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OG12.1-11,OG16.4 | Medical Disorders in Pregnancy — Practice Quiz
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A 28-year-old primigravida at 34 weeks presents with BP 160/110 mmHg, frontal headache, and 2+ proteinuria. She develops a tonic-clonic seizure. Which magnesium sulphate regimen delivers 5 g IM into each buttock as part of the loading dose?
The Pritchard (IM) regimen loads 4 g IV plus 10 g IM (5 g into each buttock), then maintains with 5 g IM every 4 hours in alternate buttocks. Zuspan uses an IV-only route: 4 g loading then 1 g/h infusion.
The Pritchard regimen: loading 4 g IV + 10 g IM (5 g each buttock); maintenance 5 g IM every 4 h. Zuspan: loading 4 g IV then 1 g/h IV infusion. Know both by name.
Zuspan is the IV-only regimen (4 g IV then 1 g/h infusion). The loading dose with 5 g IM into each buttock is the hallmark of the Pritchard regimen.
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While monitoring a patient on magnesium sulphate for eclampsia, the knee jerks become absent and the respiratory rate falls to 10 breaths/minute. What is the immediate antidote?
Calcium gluconate 1 g IV (10 mL of 10% solution) is the antidote for magnesium toxicity. Absent knee jerks (first sign) and respiratory depression (rate <12/min) indicate toxicity. Calcium chloride is more irritant and is NOT the preferred preparation.
Monitor knee jerks (must be present), RR ≥12/min, and urine output ≥30 mL/h during MgSO4 infusion. Antidote = calcium gluconate 1 g IV (NOT calcium chloride).
Calcium gluconate 1 g IV is the correct antidote. Calcium chloride is more caustic and less preferred. The warning signs of MgSO4 toxicity in order: loss of patellar reflex (serum Mg ~7–10 mEq/L), respiratory depression (~10–13 mEq/L), cardiac arrest (>15 mEq/L).
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A 24-year-old primigravida at 28 weeks is found to have Hb 7.8 g/dL on routine ANC. Her peripheral smear shows microcytic hypochromic red cells. What is the most appropriate management?
Moderate IDA (Hb 7–10.9 g/dL) in pregnancy is treated with oral iron. The WHO/NHM target is Hb ≥11 g/dL before delivery. Blood transfusion is reserved for severe anaemia (Hb <7 g/dL) or near term with no time for oral iron to work. IV iron is for oral-intolerant or non-responsive cases.
Severity tiers: mild Hb 10–10.9, moderate 7–9.9, severe <7 g/dL. Moderate IDA = oral iron. Severe IDA at term or with cardiac decompensation = blood transfusion. IV iron for oral failures.
Blood transfusion is for severe anaemia (Hb <7 g/dL). Oral iron (100–200 mg elemental iron daily) is the first-line treatment for moderate IDA. IV iron is for oral intolerance or non-response.
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A 30-year-old pregnant woman at 26 weeks attends her antenatal visit. She has had nothing to eat for the last 4 hours. A 75 g oral glucose load is given and her plasma glucose at 2 hours is 145 mg/dL. Which screening protocol was applied and what is the result?
The DIPSI protocol uses a non-fasting 75 g OGTT with a single 2-hour sample; a value of ≥140 mg/dL diagnoses GDM. The IADPSG/WHO protocol requires a fasting state and uses three thresholds (fasting ≥92, 1-h ≥180, 2-h ≥153 mg/dL — any one positive). The woman was not fully fasting (ate 4 hours ago), making this a DIPSI-type non-fasting screen.
DIPSI (non-fasting, 2-h ≥140 mg/dL) is the FOGSI-endorsed protocol in India. IADPSG/WHO requires fasting. NEVER merge the two protocols or apply one protocol's cut-off to the other.
DIPSI = non-fasting 75 g, 2-hour cut-off ≥140 mg/dL. IADPSG = fasting 75 g OGTT, cut-offs fasting ≥92/1-h ≥180/2-h ≥153 mg/dL. A result of 145 mg/dL at 2 hours under DIPSI protocol = GDM positive.
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A 26-year-old woman with rheumatic mitral stenosis (NYHA class II) is 30 weeks pregnant. During the third stage of labour, which drug must be avoided?
Ergometrine (methylergometrine) causes severe vasoconstriction and a sudden rise in central venous return and systemic vascular resistance, which can precipitate acute pulmonary oedema in a stenotic valve already operating near capacity. It is absolutely contraindicated in heart disease in pregnancy.
Ergometrine is contraindicated in heart disease and hypertension/pre-eclampsia. Carboprost (PGF2α) is contraindicated in asthma. Oxytocin 10 IU IM is the safest third-stage drug in cardiac disease (avoid rapid IV bolus).
Ergometrine is absolutely contraindicated in cardiac disease because it causes acute vasoconstriction and increased venous return, risking pulmonary oedema. Oxytocin 10 IU IM is the preferred uterotonic but must be given slowly IM (not as a bolus IV, which causes hypotension). Carboprost is contraindicated in asthma, not heart disease.
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A 22-year-old primigravida at 14 weeks has a mid-stream urine culture showing 100,000 CFU/mL of E. coli on two consecutive cultures, but has no urinary symptoms. What is the correct management?
Asymptomatic bacteriuria (ASB) in pregnancy must always be treated because 20–40% of untreated ASB progresses to acute pyelonephritis. The risk is this high due to physiological urinary stasis, ureteric dilatation, and vesicoureteral reflux in pregnancy. Antibiotic choice is guided by culture sensitivity and pregnancy safety (e.g., nitrofurantoin — avoid near term, cephalexin).
ASB = ≥100,000 CFU/mL on two consecutive cultures, no symptoms. In pregnancy it MUST be treated — 20–40% progress to pyelonephritis without treatment (vs 1–2% in non-pregnant women).
ASB in pregnancy is not a watch-and-wait diagnosis. The 20–40% risk of ascending pyelonephritis mandates treatment regardless of symptoms. This is a key distinction from non-pregnant women, where ASB is generally not treated.
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A 34-year-old multigravida at 36 weeks presents with jaundice, epigastric pain, vomiting, and hypoglycaemia. Her AST is elevated and her prothrombin time is prolonged. Which diagnosis must be excluded urgently as it requires immediate delivery?
AFLP is a mitochondrial fatty acid oxidation defect presenting in the third trimester with jaundice, abdominal pain, hypoglycaemia (a hallmark), and coagulopathy. It is a life-threatening obstetric emergency requiring immediate delivery. HELLP syndrome can co-present but lacks hypoglycaemia. ICP presents with pruritus without jaundice typically, and hepatitis E is a viral infection.
AFLP vs HELLP: both present in T3 with jaundice and abdominal pain. Key discriminator: hypoglycaemia = AFLP (hepatocyte failure); elevated LDH + haemolysis = HELLP. Both require urgent delivery. AFLP is rare but carries high maternal mortality without prompt delivery.
The hallmark of AFLP is hypoglycaemia (hepatocellular failure depletes glycogen stores) combined with jaundice and coagulopathy in the third trimester. This is the key distinguishing feature from HELLP syndrome (no hypoglycaemia). Both require delivery, but the hypoglycaemia flags AFLP specifically.
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A 25-year-old HIV-positive primigravida at 32 weeks has been on Option B+ ART since 14 weeks. Her viral load at 36 weeks is 250 copies/mL. What mode of delivery and infant feeding advice should she receive?
Under NACO 2021 PPTCT guidelines, women on ART with viral load <1000 copies/mL can deliver vaginally. Exclusive breastfeeding with infant ART prophylaxis (nevirapine daily) is recommended in India because replacement feeding requires safe water, consistent supply, and affordability — conditions often unmet. The AFASS criteria (Acceptable, Feasible, Affordable, Sustainable, Safe) must be met for formula feeding to be recommended.
NACO 2021: Option B+ ART for all HIV-positive pregnant women regardless of CD4 count. Viral load <1000 copies/mL = vaginal delivery permitted. Breastfeeding + infant nevirapine recommended in India unless AFASS criteria met. Do not universally advise against breastfeeding.
Advising all HIV-positive women to avoid breastfeeding is incorrect in India. The NACO PPTCT programme recommends breastfeeding with ART coverage unless AFASS criteria are met. Viral load <1000 copies/mL on ART permits vaginal delivery; caesarean is for VL ≥1000 copies/mL or obstetric indications.
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A Rh-negative woman at 10 weeks presents with a threatened miscarriage. Her indirect Coombs test (ICT) is negative. What action regarding anti-D is most appropriate?
Anti-D immunoglobulin is indicated for Rh-negative women following any sensitising event, including threatened miscarriage <12 weeks. The recommended dose for sensitising events before 12 weeks is the smaller 50–75 µg (250 IU) dose, as the feto-maternal haemorrhage volume at this gestation is small. It must be given within 72 hours. The full 300 µg dose is used from ≥12–13 weeks onwards.
Anti-D within 72 h of any sensitising event. <12 weeks: 50–75 µg (250 IU). ≥12 weeks: 300 µg (1500 IU). Never give anti-D if ICT is already positive. Do not omit anti-D after early pregnancy events.
Anti-D is required after sensitising events at any gestation, including threatened abortion. Before 12 weeks the smaller 50 µg (250 IU) dose is used. Anti-D must NOT be given if ICT is already positive (sensitisation has already occurred); a negative ICT confirms it is appropriate to give it.
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A 28-year-old woman with Graves' hyperthyroidism becomes pregnant at 8 weeks. She is currently on carbimazole. Which change in antithyroid drug therapy is most appropriate?
Carbimazole (and its active metabolite methimazole) causes aplasia cutis and methimazole embryopathy (choanal atresia, oesophageal atresia, abdominal wall defects) during organogenesis in the first trimester. PTU is the safer option in T1 because it crosses the placenta less and has no known teratogenic effects. However, PTU is associated with hepatotoxicity in the mother, so switching to carbimazole from the second trimester onwards is recommended.
Antithyroid drugs in pregnancy: PTU in first trimester (safer, less teratogenic), switch to carbimazole from second trimester (PTU hepatotoxicity risk). Get the timing of the switch correct: T1 = PTU; T2 onwards = carbimazole.
Carbimazole/methimazole is teratogenic in the first trimester (aplasia cutis, methimazole embryopathy). PTU is preferred in T1. The switch from PTU back to carbimazole in T2 is recommended because PTU carries a risk of maternal hepatotoxicity with prolonged use.
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A 32-year-old multigravida at 32 weeks has a symphysis-fundal height of 27 cm. Ultrasound shows estimated fetal weight on the 8th centile with reduced amniotic fluid. The umbilical artery Doppler shows absent end-diastolic flow. Which finding represents the most severe degree of fetal compromise requiring urgent delivery?
Reversed end-diastolic flow on umbilical artery Doppler represents the most severe stage of placental insufficiency, indicating very high downstream resistance with blood flowing backwards during diastole. It is associated with a high risk of fetal acidosis and stillbirth, and requires urgent delivery. Absent end-diastolic flow is severe but reversed flow is worse. EFW <10th centile defines SGA; AFI of 5 cm indicates oligohydramnios (borderline <5 cm = severe).
Umbilical artery Doppler severity: normal PI → elevated PI → absent end-diastolic flow → reversed end-diastolic flow (most severe = urgent delivery). SGA (EFW <10th centile) is not synonymous with IUGR — Doppler surveillance distinguishes the constitutionally small but well baby from the truly compromised fetus.
Umbilical artery Doppler changes grade from: normal → raised PI → absent end-diastolic flow → reversed end-diastolic flow (most severe). Reversed flow indicates near-critical placental resistance and imminent fetal compromise requiring urgent delivery.
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