Pregnancy Medicine — MCQs

A 36-year-old woman in her third pregnancy presents at 17 weeks gestation with a blood pressure of 152/98 mmHg. This is confirmed on repeat measurement. She has no symptoms and urine dipstick shows no proteinuria. Her booking blood pressure at 10 weeks was 118/76 mmHg. She has no past medical history. What is the most likely diagnosis?

Q144

A 27-year-old woman presents for her first antenatal appointment at 11 weeks gestation. She has epilepsy controlled on carbamazepine 400 mg twice daily with no seizures for 3 years. She takes no other medications and did not receive pre-pregnancy counselling. What is the most important immediate management regarding her medication?

Q145

A 38-year-old nulliparous woman at 35 weeks gestation is diagnosed with gestational diabetes. Her fasting glucose is 6.8 mmol/L and 1-hour post-prandial values range from 8.5-9.2 mmol/L. Ultrasound shows estimated fetal weight on 92nd centile and polyhydramnios with AFI of 26 cm. What is the most appropriate management plan?

Q146

A 31-year-old woman with gestational diabetes at 28 weeks gestation has fasting glucose levels consistently between 5.8-6.2 mmol/L despite optimal dietary modification for 2 weeks. Her post-prandial glucose levels are within target range. Her BMI is 28 kg/m². What is the most appropriate next step in management?

Q147

A 34-year-old woman at 16 weeks gestation in her second pregnancy presents for routine antenatal care. Her first pregnancy was complicated by severe pre-eclampsia requiring delivery at 31 weeks. She has a BMI of 33 kg/m² and her blood pressure today is 128/82 mmHg. Urine dipstick is negative for protein. What is the most appropriate prophylaxis to reduce her risk of pre-eclampsia?

Q148

A 29-year-old woman at 15 weeks gestation attends her antenatal appointment. She has no previous medical history. Her blood results show: Hb 101 g/L, MCV 72 fL, ferritin 8 μg/L. She is asymptomatic. What is the most appropriate initial management?

Q149

A 31-year-old woman with insulin-treated gestational diabetes presents at 39 weeks gestation in spontaneous labour. Her cervix is 4 cm dilated with regular contractions. She last ate four hours ago. Her capillary blood glucose is 7.2 mmol/L. She is contracting three times in 10 minutes. What is the most appropriate immediate management of her diabetes during labour?

Q150

A 26-year-old primigravida attends her booking appointment at 10 weeks gestation. She has no medical history and takes only folic acid 400 micrograms daily. Her BMI is 22 kg/m², BP is 118/72 mmHg. Booking blood tests show: haemoglobin 125 g/L, platelets 245 × 10⁹/L. She is rhesus D negative. Her partner's blood group is unknown. Which additional supplement should be recommended routinely from now until the end of the first trimester?

Pregnancy Medicine UK Medical PG Practice Questions and MCQs

Question 141: A 28-year-old woman at 22 weeks gestation is diagnosed with gestational diabetes following an OGTT showing fasting glucose 5.8 mmol/L and 2-hour value 9.2 mmol/L. She is commenced on dietary management. Which of the following glucose monitoring targets should she aim for?

A. Fasting <5.3 mmol/L and 1-hour post-prandial <7.8 mmol/L
B. Fasting <5.6 mmol/L and 1-hour post-prandial <7.8 mmol/L (Correct Answer)
C. Fasting <5.6 mmol/L and 2-hour post-prandial <6.4 mmol/L
D. Fasting <6.0 mmol/L and 2-hour post-prandial <7.8 mmol/L
E. Fasting <5.3 mmol/L and 2-hour post-prandial <7.0 mmol/L

Explanation: ***Fasting <5.6 mmol/L and 1-hour post-prandial <7.8 mmol/L***- According to **NICE guidelines**, women with **gestational diabetes** should aim for a fasting glucose target of **less than 5.6 mmol/L**.- The recommended **1-hour post-prandial** target is **less than 7.8 mmol/L**, which is widely used to reduce the risk of **macrosomia**.*Fasting <5.3 mmol/L and 1-hour post-prandial <7.8 mmol/L*- A **fasting target of <5.3 mmol/L** is typically reserved for women with **pre-existing Type 1 or Type 2 diabetes** who are pregnant.- While tighter control is good, **5.6 mmol/L** is the specific diagnostic and management threshold for **gestational diabetes** in the UK.*Fasting <5.6 mmol/L and 2-hour post-prandial <6.4 mmol/L*- While the **fasting target** is correct, this option is less ideal because **1-hour monitoring** is generally preferred in the UK for GDM.- Although a **2-hour target of <6.4 mmol/L** is a valid alternative in some contexts, the 1-hour target provides better clinical correlation with **fetal outcomes** according to NICE.*Fasting <6.0 mmol/L and 2-hour post-prandial <7.8 mmol/L*- A **fasting glucose of <6.0 mmol/L** is too high and is associated with increased risks of **neonatal hypoglycemia** and birth complications.- The **2-hour target of 7.8 mmol/L** is also too lenient; that value is actually the threshold for the **1-hour post-prandial** target, not the 2-hour.*Fasting <5.3 mmol/L and 2-hour post-prandial <7.0 mmol/L*- This combination mix-matches different guidelines; **<7.0 mmol/L** is not the standard **NICE** target for 2-hour post-prandial monitoring for GDM.- The **fasting target of <5.3 mmol/L** again applies primarily to **pre-existing diabetes** rather than the standard management of GDM.

Question 142: What is the definition of severe hypertension in pregnancy according to current UK guidelines?

A. Blood pressure ≥140/90 mmHg on two occasions
B. Blood pressure ≥150/100 mmHg on two occasions
C. Blood pressure ≥160/110 mmHg (Correct Answer)
D. Systolic blood pressure ≥170 mmHg or diastolic blood pressure ≥120 mmHg
E. Blood pressure ≥140/90 mmHg with proteinuria

Explanation: ***Blood pressure ≥160/110 mmHg*** - In the UK, **NICE guidelines** define **severe hypertension** in pregnancy as a sustained blood pressure of **160/110 mmHg** or higher. - This threshold indicates a medical emergency requiring **urgent antihypertensive treatment** to prevent maternal **cerebrovascular accidents** and eclampsia. *Blood pressure ≥140/90 mmHg on two occasions* - This is the diagnostic criterion for **hypertension in pregnancy** (either gestational hypertension or chronic hypertension) rather than severe hypertension. - Readings should be confirmed on at least **two occasions**, typically 4-6 hours apart, or within a shorter period if immediate treatment is indicated. *Blood pressure ≥150/100 mmHg on two occasions* - This level is considered **moderate hypertension** in pregnancy and usually warrants the initiation or intensification of **antihypertensive treatment**. - However, it does not meet the specific threshold of **160/110 mmHg** required to classify it as severe hypertension by UK guidelines. *Systolic blood pressure ≥170 mmHg or diastolic blood pressure ≥120 mmHg* - While these represent **extremely high and dangerous blood pressure levels**, the definition of severe hypertension in pregnancy specifically begins at **160/110 mmHg**. - Waiting for blood pressure to reach these higher values before classifying it as severe would delay **critical intervention** and significantly increase maternal and fetal risks. *Blood pressure ≥140/90 mmHg with proteinuria* - This combination of signs is characteristic of **pre-eclampsia**, a multi-system disorder unique to pregnancy, rather than solely a definition of **hypertensive severity**. - Although pre-eclampsia can involve severe hypertension, this option describes the **syndrome** itself, not the direct numerical cut-off for severe hypertension.

Question 143: A 36-year-old woman in her third pregnancy presents at 17 weeks gestation with a blood pressure of 152/98 mmHg. This is confirmed on repeat measurement. She has no symptoms and urine dipstick shows no proteinuria. Her booking blood pressure at 10 weeks was 118/76 mmHg. She has no past medical history. What is the most likely diagnosis?

A. Chronic hypertension (Correct Answer)
B. Gestational hypertension
C. White coat hypertension
D. Pre-eclampsia
E. Secondary hypertension

Explanation: ***Chronic hypertension*** - **Chronic hypertension** in pregnancy is defined as hypertension present before pregnancy or diagnosed **before 20 weeks** of gestation. The patient's blood pressure elevation at 17 weeks falls within this diagnostic window. - Although her booking blood pressure was normal at 10 weeks, the physiological **nadir in blood pressure** during the early second trimester can often temporarily mask pre-existing hypertension, which then becomes evident as blood pressure rises again later. *Gestational hypertension* - This diagnosis is reserved for new-onset hypertension occurring specifically **after 20 weeks** of gestation, without associated proteinuria or other signs of pre-eclampsia. - Since this patient is only at **17 weeks** gestation, she does not meet the necessary temporal criteria for gestational hypertension. *White coat hypertension* - This refers to a phenomenon where blood pressure readings are elevated in a clinical setting but are normal when measured outside this environment. - While possible, confirming this would require **ambulatory blood pressure monitoring (ABPM)** or home blood pressure readings, and it's not the primary diagnostic label for new-onset hypertension detected at 17 weeks. *Pre-eclampsia* - **Pre-eclampsia** typically occurs **after 20 weeks** of gestation and requires the presence of new-onset hypertension *plus* **proteinuria** or other signs of end-organ dysfunction. - This patient lacks **proteinuria** and is asymptomatic, and her gestation is at 17 weeks, thus ruling out pre-eclampsia based on both timing and clinical features. *Secondary hypertension* - While secondary causes (such as renal artery disease, thyroid dysfunction, or adrenal disorders) can lead to hypertension, they are generally less common in this demographic without other specific symptoms. - In the absence of an obvious underlying cause or atypical features, hypertension identified in the first half of pregnancy is formally classified as **chronic hypertension**, making this a less likely primary diagnosis without further investigation.

Question 144: A 27-year-old woman presents for her first antenatal appointment at 11 weeks gestation. She has epilepsy controlled on carbamazepine 400 mg twice daily with no seizures for 3 years. She takes no other medications and did not receive pre-pregnancy counselling. What is the most important immediate management regarding her medication?

A. Continue carbamazepine and prescribe high-dose folic acid 5 mg daily
B. Switch to lamotrigine immediately
C. Stop carbamazepine and monitor for seizures
D. Reduce carbamazepine dose by 50%
E. Continue carbamazepine at current dose and arrange detailed fetal anomaly scan (Correct Answer)

Explanation: ***Continue carbamazepine at current dose and arrange detailed fetal anomaly scan*** - By **11 weeks gestation**, the neural tube has already closed (completes by day 28 post-conception), so changing medications will not prevent major **congenital malformations** caused by first-trimester exposure. - Maintaining the current dose is vital to prevent **seizures**, which pose a significant risk of **hypoxia** and trauma to both the mother and the fetus. *Continue carbamazepine and prescribe high-dose folic acid 5 mg daily* - While **5 mg folic acid** is recommended for women on antiepileptics, it is most effective when started **pre-conception** to prevent neural tube defects. - Starting it at 11 weeks is less critical than arranging for **detailed morphology ultrasound** screening because organogenesis is largely complete. *Switch to lamotrigine immediately* - Switching medications during pregnancy risks a **seizure breakthrough** during the titration period required for drugs like **lamotrigine**. - Sudden changes to antiepileptic therapy should be avoided once pregnancy is confirmed unless the risk of the drug far outweighs the risk of the seizure. *Stop carbamazepine and monitor for seizures* - Abruptly stopping medication in a stable patient can trigger **status epilepticus**, which has a high maternal and fetal **mortality rate**. - International guidelines state that epilepsy should be managed with the **lowest effective dose** of a single agent that controls seizures, rather than complete cessation. *Reduce carbamazepine dose by 50%* - Arbitrarily reducing the dose increases the risk of **sub-therapeutic levels**, especially as blood volume increases and drug metabolism changes during pregnancy. - Dose adjustments should be guided by **clinical seizure control** and, in some cases, plasma level monitoring rather than a fixed percentage reduction.

Question 145: A 38-year-old nulliparous woman at 35 weeks gestation is diagnosed with gestational diabetes. Her fasting glucose is 6.8 mmol/L and 1-hour post-prandial values range from 8.5-9.2 mmol/L. Ultrasound shows estimated fetal weight on 92nd centile and polyhydramnios with AFI of 26 cm. What is the most appropriate management plan?

A. Start metformin and review in 1 week
B. Start insulin therapy immediately and arrange consultant review (Correct Answer)
C. Arrange induction of labour at 37 weeks
D. Start metformin and arrange induction at 40 weeks
E. Intensive dietary modification and daily glucose monitoring

Explanation: ***Start insulin therapy immediately and arrange consultant review*** - Per **NICE guidelines**, insulin is indicated for women with gestational diabetes if the **fasting glucose** is ≥7.0 mmol/L or if it is ≥6.0 mmol/L with complications like **macrosomia** or **polyhydramnios**. - This patient presents with multiple complications including **fetal weight >90th centile** and **polyhydramnios (AFI 26 cm)**, necessitating rapid glycemic control that only **insulin** provides. *Start metformin and review in 1 week* - **Metformin** is usually the first-line pharmacological treatment when diet fails, but it is insufficient for patients presenting with clinical evidence of **fetal macrosomia** or very high glucose levels. - A review in 1 week is too long a delay given the significant **polyhydramnios** and the advanced gestational age of **35 weeks**. *Arrange induction of labour at 37 weeks* - While **induction of labour** between 37+0 and 38+6 weeks is recommended for women on medication, the immediate priority is achieving **glycemic control** to prevent further complications. - Management must focus on stabilization with **insulin** before finalising the mode and timing of delivery. *Start metformin and arrange induction at 40 weeks* - Waiting until **40 weeks** is inappropriate for a patient with poorly controlled gestational diabetes and **fetal complications**, as it increases the risk of **stillbirth** and shoulder dystocia. - **Metformin** alone would take too long to titrate and likely fail to achieve the required rapid normalization of maternal glucose. *Intensive dietary modification and daily glucose monitoring* - **Dietary modification** is the initial step for mild cases, but this patient's fasting glucose of **6.8 mmol/L** and fetal symptoms bypass this conservative stage. - Failure to initiate **pharmacotherapy** immediately in the presence of **macrosomia** constitutes suboptimal care and risks urgent obstetric complications.

Question 146: A 31-year-old woman with gestational diabetes at 28 weeks gestation has fasting glucose levels consistently between 5.8-6.2 mmol/L despite optimal dietary modification for 2 weeks. Her post-prandial glucose levels are within target range. Her BMI is 28 kg/m². What is the most appropriate next step in management?

A. Continue dietary management alone and review in 2 weeks
B. Start metformin 500 mg once daily (Correct Answer)
C. Start insulin therapy
D. Start glibenclamide 2.5 mg once daily
E. Arrange early delivery at 38 weeks

Explanation: ***Start metformin 500 mg once daily*** - The patient's **fasting glucose levels (5.8-6.2 mmol/L)** are consistently above the target of **<5.3 mmol/L (or <5.6 mmol/L per NICE)** despite two weeks of optimal **dietary modification**. - According to guidelines for gestational diabetes, if glycemic targets are not met with lifestyle interventions after 1-2 weeks, **metformin** is generally the first-line oral pharmacological agent to be initiated. *Continue dietary management alone and review in 2 weeks* - This approach is inappropriate because the patient has already completed a **2-week trial of diet** without achieving the required glycemic targets. - Prolonged **hyperglycemia** increases the risk of fetal complications, so treatment should not be delayed further. *Start insulin therapy* - **Insulin** is usually reserved for cases where **metformin** is contraindicated, not tolerated, or if glucose levels are significantly higher (e.g., fasting >7.0 mmol/L at diagnosis). - While insulin is effective, metformin is the preferred **first-line oral agent** as it is associated with less **maternal weight gain** and a lower risk of **neonatal hypoglycemia**. *Start glibenclamide 2.5 mg once daily* - **Glibenclamide** is a sulfonylurea that is generally considered **second-line** therapy when metformin is not tolerated or targets are not met. - It is rarely used as a first-line agent because it is associated with a higher risk of **neonatal hypoglycemia** compared to metformin. *Arrange early delivery at 38 weeks* - Decisions regarding **delivery timing** are typically made later in the pregnancy based on glycemic control, ultrasound findings (e.g., **fetal growth**), and overall clinical status. - The immediate priority at 28 weeks gestation is achieving **glycemic control** through medication, rather than planning delivery logistics.

Question 147: A 34-year-old woman at 16 weeks gestation in her second pregnancy presents for routine antenatal care. Her first pregnancy was complicated by severe pre-eclampsia requiring delivery at 31 weeks. She has a BMI of 33 kg/m² and her blood pressure today is 128/82 mmHg. Urine dipstick is negative for protein. What is the most appropriate prophylaxis to reduce her risk of pre-eclampsia?

A. Aspirin 75 mg daily from 12 weeks until delivery
B. Aspirin 150 mg daily from 12 weeks until delivery (Correct Answer)
C. Aspirin 75 mg daily from 20 weeks until delivery
D. Labetalol 100 mg twice daily
E. No prophylaxis required as current blood pressure is normal

Explanation: ***Aspirin 150 mg daily from 12 weeks until delivery*** - This patient has a **high-risk factor** (history of severe pre-eclampsia requiring preterm delivery) and a **moderate-risk factor** (BMI >30), necessitating pharmacological prophylaxis. - Current guidelines and the **ASPRE trial** support the use of **150 mg of Aspirin** daily starting before 16 weeks to significantly reduce the risk of preterm pre-eclampsia. *Aspirin 75 mg daily from 12 weeks until delivery* - While 75 mg was historically recommended, **150 mg** is now the preferred evidence-based dose for superior reduction in pre-eclampsia incidence among high-risk patients. - A lower dose of 75 mg may be less effective in patients with a **high BMI**, as seen in this clinical scenario (BMI 33 kg/m²). *Aspirin 75 mg daily from 20 weeks until delivery* - Prophylaxis started at **20 weeks** is less effective because the process of **impaired placentation** and spiral artery remodeling begins much earlier in pregnancy. - Guidelines emphasize starting aspirin ideally by **12 weeks** and no later than 16 weeks to achieve the necessary clinical benefit. *Labetalol 100 mg twice daily* - Labetalol is an **antihypertensive medication** used to manage existing hypertension, not a prophylactic agent to prevent the development of pre-eclampsia. - Starting an antihypertensive is inappropriate here as the patient's current blood pressure is within the **normal range** (128/82 mmHg). *No prophylaxis required as current blood pressure is normal* - The need for prophylaxis is determined by **risk factors** in the medical history (previous severe pre-eclampsia), not the blood pressure reading at the booking visit. - Normal blood pressure in the early second trimester does not predict the subsequent development of **placental dysfunction** later in pregnancy.

Question 148: A 29-year-old woman at 15 weeks gestation attends her antenatal appointment. She has no previous medical history. Her blood results show: Hb 101 g/L, MCV 72 fL, ferritin 8 μg/L. She is asymptomatic. What is the most appropriate initial management?

A. Oral ferrous sulfate 200 mg once daily
B. Intravenous iron infusion
C. Oral ferrous sulfate 200 mg twice daily (Correct Answer)
D. Blood transfusion
E. Reassurance and repeat bloods in 4 weeks

Explanation: ***Oral ferrous sulfate 200 mg twice daily***- The patient has **iron deficiency anaemia** (Hb < 105 g/L in the second trimester and low **ferritin**); standard UK guidelines recommend 65 mg of elemental iron (e.g., **200 mg ferrous sulfate**) twice or three times daily for treatment.- Target restoration of iron stores is crucial to reduce the risks of **preterm delivery**, **low birth weight**, and postpartum haemorrhage.*Oral ferrous sulfate 200 mg once daily*- This dose is often used for **prophylaxis** or for patients who cannot tolerate higher doses due to GI side effects.- It is generally considered insufficient for the initial therapeutic management of established **microcytic anaemia** where rapid stores replacement is needed.*Intravenous iron infusion*- Reserved for patients who are **intolerant** of oral iron, show a lack of response to oral treatment, or require rapid iron replacement in late pregnancy (usually after **34 weeks**).- It is not the appropriate **initial management** for an asymptomatic patient at 15 weeks gestation.*Blood transfusion*- Transfusion is only indicated for **severe symptomatic anaemia** or when there is acute **haemodynamic compromise**.- With an Hb of 101 g/L and no symptoms, the risks of transfusion (e.g., **TRALI**, alloimmunisation) far outweigh the benefits.*Reassurance and repeat bloods in 4 weeks*- This approach is inappropriate as the patient already meets the diagnostic criteria for **anaemia in pregnancy** (Hb < 105 g/L in second trimester).- Delaying treatment allows the anaemia to worsen, potentially leading to **fetal growth restriction** and worsening maternal symptoms.

Question 149: A 31-year-old woman with insulin-treated gestational diabetes presents at 39 weeks gestation in spontaneous labour. Her cervix is 4 cm dilated with regular contractions. She last ate four hours ago. Her capillary blood glucose is 7.2 mmol/L. She is contracting three times in 10 minutes. What is the most appropriate immediate management of her diabetes during labour?

A. Continue usual subcutaneous insulin regimen with hourly blood glucose monitoring (Correct Answer)
B. Discontinue subcutaneous insulin and commence intravenous insulin infusion with dextrose
C. Withhold insulin and monitor blood glucose hourly, treating only if glucose >7.0 mmol/L
D. Continue usual subcutaneous insulin with blood glucose checks every 2 hours
E. Administer variable rate intravenous insulin infusion only, without dextrose

Explanation: ***Continue usual subcutaneous insulin regimen with hourly blood glucose monitoring*** - For women with **gestational diabetes** managed with insulin, current guidelines recommend continuing their subcutaneous regimen while maintaining **hourly capillary blood glucose** monitoring during labor. - The target blood glucose range during labor is **4–7 mmol/L**; since her glucose is 7.2 mmol/L, frequent monitoring is required to ensure it stays close to this range without immediately switching to intensive interventions. *Discontinue subcutaneous insulin and commence intravenous insulin infusion with dextrose* - **Intravenous insulin (VRIII)** with dextrose is primarily indicated for women with **Type 1 diabetes** or those whose glucose remains outside the 4–7 mmol/L range despite usual treatment. - Starting an IV infusion is unnecessary at this stage as she is stable and her blood glucose is only **minimally elevated** above the target range. *Withhold insulin and monitor blood glucose hourly, treating only if glucose >7.0 mmol/L* - **Withholding insulin** in a patient who requires it for glycemic control risks significant **hyperglycemia**, which increases the risk of neonatal hypoglycemia after delivery. - Proper management involves continuing the treatment that has been maintaining her control rather than waiting for **hyperglycemic excursions** to react. *Continue usual subcutaneous insulin with blood glucose checks every 2 hours* - Blood glucose checks every **two hours** are insufficient for insulin-treated patients in the **active phase** of labor. - **Hourly monitoring** is mandatory to detect rapid changes in metabolic demand and insulin sensitivity during uterine contractions and physical exertion. *Administer variable rate intravenous insulin infusion only, without dextrose* - Administering a **Variable Rate Intravenous Insulin Infusion (VRIII)** without concurrent dextrose is dangerous as it significantly increases the risk of **maternal hypoglycemia**. - This approach is not standard practice for **gestational diabetes** in labor and represents an inappropriate escalation of care for this patient's current status.

Question 150: A 26-year-old primigravida attends her booking appointment at 10 weeks gestation. She has no medical history and takes only folic acid 400 micrograms daily. Her BMI is 22 kg/m², BP is 118/72 mmHg. Booking blood tests show: haemoglobin 125 g/L, platelets 245 × 10⁹/L. She is rhesus D negative. Her partner's blood group is unknown. Which additional supplement should be recommended routinely from now until the end of the first trimester?

A. Vitamin D 10 micrograms daily only
B. Iron 200mg daily only
C. Increase folic acid to 5mg daily and add vitamin D 10 micrograms daily
D. Continue folic acid 400 micrograms daily and add vitamin D 10 micrograms daily (Correct Answer)
E. Vitamin B12 50 micrograms daily and vitamin D 10 micrograms daily

Explanation: ***Continue folic acid 400 micrograms daily and add vitamin D 10 micrograms daily*** - **Folic acid** at 400 micrograms daily is recommended for all low-risk women from pre-conception until **12 weeks gestation** to reduce the risk of **neural tube defects**. - **Vitamin D** at 10 micrograms (400 IU) daily is universally recommended for all pregnant and breastfeeding women throughout pregnancy to support **maternal and fetal bone health**. *Vitamin D 10 micrograms daily only* - This option is incomplete as the patient is only at **10 weeks gestation** and still requires **folic acid supplementation** until 12 weeks. - While **Vitamin D** is essential, continuing **folic acid** is a critical priority during the **first trimester** for neural tube development. *Iron 200mg daily only* - Routine **iron supplementation** is not indicated in pregnancy unless the woman has confirmed **anaemia** (Haemoglobin <110 g/L in the first trimester). - The patient's booking **haemoglobin (125 g/L)** is within the normal range, so iron supplementation is unnecessary and could cause side effects like constipation. *Increase folic acid to 5mg daily and add vitamin D 10 micrograms daily* - A higher dose of **folic acid (5mg)** is reserved for high-risk patients, such as those with a **BMI >30**, pre-existing **diabetes**, or a history of **neural tube defects**. - This patient has a healthy **BMI of 22 kg/m²** and no relevant medical history, meaning the standard 400 microgram dose is appropriate. *Vitamin B12 50 micrograms daily and vitamin D 10 micrograms daily* - Routine **Vitamin B12** supplementation is not part of standard antenatal guidelines for the general population. - It is typically only recommended for pregnant women who follow a **vegan diet** or have a known **Vitamin B12 deficiency**.

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