LE4 - HTN Flashcards
A 32-year-old G2P1 (1-0-0-1) presents for her first prenatal visit at 12 weeks of gestation. Her medical history reveals a BMI of 33 kg/m² and chronic hypertension well-controlled on medication. She denies any significant family or obstetric history.
Which of the following is the most appropriate next step in managing her pregnancy?
A. Reassure and proceed with routine prenatal care
B. Initiate low-dose aspirin at 12 weeks gestation
C. Advise strict bed rest starting at the second trimester
D. Perform biweekly fetal growth scans starting at 20 weeks
B. Initiate low-dose aspirin at 12 weeks gestation
Rationale: The patient has two high-risk factors for preeclampsia: chronic hypertension and obesity (BMI >30 kg/m²). Low-dose aspirin initiated between 12-28 weeks (preferably before 16 weeks) is recommended to reduce the risk of preeclampsia.
A 28-year-old G1 presents for her first prenatal visit at 9 weeks of gestation. She is nulliparous, has a family history of preeclampsia in her mother, and reports a low socioeconomic status.
What is the most appropriate recommendation to reduce her risk of developing preeclampsia?
A. No intervention is necessary at this time
B. Start calcium supplementation
C. Prescribe low-dose aspirin
D. Schedule early delivery at 36 weeks
C. Prescribe low-dose aspirin
Rationale: The patient has three moderate-risk factors: nulliparity, family history of preeclampsia, and low socioeconomic status. The presence of at least two moderate-risk factors warrants the use of low-dose aspirin as a preventive measure.
A 38-year-old G3P2 (2-0-0-2) presents at 10 weeks gestation for prenatal care. She has a history of preeclampsia in her second pregnancy and reports a 12-year interval since her last delivery.
What combination of factors qualifies her for preeclampsia prevention with low-dose aspirin?
A. History of preeclampsia only
B. >10-year pregnancy interval only
C. Both history of preeclampsia and >10-year pregnancy interval
D. Advanced maternal age (>35 years) and >10-year pregnancy interval
C. Both history of preeclampsia and >10-year pregnancy interval
Rationale: The patient has one high-risk factor (history of preeclampsia) and one moderate-risk factor (>10-year pregnancy interval). A single high-risk factor is sufficient to recommend low-dose aspirin.
A 29-year-old G2P1 presents for her first prenatal visit at 8 weeks gestation. She has a history of lupus, which has been stable for several years, and diabetes mellitus type 1.
Which of the following best describes her risk category for preeclampsia?
A. Moderate risk
B. High risk
C. Low risk
D. No risk
B. High risk
Rationale: The patient has two high-risk factors: lupus (an autoimmune disease) and type 1 diabetes mellitus. High-risk factors warrant preventive measures, such as low-dose aspirin, to lower her risk of preeclampsia.
A 36-year-old G1 presents at 11 weeks gestation for her first prenatal visit. She reports a family history of preeclampsia in her sister and has a history of delivering a low-birth-weight infant in a prior pregnancy.
What is the minimum number of additional moderate-risk factors required to recommend low-dose aspirin?
A. None
B. One
C. Two
D. Three
B. One
Rationale: The patient already has two moderate-risk factors (family history of preeclampsia and history of low birth weight). Adding just one more moderate-risk factor (e.g., nulliparity or maternal age >35 years) would warrant preeclampsia prevention with low-dose aspirin.
A 29-year-old G1P0 is undergoing routine prenatal screening at 12 weeks gestation. Uterine artery Doppler shows high resistance flow with a persistent diastolic notch.
What does this finding most likely indicate?
A. Normal placental development
B. Increased risk of preeclampsia due to poor trophoblastic invasion
C. Reduced fetal growth due to elevated placental growth factors
D. Early signs of preterm labor
B. Increased risk of preeclampsia due to poor trophoblastic invasion
Rationale: High resistance in uterine artery Doppler indices, along with a persistent diastolic notch, suggests poor endovascular trophoblast invasion, a hallmark of abnormal placentation associated with preeclampsia.
A 34-year-old G2P1 presents for her prenatal visit at 13 weeks gestation. The physician plans to assess preeclampsia risk using uterine artery Doppler and maternal serum biomarkers.
Which combination of predictors provides the highest sensitivity and specificity for preeclampsia risk?
A. PP13 + Uterine Artery Doppler
B. MAP + PAPP-A + Uterine Artery Doppler + PlGF
C. PlGF + VEGF + sFLT-1
D. PP13 + PAPP-A + Activin A
B. MAP + PAPP-A + Uterine Artery Doppler + PlGF
Rationale: The combination of MAP, PAPP-A, uterine artery Doppler, and PlGF provides a sensitivity of 93% and specificity of 95%, making it the best approach for predicting preeclampsia.
A 35-year-old G2P1 presents at 24 weeks gestation. Uterine artery Doppler shows abnormal flow velocity ratios and a persistent diastolic notch. Her MAP is 94 mmHg.
What does this combination of findings most likely suggest?
A. Increased risk of fetal macrosomia
B. High risk of preeclampsia with potential adverse outcomes
C. Low risk of preeclampsia and normal fetal growth
D. No significant impact on placental function
B. High risk of preeclampsia with potential adverse outcomes
Rationale: A persistent diastolic notch and MAP >90 mmHg are strong indicators of poor placentation and increased risk of preeclampsia, potentially leading to adverse pregnancy outcomes.
A 28-year-old G1P0 presents at 10 weeks gestation for her first prenatal visit. She has a BMI of 35 kg/m² and a history of chronic hypertension.
What is the most appropriate preventive measure for reducing her risk of preeclampsia?
A. Low-dose aspirin, 81 mg daily, starting at 20 weeks gestation
B. High-dose calcium, 1500-2000 mg daily, starting immediately
C. Salt restriction and bed rest starting at the second trimester
D. Vitamin C and E supplementation starting in the first trimester
B. High-dose calcium, 1500-2000 mg daily, starting immediately
Rationale: High-dose calcium supplementation is recommended starting as early as the first prenatal visit, especially for patients at high risk of preeclampsia. Additionally, low-dose aspirin should be initiated before 16 weeks at a higher dosage (100-150 mg daily). Salt restriction, bed rest, and vitamin supplementation are not effective preventive measures.
A 30-year-old G2P1 presents for her prenatal visit at 12 weeks gestation. She has a history of preeclampsia in her previous pregnancy and is currently normotensive.
What is the most appropriate preventive strategy to reduce her risk of preeclampsia?
A. Initiate low-dose aspirin, 100-150 mg daily
B. Restrict dietary salt intake
C. Recommend moderate aerobic exercise
D. Prescribe folic acid supplementation
A. Initiate low-dose aspirin, 100-150 mg daily
Rationale: Low-dose aspirin (100-150 mg daily) initiated before 16 weeks gestation is strongly recommended for patients with a high risk of preeclampsia, such as those with a prior history of the condition. Restricting salt, exercise, and folic acid supplementation are not effective preventive measures.
A 24-year-old G1P0 presents at 8 weeks gestation for her first prenatal visit. She reports a low-calcium diet. She has no significant medical history but is concerned about developing preeclampsia.
What is the most appropriate recommendation to reduce her risk?
A. Low-dose aspirin
B. High-dose calcium supplementation
C. Vitamin C and E supplementation
D. Bed rest
B. High-dose calcium supplementation
Rationale: For patients with inadequate dietary calcium intake, high-dose calcium supplementation (1500-2000 mg daily) is recommended starting early in pregnancy to reduce the risk of preeclampsia. Low-dose aspirin is not indicated for patients without additional high-risk factors.
A 35-year-old G2P1 presents at 14 weeks gestation with a history of lupus and chronic hypertension. She is currently on antihypertensive therapy.
What preventive measures should be implemented to reduce her risk of preeclampsia?
A. Low-dose aspirin and high-dose calcium supplementation
B. Exercise and salt restriction
C. Marine oil supplementation and vitamin E
D. Progestogen therapy
A. Low-dose aspirin and high-dose calcium supplementation
Rationale: For high-risk patients (e.g., with lupus and chronic hypertension), low-dose aspirin (100-150 mg daily) and high-dose calcium (1500-2000 mg daily) are recommended. Exercise, salt restriction, marine oil, vitamin E, and progestogens have no proven benefit in preventing preeclampsia.
A 27-year-old G1P0 presents at 20 weeks gestation with a BMI of 32 kg/m². She asks about preventive strategies for preeclampsia.
Which of the following strategies is NOT recommended for preeclampsia prevention?
A. High-dose calcium supplementation
B. Bed rest
C. Low-dose aspirin
D. Dietary calcium intake
B. Bed rest
Rationale: Bed rest is not effective in preventing preeclampsia and is therefore not recommended. High-dose calcium supplementation, low-dose aspirin, and ensuring adequate dietary calcium intake are appropriate preventive measures.
A 33-year-old G2P1 presents at 9 weeks gestation with a history of gestational hypertension in her previous pregnancy. She inquires about folic acid supplementation for preeclampsia prevention.
What is the role of folic acid in preeclampsia prevention?
A. Strongly recommended for all pregnancies
B. Effective only for high-risk pregnancies
C. Not recommended due to low-grade evidence
D. Recommended with low-dose aspirin
C. Not recommended due to low-grade evidence
Rationale: Folic acid supplementation has low-grade evidence (Level IIB) for its effectiveness in preventing preeclampsia and is not routinely recommended for this purpose.
A 29-year-old G1P0 with no high-risk factors asks about the timing of starting low-dose aspirin for preeclampsia prevention.
What is the most appropriate timing for initiating low-dose aspirin?
A. As soon as pregnancy is confirmed
B. Before 16 weeks gestation
C. After 20 weeks gestation
D. At the onset of preeclampsia symptoms
B. Before 16 weeks gestation
Rationale: Low-dose aspirin (100-150 mg daily) should be started before 16 weeks gestation and continued until 36 weeks or delivery for patients at high risk of preeclampsia. Starting after 20 weeks is less effective.
A 30-year-old G1P0 presents at 34 weeks gestation with blood pressure readings of 160/100 mmHg and significant proteinuria. On examination, fundoscopy reveals retinal arteriolar narrowing.
What is the primary pathological mechanism responsible for her condition?
A. Glomerular hypertrophy
B. Endothelial cell activation and vascular constriction
C. Chronic renal ischemia
D. Increased cytokine production without vascular involvement
B. Endothelial cell activation and vascular constriction
Rationale: The main pathology in preeclampsia is endothelial cell activation, leading to vascular constriction, increased resistance, and hypertension. Endothelial damage results in vascular dysfunction, which can be detected through retinal changes like arteriolar narrowing.
A 32-year-old G2P1 presents at 36 weeks gestation with severe hypertension, proteinuria, and peripheral edema. Laboratory tests reveal low glomerular filtration rate (GFR) and significant proteinuria.
What pathological process is most likely causing her renal dysfunction?
A. Ischemia-induced glomerulosclerosis
B. Glomerular endotheliosis with basement membrane thickening
C. Increased oxidative stress in the renal cortex
D. Deposition of fibrin and platelets in the renal tubules
B. Glomerular endotheliosis with basement membrane thickening
Rationale: The kidney is the first organ affected in preeclampsia. Glomerular endotheliosis, characterized by thickened basement membranes and increased capillary permeability, leads to decreased GFR and proteinuria.
A 28-year-old G1P0 at 35 weeks gestation is diagnosed with preeclampsia. Placental biopsy reveals evidence of ischemia and oxidative stress.
Which of the following best explains the systemic effects of these findings?
A. Localized placental ischemia without systemic impact
B. Oxidative stress induces cytokine release, leading to endothelial activation
C. Decreased circulating endothelial cells reduce vascular resistance
D. Ischemia primarily leads to hepatic necrosis without vascular involvement
B. Oxidative stress induces cytokine release, leading to endothelial activation
Rationale: Oxidative stress in the placenta provokes the release of cytokines (e.g., TNF-alpha, IL), which activate maternal endothelial cells, increasing capillary permeability and contributing to the systemic features of preeclampsia.
A 35-year-old G2P1 at 36 weeks gestation presents with severe preeclampsia. She has elevated liver enzymes and thrombocytopenia.
What is the underlying mechanism of these complications?
A. Ischemia and necrosis due to diminished organ perfusion
B. Platelet aggregation in hepatic veins
C. Increased glomerular filtration rate
D. Increased production of placental angiogenic factors
A. Ischemia and necrosis due to diminished organ perfusion
Rationale: In preeclampsia, systemic ischemia leads to end-organ damage, including hepatic necrosis and hemorrhage, manifesting as elevated liver enzymes and thrombocytopenia.
A 29-year-old G1P0 presents at 33 weeks gestation with hypertension, proteinuria, and visual disturbances. Examination reveals subconjunctival hemorrhages and arteriolar narrowing.
What explains the visual symptoms in this patient?
A. Elevated intracranial pressure due to eclampsia
B. Oxidative stress affecting retinal perfusion
C. Vasospasm causing retinal ischemia and arteriolar damage
D. Increased permeability of retinal vessels due to proteinuria
C. Vasospasm causing retinal ischemia and arteriolar damage
Rationale: Visual symptoms in preeclampsia are often due to vasospasm and ischemia affecting the retinal arterioles, resulting in arteriolar narrowing, hemorrhages, and potential visual disturbances.
A 37-year-old G3P2 at 34 weeks gestation presents with worsening hypertension and severe proteinuria. Laboratory studies show elevated TNF-alpha levels and circulating endothelial microparticles (EMP).
What is the significance of these findings in the context of preeclampsia?
A. TNF-alpha and EMP indicate renal-specific damage
B. EMP levels predict immediate onset of eclampsia
C. Cytokine release and EMP reflect systemic endothelial activation
D. TNF-alpha directly reduces GFR without vascular involvement
C. Cytokine release and EMP reflect systemic endothelial activation
Rationale: Increased levels of TNF-alpha and endothelial microparticles in preeclampsia are markers of systemic endothelial activation, which contributes to vascular dysfunction and the clinical manifestations of the disease.
A 34-year-old G2P1 with preeclampsia develops hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome).
What is the primary pathology underlying these findings?
A. Hepatic microvascular thrombosis and necrosis
B. Placental ischemia without systemic involvement
C. Glomerular hyperperfusion and protein loss
D. Cytokine-mediated vascular constriction in the kidneys
A. Hepatic microvascular thrombosis and necrosis
Rationale: HELLP syndrome results from severe systemic endothelial damage leading to microvascular thrombosis, ischemia, and necrosis, especially in the liver, causing elevated liver enzymes and hemolysis.
A 29-year-old G1P0 presents at 32 weeks gestation with blood pressure readings of 150/95 mmHg on two separate occasions 6 hours apart. She reports no headaches, visual changes, or right upper quadrant pain. Urinalysis shows 2+ protein.
What is the most likely diagnosis?
A. Gestational hypertension
B. Chronic hypertension
C. Preeclampsia without severe features
D. Preeclampsia with severe features
What is the most appropriate management for this patient?
A. Immediate delivery
B. Start magnesium sulfate prophylaxis
C. Expectant management with close monitoring
D. Initiate antihypertensive therapy
C. Preeclampsia without severe features
Rationale: Preeclampsia is diagnosed based on hypertension (≥140/90 mmHg after 20 weeks gestation) and proteinuria (≥1+ on dipstick). The absence of severe features such as severe hypertension, end-organ dysfunction, or symptoms indicates preeclampsia without severe features.
C. Expectant management with close monitoring
Rationale: Preeclampsia without severe features can be managed expectantly, particularly if gestational age is <37 weeks. Regular monitoring of BP, proteinuria, maternal symptoms, and fetal well-being is essential.
A 35-year-old G2P1 at 34 weeks gestation presents with severe hypertension (170/110 mmHg), proteinuria, and persistent epigastric pain. Lab results reveal AST and ALT levels 3x normal and platelets of 90,000/mm³.
What is the most likely diagnosis?
A. Preeclampsia without severe features
B. Preeclampsia with severe features
C. Eclampsia
D. HELLP syndrome
What is the most appropriate management for this patient?
A. Continue pregnancy with antihypertensive therapy
B. Immediate delivery
C. Administer magnesium sulfate and delay delivery until 37 weeks
D. Observe for progression to eclampsia
B. Preeclampsia with severe features
Rationale: Severe hypertension, elevated liver enzymes, and thrombocytopenia (<100,000/mm³) classify this case as preeclampsia with severe features. Epigastric pain suggests hepatic involvement, a common severe feature.
B. Immediate delivery
Rationale: Delivery is the definitive treatment for preeclampsia with severe features at or beyond 34 weeks gestation. Magnesium sulfate should be administered for seizure prophylaxis, and antihypertensive therapy can be initiated to control BP.
A 27-year-old G1P0 presents at 31 weeks gestation with generalized tonic-clonic seizures. BP is 160/105 mmHg, and urinalysis shows 3+ protein.
What is the most likely diagnosis?
A. Eclampsia
B. Severe preeclampsia
C. Chronic hypertension with superimposed preeclampsia
D. Epilepsy
What is the first-line treatment to control the seizures?
A. Diazepam
B. Magnesium sulfate
C. Phenytoin
D. Labetalol
A. Eclampsia
Rationale: Eclampsia is characterized by generalized tonic-clonic seizures in a patient with preeclampsia and no other identifiable causes.
B. Magnesium sulfate
Rationale: Magnesium sulfate is the drug of choice for both prevention and treatment of seizures in eclampsia. Diazepam and phenytoin are not first-line treatments for eclampsia-related seizures.
A 30-year-old G2P1 presents at 36 weeks gestation with BP of 165/110 mmHg. She complains of severe headaches and visual disturbances. Lab results show normal platelets and liver enzymes but a serum creatinine of 1.4 mg/dL.
What is the most appropriate classification of her condition?
A. Gestational hypertension
B. Preeclampsia without severe features
C. Preeclampsia with severe features
D. Chronic hypertension
What is the next best step in management?
A. Initiate labetalol and expectant management
B. Immediate delivery after stabilizing BP and administering magnesium sulfate
C. Observe and repeat BP readings in 4 hours
D. Administer aspirin and repeat labs in 1 week
C. Preeclampsia with severe features
Rationale: Severe hypertension, new-onset cerebral symptoms (headache, visual changes), and renal insufficiency (creatinine >1.1 mg/dL) meet the criteria for preeclampsia with severe features.
B. Immediate delivery after stabilizing BP and administering magnesium sulfate
Rationale: For preeclampsia with severe features at ≥34 weeks, delivery is the definitive treatment. Magnesium sulfate prevents seizures, and antihypertensive therapy prevents complications such as stroke.
A 34-year-old G3P2 is admitted postpartum after a spontaneous vaginal delivery 2 days ago. She develops generalized tonic-clonic seizures. BP is 150/95 mmHg, and urinalysis shows proteinuria.
What is the most likely cause of her seizures?
A. Stroke
B. Postpartum eclampsia
C. Epilepsy
D. Hypoglycemia
What is the most appropriate management for this patient?
A. Administer magnesium sulfate and continue monitoring
B. Initiate phenytoin therapy for seizure control
C. Start antihypertensive therapy only
D. Perform brain imaging immediately
B. Postpartum eclampsia
Rationale: Eclampsia can occur postpartum, typically within 48 hours but sometimes later. The presence of hypertension and proteinuria supports the diagnosis.
A. Administer magnesium sulfate and continue monitoring
Rationale: Magnesium sulfate is the first-line treatment for eclampsia, including postpartum cases. Brain imaging is reserved for atypical presentations or if the patient does not improve.
A 34-year-old G2P1 presents at 18 weeks gestation with a BP of 145/95 mmHg. She denies any previous history of hypertension but notes that her BP was borderline elevated before conception. Laboratory tests show no proteinuria or systemic findings.
What is the most likely diagnosis?
A. Preeclampsia without severe features
B. Chronic hypertension
C. Gestational hypertension
D. Chronic hypertension with superimposed preeclampsia
Follow-Up Question
What is the most appropriate management for this patient?
A. Initiate magnesium sulfate prophylaxis
B. Monitor BP closely and repeat testing in 4 weeks
C. Prescribe low-dose aspirin and initiate antihypertensive therapy if BP exceeds 160/105 mmHg
D. Immediate delivery due to maternal risk
Answer: B. Chronic hypertension
Rationale: Hypertension diagnosed before 20 weeks gestation is classified as chronic hypertension, even in the absence of proteinuria or systemic findings.
Answer: C. Prescribe low-dose aspirin and initiate antihypertensive therapy if BP exceeds 160/105 mmHg
Rationale: Chronic hypertension requires close monitoring and preventive measures, such as low-dose aspirin to reduce preeclampsia risk. Antihypertensives are initiated for severe hypertension (≥160/105 mmHg).
A 36-year-old G3P2 at 28 weeks gestation has a history of chronic hypertension. Her BP today is 180/110 mmHg. Laboratory results show proteinuria (2+ on dipstick), platelets of 90,000/mm³, and AST elevated to 80 U/L.
What is the most likely diagnosis?
A. Chronic hypertension
B. Chronic hypertension with superimposed preeclampsia
C. Gestational hypertension
D. Preeclampsia with severe features
Follow-Up Question
What is the next best step in management?
A. Immediate delivery after stabilizing BP and administering magnesium sulfate
B. Continue monitoring and delay delivery until 37 weeks
C. Prescribe aspirin and calcium supplementation
D. Perform a repeat BP measurement in 4 hours
Answer: B. Chronic hypertension with superimposed preeclampsia
Rationale: Chronic hypertension complicated by new-onset proteinuria, thrombocytopenia, and elevated liver enzymes meets the criteria for chronic hypertension with superimposed preeclampsia.
Answer: A. Immediate delivery after stabilizing BP and administering magnesium sulfate
Rationale: Chronic hypertension with superimposed preeclampsia and severe features requires immediate delivery if gestational age is ≥34 weeks or maternal-fetal condition worsens. Magnesium sulfate is administered for seizure prophylaxis.
A 28-year-old G1P0 at 32 weeks gestation presents with a BP of 150/95 mmHg on two separate occasions 6 hours apart. Urinalysis is negative for proteinuria, and no systemic symptoms are reported.
What is the most likely diagnosis?
A. Chronic hypertension
B. Chronic hypertension with superimposed preeclampsia
C. Gestational hypertension
D. Preeclampsia
Follow-Up Question
What is the most appropriate management for this patient?
A. Immediate delivery
B. Continue monitoring BP and fetal well-being
C. Initiate antihypertensive therapy
D. Administer magnesium sulfate prophylaxis
Answer: B. Continue monitoring BP and fetal well-being
Rationale: Gestational hypertension without severe features is managed expectantly with regular monitoring of BP and fetal well-being. Antihypertensives are only indicated for severe hypertension (≥160/105 mmHg).
Answer: C. Gestational hypertension
Rationale: Hypertension diagnosed after 20 weeks gestation in a previously normotensive woman, without proteinuria or systemic features, is classified as gestational hypertension.
Answer: B. Continue monitoring BP and fetal well-being
Rationale: Gestational hypertension without severe features is managed expectantly with regular monitoring of BP and fetal well-being. Antihypertensives are only indicated for severe hypertension (≥160/105 mmHg).
A 30-year-old G2P1 at 24 weeks gestation presents with a BP of 165/105 mmHg. Laboratory results reveal normal platelets, creatinine, and liver enzymes. Urinalysis shows no proteinuria.
What is the most likely diagnosis?
A. Severe gestational hypertension
B. Preeclampsia without severe features
C. Chronic hypertension
D. Chronic hypertension with superimposed preeclampsia
Follow-Up Question
What is the next best step in management?
A. Immediate delivery
B. Initiate antihypertensive therapy and close monitoring
C. Administer magnesium sulfate
D. Repeat BP measurements in 1 week
Answer: A. Severe gestational hypertension
Rationale: Hypertension ≥160/110 mmHg without proteinuria or systemic findings is classified as severe gestational hypertension, which requires close monitoring to differentiate from preeclampsia.
Answer: B. Initiate antihypertensive therapy and close monitoring
Rationale: Severe hypertension (≥160/110 mmHg) requires antihypertensive therapy to reduce maternal risks, such as stroke, even in the absence of preeclampsia. Delivery is not indicated unless maternal or fetal conditions worsen.
A 32-year-old G2P1 presents at 36 weeks gestation with complaints of fatigue, nausea, and right upper quadrant pain. Blood pressure is 140/90 mmHg. Laboratory results show:
Platelets: 80,000/mm³
ALT: 120 U/L
LDH: 700 U/L
Peripheral smear: Crenated red cells and reticulocytosis
What is the most likely diagnosis?
A. Preeclampsia with severe features
B. HELLP syndrome
C. Acute fatty liver of pregnancy (AFLP)
D. Viral hepatitis
Follow-Up Question
What is the most appropriate next step in management?
A. Administer plasma exchange therapy
B. Start betamethasone and delay delivery for 24-48 hours
C. Immediate delivery after stabilizing maternal condition
D. Monitor and repeat laboratory studies in 24 hours
Answer: B. HELLP syndrome
Rationale: The patient meets the laboratory criteria for HELLP syndrome, including thrombocytopenia (<100,000/mm³), elevated liver enzymes (ALT >70 U/L, LDH >600 U/L), and hemolysis (abnormal peripheral smear and reticulocytosis). The presence of right upper quadrant pain and mild hypertension supports this diagnosis.
Answer: C. Immediate delivery after stabilizing maternal condition
Rationale: At 36 weeks gestation, delivery is the cornerstone of therapy for HELLP syndrome. Maternal stabilization with antihypertensives, magnesium sulfate, and platelet transfusion (if necessary) should precede delivery.
A 28-year-old G1P0 at 32 weeks gestation presents with complaints of malaise and epigastric pain. Blood pressure is 125/85 mmHg, and there is 1+ proteinuria. Laboratory findings include:
Platelets: 90,000/mm³
AST: 95 U/L
LDH: 650 U/L
Which of the following best differentiates HELLP syndrome from preeclampsia in this patient?
A. Proteinuria
B. Severe hypertension
C. Hemolysis on peripheral smear
D. Elevated transaminases
Follow-Up Question
What is the most appropriate management if the fetus is 32 weeks gestation and stable?
A. Immediate delivery without further intervention
B. Administer betamethasone and delay delivery for 24-48 hours
C. Start plasma exchange therapy
D. Observe and monitor for progression of symptoms
Answer: C. Hemolysis on peripheral smear
Rationale: Hemolysis is a hallmark of HELLP syndrome that differentiates it from preeclampsia. Elevated liver enzymes and thrombocytopenia are shared features, but hemolysis is unique to HELLP syndrome.
Answer: B. Administer betamethasone and delay delivery for 24-48 hours
Rationale: At 32 weeks, delivery can be delayed by 24-48 hours if maternal and fetal conditions are stable. Betamethasone is administered to promote fetal lung maturity.
A 35-year-old G3P2 presents postpartum 48 hours after cesarean delivery with complaints of malaise, nausea, and right upper quadrant pain. Laboratory tests show:
Platelets: 70,000/mm³
ALT: 105 U/L
LDH: 800 U/L
What is the most likely diagnosis?
A. Postpartum preeclampsia
B. Acute fatty liver of pregnancy (AFLP)
C. HELLP syndrome
D. Idiopathic thrombocytopenic purpura (ITP)
Follow-Up Question
What supportive measures are recommended for this patient?
A. Dexamethasone for platelet stabilization
B. Platelet transfusion to maintain platelets ≥40,000 cells/μL
C. Plasma exchange therapy to remove hemolytic factors
D. Observation and symptomatic management
Answer: C. HELLP syndrome
Rationale: HELLP syndrome can occur postpartum, typically within 48 hours of delivery. Laboratory findings of thrombocytopenia, elevated liver enzymes, and hemolysis (LDH >600 U/L) confirm the diagnosis.
Answer: B. Platelet transfusion to maintain platelets ≥40,000 cells/μL
Rationale: Platelet transfusion is indicated in HELLP syndrome to stabilize platelet counts, particularly if invasive procedures are necessary. Dexamethasone and plasma exchange are not recommended for HELLP syndrome.
A 30-year-old G2P1 at 28 weeks gestation presents with nausea, fatigue, and mild hypertension (BP 140/90 mmHg). Lab findings include:
Platelets: 95,000/mm³
AST: 100 U/L
LDH: 750 U/L
Which of the following conditions should be included in the differential diagnosis?
A. Viral hepatitis
B. Acute fatty liver of pregnancy (AFLP)
C. Thrombotic thrombocytopenic purpura (TTP)
D. All of the above
Follow-Up Question
What laboratory test can help differentiate HELLP syndrome from AFLP?
A. ALT and AST levels
B. Blood glucose levels
C. Peripheral smear findings
D. Proteinuria measurement
Answer: D. All of the above
Rationale: HELLP syndrome shares overlapping features with other conditions, such as viral hepatitis, AFLP, and TTP. A thorough history, physical exam, and additional testing are necessary to confirm the diagnosis.
Answer: B. Blood glucose levels
Rationale: AFLP often presents with hypoglycemia, which is not a feature of HELLP syndrome. Blood glucose levels can help differentiate these conditions.
A 31-year-old G2P1 presents at 34 weeks gestation with complaints of malaise and right upper quadrant tenderness. Blood pressure is 145/90 mmHg, and urinalysis shows 2+ protein. Laboratory results are as follows:
Platelets: 85,000/mm³
AST: 90 U/L
LDH: 700 U/L
What is the most appropriate classification of this condition based on the Tennessee criteria?
A. Complete HELLP syndrome
B. Partial HELLP syndrome (ELLP)
C. Partial HELLP syndrome (EL)
D. Severe preeclampsia
Follow-Up Question
What is the most appropriate management for this patient?
A. Observe and repeat laboratory tests in 24 hours
B. Immediate delivery after stabilizing maternal condition
C. Administer betamethasone and delay delivery for 48 hours
D. Start dexamethasone for platelet stabilization
Answer: A. Complete HELLP syndrome
Rationale: The patient meets the criteria for complete HELLP syndrome with thrombocytopenia (<100,000/mm³), elevated AST (>70 U/L), and elevated LDH (>600 U/L).
Answer: B. Immediate delivery after stabilizing maternal condition
Rationale: At 34 weeks gestation, delivery is the definitive treatment for complete HELLP syndrome. Maternal stabilization with magnesium sulfate for seizure prophylaxis and antihypertensive therapy is essential before delivery.
A 28-year-old G1P0 at 32 weeks gestation presents with proteinuria, malaise, and right upper quadrant tenderness. Blood pressure is 135/85 mmHg. Laboratory findings include:
Platelets: 120,000/mm³
AST: 100 U/L
LDH: 700 U/L
What is the most appropriate classification based on the Tennessee criteria?
A. Complete HELLP syndrome
B. Partial HELLP syndrome (EL)
C. Partial HELLP syndrome (ELLP)
D. Severe preeclampsia
Follow-Up Question
What is the next step in management if maternal and fetal conditions are stable?
A. Delay delivery for 24-48 hours with betamethasone administration
B. Immediate delivery regardless of stability
C. Start dexamethasone for liver enzyme control
D. Perform plasma exchange therapy
Answer: B. Partial HELLP syndrome (EL)
Rationale: The patient meets the criteria for partial HELLP syndrome with elevated liver enzymes (AST >70 U/L) and LDH >600 U/L but does not meet the platelet threshold (<100,000/mm³) for complete HELLP syndrome.
Answer: A. Delay delivery for 24-48 hours with betamethasone administration
Rationale: If maternal and fetal conditions are stable, delivery can be delayed to allow for betamethasone administration, which promotes fetal lung maturity. This is particularly important at 32 weeks gestation
A 35-year-old G2P1 presents postpartum with complaints of fatigue and right upper quadrant pain. Laboratory tests reveal the following:
Platelets: 95,000/mm³
AST: 85 U/L
LDH: 650 U/L
Peripheral smear: Hemolysis present
What is the Tennessee classification for this condition?
A. Complete HELLP syndrome
B. Partial HELLP syndrome (HEL)
C. Partial HELLP syndrome (ELLP)
D. Severe preeclampsia
Follow-Up Question
What supportive therapy is recommended in this patient?
A. Platelet transfusion
B. Plasma exchange therapy
C. Magnesium sulfate and close monitoring
D. Immediate hysterectomy
Answer: B. Partial HELLP syndrome (HEL)
Rationale: The patient demonstrates hemolysis, elevated liver enzymes, and low platelets (though >100,000/mm³). This fits the criteria for partial HELLP syndrome (HEL).
Answer: C. Magnesium sulfate and close monitoring
Rationale: Postpartum HELLP syndrome requires supportive care, including seizure prophylaxis with magnesium sulfate and close monitoring of maternal condition. Platelet transfusion is not indicated unless platelet count is <40,000/mm³ or delivery is planned.
Question 4
A 30-year-old G3P2 at 36 weeks gestation presents with hypertension, proteinuria, malaise, and right upper quadrant pain. Laboratory findings include:
Platelets: 80,000/mm³
AST: 110 U/L
LDH: 900 U/L
What percentage of patients with HELLP syndrome typically present with proteinuria?
A. 50%
B. 65%
C. 86-100%
D. 90-95%
Follow-Up Question
What is the definitive management for this patient?
A. Observation with repeat labs in 12 hours
B. Immediate delivery after maternal stabilization
C. Administer antihypertensives and observe until 37 weeks
D. Administer plasma exchange therapy
Answer: C. 86-100%
Rationale: Proteinuria is a common feature of HELLP syndrome and is present in 86-100% of cases, distinguishing it from some conditions in the differential diagnosis.
Answer: B. Immediate delivery after maternal stabilization
Rationale: At 36 weeks gestation, delivery is the definitive treatment for HELLP syndrome. Stabilization of maternal condition with antihypertensives and magnesium sulfate should precede delivery.
Question 1
A 30-year-old G1P0 presents at 33 weeks gestation with mild hypertension (BP 145/90 mmHg) and 1+ proteinuria. She denies any symptoms such as headache, visual changes, or right upper quadrant pain. Fetal growth and amniotic fluid index are within normal limits.
What is the most appropriate management for this patient?
A. Immediate delivery
B. Admit for inpatient monitoring and initiate antihypertensive therapy
C. Home management with close maternal and fetal monitoring
D. Administer antenatal corticosteroids and plan delivery at 34 weeks
Follow-Up Question
What instructions should be provided for home monitoring in this patient?
A. Blood pressure should be measured weekly
B. Perform daily fetal kick counts and report any decreased movements
C. Non-stress testing should be performed daily
D. Avoid all physical activity until delivery
Answer: C. Home management with close maternal and fetal monitoring
Rationale: This patient has preeclampsia without severe features at <34 weeks gestation, making her eligible for home management. Regular BP monitoring, weekly lab tests, and antenatal testing (e.g., NST) are required.
Answer: B. Perform daily fetal kick counts and report any decreased movements
Rationale: Patients on home management should monitor BP at least twice daily, perform daily fetal kick counts, and promptly report symptoms such as severe headache, visual changes, or decreased fetal movements.
A 28-year-old G2P1 at 35 weeks gestation presents with severe hypertension (BP 170/110 mmHg) and proteinuria. She reports a persistent headache and visual disturbances. Laboratory results show platelet count 90,000/mm³ and AST 100 U/L.
What is the next best step in management?
A. Initiate magnesium sulfate and plan for immediate delivery
B. Admit for observation and repeat labs in 24 hours
C. Home management with close BP monitoring
D. Delay delivery and administer antenatal corticosteroids
Answer: A. Initiate magnesium sulfate and plan for immediate delivery
Rationale: The patient has preeclampsia with severe features, including severe hypertension, headache, visual changes, thrombocytopenia, and elevated liver enzymes. Immediate delivery is indicated after maternal stabilization with magnesium sulfate and antihypertensives.
Question 3
A 34-year-old G1P0 presents at 36 weeks gestation with BP 150/95 mmHg and 2+ proteinuria. She denies symptoms of severe preeclampsia, and fetal well-being is reassuring on NST.
What is the recommended management for this patient?
A. Immediate delivery
B. Expectant management until 37 weeks
C. Initiate magnesium sulfate and delay delivery
D. Start antihypertensives and plan for delivery at 39 weeks
Follow-Up Question
What additional steps should be taken to manage this patient prior to delivery?
A. Administer antenatal corticosteroids for fetal lung maturity
B. Monitor for seizure prophylaxis with magnesium sulfate
C. Delay delivery and repeat NST in 48 hours
D. Perform an urgent cesarean section
Answer: A. Immediate delivery
Rationale: At 36 weeks, delivery is the preferred management for preeclampsia, even in the absence of severe features, as fetal lungs are mature and the risks of continuing pregnancy outweigh the benefits.
Answer: B. Monitor for seizure prophylaxis with magnesium sulfate
Rationale: Seizure prophylaxis with magnesium sulfate is indicated for patients with preeclampsia to prevent progression to eclampsia. Delivery timing is not dependent on NST results if preeclampsia is confirmed.
A 29-year-old G2P1 at 32 weeks gestation is being managed at home for gestational hypertension. Her latest BP readings are stable at 135/85 mmHg, but she reports a persistent headache and decreased fetal movements.
What is the most appropriate next step?
A. Continue home monitoring and schedule an antenatal visit in 1 week
B. Admit to the hospital for evaluation and monitoring
C. Perform an urgent growth ultrasound and NST at the clinic
D. Administer antihypertensives and continue home management
B. Admit to the hospital for evaluation and monitoring
Rationale: New symptoms such as headache and decreased fetal movements warrant hospital admission for further evaluation and monitoring, as they may indicate progression to preeclampsia with severe features.
A 32-year-old G1P0 with mild preeclampsia is being managed expectantly at 33 weeks gestation. Fetal NST and Doppler studies are normal, and BP is stable.
When should delivery be planned for this patient?
A. At 34 weeks gestation
B. At 37 weeks gestation
C. When fetal growth restriction or oligohydramnios is detected
D. Only if severe features develop
A. At 34 weeks gestation
Rationale: Delivery is recommended at 34 weeks gestation for preeclampsia, even without severe features, as fetal lung maturity is expected and maternal/fetal risks increase with prolonged pregnancy.
