of **HELLP syndrome**.- This approach dramatically increases risks of **eclampsia**, **placental abruption**, acute kidney injury, and other severe maternal and fetal complications.
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