Pregnancy Medicine — MCQs

Pregnancy Medicine UK Medical PG Practice Questions and MCQs

Question 11: A 33-year-old woman at 28 weeks gestation presents with sudden onset dyspnea and chest pain. D-dimer is elevated. What is the most appropriate investigation?

A. Chest X-ray
B. V/Q scan (Correct Answer)
C. CT pulmonary angiogram
D. Echocardiogram
E. Arterial blood gas

Explanation: ***V/Q scan***- The **Ventilation/Perfusion (V/Q) scan** is the preferred initial imaging modality for suspected PE in **pregnant patients** when the Chest X-ray (CXR) is normal, due to its significantly **lower fetal radiation exposure** compared to CTPA.- A V/Q scan that yields a high probability result is highly suggestive of PE, while a normal scan essentially rules out the diagnosis. *Chest X-ray*- A **CXR** should be performed initially in all patients with suspected PE to exclude other pulmonary pathology (e.g., pneumothorax, pneumonia) that may mimic PE symptoms.- While important for differential diagnosis, the CXR is rarely diagnostic for PE, as classic findings like the **Westermark sign** or **Hampton's hump** are uncommon. *CT pulmonary angiogram*- **CTPA** is highly sensitive for PE but delivers a higher radiation dose to both the fetus and the **maternal breast tissue** (increasing lifetime risk of cancer).- CTPA is usually reserved for situations where the initial CXR is abnormal (which limits the interpretability of a V/Q scan) or when the V/Q scan results are indeterminate. *Echocardiogram*- An **echocardiogram** is primarily used to assess the presence of **right ventricular (RV) strain** or dysfunction, a crucial prognostic marker in submassive or massive PE.- It helps differentiate PE from cardiac causes of chest pain/dyspnea but is not the study of choice for the definitive anatomical diagnosis of a pulmonary embolus. *Arterial blood gas*- **ABG** analysis often reveals **hypoxemia** and **respiratory alkalosis** (due to hyperventilation) in acute PE.- This test is non-specific, as these findings can occur in various causes of acute respiratory distress, thus an ABG cannot confirm the diagnosis of PE.

Question 12: A 31-year-old woman at 16 weeks gestation presents with severe nausea, vomiting, and dehydration. She has lost 8% of her pre-pregnancy weight. Urine shows 3+ ketones. What is the most appropriate management?

A. Oral antiemetics only
B. IV fluids and thiamine (Correct Answer)
C. Immediate termination
D. High-dose steroids
E. Enteral feeding

Explanation: ***IV fluids and thiamine***- This patient presents with **Hyperemesis Gravidarum (HG)**, evidenced by severe vomiting, dehydration, and significant weight loss (>5%), requiring immediate **intravenous crystalloid** treatment for fluid and electrolyte restoration.- Thiamine (Vitamin B1) must be administered concurrently, or before, glucose-containing fluids to prevent the precipitation of **Wernicke's encephalopathy**, a serious complication of prolonged vomiting and malnutrition.*Oral antiemetics only*- Oral antiemetics are insufficient as monotherapy when the patient exhibits signs of severe systemic illness, such as **dehydration**, significant weight loss (8%), and ketonuria.- Due to the severity, hospitalization and intensive **IV rehydration** and electrolyte correction are mandatory steps before focusing solely on antiemetic medication routes.*Immediate termination*- Termination of pregnancy is reserved only for extremely rare cases of HG that are completely refractory to all medical management and threaten the mother's life.- The immediate priority is stabilizing the patient through **fluid resuscitation** and nutritional support, not proceeding directly to termination.*High-dose steroids*- Corticosteroids (e.g., prednisolone) are generally considered third-line agents and are reserved for patients with HG refractory to first- and second-line antiemetics (such as **pyridoxine/doxylamine** or **ondansetron**).- They are not the most appropriate first management step for correcting acute, life-threatening metabolic derangements like dehydration.*Enteral feeding*- Enteral or parenteral **nutritional support** is reserved for patients who continue to experience weight loss, nutritional deficiency, or lack of significant improvement despite optimized intravenous rehydration and aggressive antiemetic regimens.- Initial management strictly focuses on correcting **fluid deficits** and administering necessary micronutrients like thiamine.

Question 13: A 35-year-old woman at 28 weeks gestation presents with severe headache, visual disturbances, and epigastric pain. Her BP is 170/110 mmHg. Urine shows 3+ protein. Platelet count is 90,000/μL. What is the most likely diagnosis?

A. Gestational hypertension
B. Pre-eclampsia
C. HELLP syndrome (Correct Answer)
D. Eclampsia
E. Chronic hypertension

Explanation: ***HELLP syndrome*** - This diagnosis is characterized by **H**emolysis (implied by severe features), **E**levated **L**iver enzymes (implied by **epigastric pain** due to liver capsule distension), and **L**ow **P**latelets (confirmed by **thrombocytopenia of 90,000/μL**). - The combination of **severe hypertension**, **proteinuria**, and these specific laboratory and clinical findings (headache, visual disturbances) at 28 weeks gestation is pathognomonic for **HELLP syndrome**. *Gestational hypertension* - **Gestational hypertension** is characterized by new-onset hypertension after 20 weeks gestation without **proteinuria** or signs of **end-organ damage**. - This patient has significant **proteinuria (3+)** and severe features including **thrombocytopenia** and **epigastric pain**, which rules out gestational hypertension alone. *Pre-eclampsia* - **Pre-eclampsia** involves new-onset hypertension and proteinuria, or hypertension with severe features; however, **HELLP syndrome** is a specific, severe *complication* defined by specific laboratory abnormalities. - Given the severe symptoms and documented **thrombocytopenia (90,000/μL)**, the diagnosis has progressed beyond generalized pre-eclampsia to the specific entity of **HELLP syndrome**. *Eclampsia* - **Eclampsia** is defined as pre-eclampsia complicated by new-onset generalized tonic-clonic **seizures**. - Although the patient has severe features (headache, visual changes), the critical feature of a **seizure** is absent in this presentation. *Chronic hypertension* - **Chronic hypertension** is defined as hypertension present before pregnancy or diagnosed before **20 weeks gestation**. - The acute onset of **proteinuria**, severe symptoms (headache, visual disturbances, epigastric pain), and **thrombocytopenia** indicate an acute pregnancy-induced disorder rather than isolated chronic hypertension.

Question 14: A 30-year-old pregnant woman at 32 weeks gestation presents with sudden severe abdominal pain and vaginal bleeding. On examination, the uterus is tender and tense. Fetal monitoring shows bradycardia. What is the most likely diagnosis?

A. Placenta previa
B. Placental abruption (Correct Answer)
C. Uterine rupture
D. Preterm labor
E. Vasa previa

Explanation: ***Placental abruption***- This diagnosis is characterized by the classic triad of **sudden severe abdominal pain**, **vaginal bleeding**, and a **tender/tense (hypertonic) uterus**, indicating premature separation of the placenta from the uterine wall.- **Fetal bradycardia** or distress occurs due to impaired maternal-fetal oxygen exchange resulting from the separation.*Placenta previa*- The hallmark presentation is **painless vaginal bleeding** after 20 weeks gestation, typically without severe abdominal pain.- The uterus usually remains **soft and non-tender** because there is no myometrial irritation or hypertonicity associated with the implantation site.*Uterine rupture*- Symptoms include sudden, severe pain and typically leads to cessation of contractions and often **loss of uterine tone** or easy palpation of fetal parts outside the uterus.- While associated with acute fetal distress, the presence of a **tense and tender uterus** makes abruption more likely than rupture.*Preterm labor*- This involves rhythmic **uterine contractions** leading to cervical change; while pain is present, the severe bleeding and intense **uterine rigidity** are not typical primary distinguishing features.- Fetal distress, while possible, is usually secondary to prolonged labor or other complications, and not the immediate presenting sign alongside the rigid uterus.*Vasa previa*- Presents with **painless vaginal bleeding** following rupture of membranes when fetal vessels overlie the cervix (rupture of the vessels).- It causes immediate and profound **fetal distress/bradycardia** but does not cause acute maternal abdominal pain or a tender, hypertonic uterus.

Question 15: A 35-year-old woman at 20 weeks gestation presents with fever, dysuria, and loin pain. Urine culture grows E. coli sensitive to amoxicillin. What is the most appropriate treatment?

A. Trimethoprim
B. Nitrofurantoin
C. Amoxicillin (Correct Answer)
D. Ciprofloxacin
E. Co-amoxiclav

Explanation: ***Amoxicillin***- The patient presents with **pyelonephritis** in pregnancy, and the urine culture confirms **E. coli sensitivity to amoxicillin**.- **Amoxicillin is a beta-lactam antibiotic**, generally considered **safe and effective in pregnancy** (Category B) for susceptible organisms.*Trimethoprim*- **Trimethoprim is contraindicated in the first trimester** of pregnancy due to its **folate antagonist** effects, potentially leading to neural tube defects.- Although its use in later trimesters is debated, **amoxicillin is a preferred and safer option** when indicated by culture sensitivity.*Nitrofurantoin*- While commonly used for **lower urinary tract infections (cystitis)** in pregnancy, **nitrofurantoin is less effective for pyelonephritis** due to poor tissue penetration.- It is **contraindicated in the third trimester (especially near term)** due to the risk of **hemolytic anemia in the neonate**.*Ciprofloxacin*- **Ciprofloxacin is a fluoroquinolone**, which is generally **contraindicated in pregnancy** due to concerns about **fetal cartilage damage**.- It should only be considered if safer alternatives are unavailable or ineffective, which is not the case here given amoxicillin sensitivity.*Co-amoxiclav*- While related to amoxicillin, the addition of **clavulanic acid in co-amoxiclav has been linked to a potential increased risk of necrotizing enterocolitis in premature infants**.- Given that **amoxicillin alone is effective** and well-tolerated, it is the more appropriate and safer choice for this patient.

Question 16: A 25-year-old woman at 10 weeks gestation presents with nausea, vomiting, and inability to keep fluids down for 3 days. She has lost 3kg in weight. Urine shows 3+ ketones. What is the most appropriate management?

A. Oral antiemetics
B. IV fluids and antiemetics (Correct Answer)
C. Immediate delivery
D. Dietary advice only
E. Psychological support

Explanation: ***IV fluids and antiemetics*** - The patient's presentation with intractable nausea and vomiting, inability to keep fluids down, significant weight loss (3kg), and **ketonuria** (3+ ketones) are classic signs of **Hyperemesis Gravidarum (HG)**. - **Intravenous fluids** are crucial to correct severe **dehydration** and electrolyte imbalances, while parenteral antiemetics are necessary as oral intake is not tolerated due to persistent vomiting. *Oral antiemetics* - Given the patient's inability to keep fluids down, oral medications would be ineffective due to likely vomiting and poor absorption. - Oral antiemetics are appropriate for milder forms of **nausea and vomiting of pregnancy**, not for severe HG with evidence of **dehydration** and **ketosis**. *Immediate delivery* - **Immediate delivery** or termination of pregnancy is an extreme measure not indicated at 10 weeks gestation for HG, especially as it usually resolves spontaneously by the second trimester. - This intervention is only considered in extremely rare, life-threatening situations where HG is refractory to maximal medical therapy and causes severe, irreversible maternal complications like **Wernicke encephalopathy**. *Dietary advice only* - Dietary advice is suitable for mild cases of **nausea and vomiting of pregnancy**, but it is insufficient for a patient with established **Hyperemesis Gravidarum** manifesting with severe **dehydration**, **weight loss**, and **ketonuria**. - The severity of symptoms requires aggressive medical intervention, including **IV rehydration** and antiemetics, not just simple lifestyle modifications. *Psychological support* - While **psychological support** can be beneficial as an adjunct for the distress associated with HG, it does not address the immediate and urgent medical needs of **dehydration**, electrolyte imbalance, and nutritional deficits. - The priority is the physical stabilization of the patient through **IV fluids** and antiemetics, after which psychological support can be incorporated.

Question 17: A 30-year-old pregnant woman at 28 weeks gestation presents with sudden onset severe headache and blurred vision. Her BP is 170/110 mmHg. Urinalysis shows 2+ protein. What is the most appropriate initial treatment?

A. Sublingual nifedipine
B. IV labetalol (Correct Answer)
C. Oral methyldopa
D. IV hydralazine
E. Oral amlodipine

Explanation: ***IV labetalol***- **IV Labetalol** is the recommended first-line agent for the acute management of **severe hypertension** in pregnancy (BP \u2265 160/110 mmHg) because it acts rapidly and is safely titratable to reduce the risk of maternal stroke.- It provides effective blood pressure control while minimizing risks to the fetus and typically avoiding severe **maternal hypotension**, which could compromise placental perfusion.*Sublingual nifedipine*- **Sublingual preparations** of nifedipine are generally avoided in acute severe hypertension due to the risk of a **precipitous drop in blood pressure**.- This rapid drop can lead to uteroplacental hypoperfusion and **fetal distress**, making it unsuitable for initial stabilization of severe preeclampsia.*Oral methyldopa*- Methyldopa is a highly safe agent used predominantly for the **chronic management** of mild to moderate hypertension in pregnancy.- It has a **slow onset of action** (several hours) and is therefore ineffective for treating the acute hypertensive crisis presented here (BP 170/110 mmHg).*IV hydralazine*- IV hydralazine is an effective **vasodilator** and a traditional second-line agent for severe hypertension in pregnancy, often used if labetalol is contraindicated.- Compared to labetalol, it can cause more frequent side effects, including **maternal tachycardia** and severe headaches, making labetalol the preferred first choice.*Oral amlodipine*- Amlodipine is an oral **calcium channel blocker** typically used for maintenance therapy of chronic hypertension.- Its **onset of action is too slow** to address the immediate danger posed by severe-range blood pressure, which requires immediate, titratable IV therapy.

Question 18: A 32-year-old pregnant woman at 36 weeks gestation presents with severe headache, visual disturbances, and epigastric pain. Her BP is 165/110 mmHg. Urine protein is 3+. What is the most likely diagnosis?

A. Gestational hypertension
B. Chronic hypertension
C. Pre-eclampsia (Correct Answer)
D. Eclampsia
E. HELLP syndrome

Explanation: ***Pre-eclampsia*** - The combination of **new-onset hypertension** (BP > 140/90 mmHg) and **proteinuria** (3+) developing after 20 weeks of gestation defines pre-eclampsia. - Severe features, including **BP 165/110 mmHg**, **severe headache**, **visual disturbances**, and **epigastric pain** (indicative of liver capsule distension), confirm the diagnosis of pre-eclampsia with severe features. *Gestational hypertension* - This diagnosis applies only if a patient develops hypertension after 20 weeks without any accompanying **proteinuria** or signs of **end-organ dysfunction**. - The presence of 3+ proteinuria and severe symptoms (headache, visual changes) explicitly excludes the diagnosis of simple **gestational hypertension**. *Chronic hypertension* - Chronic hypertension is defined as hypertension present before pregnancy or diagnosed before **20 weeks of gestation**. - This diagnosis is unlikely as the patient is 36 weeks pregnant, and the presentation of new severe features with proteinuria points toward a pregnancy-specific disorder. *Eclampsia* - Eclampsia is diagnosed when **tonic-clonic seizures** occur in a woman with pre-eclampsia. - While the patient has severe pre-eclampsia, the absence of reported **convulsions** means she currently does not meet the diagnostic criteria for eclampsia. *HELLP syndrome* - HELLP is a specific complication of pre-eclampsia defined by **Hemolysis**, **Elevated Liver enzymes**, and **Low Platelets**. - While the patient's severe symptoms (epigastric pain) suggest she may be developing HELLP, pre-eclampsia is the overall, most encompassing diagnosis based on the initial presentation of hypertension and proteinuria.

Question 19: A 39-year-old woman at 32 weeks gestation presents with severe headache, blurred vision, and RUQ pain. BP is 165/105 mmHg. Blood tests show AST 150 U/L, platelets 80,000/μL. What is the most appropriate management?

A. Antihypertensive therapy
B. Magnesium sulfate
C. Immediate delivery (Correct Answer)
D. Corticosteroids
E. Plasma exchange

Explanation: ***Immediate delivery*** - The clinical presentation of severe headache, blurred vision, RUQ pain, **hypertension (165/105 mmHg)**, **elevated AST (150 U/L)**, and **thrombocytopenia (80,000/μL)** defines **HELLP syndrome**, a life-threatening obstetric emergency. - At 32 weeks gestation, with signs of severe preeclampsia and HELLP syndrome, **immediate delivery** is the definitive treatment to prevent further maternal and fetal morbidity and mortality, as it removes the underlying placental cause. *Antihypertensive therapy* - **Antihypertensive therapy** is crucial for managing severe hypertension (BP 165/105 mmHg) to prevent **maternal complications** like stroke. - While essential for **maternal stabilization** prior to delivery, it addresses only a symptom and does not resolve the underlying pathology of HELLP syndrome. *Magnesium sulfate* - **Magnesium sulfate** is indicated for **seizure prophylaxis** in patients with severe preeclampsia or HELLP syndrome to prevent **eclampsia**. - It is a vital component of maternal management but serves as an adjunct and does not treat the HELLP syndrome itself, which requires delivery. *Corticosteroids* - **Antenatal corticosteroids** (e.g., betamethasone) are typically given to promote **fetal lung maturity** when delivery is anticipated before 34 weeks gestation. - In rapidly progressive or severe HELLP syndrome, the risks of delaying delivery to complete a full course of corticosteroids often outweigh the benefits, making immediate delivery paramount. *Plasma exchange* - **Plasma exchange** is primarily indicated for other microangiopathic hemolytic anemias such as **Thrombotic Thrombocytopenic Purpura (TTP)** or atypical Hemolytic Uremic Syndrome (aHUS). - While HELLP syndrome involves microangiopathic hemolysis, its resolution is achieved by **delivery of the placenta**, and plasma exchange is not typically a standard treatment.

Question 20: A 34-year-old woman at 20 weeks gestation presents with fever, flank pain, and dysuria. Urine culture grows E. coli sensitive to amoxicillin. What is the most appropriate treatment?

A. Trimethoprim
B. Nitrofurantoin
C. Amoxicillin (Correct Answer)
D. Ciprofloxacin
E. Co-amoxiclav

Explanation: ***Amoxicillin***- This is an appropriate choice as it is a **Category B** drug, confirming it is safe for use throughout all trimesters of pregnancy, and the *E. coli* strain is specifically reported as **sensitive** to it.- Pyelonephritis in pregnancy requires treatment with safe, effective agents; **Amoxicillin** (or other beta-lactams like cephalosporins) meets both criteria.*Trimethoprim*- **Trimethoprim** is a **folate antagonist** and is generally avoided during the first trimester due to the risk of fetal **neural tube defects**.- Though the patient is in the second trimester, it is typically reserved only if safer alternatives like penicillins or cephalosporins cannot be used, prioritizing safety.*Nitrofurantoin*- **Nitrofurantoin** is generally effective only for lower UTIs (**cystitis**) because it does not achieve high concentrations in renal tissue, making it inappropriate for treating **pyelonephritis**.- While safe during the second trimester, it is avoided close to term (after 36 weeks) due to the risk of neonatal **hemolytic anemia**.*Ciprofloxacin*- **Ciprofloxacin** belongs to the class of **fluoroquinolones**, which are contraindicated throughout pregnancy.- These drugs are associated with potential risk of fetal **arthropathy** or damage to developing fetal cartilage.*Co-amoxiclav*- While safe in pregnancy (**Category B**), using the combination drug **Co-amoxiclav** is unnecessary when the organism is specifically sensitive to **Amoxicillin** alone.- Using the combination formulation increases the cost and risk of adverse effects, such as **diarrhea** or **hepatic dysfunction**, without providing additional clinical benefit here.

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