Managing Pre-eclampsia – A High-Yield UKMLA/PLAB Scenario
Essential Insights for Medical Licensing Exams: Pre-eclampsia in Pregnancy
This article focuses on a critical question from the August 2024 PLAB 1 exam, highlighting the clinical recognition and management of pre-eclampsia. This condition tests your ability to differentiate between hypertensive disorders of pregnancy, a crucial skill for UKMLA, PLAB, and other medical exams.
PLAB 1 Exam style Case Scenario: A 32-year-old woman, 28 weeks pregnant with her first child, presents with severe headaches, visual disturbances, and swelling of her hands and feet. Her blood pressure is 165/100 mmHg, and urinalysis shows 3+ protein. She has no significant past medical history. Which is the most likely diagnosis?
A. Gestational hypertension
B. Pre-eclampsia
C. Chronic hypertension
D. Eclampsia
E. Urinary tract infection
Answer with an explanation is provided below.
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Correct Answer: B) Pre-eclampsia
Explanation and Clinical Reasoning
Key Features of Pre-eclampsia
Pre-eclampsia is a multisystem disorder characterised by:
New-onset Hypertension:
Defined as BP ≥140/90 mmHg after 20 weeks gestation. Severe hypertension is defined as BP ≥160/110 mmHg.
Proteinuria:
Significant protein loss, indicated by ≥1+ on dipstick or ≥300 mg in a 24-hour urine collection.
End-Organ Symptoms:
Includes headache, visual disturbances, epigastric pain, or abnormal lab results (e.g., thrombocytopenia, elevated liver enzymes).
Oedema:
Although not diagnostic, swelling of hands and feet is common due to fluid retention.
Why Pre-eclampsia is the Most Likely Diagnosis
Hypertension and Proteinuria:
The patient’s BP of 165/100 mmHg and 3+ protein on urinalysis fulfil the diagnostic criteria.
Neurological Symptoms:
Severe headaches and visual disturbances indicate end-organ involvement.
Gestational Timing:
Symptoms after 20 weeks of gestation strongly suggest pre-eclampsia.
Why Other Options Are Less Likely
A) Gestational Hypertension:
Involves hypertension without proteinuria or systemic symptoms. The presence of proteinuria and neurological symptoms excludes this diagnosis.
C) Chronic Hypertension:
Diagnosed before pregnancy or before 20 weeks gestation. The patient has no history of hypertension, making this unlikely.
D) Eclampsia:
Defined as seizures in the presence of pre-eclampsia. While this patient has severe pre-eclampsia, there are no seizures.
E) Urinary Tract Infection:
UTIs may cause mild proteinuria but are unlikely to present with severe hypertension, neurological symptoms, or significant oedema.
Management and Follow-Up
Immediate Management:
Hospital Admission:
Admit for close monitoring of maternal and foetal health.
Blood Pressure Control:
Initiate antihypertensive therapy:
Labetalol: First-line agent in pregnancy.
Nifedipine: Alternative if labetalol is contraindicated.
Prevent Eclampsia:
Administer magnesium sulfate in cases of severe pre-eclampsia to reduce the risk of seizures.
Monitor Maternal and Foetal Well-Being:
Regularly assess for complications such as:
HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets).
Foetal growth restriction or distress (via ultrasound and cardiotocography).
Definitive Treatment:
Delivery:
The only cure for pre-eclampsia.
Timing depends on:
Severity of the condition.
Gestational age.
Maternal and foetal status.
In this case, aim to prolong pregnancy if maternal and foetal conditions are stable, with frequent reassessment.
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