A 31-year-old woman presents to the antenatal clinic at 14 weeks gestation for her booking appointment. She has no significant medical history. Her booking bloods reveal: Hb 102 g/L, MCV 71 fL, ferritin 8 mcg/L, HbA1c 34 mmol/mol. Blood pressure is 122/78 mmHg. She asks about the implications of her blood results. What is the most appropriate explanation regarding her anaemia?
Q72
A 34-year-old woman attends her booking appointment at 10 weeks gestation in her second pregnancy. She had a previous postpartum haemorrhage requiring blood transfusion. She takes no regular medications and has no known allergies. Her BMI is 32 kg/m². Blood pressure is 118/76 mmHg and urinalysis is normal. She is keen to know about vitamin supplementation during pregnancy. What is the recommended daily dose of folic acid supplementation for this woman throughout the first trimester?
Q73
A 37-year-old woman with gestational diabetes on metformin 1000 mg twice daily is reviewed at 34 weeks gestation. Her recent blood glucose monitoring shows: fasting values 5.0-5.4 mmol/L and 1-hour post-prandial values 8.2-8.9 mmol/L despite dietary compliance. Ultrasound shows estimated fetal weight on 75th centile and normal amniotic fluid volume. Her metformin has been optimized and she is already on the maximum dose. She has no contraindications to insulin. What is the most appropriate modification to her treatment regimen?
Q74
A 26-year-old woman attends her booking appointment at 8 weeks gestation. This is her second pregnancy; her first child was delivered by emergency caesarean section at 36 weeks for fetal distress. She has no medical problems and takes only folic acid 400 mcg daily. Her BMI is 24 kg/m². Blood tests show: Hb 118 g/L, ferritin 22 mcg/L, TSH 2.1 mIU/L. Her blood pressure is 118/72 mmHg. Urinalysis is normal. According to current NICE antenatal care guidelines, what additional screening test should be offered at this visit?
Q75
A 29-year-old woman with type 1 diabetes is seen in the joint diabetes-obstetric clinic at 32 weeks gestation. She has been taking insulin aspart before meals and insulin detemir at bedtime. Her HbA1c is 52 mmol/mol (6.9%). Home blood glucose monitoring shows occasional pre-breakfast values of 5.8-6.2 mmol/L, with other readings within target. She has had two episodes of nocturnal hypoglycemia (glucose 2.8 and 3.1 mmol/L) in the past week. Growth scans show fetal abdominal circumference on 55th centile. What is the most appropriate adjustment to her insulin regimen?
Q76
A 42-year-old woman presents to the antenatal clinic at 16 weeks gestation in her fourth pregnancy. Her obstetric history includes: first pregnancy - spontaneous vaginal delivery at term; second pregnancy - emergency caesarean section at 30 weeks for severe pre-eclampsia; third pregnancy - spontaneous vaginal delivery at 37 weeks on antihypertensive medication for gestational hypertension. She has no chronic medical conditions. Her booking blood pressure was 132/84 mmHg. Today her BP is 128/78 mmHg. What is her risk category for developing pre-eclampsia in this pregnancy?
Q77
A 35-year-old woman is diagnosed with gestational diabetes at 26 weeks gestation following a screening OGTT (fasting 5.9 mmol/L, 2-hour 9.5 mmol/L). She is established on dietary modifications and home blood glucose monitoring. At review 2 weeks later, her fasting glucose values are consistently 5.6-6.2 mmol/L despite good compliance with diet. Her 1-hour post-prandial values are 6.5-7.2 mmol/L. What is the most appropriate adjustment to her management?
Q78
A 33-year-old woman attends her booking appointment at 10 weeks gestation. She has a BMI of 38 kg/m², hypertension managed with methyldopa, and a family history of type 2 diabetes in both parents. She had a previous baby weighing 4.6 kg at birth. What is the most appropriate screening strategy for gestational diabetes in this pregnancy?
Q79
A 39-year-old woman in her third pregnancy attends the emergency department at 34 weeks gestation with a severe frontal headache and visual disturbances described as flashing lights. Her blood pressure is 178/118 mmHg. She has 3+ proteinuria on dipstick. Neurological examination shows brisk reflexes with 3 beats of clonus at the ankles. Bloods show normal platelet count and liver function. She is started on intravenous labetalol. What additional immediate management should be initiated?
Q80
A 28-year-old woman with diet-controlled gestational diabetes is reviewed at 37 weeks gestation. Her home blood glucose monitoring over the past 2 weeks shows: fasting values 4.8-5.1 mmol/L and 1-hour post-prandial values 6.9-7.5 mmol/L. Ultrasound scan today shows estimated fetal weight on 60th centile, normal liquor volume, and normal umbilical artery Doppler. She asks about the timing of delivery. What is the most appropriate advice regarding delivery timing?
Pregnancy Medicine UK Medical PG Practice Questions and MCQs
Question 71: A 31-year-old woman presents to the antenatal clinic at 14 weeks gestation for her booking appointment. She has no significant medical history. Her booking bloods reveal: Hb 102 g/L, MCV 71 fL, ferritin 8 mcg/L, HbA1c 34 mmol/mol. Blood pressure is 122/78 mmHg. She asks about the implications of her blood results. What is the most appropriate explanation regarding her anaemia?
A. This represents physiological haemodilution of pregnancy and requires no intervention
B. She has iron deficiency anaemia and should commence oral iron supplementation (Correct Answer)
C. She requires vitamin B12 and folate levels to exclude deficiency
D. This likely represents thalassaemia trait and partner screening should be arranged
E. She should be referred for haematology assessment for possible bone marrow disorder
Explanation: ***She has iron deficiency anaemia and should commence oral iron supplementation***
- The patient presents with **microcytic anaemia** (low MCV 71 fL) and a severely **low ferritin** (8 mcg/L), which is the most sensitive and specific indicator of **iron deficiency**.
- In pregnancy, **iron requirements increase significantly**, and a haemoglobin of 102 g/L at 14 weeks gestation, coupled with confirmed iron deficiency, warrants immediate **oral iron supplementation**.
*This represents physiological haemodilution of pregnancy and requires no intervention*
- While **physiological haemodilution** does occur in pregnancy and lowers Hb, it typically results in **normocytic anaemia** and would not be associated with such a profoundly **low ferritin** level.
- The combination of **microcytosis** and **low ferritin** points definitively to a pathological cause (iron deficiency) requiring intervention, not just observation.
*She requires vitamin B12 and folate levels to exclude deficiency*
- Deficiencies in **vitamin B12** or **folate** cause **macrocytic (megaloblastic) anaemia** (high MCV), which contradicts the patient's **microcytic** MCV of 71 fL.
- The presence of **microcytosis** and **low ferritin** clearly establishes **iron deficiency anaemia**, making B12 and folate levels unnecessary as a primary diagnostic step for *this type* of anaemia.
*This likely represents thalassaemia trait and partner screening should be arranged*
- **Thalassaemia trait** causes **microcytic anaemia** but is typically associated with **normal or elevated ferritin** levels, as it is a disorder of globin chain synthesis, not iron availability.
- Given the extremely **low ferritin** in this patient, **iron deficiency** is the primary diagnosis and should be treated first; thalassaemia screening (e.g., **Hb electrophoresis**) would only be considered if microcytosis persists after iron repletion.
*She should be referred for haematology assessment for possible bone marrow disorder*
- There is no indication of a **bone marrow disorder**, as the patient's anaemia is fully explained by **iron deficiency**, a common and treatable condition in pregnancy.
- **Iron deficiency anaemia** in pregnancy is typically managed in the antenatal clinic with **oral iron supplementation**, and specialist haematology referral is not usually required unless there are complications or a failure to respond to treatment.
Question 72: A 34-year-old woman attends her booking appointment at 10 weeks gestation in her second pregnancy. She had a previous postpartum haemorrhage requiring blood transfusion. She takes no regular medications and has no known allergies. Her BMI is 32 kg/m². Blood pressure is 118/76 mmHg and urinalysis is normal. She is keen to know about vitamin supplementation during pregnancy. What is the recommended daily dose of folic acid supplementation for this woman throughout the first trimester?
A. 400 micrograms
B. 1 mg
C. 2.5 mg
D. 5 mg (Correct Answer)
E. 10 mg
Explanation: ***5 mg***- A high dose of **5 mg folic acid** is recommended for women with a **BMI 30 kg/m ** to decrease the risk of **neural tube defects (NTDs)**.- Other indications for this dose include maternal **diabetes**, use of **anti-epileptic drugs**, or a personal/family history of NTDs.*400 micrograms*- This is the standard dose for **low-risk women** without comorbid conditions or a high BMI.- It is insufficient for this patient due to her **obesity (BMI 32 kg/m )**, which increases the baseline risk of fetal malformations.*1 mg*- This dose is not a standard recommendation in national guidelines for any specific maternal risk group.- Clinical protocols strictly differentiate between the low-risk **400 mcg** dose and the high-risk **5 mg** dose.*2.5 mg*- There is no clinical evidence or guideline supporting the use of a **2.5 mg** dose for routine pregnancy supplementation.- For patients identified as high-risk, a full **5 mg** daily dose is required to provide adequate protection.*10 mg*- A **10 mg** dose exceeds the recommended therapeutic upper limit for folic acid in standard obstetric practice.- Excessive supplementation is not proven to provide additional benefit over the **5 mg** dose and is not part of standard guideline protocols.
Question 73: A 37-year-old woman with gestational diabetes on metformin 1000 mg twice daily is reviewed at 34 weeks gestation. Her recent blood glucose monitoring shows: fasting values 5.0-5.4 mmol/L and 1-hour post-prandial values 8.2-8.9 mmol/L despite dietary compliance. Ultrasound shows estimated fetal weight on 75th centile and normal amniotic fluid volume. Her metformin has been optimized and she is already on the maximum dose. She has no contraindications to insulin. What is the most appropriate modification to her treatment regimen?
A. Add long-acting insulin at bedtime while continuing metformin
B. Continue current metformin dose and arrange repeat scan in 2 weeks
C. Add gliclazide 40 mg daily while continuing metformin
D. Add short-acting insulin before meals while continuing metformin (Correct Answer)
E. Switch from metformin to a twice-daily mixed insulin regimen
Explanation: ***Add short-acting insulin before meals while continuing metformin***- The patient's **1-hour post-prandial** glucose levels (8.2-8.9 mmol/L) are above the target of **<7.8 mmol/L**, indicating she specifically needs mealtime glycemic control.- **Metformin** should be continued as it improves insulin sensitivity and reduces the total dose of insulin required during pregnancy.*Add long-acting insulin at bedtime while continuing metformin*- **Long-acting insulin** at bedtime is used to target **fasting hyperglycemia**, but this patient's fasting levels (5.0-5.4 mmol/L) are currently within the acceptable range (<5.3 mmol/L).- Adding basal insulin would not effectively address the primary issue of elevated **post-prandial excursions** seen in this patient.*Continue current metformin dose and arrange repeat scan in 2 weeks*- Failing to meet **glycemic targets** requires active medical intervention to reduce the risk of **macrosomia** and polyhydramnios, especially given the estimated fetal weight on the 75th centile.- Conservative management is inappropriate here because the glucose monitoring already proves that current **dietary compliance** and metformin are insufficient.*Add gliclazide 40 mg daily while continuing metformin*- **Gliclazide** (a sulfonylurea) is generally avoided in pregnancy as first-line add-on therapy due to concerns regarding **neonatal hypoglycemia** and cross-placental passage.- **Insulin** is the preferred second-line agent after metformin because it does not cross the placenta and allows for more precise titration without fetal risk.*Switch from metformin to a twice-daily mixed insulin regimen*- There is no clinical indication to discontinue **metformin**, as it provides baseline stability and prevents excessive weight gain during pregnancy.- A **twice-daily mixed regimen** is less flexible and less physiological than a basal-bolus or targeted bolus approach for managing specific post-meal spikes effectively.
Question 74: A 26-year-old woman attends her booking appointment at 8 weeks gestation. This is her second pregnancy; her first child was delivered by emergency caesarean section at 36 weeks for fetal distress. She has no medical problems and takes only folic acid 400 mcg daily. Her BMI is 24 kg/m². Blood tests show: Hb 118 g/L, ferritin 22 mcg/L, TSH 2.1 mIU/L. Her blood pressure is 118/72 mmHg. Urinalysis is normal. According to current NICE antenatal care guidelines, what additional screening test should be offered at this visit?
A. Screening for pre-eclampsia risk with uterine artery Doppler
B. Screening for fetal aneuploidy with cell-free DNA testing
C. Screening for group B streptococcus with vaginal-rectal swab
D. Screening for gestational diabetes with oral glucose tolerance test
E. Screening for asymptomatic bacteriuria with urine culture (Correct Answer)
Explanation: ***Screening for asymptomatic bacteriuria with urine culture***- **NICE guidelines** recommend offering screening for **asymptomatic bacteriuria** at the booking appointment to all pregnant women using a **midstream urine culture**.- Routine screening and treatment of asymptomatic bacteriuria reduce the risk of progressing to **pyelonephritis**, **preterm delivery**, and low birth weight.*Screening for pre-eclampsia risk with uterine artery Doppler*- This is not a routine screening test in **standard antenatal care**; pre-eclampsia risk is primarily assessed through clinical history and **blood pressure/proteinuria** monitoring.- Women at high risk are usually offered **aspirin** rather than routine specialized Doppler at the booking visit.*Screening for fetal aneuploidy with cell-free DNA testing*- While increasingly used, **cfDNA** is not the standard first-line screening; the **combined test** (nuchal translucency, PAPP-A, and beta-hCG) is the routine primary screening tool offered at 11-14 weeks.- On the NHS, cfDNA is typically offered as a **second-line test** following a high-risk result from the combined or quadruple test.*Screening for group B streptococcus with vaginal-rectal swab*- Universal screening for **Group B Streptococcus (GBS)** is not currently recommended by **NICE** or the RCOG in the UK.- Management focuses on identifying **risk factors** during labor to determine the need for **intrapartum antibiotic prophylaxis**.*Screening for gestational diabetes with oral glucose tolerance test*- The **OGTT** is typically performed between **24 and 28 weeks** of gestation for women with risk factors such as high BMI or a family history of diabetes.- This patient's **BMI of 24** and lack of risk factors mean she would not be offered an early OGTT at booking.
Question 75: A 29-year-old woman with type 1 diabetes is seen in the joint diabetes-obstetric clinic at 32 weeks gestation. She has been taking insulin aspart before meals and insulin detemir at bedtime. Her HbA1c is 52 mmol/mol (6.9%). Home blood glucose monitoring shows occasional pre-breakfast values of 5.8-6.2 mmol/L, with other readings within target. She has had two episodes of nocturnal hypoglycemia (glucose 2.8 and 3.1 mmol/L) in the past week. Growth scans show fetal abdominal circumference on 55th centile. What is the most appropriate adjustment to her insulin regimen?
A. Switch from insulin detemir to insulin glargine for better overnight control
B. Reduce evening insulin detemir dose and ensure bedtime snack (Correct Answer)
C. Add metformin to reduce insulin requirements and hypoglycemia risk
D. Increase evening insulin detemir to achieve lower fasting glucose levels
E. Switch to continuous subcutaneous insulin infusion (insulin pump)
Explanation: ***Reduce evening insulin detemir dose and ensure bedtime snack***- The patient is experiencing **recurrent nocturnal hypoglycemia** (glucose 2.8 and 3.1 mmol/L), which is a critical finding requiring immediate attention and indicates an excessive dose of **basal insulin** overnight.- Reducing the evening detemir dose directly addresses the hypoglycemia, and incorporating a **bedtime snack** with complex carbohydrates can help stabilize blood glucose levels and prevent further overnight drops.*Switch from insulin detemir to insulin glargine for better overnight control*- **Insulin detemir** is a well-established and safe long-acting insulin for use in pregnancy, and there is no inherent clinical advantage of switching to **insulin glargine** in this specific dose-related issue.- The problem stems from an **insulin dose mismatch** causing hypoglycemia, not the specific type of basal insulin being used.*Add metformin to reduce insulin requirements and hypoglycemia risk*- **Metformin** is not indicated for the primary management of **type 1 diabetes** in pregnancy, especially for correcting insulin-induced nocturnal hypoglycemia.- While metformin may be used adjunctively in some specific cases, it is not the appropriate first-line strategy when the core issue is an excessive basal insulin dose.*Increase evening insulin detemir to achieve lower fasting glucose levels*- Increasing the evening detemir dose would critically **worsen the nocturnal hypoglycemia**, posing a significant risk of severe adverse events for the mother.- In pregnant individuals with type 1 diabetes, preventing **hypoglycemia** is a paramount concern and takes precedence over aggressively lowering slightly elevated fasting glucose levels.*Switch to continuous subcutaneous insulin infusion (insulin pump)*- Switching to **CSII (insulin pump) therapy** is a complex change requiring extensive training and is generally reserved for patients unable to achieve glycemic targets with **multiple daily injections (MDI)**.- Given the patient's otherwise reasonable HbA1c and normal fetal growth, a simple and immediate **insulin dose adjustment** is the more appropriate intervention rather than a complete change in delivery method.
Question 76: A 42-year-old woman presents to the antenatal clinic at 16 weeks gestation in her fourth pregnancy. Her obstetric history includes: first pregnancy - spontaneous vaginal delivery at term; second pregnancy - emergency caesarean section at 30 weeks for severe pre-eclampsia; third pregnancy - spontaneous vaginal delivery at 37 weeks on antihypertensive medication for gestational hypertension. She has no chronic medical conditions. Her booking blood pressure was 132/84 mmHg. Today her BP is 128/78 mmHg. What is her risk category for developing pre-eclampsia in this pregnancy?
A. High-risk (one high-risk factor) - should receive aspirin prophylaxis (Correct Answer)
B. Moderate-risk (two or more moderate-risk factors) - should receive aspirin prophylaxis
C. Moderate-risk (one moderate-risk factor) - no aspirin prophylaxis indicated
D. Low-risk - routine antenatal care appropriate
E. High-risk (advanced maternal age and previous pre-eclampsia) - should receive aspirin and increased surveillance
Explanation: ***High-risk (one high-risk factor) - should receive aspirin prophylaxis***
- A history of **hypertensive disease** during a previous pregnancy (specifically **severe pre-eclampsia** in her second pregnancy) is classified as a **high-risk factor** according to NICE guidelines.
- Patients with **one high-risk factor** are indicated for **aspirin prophylaxis** (75–150 mg) daily from 12 weeks gestation until birth to reduce the risk of recurrence.
*Moderate-risk (two or more moderate-risk factors) - should receive aspirin prophylaxis*
- While the patient has one moderate-risk factor (**age ≥40 years**), her history of pre-eclampsia automatically upgrades her to the **high-risk category**.
- This classification is incorrect because the presence of even a single high-risk factor supersedes the requirement for multiple moderate-risk factors.
*Moderate-risk (one moderate-risk factor) - no aspirin prophylaxis indicated*
- Defining her as only moderate-risk ignores her significant obstetric history of **severe pre-eclampsia** and subsequent **gestational hypertension**.
- Aspirin is indeed indicated in this patient due to her **high-risk** status, making the recommendation of "no prophylaxis" clinically inappropriate.
*Low-risk - routine antenatal care appropriate*
- Routine care is only for patients with no high or moderate risk factors; this patient has significant **risk factors** that require intervention.
- Failing to identify her risk of **pre-eclampsia** could lead to a lack of necessary monitoring and preventive pharmacological treatment.
*High-risk (advanced maternal age and previous pre-eclampsia) - should receive aspirin and increased surveillance*
- Although she has these factors, **advanced maternal age** is a moderate-risk factor, not a high-risk factor on its own according to guidelines.
- This option incorrectly combines a moderate factor into the high-risk definition, whereas the **previous pre-eclampsia** alone is the primary high-risk driver for prophylaxis.
Question 77: A 35-year-old woman is diagnosed with gestational diabetes at 26 weeks gestation following a screening OGTT (fasting 5.9 mmol/L, 2-hour 9.5 mmol/L). She is established on dietary modifications and home blood glucose monitoring. At review 2 weeks later, her fasting glucose values are consistently 5.6-6.2 mmol/L despite good compliance with diet. Her 1-hour post-prandial values are 6.5-7.2 mmol/L. What is the most appropriate adjustment to her management?
A. Add metformin and continue dietary measures (Correct Answer)
B. Add bedtime insulin and continue dietary measures
C. Add metformin for daytime glucose control and bedtime insulin for fasting glucose
D. Continue dietary management alone for a further 2 weeks before considering medication
E. Commence mixed insulin regimen twice daily
Explanation: ***Add metformin and continue dietary measures***
- Per **NICE guidelines**, if blood glucose targets (fasting <5.3 mmol/L) are not met within 1-2 weeks of lifestyle changes, **metformin** should be offered as the first-line pharmacological treatment.
- This patient's **fasting glucose** remains elevated (5.6-6.2 mmol/L) despite diet, making the addition of an oral hypoglycemic agent the appropriate next step.
*Add bedtime insulin and continue dietary measures*
- **Insulin** is typically reserved as a second-line option if metformin is contraindicated, not tolerated, or if glucose targets are not met with metformin alone.
- It may be considered first-line only if the **fasting glucose** is significantly higher (typically ">=7.0 mmol/L") at diagnosis or if there are signs of **fetal macrosomia**.
*Add metformin for daytime glucose control and bedtime insulin for fasting glucose*
- Starting a **combination therapy** of metformin and insulin simultaneously is premature at this stage as her post-prandial levels are already within the target range.
- Management should follow a **step-wise approach**, assessing the response to metformin before adding insulin for nocturnal glucose control.
*Continue dietary management alone for a further 2 weeks before considering medication*
- Delaying treatment for another 2 weeks increases the risk of **fetal complications** like macrosomia and neonatal hypoglycemia since targets are already not being met.
- Evidence suggests that failing to achieve **glycemic control** within the first 1-2 weeks of lifestyle intervention warrants immediate pharmacological escalation.
*Commence mixed insulin regimen twice daily*
- A **twice-daily mixed insulin** regimen is overly complex for initial therapy, especially since the patient's primary issue is fasting hyperglycemia rather than post-prandial spikes.
- Such a regimen carries a higher risk of **hypoglycemia** compared to metformin or targeted basal insulin and is not the standard first-line intervention.
Question 78: A 33-year-old woman attends her booking appointment at 10 weeks gestation. She has a BMI of 38 kg/m², hypertension managed with methyldopa, and a family history of type 2 diabetes in both parents. She had a previous baby weighing 4.6 kg at birth. What is the most appropriate screening strategy for gestational diabetes in this pregnancy?
A. Perform oral glucose tolerance test at booking and repeat at 28 weeks if normal (Correct Answer)
B. Arrange oral glucose tolerance test at 24-28 weeks gestation only
C. Check HbA1c at booking and arrange OGTT at 28 weeks if HbA1c is normal
D. Commence home blood glucose monitoring immediately without OGTT
E. Perform random blood glucose at each antenatal visit and OGTT if elevated
Explanation: ***Perform oral glucose tolerance test at booking and repeat at 28 weeks if normal***
- Women with **multiple high-risk factors** like a **previous macrosomic baby** (≥4.5 kg), **BMI >30**, and a **family history of type 2 diabetes** require early screening for gestational diabetes (GDM) as soon as possible after booking.
- A repeat **oral glucose tolerance test (OGTT) at 24-28 weeks** is crucial if the initial test is normal, as insulin resistance often peaks in the late second and third trimesters, potentially leading to later onset GDM.
*Arrange oral glucose tolerance test at 24-28 weeks gestation only*
- This strategy is typically reserved for women with **moderate risk factors** who do not have a history of previous GDM or other clear indications for early first-trimester screening.
- Delaying the OGTT until 24-28 weeks in a patient with this many significant risk factors could miss **pre-existing undiagnosed type 2 diabetes** or early-onset GDM, which could lead to adverse outcomes.
*Check HbA1c at booking and arrange OGTT at 28 weeks if HbA1c is normal*
- **HbA1c** is not recommended as a primary screening tool for GDM due to physiological changes in pregnancy, such as increased **red cell turnover** and hemodilution, which can lead to falsely low results.
- While HbA1c can help identify pre-existing type 2 diabetes, the **75g OGTT** remains the gold standard for diagnosing GDM, and waiting until 28 weeks for the OGTT would be too late for early detection in a high-risk patient.
*Commence home blood glucose monitoring immediately without OGTT*
- Home blood glucose monitoring is generally used for **managing** diagnosed GDM or as an alternative *screening* option for women with a **history of previous GDM** who prefer it over repeated OGTTs.
- For women with risk factors but no prior diagnosis, a formal **diagnostic test (OGTT)** is required to establish the presence of GDM before commencing intensive self-monitoring.
*Perform random blood glucose at each antenatal visit and OGTT if elevated*
- **Random blood glucose** testing lacks the necessary sensitivity and specificity for effective screening of gestational diabetes and is not a recommended primary screening method.
- Relying on intermittent random checks or **glycosuria** as a screening approach can result in missed diagnoses, potentially leading to suboptimal maternal and fetal outcomes.
Question 79: A 39-year-old woman in her third pregnancy attends the emergency department at 34 weeks gestation with a severe frontal headache and visual disturbances described as flashing lights. Her blood pressure is 178/118 mmHg. She has 3+ proteinuria on dipstick. Neurological examination shows brisk reflexes with 3 beats of clonus at the ankles. Bloods show normal platelet count and liver function. She is started on intravenous labetalol. What additional immediate management should be initiated?
A. Intravenous magnesium sulphate 4 g loading dose over 20 minutes followed by infusion (Correct Answer)
B. Oral nifedipine 10 mg immediate release
C. Intravenous hydralazine 5 mg bolus
D. Intramuscular betamethasone 12 mg
E. Emergency caesarean section under general anaesthesia
Explanation: ***Intravenous magnesium sulphate 4 g loading dose over 20 minutes followed by infusion***
- This patient presents with **severe pre-eclampsia** and clinical features of **imminent eclampsia**, including a severe headache, visual disturbances, and **clonus**.
- **Magnesium sulphate** is the treatment of choice for the prevention of eclamptic seizures and should be initiated immediately to reduce the risk by over 50%.
*Oral nifedipine 10 mg immediate release*
- While blood pressure control is vital, **immediate-release nifedipine** is generally avoided in pregnancy due to the risk of sudden hypotension and fetal distress.
- The patient is already receiving **intravenous labetalol**, which is a first-line agent for managing hypertensive crises in pregnancy.
*Intravenous hydralazine 5 mg bolus*
- **Hydralazine** is an alternative antihypertensive for acute control, but it is typically used if there is an inadequate response to **labetalol**.
- It does not address the immediate risk of **seizure/eclampsia**, which is the primary concern given the neurological symptoms.
*Intramuscular betamethasone 12 mg*
- **Corticosteroids** are indicated at 34 weeks gestation to promote **fetal lung maturity** in anticipation of preterm delivery.
- Although important, it is not the most immediate priority compared to preventing **maternal seizure** and stabilizing life-threatening blood pressure.
*Emergency caesarean section under general anaesthesia*
- Delivery is the definitive treatment for pre-eclampsia/eclampsia, but the mother must be **stabilized first** with antihypertensives and magnesium sulphate.
- An **emergency caesarean** without stabilization significantly increases maternal and fetal morbidity and is not indicated before attempting medical management.
Question 80: A 28-year-old woman with diet-controlled gestational diabetes is reviewed at 37 weeks gestation. Her home blood glucose monitoring over the past 2 weeks shows: fasting values 4.8-5.1 mmol/L and 1-hour post-prandial values 6.9-7.5 mmol/L. Ultrasound scan today shows estimated fetal weight on 60th centile, normal liquor volume, and normal umbilical artery Doppler. She asks about the timing of delivery. What is the most appropriate advice regarding delivery timing?
A. Offer elective induction of labour at 38 weeks gestation
B. Recommend expectant management with weekly monitoring until 42 weeks if uncomplicated
C. Offer elective caesarean section at 38 weeks due to gestational diabetes
D. Offer elective induction of labour at 40 weeks or earlier if there are maternal or fetal complications (Correct Answer)
E. Recommend delivery at 37 weeks as she has completed this gestation
Explanation: ***Offer elective induction of labour at 40 weeks or earlier if there are maternal or fetal complications***
- This patient has **well-controlled gestational diabetes** (diet-controlled, normal blood glucose values) and a **normal fetal ultrasound**, indicating no immediate complications.
- According to **NICE guidelines**, for women with diet-controlled gestational diabetes without complications, birth should be offered by **40+6 weeks gestation** to reduce the risk of stillbirth and other adverse outcomes associated with prolonged pregnancy in GDM.
*Offer elective induction of labour at 38 weeks gestation*
- Induction at **37+0 to 38+6 weeks** is typically reserved for women with gestational diabetes who require **medication (metformin or insulin)** for glycemic control or have evidence of **fetal macrosomia** or other complications.
- Given this patient's **excellent diet-controlled glucose levels** and normal fetal growth (60th centile), early induction at 38 weeks is not clinically indicated.
*Recommend expectant management with weekly monitoring until 42 weeks if uncomplicated*
- Extending pregnancy to **42 weeks** in gestational diabetes significantly increases the risk of **fetal demise**, **macrosomia**, and **placental insufficiency**, even with good glucose control.
- Current guidelines recommend against prolonged pregnancy beyond **40+6 weeks** for GDM, regardless of control method, to mitigate these risks.
*Offer elective caesarean section at 38 weeks due to gestational diabetes*
- **Gestational diabetes** itself is not an absolute indication for a **caesarean section**; vaginal delivery is the preferred mode unless specific obstetric complications, such as significant **macrosomia** or other contraindications, arise.
- There is no indication for an elective caesarean section at 38 weeks here, as the patient's GDM is well-managed and the estimated fetal weight is normal (60th centile), suggesting no increased risk of **shoulder dystocia** requiring C-section.
*Recommend delivery at 37 weeks as she has completed this gestation*
- Elective delivery at **37 weeks** without specific indications (e.g., poor glycemic control, preeclampsia, fetal distress) is not recommended, as it may increase the risk of **neonatal respiratory distress syndrome** and other prematurity-related complications.
- For **well-controlled gestational diabetes**, the benefits of allowing the pregnancy to progress closer to term (up to 40+6 weeks) generally outweigh the risks, as long as maternal and fetal surveillance remains reassuring.
