A 32-year-old woman presents to the antenatal day unit at 36 weeks gestation with a blood pressure reading of 152/96 mmHg. She is asymptomatic. Her booking blood pressure at 10 weeks was 118/72 mmHg, and all subsequent readings have been normal until today. Repeat blood pressure after 20 minutes rest is 148/94 mmHg. Urinalysis shows no proteinuria. Blood tests show: platelets 198 × 10⁹/L, ALT 28 U/L, creatinine 62 µmol/L. What is the most accurate diagnosis?
Q42
A 36-year-old woman in her third pregnancy presents at 14 weeks gestation for routine antenatal care. In her previous pregnancy, she developed pre-eclampsia at 34 weeks requiring emergency caesarean section for severe disease. Her blood pressure today is 128/78 mmHg, and urinalysis shows no protein. Her BMI is 29 kg/m². She is otherwise well with no other medical history. What is the most appropriate prophylaxis to reduce her risk of pre-eclampsia?
Q43
A 30-year-old woman with gestational diabetes diagnosed at 26 weeks gestation attends clinic at 34 weeks for review. She has been managing with diet modification alone. Her home blood glucose monitoring shows: fasting glucose 5.0-5.4 mmol/L and 1-hour post-prandial readings 7.2-7.9 mmol/L. She reports good fetal movements. Ultrasound shows estimated fetal weight on 85th centile with abdominal circumference on 90th centile. What is the most appropriate management?
Q44
A 33-year-old woman presents at 11 weeks gestation for antenatal booking. She mentions that her sister recently had a baby with a neural tube defect. The woman herself has no history of neural tube defects in previous pregnancies and is not taking any anti-epileptic medications. She has been taking folic acid 400 micrograms daily since confirming her pregnancy 3 weeks ago. What advice should be given regarding folic acid supplementation?
Q45
A 44-year-old woman in her fifth pregnancy presents to the emergency department at 35 weeks gestation with sudden onset severe headache, confusion, and right upper quadrant pain. Her blood pressure on arrival is 178/118 mmHg. She has one tonic-clonic seizure lasting 90 seconds while in the department. Blood tests show: Hb 108 g/L, platelets 78 × 10⁹/L, ALT 245 U/L, AST 268 U/L, LDH 850 U/L, urea 8.5 mmol/L, creatinine 145 μmol/L. Urinalysis shows 4+ protein. Which of the following represents the most appropriate immediate management sequence?
Q46
A 36-year-old woman with insulin-treated gestational diabetes attends for review at 33 weeks gestation. Serial growth scans have shown progressive crossing of centiles: estimated fetal weight was on 65th centile at 28 weeks, 75th centile at 30 weeks, and 85th centile today at 33 weeks. Abdominal circumference is on 90th centile. Amniotic fluid index is 26 cm. Her capillary blood glucose readings show: fasting 4.8-5.4 mmol/L, 1-hour postprandial 6.2-7.5 mmol/L. What is the most appropriate management?
Q47
A 31-year-old woman is seen at 14 weeks gestation in her second pregnancy. In her first pregnancy, she developed severe early-onset pre-eclampsia at 29 weeks requiring emergency delivery. Her blood pressure today is 124/78 mmHg and urinalysis is negative. Blood tests including renal and liver function are normal. She is very anxious about recurrence. What is the most evidence-based intervention to reduce her risk of developing pre-eclampsia in this pregnancy?
Q48
A 39-year-old woman with twin pregnancy (dichorionic diamniotic) is reviewed at 28 weeks gestation. She underwent OGTT at 26 weeks due to previous macrosomic baby (birth weight 4.5 kg). Results were: fasting glucose 4.9 mmol/L, 2-hour glucose 7.2 mmol/L. She was reassured and discharged. She now presents with polyuria and polydipsia. Random glucose is 11.2 mmol/L. What is the most appropriate diagnostic interpretation and management?
Q49
A 28-year-old woman is admitted at 36 weeks gestation with blood pressure 158/105 mmHg and 2+ proteinuria on dipstick testing. She reports mild frontal headache but no visual disturbances or epigastric pain. Blood tests show: Hb 125 g/L, platelets 145 × 10⁹/L, ALT 45 U/L, AST 42 U/L, urea 5.2 mmol/L, creatinine 75 μmol/L. A 24-hour urine collection confirms proteinuria of 450 mg/24 hours. Cardiotocography is normal. She is commenced on oral labetalol. After 48 hours, her blood pressure is 145/92 mmHg on labetalol 200 mg three times daily. Repeat bloods are stable and she remains asymptomatic. What is the most appropriate management plan?
Q50
A 41-year-old woman with type 2 diabetes mellitus presents at 20 weeks gestation for her anomaly scan. She was diagnosed with diabetes 3 years ago and has been taking metformin 1000 mg twice daily. Her HbA1c at booking (8 weeks) was 52 mmol/mol. The detailed fetal ultrasound scan is reported as normal. What additional fetal assessment should be offered?
Pregnancy Medicine UK Medical PG Practice Questions and MCQs
Question 41: A 32-year-old woman presents to the antenatal day unit at 36 weeks gestation with a blood pressure reading of 152/96 mmHg. She is asymptomatic. Her booking blood pressure at 10 weeks was 118/72 mmHg, and all subsequent readings have been normal until today. Repeat blood pressure after 20 minutes rest is 148/94 mmHg. Urinalysis shows no proteinuria. Blood tests show: platelets 198 × 10⁹/L, ALT 28 U/L, creatinine 62 µmol/L. What is the most accurate diagnosis?
A. Gestational hypertension (Correct Answer)
B. Pre-eclampsia
C. Chronic hypertension
D. White coat hypertension
E. Severe pre-eclampsia
Explanation: ***Gestational hypertension***
- This diagnosis is defined by new-onset **hypertension (≥140/90 mmHg)** occurring after **20 weeks of gestation** in a previously normotensive woman.
- The patient meets these criteria at 36 weeks with a BP of 152/96 mmHg and **no proteinuria** or evidence of multi-organ dysfunction.
*Pre-eclampsia*
- Requires the presence of hypertension plus either **proteinuria** (e.g., PCR ≥30 mg/mmol) or **maternal organ dysfunction**, such as thrombocytopenia, elevated liver enzymes, or renal impairment.
- In this case, the **urinalysis is clear**, and blood results for platelets, ALT, and creatinine are all within the **normal range**, ruling out pre-eclampsia.
*Chronic hypertension*
- Defined as hypertension that is present **before pregnancy** or diagnosed **before 20 weeks** of gestation.
- This patient had a normal **booking blood pressure** (118/72 mmHg) at 10 weeks, which effectively rules out chronic hypertension.
*White coat hypertension*
- Characterized by elevated BP readings in a clinical setting but **normal readings** at home or during ambulatory monitoring.
- This diagnosis is unlikely here because the blood pressure remained elevated (**148/94 mmHg**) even after a **20-minute rest** period, suggesting true hypertension.
*Severe pre-eclampsia*
- Diagnosed when pre-eclampsia is accompanied by severe features, such as BP **≥160/110 mmHg**, severe proteinuria, or clinical symptoms like **persistent headache and visual disturbances**.
- The patient is currently **asymptomatic**, and her BP (152/96 mmHg) and blood markers do not meet the thresholds or criteria for severe disease.
Question 42: A 36-year-old woman in her third pregnancy presents at 14 weeks gestation for routine antenatal care. In her previous pregnancy, she developed pre-eclampsia at 34 weeks requiring emergency caesarean section for severe disease. Her blood pressure today is 128/78 mmHg, and urinalysis shows no protein. Her BMI is 29 kg/m². She is otherwise well with no other medical history. What is the most appropriate prophylaxis to reduce her risk of pre-eclampsia?
A. Aspirin 75 mg daily from now until delivery
B. Aspirin 150 mg daily from now until 36 weeks gestation (Correct Answer)
C. Aspirin 75 mg daily from 16 weeks until 36 weeks gestation
D. Calcium supplementation 1000 mg daily throughout pregnancy
E. Low molecular weight heparin daily throughout pregnancy
Explanation: ***Aspirin 150 mg daily from now until 36 weeks gestation***
- For women with a history of **pre-eclampsia** in a previous pregnancy, **150 mg of aspirin** daily is the recommended dose to reduce the risk of recurrence.
- Prophylaxis should ideally commence between **12 and 16 weeks gestation** and continue until **36 weeks gestation**, making immediate initiation at 14 weeks appropriate.
*Aspirin 75 mg daily from now until delivery*
- The **75 mg dose** is considered suboptimal for high-risk women; current evidence supports a **higher dose (150 mg)** for more effective **pre-eclampsia** prevention.
- Continuing aspirin until **delivery** is generally not recommended due to increased risk of **peripartum bleeding**; discontinuation at 36 weeks is standard.
*Aspirin 75 mg daily from 16 weeks until 36 weeks gestation*
- The **75 mg dose** is less effective than **150 mg** for this high-risk patient.
- Initiating prophylaxis at **16 weeks gestation** is slightly delayed; optimal efficacy is achieved with initiation between **12 and 16 weeks**.
*Calcium supplementation 1000 mg daily throughout pregnancy*
- **Calcium supplementation** is primarily recommended by WHO for populations with **low dietary calcium intake** to reduce pre-eclampsia risk.
- It is not a substitute for **aspirin** in patients with a significant history of pre-eclampsia and generally not indicated as primary prophylaxis in well-nourished populations.
*Low molecular weight heparin daily throughout pregnancy*
- **Low molecular weight heparin (LMWH)** is indicated for conditions like **venous thromboembolism (VTE) prophylaxis** or in cases of **antiphospholipid syndrome (APS)**.
- There is no robust evidence to support its use as a primary prophylactic agent for **pre-eclampsia** in the absence of other specific indications.
Question 43: A 30-year-old woman with gestational diabetes diagnosed at 26 weeks gestation attends clinic at 34 weeks for review. She has been managing with diet modification alone. Her home blood glucose monitoring shows: fasting glucose 5.0-5.4 mmol/L and 1-hour post-prandial readings 7.2-7.9 mmol/L. She reports good fetal movements. Ultrasound shows estimated fetal weight on 85th centile with abdominal circumference on 90th centile. What is the most appropriate management?
A. Continue diet control alone with weekly monitoring
B. Commence metformin therapy
C. Commence insulin therapy (Correct Answer)
D. Arrange immediate delivery by induction of labour
E. Commence both metformin and insulin therapy
Explanation: ***Commence insulin therapy***- The **ultrasound findings** of estimated fetal weight on the 85th centile and abdominal circumference on the **90th centile** indicate **fetal macrosomia** or accelerated growth, which is a key indicator for commencing pharmacological treatment, even with borderline glucose readings.- **Insulin** is the preferred first-line pharmacological treatment in gestational diabetes when there is evidence of fetal overgrowth, as it is highly effective in controlling maternal glucose without crossing the placenta, thereby reducing the risk of macrosomia and related complications.*Continue diet control alone with weekly monitoring*- Despite current management, the **fetal growth parameters** (EFW 85th centile, AC 90th centile) suggest that **diet control alone is insufficient** to achieve optimal glycaemic control and prevent fetal overgrowth.- Continuing diet alone would increase the risk of adverse outcomes such as **shoulder dystocia**, birth trauma, and neonatal **hypoglycaemia** due to uncontrolled fetal growth.*Commence metformin therapy*- While **metformin** is an oral agent that can be used for gestational diabetes, it is generally considered less effective than insulin in addressing **accelerated fetal growth** or confirmed macrosomia.- Metformin crosses the placenta and might not achieve the tight glucose control needed to manage significant fetal overgrowth effectively, making insulin a more appropriate choice in this scenario.*Arrange immediate delivery by induction of labour*- Immediate delivery at **34 weeks gestation** is premature and not indicated in a stable patient with good fetal movements and no acute complications.- Preterm delivery carries significant risks for the neonate, including **respiratory distress syndrome**, and is typically only considered for severe complications or after 37-38+6 weeks for GDM, often with poor control.*Commence both metformin and insulin therapy*- **Dual therapy** with both metformin and insulin is usually reserved for cases of gestational diabetes with more **severe hyperglycaemia** or when monotherapy (typically insulin) fails to achieve adequate control.- In this case, given the initial evidence of fetal overgrowth despite borderline maternal glucose, **insulin monotherapy** is the standard first step, with dose adjustments based on further monitoring.
Question 44: A 33-year-old woman presents at 11 weeks gestation for antenatal booking. She mentions that her sister recently had a baby with a neural tube defect. The woman herself has no history of neural tube defects in previous pregnancies and is not taking any anti-epileptic medications. She has been taking folic acid 400 micrograms daily since confirming her pregnancy 3 weeks ago. What advice should be given regarding folic acid supplementation?
A. Continue folic acid 400 micrograms daily until 12 weeks gestation
B. Increase to folic acid 5 mg daily for the remainder of pregnancy
C. Increase to folic acid 5 mg daily until 12 weeks gestation (Correct Answer)
D. Continue folic acid 400 micrograms daily for the remainder of pregnancy
E. Stop folic acid as she is past the critical period for neural tube defect prevention
Explanation: ***Increase to folic acid 5 mg daily until 12 weeks gestation***
- Women with a **first-degree relative** (such as a sibling) affected by a **neural tube defect (NTD)** are considered high-risk and require a higher dose of **5 mg folic acid daily**.
- Supplementation at this dose is crucial until **12 weeks gestation**, as this is the period when the **neural tube closes** and the risk of NTDs is highest.
*Continue folic acid 400 micrograms daily until 12 weeks gestation*
- The **400 microgram dose** is the standard for low-risk women but is insufficient for those with a positive **family history** in a first-degree relative.
- Current guidelines recommend moving to the **high-dose supplement (5 mg)** as soon as a high-risk factor is identified during the first trimester.
*Increase to folic acid 5 mg daily for the remainder of pregnancy*
- While the **5 mg dose** is correct for her risk profile, **folic acid supplementation** specifically for NTD prevention is generally not required beyond **12 weeks gestation**.
- Continuing high-dose supplementation for the entire pregnancy is not supported by routine **obstetric guidelines** unless other specific medical indications exist.
*Continue folic acid 400 micrograms daily for the remainder of pregnancy*
- This option provides both an **insufficient dose** for a high-risk patient and an unnecessarily **extended duration** of supplementation.
- A dose of **400 micrograms** fails to provide the maximal protective benefit against **NTD recurrence** in a high-risk individual.
*Stop folic acid as she is past the critical period for neural tube defect prevention*
- Although the **neural tube closure** occurs by about 4 weeks post-conception, antenatal guidelines recommend continuing supplementation until **12 weeks** to ensure optimal prevention and safety.
- Stopping at **11 weeks** is premature and deviates from standard **antenatal booking protocols** that advise continuation until the end of the first trimester.
Question 45: A 44-year-old woman in her fifth pregnancy presents to the emergency department at 35 weeks gestation with sudden onset severe headache, confusion, and right upper quadrant pain. Her blood pressure on arrival is 178/118 mmHg. She has one tonic-clonic seizure lasting 90 seconds while in the department. Blood tests show: Hb 108 g/L, platelets 78 × 10⁹/L, ALT 245 U/L, AST 268 U/L, LDH 850 U/L, urea 8.5 mmol/L, creatinine 145 μmol/L. Urinalysis shows 4+ protein. Which of the following represents the most appropriate immediate management sequence?
A. IV labetalol bolus, IV magnesium sulphate loading dose, arrange urgent delivery after maternal stabilisation (Correct Answer)
B. CT head scan, IV phenytoin loading, then consider delivery if scan normal
C. IV magnesium sulphate loading dose, IV antihypertensive, arrange immediate caesarean section without delay
D. IV diazepam for seizure control, oral antihypertensive, admit for observation and blood pressure monitoring
E. IV hydralazine, IV magnesium sulphate, await spontaneous labour onset
Explanation: ***IV labetalol bolus, IV magnesium sulphate loading dose, arrange urgent delivery after maternal stabilisation***
- The patient presents with **eclampsia** (seizure with pre-eclampsia) and features of **HELLP syndrome** (thrombocytopenia, elevated liver enzymes, hemolysis), requiring immediate control of **severe hypertension** and **seizures**.
- **IV labetalol** is appropriate for rapid blood pressure control, and **IV magnesium sulphate** is the cornerstone for preventing and treating eclamptic seizures; delivery is the definitive treatment but should occur once the **mother is stabilized**.
*CT head scan, IV phenytoin loading, then consider delivery if scan normal*
- A **CT head scan** is generally not the first-line intervention in a clear case of eclampsia and would delay critical initial management.
- **Phenytoin** is less effective than **magnesium sulphate** for eclamptic seizure control and is not the preferred anticonvulsant.
*IV magnesium sulphate loading dose, IV antihypertensive, arrange immediate caesarean section without delay*
- While magnesium sulphate and antihypertensives are correct, proceeding to an **immediate caesarean section without delay** can increase risks due to potential **coagulopathy** and unstable maternal condition before adequate stabilization.
- **Maternal stabilization** (e.g., blood pressure control, cessation of seizures) is crucial before initiating urgent delivery to optimize outcomes.
*IV diazepam for seizure control, oral antihypertensive, admit for observation and blood pressure monitoring*
- **Diazepam** is not the first-line anticonvulsant for eclampsia due to risks of maternal and neonatal **respiratory depression**; **magnesium sulphate** is preferred.
- An **oral antihypertensive** is insufficient for managing **hypertensive emergency** (BP 178/118 mmHg) in eclampsia; rapid-acting **intravenous agents** are necessary.
*IV hydralazine, IV magnesium sulphate, await spontaneous labour onset*
- Although **IV hydralazine** and **magnesium sulphate** are appropriate treatments for hypertension and seizures, **awaiting spontaneous labour** is contraindicated in eclampsia.
- **Delivery** is the definitive treatment for eclampsia and must be expedited after maternal stabilization, as the condition will not resolve until the placenta is removed.
Question 46: A 36-year-old woman with insulin-treated gestational diabetes attends for review at 33 weeks gestation. Serial growth scans have shown progressive crossing of centiles: estimated fetal weight was on 65th centile at 28 weeks, 75th centile at 30 weeks, and 85th centile today at 33 weeks. Abdominal circumference is on 90th centile. Amniotic fluid index is 26 cm. Her capillary blood glucose readings show: fasting 4.8-5.4 mmol/L, 1-hour postprandial 6.2-7.5 mmol/L. What is the most appropriate management?
A. Increase insulin doses to achieve tighter glycaemic control and repeat scan in 2 weeks (Correct Answer)
B. Continue current insulin regime as glucose levels are at target and arrange delivery at 38 weeks
C. Diagnose suspected fetal macrosomia and offer elective caesarean section at 37 weeks
D. The polyhydramnios suggests poor glucose control; significantly increase insulin and recheck glucose monitoring technique
E. Arrange urgent delivery due to excessive fetal growth and polyhydramnios
Explanation: ***Increase insulin doses to achieve tighter glycaemic control and repeat scan in 2 weeks***
- Despite the maternal capillary blood glucose readings appearing within target ranges, the **progressive crossing of centiles** for estimated fetal weight and the **90th centile abdominal circumference** combined with **polyhydramnios (AFI 26 cm)** are clear indicators of **fetal hyperinsulinism** and inadequate glycaemic control.
- The most appropriate action is to intensify maternal insulin therapy to achieve tighter control, aiming to slow excessive fetal growth, and then reassess the fetal parameters with a **repeat scan in 2 weeks**.
*Continue current insulin regime as glucose levels are at target and arrange delivery at 38 weeks*
- This option is incorrect because relying solely on seemingly normal maternal blood glucose levels is insufficient when there is clear sonographic evidence of **accelerating fetal growth** and **polyhydramnios**, both suggesting suboptimal glucose control affecting the fetus.
- Continuing the current regimen would likely lead to further **fetal macrosomia**, increasing risks of birth trauma and neonatal complications, and a delivery at 38 weeks without addressing the underlying issue is not ideal.
*Diagnose suspected fetal macrosomia and offer elective caesarean section at 37 weeks*
- While **fetal macrosomia** is a significant concern, the estimated fetal weight at 33 weeks does not typically warrant an immediate diagnosis of macrosomia requiring delivery at 37 weeks, especially when intervention can still modify fetal growth.
- The primary goal at this stage is to **optimize glucose control** to prevent further excessive growth, rather than prematurely committing to a surgical delivery, which carries its own risks.
*The polyhydramnios suggests poor glucose control; significantly increase insulin and recheck glucose monitoring technique*
- Although **polyhydramnios** correctly suggests poor glucose control and **rechecking glucose monitoring technique** is a good general practice, simply
Question 47: A 31-year-old woman is seen at 14 weeks gestation in her second pregnancy. In her first pregnancy, she developed severe early-onset pre-eclampsia at 29 weeks requiring emergency delivery. Her blood pressure today is 124/78 mmHg and urinalysis is negative. Blood tests including renal and liver function are normal. She is very anxious about recurrence. What is the most evidence-based intervention to reduce her risk of developing pre-eclampsia in this pregnancy?
A. Low-dose aspirin 150 mg daily commenced before 16 weeks and continued until delivery (Correct Answer)
B. Calcium supplementation 1 gram daily throughout pregnancy
C. Low-dose aspirin 75 mg daily commenced at 20 weeks until 36 weeks
D. Prophylactic low molecular weight heparin throughout pregnancy
E. Monthly uterine artery Doppler surveillance from 20 weeks
Explanation: ***Low-dose aspirin 150 mg daily commenced before 16 weeks and continued until delivery***
- A history of **early-onset pre-eclampsia** (before 34 weeks) is a major high-risk factor; starting **aspirin 150 mg** daily reduces the risk of recurrence significantly.
- Effectiveness depends on early initiation, ideally before **16 weeks gestation**, to positively influence **trophoblastic invasion** and placentation.
*Calcium supplementation 1 gram daily throughout pregnancy*
- **Calcium supplementation** is primarily recommended for women with **low dietary intake** of calcium to reduce pre-eclampsia risk.
- It is not the first-line evidence-based intervention for a patient with a specific high-risk history in populations with adequate calcium intake.
*Low-dose aspirin 75 mg daily commenced at 20 weeks until 36 weeks*
- While 75 mg was previously common, the **ASPRE trial** demonstrated that **150 mg** is more effective for preventing preterm pre-eclampsia.
- Initiating treatment at **20 weeks** is too late to affect the physiologic remodeling of **spiral arteries**, which is necessary for prevention.
*Prophylactic low molecular weight heparin throughout pregnancy*
- **LMWH** is used for preventing **venous thromboembolism** or managing antiphospholipid syndrome, not for the routine prevention of pre-eclampsia.
- There is no high-quality clinical evidence to support **heparin** as a superior or standard intervention compared to aspirin for pre-eclampsia prophylaxis.
*Monthly uterine artery Doppler surveillance from 20 weeks*
- **Uterine artery Doppler** is a **screening and monitoring tool** used to assess placental resistance and predict risk, not a preventive treatment.
- While it provides useful diagnostic information, it does not biologically **reduce the risk** of developing the condition.
Question 48: A 39-year-old woman with twin pregnancy (dichorionic diamniotic) is reviewed at 28 weeks gestation. She underwent OGTT at 26 weeks due to previous macrosomic baby (birth weight 4.5 kg). Results were: fasting glucose 4.9 mmol/L, 2-hour glucose 7.2 mmol/L. She was reassured and discharged. She now presents with polyuria and polydipsia. Random glucose is 11.2 mmol/L. What is the most appropriate diagnostic interpretation and management?
A. This is normal physiological change in twin pregnancy; reassure and monitor symptoms
B. Gestational diabetes has developed since the previous normal OGTT; commence treatment as per protocol (Correct Answer)
C. The previous OGTT may have been a false negative; confirm diagnosis with repeat OGTT
D. She likely has developed type 2 diabetes in pregnancy; perform HbA1c testing
E. Random glucose is not diagnostic; arrange fasting glucose measurement
Explanation: ***Gestational diabetes has developed since the previous normal OGTT; commence treatment as per protocol***
- A **random plasma glucose** of **≥11.1 mmol/L** in the presence of classical symptoms such as **polyuria** and **polydipsia** is diagnostic of diabetes mellitus, requiring immediate treatment.
- **Insulin resistance** naturally increases as pregnancy progresses, and this effect is amplified in **twin pregnancies** due to a larger placental mass, meaning gestational diabetes can develop even after a previously normal OGTT.
*This is normal physiological change in twin pregnancy; reassure and monitor symptoms*
- **Polyuria and polydipsia** are classic symptoms of **hyperglycemia** and are never considered normal physiological changes of pregnancy.
- A **random glucose of 11.2 mmol/L** is significantly elevated and meets diagnostic criteria for diabetes, necessitating active intervention rather than reassurance.
*The previous OGTT may have been a false negative; confirm diagnosis with repeat OGTT*
- The previous OGTT results (fasting 4.9 mmol/L, 2-hour 7.2 mmol/L) were within normal limits at 26 weeks, indicating it was likely a true negative at that time, not a **false negative**.
- With definitive symptoms and a diagnostic **random glucose** level, a repeat OGTT is unnecessary and would only delay crucial treatment for confirmed gestational diabetes.
*She likely has developed type 2 diabetes in pregnancy; perform HbA1c testing*
- While the patient has risk factors for diabetes (previous macrosomia), the current diagnosis is **Gestational Diabetes Mellitus (GDM)** given the onset during pregnancy.
- **HbA1c** is not recommended for diagnosing diabetes during pregnancy due to physiological changes affecting red blood cell turnover, which can lead to inaccurate results.
*Random glucose is not diagnostic; arrange fasting glucose measurement*
- According to international guidelines (e.g., WHO), a **random plasma glucose of ≥11.1 mmol/L** combined with classical symptoms (polyuria, polydipsia) is sufficient for a definitive diagnosis of diabetes.
- Requesting further tests like a **fasting glucose** would unnecessarily delay the initiation of treatment for significant maternal hyperglycemia, risking adverse fetal and maternal outcomes.
Question 49: A 28-year-old woman is admitted at 36 weeks gestation with blood pressure 158/105 mmHg and 2+ proteinuria on dipstick testing. She reports mild frontal headache but no visual disturbances or epigastric pain. Blood tests show: Hb 125 g/L, platelets 145 × 10⁹/L, ALT 45 U/L, AST 42 U/L, urea 5.2 mmol/L, creatinine 75 μmol/L. A 24-hour urine collection confirms proteinuria of 450 mg/24 hours. Cardiotocography is normal. She is commenced on oral labetalol. After 48 hours, her blood pressure is 145/92 mmHg on labetalol 200 mg three times daily. Repeat bloods are stable and she remains asymptomatic. What is the most appropriate management plan?
A. Continue expectant management with increased monitoring and plan delivery at 37 weeks (Correct Answer)
B. Increase labetalol dose and aim for delivery at 38-39 weeks
C. Commence magnesium sulphate prophylaxis and deliver immediately
D. Switch to nifedipine and continue monitoring until 40 weeks
E. Add methyldopa to labetalol and monitor for further 2 weeks
Explanation: ***Continue expectant management with increased monitoring and plan delivery at 37 weeks***
- This patient has **non-severe pre-eclampsia** (BP <160/110 mmHg, stable labs) at 36 weeks; the recommended management is to reach **37 weeks** for a term delivery to balance fetal and maternal risks.
- **Expectant management** includes frequent blood pressure monitoring, bi-weekly blood tests (LFTs, U&Es, FBC), and **fetal surveillance** to ensure no progression to severe disease.
*Increase labetalol dose and aim for delivery at 38-39 weeks*
- While the dose could be adjusted, **pre-eclampsia** management guidelines advise against routine expectant management beyond **37 weeks** due to the risk of maternal and fetal complications.
- Delaying delivery until 38-39 weeks in the presence of **proteinuria** and hypertension increases the risk of **placental abruption** and eclamptic seizures.
*Commence magnesium sulphate prophylaxis and deliver immediately*
- **Magnesium sulphate** is indicated for the prevention of seizures in **severe pre-eclampsia** or eclampsia, but this patient currently lacks severe features like end-organ damage or refractory hypertension.
- **Immediate delivery** at 36 weeks is generally reserved for maternal or fetal distress, as delivery before 37 weeks increases the risk of **neonatal respiratory morbidity**.
*Switch to nifedipine and continue monitoring until 40 weeks*
- Nifedipine is a valid alternative, but switching medications does not change the fact that **pre-eclampsia** necessitates delivery by **37 weeks** rather than 40 weeks.
- Continuing to **40 weeks** is inappropriate as pre-eclampsia is a progressive condition that only resolves upon **delivery of the placenta**.
*Add methyldopa to labetalol and monitor for further 2 weeks*
- Dual therapy may be required if BP remains uncontrolled, but this patient's BP is currently responding to 200mg **labetalol**, making an immediate second agent unnecessary.
- Monitoring for a further 2 weeks would take the patient to **38 weeks**, which exceeds the standard recommendation for delivery at the **37-week threshold** for pre-eclamptic patients.
Question 50: A 41-year-old woman with type 2 diabetes mellitus presents at 20 weeks gestation for her anomaly scan. She was diagnosed with diabetes 3 years ago and has been taking metformin 1000 mg twice daily. Her HbA1c at booking (8 weeks) was 52 mmol/mol. The detailed fetal ultrasound scan is reported as normal. What additional fetal assessment should be offered?
A. Fetal echocardiography at 22-24 weeks gestation (Correct Answer)
B. Repeat anomaly scan at 24 weeks gestation
C. Amniocentesis for fetal karyotyping
D. Monthly growth scans from 24 weeks onwards
E. Fetal MRI to exclude neural tube defects
Explanation: ***Fetal echocardiography at 22-24 weeks gestation***- Pre-existing **Type 2 Diabetes** and suboptimal glycaemic control (HbA1c 52 mmol/mol at 8 weeks) significantly increase the risk of **congenital heart defects**.- A **fetal echocardiography** is a specialized ultrasound specifically designed to evaluate cardiac structures in detail, often indicated between **22-24 weeks gestation** in high-risk pregnancies, even if a routine anomaly scan appears normal.*Repeat anomaly scan at 24 weeks gestation*- A **routine anomaly scan** at 20 weeks was reported as normal, implying a thorough general anatomical survey has already been performed.- Repeating a general anomaly scan at 24 weeks is not the most targeted intervention for the specific increased risk of **cardiac anomalies** in diabetic pregnancies.*Amniocentesis for fetal karyotyping*- While diabetes is a risk factor for **structural malformations**, it is not a primary risk factor for **chromosomal aneuploidies**, which is what **amniocentesis for karyotyping** would investigate.- This is an **invasive procedure** with associated risks, and it is not routinely offered in diabetic pregnancies unless there are other indications for chromosomal analysis.*Monthly growth scans from 24 weeks onwards*- While **macrosomia** is a concern in diabetic pregnancies, **growth scans** for this purpose are typically initiated later, usually from **28 weeks gestation** according to most guidelines.- Growth scans primarily monitor fetal size and **amniotic fluid volume**, not the detailed structural integrity of organs like the heart.*Fetal MRI to exclude neural tube defects*- **Neural tube defects (NTDs)** are primarily screened for during the routine **20-week anomaly scan**, which was reported as normal in this case.- **Fetal MRI** is reserved for situations where ultrasound findings are unclear or require further detailed characterization, not as a first-line additional screening tool for NTDs after a normal anomaly scan.
