Pregnancy Medicine — MCQs
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A 33-year-old woman at 20 weeks gestation presents with fever, dysuria, and right loin pain. Urine culture grows E. coli. What is the most appropriate antibiotic?
A 29-year-old pregnant woman at 36 weeks presents with sudden onset severe chest pain and dyspnea. D-dimer is elevated. CT pulmonary angiogram shows multiple bilateral pulmonary emboli. What is the most appropriate treatment?
A 32-year-old pregnant woman at 38 weeks gestation presents with sudden onset severe abdominal pain and cessation of fetal movements. Her previous pregnancy was delivered by cesarean section. On examination, the fetal heart rate is absent and the uterine contour is abnormal. What is the most likely diagnosis?
A 39-year-old woman with gestational diabetes on metformin and insulin is reviewed at 36 weeks gestation. Her glycaemic control has been excellent throughout. She has had serial growth scans which show estimated fetal weight consistently on the 75th centile. Today's scan shows the estimated fetal weight is 3.6 kg (75th centile). She asks about the risk of shoulder dystocia and whether caesarean section should be considered. What is the most appropriate counselling?
A 26-year-old woman is admitted at 35 weeks gestation with pre-eclampsia. Blood pressure is 156/102 mmHg on labetalol 200 mg three times daily. Blood tests show: platelets 132 × 10⁹/L, ALT 45 U/L, creatinine 78 µmol/L, urate 0.38 mmol/L. Urinary protein:creatinine ratio is 42 mg/mmol. CTG is reassuring. She has no symptoms. The team plans expectant management with close monitoring. What additional medication should be administered now?
A 35-year-old woman in her second pregnancy attends for her booking appointment at 12 weeks gestation. In her previous pregnancy, she had gestational diabetes requiring insulin and developed polyhydramnios. Her baby was delivered at 37 weeks by emergency caesarean section for fetal distress and weighed 4.2 kg. Her booking BMI is 31 kg/m² and random glucose today is 6.8 mmol/L. What is the most appropriate screening approach for gestational diabetes in this pregnancy?
A 31-year-old woman presents to antenatal clinic at 29 weeks gestation with blood pressure 172/118 mmHg. She reports a severe headache and visual disturbances described as flashing lights. This is her first pregnancy. Urinalysis shows 2+ proteinuria. She is already taking labetalol 200 mg three times daily, started 2 weeks ago for gestational hypertension. What is the most appropriate immediate management?
A 37-year-old woman with type 1 diabetes presents for pre-pregnancy counselling. She has had diabetes for 15 years and her most recent HbA1c is 68 mmol/mol (8.4%). She takes insulin aspart three times daily and insulin glargine once at night. Retinal screening 6 months ago showed background diabetic retinopathy. Her BMI is 26 kg/m². What is the single most important immediate action before conception?
A 29-year-old primigravida is admitted at 33 weeks gestation with severe pre-eclampsia. Her blood pressure is 168/114 mmHg despite treatment with labetalol and nifedipine. She has 3+ proteinuria on dipstick. Blood tests show: platelets 89 × 10⁹/L, ALT 156 U/L, AST 142 U/L, LDH 680 U/L, haemoglobin 102 g/L. Blood film shows fragmented red cells. She is asymptomatic and CTG is reassuring. What is the most appropriate immediate management?
A 34-year-old woman undergoes oral glucose tolerance test at 28 weeks gestation due to BMI of 33 kg/m². Results show: fasting glucose 4.9 mmol/L, 2-hour glucose 8.2 mmol/L. She is given a blood glucose monitor and advised on diet and lifestyle modifications. After 1 week of monitoring, her blood glucose diary shows: fasting glucose 4.8-5.1 mmol/L on all days, and 1-hour post-prandial readings ranging from 7.4-8.6 mmol/L. What is the most appropriate next step in management?
Pregnancy Medicine UK Medical PG Practice Questions and MCQs
Question 31: A 33-year-old woman at 20 weeks gestation presents with fever, dysuria, and right loin pain. Urine culture grows E. coli. What is the most appropriate antibiotic?
- A. Trimethoprim
- B. Nitrofurantoin
- C. Amoxicillin (Correct Answer)
- D. Ciprofloxacin
- E. Gentamicin
Explanation: ***Amoxicillin*** - **Amoxicillin** is a penicillin (beta-lactam) and is classified as **Pregnancy Category B**, making it one of the safest first-line antibiotics for treating infections, including pyelonephritis, during pregnancy. - As an oral beta-lactam, it is often used as initial **empirical therapy** or for step-down treatment, provided the *E. coli* strain is confirmed to be sensitive. *Trimethoprim* - **Trimethoprim** is generally discouraged in the first trimester due to its **folate antagonism**, which poses a theoretical risk of teratogenicity. - It is also generally avoided in the third trimester due to the risk of **kernicterus** in the neonate by displacing bilirubin from albumin. *Nitrofurantoin* - This agent is primarily used for **cystitis** (lower UTI) or prophylaxis during pregnancy because it does not achieve adequate **therapeutic concentrations** in the renal parenchyma. - Therefore, it is ineffective for treating **pyelonephritis**, which involves infection of the kidney tissue (upper UTI). *Ciprofloxacin* - **Ciprofloxacin** is a fluoroquinolone, generally avoided during pregnancy (Pregnancy Category C/D) due to experimental evidence showing potential damage to developing **fetal cartilage** and joints (arthropathy). - Fluoroquinolones are typically reserved only for severe infections where safer alternatives are unavailable and benefits outweigh significant risks. *Gentamicin* - **Gentamicin** is an aminoglycoside (Pregnancy Category D), associated with risks of **ototoxicity** and **nephrotoxicity** to the fetus. - While it can be used intravenously for severe pyelonephritis, safer alternatives like cephalosporins or Amoxicillin are preferred for initial management or step-down therapy.
Question 32: A 29-year-old pregnant woman at 36 weeks presents with sudden onset severe chest pain and dyspnea. D-dimer is elevated. CT pulmonary angiogram shows multiple bilateral pulmonary emboli. What is the most appropriate treatment?
- A. Warfarin
- B. Unfractionated heparin
- C. Low molecular weight heparin (Correct Answer)
- D. Rivaroxaban
- E. Thrombolysis
Explanation: ***Low molecular weight heparin***- This is the standard of care for treating **pulmonary embolism** during pregnancy because it does not cross the **placenta**, ensuring fetal safety.- It offers predictable dosing and allows outpatient management without the intense laboratory monitoring required by unfractionated heparin.*Warfarin*- **Warfarin** is a known teratogen and is contraindicated during pregnancy, particularly in the first trimester (leading to **Warfarin embryopathy**).- It also significantly increases the risk of maternal and fetal hemorrhage later in pregnancy as it crosses the placenta.*Unfractionated heparin*- While safe for the fetus, **unfractionated heparin (UFH)** requires constant intravenous infusion or frequent subcutaneous injections and close monitoring of the **aPTT**.- UFH is usually reserved for initial management in hemodynamically unstable patients or those with severe **renal impairment**.*Rivaroxaban*- **Rivaroxaban**, an oral direct Factor Xa inhibitor (DOAC), is contraindicated in pregnancy due to insufficient data regarding its **fetal safety** and potential teratogenicity.- Current guidelines prioritize agents with robust safety data, such as heparins (LMWH or UFH).*Thrombolysis*- **Thrombolysis** (fibrinolytic therapy) is generally reserved only for patients with **massive PE** who present with **hemodynamic instability** or shock.- The patient, though symptomatic, is presumed stable; thrombolysis carries a high risk of major bleeding and is not indicated as initial therapy for stable PE.
Question 33: A 32-year-old pregnant woman at 38 weeks gestation presents with sudden onset severe abdominal pain and cessation of fetal movements. Her previous pregnancy was delivered by cesarean section. On examination, the fetal heart rate is absent and the uterine contour is abnormal. What is the most likely diagnosis?
- A. Placental abruption
- B. Uterine rupture (Correct Answer)
- C. Cord prolapse
- D. Fetal death
- E. Preterm labor
Explanation: ***Uterine rupture*** - The history of a previous **Cesarean section** is the most significant risk factor, and the classic features include sudden, **severe abdominal pain**, cessation of fetal movements, and signs of fetal demise. - The crucial differentiating finding is the **abnormal uterine contour** (often loss of tone or easily palpable fetal parts), indicating disruption of the **myometrium** and fetal expulsion into the peritoneal cavity.*Placental abruption* - While causing sudden **severe abdominal pain** and fetal compromise, abruption leads to a **firm, board-like uterus** due to internal hemorrhage, not an abnormal contour. - The most classic presenting feature is often painful vaginal bleeding, although concealed abruption is possible, the physical finding of an abnormal contour points away from abruption.*Cord prolapse* - This usually presents as sudden fetal distress (e.g., severe FHR decelerations) or the visualization/palpation of the cord in the vagina, but it is not typically associated with **acute, severe maternal abdominal pain**. - Cord prolapse primarily affects the fetus and does not cause the loss of uterine integrity or the consequent **abnormal uterine contour** seen in rupture.*Fetal death* - Fetal death (absent FHR) is the *result* of the underlying catastrophic event (rupture or severe abruption), not the primary diagnosis that explains the mother's intense **abdominal pain** and the physical exam finding of an abnormal uterine contour. - If fetal death occurred primarily (e.g., due to placental insufficiency), the mother would experience cessation of fetal movements but typically not acute, severe pain or change in **uterine shape**.*Preterm labor* - The patient is 38 weeks gestation, making the term **preterm labor** inappropriate, and while labor can be painful, the pain is expected to be intermittent (contractions). - Labor does not cause the catastrophic finding of the **absent fetal heart rate** and an **abnormal uterine contour**, which signifies a structural catastrophe.
Question 34: A 39-year-old woman with gestational diabetes on metformin and insulin is reviewed at 36 weeks gestation. Her glycaemic control has been excellent throughout. She has had serial growth scans which show estimated fetal weight consistently on the 75th centile. Today's scan shows the estimated fetal weight is 3.6 kg (75th centile). She asks about the risk of shoulder dystocia and whether caesarean section should be considered. What is the most appropriate counselling?
- A. Offer elective caesarean section as estimated fetal weight exceeds 3.5 kg in diabetic pregnancy
- B. Recommend awaiting spontaneous labour as shoulder dystocia risk is not significantly increased
- C. Offer elective caesarean section if estimated fetal weight exceeds 4.0 kg
- D. Offer elective caesarean section if estimated fetal weight exceeds 4.5 kg (Correct Answer)
- E. Recommend induction of labour at 37 weeks to prevent further fetal growth
Explanation: ***Offer elective caesarean section if estimated fetal weight exceeds 4.5 kg*** - According to **NICE** and **RCOG** guidelines, women with **diabetes in pregnancy** should be offered an elective caesarean section only if the **estimated fetal weight (EFW)** is greater than **4.5 kg**. - This threshold is set because the risk of **shoulder dystocia** and permanent brachial plexus injury increases significantly in diabetic pregnancies due to **asymmetric fetal growth** (larger trunk/shoulders relative to head circumference). *Offer elective caesarean section as estimated fetal weight exceeds 3.5 kg in diabetic pregnancy* - **3.5 kg** is within the normal range for birth weight, and there is no evidence that routine caesarean at this weight prevents significant morbidity. - **Over-intervention** at this weight would lead to unnecessary surgical risks without corresponding benefits in reducing **birth trauma**. *Recommend awaiting spontaneous labour as shoulder dystocia risk is not significantly increased* - In diabetic pregnancies, the risk of **shoulder dystocia** is inherently increased regardless of weight, but specific counselling on the mode of delivery is required. - Awaiting **spontaneous labour** may be inappropriate as diabetic patients are typically offered **induction of labour** or elective delivery between **37+0 and 38+6 weeks**. *Offer elective caesarean section if estimated fetal weight exceeds 4.0 kg* - While **4.0 kg** (macrosomia) increases the clinical suspicion of difficulty, it is not the evidence-based threshold for recommending an elective caesarean in **UK guidelines**. - Ultrasound EFW accuracy has a **margin of error of ±15%**, making a 4.0 kg cutoff unreliable for mandating surgical delivery. *Recommend induction of labour at 37 weeks to prevent further fetal growth* - **Induction of labour** is offered to diabetic patients for maternal/fetal indications, but doing so solely to prevent growth in a baby on the **75th centile** is not standard practice. - Early induction (e.g., at 37 weeks) just to "limit size" has not been shown to reduce the rates of **caesarean section** or **fetal injury** compared to management at 38 weeks.
Question 35: A 26-year-old woman is admitted at 35 weeks gestation with pre-eclampsia. Blood pressure is 156/102 mmHg on labetalol 200 mg three times daily. Blood tests show: platelets 132 × 10⁹/L, ALT 45 U/L, creatinine 78 µmol/L, urate 0.38 mmol/L. Urinary protein:creatinine ratio is 42 mg/mmol. CTG is reassuring. She has no symptoms. The team plans expectant management with close monitoring. What additional medication should be administered now?
- A. Magnesium sulphate infusion for seizure prophylaxis
- B. Betamethasone for fetal lung maturation
- C. Increase labetalol to 400 mg three times daily
- D. Add nifedipine modified release 10 mg twice daily
- E. No additional medication required currently (Correct Answer)
Explanation: ***No additional medication required currently*** - The patient's **blood pressure** is currently managed around the target range, and she exhibits no **severe features** of pre-eclampsia (symptoms or significant biochemical derangement like platelets <100 or ALT >70). - Management at **35 weeks** for mild pre-eclampsia involves **expectant monitoring** of maternal and fetal well-being, with delivery typically planned at **37 weeks** unless maternal or fetal conditions deteriorate. *Magnesium sulphate infusion for seizure prophylaxis* - **Magnesium sulphate** is indicated for the prevention of seizures in **severe pre-eclampsia** or during the peripartum period if delivery is imminent or pre-eclampsia is worsening. - This patient is currently asymptomatic with non-severe pre-eclampsia criteria and does not meet the thresholds that would justify immediate **seizure prophylaxis**. *Betamethasone for fetal lung maturation* - **Corticosteroids** like betamethasone are generally recommended for fetal lung maturation if delivery is anticipated before **34 weeks** gestation, or between 34 and 35+6 weeks if delivery is planned within 7 days. - Since the patient is at **35 weeks** and being managed expectantly without plans for immediate delivery, routine administration is usually not indicated. *Increase labetalol to 400 mg three times daily* - The therapeutic goal for BP in pre-eclampsia is typically to maintain it below **150/100 mmHg** or **160/110 mmHg**, depending on guidelines. Her current reading of **156/102 mmHg** is elevated but not in the **severe hypertension** range (>160/110 mmHg). - Escalation of antihypertensive therapy is not mandatory unless there is a persistent trend of uncontrolled pressures, development of **severe features**, or the blood pressure consistently exceeds 160/110 mmHg. *Add nifedipine modified release 10 mg twice daily* - **Nifedipine** is an alternative or additive antihypertensive agent, but adding a second agent is reserved for patients whose BP remains uncontrolled on **maximal doses** of the first agent or if severe hypertension is present. - Current management prioritizes **monitoring** rather than immediate aggressive polypharmacy, as abrupt drops in BP can potentially compromise **placental perfusion**.
Question 36: A 35-year-old woman in her second pregnancy attends for her booking appointment at 12 weeks gestation. In her previous pregnancy, she had gestational diabetes requiring insulin and developed polyhydramnios. Her baby was delivered at 37 weeks by emergency caesarean section for fetal distress and weighed 4.2 kg. Her booking BMI is 31 kg/m² and random glucose today is 6.8 mmol/L. What is the most appropriate screening approach for gestational diabetes in this pregnancy?
- A. Perform OGTT at 24-28 weeks gestation as per standard protocol
- B. Perform OGTT at booking and again at 24-28 weeks if initial test is normal (Correct Answer)
- C. Check HbA1c at booking only
- D. Check fasting glucose at booking and arrange OGTT if ≥5.6 mmol/L
- E. Commence insulin therapy immediately without screening tests
Explanation: ***Perform OGTT at booking and again at 24-28 weeks if initial test is normal***- Given her history of **previous gestational diabetes requiring insulin**, **macrosomic baby (4.2 kg)**, and **obesity (BMI 31)**, this patient has multiple significant risk factors for recurrent and early-onset GDM.- Current guidelines recommend **early screening** with an **OGTT at booking** (10-16 weeks) for women with a history of GDM. If this is normal, a repeat **OGTT at 24-28 weeks** is crucial due to the progressive nature of insulin resistance in pregnancy.*Perform OGTT at 24-28 weeks gestation as per standard protocol*- While an **OGTT at 24-28 weeks** is standard for women with *general* risk factors, it is insufficient for those with a **history of GDM**.- Delaying screening until the mid-trimester could miss **early-onset gestational diabetes** or even undiagnosed pre-existing diabetes, leading to prolonged fetal exposure to hyperglycemia.*Check HbA1c at booking only*- **HbA1c** at booking can identify pre-existing diabetes but is **less sensitive** than an OGTT for diagnosing GDM, especially early-onset forms.- A single test at booking does not account for the **progressive insulin resistance** that typically develops in the second and third trimesters, which is characteristic of GDM.*Check fasting glucose at booking and arrange OGTT if - Women previously affected by **gestational diabetes (GDM)** are considered high-risk for developing it again in subsequent pregnancies or even developing **type 2 diabetes** later in life. Therefore, early and repeated screening is vital.- The first screening with an **Oral Glucose Tolerance Test (OGTT)** should occur at the earliest opportunity (booking), ideally at 10-16 weeks. If results are normal, a repeat OGTT is recommended at **24-28 weeks** due to increasing insulin resistance as pregnancy progresses.*Perform OGTT at 24-28 weeks gestation as per standard protocol*- This approach is appropriate for women with *other* risk factors, such as a **BMI over 30**, but it is insufficient for women with a **history of GDM**.- Delaying screening until the second trimester may lead to missed diagnoses of **early-onset GDM** or undiagnosed pre-existing diabetes, resulting in suboptimal management and potential adverse outcomes.*Check HbA1c at booking only*- While **HbA1c** provides information about average glucose levels over the past 2-3 months, it is **not the primary diagnostic test** for GDM due to lower sensitivity compared to OGTT.- A single **HbA1c** measurement at booking may not detect GDM that develops later in pregnancy, missing the progressive nature of insulin resistance.*Check fasting glucose at booking and arrange OGTT if - Women previously affected by gestational diabetes are considered at **high-risk** for developing it again in their current or next pregnancies and even developing **type 2 diabetes** later in life. Therefore, early screening is crucial. - The initial screening with an **Oral Glucose Tolerance Test (OGTT)** should be performed at the booking appointment (ideally 10-16 weeks) to identify **pre-existing diabetes** or **early-onset GDM**. If the first test is normal, a repeat OGTT is indicated at **24-28 weeks gestation** as insulin resistance progresses with pregnancy.
Question 37: A 31-year-old woman presents to antenatal clinic at 29 weeks gestation with blood pressure 172/118 mmHg. She reports a severe headache and visual disturbances described as flashing lights. This is her first pregnancy. Urinalysis shows 2+ proteinuria. She is already taking labetalol 200 mg three times daily, started 2 weeks ago for gestational hypertension. What is the most appropriate immediate management?
- A. Increase labetalol dose to 400 mg three times daily and review in 48 hours
- B. Add nifedipine modified release 10 mg twice daily and review in 24 hours
- C. Admit for immediate assessment and consideration of delivery (Correct Answer)
- D. Prescribe sublingual nifedipine 10 mg immediately and review in 1 hour
- E. Arrange urgent MRI brain to exclude intracranial pathology
Explanation: ***Admit for immediate assessment and consideration of delivery*** - This patient exhibits classic signs of **severe pre-eclampsia**, including **severe hypertension** (BP ">=" 160/110 mmHg), **proteinuria**, and **neurological features** like headache and visual disturbances. - **Immediate hospital admission** is critical for close monitoring, **antihypertensive management**, **seizure prophylaxis (magnesium sulfate)**, and urgent evaluation for **delivery**, especially given the uncontrolled hypertension despite current medication. *Increase labetalol dose to 400 mg three times daily and review in 48 hours* - Outpatient management, even with increased medication, is inappropriate for **severe pre-eclampsia** with **neurological symptoms**, as it poses an immediate risk of **eclampsia**, stroke, or placental abruption. - A **48-hour delay** in reassessment is unsafe for a patient presenting with uncontrolled severe hypertension and symptoms indicating **end-organ dysfunction**. *Add nifedipine modified release 10 mg twice daily and review in 24 hours* - Adding oral antihypertensives for outpatient review is insufficient when **severe pre-eclampsia** with impending complications is suspected, as this requires **inpatient stabilization** and comprehensive management. - A **24-hour delay** for review is too long given the acute severity and risk of **maternal and fetal morbidity/mortality**. *Prescribe sublingual nifedipine 10 mg immediately and review in 1 hour* - **Sublingual nifedipine** can cause a **rapid and precipitous drop in blood pressure**, which can compromise **placental perfusion** and lead to fetal distress, making it generally unsuitable in pregnancy for acute hypertension. - While rapid blood pressure control is needed, it should occur in a **monitored inpatient setting** with intravenous options, not with sublingual nifedipine in an uncontrolled environment. *Arrange urgent MRI brain to exclude intracranial pathology* - Although neurological symptoms are present, the overall clinical picture strongly points to **severe pre-eclampsia**, which is an obstetric emergency requiring immediate obstetric and medical management, not primarily neurological workup. - An **MRI brain** should not delay crucial interventions like blood pressure control, **seizure prophylaxis**, and assessment for delivery, which are paramount in managing severe pre-eclampsia.
Question 38: A 37-year-old woman with type 1 diabetes presents for pre-pregnancy counselling. She has had diabetes for 15 years and her most recent HbA1c is 68 mmol/mol (8.4%). She takes insulin aspart three times daily and insulin glargine once at night. Retinal screening 6 months ago showed background diabetic retinopathy. Her BMI is 26 kg/m². What is the single most important immediate action before conception?
- A. Commence high-dose folic acid 5 mg daily
- B. Refer for urgent ophthalmology review
- C. Optimize glycaemic control to achieve HbA1c <48 mmol/mol (Correct Answer)
- D. Switch insulin glargine to NPH insulin
- E. Commence low-dose aspirin 150 mg daily
Explanation: ***Optimize glycaemic control to achieve HbA1c <48 mmol/mol***- Achieving an **HbA1c <48 mmol/mol (6.5%)** prior to conception is the most critical intervention to minimize the risk of **congenital malformations**, miscarriage, and neonatal death.- This patient's current HbA1c of **68 mmol/mol (8.4%)** puts her at high risk, and she should be advised to use **contraception** until targets are met.*Commence high-dose folic acid 5 mg daily*- While **5 mg folic acid** is essential for women with diabetes to prevent **neural tube defects**, it does not mitigate the broader teratogenic risks of poor maternal glycaemia.- It is a necessary concurrent step but remains secondary to the physiological stabilization of **blood glucose** levels.*Refer for urgent ophthalmology review*- **Retinal screening** is required pre-conception; however, this patient had screening 6 months ago showing only **background retinopathy**, which is not an acute contraindication to pregnancy.- Urgent referral is reserved for **proliferative retinopathy** or stable maculopathy requiring intervention before the rapid glycaemic changes of pregnancy.*Switch insulin glargine to NPH insulin*- Modern guidelines, including **NICE**, state that long-acting analogues like **insulin glargine** can be safely continued throughout pregnancy if they provide good control.- Switching to **NPH insulin** is no longer a mandatory immediate action and might temporarily worsen glycaemic stability during the transition.*Commence low-dose aspirin 150 mg daily*- **Aspirin** is indicated for women with diabetes to reduce the risk of **pre-eclampsia**, but it is typically started at **12 weeks gestation**.- There is no clinical benefit to starting aspirin during the **pre-conception period** compared to the crucial impact of glycaemic optimization.
Question 39: A 29-year-old primigravida is admitted at 33 weeks gestation with severe pre-eclampsia. Her blood pressure is 168/114 mmHg despite treatment with labetalol and nifedipine. She has 3+ proteinuria on dipstick. Blood tests show: platelets 89 × 10⁹/L, ALT 156 U/L, AST 142 U/L, LDH 680 U/L, haemoglobin 102 g/L. Blood film shows fragmented red cells. She is asymptomatic and CTG is reassuring. What is the most appropriate immediate management?
- A. Continue expectant management with intensive monitoring
- B. Administer magnesium sulphate and plan delivery within 24-48 hours (Correct Answer)
- C. Arrange immediate delivery by emergency caesarean section
- D. Commence intravenous hydralazine and continue expectant management
- E. Administer platelet transfusion before delivery
Explanation: ***Administer magnesium sulphate and plan delivery within 24-48 hours***- The patient presents with **HELLP syndrome** (Hemolysis, Elevated Liver enzymes, Low Platelets), indicated by fragmented RBCs, high AST/ALT, and low platelets, which necessitates **definitive delivery**.- Planning delivery within 24-48 hours allows for maternal stabilization and the administration of **corticosteroids** for fetal lung maturity while **magnesium sulphate** prevents eclamptic seizures.*Continue expectant management with intensive monitoring*- Expectant management is inappropriate for **HELLP syndrome** at 33 weeks as it severely increases the risk of maternal complications like **placental abruption** or hepatic rupture.- Persistent **severe hypertension** despite dual therapy and laboratory evidence of organ failure are clear indications to end the pregnancy.*Arrange immediate delivery by emergency caesarean section*- Immediate emergency delivery is not mandatory because the patient is currently **asymptomatic** and the **CTG is reassuring**.- A controlled delivery within 24-48 hours is preferred to provide a window for **steroid benefit** to the neonate and to optimize the mother's coagulation status.*Commence intravenous hydralazine and continue expectant management*- While **hydralazine** can help control refractory hypertension, it does not treat the underlying pathology of **HELLP syndrome**.- Continuing expectant management solely based on blood pressure control ignores the progressive maternal **multi-organ dysfunction** evidenced by the blood results.*Administer platelet transfusion before delivery*- Platelet transfusion is generally not required unless the count is **<50 × 10⁹/L** (for vaginal delivery) or if there is active bleeding.- Since the current count is **89 × 10⁹/L** and there is no mention of hemorrhage, the priority remains the management of the underlying pre-eclampsia and timing of delivery.
Question 40: A 34-year-old woman undergoes oral glucose tolerance test at 28 weeks gestation due to BMI of 33 kg/m². Results show: fasting glucose 4.9 mmol/L, 2-hour glucose 8.2 mmol/L. She is given a blood glucose monitor and advised on diet and lifestyle modifications. After 1 week of monitoring, her blood glucose diary shows: fasting glucose 4.8-5.1 mmol/L on all days, and 1-hour post-prandial readings ranging from 7.4-8.6 mmol/L. What is the most appropriate next step in management?
- A. Continue diet and lifestyle measures with further review in 2 weeks
- B. Commence metformin therapy (Correct Answer)
- C. Commence insulin therapy
- D. Request review by specialist diabetes team within 1 week
- E. Commence both metformin and insulin therapy simultaneously
Explanation: ***Commence metformin therapy***- The patient's **1-hour post-prandial glucose levels** (7.4-8.6 mmol/L) are consistently above target levels (e.g., <7.8 mmol/L or <7.0 mmol/L) after a 1-week trial of diet and lifestyle modifications.- When diet and lifestyle measures fail to achieve glycemic targets in gestational diabetes, **metformin** is typically the recommended first-line oral pharmacological agent, especially when fasting levels are well-controlled and post-prandial levels are elevated.*Continue diet and lifestyle measures with further review in 2 weeks*- This option is inappropriate because the patient's **post-prandial blood glucose targets are not being met** after a dedicated 1-week trial of diet and lifestyle changes.- Delaying pharmacological intervention when targets are consistently missed increases the risk of **adverse maternal and fetal outcomes**, such as macrosomia or pre-eclampsia.*Commence insulin therapy*- **Insulin** is usually reserved for cases where metformin is contraindicated, or if blood glucose levels are severely elevated at diagnosis (e.g., fasting >7.0 mmol/L), or if metformin fails to achieve glycemic control.- Given that her **fasting glucose is controlled** and there's no immediate indication of severe hyperglycemia or fetal macrosomia, metformin is the more appropriate initial pharmacological step.*Request review by specialist diabetes team within 1 week*- While a specialist diabetes team plays a crucial role in managing gestational diabetes, the immediate next step when targets are not met after a lifestyle trial is to **initiate appropriate pharmacological therapy**.- In many healthcare settings, primary care providers or obstetricians are equipped to commence **metformin** for gestational diabetes based on established protocols, without requiring an immediate specialist referral for initiation.*Commence both metformin and insulin therapy simultaneously*- Initiating both **metformin and insulin simultaneously** is not the standard first-line approach in gestational diabetes unless there is severe, uncontrolled hyperglycemia or significant fetal complications (e.g., severe macrosomia) at presentation.- Management typically follows a **stepwise escalation**, starting with a single agent and adding others only if glycemic targets remain unmet.
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