Diabetes Mellitus in Pregnancy MCQ
Diabetes Mellitus in Pregnancy
20 Case-Based Multiple Choice Questions
Instructions: Select the single best answer for each question. All questions are based on clinical scenarios.
Question 1
Sarah, a 28-year-old woman with a BMI of 32 kg/m² and a family history of type 2 diabetes, presents for her first prenatal visit at 8 weeks gestation. Her mother developed gestational diabetes in two previous pregnancies.
What is the most appropriate next step in managing her diabetes risk?
A) Wait until 24-28 weeks for routine gestational diabetes screening B) Perform 75g oral glucose tolerance test immediately C) Start prophylactic metformin therapy D) Order HbA1c and fasting glucose now E) Recommend intensive dietary counseling only
Answer: B) Perform 75g oral glucose tolerance test immediately
Rationale: High-risk patients (previous GDM, family history, obesity, certain ethnicities) should be screened early in pregnancy using the same IADPSG criteria.
Question 2
Maria, a 26-year-old woman at 26 weeks gestation, undergoes a 75g OGTT with the following results: Fasting glucose 88 mg/dL (4.9 mmol/L), 1-hour glucose 185 mg/dL (10.3 mmol/L), 2-hour glucose 145 mg/dL (8.1 mmol/L).
Based on IADPSG criteria, what is her diagnosis?
A) Normal glucose tolerance B) Impaired glucose tolerance C) Gestational diabetes mellitus D) Diabetes in pregnancy E) Requires repeat testing
Answer: C) Gestational diabetes mellitus
Rationale: Only one abnormal value (1-hour ≥180 mg/dL) is needed for GDM diagnosis using IADPSG criteria.
Question 3
Linda, diagnosed with gestational diabetes at 28 weeks, has been following dietary recommendations for 2 weeks. Her home glucose readings show: fasting 102-110 mg/dL, 1-hour postprandial 150-165 mg/dL.
What is the most appropriate next step?
A) Continue dietary management for another 2 weeks B) Add metformin 500mg twice daily C) Start insulin therapy D) Increase exercise intensity E) Reduce caloric intake by 20%
Answer: C) Start insulin therapy
Rationale: Target not achieved after 2-week dietary trial (fasting >95 mg/dL, 1-hr postprandial >140 mg/dL), insulin is first-line pharmacotherapy.
Question 4
Rebecca, a 24-year-old woman with Type 1 diabetes for 12 years, is planning pregnancy. Her current HbA1c is 7.8%. She takes insulin glargine and lispro.
What preconceptional advice is most important?
A) Switch from glargine to NPH insulin immediately B) Achieve HbA1c <6.5% before attempting conception C) Discontinue all insulin during organogenesis D) Start metformin to improve insulin sensitivity E) Reduce insulin doses to prevent hypoglycemia
Answer: B) Achieve HbA1c <6.5% before attempting conception
Rationale: Optimal glycemic control before conception (HbA1c <6.5%) reduces risk of congenital anomalies.
Question 5
Anna, a 32-year-old with gestational diabetes well-controlled on insulin, is at 38 weeks gestation. Fetal ultrasound shows estimated fetal weight of 4.7 kg (95th percentile for gestational age).
What delivery recommendation should be made?
A) Continue expectant management until 40 weeks B) Plan vaginal delivery with shoulder dystocia precautions C) Recommend cesarean section delivery D) Induce labor immediately with amniocentesis for lung maturity E) Perform serial growth scans weekly
Answer: C) Recommend cesarean section delivery
Rationale: Estimated fetal weight >4250g with maternal diabetes is an indication for cesarean section due to high risk of shoulder dystocia.
Question 6
During labor, Jennifer, a woman with gestational diabetes, has her blood glucose checked every 2 hours. Her readings are: 95 mg/dL at admission, 145 mg/dL after 4 hours of labor.
What is the most appropriate immediate action?
A) Continue current monitoring schedule B) Start IV insulin infusion immediately C) Give 50% dextrose bolus intravenously D) Administer subcutaneous rapid-acting insulin E) Check arterial blood gas for ketosis
Answer: B) Start IV insulin infusion immediately
Rationale: Intrapartum glucose target is 70-110 mg/dL. Level of 145 mg/dL requires IV insulin infusion for immediate control.
Question 7
Emma delivers a 4.1 kg baby after well-controlled gestational diabetes. Two hours after birth, the neonate becomes jittery and lethargic. Bedside glucose testing shows 35 mg/dL.
What is the most likely explanation for this finding?
A) Neonatal sepsis with hypoglycemia B) Congenital adrenal hyperplasia C) Rebound hypoglycemia from fetal hyperinsulinemia D) Inadequate caloric intake postpartum E) Prematurity-related metabolic immaturity
Answer: C) Rebound hypoglycemia from fetal hyperinsulinemia
Rationale: Maternal hyperglycemia leads to fetal hyperinsulinemia, causing rebound hypoglycemia when maternal glucose supply ceases after birth.
Question 8
Catherine had gestational diabetes treated with insulin during pregnancy. She delivered 8 weeks ago and is breastfeeding exclusively. At her postpartum visit, her 75g OGTT shows: fasting 108 mg/dL, 2-hour 165 mg/dL.
How should these results be interpreted?
A) Normal glucose tolerance B) Impaired fasting glucose only C) Impaired glucose tolerance only D) Type 2 diabetes mellitus E) Requires HbA1c for proper classification
Answer: C) Impaired glucose tolerance only
Rationale: Fasting <126 mg/dL but 2-hour glucose 140-199 mg/dL indicates impaired glucose tolerance (prediabetes).
Question 9
Michelle, a 35-year-old with Type 2 diabetes, is at 32 weeks gestation. Her recent ophthalmologic examination reveals new cotton wool spots and hard exudates in both eyes that weren't present at her first trimester visit.
What is the most appropriate management?
A) Deliver immediately due to severe retinopathy B) Arrange urgent laser photocoagulation C) Switch to more intensive insulin regimen D) Start systemic corticosteroids E) Plan cesarean delivery at 34 weeks
Answer: B) Arrange urgent laser photocoagulation
Rationale: Proliferative diabetic retinopathy can progress rapidly in pregnancy. Laser photocoagulation is safe and necessary to prevent vision loss.
Question 10
Laura, diagnosed with gestational diabetes, asks about recurrence risk in future pregnancies. She had good glycemic control and delivered a healthy 3.4 kg baby at 39 weeks.
What information should she receive about future pregnancy risk?
A) Gestational diabetes recurrence risk is approximately 15-20% B) Future pregnancies have 50-70% chance of gestational diabetes C) Her good control eliminates risk in subsequent pregnancies D) Only maternal weight gain affects recurrence risk E) Recurrence risk is the same as general population
Answer: B) Future pregnancies have 50-70% chance of gestational diabetes
Rationale: Women with previous gestational diabetes have a high recurrence rate (50-70%) in subsequent pregnancies.
Question 11
Diana, at 16 weeks gestation, has an HbA1c of 8.2%. She was recently diagnosed with diabetes based on early pregnancy screening. She has no prior history of diabetes.
What type of diabetes does she most likely have?
A) Gestational diabetes mellitus B) Type 1 diabetes mellitus C) Type 2 diabetes mellitus D) MODY (Maturity Onset Diabetes of the Young) E) Secondary diabetes
Answer: C) Type 2 diabetes mellitus
Rationale: High HbA1c (>6.5%) in early pregnancy suggests pregestational diabetes, most commonly undiagnosed Type 2 diabetes.
Question 12
Patricia, with well-controlled gestational diabetes on metformin, is at 36 weeks gestation. Fetal monitoring shows decreased variability and late decelerations. Her glucose logs show excellent control over the past 2 weeks.
What is the most likely cause of the fetal heart rate abnormalities?
A) Maternal hypoglycemia B) Diabetic ketoacidosis C) Uteroplacental insufficiency D) Fetal macrosomia E) Polyhydramnios
Answer: C) Uteroplacental insufficiency
Rationale: Even well-controlled diabetes can be associated with placental vascular disease leading to uteroplacental insufficiency and fetal compromise.
Question 13
Rachel, a 30-year-old with Type 1 diabetes, is at 8 weeks gestation. Her pre-pregnancy HbA1c was 6.2%. She reports 3-4 episodes of severe hypoglycemia weekly since becoming pregnant.
What is the most appropriate adjustment to her insulin regimen?
A) Increase rapid-acting insulin doses B) Add metformin to improve insulin sensitivity
C) Reduce overall insulin doses by 20-25% D) Switch to insulin pump therapy immediately E) Discontinue basal insulin completely
Answer: C) Reduce overall insulin doses by 20-25%
Rationale: First trimester features increased insulin sensitivity, requiring reduction in insulin doses to prevent frequent hypoglycemia.
Question 14
Karen had gestational diabetes and delivered 6 months ago. She is not breastfeeding and wants to start contraception. Her 6-week postpartum OGTT was normal.
What contraceptive method is most appropriate?
A) Combined oral contraceptive pills B) Progestin-only pills C) Depot medroxyprogesterone acetate D) Copper intrauterine device E) Emergency contraception only
Answer: D) Copper intrauterine device
Rationale: IUD (copper or hormonal) is preferred for women with history of GDM as it doesn't affect glucose metabolism.
Question 15
Sandra, at 30 weeks gestation with insulin-treated gestational diabetes, presents with nausea, vomiting, and abdominal pain. Her blood glucose is 280 mg/dL and urine ketones are strongly positive.
What is the most appropriate initial management?
A) Give subcutaneous rapid-acting insulin B) Start IV insulin infusion and fluid resuscitation C) Perform immediate cesarean section D) Administer anti-emetic medications only E) Order abdominal ultrasound for gallbladder
Answer: B) Start IV insulin infusion and fluid resuscitation
Rationale: This presentation suggests diabetic ketoacidosis, which requires immediate IV insulin and fluid management.
Question 16
Nicole, with Type 2 diabetes, is planning pregnancy. She currently takes metformin, glyburide, and lisinopril. Her HbA1c is 6.8%.
What medication adjustment is most important before conception?
A) Discontinue glyburide and start insulin B) Stop metformin and increase glyburide C) Discontinue lisinopril immediately D) Add long-acting insulin to current regimen E) Switch lisinopril to a calcium channel blocker
Answer: C) Discontinue lisinopril immediately
Rationale: ACE inhibitors (lisinopril) are teratogenic and must be stopped before conception. Other adjustments can be made after conception.
Question 17
Amy, with gestational diabetes, delivers vaginally. Immediately postpartum, her blood glucose is 195 mg/dL. She had been on NPH insulin twice daily during pregnancy.
What is the most appropriate postpartum insulin management?
A) Continue the same NPH insulin doses B) Reduce NPH insulin doses by 50% C) Discontinue all insulin immediately D) Switch to oral antidiabetic agents E) Start continuous insulin infusion
Answer: C) Discontinue all insulin immediately
Rationale: Gestational diabetes medications should be discontinued immediately postpartum as insulin resistance rapidly decreases.
Question 18
Helen, diagnosed with gestational diabetes at 28 weeks, has been diet-controlled with good glucose levels. At 34 weeks, her ultrasound shows polyhydramnios (AFI = 28 cm).
What does this finding most likely indicate?
A) Poor glycemic control despite normal home readings B) Fetal renal anomaly C) Multiple pregnancy not previously detected D) Imminent preterm labor E) Maternal dehydration
Answer: A) Poor glycemic control despite normal home readings
Rationale: Polyhydramnios in diabetic pregnancy usually indicates poor glycemic control causing fetal polyuria, even when home readings appear normal.
Question 19
Tina, with well-controlled Type 1 diabetes, is at 37 weeks gestation. Her insulin requirements have plateaued over the past week after steadily increasing throughout pregnancy.
What does this pattern suggest?
A) Development of insulin resistance B) Impending labor onset C) Placental insufficiency D) Normal late pregnancy physiology E) Need for increased caloric intake
Answer: C) Placental insufficiency
Rationale: Plateauing or decreasing insulin requirements in late pregnancy may indicate placental insufficiency and requires fetal surveillance.
Question 20
Brenda had gestational diabetes in her first pregnancy 3 years ago. She is now at 12 weeks in her second pregnancy. Her early pregnancy glucose screening is normal.
What follow-up screening should be recommended?
A) No further screening needed this pregnancy B) Repeat screening at 20 weeks gestation C) Repeat screening at 24-28 weeks gestation D) Monthly glucose screening throughout pregnancy E) Continuous glucose monitoring
Answer: C) Repeat screening at 24-28 weeks gestation
Rationale: Even with normal early screening, women with previous GDM should have repeat screening at the standard 24-28 week interval.
Answer Key:
B | 2. C | 3. C | 4. B | 5. C | 6. B | 7. C | 8. C | 9. B | 10. B
C | 12. C | 13. C | 14. D | 15. B | 16. C | 17. C | 18. A | 19. C | 20. C
Scoring:
18-20 correct: Excellent understanding
15-17 correct: Good grasp of concepts
12-14 correct: Adequate knowledge, review needed
<12 correct: Significant review required
These MCQs are designed to test practical clinical knowledge and decision-making skills in managing diabetes during pregnancy, covering screening, diagnosis, management, complications, and postpartum care.
Extended Marking Questions
(Each question worth 20 marks - Answer in essay format)
Extended Question 1 (20 marks)
Case Scenario: Mrs. Johnson, a 34-year-old African-American woman, presents at 8 weeks gestation for her first prenatal visit. She has a BMI of 35 kg/m², a family history of Type 2 diabetes (mother and sister), and delivered a 4.3 kg baby in her previous pregnancy 3 years ago. She reports excessive thirst and frequent urination over the past 2 months.
Question: Critically analyze the approach to screening, diagnosis, and initial management of diabetes in this patient. Discuss the potential complications she may face and outline a comprehensive management plan from now until delivery.
Marking Scheme:
Risk factor identification and early screening rationale (4 marks)
Appropriate diagnostic tests and interpretation (4 marks)
Classification of diabetes type and implications (3 marks)
Immediate management strategies (4 marks)
Potential maternal and fetal complications (3 marks)
Long-term monitoring and delivery planning (2 marks)
Model Answer Points:
High-risk factors warrant immediate screening (obesity, ethnicity, family history, previous macrosomia, symptoms)
Perform 75g OGTT or HbA1c + fasting glucose immediately
Symptoms suggest possible pregestational diabetes
Initial management includes nutrition counseling, insulin if needed, folic acid supplementation
Complications: preeclampsia, macrosomia, shoulder dystocia, neonatal hypoglycemia
Multidisciplinary care, ophthalmology referral, planned delivery 38-39 weeks
Extended Question 2 (20 marks)
Case Scenario: A 28-year-old primigravida with Type 1 diabetes for 15 years presents at 6 weeks gestation. Her HbA1c is 8.5%, and she reports 2-3 severe hypoglycemic episodes monthly. She uses insulin glargine 24 units at bedtime and insulin aspart with meals. She has mild background retinopathy and microalbuminuria (albumin/creatinine ratio 45 mg/g).
Question: Evaluate the preconceptional counseling gaps and develop a comprehensive management strategy for optimizing outcomes in this high-risk pregnancy. Address both maternal and fetal considerations throughout pregnancy.
Marking Scheme:
Assessment of current diabetes control and complications (4 marks)
Preconceptional counseling deficiencies (3 marks)
Insulin regimen optimization strategies (4 marks)
Monitoring protocols throughout pregnancy (3 marks)
Complication prevention and management (4 marks)
Delivery planning and postpartum considerations (2 marks)
Model Answer Points:
Suboptimal preconceptional control increases teratogenic risk
Frequent hypoglycemia indicates need for regimen adjustment
Consider insulin pump or multiple daily injections
Ophthalmology evaluation each trimester, monitor nephropathy
Frequent glucose monitoring, continuous glucose monitoring consideration
Target HbA1c <6.0%, prevent severe hypoglycemia
Fetal surveillance from 32 weeks, deliver 38-39 weeks
Extended Question 3 (20 marks)
Case Scenario: Mrs. Patel, diagnosed with gestational diabetes at 28 weeks, has been following dietary recommendations for 3 weeks. Her glucose logs show: fasting 98-108 mg/dL, 1-hour postprandial 145-170 mg/dL. She is concerned about insulin use and prefers "natural" treatments. Her BMI is 31 kg/m², and ultrasound shows estimated fetal weight at 75th percentile for gestational age.
Question: Analyze the current management approach and discuss the evidence-based rationale for treatment intensification. Address patient concerns while ensuring optimal maternal-fetal outcomes. Include consideration of alternative pharmacological options and long-term implications.
Marking Scheme:
Evaluation of current glycemic control (3 marks)
Evidence for treatment intensification (4 marks)
Addressing patient concerns about insulin (4 marks)
Discussion of metformin as alternative (3 marks)
Fetal monitoring and growth considerations (3 marks)
Long-term maternal diabetes risk counseling (3 marks)
Model Answer Points:
Current control suboptimal (targets: fasting <95, 1-hr PP <140 mg/dL)
Evidence shows untreated GDM increases complications
Insulin is pregnancy category B, doesn't cross placenta
Metformin crosses placenta but may be considered as second-line
Fetal growth acceleration requires closer monitoring
40-60% lifetime risk of Type 2 diabetes
Extended Question 4 (20 marks)
Case Scenario: A 32-year-old woman with well-controlled gestational diabetes (diet-managed) presents at 38 weeks gestation in active labor. Her admission glucose is 78 mg/dL. Four hours later, during active labor, her glucose is 145 mg/dL. The fetal heart rate shows minimal variability with occasional late decelerations. She has gained 18 kg during pregnancy and ultrasound at 36 weeks showed estimated fetal weight of 4.2 kg.
Question: Provide a comprehensive analysis of the intrapartum management challenges in this case. Discuss immediate priorities, decision-making regarding mode of delivery, and prepare for potential neonatal complications.
Marking Scheme:
Intrapartum glucose management priorities (4 marks)
Interpretation of fetal heart rate changes (3 marks)
Mode of delivery decision-making (4 marks)
Maternal monitoring during labor (3 marks)
Preparation for neonatal complications (4 marks)
Immediate postpartum management (2 marks)
Model Answer Points:
Immediate need for IV insulin infusion (target 70-110 mg/dL)
FHR changes may indicate uteroplacental insufficiency
Consider cesarean section for estimated fetal weight >4.25 kg
Continue glucose monitoring every 2 hours
Prepare for neonatal hypoglycemia, respiratory distress
Discontinue diabetes medications postpartum
Extended Question 5 (20 marks)
Case Scenario: Ms. Rodriguez had gestational diabetes in her recent pregnancy, managed with metformin and insulin. She delivered a healthy 3.8 kg baby 8 weeks ago and is exclusively breastfeeding. Her postpartum 75g OGTT results are: fasting 118 mg/dL, 2-hour 175 mg/dL. She wants to start contraception and is planning another pregnancy in 2-3 years.
Question: Develop a comprehensive postpartum management plan addressing her current glucose status, contraceptive choices, breastfeeding considerations, and preconceptional planning for future pregnancies. Include evidence-based recommendations for diabetes prevention.
Marking Scheme:
Interpretation of postpartum OGTT results (3 marks)
Contraceptive counseling for women with glucose intolerance (4 marks)
Breastfeeding support and metabolic benefits (3 marks)
Future pregnancy planning and optimization (4 marks)
Diabetes prevention strategies (4 marks)
Long-term monitoring recommendations (2 marks)
Model Answer Points:
Results indicate impaired glucose tolerance (prediabetes)
Recommend progestin-only pills or IUD (avoid combined OCPs)
Breastfeeding improves glucose tolerance, encourage continuation
Optimize weight and glucose control before next conception
Lifestyle interventions, consider metformin if not breastfeeding
Annual diabetes screening, cardiovascular risk assessment
Short Answer Questions
(Each question worth 5 marks - Answer in 3-4 sentences)
Short Answer Question 1 (5 marks)
A 30-year-old woman with Type 2 diabetes is planning pregnancy. Her current HbA1c is 7.8% and she takes metformin and glyburide. What are the THREE most important preconceptional interventions?
Model Answer: Achieve optimal glycemic control with target HbA1c <6.5% before conception to reduce teratogenic risk. Start high-dose folic acid supplementation (5mg daily) to prevent neural tube defects. Discontinue glyburide and initiate insulin therapy as sulfonylureas may cause neonatal hypoglycemia. Review and discontinue any teratogenic medications.
Marking:
Glycemic optimization (2 marks)
Folic acid supplementation (1 mark)
Medication adjustment (2 marks)
Short Answer Question 2 (5 marks)
Explain the physiological basis for why insulin requirements typically increase during the second and third trimesters of pregnancy in women with pregestational diabetes.
Model Answer: During the second and third trimesters, placental hormones including human placental lactogen (hPL), cortisol, progesterone, and growth hormone create progressive insulin resistance. These diabetogenic hormones antagonize insulin action at the receptor and post-receptor levels, requiring 2-3 fold increase in insulin doses. This physiological insulin resistance ensures adequate glucose supply to the growing fetus but necessitates increased maternal insulin production or supplementation.
Marking:
Identification of placental hormones (2 marks)
Mechanism of insulin resistance (2 marks)
Clinical implication for insulin requirements (1 mark)
Short Answer Question 3 (5 marks)
A neonate born to a mother with poorly controlled gestational diabetes develops jitteriness and poor feeding 2 hours after birth. Bedside glucose is 30 mg/dL. What is the pathophysiology of this condition and immediate management?
Model Answer: Maternal hyperglycemia causes fetal hyperglycemia, stimulating excessive fetal insulin production (hyperinsulinemia). After birth, when maternal glucose supply ceases, the neonate's elevated insulin levels cause rebound hypoglycemia. Immediate management includes early feeding if alert, or IV glucose (2-4 mL/kg of 10% dextrose) if symptomatic, followed by continuous glucose monitoring and feeding support.
Marking:
Pathophysiology explanation (3 marks)
Immediate management (2 marks)
Short Answer Question 4 (5 marks)
Compare the diagnostic advantages and disadvantages of the one-step versus two-step screening approach for gestational diabetes.
Model Answer: The one-step approach (75g OGTT) identifies more women with GDM using internationally standardized criteria, requires only one test, and is based on pregnancy outcome data. However, it increases healthcare costs and medicalizes more pregnancies. The two-step approach (50g GCT followed by 100g OGTT) reduces the number of women requiring diagnostic testing and has historical validation, but may miss cases of mild GDM and uses different diagnostic criteria globally.
Marking:
One-step advantages (2 marks)
Two-step advantages (1 mark)
Disadvantages of each approach (2 marks)
Short Answer Question 5 (5 marks)
A woman with previous gestational diabetes asks about her long-term diabetes risk and prevention strategies. What evidence-based counseling should be provided?
Model Answer: Women with previous gestational diabetes have a 40-60% risk of developing Type 2 diabetes within 10-20 years. Risk factors include obesity, family history, and ethnicity. Prevention strategies include maintaining healthy weight through diet and exercise, annual diabetes screening with fasting glucose or HbA1c, and considering metformin therapy if prediabetes develops (when not breastfeeding). Lifestyle interventions can reduce diabetes risk by up to 60%.
Marking:
Risk quantification (2 marks)
Prevention strategies (2 marks)
Screening recommendations (1 mark)
Answer Guidelines for Extended Questions:
Extended Question Scoring:
18-20 marks: Comprehensive answer demonstrating excellent clinical understanding
15-17 marks: Good answer with minor omissions
12-14 marks: Adequate answer missing some key components
8-11 marks: Basic answer with significant gaps
<8 marks: Insufficient answer requiring major review
Short Answer Scoring:
5 marks: Complete and accurate answer
4 marks: Minor omissions or inaccuracies
3 marks: Adequate but incomplete
2 marks: Basic understanding shown
0-1 marks: Inadequate or incorrect
These questions assess deeper understanding, clinical reasoning, and ability to integrate knowledge across the spectrum of diabetes in pregnancy care.
OSCE Station Features:
Station 1: Gestational Diabetes Counseling
Skills Assessed:
Patient communication and counseling
Breaking news and providing reassurance
Explaining complex medical conditions in lay terms
Addressing patient concerns and anxieties
Developing therapeutic relationships
Key Learning Outcomes:
Understanding of gestational diabetes pathophysiology
Knowledge of management principles
Patient education skills
Empathetic communication
Station 2: Insulin Administration Teaching
Skills Assessed:
Teaching practical clinical procedures
Patient education for medication administration
Building patient confidence with new skills
Safety considerations in medication use
Addressing patient fears about injections
Key Learning Outcomes:
Insulin injection technique mastery
Patient safety in medication administration
Teaching skills for healthcare providers
Practical medication management