Pregnancy Medicine — MCQs
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A 37-year-old woman presents at 24 weeks gestation for her OGTT following a previous pregnancy complicated by gestational diabetes. Fasting glucose is 6.8 mmol/L and 2-hour value is 9.2 mmol/L. She is referred to the joint diabetes-antenatal clinic. At this first specialist appointment three days later, what is the most appropriate initial management strategy?
A 30-year-old woman is diagnosed with gestational hypertension at 32 weeks gestation with BP 142/92 mmHg. She is started on labetalol 100mg three times daily. At review one week later, her BP is 136/88 mmHg. She mentions feeling tired and occasionally dizzy on standing. Urinalysis remains negative for protein. What is the most appropriate adjustment to her management?
A 28-year-old woman presents to the antenatal day unit at 33 weeks gestation with reduced fetal movements. Cardiotocography is reassuring. Her BP is 148/96 mmHg (booking BP was 110/70 mmHg). Urinalysis shows protein 2+. Blood tests reveal: haemoglobin 118 g/L, platelets 145 × 10⁹/L, ALT 32 U/L, creatinine 68 μmol/L. Urine protein:creatinine ratio is 35 mg/mmol. She is asymptomatic. What is the most appropriate classification of her condition?
What is the recommended target range for 1-hour post-prandial blood glucose in women with gestational diabetes according to NICE guidelines?
A 41-year-old woman attends for combined screening at 12 weeks gestation in her fourth pregnancy. She has had three previous term deliveries with no complications. Her BMI is 28 kg/m² and she has no medical conditions. Blood tests show her HbA1c is 42 mmol/mol (6.0%). Which single investigation or management is most appropriate based on her age alone?
A 24-year-old primigravida attends her booking appointment at 9 weeks gestation. She mentions that her sister developed pre-eclampsia in her first pregnancy requiring early delivery at 34 weeks. She asks about her own risk and whether anything can be done to reduce it. Her booking BP is 112/68 mmHg, BMI is 23 kg/m², and she has no other medical history. What is the most appropriate advice?
A 36-year-old woman with gestational diabetes on insulin therapy attends for growth scan at 38 weeks gestation. The estimated fetal weight is on the 92nd centile and amniotic fluid index is raised at 26 cm. Her diabetes has been well controlled with most glucose readings within target. She had a previous spontaneous vaginal delivery of a 3.6 kg baby at term. What is the most appropriate counselling regarding mode of delivery?
A 33-year-old woman is admitted at 37 weeks gestation with severe pre-eclampsia. Her BP is 162/108 mmHg despite labetalol 200mg three times daily. Blood tests show: platelet count 78 × 10⁹/L, ALT 145 U/L, AST 178 U/L, creatinine 125 μmol/L. She complains of severe right upper quadrant pain and has generalised oedema. She has had one previous uncomplicated pregnancy. What is the single most important immediate management priority?
A 29-year-old nulliparous woman is reviewed at 34 weeks gestation. She has diet-controlled gestational diabetes diagnosed at 28 weeks. Her fasting glucose values over the past 2 weeks have ranged from 5.0-5.4 mmol/L and post-prandial values from 6.8-7.8 mmol/L. Ultrasound scan today shows estimated fetal weight on 75th centile with amniotic fluid index within normal limits. What is the most appropriate management of her glycaemic control?
A 32-year-old woman in her second pregnancy attends the community midwife at 22 weeks gestation for a routine antenatal appointment. Her blood pressure is 138/88 mmHg. Her booking BP at 10 weeks was 118/72 mmHg. Urinalysis shows no proteinuria. She is asymptomatic with no visual symptoms or epigastric pain. Blood tests show normal renal function and normal platelet count. What is the most appropriate initial management?
Pregnancy Medicine UK Medical PG Practice Questions and MCQs
Question 151: A 37-year-old woman presents at 24 weeks gestation for her OGTT following a previous pregnancy complicated by gestational diabetes. Fasting glucose is 6.8 mmol/L and 2-hour value is 9.2 mmol/L. She is referred to the joint diabetes-antenatal clinic. At this first specialist appointment three days later, what is the most appropriate initial management strategy?
- A. Trial of diet and exercise modifications with review in 1-2 weeks
- B. Commence metformin immediately and arrange dietitian review
- C. Commence insulin therapy immediately given high glucose values
- D. Arrange for immediate dietitian consultation and commence self-monitoring, starting metformin if targets not met within one week (Correct Answer)
- E. Repeat OGTT to confirm diagnosis before commencing treatment
Explanation: ***Arrange for immediate dietitian consultation and commence self-monitoring, starting metformin if targets not met within one week***- This approach aligns with guidelines for **gestational diabetes** where **fasting glucose** is between **5.6 and 6.9 mmol/L**. Initial management focuses on **medical nutrition therapy** (dietitian consultation) and empowering the patient through **self-monitoring of blood glucose**.- It also provides a clear **escalation plan**: if blood glucose targets are not met with lifestyle modifications within one week, **metformin** is the recommended first-line pharmacological agent.*Trial of diet and exercise modifications with review in 1-2 weeks*- While diet and exercise are crucial, this option is incomplete as it lacks the essential component of **self-monitoring of blood glucose (SMBG)**, which is vital to assess the efficacy of lifestyle changes.- It also doesn't specify a clear timeframe or the next steps (e.g., pharmacotherapy) if initial modifications are insufficient to meet glycemic targets.*Commence metformin immediately and arrange dietitian review*- Immediate pharmacological intervention with **metformin** is typically considered if the **fasting plasma glucose** is ** ≥ 7.0 mmol/L**, or if there are concerns like early evidence of **macrosomia**.- With a fasting glucose of **6.8 mmol/L**, there is still a window for a supervised trial of lifestyle modification before initiating medication, though prompt referral to a dietitian is critical.*Commence insulin therapy immediately given high glucose values*- **Insulin therapy** is usually reserved for cases where **metformin is contraindicated**, or when initial **metformin** and lifestyle interventions fail to achieve glycemic targets, or if **fasting glucose is ≥ 7.0 mmol/L** at diagnosis.- For a fasting value of **6.8 mmol/L**, metformin is generally the preferred initial pharmacological agent if lifestyle changes are inadequate.*Repeat OGTT to confirm diagnosis before commencing treatment*- The given **OGTT results** (fasting 6.8 mmol/L and 2-hour 9.2 mmol/L) already meet the diagnostic criteria for **gestational diabetes** (e.g., NICE criteria: fasting >5.6 mmol/L and/or 2-hour >7.8 mmol/L).- **Repeating the OGTT** would unnecessarily delay the initiation of crucial management, which could increase the risk of maternal and fetal complications associated with uncontrolled hyperglycemia.
Question 152: A 30-year-old woman is diagnosed with gestational hypertension at 32 weeks gestation with BP 142/92 mmHg. She is started on labetalol 100mg three times daily. At review one week later, her BP is 136/88 mmHg. She mentions feeling tired and occasionally dizzy on standing. Urinalysis remains negative for protein. What is the most appropriate adjustment to her management?
- A. Continue current dose as BP is well controlled
- B. Increase labetalol to 200mg three times daily to achieve better control
- C. Reduce labetalol to 100mg twice daily (Correct Answer)
- D. Switch from labetalol to nifedipine modified-release
- E. Stop labetalol and monitor BP twice weekly
Explanation: ***Reduce labetalol to 100mg twice daily*** - The patient's symptoms of **tiredness and dizziness on standing** are highly suggestive of **postural hypotension**, indicating that the current dose of labetalol is likely too high. - While the clinic BP of 136/88 mmHg is well-controlled, it's crucial to prevent **over-treatment** which can compromise **uteroplacental perfusion**, making a dose reduction the safest next step. *Continue current dose as BP is well controlled* - Although the BP is near the target of **135/85 mmHg**, the presence of symptomatic side effects like **orthostatic hypotension** makes the current regimen inappropriate. - Ignoring these symptoms can lead to **falls** and potentially reduced **placental blood flow**, necessitating a dose adjustment. *Increase labetalol to 200mg three times daily to achieve better control* - Increasing the dose would exacerbate the patient's **hypotensive symptoms**, significantly increasing the risk of maternal discomfort and potential complications. - The current BP is already close to the therapeutic target for gestational hypertension, so an **escalation of therapy** is clinically unwarranted. *Switch from labetalol to nifedipine modified-release* - Switching medications is unnecessary as labetalol is a safe and effective agent, and the problem appears to be a **dose-related side effect** rather than a drug intolerance. - **Nifedipine** can also cause vasodilatory side effects like dizziness, and simply switching drugs might not resolve the underlying issue of **over-medication**. *Stop labetalol and monitor BP twice weekly* - Stopping the medication entirely risks a rebound of **gestational hypertension**, which can progress to **pre-eclampsia** if left uncontrolled. - Pharmacotherapy is still indicated to manage the patient's condition, with the goal of finding the **minimum effective dose** to maintain adequate BP control without adverse effects.
Question 153: A 28-year-old woman presents to the antenatal day unit at 33 weeks gestation with reduced fetal movements. Cardiotocography is reassuring. Her BP is 148/96 mmHg (booking BP was 110/70 mmHg). Urinalysis shows protein 2+. Blood tests reveal: haemoglobin 118 g/L, platelets 145 × 10⁹/L, ALT 32 U/L, creatinine 68 μmol/L. Urine protein:creatinine ratio is 35 mg/mmol. She is asymptomatic. What is the most appropriate classification of her condition?
- A. Mild pre-eclampsia (Correct Answer)
- B. Moderate pre-eclampsia
- C. Severe pre-eclampsia
- D. Gestational hypertension with incidental proteinuria
- E. Chronic hypertension with superimposed pre-eclampsia
Explanation: ***Mild pre-eclampsia*** - This patient has **new-onset hypertension** (BP 148/96 mmHg) after **20 weeks gestation** and **significant proteinuria** (Urine PCR 35 mg/mmol, which is ≥30 mg/mmol), fulfilling the primary diagnostic criteria for pre-eclampsia. - It is classified as **mild (non-severe)** because she is **asymptomatic**, her BP is below the **severe threshold** (160/110 mmHg), and her blood tests (platelets, ALT, creatinine) are within **normal ranges**, indicating no end-organ dysfunction. *Moderate pre-eclampsia* - This classification term, **"moderate pre-eclampsia"**, is **not standardly used** in many current clinical guidelines, which typically differentiate pre-eclampsia into **non-severe** and **severe** categories. - Management and intervention decisions are primarily guided by the presence or absence of **severe features**, rather than an intermediate
Question 154: What is the recommended target range for 1-hour post-prandial blood glucose in women with gestational diabetes according to NICE guidelines?
- A. Less than 6.4 mmol/L
- B. Less than 7.0 mmol/L
- C. Less than 7.8 mmol/L (Correct Answer)
- D. Less than 8.5 mmol/L
- E. Less than 9.0 mmol/L
Explanation: ***Less than 7.8 mmol/L***- According to **NICE guidelines (NG3)**, the recommended target for blood glucose measured **1 hour** after a meal in women with **gestational diabetes** is below **7.8 mmol/L**.- Achieving this target significantly helps to reduce the risk of **fetal macrosomia** and other adverse neonatal outcomes linked to maternal hyperglycemia.*Less than 6.4 mmol/L*- This value represents the **2-hour post-prandial** blood glucose target, not the **1-hour** target, for women with gestational diabetes according to NICE.- Applying this stricter threshold for a 1-hour measurement would be overly aggressive and could increase the risk of maternal **hypoglycemia**.*Less than 7.0 mmol/L*- This is not a specific **NICE target** for **1-hour post-prandial** glucose in gestational diabetes management.- While **7.0 mmol/L** is a fasting plasma glucose threshold for diagnosing diabetes, it is not relevant for post-meal monitoring in this context.*Less than 8.5 mmol/L*- This target is too high and exceeds the evidence-based recommendations by **NICE** for optimal glycemic control in gestational diabetes.- Blood glucose levels consistently at or above this level **1 hour post-prandially** are associated with an increased risk of **large-for-gestational-age (LGA)** infants and other complications.*Less than 9.0 mmol/L*- This value is well above any acceptable clinical target for **1-hour post-prandial** glucose in the management of gestational diabetes.- Such high glucose levels significantly elevate the risk of severe complications, including **polyhydramnios**, fetal distress, and increased need for obstetric interventions.
Question 155: A 41-year-old woman attends for combined screening at 12 weeks gestation in her fourth pregnancy. She has had three previous term deliveries with no complications. Her BMI is 28 kg/m² and she has no medical conditions. Blood tests show her HbA1c is 42 mmol/mol (6.0%). Which single investigation or management is most appropriate based on her age alone?
- A. Oral glucose tolerance test at 24-28 weeks
- B. Repeat HbA1c at 16 weeks to exclude pre-existing diabetes
- C. Offer referral for diagnostic testing with chorionic villus sampling (Correct Answer)
- D. Commence aspirin 150mg daily from 12 weeks
- E. Arrange detailed anomaly scan at 16 weeks instead of routine 20-week scan
Explanation: ***Offer referral for diagnostic testing with chorionic villus sampling*** - At 41 years old, the patient's **advanced maternal age** significantly increases the baseline risk for **chromosomal abnormalities** such as **Trisomy 21** (Down syndrome). - Combined screening only provides a risk assessment; offering **diagnostic testing** like **CVS** (typically performed between 11-14 weeks) provides a definitive diagnosis based on this elevated age-related risk. *Oral glucose tolerance test at 24-28 weeks* - While advanced maternal age is a risk factor for **gestational diabetes (GDM)**, screening with an **OGTT** is typically performed later in pregnancy, specifically between **24 and 28 weeks**. - The immediate and most critical concern at 12 weeks gestation, specifically considering her age, is the elevated risk of **fetal aneuploidy**. *Repeat HbA1c at 16 weeks to exclude pre-existing diabetes* - An HbA1c of 42 mmol/mol (6.0%) in early pregnancy is considered to be in the **non-diabetic range** (the diagnostic threshold for diabetes outside pregnancy is 48 mmol/mol). - Repeating HbA1c at 16 weeks is not a standard protocol for diagnosing or excluding **pre-existing diabetes** based on this initial value, and an earlier **OGTT** would be performed if there were strong concerns. *Commence aspirin 150mg daily from 12 weeks* - Maternal age of **40 years or older** is classified as a **moderate risk factor** for **pre-eclampsia** according to current guidelines (e.g., NICE). - **Aspirin prophylaxis** (150mg daily) is typically recommended for individuals with one high-risk factor or **two or more moderate risk factors**, and this patient only has one moderate risk factor. *Arrange detailed anomaly scan at 16 weeks instead of routine 20-week scan* - The routine **mid-pregnancy anomaly scan** is generally performed between **18 and 20+6 weeks of gestation** to allow for optimal visualization of fetal structures. - Advancing the scan to 16 weeks is not standard practice based on maternal age alone, although earlier targeted scans might be considered for specific indications like very high risk of **cardiac anomalies**.
Question 156: A 24-year-old primigravida attends her booking appointment at 9 weeks gestation. She mentions that her sister developed pre-eclampsia in her first pregnancy requiring early delivery at 34 weeks. She asks about her own risk and whether anything can be done to reduce it. Her booking BP is 112/68 mmHg, BMI is 23 kg/m², and she has no other medical history. What is the most appropriate advice?
- A. She has a moderate risk factor; commence aspirin 150mg daily from 12 weeks (Correct Answer)
- B. She has a high risk factor; commence aspirin 75mg daily now and calcium supplementation
- C. She has no significant risk factors; reassure and arrange routine antenatal care
- D. She has a moderate risk factor; arrange more frequent BP monitoring from 20 weeks
- E. Commence aspirin 150mg daily now and continue until delivery
Explanation: ***She has a moderate risk factor; commence aspirin 150mg daily from 12 weeks***- According to **NICE guidelines**, patients with **two or more moderate risk factors** require aspirin prophylaxis; this patient is a **primigravida** and has a **family history of pre-eclampsia** (sister). - The recommended dose is **150mg aspirin daily**, starting from **12 weeks gestation** until birth to effectively reduce the risk of developing pre-eclampsia. *She has a high risk factor; commence aspirin 75mg daily now and calcium supplementation* - **High-risk factors** include chronic hypertension, CKD, or autoimmune diseases, none of which this patient possesses. - Current guidelines recommend a higher dose of **150mg aspirin** rather than 75mg, and **calcium supplementation** is only indicated if dietary intake is deficient. *She has no significant risk factors; reassure and arrange routine antenatal care* - This is incorrect because the patient has two **moderate risk factors** (nulliparity and family history in a first-degree relative). - Failing to prescribe **aspirin prophylaxis** in this scenario misses an evidence-based opportunity to prevent serious maternal and fetal complications. *She has a moderate risk factor; arrange more frequent BP monitoring from 20 weeks* - While monitoring is essential, it is a diagnostic step and does not serve as a **preventative intervention** like aspirin does. - Guidelines emphasize **chemoprophylaxis with aspirin** for women with two moderate risk factors to improve placentation early in pregnancy. *Commence aspirin 150mg daily now and continue until delivery* - Although the dose is correct, **aspirin prophylaxis** is typically advised to begin at **12 weeks gestation**, and she is currently only at 9 weeks. - Starting before 12 weeks is not the standard protocol for pre-eclampsia prevention as the most critical period for **trophoblast invasion** modulation begins later.
Question 157: A 36-year-old woman with gestational diabetes on insulin therapy attends for growth scan at 38 weeks gestation. The estimated fetal weight is on the 92nd centile and amniotic fluid index is raised at 26 cm. Her diabetes has been well controlled with most glucose readings within target. She had a previous spontaneous vaginal delivery of a 3.6 kg baby at term. What is the most appropriate counselling regarding mode of delivery?
- A. Offer induction of labour at 39 weeks with caesarean section if labour fails to progress
- B. Recommend elective caesarean section due to suspected fetal macrosomia
- C. Offer induction of labour at 38 weeks given the current gestation (Correct Answer)
- D. Recommend awaiting spontaneous labour up to 40 weeks with continuous glucose monitoring
- E. Recommend elective caesarean section only if estimated fetal weight exceeds 4.5 kg
Explanation: ***Offer induction of labour at 38 weeks given the current gestation***- For women with **gestational diabetes** requiring **insulin**, NICE guidelines recommend offering elective birth (induction or caesarean) between **37+0 and 38+6 weeks**.- Despite good glycaemic control, the **92nd centile weight** and **polyhydramnios** (AFI 26 cm) suggest fetal markers of diabetes complications, making immediate induction at 38 weeks appropriate.*Offer induction of labour at 39 weeks with caesarean section if labour fails to progress*- While **39 weeks** is acceptable for some, this patient is already at 38 weeks with evidence of **macrosomia** and polyhydramnios, necessitating earlier intervention.- Modern guidelines emphasize that those on pharmacological treatment should be offered delivery by the end of the **38th week**.*Recommend elective caesarean section due to suspected fetal macrosomia*- Suspected **fetal macrosomia** alone is not an absolute indication for **caesarean section** in diabetic patients unless the estimated weight is significantly higher.- This patient has a history of a successful **previous vaginal delivery**, increasing the likelihood of a successful induction and vaginal birth.*Recommend awaiting spontaneous labour up to 40 weeks with continuous glucose monitoring*- Waiting until **40 weeks** is generally reserved for diet-controlled gestational diabetes without fetal complications; it is not recommended for those on **insulin**.- Delaying delivery in insulin-dependent patients increases the risk of **stillbirth** and complications like **shoulder dystocia** due to ongoing fetal growth.*Recommend elective caesarean section only if estimated fetal weight exceeds 4.5 kg*- While a threshold of **4.5 kg** is often used to discuss the risks of vaginal birth in diabetes, it does not preclude the offer of **induction of labour** at an earlier gestation.- This option ignores the need for timed delivery (37-38 weeks) based on **insulin therapy** and current fetal ultrasound findings.
Question 158: A 33-year-old woman is admitted at 37 weeks gestation with severe pre-eclampsia. Her BP is 162/108 mmHg despite labetalol 200mg three times daily. Blood tests show: platelet count 78 × 10⁹/L, ALT 145 U/L, AST 178 U/L, creatinine 125 μmol/L. She complains of severe right upper quadrant pain and has generalised oedema. She has had one previous uncomplicated pregnancy. What is the single most important immediate management priority?
- A. Administer magnesium sulphate and plan delivery within 24-48 hours (Correct Answer)
- B. Increase labetalol dose and recheck blood pressure in 30 minutes
- C. Arrange urgent CT scan of abdomen to exclude hepatic rupture
- D. Administer intravenous hydralazine and commence fluid restriction
- E. Give platelet transfusion to correct thrombocytopenia before any intervention
Explanation: ***Administer magnesium sulphate and plan delivery within 24-48 hours*** - This patient exhibits signs of **HELLP syndrome** (low platelets, elevated liver enzymes, RUQ pain) and severe pre-eclampsia at **37 weeks gestation**, where the definitive treatment is delivery. - **Magnesium sulphate** is the mandatory immediate priority for **seizure prophylaxis** (eclampsia prevention) in patients with severe pre-eclampsia, especially with features like RUQ pain indicating liver involvement. *Increase labetalol dose and recheck blood pressure in 30 minutes* - While blood pressure control is necessary, simply adjusting oral medications is insufficient for a patient with **multi-organ dysfunction** and term pregnancy complicated by severe pre-eclampsia/HELLP syndrome. - **Delivery** is the only cure for pre-eclampsia/HELLP; delaying the decision to deliver increases the risk of maternal and fetal complications, and this option does not address seizure risk. *Arrange urgent CT scan of abdomen to exclude hepatic rupture* - Although severe right upper quadrant pain can indicate **subcapsular hepatic hematoma**, a CT scan is not the first priority unless there is acute **hemodynamic instability** or suspicion of rupture. - Management of the underlying severe pre-eclampsia and stabilization with **magnesium sulphate** takes precedence over non-essential or delayed imaging. *Administer intravenous hydralazine and commence fluid restriction* - **Hydralazine** is an option for acute hypertensive crises, but the patient's current BP (162/108) requires management in the context of broader HELLP syndrome, not as the single most important immediate priority. - **Fluid restriction** is important to prevent pulmonary edema in pre-eclampsia, but it is a supportive measure, not the primary, most urgent management priority for a patient at risk of seizures and requiring delivery. *Give platelet transfusion to correct thrombocytopenia before any intervention* - Platelet transfusion is generally reserved for counts **<20 × 10⁹/L** or if there is active bleeding/impending surgery with counts below 50 × 10⁹/L. - A platelet count of **78 × 10⁹/L** does not require immediate transfusion and should not delay the administration of **magnesium sulphate** or delivery planning, which are more critical for maternal safety.
Question 159: A 29-year-old nulliparous woman is reviewed at 34 weeks gestation. She has diet-controlled gestational diabetes diagnosed at 28 weeks. Her fasting glucose values over the past 2 weeks have ranged from 5.0-5.4 mmol/L and post-prandial values from 6.8-7.8 mmol/L. Ultrasound scan today shows estimated fetal weight on 75th centile with amniotic fluid index within normal limits. What is the most appropriate management of her glycaemic control?
- A. Continue with diet control only
- B. Commence metformin (Correct Answer)
- C. Commence insulin therapy
- D. Commence metformin and insulin in combination
- E. Recheck fasting and post-prandial glucose in one week
Explanation: ***Commence metformin*** - NICE guidelines recommend pharmacological intervention if **glucose targets** (fasting <5.3 mmol/L and 1-hour post-prandial <7.8 mmol/L) are not met through diet and exercise within 1–2 weeks. - This patient's post-prandial readings (6.8-7.8 mmol/L) are consistently at the upper limit or **exceeding the target**, making **metformin** the first-line oral hypoglycemic agent to initiate when diet fails. *Continue with diet control only* - Diet control has already been attempted for two weeks, and glucose levels remain above the recommended **NICE targets**, indicating a need for escalation. - Delaying treatment increases the risk of **macrosomia**, **neonatal hypoglycemia**, and other gestational complications, even if the current fetal weight is on the 75th centile. *Commence insulin therapy* - **Insulin** is usually reserved as first-line if the fasting glucose is >7.0 mmol/L at diagnosis or if there is evidence of **fetal macrosomia** or polyhydramnios requiring urgent control. - In this case, the patient is currently on diet control alone and has not yet failed a trial of **metformin**, which is the preferred initial medication for mild elevations. *Commence metformin and insulin in combination* - Combination therapy is typically indicated only if **metformin monotherapy** fails to achieve adequate glycemic control or if blood glucose is severely elevated at presentation. - Starting both simultaneously is premature given the current blood glucose values are only **marginally above target** and fetal growth is within normal limits for now. *Recheck fasting and post-prandial glucose in one week* - Monitoring without intervention is inappropriate because the current data already demonstrates that **dietary modifications** have failed to meet targets over two weeks. - NICE recommends moving to pharmacological therapy promptly to achieve **euglycemia** rather than continuing a failed management strategy and risking complications.
Question 160: A 32-year-old woman in her second pregnancy attends the community midwife at 22 weeks gestation for a routine antenatal appointment. Her blood pressure is 138/88 mmHg. Her booking BP at 10 weeks was 118/72 mmHg. Urinalysis shows no proteinuria. She is asymptomatic with no visual symptoms or epigastric pain. Blood tests show normal renal function and normal platelet count. What is the most appropriate initial management?
- A. Start labetalol and review in one week
- B. Arrange blood pressure monitoring twice weekly and review if BP ≥140/90 mmHg (Correct Answer)
- C. Admit for further assessment and monitoring
- D. Reassure and continue routine antenatal care
- E. Request 24-hour urine collection for protein quantification
Explanation: ***Arrange blood pressure monitoring twice weekly and review if BP 140/90 mmHg*** - This patient has a significant rise in **blood pressure** after 20 weeks gestation, currently at **138/88 mmHg**, which requires increased surveillance to detect **gestational hypertension** or **pre-eclampsia**. - Per guidelines, while this level does not yet meet the **140/90 mmHg threshold** for pharmacological treatment, **monitoring twice weekly** is the appropriate step to ensure early intervention if pressures rise further. *Start labetalol and review in one week* - Antihypertensive treatment like **labetalol** is typically initiated when blood pressure consistently exceeds **140/90 mmHg** in pregnancy. - Starting medication prematurely without meeting the threshold or having evidence of **end-organ damage** is not recommended for mild elevations below 140/90 mmHg. *Admit for further assessment and monitoring* - **Admission** is generally reserved for patients with **severe hypertension** ( 160/110 mmHg) or those showing symptoms of **pre-eclampsia**. - Since the patient is **asymptomatic**, has **no proteinuria**, and normal lab results, outpatient management is considered safe and appropriate. *Reassure and continue routine antenatal care* - Routine care is insufficient because the patient has developed a meaningful increase from her **booking BP (118/72 mmHg)** after the 20-week mark. - Ignoring this trend risks missing the progression to **pre-eclampsia**, which carries significant maternal and **fetal risks**. *Request 24-hour urine collection for protein quantification* - Protein quantification (via **PCR** or 24-hour collection) is only indicated if **urinalysis** shows 1+ or more of protein on a dipstick. - As this patient ’s urinalysis showed **no proteinuria**, there is no current indication to perform more invasive or time-consuming protein testing.
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