Give me imp questions and there answers for mbbs obg exam on topics hypertension in pregnancy and antepartum hemorrhage

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Important Questions & Answers: MBBS OBG Exam

SECTION A: HYPERTENSION IN PREGNANCY

Q1. Classify the hypertensive disorders of pregnancy.

A. Hypertensive disorders of pregnancy are classified into:

Gestational Hypertension - New hypertension developing after 20 weeks' gestation WITHOUT features of preeclampsia. Resolves by 12 weeks postpartum. ~25% progress to preeclampsia.
Preeclampsia - New hypertension after 20 weeks WITH maternal organ dysfunction (proteinuria, AKI, elevated transaminases, neurological, hepatic, or clotting abnormalities) OR uteroplacental dysfunction (fetal growth restriction, abnormal umbilical artery Doppler, stillbirth).
Eclampsia - Seizure activity in a woman with preeclampsia.
Chronic Hypertension - BP ≥140/90 mmHg predating pregnancy or detected before 20 weeks, persisting beyond 12 weeks postpartum.
Superimposed Preeclampsia - New development of preeclampsia features after 20 weeks in a woman with pre-existing chronic hypertension.
White-coat Hypertension - Office BP ≥140/90 but home BP <135/85 mmHg. Associated with ~8% risk of preeclampsia.

(Comprehensive Clinical Nephrology, 7th Ed.)

Q2. What are the diagnostic criteria for preeclampsia?

A. Diagnostic criteria (Table 44.4, Comprehensive Clinical Nephrology):

Essential criteria:

Gestation >20 weeks
New hypertension: systolic BP ≥140 mmHg OR diastolic BP ≥90 mmHg on two occasions

Additional criteria (at least one must be present):

Proteinuria: uPCR >30 mg/mmol, or >300 mg/24 hr, or dipstick ≥2+ (note: proteinuria is NOT essential if other criteria are present)
Renal: Serum creatinine >1.0-1.1 mg/dL or doubling of serum creatinine
Hematologic: Platelets <150 × 10⁹/L; hemolysis; DIC
Hepatic: AST/ALT >40 U/L or double normal; epigastric/RUQ pain
Neurological: Eclampsia, altered mental status, blindness, persistent visual scotomata, stroke, clonus, new-onset headache
Respiratory: Pulmonary edema
Uteroplacental: Fetal growth restriction, abnormal umbilical artery Doppler, stillbirth

(Comprehensive Clinical Nephrology, 7th Ed.)

Q3. What is the incidence and epidemiology of hypertensive disorders of pregnancy?

Hypertension affects 10-12% of all pregnancies
Global incidence of preeclampsia: 4.6% of all pregnancies
Incidence of eclampsia globally: 1.4% of pregnancies (prevalence ~0.3% of hypertensive pregnancies in high-income countries)
Hypertensive disorders account for 10-20% of the ~300,000 maternal deaths annually worldwide
In the USA, preeclampsia and eclampsia account for 16-20% of all maternal deaths

(Brenner and Rector's The Kidney; Comprehensive Clinical Nephrology)

Q4. What are the risk factors for preeclampsia?

Previous history of preeclampsia (15-65% recurrence risk; highest if delivery was before 34 weeks)
Antiphospholipid syndrome
Diabetes mellitus
Obesity
Chronic hypertension
Chronic kidney disease (CKD)
Assisted reproduction
Nulliparity (first pregnancy)
New partner or interpregnancy interval >7 years (risk returns to that of a first pregnancy)
Multiple gestation

(Comprehensive Clinical Nephrology, 7th Ed.)

Q5. What is the role of magnesium sulfate in preeclampsia/eclampsia?

A. Magnesium sulfate is the drug of choice for prevention and treatment of eclamptic seizures.

Evidence:

The Magpie Trial (10,000+ preeclamptic women, 33 countries): magnesium vs placebo - magnesium decreased eclamptic seizures by 50% (0.8% vs 1.9%)
Superior to diazepam and phenytoin for seizure prevention (RCTs, 1995)

Mechanism: In the therapeutic range (serum level 5-9 mg/dL), magnesium sulfate slows neuromuscular conduction and depresses CNS irritability.

Regimen: IV bolus (4-6 g loading dose) followed by continuous infusion (2 g/hr)

Toxicity monitoring: Loss of deep tendon reflexes, flushing, somnolence, muscle weakness, decreased respiratory rate. Use with caution in renal impairment.

Contraindications to magnesium: Myasthenia gravis, severe renal failure, significant pulmonary concerns/risk of respiratory failure (phenytoin may be substituted in these cases).

(Brenner and Rector's The Kidney; Creasy & Resnik's Maternal-Fetal Medicine; Goldman-Cecil Medicine)

Q6. What antihypertensive drugs are used in pregnancy? Name the drugs of choice and contraindicated drugs.

First-Line Oral Agents:

Drug	Notes
Methyldopa	Drug of choice; centrally acting α2-agonist; most extensive safety data; no adverse fetal effects
Labetalol	Preferred β-blocker; α+β blockade improves uteroplacental flow
Long-acting Nifedipine	Once-daily dosing

First-Line IV Agents:

Labetalol IV, Nicardipine IV

Second-Line:

Hydralazine (increased risk of maternal hypotension and placental abruption)
Metoprolol, Verapamil, Diltiazem

Generally Avoided:

Diuretics (may impair plasma volume expansion)
Atenolol (may impair fetal growth)
Nitroprusside (risk of fetal cyanide poisoning if >4 hours)

Absolutely Contraindicated:

ACE inhibitors - multiple fetal anomalies
Angiotensin receptor blockers (ARBs) - similar risks as ACE inhibitors

(Brenner and Rector's The Kidney, 2-Volume Set)

Q7. What is HELLP syndrome? How does it differ from TTP/HUS and AFLP?

A. HELLP syndrome stands for: Hemolysis + Elevated Liver enzymes + Low Platelets. It is a severe form of preeclampsia and can occur even in the absence of proteinuria.

Comparison Table (HELLP vs HUS/TTP vs AFLP):

Feature	HUS/TTP	HELLP	AFLP
Hemolytic anemia	+++	++	±
Thrombocytopenia	+++	++	±
Coagulopathy	-	±	+
CNS symptoms	++	±	±
Renal failure	+++	+	++
Hypertension	±	+++	±
Elevated AST	±	++	+++
Elevated bilirubin	++	+	+++
Ammonia	Normal	Normal	High
Effect of delivery	None	Recovery	Recovery
Management	Plasma exchange	Supportive + delivery	Supportive + delivery

Management of HELLP:

Delivery is definitive treatment
In 24-34 weeks with stable status: expectant management is an option
High-dose dexamethasone: RCT showed no benefit; possible benefit in severe thrombocytopenia (platelets <50,000) - subgroup only
Plasmapheresis: limited evidence for antepartum use

(Brenner and Rector's The Kidney)

Q8. Write a short note on gestational hypertension vs. chronic hypertension.

Feature	Gestational HTN	Chronic HTN
Onset	After 20 weeks' gestation	Before pregnancy or <20 weeks
Resolution	By 12 weeks postpartum	Persists beyond 12 weeks postpartum
Proteinuria/organ involvement	Absent (if present, diagnosis changes to preeclampsia)	May have if superimposed PE develops
Risk of progression	25% develop preeclampsia	Risk of superimposed preeclampsia
Diagnosis confirmation	Retrospective	Confirmed by home BP monitoring or 24-hr ABPM

Normal BP in pregnancy: Nadir of 113/69 at 18-19 weeks; upper limit at term = 144/95 mmHg (97th centile). The threshold for intervention remains 140/90 mmHg.

(Comprehensive Clinical Nephrology, 7th Ed.)

SECTION B: ANTEPARTUM HEMORRHAGE (APH)

Q9. Define antepartum hemorrhage and name its causes.

A. Antepartum hemorrhage (APH) is defined as bleeding from the genital tract after 28 weeks of pregnancy and before delivery of the baby (some sources state after 20 weeks; the classical OBG definition is after 28 weeks).

Incidence: Complicates 3-5% of pregnancies and is a leading cause of maternal and perinatal mortality worldwide.

Causes:

Placenta Previa - most common serious cause
Placental Abruption (Abruptio Placentae)
Vasa Previa
Local causes: cervical erosion, cervical polyp, carcinoma cervix, varicosities
APH associated with coagulation defects

(Barash Clinical Anesthesia, 9th Ed.; Tintinalli's Emergency Medicine)

Q10. What is placenta previa? Classify it and describe its clinical features and management.

A. Placenta previa refers to abnormal placental implantation on the lower uterine segment with partial-to-total occlusion of the internal cervical os.

Classification (degrees):

Grade I (Low-lying): Placenta in lower segment but not reaching os
Grade II (Marginal): Placenta reaches but does not cover the os
Grade III (Partial): Placenta partially covers the os
Grade IV (Complete/Central): Placenta completely covers the os

Risk Factors:

Previous uterine scar/prior cesarean delivery (dose-dependent: 3% risk with 1st cesarean; 61% with 3+ cesareans)
Tobacco use
Advanced maternal age (AMA)
Multiparity
Multiple gestation
Prior uterine surgery

Clinical Features:

Painless, bright red vaginal bleeding (typically after 7th month)
Abnormal lie of fetus (transverse/oblique)
Soft, non-tender uterus
High head (presenting part not engaged)

Diagnosis: Confirmed by ultrasonography. Do NOT perform digital or speculum examination until placenta previa is ruled out.

Management:

Expectant (conservative): If bleeding is not profuse and fetus is immature - admit to high-risk unit, IV access, cross-match blood, bed rest
Active (delivery): If bleeding is severe or fetus is mature - Cesarean section (vaginal birth is CONTRAINDICATED in placenta previa)
Neuraxial anesthesia preferred if mother is hemodynamically stable
Watch for postpartum hemorrhage (associated with uterine atony and placenta accreta)

(Barash Clinical Anesthesia, 9th Ed.; Tintinalli's Emergency Medicine; Morgan and Mikhail's Clinical Anesthesiology)

Q11. What is placental abruption? Describe its clinical features, complications, and management.

A. Placental abruption is the premature separation of a normally situated placenta from the uterine wall before delivery of the fetus.

Incidence: Complicates approximately 1% of deliveries, usually in the final 10 weeks of gestation.

Risk Factors:

Tobacco use
Cocaine use
Trauma
Multiple gestation
Hypertension and preeclampsia
Advanced maternal age
Preterm premature rupture of membranes

Classification (Grades):

Grade 0: Asymptomatic (diagnosed retrospectively)
Grade 1: Mild - slight vaginal bleeding, minimal uterine tenderness, no fetal distress
Grade 2: Moderate - uterine tenderness, fetal distress present
Grade 3: Severe - severe bleeding (may be concealed), uterine rigidity, maternal shock, fetal death

Clinical Features:

Painful, dark, clotted vaginal bleeding
Uterine tenderness and hypertonus (board-like uterus)
Bleeding may be concealed if placental margins remain attached
Signs of hypovolemia if significant blood loss
Fetal distress or demise (>50% placental separation = likely stillbirth)

Complications:

DIC (disseminated intravascular coagulation) - most important
Maternal hemorrhagic shock
Renal cortical necrosis (Couvelaire uterus in severe cases)
Perinatal mortality: 9-12% in developed countries; maternal mortality <1%

Management:

Coagulation studies (watch for DIC); prepare for massive transfusion
Mild/distant from term: expectant management with close observation; artificial rupture of membranes + oxytocin augmentation if needed
Non-reassuring fetal status: emergency cesarean section
Fetal death with severe abruption: attempted vaginal delivery if mother is stable
Neuraxial analgesia/anesthesia appropriate only if mother is hemodynamically stable and coagulation is normal

(Barash Clinical Anesthesia, 9th Ed.; Tintinalli's Emergency Medicine)

Q12. Differentiate placenta previa from placental abruption.

Feature	Placenta Previa	Placental Abruption
Onset of bleeding	Spontaneous, episodic	Sudden, may follow trauma
Nature of bleeding	Painless, bright red	Painful, dark, clotted
Uterus	Soft, non-tender, normal tone	Tender, hard, hypertonic (board-like)
Bleeding	Usually revealed	May be concealed
Abnormal lie	Common	Uncommon
Fetal presentation	High, not engaged	May be engaged
Fetal heart rate	Usually normal	May show distress
Cause	Low placental implantation	Premature separation of normally placed placenta
Recurrence	Low in same pregnancy	Risk with subsequent pregnancies
DIC	Rare	Common in severe cases
Diagnosis	USG (gold standard)	Clinical + USG (abruption may be missed on USG)
Vaginal delivery	Contraindicated	Possible if fetus is dead/mild cases
Antenatal steroids	May be given	As needed

Q13. What is vasa previa and why is it dangerous?

A. Vasa previa is a condition in which fetal blood vessels traverse the fetal membranes across or near the internal cervical os, unsupported by the placenta or umbilical cord.

Danger: When membranes rupture (spontaneously or artificially), these unprotected vessels can tear, causing fetal exsanguination - this is an obstetric emergency with very high fetal mortality if not recognized.

Clinical presentation: Painless vaginal bleeding at the time of rupture of membranes, often with sudden onset of severe fetal bradycardia.

Management: Diagnosed by color Doppler ultrasound antenatally. If diagnosed before labor, elective cesarean section before rupture of membranes is recommended (usually 35-36 weeks).

(Tintinalli's Emergency Medicine)

Q14. What is the initial management of a patient presenting with APH?

A. The ABC approach for any patient with APH:

Do NOT perform digital or speculum examination until placenta previa is excluded by ultrasound
IV access - two large-bore cannulae
Blood investigations: CBC, coagulation studies (PT, APTT, fibrinogen), blood group and cross-match, serum creatinine, LFT
Ultrasound to localize placenta and assess fetal well-being
IV fluids - crystalloids for volume replacement
Blood transfusion if required; fresh frozen plasma (FFP) or fresh whole blood for coagulopathy
Monitor: Maternal vitals, urine output, fetal heart rate (CTG)
Rh status: If mother is Rh-negative, give anti-D immunoglobulin (feto-maternal hemorrhage risk with abruption)
Corticosteroids for fetal lung maturity if <34 weeks
Definitive management based on cause (see Q10, Q11)

(Tintinalli's Emergency Medicine; ROSEN's Emergency Medicine)

Q15. Write a note on Couvelaire uterus.

A. Couvelaire uterus (uteroplacental apoplexy) is a severe complication of placental abruption.

Pathophysiology: In severe abruption, blood extravasates into the myometrium between muscle bundles, tracking beneath the uterine serosa. This causes the uterus to appear blue-purple, board-like, and ecchymotic (bruised). The extravasated blood disrupts myometrial contractility.

Significance:

Uterus fails to contract after delivery, leading to postpartum hemorrhage
Coagulopathy (DIC) is commonly associated
May require hysterectomy if uterus fails to contract

Gross appearance: Uterus is copper/purple-colored with petechial hemorrhages on the serosa.

Quick Exam Tips:

APH = bleeding after 28 weeks (classical OBG definition)

Preeclampsia diagnostic BP threshold = 140/90 mmHg after 20 weeks

Drug of choice for eclampsia seizures = Magnesium Sulfate

Drug of choice for antihypertensive in pregnancy = Methyldopa (oral)

ACE inhibitors and ARBs are absolutely contraindicated in pregnancy

Placenta previa = painless, bright red; vaginal delivery contraindicated

Abruption = painful, dark blood; DIC is the key complication

HELLP = Hemolysis + Elevated Liver enzymes + Low Platelets

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