Pregnancy Medicine — MCQs
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A 29-year-old woman with gestational diabetes controlled on metformin presents at 38 weeks gestation for induction of labour. Her fasting glucose this morning was 5.2 mmol/L. She asks about glucose monitoring during labour. What is the most appropriate intrapartum glucose management?
A 34-year-old woman at 30 weeks gestation presents with a 24-hour history of severe generalised pruritus, particularly affecting her palms and soles, worse at night. She has no rash. Blood tests show: ALT 180 U/L (normal 5-40), bile acids 42 µmol/L (normal <10). Blood pressure is 118/72 mmHg, urine dipstick negative for protein. What is the most important immediate management step?
A 25-year-old primigravida at 16 weeks gestation attends routine antenatal clinic. Her booking bloods showed blood group O negative and antibody screen was negative. She asks about anti-D prophylaxis. What is the correct advice regarding routine antenatal anti-D prophylaxis?
A 31-year-old woman attends the antenatal clinic at 12 weeks gestation for her booking appointment. She has no significant medical history. Blood tests reveal haemoglobin 105 g/L, MCV 72 fL, ferritin 8 µg/L. She reports no symptoms. What is the most appropriate initial management?
A 42-year-old woman presents for pre-pregnancy counselling. She has a history of severe early-onset pre-eclampsia at 28 weeks in her previous pregnancy 3 years ago, which resulted in emergency delivery and a 6-week neonatal intensive care admission. She now wishes to conceive again. Her current blood pressure is 118/72 mmHg, BMI is 27 kg/m², and she has no other medical problems. Results of investigations show: negative antiphospholipid antibodies, negative lupus anticoagulant, normal renal function with urinary albumin:creatinine ratio of 2.5 mg/mmol. Given her history, which of the following represents the most evidence-based package of preventative interventions for her next pregnancy?
A 36-year-old woman is admitted at 35 weeks gestation with severe pre-eclampsia. Blood pressure is 162/108 mmHg despite intravenous labetalol. Blood tests show: platelets 142 × 10⁹/L, ALT 58 U/L, creatinine 82 μmol/L. She has been commenced on intravenous magnesium sulphate for seizure prophylaxis. After 6 hours of treatment, she becomes increasingly drowsy and difficult to rouse. Respiratory rate is 8 breaths per minute. Patellar reflexes are absent. What is the most appropriate immediate management?
A 34-year-old woman with pre-existing type 1 diabetes is reviewed at 16 weeks gestation. Her HbA1c has improved from 58 mmol/mol pre-conception to 42 mmol/mol currently. She is experiencing frequent hypoglycaemic episodes (3-4 per week) with blood glucose values of 2.8-3.5 mmol/L. She is asymptomatic during these episodes and treats them with oral carbohydrates. She is increasingly anxious about further reducing her insulin doses. What is the most appropriate approach to counselling this patient?
A 27-year-old woman presents to the emergency department at 20 weeks gestation with a blood pressure of 172/115 mmHg. She reports this is her first antenatal appointment as she has just moved to the UK. She denies headache, visual disturbances, or epigastric pain. Urine dipstick shows trace protein. Her blood pressure was 145/95 mmHg when measured again 30 minutes later. Blood tests including renal function, liver function, and full blood count are normal. What is the most appropriate initial classification of her hypertension?
A 40-year-old woman in her third pregnancy presents to clinic at 32 weeks gestation. Her first pregnancy was complicated by early-onset severe pre-eclampsia requiring delivery at 30 weeks. Her current pregnancy has been uncomplicated so far. Her blood pressure today is 128/78 mmHg and urinalysis is negative for protein. She is taking aspirin 150 mg daily started at 12 weeks. What additional monitoring should be arranged for the remainder of this pregnancy?
A 38-year-old woman presents at 29 weeks gestation with sudden onset severe epigastric pain and vomiting. Her blood pressure is 145/95 mmHg and she has significant right upper quadrant tenderness. Blood tests show: haemoglobin 105 g/L, platelets 78 × 10⁹/L, white cell count 12.5 × 10⁹/L, bilirubin 35 μmol/L, ALT 420 U/L, AST 385 U/L, LDH 650 U/L, and a blood film shows schistocytes. Urine shows 2+ protein. What is the most likely diagnosis?
Pregnancy Medicine UK Medical PG Practice Questions and MCQs
Question 171: A 29-year-old woman with gestational diabetes controlled on metformin presents at 38 weeks gestation for induction of labour. Her fasting glucose this morning was 5.2 mmol/L. She asks about glucose monitoring during labour. What is the most appropriate intrapartum glucose management?
- A. Capillary blood glucose monitoring every 4 hours, aiming for 4-7 mmol/L
- B. Capillary blood glucose monitoring hourly, aiming for 4-7 mmol/L (Correct Answer)
- C. Capillary blood glucose monitoring every 2 hours, aiming for 4-10 mmol/L
- D. No glucose monitoring required as she is on metformin only
- E. Continuous intravenous insulin infusion regardless of glucose levels
Explanation: ***Capillary blood glucose monitoring hourly, aiming for 4-7 mmol/L*** - **NICE guidelines** recommend that all women with **gestational diabetes (GDM)**, regardless of whether they are treated with diet, metformin, or insulin, should have **hourly** glucose monitoring during established labor. - Maintaining blood glucose within the **4–7 mmol/L** range is critical to minimize the risk of **neonatal hypoglycemia** following delivery. *Capillary blood glucose monitoring every 4 hours, aiming for 4-7 mmol/L* - Monitoring every **4 hours** is insufficient during the active phase of labor because glucose levels can fluctuate rapidly due to the metabolic demands of uterine contractions. - This frequency is generally reserved for the latent phase or for women with low-risk pregnancies without **glycemic control issues**. *Capillary blood glucose monitoring every 2 hours, aiming for 4-10 mmol/L* - An upper target of **10 mmol/L** is too high for intrapartum management and is associated with increased risks of **fetal hyperglycemia** and subsequent neonatal complications. - **Every 2 hours** does not meet the standard of care for intrapartum monitoring in GDM where tighter **hourly surveillance** is mandated. *No glucose monitoring required as she is on metformin only* - Although **metformin** has a lower risk of maternal hypoglycemia than insulin, the physiological stress of labor can still cause **maternal hyperglycemia**. - Even diet-controlled patients require monitoring to ensure the fetus is not exposed to high glucose levels, which can trigger **fetal hyperinsulinemia**. *Continuous intravenous insulin infusion regardless of glucose levels* - A **sliding scale** or continuous insulin infusion is not routinely required unless blood glucose levels exceed **7 mmol/L** during labor. - Routine use in all GDM patients would unnecessarily increase the risk of **maternal hypoglycemia** and requires invasive intravenous access.
Question 172: A 34-year-old woman at 30 weeks gestation presents with a 24-hour history of severe generalised pruritus, particularly affecting her palms and soles, worse at night. She has no rash. Blood tests show: ALT 180 U/L (normal 5-40), bile acids 42 µmol/L (normal <10). Blood pressure is 118/72 mmHg, urine dipstick negative for protein. What is the most important immediate management step?
- A. Commence ursodeoxycholic acid and plan delivery at 37-38 weeks (Correct Answer)
- B. Arrange immediate delivery by caesarean section
- C. Prescribe antihistamines and repeat liver function tests in 2 weeks
- D. Commence high-dose corticosteroids
- E. Perform liver ultrasound to exclude gallstones
Explanation: ***Commence ursodeoxycholic acid and plan delivery at 37-38 weeks***- The patient's presentation of **palmar/solar pruritus**, elevated **ALT**, and **bile acids >10 µmol/L** (specifically 42 µmol/L) confirms a diagnosis of **Intrahepatic Cholestasis of Pregnancy (ICP)**.- **Ursodeoxycholic acid** is the primary treatment to improve maternal symptoms and biochemical markers, while **planned delivery at 37-38 weeks** is recommended to mitigate the increased risk of **stillbirth** associated with severe cholestasis.*Arrange immediate delivery by caesarean section*- Immediate delivery at **30 weeks gestation** is premature and is only indicated if there is evidence of acute **fetal compromise** or maternal instability.- The goal is to balance the risks of **preterm birth** complications against the risk of late-gestation stillbirth.*Prescribe antihistamines and repeat liver function tests in 2 weeks*- **Antihistamines** provide very limited relief for the pruritus of ICP as the itching is mediated by **bile salt deposition**, not histamine release.- Repeating tests in 2 weeks without initiating treatment is inappropriate because **bile acids >40 µmol/L** represent a high-risk state requiring active management.*Commence high-dose corticosteroids*- **Corticosteroids** are not the standard treatment for ICP; they are typically used for fetal lung maturity in threatened preterm labor or in cases of **HELLP syndrome**.- High-dose steroids do not effectively lower bile acid levels or reduce the risk of **fetal demise** in obstetric cholestasis.*Perform liver ultrasound to exclude gallstones*- While a **liver ultrasound** may be useful to exclude other hepatobiliary pathologies, it is not the most important immediate management step for the safety of the fetus.- Delaying the initiation of **ursodeoxycholic acid** while waiting for imaging would postpone necessary treatment for severe maternal symptoms and fetal risk reduction.
Question 173: A 25-year-old primigravida at 16 weeks gestation attends routine antenatal clinic. Her booking bloods showed blood group O negative and antibody screen was negative. She asks about anti-D prophylaxis. What is the correct advice regarding routine antenatal anti-D prophylaxis?
- A. Single dose at 28 weeks gestation only
- B. Two doses at 28 and 34 weeks gestation (Correct Answer)
- C. Single dose at 34 weeks gestation only
- D. Three doses at 20, 28 and 34 weeks gestation
- E. Only given after delivery if baby is rhesus positive
Explanation: ***Two doses at 28 and 34 weeks gestation*** - In **Rhesus-negative** women who are not yet sensitized, a standard clinical regimen involves administering two doses of **anti-D immunoglobulin** at **28 and 34 weeks** gestation. - This approach, known as **Routine Antenatal Anti-D Prophylaxis (RAADP)**, effectively reduces the risk of sensitization from silent **fetomaternal hemorrhage** during the third trimester. *Single dose at 28 weeks gestation only* - While a **single-dose regimen** is an alternative, the standard single-dose protocol usually requires a higher dose (typically **1500 IU**) specifically between **28 and 30 weeks**. - Only one dose at 28 weeks would not align with the standard 2-dose regimen requirements to ensure coverage until delivery. *Single dose at 34 weeks gestation only* - Administering anti-D only at **34 weeks** leaves the patient at risk for sensitization during the early third trimester starting from 28 weeks. - Prophylaxis must begin by **28-30 weeks** to be clinically effective in preventing **haemolytic disease of the newborn**. *Three doses at 20, 28 and 34 weeks gestation* - Starting prophylaxis at **20 weeks** is not indicated as routine; significant **fetal-to-maternal bleeding** is rare before the third trimester. - Standard guidelines do not recommend a **three-dose** schedule for routine antenatal care. *Only given after delivery if baby is rhesus positive* - This was the historical protocol; however, it is now considered insufficient because sensitization often occurs **antenatally** before birth. - While a dose is given **postpartum** within 72 hours, it must be preceded by **routine antenatal prophylaxis** for maximum protection.
Question 174: A 31-year-old woman attends the antenatal clinic at 12 weeks gestation for her booking appointment. She has no significant medical history. Blood tests reveal haemoglobin 105 g/L, MCV 72 fL, ferritin 8 µg/L. She reports no symptoms. What is the most appropriate initial management?
- A. Oral ferrous sulfate 200 mg once daily
- B. Oral ferrous sulfate 200 mg twice daily (Correct Answer)
- C. Intravenous iron infusion
- D. Blood transfusion
- E. Reassurance and repeat bloods at 28 weeks
Explanation: ***Oral ferrous sulfate 200 mg twice daily*** - The patient has confirmed **iron deficiency anaemia** (IDA) in pregnancy, indicated by **Hb 105 g/L** (below 1st trimester threshold of 110 g/L) and severely low **ferritin 8 µg/L**. - Therapeutic oral iron supplementation, such as **ferrous sulfate 200 mg twice daily**, is the most appropriate initial management to replete iron stores and meet increased maternal and fetal demands. *Oral ferrous sulfate 200 mg once daily* - While **once-daily dosing** or alternate-day regimens can improve tolerance, this dose is often insufficient for treating **established iron deficiency anaemia** in pregnancy. - This lower dose is more typically recommended for **iron prophylaxis** in high-risk pregnant women rather than for correcting existing anaemia. *Intravenous iron infusion* - **Intravenous iron** is generally reserved for cases of **oral iron intolerance**, malabsorption, severe anaemia in late pregnancy, or when a rapid response is urgently required. - It is usually avoided in the **first trimester** due to limited safety data and because oral iron is typically effective and safer for initial management. *Blood transfusion* - **Blood transfusion** is an intervention reserved for **severe symptomatic anaemia** (e.g., Hb < 70 g/L or significant cardiorespiratory compromise) or active haemorrhage. - This patient is **asymptomatic** with an Hb of 105 g/L, which does not meet the criteria for emergent transfusion, and the risks outweigh the benefits. *Reassurance and repeat bloods at 28 weeks* - Failing to treat confirmed **iron deficiency anaemia** increases risks such as **preterm delivery**, **low birth weight**, and the need for peripartum blood transfusions. - Routine screening at 28 weeks does not negate the need for immediate treatment of anaemia diagnosed earlier in pregnancy.
Question 175: A 42-year-old woman presents for pre-pregnancy counselling. She has a history of severe early-onset pre-eclampsia at 28 weeks in her previous pregnancy 3 years ago, which resulted in emergency delivery and a 6-week neonatal intensive care admission. She now wishes to conceive again. Her current blood pressure is 118/72 mmHg, BMI is 27 kg/m², and she has no other medical problems. Results of investigations show: negative antiphospholipid antibodies, negative lupus anticoagulant, normal renal function with urinary albumin:creatinine ratio of 2.5 mg/mmol. Given her history, which of the following represents the most evidence-based package of preventative interventions for her next pregnancy?
- A. Low-dose aspirin 75mg daily from positive pregnancy test, high-dose folic acid, and intensive monitoring from 12 weeks
- B. Low-dose aspirin 150mg daily from before 16 weeks gestation, calcium supplementation 1g daily, prophylactic low molecular weight heparin, and enhanced fetal surveillance
- C. Low-dose aspirin 75-150mg daily from before 16 weeks gestation, weight reduction to BMI <25, and serial growth scans from 24 weeks
- D. Low-dose aspirin 75-150mg daily from before 16 weeks gestation, consideration of prophylactic labetalol from 12-16 weeks, and enhanced surveillance including serial growth scans with umbilical artery Doppler (Correct Answer)
- E. Calcium supplementation 1g daily from 12 weeks, vitamin D supplementation, early serial uterine artery Doppler, and low molecular weight heparin if abnormal Doppler
Explanation: ***Low-dose aspirin 75-150mg daily from before 16 weeks gestation, consideration of prophylactic labetalol from 12-16 weeks, and enhanced surveillance including serial growth scans with umbilical artery Doppler*** - A history of **severe early-onset pre-eclampsia** (delivery before 34 weeks) is a major risk factor, and **low-dose aspirin** (75-150mg) started before 16 weeks significantly reduces recurrence. - **Prophylactic labetalol** from 12-16 weeks is a reasonable consideration for very high-risk women, and **enhanced surveillance** with serial growth scans and **umbilical artery Doppler** is crucial for monitoring fetal well-being. *Low-dose aspirin 75mg daily from positive pregnancy test, high-dose folic acid, and intensive monitoring from 12 weeks* - While aspirin is correct, commencing it *from positive pregnancy test* is less ideal than starting **before 16 weeks gestation** for maximal benefit, and 75mg might be suboptimal compared to 150mg for high-risk cases. - **High-dose folic acid** is primarily indicated for previous neural tube defects or specific comorbidities, not as a direct preventative measure for **pre-eclampsia**. *Low-dose aspirin 150mg daily from before 16 weeks gestation, calcium supplementation 1g daily, prophylactic low molecular weight heparin, and enhanced fetal surveillance* - **Prophylactic low molecular weight heparin (LMWH)** is generally not recommended for pre-eclampsia prevention in the absence of a **thrombophilia** or prior VTE, as the patient tested negative for antiphospholipid antibodies and lupus anticoagulant. - **Calcium supplementation** is primarily beneficial in populations with **low dietary calcium intake**, which is not explicitly stated or implied as a risk factor for this patient. *Low-dose aspirin 75-150mg daily from before 16 weeks gestation, weight reduction to BMI <25, and serial growth scans from 24 weeks* - **Weight reduction to BMI <25** is an important pre-conception goal, but it is not an *intervention during pregnancy* once counselling or conception has occurred. - While serial growth scans are part of surveillance, this option **lacks the consideration of prophylactic blood pressure management** (e.g., labetalol) which is critical for someone with a history of severe early-onset pre-eclampsia. *Calcium supplementation 1g daily from 12 weeks, vitamin D supplementation, early serial uterine artery Doppler, and low molecular weight heparin if abnormal Doppler* - There is **insufficient evidence** to support **vitamin D supplementation** as a primary strategy for preventing pre-eclampsia recurrence. - Relying on **uterine artery Doppler** to trigger LMWH is not a standard evidence-based approach; **aspirin** is the established primary pharmacological intervention regardless of Doppler findings in a high-risk patient.
Question 176: A 36-year-old woman is admitted at 35 weeks gestation with severe pre-eclampsia. Blood pressure is 162/108 mmHg despite intravenous labetalol. Blood tests show: platelets 142 × 10⁹/L, ALT 58 U/L, creatinine 82 μmol/L. She has been commenced on intravenous magnesium sulphate for seizure prophylaxis. After 6 hours of treatment, she becomes increasingly drowsy and difficult to rouse. Respiratory rate is 8 breaths per minute. Patellar reflexes are absent. What is the most appropriate immediate management?
- A. Increase the rate of intravenous fluids
- B. Administer naloxone 400 micrograms intravenously
- C. Stop magnesium sulphate infusion and check serum magnesium level
- D. Stop magnesium sulphate infusion and administer calcium gluconate 10ml of 10% solution intravenously (Correct Answer)
- E. Arrange urgent CT head scan to exclude intracranial haemorrhage
Explanation: ***Stop magnesium sulphate infusion and administer calcium gluconate 10ml of 10% solution intravenously***- The patient exhibits core signs of **magnesium toxicity**, including **respiratory depression** (RR < 12) and **absent patellar reflexes**, requiring immediate reversal.- **Calcium gluconate** acts as a direct physiological antagonist to magnesium, effectively reversing life-threatening neuromuscular and cardiac effects.*Increase the rate of intravenous fluids*- While magnesium is renally excreted, increasing fluids is not an antidote and does nothing to stabilize the immediate **respiratory depression**.- Excessive fluids in severe pre-eclampsia can exacerbate **pulmonary edema**, a major cause of maternal morbidity.*Administer naloxone 400 micrograms intravenously*- **Naloxone** is used for opioid overdose; there is no evidence this patient received opioids, and it will not reverse **magnesium toxicity**.- Using naloxone here would inappropriately delay the administration of the life-saving antidote, **calcium gluconate**.*Stop magnesium sulphate infusion and check serum magnesium level*- While stopping the infusion and checking levels are necessary, this answer is incomplete as it lacks the **calcium gluconate** required for symptomatic toxicity.- Management of severe toxicity symptoms like **hypoventilation** must be clinical and immediate rather than waiting for laboratory confirmation.*Arrange urgent CT head scan to exclude intracranial haemorrhage*- Although drowsiness can occur in stroke, the classic triad of **magnesium infusion**, **absent reflexes**, and **respiratory depression** makes toxicity the primary diagnosis.- Clinical stabilization of the patient's airway and **cardiorespiratory status** with an antidote must precede any diagnostic imaging.
Question 177: A 34-year-old woman with pre-existing type 1 diabetes is reviewed at 16 weeks gestation. Her HbA1c has improved from 58 mmol/mol pre-conception to 42 mmol/mol currently. She is experiencing frequent hypoglycaemic episodes (3-4 per week) with blood glucose values of 2.8-3.5 mmol/L. She is asymptomatic during these episodes and treats them with oral carbohydrates. She is increasingly anxious about further reducing her insulin doses. What is the most appropriate approach to counselling this patient?
- A. Reassure that hypoglycaemia is harmful to the fetus and insulin doses must be reduced immediately
- B. Explain that hypoglycaemia awareness may be reduced in pregnancy and frequent hypoglycaemia increases risk of severe episodes (Correct Answer)
- C. Advise that the current HbA1c is too low for pregnancy and glycaemic targets should be relaxed
- D. Recommend admission for continuous glucose monitoring and intravenous glucose therapy
- E. Suggest switching from insulin to metformin to reduce hypoglycaemia risk
Explanation: ***Explain that hypoglycaemia awareness may be reduced in pregnancy and frequent hypoglycaemia increases risk of severe episodes***- Pregnancy itself can **impair hypoglycaemia awareness** due to hormonal changes, and this patient's asymptomatic nature during low readings (2.8-3.5 mmol/L) demonstrates this.- Frequent mild episodes significantly elevate the risk of future **severe hypoglycaemia** requiring third-party assistance, which poses a significant safety risk to the mother.*Reassure that hypoglycaemia is harmful to the fetus and insulin doses must be reduced immediately*- Moderate **maternal hypoglycaemia** is generally not directly teratogenic or harmful to the fetus, as the fetus maintains glucose levels through placental gradients.- While education on **insulin dose reduction** is necessary given the frequent episodes, the rationale provided regarding direct fetal harm is medically inaccurate.*Advise that the current HbA1c is too low for pregnancy and glycaemic targets should be relaxed*- An **HbA1c of 42 mmol/mol** is excellent and meets the target of **<48 mmol/mol** recommended to reduce pregnancy complications in type 1 diabetes.- Glycaemic targets should not be relaxed, but the insulin regimen must be optimized to achieve these targets **without problematic hypoglycaemia**.*Recommend admission for continuous glucose monitoring and intravenous glucose therapy*- **Intravenous glucose** is reserved for acute, severe hypoglycaemic emergencies where oral intake is impossible or rapid correction is critical, not for managed asymptomatic episodes.- While **Continuous Glucose Monitoring (CGM)** is highly recommended in Type 1 Diabetes during pregnancy, it is typically initiated as an outpatient; inpatient admission is unnecessary for this presentation.*Suggest switching from insulin to metformin to reduce hypoglycaemia risk*- **Type 1 Diabetes** is characterized by absolute insulin deficiency, making insulin an essential, life-sustaining treatment that cannot be replaced by **metformin**.- Although metformin may be used as an adjunct in Type 2 or Gestational Diabetes, its use here would lead to severe hyperglycaemia and life-threatening **diabetic ketoacidosis**.
Question 178: A 27-year-old woman presents to the emergency department at 20 weeks gestation with a blood pressure of 172/115 mmHg. She reports this is her first antenatal appointment as she has just moved to the UK. She denies headache, visual disturbances, or epigastric pain. Urine dipstick shows trace protein. Her blood pressure was 145/95 mmHg when measured again 30 minutes later. Blood tests including renal function, liver function, and full blood count are normal. What is the most appropriate initial classification of her hypertension?
- A. Chronic hypertension
- B. Gestational hypertension
- C. Pre-eclampsia
- D. White coat hypertension
- E. Unclassified hypertension requiring further assessment (Correct Answer)
Explanation: ***Unclassified hypertension requiring further assessment*** - This classification is appropriate when hypertension is first detected at or after **20 weeks gestation** without documented pre-pregnancy or early pregnancy blood pressure readings. - As the patient is at exactly **20 weeks** and this is her first antenatal appointment, it's impossible to differentiate between **chronic hypertension** (onset before 20 weeks) and **gestational hypertension** (new-onset after 20 weeks) without prior records. *Chronic hypertension* - Defined as hypertension (blood pressure ">" 140/90 mmHg) present **before pregnancy** or diagnosed **before 20 weeks gestation**. - The patient lacks prior blood pressure documentation, preventing confirmation of hypertension's onset before 20 weeks, making this an unsuitable definitive initial classification. *Gestational hypertension* - This diagnosis requires **new-onset hypertension** (blood pressure ">" 140/90 mmHg) occurring specifically **after 20 weeks** of pregnancy in a previously normotensive woman, without proteinuria or organ dysfunction. - Without early pregnancy blood pressure records to establish a normotensive baseline, it cannot be definitively classified as new-onset hypertension after 20 weeks. *Pre-eclampsia* - Characterized by new-onset hypertension (after 20 weeks) accompanied by **significant proteinuria** or evidence of **maternal organ dysfunction** (e.g., renal insufficiency, liver involvement, neurological symptoms). - The patient exhibits only **trace protein** on urine dipstick and has normal blood tests, failing to meet the criteria for significant proteinuria or organ dysfunction required for pre-eclampsia. *White coat hypertension* - Defined by consistently elevated blood pressure readings in a clinical setting that are **normal** when measured by **ambulatory blood pressure monitoring (ABPM)** or home blood pressure monitoring. - While the second reading was lower, the initial severe elevation (172/115 mmHg) at 20 weeks gestation requires further assessment to confirm or rule out true hypertension, rather than immediately classifying it as white coat effect.
Question 179: A 40-year-old woman in her third pregnancy presents to clinic at 32 weeks gestation. Her first pregnancy was complicated by early-onset severe pre-eclampsia requiring delivery at 30 weeks. Her current pregnancy has been uncomplicated so far. Her blood pressure today is 128/78 mmHg and urinalysis is negative for protein. She is taking aspirin 150 mg daily started at 12 weeks. What additional monitoring should be arranged for the remainder of this pregnancy?
- A. Standard antenatal care with routine blood pressure checks only
- B. Fortnightly ultrasound scans for fetal growth from 32 weeks
- C. Serial uterine artery Doppler assessments every 2 weeks
- D. Increased monitoring with blood pressure checks, urine protein assessment, and serial growth scans with umbilical artery Doppler from 32 weeks (Correct Answer)
- E. Weekly blood pressure and urine protein checks from 32 weeks
Explanation: ***Increased monitoring with blood pressure checks, urine protein assessment, and serial growth scans with umbilical artery Doppler from 32 weeks*** - This patient is at high risk due to a history of **early-onset severe pre-eclampsia** (delivery before 34 weeks), requiring enhanced surveillance to detect recurrence.- **NICE guidelines** recommend frequent clinical assessment combined with **serial ultrasound scans** and **umbilical artery Doppler** to monitor for fetal growth restriction (FGR).*Standard antenatal care with routine blood pressure checks only*- Standard care is insufficient for patients with a **high-risk obstetric history**, as it fails to provide the vigilant monitoring needed for early detection of complications.- Patients with previous severe pre-eclampsia have a **recurrence risk** of up to 25-65%, necessitating more than basic screening.*Fortnightly ultrasound scans for fetal growth from 32 weeks*- While growth scans are necessary, this option is incomplete as it ignores the clinical monitoring of **maternal blood pressure** and **proteinuria**, which are essential for diagnosing pre-eclampsia.- In high-risk pregnancies, fetal and maternal surveillance must be integrated rather than focusing on **fetal growth** alone.*Serial uterine artery Doppler assessments every 2 weeks*- **Uterine artery Dopplers** are typically used as a screening tool in the first or second trimester to predict pre-eclampsia, rather than for late-third-trimester monitoring.- At 32 weeks, **umbilical artery Doppler** is the preferred modality for assessing fetal well-being and placental function in high-risk scenarios.*Weekly blood pressure and urine protein checks from 32 weeks*- This approach correctly addresses maternal monitoring but completely omits **fetal surveillance** through ultrasound and Doppler.- Since early-onset pre-eclampsia is strongly associated with **placental insufficiency**, assessing the fetus for growth restriction is a mandatory component of the care plan.
Question 180: A 38-year-old woman presents at 29 weeks gestation with sudden onset severe epigastric pain and vomiting. Her blood pressure is 145/95 mmHg and she has significant right upper quadrant tenderness. Blood tests show: haemoglobin 105 g/L, platelets 78 × 10⁹/L, white cell count 12.5 × 10⁹/L, bilirubin 35 μmol/L, ALT 420 U/L, AST 385 U/L, LDH 650 U/L, and a blood film shows schistocytes. Urine shows 2+ protein. What is the most likely diagnosis?
- A. Acute fatty liver of pregnancy
- B. HELLP syndrome (Correct Answer)
- C. Severe pre-eclampsia without HELLP
- D. Acute cholecystitis
- E. Thrombotic thrombocytopenic purpura
Explanation: ***HELLP syndrome*** - This diagnosis is confirmed by the presentation of **haemolysis** (low Hb, elevated LDH and bilirubin, **schistocytes** on blood film), **elevated liver enzymes** (ALT, AST > 2x normal), and **low platelets** (<100 × 10⁹/L). - The sudden onset of **epigastric or RUQ pain** in a pregnant patient with **hypertension** (145/95 mmHg) and **proteinuria** (2+) at **29 weeks gestation** is a classic clinical manifestation. *Acute fatty liver of pregnancy* - While AFLP occurs in the third trimester and involves liver dysfunction, it typically presents with more profound **hypoglycaemia**, **coagulopathy** (prolonged PT/INR), and often more severe **hepatic encephalopathy**. - Although transaminases are elevated, the prominent **microangiopathic haemolytic anaemia** (schistocytes, low platelets, high LDH) is a hallmark of HELLP, not typically the primary feature of AFLP. *Severe pre-eclampsia without HELLP* - Although the patient meets the criteria for **severe pre-eclampsia** (hypertension and proteinuria), the specific laboratory findings of **thrombocytopenia** (<100,000/µL), **elevated liver enzymes**, and evidence of **haemolysis** (schistocytes, elevated LDH/bilirubin) explicitly define **HELLP syndrome**. - HELLP is a distinct and more severe complication; identifying it is critical as it carries a higher risk of **maternal and fetal morbidity and mortality** than pre-eclampsia alone. *Acute cholecystitis* - While **epigastric/RUQ pain** and vomiting can occur with acute cholecystitis, this diagnosis would not explain the comprehensive systemic abnormalities such as **hypertension**, **proteinuria**, **thrombocytopenia**, **elevated liver enzymes**, or the presence of **schistocytes**. - Cholecystitis is primarily a localized gallbladder inflammation, and while WBC count might be elevated, the widespread organ dysfunction points away from it. *Thrombotic thrombocytopenic purpura* - TTP is characterized by the classic pentad including **fever**, **neurological symptoms**, and **renal failure**, which are not the primary features described here. - Unlike HELLP, TTP is not fundamentally associated with **pregnancy-induced hypertension** or significant **proteinuria**; the clinical context points more strongly to HELLP.
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