A 33-year-old woman with gestational diabetes diagnosed at 28 weeks is now 32 weeks pregnant. She has been following dietary advice for 2 weeks. Her home blood glucose monitoring shows: fasting values 5.0-5.8 mmol/L and 1-hour post-prandial values 7.2-8.5 mmol/L. Ultrasound scan shows fetal abdominal circumference above the 75th centile. What is the most appropriate next step in management?
Q182
A 29-year-old woman attends her booking appointment at 11 weeks gestation. She is of South Asian origin with a body mass index of 28 kg/m². Her sister was diagnosed with gestational diabetes in her pregnancy. Random glucose at booking is 5.8 mmol/L. According to NICE guidelines, when should she be offered an oral glucose tolerance test?
Q183
A 26-year-old woman in her first pregnancy attends the emergency department at 34 weeks gestation with a severe frontal headache and visual disturbances described as 'flashing lights'. Her blood pressure is 168/112 mmHg. Urine dipstick shows 3+ protein. Bloods reveal: platelets 95 × 10⁹/L, ALT 85 U/L, creatinine 105 μmol/L. Cardiotocography shows a reassuring fetal heart rate pattern. What is the most appropriate immediate management?
Q184
A 30-year-old woman presents to the antenatal clinic at 26 weeks gestation with a random blood glucose of 11.2 mmol/L found at a routine appointment. She is asymptomatic and has no polyuria or polydipsia. Her body mass index at booking was 32 kg/m². She has no personal history of diabetes but her mother has type 2 diabetes. An oral glucose tolerance test (OGTT) is arranged. What fasting plasma glucose level would confirm a diagnosis of gestational diabetes according to current UK diagnostic criteria?
Q185
A 35-year-old woman with type 1 diabetes mellitus is planning her first pregnancy. She currently takes insulin aspart and insulin detemir, and her HbA1c is 58 mmol/mol (7.5%). She takes no other medications. According to current UK guidelines for preconception care in diabetic women, which additional medication should be commenced at an increased dose compared to the general population?
Q186
A 32-year-old woman attends antenatal clinic at 28 weeks gestation in her second pregnancy. She had a normal vaginal delivery in her first pregnancy. Her blood pressure today is 152/98 mmHg. A urine dipstick shows 2+ protein. Blood tests reveal: haemoglobin 118 g/L, platelets 145 × 10⁹/L, ALT 42 U/L, and creatinine 78 μmol/L. A spot urine protein:creatinine ratio is 45 mg/mmol. What is the most appropriate classification of her condition?
Q187
A 28-year-old primigravida attends her booking appointment at 10 weeks gestation. She has no significant past medical history and takes no regular medications. Her body mass index is 24 kg/m². Blood tests reveal she is rhesus negative. According to current UK guidelines, at what gestational age should she receive her first routine dose of anti-D immunoglobulin?
Pregnancy Medicine UK Medical PG Practice Questions and MCQs
Question 181: A 33-year-old woman with gestational diabetes diagnosed at 28 weeks is now 32 weeks pregnant. She has been following dietary advice for 2 weeks. Her home blood glucose monitoring shows: fasting values 5.0-5.8 mmol/L and 1-hour post-prandial values 7.2-8.5 mmol/L. Ultrasound scan shows fetal abdominal circumference above the 75th centile. What is the most appropriate next step in management?
A. Continue with diet and lifestyle modifications alone
B. Commence insulin therapy
C. Commence metformin therapy (Correct Answer)
D. Commence gliclazide therapy
E. Increase frequency of blood glucose monitoring to 8 times daily
Explanation: ***Commence metformin therapy***
- According to **NICE guidelines**, metformin should be offered as first-line pharmacological therapy if glucose targets are not met within **1–2 weeks** of diet and exercise.
- In this case, the **fetal abdominal circumference >75th centile** indicates macrosomia risk and inadequate glycemic control, necessitating pharmacological intervention despite lifestyle changes.
*Continue with diet and lifestyle modifications alone*
- The patient has already attempted diet and lifestyle for **2 weeks**, yet her 1-hour post-prandial levels remain above the target of **<7.8 mmol/L**.
- Continuing conservative management is inappropriate when there is ultrasound evidence of **fetal macrosomia** (abdominal circumference >75th centile).
*Commence insulin therapy*
- **Insulin therapy** is typically reserved as first-line if the fasting glucose is significantly high (e.g., >7.0 mmol/L) or if metformin is contraindicated or poorly tolerated.
- While her targets are not met, her glucose levels are not severely elevated enough to bypass **metformin** as the initial pharmacological choice.
*Commence gliclazide therapy*
- **Gliclazide** (a sulfonylurea) is not the first-line oral agent in gestational diabetes and is generally considered only if metformin is not tolerated or as an adjunct.
- It carries a higher risk of **fetal hypoglycemia** compared to metformin and is therefore not the preferred initial medication.
*Increase frequency of blood glucose monitoring to 8 times daily*
- Increasing the frequency of monitoring does not address the underlying **hyperglycemia** and evidence of fetal effects already documented.
- Management must shift toward **pharmacological control** rather than more frequent observation once diagnostic thresholds for treatment are crossed.
Question 182: A 29-year-old woman attends her booking appointment at 11 weeks gestation. She is of South Asian origin with a body mass index of 28 kg/m². Her sister was diagnosed with gestational diabetes in her pregnancy. Random glucose at booking is 5.8 mmol/L. According to NICE guidelines, when should she be offered an oral glucose tolerance test?
A. Immediately at the booking visit
B. At 16 weeks and if normal, repeat at 28 weeks
C. At 24-28 weeks only (Correct Answer)
D. At 28 weeks and if normal, repeat at 32 weeks
E. Only if she develops symptoms of diabetes
Explanation: ***At 24-28 weeks only***
- According to **NICE guidelines**, pregnant women with standard risk factors such as **South Asian origin**, a BMI > 30 kg/m² (or >25 kg/m² for some ethnic groups like South Asian), or a **first-degree relative** with diabetes should be offered an **oral glucose tolerance test (OGTT) at 24-28 weeks**.
- This patient satisfies multiple risk factors (South Asian origin, BMI 28, sister with GDM) but does not have a personal history of **gestational diabetes (GDM)**, which would mandate earlier testing.
*Immediately at the booking visit*
- Early testing is reserved for women with **previous gestational diabetes** to identify recurrence as soon as possible, or those with highly suggestive symptoms/blood tests.
- A **random glucose** of 5.8 mmol/L at booking is within normal limits and does not necessitate immediate diagnostic intervention for GDM.
*At 16 weeks and if normal, repeat at 28 weeks*
- This specific two-step testing protocol (at 16 weeks and if normal, repeat at 28 weeks) is indicated for women who have had **gestational diabetes** in a previous pregnancy.
- Since the patient's sister had GDM (family history) rather than the patient herself, the standard **24-28 week window** applies.
*At 28 weeks and if normal, repeat at 32 weeks*
- There is no routine recommendation in **NICE guidelines** to repeat a normal OGTT at 32 weeks based on standard risk factors alone.
- Repeating the test beyond the standard window is only considered clinically if new concerns, such as **macrosomia** or **polyhydramnios**, develop later in the pregnancy.
*Only if she develops symptoms of diabetes*
- **Gestational diabetes** is frequently **asymptomatic**, making symptom-based screening an unreliable and dangerous strategy.
- Screening is performed based on identified **risk factors** to enable early intervention and prevent maternal and fetal complications like **preeclampsia**, **macrosomia**, and **neonatal hypoglycemia**.
Question 183: A 26-year-old woman in her first pregnancy attends the emergency department at 34 weeks gestation with a severe frontal headache and visual disturbances described as 'flashing lights'. Her blood pressure is 168/112 mmHg. Urine dipstick shows 3+ protein. Bloods reveal: platelets 95 × 10⁹/L, ALT 85 U/L, creatinine 105 μmol/L. Cardiotocography shows a reassuring fetal heart rate pattern. What is the most appropriate immediate management?
A. Admit for observation and repeat blood pressure in 4 hours
B. Admit, commence intravenous magnesium sulphate and labetalol, plan delivery within 24-48 hours (Correct Answer)
C. Commence oral nifedipine and steroids, plan delivery at 37 weeks
D. Commence oral labetalol and arrange outpatient follow-up
E. Emergency caesarean section under general anaesthesia
Explanation: ***Admit, commence intravenous magnesium sulphate and labetalol, plan delivery within 24-48 hours***
- The patient presents with **severe pre-eclampsia** characterized by **severe hypertension** (168/112 mmHg), **proteinuria (3+)**, and **end-organ dysfunction** (thrombocytopenia, elevated liver enzymes, elevated creatinine), along with neurological symptoms like **severe headache** and **visual disturbances**. **Intravenous magnesium sulphate** is essential for **seizure prophylaxis** in this critical condition.
- Immediate **hospital admission** for close monitoring and stabilization of **blood pressure** with intravenous antihypertensives like **labetalol** is crucial. Delivery is the definitive treatment for pre-eclampsia, and planning it within 24-48 hours allows for maternal stabilization and administration of **corticosteroids** to enhance fetal lung maturity, especially at 34 weeks gestation.
*Admit for observation and repeat blood pressure in 4 hours*
- This approach is dangerously insufficient for **severe pre-eclampsia** with features of **end-organ damage** and severe maternal symptoms. Delaying active intervention significantly increases the risk of complications such as **eclampsia**, **stroke**, or **HELLP syndrome**.
- The patient's condition requires immediate pharmacological management, including **antihypertensives** and **magnesium sulphate**, not merely observation, due to the established diagnosis and severity.
*Commence oral nifedipine and steroids, plan delivery at 37 weeks*
- Planning delivery at 37 weeks is too late for a patient with **severe pre-eclampsia** and active symptoms at 34 weeks, as it poses unacceptable risks of **maternal morbidity and mortality**. Definitive management (delivery) must occur earlier.
- While **corticosteroids** are given for fetal lung maturity, **oral nifedipine** may not be sufficient for initial rapid blood pressure control in severe hypertension, and delaying delivery to 37 weeks is not appropriate here.
*Commence oral labetalol and arrange outpatient follow-up*
- **Outpatient management** is absolutely contraindicated for severe pre-eclampsia. This is a medical emergency requiring **in-patient care** and constant monitoring due to the high risk of rapid deterioration.
- Oral labetalol might be part of maintenance therapy, but it is insufficient as an immediate sole intervention, and **magnesium sulphate** for seizure prophylaxis is critically missing from this plan.
*Emergency caesarean section under general anaesthesia*
- While delivery is the definitive treatment, an **immediate emergency caesarean section** is generally not the first step if the fetus is **reassuring** on CTG and maternal stabilization is possible.
- The mother first needs **stabilization** of blood pressure and **seizure prophylaxis** with magnesium sulphate before delivery, and usually, time is allowed for **corticosteroids** to take effect for fetal lung maturity at 34 weeks. Delivery is planned, not an immediate emergency in this specific scenario.
Question 184: A 30-year-old woman presents to the antenatal clinic at 26 weeks gestation with a random blood glucose of 11.2 mmol/L found at a routine appointment. She is asymptomatic and has no polyuria or polydipsia. Her body mass index at booking was 32 kg/m². She has no personal history of diabetes but her mother has type 2 diabetes. An oral glucose tolerance test (OGTT) is arranged. What fasting plasma glucose level would confirm a diagnosis of gestational diabetes according to current UK diagnostic criteria?
A. ≥5.1 mmol/L
B. ≥5.6 mmol/L (Correct Answer)
C. ≥6.0 mmol/L
D. ≥6.5 mmol/L
E. ≥7.0 mmol/L
Explanation: ***≥5.6 mmol/L***- According to **NICE guidelines** in the UK, a diagnosis of **gestational diabetes (GDM)** is confirmed if the **fasting plasma glucose** is **≥5.6 mmol/L** during a 75g **OGTT**.- Only one abnormal value is required for diagnosis, with the other threshold being a **2-hour plasma glucose** of **≥7.8 mmol/L**.*≥5.1 mmol/L*- This threshold is used by the **WHO (World Health Organization)** and the International Association of Diabetes and Pregnancy Study Groups (**IADPSG**).- However, it is **not used in the UK** under current **NICE (NG3)** diagnostic criteria for pregnancy.*≥6.0 mmol/L*- This is not a specific diagnostic threshold for **gestational diabetes** or impaired fasting glucose in the context of pregnancy under UK guidelines.- While higher than normal, it does not represent the specific **NICE-defined cutoff** of 5.6 mmol/L.*≥6.5 mmol/L*- This value is not used for GDM diagnosis; however, a level of **6.5% (48 mmol/mol)** is the **HbA1c threshold** for diagnosing **Type 2 Diabetes** outside of pregnancy.- Gestational diabetes screening relies on **plasma glucose levels** via OGTT rather than HbA1c due to physiological changes in blood cell turnover during pregnancy.*≥7.0 mmol/L*- A fasting plasma glucose of **≥7.0 mmol/L** is the threshold used to diagnose **pre-existing (pre-gestational) diabetes** or Type 2 Diabetes.- If this level is reached during screening, the patient is managed for **Type 2 Diabetes** manifesting in pregnancy rather than standard GDM.
Question 185: A 35-year-old woman with type 1 diabetes mellitus is planning her first pregnancy. She currently takes insulin aspart and insulin detemir, and her HbA1c is 58 mmol/mol (7.5%). She takes no other medications. According to current UK guidelines for preconception care in diabetic women, which additional medication should be commenced at an increased dose compared to the general population?
A. Folic acid 5 mg daily (Correct Answer)
B. Folic acid 400 micrograms daily
C. Vitamin D 400 IU daily
D. Aspirin 75 mg daily
E. Metformin 500 mg twice daily
Explanation: ***Folic acid 5 mg daily***- NICE and UK guidelines recommend that women with **pre-existing diabetes** take a high dose of **5 mg folic acid** daily to reduce the risk of **neural tube defects**.- This dose should be started at least **one month preconception** and continued until the **12th week of gestation**.*Folic acid 400 micrograms daily*- This is the standard dose recommended for the **general population** with low risk for neural tube defects.- Women with diabetes are at a **higher risk** of neural tube defects, necessitating the larger 5 mg pharmacological dose.*Vitamin D 400 IU daily*- Routine **Vitamin D supplementation** is recommended for all pregnant women, but this dose is not specifically increased for diabetic patients compared to the general population.- It plays a role in bone health but does not mitigate the specific diabetic-related risk of **congenital malformations**.*Aspirin 75 mg daily*- Low-dose aspirin is recommended to reduce the risk of **pre-eclampsia** in women with pre-existing diabetes.- However, it is typically commenced at **12 weeks gestation** rather than as a preconception requirement.*Metformin 500 mg twice daily*- **Metformin** may be used in Type 2 diabetes or PCOS, but this patient has **Type 1 diabetes** where insulin is the primary treatment.- While Metformin is sometimes added to insulin in T1DM, it is not a routine **preconception requirement** for all diabetic women regardless of glycemic control to prevent specific fetal anomalies.
Question 186: A 32-year-old woman attends antenatal clinic at 28 weeks gestation in her second pregnancy. She had a normal vaginal delivery in her first pregnancy. Her blood pressure today is 152/98 mmHg. A urine dipstick shows 2+ protein. Blood tests reveal: haemoglobin 118 g/L, platelets 145 × 10⁹/L, ALT 42 U/L, and creatinine 78 μmol/L. A spot urine protein:creatinine ratio is 45 mg/mmol. What is the most appropriate classification of her condition?
A. Gestational hypertension
B. Mild pre-eclampsia
C. Moderate pre-eclampsia (Correct Answer)
D. Severe pre-eclampsia
E. Chronic hypertension with superimposed pre-eclampsia
Explanation: ***Moderate pre-eclampsia***
- This patient has **new-onset hypertension** (152/98 mmHg) and significant **proteinuria** (uPCR 45 mg/mmol) developing after 20 weeks gestation, confirming **pre-eclampsia**.
- The blood pressure of 152/98 mmHg falls into the **moderate hypertension** range, and there are no features indicating severe disease (e.g., BP ≥160/110 mmHg, platelets <100 × 10⁹/L, ALT >70 U/L).
*Gestational hypertension*
- This diagnosis is characterized by **new-onset hypertension** after 20 weeks of gestation **without significant proteinuria** or signs of end-organ damage.
- The presence of a **protein:creatinine ratio (uPCR) of 45 mg/mmol** (above the 30 mg/mmol threshold) explicitly rules out gestational hypertension.
*Mild pre-eclampsia*
- While sometimes used, **mild pre-eclampsia** typically refers to blood pressures between 140/90 and 149/99 mmHg.
- With a diastolic blood pressure of **98 mmHg** and systolic of **152 mmHg**, the patient's condition exceeds the
Question 187: A 28-year-old primigravida attends her booking appointment at 10 weeks gestation. She has no significant past medical history and takes no regular medications. Her body mass index is 24 kg/m². Blood tests reveal she is rhesus negative. According to current UK guidelines, at what gestational age should she receive her first routine dose of anti-D immunoglobulin?
A. 16 weeks
B. 20 weeks
C. 28 weeks (Correct Answer)
D. 32 weeks
E. 36 weeks
Explanation: ***28 weeks***
- In the UK, **NICE guidelines** recommend routine antenatal anti-D prophylaxis (**RAADP**) be administered at **28 weeks** gestation for Rhesus-negative women.
- This timing is chosen because the risk of **sensitization** (maternal production of anti-D antibodies) increases significantly in the **third trimester**.
*16 weeks*
- Administration at **16 weeks** is too early for routine prophylaxis, as fetal-to-maternal **hemorrhage** sufficient to cause sensitization is rare at this stage.
- Anti-D would only be given this early if a specific **sensitizing event** occurred, such as a miscarriage after 12 weeks or an invasive procedure.
*20 weeks*
- Although fetal blood cells are present in the maternal circulation, the **standard protocol** does not initiate routine prophylaxis at the **mid-pregnancy scan** stage.
- Routine prophylaxis at this time would not provide adequate coverage through to the end of the **term pregnancy**.
*32 weeks*
- While some two-dose regimens include a second injection at **34 weeks**, the **initial dose** must be given earlier at 28 weeks to ensure coverage.
- Waiting until **32 weeks** leaves a window of vulnerability where **silent sensitization** could occur during the start of the third trimester.
*36 weeks*
- Administering the first dose at **36 weeks** is far too late to be effective as **routine prophylaxis** against sensitizing events occurring earlier in the trimester.
- By this stage, the woman may have already been exposed to **fetal D-positive cells**, rendering the late administration ineffective for preventing sensitization.
