Which of the following is/are risk factor(s) for pre-eclampsia?

• a)

  Smoking in early pregnancy.

• b)

  Smoking in late pregnancy.

• c)

  A previous pregnancy loss.

• d)

  Prolonged pre-pregnancy co-habitation.

• e)

  Residence at high altitude.

Evidence supporting the hypothesis that pre-eclampsia consists of several different disease subtypes include(s):

• a)

  A higher risk of recurrence after a twin pregnancy complicated by pre-eclampsia compared with a singleton pregnancy complicated by pre-eclampsia.

• b)

  Increased placental lesions in cases of early onset pre-eclampsia compared with late onset.

• c)

  An increased risk of mortality among women with early onset pre-eclampsia.

• d)

  An increased risk of intrauterine growth restriction among offspring of women with pre-eclampsia apparent only when disease onset occurs before 34 weeks.

• e)

  An increased risk of intrauterine growth restriction among offspring of women with pre-eclampsia apparent only when disease onset occurs after 34 weeks.

The fetuses-at-risk hypothesis explains the survival advantage observed among preterm infants from pregnancies complicated by pre-eclampsia (compared with preterm infants from pregnancies not complicated by pre-eclampsia) through the following mechanism(s):

• a)

  At-risk fetuses of women with pre-eclampsia induce an increase in maternal blood pressure resulting in increased nutrient and oxygen supply to the placenta.

• b)

  Faster lung maturation in fetuses at risk of being born preterm due to pre-eclampsia.

• c)

  The use of an incorrect denominator in the calculation of neonatal mortality rates.

• d)

  Fetuses in pregnancies complicated by pre-eclampsia receive increased antenatal surveillance as a result of their at-risk status, leading to increased survival.

• e)

  Screening for pre-eclampsia enables effective strategies for amelioration of pre-eclampsia.

Factors contributing to regional and international variations in reported incidence of pre-eclampsia include:

• a)

  Different maternal ages among pregnant women in different countries.

• b)

  Differences in data sources used to generate national statistics.

• c)

  Inconsistent use of the International Classification of Diseases (ICD) coding systems by different countries.

• d)

  Different diagnostic criteria between different ICD codes.

• e)

  Temporal changes in disease incidence.

Which of the following is or are true regarding a woman presenting with a suspected diagnosis of pre-eclampsia?

• a)

  The definition of hypertension (blood pressure ≥140/90 mmHg) is shared between current international guidelines (Australasia [2008], Canada [2008], UK [2010], and USA [2008]).

• b)

  Current definitions of ‘severe’ pre-eclampsia are common between guidelines and have been tested for their ability to identify maternal and perinatal risks.

• c)

  The definition of significant proteinuria (≥0.3 g/24 h or ≥30 mg protein/mmol creatinine on a random urine sample) is shared between current guidelines.

• d)

  Severe hypertension is commonly defined as a diastolic blood pressure ≥110 mmHg, systolic hypertension ≥160–170 mmHg, or both.

• e)

  Maternal risks associated with the diagnosis of pre-eclampsia remain stable across gestational age.

A woman is admitted at 28 + 2 weeks gestation with blood pressure 152/98, ++++ dipstick proteinuria, without symptoms, SpO ₂ 97%, platelet count 103 × 10 ⁹ /L, serum creatinine 67 mM, and AST 56 U/L. Her recent 24-h urine protein estimation was 5.2 g/24 h. She received antenatal corticosteroids for fetal lung maturity 6 days ago. The fetal abdominal circumference is at the 3rd percentile for gestational age. Which of the following statements about this woman is/are true?

• a)

  Her blood pressure should be reduced to below 140/90 mmHg to optimise pregnancy outcomes.

• b)

  It is possible to estimate her personal risks of severe complications for up to 7 days and to balance those risks against potential perinatal gains when counselling the woman and her family.

• c)

  She should be delivered for heavy proteinuria and fetal growth restriction, as she has already received steroids.

• d)

  It is possible to identify her personal risks of severe complications at any time between admission and hospital discharge.

• e)

  The probability that she will experience one or more component of the PIERS combined adverse maternal outcome within the next 48 h is 6.6%.

Which of the following is thought to contribute to the common pathophysiology of pre-eclampsia?

• a)

  Reduction in plasma volume due to capillary leakage and redistribution of total extracellular fluid volume from intravascular to interstitial compartments.

• b)

  Microangiopathic haemolytic anaemia due to antiphospholipid antibody-mediated destruction of erythrocytes.

• c)

  Vasoconstriction with enhanced responses to vasoactive substances such as angiotensin and endothelin.

• d)

  Platelet activation triggered by endothelial activation.

• e)

  Intravascular thrombosis.

Decidual natural killer cells are thought to mediate trophoblast invasion through which of the following mechanisms?

• a)

  Secretion of interferon gamma, which limits trophoblast migration from villous tips.

• b)

  Secretion of interferon gamma, which promotes the formation and maintenance of vascular tube-like projections from extravillous trophoblast.

• c)

  Binding of killer inhibitory receptors with HLA-C, -E, and -G expressed on trophoblast, which prevents trophoblast lysis and contributes to facilitating trophoblast invasion.

• d)

  Ingestion of apoptotic trophoblast debris, resulting in increased Type 2 cytokine secretion.

• e)

  Production of pro- and anti-angiogenic chemokines including IL-8 and IP-10, which have roles in endovascular remodeling.

Which of the following statements is/are false regarding the pathophysiology of end-organ damage in pre-eclampsia?

• a)

  In the kidney, proteinuria results from dysregulation of the glomerular endothelium, which is induced by vascular endothelial growth factor deficiency.

• b)

  In the liver, hepatic sinusoids may be blocked by intravascular fibrin deposition with consequent obstructed blood flow and hepatic ischaemia.

• c)

  In the brain, reversible posterior leucoencephalopathy (PRES) is thought to arise from dysregulation of the cerebral vasculature as a consequence of rapid elevations in blood pressure.

• d)

  In the brain, areas of both vasoconstriction and forced vasodilation develop, particularly in the posterior circulation.

• e)

  In the lung, spontaneous pulmonary oedema most commonly develops intrapartum due to decreased plasma colloid pressure from massive proteinuria and increased cardiac output during labour.

Which of the following statements about genome-wide linkage analysis is/are true:

• a)

  Affected sib-pair analysis is an appropriate strategy to use for genome-wide linkage analysis in complex genetic disorders.

• b)

  Microsatellite markers are the most extensively used markers for genome-wide linkage analysis.

• c)

  A case-control design is appropriate for genome-wide linkage studies in complex genetic disorders.

• d)

  The results of genome-wide linkage analysis can inform the selection of positional candidate genes for further study.

• e)

  Genome-wide linkage analysis typically identifies regions of the genome containing a single susceptibility gene.

11. A primigravida attends the antenatal clinic for her booking appointment. Her sister developed severe pre-eclampsia at 30 weeks’ gestation leading to a preterm delivery. Her clinician plans to perform tests for the prediction of pre-eclampsia and plan her management. Which of the following test(s) is/are good predictors for the occurrence of pre-eclampsia?

• a)

  Blood-pressure measurement at booking.

• b)

  Serum uric acid.

• c)

  Estimation of 24 h proteinuria.

• d)

  Measuring placental growth factor (PlGF).

• e)

  Test for alpha-fetoprotein.

A woman who had severe pre-eclampsia in her previous history is now 9 weeks pregnant. What treatment(s) have been shown to reduce the risk of pre-eclampsia in this pregnancy?

• a)

  60–100 mg aspirin daily.

• b)

  Rest; at least 30 mins per day.

• c)

  Marine oil (omega-3 fatty acids) capsules 1 per day.

• d)

  Vitamins C.

• e)

  Vitamins E.

In the presence of severe pre-eclampsia, expectant management is associated with the highest adverse maternal and perinatal outcomes in which of the following:

• a)

  In the presence of appropriately grown fetus with normal amniotic fluid.

• b)

  At gestational age less than 26 weeks.

• c)

  When there is evidence of vaginal bleeding.

• d)

  When Doppler studies show that the fetus has absent or reverse umbilical artery flow.

• e)

  When the mother develops seizures.

Which of the following statement(s) is or are true regarding a woman with pre-existing hypertension who is otherwise well, and who has conceived on enalapril? Her blood pressure is currently 145/90 mmHg at 8 weeks’ gestation.

• a)

  The pregnancy should be terminated because enalapril is associated with a much higher risk of major fetal malformations, above the baseline of 10%.

• b)

  This woman must discontinue her enalapril and restart methyldopa to decrease her risk of developing pre-eclampsia.

• c)

  If the enalapril is discontinued, this woman’s blood pressure may normalise over the subsequent weeks.

• d)

  This woman should take methyldopa. It is the drug of choice because it is associated with the best child neurodevelopmental outcome.

• e)

  A reasonable goal for this woman’s blood pressure goal in pregnancy is 150/100 mmHg.

A woman presents to delivery suite at 31 weeks’ gestation because, at a routine antenatal visit, she was noted to have a blood pressure of 170/110 mmHg and new 2+ proteinuria by urinary dipstick testing. She is asymptomatic. Which of the following statement(s) about this woman is or are true?

• a)

  This woman is a candidate for antepartum home care.

• b)

  The drug of first choice for treatment of this severe hypertension is parenteral hydralazine.

• c)

  Oral antihypertensive may be appropriate to treat the hypertension in this setting.

• d)

  This woman most likely has severe pre-eclampsia and should receive MgSO ₄ .

• e)

  If MgSO ₄ is prescribed, then nifedipine should not be prescribed as an antihypertensive agent.

When considering use of regional anaesthesia in a woman with pre-eclampsia, which of the following statements is/are true?

• a)

  Anaesthetists worry about causing bleeding around the spinal cord.

• b)

  Use of low-dose aspirin is a contraindication to regional anaesthesia.

• c)

  It is advisable to wait 12 h before insertion of an epidural in a parturient on therapeutic doses of low molecular weight heparin.

• d)

  Neuraxial anaesthesia impairs blood flow to the fetus.

• e)

  Neuraxial haematoma can occur upon removal of the epidural catheter.

In pre-eclamptic toxaemia, perinatal outcome has been shown to most reliably relate to:

• a)

  Severity of hypertension.

• b)

  Gestational age at delivery.

• c)

  Birth weight.

• d)

  Non-reactive non-stress test.

• e)

  Mode of delivery.

18. Fetal movement counting has been shown to:

• a)

  Be associated with an increase in hospital admissions.

• b)

  Be influenced by administration of oral antihypertensive drugs.

• c)

  Be not influenced by gestational age.

• d)

  Be reliably perceived by 16 weeks in nulliparous women.

• e)

  Be predictive of perinatal outcome in pre-eclamptic toxaemia.

The biophysical profile:

• a)

  Predicts perinatal acidosis in pre-eclamptic toxaemia.

• b)

  Predicts long-term neonatal outcomes after pre-eclamptic toxaemia.

• c)

  Has not been evaluated by a randomised-control trial as a test of fetal well-being in pre-eclamptic toxaemia.

• d)

  Can be used to assess longitudinal progression of disease in pre-eclamptic toxaemia.

• e)

  Is based on short-term alterations in fetal behaviour produced by exposure to hypoxia.

Which of the following is/are true regarding Doppler measurements?

• a)

  Umbilical Doppler can improve the identification of the fetus at risk of poor outcome in high-risk pregnancies.

• b)

  A decrease in middle cerebral artery flow is triggered by acute hypoxemia.

• c)

  Ductal flow is increased in cases of pre-eclamptic toxaemia with severe utero placental insufficiency.

• d)

  The ratio of umbilical : renal flow is most helpful in recognising the growth-restricted fetus at risk of mortality.

• e)

  Middle cerebral artery blood flow is very constant and is not affected by fetal behaviour.

Benchmarking is an effective tool for continuous quality improvement if:

• a)

  All units involved are using the same disease diagnostic criteria.

• b)

  It is only conducted for pure research purposes.

• c)

  The cyclical nature of the concept is completed fully.

• d)

  Reliable data are available from those units involved.

• e)

  It leads to review of clinical activity and practice change.

Acute pulmonary oedema in women with pre-eclampsia results most commonly from:

• a)

  The reason is unknown but it is most likely inherently part of the disease process.

• b)

  Iatrogenic administration of intravenous fluids.

• c)

  The administration of intravenous magnesium sulphate.

• d)

  The use of oral beta blockers.

• e)

  Hypoalbuminaemia.

23. The most commonly cited reasons in studies of occurrence of preventable deaths in the maternity setting are:

• a)

  Inadequate supervision of health practitioners.

• b)

  Lack of communication between health practitioners and patients.

• c)

  Medication errors.

• d)

  Inadequate training of health professionals.

• e)

  Failure to appreciate the whole clinical picture.

The following statement(s) is/are true regarding expectant management of severe pre-eclampsia:

• a)

  It is safe for the mother and fetus when gestational age is 34–35 weeks.

• b)

  Antihypertensive medications are indicated when systolic blood pressure is ≥160 mmHg, diastolic blood pressure is ≥110 mmHg, or both.

• c)

  Intravenous magnesium sulfate given prophylactically reduces the risks of convulsions.

• d)

  Corticosteroids do not reduce neonatal morbidity when gestational age is 30–32 weeks in the presence of severe pre-eclampsia.

• e)

  Expectant management improves outcome when gestational age is 21–22 weeks.

Providing a pregnant woman with understandable information about pre-eclampsia has been shown to result in:

• a)

  Greater compliance with bed rest or other care-provider counsel.

• b)

  Timely reporting of relevant symptoms.

• c)

  Mental anxiety.

• d)

  Information overload.

• e)

  Improved perinatal outcome.

Patient advocacy organisations can help improve the field of pre-eclampsia through:

• a)

  Recruitment of research study participants.

• b)

  Funding research.

• c)

  Educating patients and providing emotional support.

• d)

  Developing compelling messages and influencing public policy.

• e)

  Development of practice guidelines.

The following is/are true about the use of magnesium sulfate in pre-eclampsia and eclampsia:

• a)

  Magnesium sulfate is the drug of choice for the treatment and prevention of eclampsia.

• b)

  Magnesium sulfate reduces the risk of eclampsia significantly.

• c)

  Magnesium sulfate should only be used in women with severe pre-eclampsia.

• d)

  Magnesium sulfate reduces perinatal mortality and morbidity.

• e)

  Magnesium sulfate is widely available and utilized.

Which of the following is/are correct regarding the use of calcium for the prevention of pre-eclampsia?

• a)

  Calcium reduces the risk of pre-eclampsia in women with low calcium intake.

• b)

  Calcium supplementation improves biochemical parameters like proteinuria and platelet counts.

• c)

  Calcium is associated with a reduction in pre-eclampsia when started before 20 weeks gestational age.

• d)

  Calcium supplementation is challenging in LMIC.

• e)

  Calcium cannot be taken at the same time as iron.

In the postpartum evaluation of a woman with a history of pre-eclampsia, with respect to future cardiovascular risk the following should be undertaken:

• a)

  Screening for traditional cardiovascular risk factors.

• b)

  Counselling about a heart-healthy lifestyle.

• c)

  Treating blood pressure, dyslipidemia and blood sugar according to locally accepted guidelines.

• d)

  Treating blood pressure, dyslipidemia and blood sugar at lower targets than those in locally accepted guidelines.

• e)

  Discussion about postpartum weight loss.

Of the following groups of women, which one has the highest risk for premature cardiovascular disease?

• a)

  A woman who develops gestational hypertension.

• b)

  A woman who develops pre-eclampsia at 36 weeks gestational age.

• c)

  A woman who develops severe pre-eclampsia at 38 weeks gestational age.

• d)

  A woman who develops mild pre-eclampsia at 38 weeks gestational age.

• e)

  A woman with pre-existing hypertension who does not develop a hypertensive disorder of pregnancy.