A 30-year-old primigravida is reviewed at 28 weeks gestation. She was diagnosed with gestational diabetes at 26 weeks and has been following dietary advice for two weeks. Her home blood glucose monitoring shows: fasting 5.1-5.4 mmol/L, 1-hour post-prandial values 7.2-8.1 mmol/L. She is compliant with diet and monitoring. Fetal growth scan shows estimated fetal weight on 60th centile with normal liquor volume. What is the most appropriate management?
Q62
A 35-year-old woman with type 1 diabetes mellitus attends pre-pregnancy counselling. She has had diabetes for 15 years and her most recent HbA1c is 58 mmol/mol (7.5%). She takes insulin glargine 20 units at night and insulin aspart before meals. She also takes ramipril 5 mg daily for microalbuminuria and atorvastatin 20 mg daily for hyperlipidaemia. Her retinal screening last year showed no retinopathy. Which medication change is most important before conception?
Q63
A 26-year-old woman attends the antenatal clinic at 36 weeks gestation for routine review. She has chronic hypertension and has been taking methyldopa 500 mg three times daily throughout pregnancy. Her blood pressure today is 152/98 mmHg. She is asymptomatic. Urinalysis shows 1+ proteinuria. Blood tests show: Hb 118 g/L, platelets 178 × 10⁹/L, ALT 32 IU/L, creatinine 76 μmol/L. Her booking blood pressure was 138/88 mmHg with no proteinuria. Fetal growth and amniotic fluid are normal on ultrasound. What is the most appropriate next step in management?
Q64
A 37-year-old woman attends antenatal clinic at 12 weeks gestation in her second pregnancy. Her first pregnancy was complicated by gestational diabetes requiring insulin therapy. Her BMI is 33 kg/m². Random blood glucose today is 6.8 mmol/L. HbA1c is 42 mmol/mol (6.0%). She asks about screening for gestational diabetes in this pregnancy. What is the most appropriate screening approach for this woman?
Q65
A 32-year-old woman is admitted at 35 weeks gestation with severe pre-eclampsia. Blood pressure is 168/114 mmHg despite treatment with labetalol 200 mg three times daily. Blood tests show: platelets 98 × 10⁹/L, ALT 156 IU/L, AST 178 IU/L, bilirubin 32 μmol/L, creatinine 118 μmol/L, urea 8.2 mmol/L, LDH 642 IU/L. Blood film shows fragmented red cells. She has right upper quadrant pain and is being prepared for delivery. In addition to continuing antihypertensive therapy, what other medication should be administered immediately?
Q66
A 40-year-old woman in her third pregnancy attends the antenatal clinic at 16 weeks gestation. She has a history of previous pregnancies: first pregnancy resulted in emergency caesarean section at 32 weeks for severe pre-eclampsia with HELLP syndrome, and second pregnancy ended in miscarriage at 8 weeks. Her BMI is 28 kg/m². Blood pressure today is 128/82 mmHg. She is taking folic acid 400 micrograms daily. What is the most appropriate additional intervention at this stage?
Q67
A 28-year-old woman presents to the emergency department at 34 weeks gestation with a severe frontal headache of sudden onset that started 3 hours ago. She describes it as the worst headache of her life. Her blood pressure is 162/104 mmHg. She has photophobia and neck stiffness. Urinalysis shows 2+ proteinuria. Blood tests show: platelets 142 × 10⁹/L, ALT 45 IU/L, creatinine 82 μmol/L. Fundoscopy reveals no papilloedema. She is drowsy but oriented. What is the most appropriate immediate investigation?
Q68
A 33-year-old woman with gestational diabetes diagnosed at 27 weeks gestation is now 36 weeks pregnant. She has been managed with diet alone and her blood glucose control has been good with fasting values 4.8-5.1 mmol/L and 1-hour post-prandial values 6.8-7.4 mmol/L. Growth scans show the fetal abdominal circumference consistently on the 95th centile with estimated fetal weight on the 92nd centile. The head circumference and femur length are on the 50th centile. Amniotic fluid volume is normal. What is the most appropriate next step in management?
Q69
A 36-year-old woman presents to the antenatal day unit at 30 weeks gestation with a blood pressure reading of 146/96 mmHg taken by her community midwife. This is her first pregnancy. Her booking blood pressure at 12 weeks was 118/72 mmHg. She is asymptomatic with no headache, visual disturbances, or epigastric pain. Repeat blood pressure in the unit is 148/94 mmHg. Urinalysis shows no proteinuria. Blood tests show: platelets 189 × 10⁹/L, ALT 28 IU/L, creatinine 68 μmol/L. What is the most appropriate initial management?
Q70
A 29-year-old woman in her first pregnancy attends the antenatal clinic at 26 weeks gestation. She underwent oral glucose tolerance test (OGTT) following a random glucose of 8.4 mmol/L at 24 weeks. Her OGTT results show: fasting glucose 5.8 mmol/L, 2-hour glucose 9.1 mmol/L. She has been commenced on dietary modifications two weeks ago. She presents her home blood glucose monitoring showing fasting values ranging 5.4-5.8 mmol/L and 1-hour post-prandial values of 8.2-9.5 mmol/L. What is the most appropriate next step in her management?
Pregnancy Medicine UK Medical PG Practice Questions and MCQs
Question 61: A 30-year-old primigravida is reviewed at 28 weeks gestation. She was diagnosed with gestational diabetes at 26 weeks and has been following dietary advice for two weeks. Her home blood glucose monitoring shows: fasting 5.1-5.4 mmol/L, 1-hour post-prandial values 7.2-8.1 mmol/L. She is compliant with diet and monitoring. Fetal growth scan shows estimated fetal weight on 60th centile with normal liquor volume. What is the most appropriate management?
A. Add metformin 500 mg once daily (Correct Answer)
B. Continue dietary management alone with review in 2 weeks
C. Add metformin 500 mg twice daily
D. Commence insulin therapy
E. Arrange admission for stabilisation of blood glucose
Explanation: ***Add metformin 500 mg once daily*** - The patient's **1-hour post-prandial glucose values** (up to 8.1 mmol/L) are consistently above the target of <7.8 mmol/L, despite **two weeks of compliant dietary management**. This indicates a need for pharmacological intervention. - **Metformin** is the recommended **first-line oral medication** for gestational diabetes after lifestyle modifications fail. Starting with a **low dose** (500 mg once daily) helps assess tolerance and minimizes **gastrointestinal side effects**.*Continue dietary management alone with review in 2 weeks* - This patient has already followed **lifestyle modifications** for two weeks, and her **post-prandial values** are still above the target of 7.8 mmol/L, indicating inadequate glycemic control. - Delaying treatment would increase the risk of **macrosomia**, pre-eclampsia, and other **maternal and fetal complications**, despite the current normal fetal growth.*Add metformin 500 mg twice daily* - While **metformin** is the correct medication, initiating with 500 mg twice daily as a starting dose is generally not recommended. - Guidelines suggest a **gradual titration** starting once daily to improve **tolerability** and reduce the incidence of **gastrointestinal side effects** like nausea and abdominal pain.*Commence insulin therapy* - **Insulin** is typically reserved as first-line treatment if the **fasting glucose** is significantly elevated (e.g., >7.0 mmol/L) or if metformin is contraindicated or ineffective. - For this patient, whose fasting levels are borderline and post-prandial values are only moderately elevated, a trial of **oral metformin** is the next appropriate step.*Arrange admission for stabilisation of blood glucose* - Admission for **blood glucose stabilization** is only indicated for patients with **severe hyperglycaemia**, metabolic instability like **ketoacidosis**, or acute fetal distress. - GDM management is primarily **outpatient-based**, with medication adjustments made based on home blood glucose monitoring.
Question 62: A 35-year-old woman with type 1 diabetes mellitus attends pre-pregnancy counselling. She has had diabetes for 15 years and her most recent HbA1c is 58 mmol/mol (7.5%). She takes insulin glargine 20 units at night and insulin aspart before meals. She also takes ramipril 5 mg daily for microalbuminuria and atorvastatin 20 mg daily for hyperlipidaemia. Her retinal screening last year showed no retinopathy. Which medication change is most important before conception?
A. Stop ramipril and commence labetalol
B. Stop atorvastatin and ramipril (Correct Answer)
C. Increase folic acid to 5 mg daily and stop atorvastatin
D. Stop all medications except insulin and commence aspirin 150 mg daily
E. Switch from insulin glargine to insulin detemir
Explanation: ***Stop atorvastatin and ramipril***
- Both **statins** (atorvastatin) and **ACE inhibitors** (ramipril) are strictly contraindicated in pregnancy due to their significant **teratogenic effects** on the fetus.
- **ACE inhibitors** are associated with **fetal renal dysgenesis** and skull ossification defects, while **statins** may interfere with fetal cholesterol synthesis, which is essential for development.
*Stop ramipril and commence labetalol*
- While **ramipril** must be stopped due to its teratogenicity, **labetalol** is only indicated if the patient is actually **hypertensive**; this patient uses ramipril for **microalbuminuria**, not necessarily for blood pressure control.
- Commencing a beta-blocker without a clear clinical indication for hypertension is not the most important immediate step compared to stopping both identified teratogens.
*Increase folic acid to 5 mg daily and stop atorvastatin*
- High-dose **folic acid (5 mg)** is indeed recommended for women with diabetes preconception, and stopping **atorvastatin** is correct; however, this option fails to address the critical need to discontinue **ramipril**, another major teratogen.
- Both potentially harmful medications (statin and ACE inhibitor) must be addressed simultaneously before conception occurs for optimal fetal safety.
*Stop all medications except insulin and commence aspirin 150 mg daily*
- **Aspirin 150 mg** daily is indicated for **pre-eclampsia prophylaxis** in diabetic pregnancies, but it is typically commenced from **12 weeks gestation**, not during the pre-conception phase.
- The instruction to "stop all medications" is imprecise and does not specifically highlight the critical need to discontinue known **teratogenic drugs** like ramipril and atorvastatin.
*Switch from insulin glargine to insulin detemir*
- Modern guidelines indicate that both **insulin glargine** and **insulin detemir** are considered safe for use throughout pregnancy and do not necessitate a switch if glycaemic control is stable.
- This change is unnecessary and does not address the high-risk issues posed by the patient's **statin** and **ACE inhibitor** therapy, which are the primary concerns pre-conception.
Question 63: A 26-year-old woman attends the antenatal clinic at 36 weeks gestation for routine review. She has chronic hypertension and has been taking methyldopa 500 mg three times daily throughout pregnancy. Her blood pressure today is 152/98 mmHg. She is asymptomatic. Urinalysis shows 1+ proteinuria. Blood tests show: Hb 118 g/L, platelets 178 × 10⁹/L, ALT 32 IU/L, creatinine 76 μmol/L. Her booking blood pressure was 138/88 mmHg with no proteinuria. Fetal growth and amniotic fluid are normal on ultrasound. What is the most appropriate next step in management?
A. Increase methyldopa dose to 750 mg three times daily and review in one week
B. Send urine protein:creatinine ratio and review in clinic in 48 hours (Correct Answer)
C. Admit for inpatient monitoring and consider delivery
D. Add nifedipine 10 mg modified release twice daily and review in 48 hours
E. Continue current management and arrange routine follow-up in one week
Explanation: ***Send urine protein:creatinine ratio and review in clinic in 48 hours*** - The patient has **chronic hypertension** with new-onset **proteinuria** after 20 weeks gestation and elevated blood pressure, which is highly suspicious for **superimposed pre-eclampsia**. - A **uPCR (urine protein:creatinine ratio)** is the gold standard for quantifying proteinuria and confirming the diagnosis; a ratio **≥30 mg/mmol** is significant. *Increase methyldopa dose to 750 mg three times daily and review in one week* - While the BP is elevated, the priority is to **quantify proteinuria** to diagnose or rule out **superimposed pre-eclampsia** before adjusting medication. - A one-week review is too prolonged for a patient with potential **superimposed pre-eclampsia** at 36 weeks gestation, given the risks of rapid deterioration. *Admit for inpatient monitoring and consider delivery* - Inpatient admission and considering delivery are typically reserved for **severe pre-eclampsia** (BP ≥160/110 mmHg) or signs of **end-organ damage**. - The patient's blood pressure is not in the severe range, she is **asymptomatic**, and her laboratory values are currently normal. *Add nifedipine 10 mg modified release twice daily and review in 48 hours* - While adding a second anti-hypertensive might be necessary, the initial priority is to **confirm the diagnosis** of **superimposed pre-eclampsia** through proteinuria quantification. - Treating blood pressure alone without confirming the diagnosis overlooks the critical aspect of **gestational risk stratification** and management. *Continue current management and arrange routine follow-up in one week* - Ignoring new-onset **1+ proteinuria** in a pregnant woman with chronic hypertension is unsafe, as it indicates a potential progression to **superimposed pre-eclampsia**. - Routine follow-up is inadequate because **superimposed pre-eclampsia** can advance rapidly, increasing the risk of both **maternal and fetal complications**.
Question 64: A 37-year-old woman attends antenatal clinic at 12 weeks gestation in her second pregnancy. Her first pregnancy was complicated by gestational diabetes requiring insulin therapy. Her BMI is 33 kg/m². Random blood glucose today is 6.8 mmol/L. HbA1c is 42 mmol/mol (6.0%). She asks about screening for gestational diabetes in this pregnancy. What is the most appropriate screening approach for this woman?
A. Commence monthly HbA1c monitoring throughout pregnancy
B. Self-monitoring of blood glucose from now until delivery
C. No screening required as her HbA1c is normal
D. Arrange oral glucose tolerance test at 24-28 weeks only
E. Arrange oral glucose tolerance test at 16 weeks and again at 28 weeks if first test is normal (Correct Answer)
Explanation: ***Arrange oral glucose tolerance test at 16 weeks and again at 28 weeks if first test is normal***- For women with a history of **gestational diabetes** and other risk factors like **high BMI**, guidelines recommend early screening with an **oral glucose tolerance test (OGTT)**, typically around **16-18 weeks**.- If the initial OGTT is normal, a repeat test is advised at **24-28 weeks** because insulin resistance naturally increases in later pregnancy, raising the risk of developing GDM.
*Commence monthly HbA1c monitoring throughout pregnancy*
- **HbA1c** is not the primary screening tool for gestational diabetes due to physiological changes in red blood cell turnover during pregnancy affecting its reliability.- While useful for assessing long-term glycemic control, it does not replace the dynamic nature of an **OGTT** for diagnosing GDM.
*Self-monitoring of blood glucose from now until delivery*
- **Self-monitoring of blood glucose (SMBG)** is a management strategy used *after* a diagnosis of gestational diabetes has been made, to help manage blood sugar levels.- It is not an initial screening method for diagnosing the condition, and starting it before diagnosis would be premature and potentially cause unnecessary anxiety.
*No screening required as her HbA1c is normal*
- A normal **HbA1c** (e.g., 42 mmol/mol or 6.0%) at booking indicates the absence of pre-existing diabetes but does not rule out the development of **gestational diabetes**.- This patient has significant risk factors (previous GDM, BMI 33 kg/m²), making screening essential despite a normal early HbA1c.
*Arrange oral glucose tolerance test at 24-28 weeks only*
- While an **OGTT at 24-28 weeks** is standard for women with other risk factors (like obesity alone), it is insufficient for those with a **history of gestational diabetes**.- Patients with prior GDM are at higher risk for early-onset disease, necessitating earlier screening to detect and manage hyperglycemia promptly.
Question 65: A 32-year-old woman is admitted at 35 weeks gestation with severe pre-eclampsia. Blood pressure is 168/114 mmHg despite treatment with labetalol 200 mg three times daily. Blood tests show: platelets 98 × 10⁹/L, ALT 156 IU/L, AST 178 IU/L, bilirubin 32 μmol/L, creatinine 118 μmol/L, urea 8.2 mmol/L, LDH 642 IU/L. Blood film shows fragmented red cells. She has right upper quadrant pain and is being prepared for delivery. In addition to continuing antihypertensive therapy, what other medication should be administered immediately?
A. Intravenous magnesium sulphate (Correct Answer)
B. Intramuscular betamethasone
C. Intravenous tranexamic acid
D. Platelet transfusion
E. Intravenous hydrocortisone
Explanation: ***Intravenous magnesium sulphate***
- This patient presents with clear signs of **HELLP syndrome** (Haemolysis, Elevated Liver enzymes, Low Platelets) and **severe pre-eclampsia**, including microangiopathic hemolytic anemia (fragmented red cells, elevated LDH, elevated bilirubin), elevated liver enzymes, and thrombocytopenia, along with uncontrolled hypertension.
- **Magnesium sulphate** is the cornerstone for **seizure prophylaxis** in women with severe pre-eclampsia or HELLP syndrome, and its immediate administration is critical to prevent eclampsia, especially with imminent delivery.
*Intramuscular betamethasone*
- **Corticosteroids** like betamethasone are primarily given to accelerate **fetal lung maturity**, usually indicated for pregnancies between 24 and 34+6 weeks gestation.
- At 35 weeks gestation, the benefit for fetal lung maturity is less pronounced, and the immediate priority is maternal stabilization and **prevention of eclampsia** over fetal lung maturation.
*Intravenous tranexamic acid*
- **Tranexamic acid** is an antifibrinolytic agent used to prevent or reduce **blood loss**, particularly in cases of significant hemorrhage like **postpartum hemorrhage**.
- While HELLP syndrome can increase the risk of bleeding due to thrombocytopenia and coagulopathy, there is no indication of active, severe hemorrhage warranting immediate tranexamic acid administration over seizure prophylaxis.
*Platelet transfusion*
- **Platelet transfusions** are typically considered for platelet counts below **20-50 × 10⁹/L** in HELLP syndrome, especially before invasive procedures like C-section or in the presence of active bleeding.
- With a platelet count of **98 × 10⁹/L**, the patient is above the usual threshold for immediate prophylactic platelet transfusion, and the most pressing concern remains eclampsia prevention.
*Intravenous hydrocortisone*
- High-dose corticosteroids like hydrocortisone have been explored in the management of HELLP syndrome but are **not a standard or immediately indicated treatment** for improving maternal or neonatal outcomes.
- It does not have a role in the **prevention of eclamptic seizures** or direct management of the severe hypertension present in this case.
Question 66: A 40-year-old woman in her third pregnancy attends the antenatal clinic at 16 weeks gestation. She has a history of previous pregnancies: first pregnancy resulted in emergency caesarean section at 32 weeks for severe pre-eclampsia with HELLP syndrome, and second pregnancy ended in miscarriage at 8 weeks. Her BMI is 28 kg/m². Blood pressure today is 128/82 mmHg. She is taking folic acid 400 micrograms daily. What is the most appropriate additional intervention at this stage?
A. Commence aspirin 75 mg daily
B. Commence aspirin 150 mg daily (Correct Answer)
C. Commence low molecular weight heparin prophylaxis
D. Arrange early glucose tolerance test at 20 weeks
E. Commence calcium supplementation 1 gram daily
Explanation: ***Commence aspirin 150 mg daily***
- This patient has one **high-risk factor** for pre-eclampsia (previous history of **HELLP syndrome** and severe pre-eclampsia requiring delivery at 32 weeks), necessitating aspirin prophylaxis.
- Current **NICE guidelines** and recent evidence (such as the ASPRE trial) recommend a dose of **150 mg daily** started at 12–16 weeks for better efficacy compared to lower doses.
*Commence aspirin 75 mg daily*
- While 75 mg was historically used, modern practice and many hospital protocols now favor **150 mg** to ensure adequate suppression of **thromboxane synthesis**.
- A lower dose may be less effective in preventing **pre-eclampsia** in patients with significant high-risk factors like previous early-onset disease.
*Commence low molecular weight heparin prophylaxis*
- **LMWH** is used for venous thromboembolism prophylaxis or for women with **antiphospholipid syndrome** (APS); this patient does not currently meet the criteria for APS despite a single miscarriage.
- While her BMI and age are noted, she lacks the threshold of risk factors required to initiate **heparin** prophylaxis at 16 weeks based solely on the provided history.
*Arrange early glucose tolerance test at 20 weeks*
- Although she is **40 years old**, which is a risk factor for gestational diabetes, an Oral Glucose Tolerance Test (OGTT) is typically performed at **24–28 weeks**.
- Prioritizing **aspirin** is more clinically urgent given the high recurrence risk of severe pre-eclampsia and the current 16-week window for intervention.
*Commence calcium supplementation 1 gram daily*
- Calcium supplementation is recommended by the **WHO** for populations with low dietary intake, but it is not standard first-line prophylaxis in the UK.
- It does not replace the requirement for **aspirin**, which provides more robust protection against placental-mediated hypertensive disorders in high-risk women.
Question 67: A 28-year-old woman presents to the emergency department at 34 weeks gestation with a severe frontal headache of sudden onset that started 3 hours ago. She describes it as the worst headache of her life. Her blood pressure is 162/104 mmHg. She has photophobia and neck stiffness. Urinalysis shows 2+ proteinuria. Blood tests show: platelets 142 × 10⁹/L, ALT 45 IU/L, creatinine 82 μmol/L. Fundoscopy reveals no papilloedema. She is drowsy but oriented. What is the most appropriate immediate investigation?
A. CT head without contrast (Correct Answer)
B. MRI brain with gadolinium contrast
C. Lumbar puncture for cerebrospinal fluid analysis
D. Urine protein:creatinine ratio
E. Repeat blood tests including full blood count and liver function
Explanation: ***CT head without contrast***- The presentation of a sudden-onset **"worst headache of life"** combined with **neck stiffness** and **photophobia** is highly suggestive of a **subarachnoid haemorrhage (SAH)**.- A **non-contrast CT head** is the immediate gold-standard investigation to detect acute intracranial bleeding and is safe during pregnancy with appropriate fetal shielding.*MRI brain with gadolinium contrast*- While sensitive for certain pathologies, **MRI** is time-consuming in an emergency setting and is not the first-line choice for ruling out acute haemorrhage.- **Gadolinium contrast** is generally avoided in pregnancy as it crosses the placenta and its long-term effects on the fetus are not fully established.*Lumbar puncture for cerebrospinal fluid analysis*- A **lumbar puncture** is used to detect **xanthochromia** if the CT is negative but suspicion of SAH remains high.- It must never be performed before neuroimaging because of the risk of **brain herniation** if raised intracranial pressure is present.*Urine protein:creatinine ratio*- Although this patient has **pre-eclampsia** (hypertension and proteinuria), this test only quantifies the degree of proteinuria.- It does not address the acute, life-threatening neurological symptoms that require **urgent intracranial imaging**.*Repeat blood tests including full blood count and liver function*- These tests monitor for **HELLP syndrome** and other complications of pre-eclampsia but do not diagnose the cause of the sudden-onset headache.- Clinical priority must be given to excluding a **haemorrhagic stroke** or SAH, which are major causes of maternal mortality.
Question 68: A 33-year-old woman with gestational diabetes diagnosed at 27 weeks gestation is now 36 weeks pregnant. She has been managed with diet alone and her blood glucose control has been good with fasting values 4.8-5.1 mmol/L and 1-hour post-prandial values 6.8-7.4 mmol/L. Growth scans show the fetal abdominal circumference consistently on the 95th centile with estimated fetal weight on the 92nd centile. The head circumference and femur length are on the 50th centile. Amniotic fluid volume is normal. What is the most appropriate next step in management?
A. Continue current management and arrange induction of labour at 40 weeks
B. Commence insulin therapy and arrange growth scan in 2 weeks (Correct Answer)
C. Continue current management and arrange induction of labour at 38-39 weeks
D. Commence metformin therapy and arrange growth scan in 2 weeks
E. Continue current management and arrange delivery by elective caesarean section at 37 weeks
Explanation: ***Commence insulin therapy and arrange growth scan in 2 weeks***- Despite seemingly normal maternal glucose readings, an **abdominal circumference (AC) at the 95th centile** indicates **fetal macrosomia** and hyperinsulinemia, requiring pharmacological intensification.- **Insulin therapy** is preferred for immediate and precise glycemic control when ultrasound evidence shows asymmetrical fetal overgrowth to reduce the risk of **shoulder dystocia**.*Continue current management and arrange induction of labour at 40 weeks*- This approach ignores the **accelerated fetal growth**, which signifies that diet alone is failing to control fetal hyperinsulinism.- Delaying to **40 weeks** in a poorly controlled or macrosomic diabetic pregnancy increases the risks of **stillbirth** and birth trauma.*Continue current management and arrange induction of labour at 38-39 weeks*- While 38-39 weeks is a standard induction window for GDM, it is inappropriate here as **active intervention** (medication) is needed now to address the **rising abdominal circumference**.- Continuing current management fails to address the underlying **fetal overgrowth** occurring at 36 weeks.*Commence metformin therapy and arrange growth scan in 2 weeks*- **Metformin** is an option for GDM, but when there is clear evidence of **macrosomia** (AC >95th centile), **insulin** is the more effective and widely recommended first-line pharmacological treatment to halt rapid growth.- Transitioning to insulin is more reliable for achieving strict targets when the fetus already shows signs of **asymmetrical growth**.*Continue current management and arrange delivery by elective caesarean section at 37 weeks*- **Elective caesarean section** is generally reserved for estimated fetal weights exceeding **4.5 kg** or other obstetric indications, not as a primary response to high AC centiles.- This ignores the need to optimize **metabolic control** via insulin to stabilize fetal growth before delivery.
Question 69: A 36-year-old woman presents to the antenatal day unit at 30 weeks gestation with a blood pressure reading of 146/96 mmHg taken by her community midwife. This is her first pregnancy. Her booking blood pressure at 12 weeks was 118/72 mmHg. She is asymptomatic with no headache, visual disturbances, or epigastric pain. Repeat blood pressure in the unit is 148/94 mmHg. Urinalysis shows no proteinuria. Blood tests show: platelets 189 × 10⁹/L, ALT 28 IU/L, creatinine 68 μmol/L. What is the most appropriate initial management?
A. Reassure and discharge with routine follow-up as this is likely white coat hypertension
B. Commence labetalol 100 mg twice daily and arrange review in 48 hours (Correct Answer)
C. Admit for inpatient monitoring and further investigation
D. Commence aspirin 150 mg daily and arrange review in one week
E. Arrange ambulatory blood pressure monitoring and review in one week
Explanation: ***Commence labetalol 100 mg twice daily and arrange review in 48 hours***
- This patient has **gestational hypertension**, defined as a blood pressure of **≥140/90 mmHg** after 20 weeks of gestation in the absence of proteinuria or other features of pre-eclampsia.
- Current **NICE guidelines** recommend pharmacological treatment for any pregnant woman with a blood pressure of **140/90 mmHg or higher**, and **labetalol** is the first-line medication.
*Reassure and discharge with routine follow-up as this is likely white coat hypertension*
- Persistent readings above 140/90 mmHg in both community and hospital settings confirm **gestational hypertension**, which requires active management.
- Routine follow-up is insufficient as this condition carries a risk of progression to **pre-eclampsia** and requires monitoring every 48–72 hours.
*Admit for inpatient monitoring and further investigation*
- Admission is generally reserved for **severe hypertension** (≥160/110 mmHg) or those with clinical features of **pre-eclampsia** (e.g., proteinuria, organ dysfunction).
- Since her bloods are normal and she is **asymptomatic**, outpatient management with close monitoring is appropriate and safe.
*Commence aspirin 150 mg daily and arrange review in one week*
- **Low-dose aspirin** is used for **preeclampsia prophylaxis** and should be started before 16 weeks gestation in high-risk patients, not as a treatment for acute hypertension.
- A one-week review is too infrequent for a new diagnosis of gestational hypertension; the first review should occur within **48 hours**.
*Arrange ambulatory blood pressure monitoring and review in one week*
- **Ambulatory blood pressure monitoring (ABPM)** is helpful for diagnosing white-coat effect, but here the patient already has two elevated readings, justifying initiation of treatment.
- Delaying management for a week increases the risk of maternal and fetal complications associated with uncontrolled **hypertensive disorders of pregnancy**.
Question 70: A 29-year-old woman in her first pregnancy attends the antenatal clinic at 26 weeks gestation. She underwent oral glucose tolerance test (OGTT) following a random glucose of 8.4 mmol/L at 24 weeks. Her OGTT results show: fasting glucose 5.8 mmol/L, 2-hour glucose 9.1 mmol/L. She has been commenced on dietary modifications two weeks ago. She presents her home blood glucose monitoring showing fasting values ranging 5.4-5.8 mmol/L and 1-hour post-prandial values of 8.2-9.5 mmol/L. What is the most appropriate next step in her management?
A. Continue diet and lifestyle modifications alone and review in 2 weeks
B. Add metformin therapy and continue dietary measures (Correct Answer)
C. Commence insulin therapy immediately
D. Arrange urgent endocrinology referral
E. Add glibenclamide therapy
Explanation: ***Add metformin therapy and continue dietary measures***
- This patient's **fasting glucose** (5.4-5.8 mmol/L) and **post-prandial** levels (8.2-9.5 mmol/L) remain above targets (<5.3 and <7.8 respectively) despite two weeks of **dietary modification**.
- According to **NICE guidelines**, if glycemic targets are not met within 1-2 weeks of lifestyle changes, **metformin** should be initiated as the first-line pharmacological treatment for **gestational diabetes mellitus**.
*Continue diet and lifestyle modifications alone and review in 2 weeks*
- Continuing lifestyle measures alone is inappropriate because her blood glucose levels remain consistently **above target** after an adequate trial period.
- Delays in achieving **glycemic control** increase the risk of maternal and neonatal complications such as **macrosomia** and birth trauma.
*Commence insulin therapy immediately*
- **Insulin** is typically reserved as first-line if the fasting glucose at diagnosis is **≥7.0 mmol/L** or if there are signs of **fetal macrosomia** or polyhydramnios.
- For this patient, whose fasting levels are only mildly elevated, **metformin** is the preferred initial pharmacological step before escalating to insulin.
*Arrange urgent endocrinology referral*
- While multidisciplinary care is essential, **gestational diabetes** is managed by established local **diabetes-obstetric teams** rather than an urgent general endocrinology referral.
- The immediate clinical priority is the initiation of **pharmacotherapy**, which should be managed within the routine antenatal diabetes pathway.
*Add glibenclamide therapy*
- **Glibenclamide** is not recommended as a first-line agent and is generally only considered for women who cannot tolerate **metformin** or who decline **insulin** therapy.
- It is less commonly used than metformin in current clinical practice due to its specific profile and the effectiveness of other **glucose-lowering** options.
