Pregnancy Medicine — MCQs
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A 32-year-old primigravida at 29 weeks gestation presents to the antenatal day unit with a 48-hour history of persistent headache and epigastric pain. Her blood pressure is 156/102 mmHg. Urinalysis shows 2+ protein. Blood tests reveal: platelet count 95 × 10⁹/L, ALT 89 U/L, AST 102 U/L, LDH 550 U/L, and uric acid 0.42 mmol/L. Ultrasound shows normal fetal biometry and amniotic fluid volume. What is the most likely diagnosis?
A 36-year-old woman presents for antenatal booking at 11 weeks gestation in her first pregnancy. She has a history of systemic lupus erythematosus, currently in remission, and chronic hypertension managed with ramipril 5 mg once daily. Her blood pressure today is 142/88 mmHg. She is also taking hydroxychloroquine 200 mg twice daily. What is the most appropriate management regarding her antihypertensive medication?
A 34-year-old woman attends her booking appointment at 9 weeks gestation in her second pregnancy. Her first pregnancy was complicated by severe pre-eclampsia requiring delivery at 32 weeks. She has a BMI of 28 kg/m² and blood pressure of 118/76 mmHg. She is otherwise well with no significant medical history. According to current NICE guidelines, what is the most appropriate prophylactic medication to reduce her risk of pre-eclampsia?
A 39-year-old woman presents to the antenatal day unit at 32 weeks gestation with reduced fetal movements for 24 hours. Her booking BMI was 35 kg/m². She was diagnosed with gestational diabetes at 28 weeks and commenced on metformin. CTG is performed and is normal. During the assessment, her blood pressure is measured as 168/114 mmHg, repeated 30 minutes later is 164/110 mmHg. She reports no headache, visual disturbances, or epigastric pain. Urinalysis shows trace protein. What is the single most important immediate management priority?
A 34-year-old woman undergoes OGTT at 27 weeks gestation. Results show: fasting glucose 5.4 mmol/L and 2-hour glucose 9.2 mmol/L. She is diagnosed with gestational diabetes and referred to the diabetes in pregnancy clinic. She has been following dietary advice for 2 weeks. Her home blood glucose monitoring over the past week shows: fasting values 4.8-5.2 mmol/L and 1-hour post-prandial values 7.2-7.9 mmol/L. What is the most appropriate next step in management?
A 27-year-old primigravida attends her booking appointment at 10 weeks gestation. She has no significant medical history. Her booking blood pressure is 146/94 mmHg, repeated after 15 minutes rest is 144/92 mmHg. Urinalysis shows no proteinuria. She mentions that her blood pressure was checked by her GP 3 months ago before pregnancy and was 142/90 mmHg. What is the most accurate diagnosis and initial management approach?
A 36-year-old woman at 38 weeks gestation with diet-controlled gestational diabetes presents to the labour ward with regular contractions. On examination, she is 4 cm dilated with intact membranes. Her blood glucose on arrival is 4.2 mmol/L. She has been eating and drinking normally. CTG is reassuring. What is the most appropriate management of her blood glucose during labour?
A 41-year-old woman in her fourth pregnancy attends the booking appointment at 11 weeks gestation. She had gestational diabetes in her previous two pregnancies, both requiring insulin treatment. Her pre-pregnancy BMI is 29 kg/m². She requests information about reducing her risk of gestational diabetes in this pregnancy. What is the most appropriate advice regarding lifestyle modifications and screening?
A 28-year-old woman is admitted at 35 weeks gestation with new-onset hypertension (BP 152/98 mmHg) and 1+ proteinuria on dipstick. Blood tests show: haemoglobin 118 g/L, platelets 178 × 10⁹/L, ALT 28 U/L, AST 32 U/L, creatinine 68 μmol/L, uric acid 0.38 mmol/L. Protein:creatinine ratio is 45 mg/mmol. She has mild headache but no visual disturbances. CTG is reassuring. What is the most appropriate next step in her management?
A 32-year-old woman with insulin-treated gestational diabetes is reviewed at 32 weeks gestation. Her home blood glucose monitoring shows: fasting values 5.8-6.2 mmol/L and 1-hour post-prandial values 8.5-9.2 mmol/L. She is on 16 units of long-acting insulin at night and 8 units of short-acting insulin before each meal. Growth scan shows estimated fetal weight on 92nd centile. What is the most appropriate adjustment to her management?
Pregnancy Medicine UK Medical PG Practice Questions and MCQs
Question 81: A 32-year-old primigravida at 29 weeks gestation presents to the antenatal day unit with a 48-hour history of persistent headache and epigastric pain. Her blood pressure is 156/102 mmHg. Urinalysis shows 2+ protein. Blood tests reveal: platelet count 95 × 10⁹/L, ALT 89 U/L, AST 102 U/L, LDH 550 U/L, and uric acid 0.42 mmol/L. Ultrasound shows normal fetal biometry and amniotic fluid volume. What is the most likely diagnosis?
- A. Severe pre-eclampsia without HELLP syndrome
- B. HELLP syndrome complicating pre-eclampsia (Correct Answer)
- C. Acute fatty liver of pregnancy
- D. Gestational hypertension with incidental thrombocytopenia
- E. Obstetric cholestasis with hypertension
Explanation: ***HELLP syndrome complicating pre-eclampsia***- This patient demonstrates the classic triad of **Hemolysis** (elevated **LDH 550 U/L**), **Elevated Liver enzymes** (**ALT 89 U/L, AST 102 U/L**), and **Low Platelets** (**95 × 10⁹/L**).- Clinical features such as **epigastric pain**, headache, and **hypertension** with proteinuria (156/102 mmHg, 2+ protein) confirm **severe pre-eclampsia** as the underlying cause.*Severe pre-eclampsia without HELLP syndrome*- While the patient meets criteria for severe pre-eclampsia, the presence of **thrombocytopenia** (<100 × 10⁹/L) and **elevated transaminases** (ALT/AST >70 U/L) explicitly defines this as HELLP syndrome.- Managing these as distinct entities is crucial as HELLP syndrome indicates a higher risk of **maternal morbidity** and complications like hepatic rupture.*Acute fatty liver of pregnancy*- Typically manifests with **hypoglycemia**, prolonged **clotting times** (PT/APTT), and profound **hyperbilirubinemia**, which are not present here.- While it also features elevated liver enzymes, it is usually associated with **acute liver failure** signs and occurs later in the third trimester.*Gestational hypertension with incidental thrombocytopenia*- Gestational hypertension by definition lacks **proteinuria**, which this patient clearly has (**2+ protein** on urinalysis).- **Incidental thrombocytopenia** of pregnancy typically stays above 100 × 10⁹/L and would not be associated with **elevated LDH** or liver enzymes.*Obstetric cholestasis with hypertension*- Obstetric cholestasis is primarily characterized by **intense pruritus** (itching) and elevated **bile acids**, neither of which are described.- It does not cause **thrombocytopenia**, hemolysis, or the level of blood pressure elevation seen in this patient.
Question 82: A 36-year-old woman presents for antenatal booking at 11 weeks gestation in her first pregnancy. She has a history of systemic lupus erythematosus, currently in remission, and chronic hypertension managed with ramipril 5 mg once daily. Her blood pressure today is 142/88 mmHg. She is also taking hydroxychloroquine 200 mg twice daily. What is the most appropriate management regarding her antihypertensive medication?
- A. Continue ramipril and monitor blood pressure regularly throughout pregnancy
- B. Switch ramipril to labetalol and aim for blood pressure <135/85 mmHg (Correct Answer)
- C. Stop all antihypertensive medication as blood pressure is acceptable in pregnancy
- D. Switch ramipril to amlodipine and increase dose if blood pressure remains elevated
- E. Continue ramipril but reduce the dose to 2.5 mg daily
Explanation: ***Switch ramipril to labetalol and aim for blood pressure <135/85 mmHg*** - **ACE inhibitors** like ramipril are **contraindicated** in pregnancy due to their **teratogenic effects**, specifically **fetal renal dysgenesis** and **oligohydramnios**, especially in the second and third trimesters. - **Labetalol** is a preferred first-line antihypertensive in pregnancy for **chronic hypertension** due to its established safety profile and efficacy, with a target blood pressure often set at **<135/85 mmHg** to reduce maternal and fetal risks. *Continue ramipril and monitor blood pressure regularly throughout pregnancy* - Continuing **ramipril** (an **ACE inhibitor**) poses significant risks to the developing fetus, including **renal malformations** and **intrauterine growth restriction**, making its continuation unsafe. - Current guidelines strongly recommend discontinuing **RAAS inhibitors** (ACEIs and ARBs) as soon as pregnancy is confirmed or planned, switching to safer alternatives. *Stop all antihypertensive medication as blood pressure is acceptable in pregnancy* - A blood pressure of 142/88 mmHg is **elevated** for a pregnant woman, particularly one with **chronic hypertension** and **SLE**, increasing risks of **preeclampsia**, **placental abruption**, and **maternal stroke**. - Uncontrolled hypertension in pregnancy can lead to severe maternal and fetal complications, necessitating appropriate pharmacologic management rather than discontinuation. *Switch ramipril to amlodipine and increase dose if blood pressure remains elevated* - While **amlodipine** (a calcium channel blocker) can be used in pregnancy, **labetalol** and **nifedipine** are generally considered the **first-line agents** for chronic hypertension due to more extensive data and guidelines recommending their use. - The initial switch should prioritize agents with the strongest evidence base for safety and efficacy in pregnancy. *Continue ramipril but reduce the dose to 2.5 mg daily* - The **teratogenic effects** of **ACE inhibitors** are a class effect and are not dose-dependent; even a reduced dose of ramipril still carries the risk of **fetal harm**. - Reducing the dose would not eliminate the fetal risks and may also lead to inadequate control of the mother's **chronic hypertension**, further complicating the pregnancy.
Question 83: A 34-year-old woman attends her booking appointment at 9 weeks gestation in her second pregnancy. Her first pregnancy was complicated by severe pre-eclampsia requiring delivery at 32 weeks. She has a BMI of 28 kg/m² and blood pressure of 118/76 mmHg. She is otherwise well with no significant medical history. According to current NICE guidelines, what is the most appropriate prophylactic medication to reduce her risk of pre-eclampsia?
- A. Aspirin 75 mg once daily from 12 weeks gestation until delivery (Correct Answer)
- B. Aspirin 150 mg once daily from 12 weeks gestation until delivery
- C. Aspirin 75 mg once daily from 16 weeks gestation until delivery
- D. Calcium supplementation 1000 mg daily from 12 weeks gestation
- E. Low molecular weight heparin from 12 weeks gestation until delivery
Explanation: ***Aspirin 75 mg once daily from 12 weeks gestation until delivery*** - Patients with **one high-risk factor** (e.g., prior hypertensive disease in pregnancy, chronic hypertension, CKD, diabetes, or autoimmune disease) should receive **low-dose aspirin**. - NICE specifically recommends **75 mg daily** starting from **12 weeks gestation** until birth to reduce the risk of pre-eclampsia. *Aspirin 150 mg once daily from 12 weeks gestation until delivery* - While some international guidelines (such as FIGO) suggest **150 mg**, current **NICE guidelines** in the UK still formally advocate for the **75 mg** dose. - Higher doses may be used in practice for specific clinical scenarios, but it is not the standard recommendation for a single high-risk factor in UK board exams. *Aspirin 75 mg once daily from 16 weeks gestation until delivery* - Prophylaxis is most effective when initiated early in the second trimester; **12 weeks** is the recommended start point to optimize **trophoblastic invasion**. - Starting at **16 weeks** is considered suboptimal according to national guidelines for preventing the onset of pre-eclampsia. *Calcium supplementation 1000 mg daily from 12 weeks gestation* - **Calcium supplementation** is primarily recommended by the WHO for populations with **low dietary calcium intake**. - It is not routinely used as a primary prophylactic measure for pre-eclampsia in the UK where dietary intake is generally sufficient. *Low molecular weight heparin from 12 weeks gestation until delivery* - **Low molecular weight heparin (LMWH)** is indicated for the prevention of **venous thromboembolism** rather than pre-eclampsia prophylaxis. - It has no proven role in the routine management or prevention of hypertensive disorders of pregnancy for this patient's profile.
Question 84: A 39-year-old woman presents to the antenatal day unit at 32 weeks gestation with reduced fetal movements for 24 hours. Her booking BMI was 35 kg/m². She was diagnosed with gestational diabetes at 28 weeks and commenced on metformin. CTG is performed and is normal. During the assessment, her blood pressure is measured as 168/114 mmHg, repeated 30 minutes later is 164/110 mmHg. She reports no headache, visual disturbances, or epigastric pain. Urinalysis shows trace protein. What is the single most important immediate management priority?
- A. Commence antihypertensive treatment to lower blood pressure urgently (Correct Answer)
- B. Arrange urgent ultrasound scan to assess fetal growth and liquor volume
- C. Take blood for full blood count, liver function tests, and renal function
- D. Arrange quantification of proteinuria with protein:creatinine ratio
- E. Commence magnesium sulphate for neuroprotection
Explanation: ***Commence antihypertensive treatment to lower blood pressure urgently*** - Severe hypertension (BP ≥160/110 mmHg) in pregnancy is a **medical emergency** requiring treatment within **30-60 minutes** to prevent catastrophic maternal complications like **hemorrhagic stroke**. - While other investigations are necessary, the **immediate priority** is to stabilize the mother by rapidly reducing blood pressure with appropriate **antihypertensive agents**. *Arrange urgent ultrasound scan to assess fetal growth and liquor volume* - Fetal assessment is important given the **reduced fetal movements** and suspected pre-eclampsia, but it is not the most immediate priority when the mother faces a **hypertensive crisis**. - The **normal CTG** provides some immediate reassurance regarding fetal well-being, allowing the focus to remain on urgent maternal stabilization. *Take blood for full blood count, liver function tests, and renal function* - These blood tests are crucial for assessing the severity of **pre-eclampsia** and ruling out complications like **HELLP syndrome** or acute kidney injury. - However, obtaining these results does not supersede the urgent need to acutely lower **dangerously high blood pressure** to prevent maternal stroke. *Arrange quantification of proteinuria with protein:creatinine ratio* - Quantification of proteinuria is essential for definitively diagnosing **pre-eclampsia**, especially when the dipstick shows trace protein. - However, the presence of **severe hypertension** with even trace proteinuria mandates immediate management to lower blood pressure, regardless of the exact protein:creatinine ratio. *Commence magnesium sulphate for neuroprotection* - **Magnesium sulphate** is indicated for the prevention of **eclampsia** in women with severe pre-eclampsia or for **fetal neuroprotection** in preterm delivery. - While important, it is not the primary immediate treatment for the acute reduction of severe **hypertensive crisis**, which must be addressed first to prevent maternal cerebrovascular events.
Question 85: A 34-year-old woman undergoes OGTT at 27 weeks gestation. Results show: fasting glucose 5.4 mmol/L and 2-hour glucose 9.2 mmol/L. She is diagnosed with gestational diabetes and referred to the diabetes in pregnancy clinic. She has been following dietary advice for 2 weeks. Her home blood glucose monitoring over the past week shows: fasting values 4.8-5.2 mmol/L and 1-hour post-prandial values 7.2-7.9 mmol/L. What is the most appropriate next step in management?
- A. Start short-acting insulin before meals to control post-prandial glucose levels
- B. Continue diet alone as all glucose values are within target ranges (Correct Answer)
- C. Add metformin as post-prandial values are consistently above 7.5 mmol/L
- D. Add long-acting insulin at bedtime to improve fasting glucose control
- E. Add metformin and start short-acting insulin before meals
Explanation: ***Continue diet alone as all glucose values are within target ranges*** - According to **NICE guidelines**, target blood glucose levels for gestational diabetes are **fasting <5.3 mmol/L** and **1-hour post-prandial <7.8 mmol/L**. - This patient's readings (fasting 4.8-5.2 and 1-hour 7.2-7.9) are largely **within target range**, meaning her current **dietary intervention** is successful and should be continued. *Start short-acting insulin before meals to control post-prandial glucose levels* - **Short-acting insulin** is only indicated if post-prandial glucose levels remain consistently above the **7.8 mmol/L target** despite diet and/or metformin. - Escalating to insulin is unnecessary here as the majority of her post-meal readings are **not significantly or consistently elevated**. *Add metformin as post-prandial values are consistently above 7.5 mmol/L* - **Metformin** is considered if glucose targets are not met after 1-2 weeks of diet; however, the threshold for concern is **>7.8 mmol/L** for 1-hour post-prandial readings. - Her values are mostly below or right at the threshold, so **pharmacological therapy** is not yet required. *Add long-acting insulin at bedtime to improve fasting glucose control* - **Long-acting insulin** is used specifically to manage **elevated fasting glucose** levels that do not respond to diet or metformin. - Since her fasting values (4.8-5.2 mmol/L) are all below the **5.3 mmol/L target**, there is no clinical indication for basal insulin. *Add metformin and start short-acting insulin before meals* - A combination of **metformin and insulin** is typically reserved for cases where single-agent therapy fails or for women with very high glucose levels at diagnosis. - This aggressive approach is inappropriate for a patient whose glucose levels are currently **well-controlled on diet alone**.
Question 86: A 27-year-old primigravida attends her booking appointment at 10 weeks gestation. She has no significant medical history. Her booking blood pressure is 146/94 mmHg, repeated after 15 minutes rest is 144/92 mmHg. Urinalysis shows no proteinuria. She mentions that her blood pressure was checked by her GP 3 months ago before pregnancy and was 142/90 mmHg. What is the most accurate diagnosis and initial management approach?
- A. White coat hypertension; arrange ambulatory blood pressure monitoring and reassess
- B. Chronic hypertension; commence labetalol and arrange blood tests including renal function and echocardiography (Correct Answer)
- C. Normal pregnancy-related blood pressure increase; provide reassurance and routine follow-up
- D. Pre-eclampsia; admit for investigation and commence antihypertensive treatment
- E. Gestational hypertension; commence labetalol and arrange blood tests for pre-eclampsia
Explanation: ***Chronic hypertension; commence labetalol and arrange blood tests including renal function and echocardiography*** - **Hypertension** is defined as **≥140/90 mmHg**. It is classified as **chronic** if it exists pre-conception or is detected before **20 weeks** gestation, as seen in this patient with prior elevated readings and current 10-week gestation. - Initial management includes first-line **labetalol** (a safe antihypertensive in pregnancy) and investigations to screen for **target organ damage**, such as renal dysfunction (blood tests) or left ventricular hypertrophy (**echocardiography**). *White coat hypertension; arrange ambulatory blood pressure monitoring and reassess* - While **ambulatory blood pressure monitoring** is useful, the patient had a documented elevated reading of **142/90 mmHg 3 months before pregnancy**, making it unlikely to be solely white coat effect and more indicative of underlying chronic hypertension. - In pregnancy, persistent clinic readings of **≥140/90 mmHg** warrant active management and baseline organ assessment, not just reassessment, due to potential maternal and fetal risks. *Normal pregnancy-related blood pressure increase; provide reassurance and routine follow-up* - Blood pressure typically **decreases** during the first and early second trimesters due to **systemic vasodilation** and reduced systemic vascular resistance. An increase to 140/90 mmHg or higher is abnormal. - Sustained readings above **140/90 mmHg** in pregnancy are associated with adverse outcomes and necessitate intervention, not just reassurance. *Pre-eclampsia; admit for investigation and commence antihypertensive treatment* - **Pre-eclampsia** is generally diagnosed **after 20 weeks** of gestation and is characterized by new-onset hypertension with **proteinuria** or other signs of end-organ dysfunction. - This patient is only at **10 weeks** gestation and has **no proteinuria**, ruling out pre-eclampsia at this stage. Early onset hypertension without proteinuria before 20 weeks points to chronic hypertension. *Gestational hypertension; commence labetalol and arrange blood tests for pre-eclampsia* - **Gestational hypertension** is defined as new-onset hypertension that develops **after 20 weeks** of gestation in a woman who was previously normotensive. - The patient's history of elevated blood pressure **prior to pregnancy** and the current presentation at **10 weeks** gestation preclude a diagnosis of gestational hypertension.
Question 87: A 36-year-old woman at 38 weeks gestation with diet-controlled gestational diabetes presents to the labour ward with regular contractions. On examination, she is 4 cm dilated with intact membranes. Her blood glucose on arrival is 4.2 mmol/L. She has been eating and drinking normally. CTG is reassuring. What is the most appropriate management of her blood glucose during labour?
- A. Commence intravenous dextrose and insulin infusion immediately to maintain tight glycaemic control
- B. Check capillary blood glucose every 1-2 hours and commence intravenous dextrose and insulin if glucose >7 mmol/L (Correct Answer)
- C. Give subcutaneous insulin now to prevent hyperglycaemia during labour
- D. Commence intravenous dextrose infusion prophylactically without insulin
- E. No specific management needed; check blood glucose only if she develops symptoms of hypoglycaemia
Explanation: ***Check capillary blood glucose every 1-2 hours and commence intravenous dextrose and insulin if glucose >7 mmol/L*** - For women with **diet-controlled gestational diabetes**, glycaemic control during labour is managed by maintaining blood glucose between **4–7 mmol/L**. - NICE guidelines recommend hourly or **1–2 hourly monitoring** of capillary blood glucose, with a **sliding scale (VRIII)** only if levels exceed the target range. *Commence intravenous dextrose and insulin infusion immediately to maintain tight glycaemic control* - **Intravenous insulin (VRIII)** is not indicated unless the patient is poorly controlled or has capillary blood glucose levels outside the target range of **4–7 mmol/L**. - Routine use of a sliding scale at the start of labour is unnecessary for **diet-controlled GDM** patients who are currently euglycaemic. *Give subcutaneous insulin now to prevent hyperglycaemia during labour* - **Subcutaneous insulin** is difficult to titrate during the active phase of labour due to unpredictable absorption and the high **metabolic demands** of uterine contractions. - If insulin is required due to hyperglycaemia in labour, **intravenous administration** is preferred for rapid and precise control. *Commence intravenous dextrose infusion prophylactically without insulin* - Administering **prophylactic dextrose** without a clear clinical indication like hypoglycemia risks causing **maternal hyperglycaemia**. - Maternal hyperglycaemia during labour can lead to **fetal academia** and subsequent **neonatal hypoglycaemia** due to fetal hyperinsulinaemia. *No specific management needed; check blood glucose only if she develops symptoms of hypoglycaemia* - Relying solely on **symptoms** is dangerous as the physical stress of labour can mask the clinical signs of **hyperglycaemia or hypoglycaemia**. - Active **biochemical monitoring** is essential for all women with gestational diabetes to ensure optimal outcomes for the mother and the neonate.
Question 88: A 41-year-old woman in her fourth pregnancy attends the booking appointment at 11 weeks gestation. She had gestational diabetes in her previous two pregnancies, both requiring insulin treatment. Her pre-pregnancy BMI is 29 kg/m². She requests information about reducing her risk of gestational diabetes in this pregnancy. What is the most appropriate advice regarding lifestyle modifications and screening?
- A. Arrange HbA1c or fasting glucose at booking, and OGTT at 24-28 weeks if initial test is normal; provide diet and exercise advice (Correct Answer)
- B. Arrange monthly HbA1c monitoring throughout pregnancy; strict calorie-restricted diet recommended
- C. Start metformin 500 mg twice daily prophylactically and arrange OGTT at 24-28 weeks only
- D. Arrange OGTT at 16 weeks and again at 28 weeks; commence low-dose aspirin 150 mg once daily
- E. She should commence insulin prophylactically at 20 weeks to prevent gestational diabetes
Explanation: ***Arrange HbA1c or fasting glucose at booking, and OGTT at 24-28 weeks if initial test is normal; provide diet and exercise advice*** - For women with **previous gestational diabetes**, NICE guidelines recommend early screening (**HbA1c** or **fasting glucose**) at **booking** to rule out pre-existing diabetes. - If the initial screening is normal, a formal **75g Oral Glucose Tolerance Test (OGTT)** is performed at **24–28 weeks** gestation to detect recurrence. *Arrange monthly HbA1c monitoring throughout pregnancy; strict calorie-restricted diet recommended* - Monthly **HbA1c** is not an evidence-based method for monitoring or screening for GDM as it reflects long-term glycemia rather than acute post-prandial spikes. - **Strict calorie restriction** is contraindicated in pregnancy; instead, focus should be on **low-glycemic index** foods and moderate physical activity. *Start metformin 500 mg twice daily prophylactically and arrange OGTT at 24-28 weeks only* - **Prophylactic metformin** is not currently recommended in standard clinical guidelines for the prevention of gestational diabetes. - Initial screening must occur at **booking** for high-risk patients, not just at 24-28 weeks, to identify undiagnosed **Type 2 diabetes**. *Arrange OGTT at 16 weeks and again at 28 weeks; commence low-dose aspirin 150 mg once daily* - While some guidelines suggest an early OGTT (16–18 weeks), the standard UK approach for previous GDM starts with **booking bloods** (**HbA1c/fasting glucose**). - **Low-dose aspirin** is indicated for the prevention of **pre-eclampsia** in high-risk groups, not for the prevention or screening of gestational diabetes. *She should commence insulin prophylactically at 20 weeks to prevent gestational diabetes* - **Prophylactic insulin** is not used to prevent GDM; pharmacological management is only initiated once a **diagnosis** is confirmed via OGTT or home monitoring. - Starting insulin without a diagnosis carries significant risks of **maternal hypoglycemia** and unnecessary medicalization of the pregnancy.
Question 89: A 28-year-old woman is admitted at 35 weeks gestation with new-onset hypertension (BP 152/98 mmHg) and 1+ proteinuria on dipstick. Blood tests show: haemoglobin 118 g/L, platelets 178 × 10⁹/L, ALT 28 U/L, AST 32 U/L, creatinine 68 μmol/L, uric acid 0.38 mmol/L. Protein:creatinine ratio is 45 mg/mmol. She has mild headache but no visual disturbances. CTG is reassuring. What is the most appropriate next step in her management?
- A. Discharge home on oral labetalol with community midwife follow-up in 48 hours
- B. Admit for observation, commence antihypertensive treatment, and plan delivery within 24-48 hours
- C. Commence magnesium sulphate for seizure prophylaxis and plan immediate delivery
- D. Admit for observation, commence antihypertensive treatment, and monitor with view to conservative management aiming for 37 weeks (Correct Answer)
- E. Arrange urgent MRI brain to investigate headache before deciding on further management
Explanation: ***Admit for observation, commence antihypertensive treatment, and monitor with view to conservative management aiming for 37 weeks*** - The patient has **pre-eclampsia** (BP >140/90 mmHg and PCR >30 mg/mmol) without **severe features** (platelets, liver enzymes, creatinine within normal limits, mild headache without visual disturbances) at 35 weeks gestation. - For preterm pre-eclampsia without severe features, **conservative management** with inpatient monitoring and antihypertensive treatment is recommended to allow for fetal maturation, aiming for delivery at **37 weeks**. *Discharge home on oral labetalol with community midwife follow-up in 48 hours* - A new diagnosis of **pre-eclampsia** at 35 weeks requires **inpatient admission** for close monitoring of both maternal and fetal well-being due to the risk of rapid deterioration. - Relying solely on community follow-up in this scenario would be **unsafe** and could lead to missed worsening disease or fetal compromise. *Admit for observation, commence antihypertensive treatment, and plan delivery within 24-48 hours* - While admission and antihypertensive treatment are appropriate, **expedited delivery within 24-48 hours** is typically reserved for **severe pre-eclampsia** or significant fetal compromise. - Given the patient's stable condition, reassuring CTG, and lack of severe features, immediate delivery at 35 weeks would unnecessarily expose the neonate to risks of **prematurity-related complications**. *Commence magnesium sulphate for seizure prophylaxis and plan immediate delivery* - **Magnesium sulphate** is indicated for **severe pre-eclampsia** or impending eclampsia, neither of which the patient currently meets the criteria for. - Planning immediate delivery is not warranted as the patient is stable, the **CTG is reassuring**, and there are no signs of HELLP syndrome, eclampsia, or placental abruption. *Arrange urgent MRI brain to investigate headache before deciding on further management* - A **mild headache** is a common symptom in pre-eclampsia; in the absence of **focal neurological deficits**, severe headache, or visual disturbances, an urgent MRI is not the priority. - The immediate focus should be on managing the **hypertension** and monitoring the progression of pre-eclampsia, which are the main threats in this condition.
Question 90: A 32-year-old woman with insulin-treated gestational diabetes is reviewed at 32 weeks gestation. Her home blood glucose monitoring shows: fasting values 5.8-6.2 mmol/L and 1-hour post-prandial values 8.5-9.2 mmol/L. She is on 16 units of long-acting insulin at night and 8 units of short-acting insulin before each meal. Growth scan shows estimated fetal weight on 92nd centile. What is the most appropriate adjustment to her management?
- A. Increase the long-acting insulin dose at night
- B. Increase the short-acting insulin doses before meals (Correct Answer)
- C. Add metformin 500 mg three times daily to her insulin regimen
- D. Increase both long-acting and short-acting insulin doses equally
- E. Continue current insulin doses and arrange repeat growth scan in 2 weeks
Explanation: ***Increase the short-acting insulin doses before meals*** - This patient's **1-hour post-prandial values** (8.5-9.2 mmol/L) are significantly above the target of **<7.8 mmol/L**, which is the primary driver of the **92nd centile fetal growth** (macrosomia). - Increasing **short-acting insulin** directly targets post-meal glucose spikes, reducing the risk of **macrosomia** and associated neonatal complications like hypoglycemia and birth trauma. *Increase the long-acting insulin dose at night* - While the fasting glucose is slightly elevated (target **<5.3 mmol/L**), the elevation in post-prandial readings is more pronounced and clinically impactful for fetal growth. - Addressing only the **long-acting insulin** would fail to correct the significant hyperglycemic excursions occurring after meals throughout the day. *Add metformin 500 mg three times daily to her insulin regimen* - Adding **metformin** is an option in gestational diabetes, but it is more efficient and appropriate to first adjust the doses of her **existing insulin regimen** to achieve rapid glycaemic control. - The immediate priority is titration of current insulin therapy given the **accelerated fetal growth** already evidenced on the growth scan, which mandates prompt and effective glucose lowering. *Increase both long-acting and short-acting insulin doses equally* - Insulin adjustments should be tailored to specific glucose patterns; a generalized **equal increase** may lead to nocturnal or pre-meal **hypoglycemia** if the basal or pre-meal levels are adequately controlled. - In this specific clinical scenario, the post-prandial readings require a more aggressive titration compared to the fasting readings, indicating a need for targeted adjustment. *Continue current insulin doses and arrange repeat growth scan in 2 weeks* - Continuing the current dose is inappropriate as the blood glucose levels are **consistently above target** and the fetus is already showing signs of **macrosomia** (>90th centile). - Delaying treatment adjustments for two weeks would increase the risk of both maternal and fetal complications associated with poorly controlled **gestational diabetes**, such as pre-eclampsia and fetal distress.
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