Hypertensive Disorders and Medical Conditions in Pregnancy: Preeclampsia, Eclampsia, HELLP, Diabetes, and Hyperemesis Practice Questions

25 multiple-choice questions on Hypertensive disorders and medical conditions in pregnancy: preeclampsia, eclampsia, HELLP, diabetes, and hyperemesis for paramedic and EMT students, from Chapter 42 (Obstetrics). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Gestational hypertension is defined as a blood pressure of at least 140/90 mmHg that:

   1. A. Begins after 20 weeks without proteinuria
   2. B. Was present before the pregnancy began
   3. C. Appears only during the active pushing stage
   4. D. Occurs with seizures and loss of consciousness
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   Answer: A. Begins after 20 weeks without proteinuria

   New hypertension after 20 weeks without protein in the urine or other organ involvement is gestational hypertension. Hypertension present before pregnancy, or before 20 weeks, is chronic hypertension.

2. Preeclampsia is best described as new hypertension after 20 weeks of gestation with:

   1. A. Proteinuria or signs of organ dysfunction
   2. B. A normal urine and no other findings
   3. C. Edema of the face and hands alone
   4. D. A seizure that cannot be otherwise explained
   Show answer

   Answer: A. Proteinuria or signs of organ dysfunction

   Preeclampsia is hypertension with proteinuria or evidence of end-organ involvement such as headache, visual change, epigastric pain, or low platelets. Gestational hypertension is the same rise in pressure with normal urine and no other findings. Edema is common in normal pregnancy and is no longer a diagnostic criterion. A seizure added to that picture defines eclampsia.

3. The underlying problem in preeclampsia is thought to begin with:

   1. A. A bacterial infection of the uterus
   2. B. Abnormal placental blood vessels
   3. C. A deficiency of maternal insulin
   4. D. Compression of the vena cava
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   Answer: B. Abnormal placental blood vessels

   Poor development of the placental vessels leads to widespread maternal endothelial dysfunction, vasospasm, and organ injury. Vena cava compression causes supine hypotension, which lowers rather than raises blood pressure.

4. A woman at 35 weeks with known preeclampsia has a BP of 164/104 mmHg on two readings 15 minutes apart. This blood pressure:

   1. A. Is expected late in pregnancy and needs no action
   2. B. Is not severe until the diastolic reaches 120 mmHg
   3. C. Is in the severe range and needs urgent treatment
   4. D. Is mild because the diastolic is still under 110
   Show answer

   Answer: C. Is in the severe range and needs urgent treatment

   Severe-range hypertension in pregnancy is a systolic of 160 mmHg or more or a diastolic of 110 or more, sustained over about 15 minutes. Either one alone qualifies, so this woman needs urgent blood pressure treatment to prevent stroke. A diastolic under 110 does not make the reading mild when the systolic is 160 or more.

5. Which symptom in a woman with preeclampsia is especially worrisome because it may signal liver involvement?

   1. A. Mild swelling of both ankles at night
   2. B. Increased urinary frequency at night
   3. C. Lower back ache after standing all day
   4. D. Right upper quadrant or epigastric pain
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   Answer: D. Right upper quadrant or epigastric pain

   Epigastric or right upper quadrant pain suggests liver swelling or bleeding and is a severe feature, often seen with HELLP syndrome. Ankle swelling is common in normal pregnancy and is no longer used to diagnose preeclampsia.

6. Eclampsia is diagnosed when a woman with preeclampsia develops:

   1. A. Seizures
   2. B. Proteinuria
   3. C. Leg edema
   4. D. Headache
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   Answer: A. Seizures

   Eclampsia is the onset of seizures, not explained by another cause, in a woman with preeclampsia; it can occur before, during, or after delivery. Headache and proteinuria are features of preeclampsia itself.

7. Medical control orders IV labetalol for a woman at 36 weeks with a BP of 176/114 mmHg. The goal of treatment is to:

   1. A. Bring it quickly down to about 110/70 mmHg
   2. B. Lower it if she goes on to have a seizure
   3. C. Lower it in steps to about 140-150/90-100
   4. D. Return it to her normal level within 5 minutes
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   Answer: C. Lower it in steps to about 140-150/90-100

   In severe hypertension of pregnancy, the aim is to prevent stroke while keeping placental blood flow, so the pressure is lowered in steps to roughly 140 to 150 systolic and 90 to 100 diastolic. Dropping it to a normal level too fast can reduce flow to the placenta and harm the fetus.

8. During an interfacility transfer, a woman with severe preeclampsia has already received her magnesium loading dose. A typical maintenance infusion is:

   1. A. 4 to 6 g per hour
   2. B. 10 to 20 mg per hour
   3. C. 0.1 to 0.2 g per hour
   4. D. 1 to 2 g per hour
   Show answer

   Answer: D. 1 to 2 g per hour

   After a 4- to 6-g loading dose, magnesium sulfate is usually continued at 1 to 2 g per hour, with checks of reflexes, breathing, and urine output. Running 4 to 6 g per hour confuses the loading dose with the hourly rate and quickly causes toxicity.

9. A woman with severe preeclampsia on a magnesium infusion has passed only 40 mL of urine in 4 hours. This matters because:

   1. A. Low urine output means the magnesium is working
   2. B. Magnesium is cleared by the kidneys and can build up
   3. C. Magnesium is cleared by the liver, so the kidneys matter less
   4. D. Low urine output lowers the blood magnesium level
   Show answer

   Answer: B. Magnesium is cleared by the kidneys and can build up

   Magnesium leaves the body almost entirely in the urine, so oliguria from preeclampsia lets levels climb toward toxicity even at a standard rate. The infusion may need to be reduced, and reflexes and breathing must be watched closely. Oliguria raises, not lowers, the magnesium level.

10. A woman at 38 weeks has an eclamptic seizure, and you cannot obtain IV or IO access. An accepted way to give the magnesium loading dose is:

    1. A. 10 g IM, split as 5 g in each buttock
    2. B. 2 g IM into one deltoid muscle
    3. C. 4 g by mouth with a small sip of water
    4. D. 1 g IM every 5 minutes, to a total of 4 g
    Show answer

    Answer: A. 10 g IM, split as 5 g in each buttock

    When IV access is not available, magnesium sulfate can be given intramuscularly as 10 g, half into each buttock (often with lidocaine for pain), then continued IM. A 2-g deltoid dose is far too small, and nothing should be given by mouth to a patient who is seizing or postictal.

11. A woman with eclampsia is still seizing after a full magnesium loading dose and an additional 2-g magnesium bolus. A reasonable next drug, if protocol allows, is:

    1. A. A further 20-g bolus of magnesium
    2. B. Calcium gluconate 1 g IV
    3. C. IV labetalol to lower the pressure
    4. D. A benzodiazepine such as midazolam
    Show answer

    Answer: D. A benzodiazepine such as midazolam

    Magnesium is first line, and a recurrent seizure is treated first with an extra 2 to 4 g of magnesium over about 5 minutes. When seizures persist despite that, or magnesium is unavailable, a benzodiazepine (midazolam in most EMS protocols; lorazepam or diazepam in hospital guidelines) is the next step, with airway equipment ready because apnea is a real risk. A further 20 g is several times a full loading dose and risks fatal magnesium toxicity. Calcium gluconate reverses magnesium toxicity and has no anticonvulsant effect. Labetalol treats severe hypertension (160/110 mmHg or higher) but does not stop seizures. (ACOG Practice Bulletin 222; National Partnership for Maternal Safety.)

12. The best environment for transporting a woman with severe preeclampsia is:

    1. A. Calm, but with the cabin lights on full
    2. B. Fast, with sirens to shorten the trip
    3. C. Calm and dim, without lights or sirens
    4. D. Supine and flat to keep her still
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    Answer: C. Calm and dim, without lights or sirens

    Bright light, noise, and jostling can trigger eclamptic seizures, so transport calmly with low lighting in the left lateral position. Full cabin lighting adds the very stimulation you are trying to avoid, and lying supine lets the uterus compress the vena cava. A hurried siren trip adds stimulation that may provoke a seizure.

13. A 21-year-old at 36 weeks begins a generalized seizure in your ambulance. Her BP before the seizure was 170/112 mmHg. Your first priority is to:

    1. A. Force a bite block between her teeth
    2. B. Protect her and keep the airway open
    3. C. Hold her arms and legs down firmly
    4. D. Start chest compressions right away
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    Answer: B. Protect her and keep the airway open

    During the seizure, protect her from injury, position her on her left side, give oxygen, and suction as needed, then give magnesium sulfate. Forcing an object between the teeth can break teeth and obstruct the airway.

14. The letters in HELLP syndrome stand for hemolysis, elevated liver enzymes, and:

    1. A. Low potassium
    2. B. Low platelets
    3. C. Low pressure
    4. D. Low protein
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    Answer: B. Low platelets

    HELLP is a severe variant of preeclampsia with red cell destruction, liver injury, and a falling platelet count that raises bleeding risk. Some women with HELLP have only mildly elevated blood pressure, which can delay recognition.

15. A woman at 34 weeks has right upper quadrant pain, nausea, and malaise. BP is 146/94 mmHg. She looks less ill than her symptoms suggest. The condition you must consider is:

    1. A. Viral gastritis
    2. B. Biliary colic
    3. C. Braxton Hicks
    4. D. HELLP syndrome
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    Answer: D. HELLP syndrome

    HELLP often presents as vague upper abdominal pain and malaise, and is easily mistaken for a viral illness or gallbladder disease. Any pregnant woman after 20 weeks with this pain and raised blood pressure needs hospital evaluation.

16. A woman whose gestational diabetes was treated with insulin delivers in the field. After the placenta delivers, her insulin needs usually:

    1. A. Rise sharply as she begins breastfeeding
    2. B. Stay the same for the next 6 months
    3. C. Fall sharply as placental hormones clear
    4. D. Double to cover the stress of labor
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    Answer: C. Fall sharply as placental hormones clear

    Placental hormones cause the insulin resistance of gestational diabetes, so needs drop quickly after the placenta delivers and she is at risk of hypoglycemia if insulin continues. Check her glucose rather than assuming her usual dose is still right.

17. Infants of mothers with poorly controlled diabetes are more likely to be:

    1. A. Large and at risk for shoulder dystocia
    2. B. Small and born with high blood glucose
    3. C. Postterm with very dry, cracked skin
    4. D. Born with fewer airway problems at birth
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    Answer: A. Large and at risk for shoulder dystocia

    High maternal glucose crosses the placenta and makes the fetus overproduce insulin and grow large, raising the risk of shoulder dystocia and newborn hypoglycemia. The newborn's glucose falls, not rises, after the cord is cut.

18. A 29-year-old at 30 weeks with insulin-treated diabetes is confused and diaphoretic. Her glucose is 42 mg/dL. You should:

    1. A. Withhold dextrose to protect the fetus
    2. B. Give half the usual dextrose dose
    3. C. Give IV dextrose per protocol
    4. D. Give D5W at a keep-open rate
    Show answer

    Answer: C. Give IV dextrose per protocol

    Treat hypoglycemia in pregnancy the same way as in other adults, because maternal hypoglycemia also harms the fetus. Withholding glucose, or giving a reduced dose, to protect the fetus is a dangerous misconception, and a keep-open D5W infusion delivers far too little glucose to correct a level of 42 mg/dL.

19. Hyperemesis gravidarum differs from ordinary morning sickness in that it causes:

    1. A. Nausea that is worst in the morning
    2. B. Mild nausea relieved by small, dry snacks
    3. C. High blood pressure with protein in urine
    4. D. Dehydration, weight loss, and ketosis
    Show answer

    Answer: D. Dehydration, weight loss, and ketosis

    Hyperemesis is persistent, severe vomiting that leads to dehydration, electrolyte loss, weight loss of 5% or more, and ketosis, often needing IV fluids. Nausea that is worst in the morning is typical of ordinary morning sickness, so it does not distinguish the two. Mild nausea eased by small, frequent snacks also describes ordinary morning sickness. Hypertension with proteinuria after 20 weeks is preeclampsia, a different condition. (ACOG Practice Bulletin No. 189, Nausea and Vomiting of Pregnancy, 2018; Caroline.)

20. A woman at 11 weeks has vomited for 3 days and cannot keep fluids down. She is tachycardic and orthostatic. Appropriate prehospital care includes:

    1. A. IV fluids and an antiemetic per protocol
    2. B. Oral fluids and wait 24 hours to improve
    3. C. An antiemetic alone, without IV fluids
    4. D. Withhold antiemetics in the first trimester
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    Answer: A. IV fluids and an antiemetic per protocol

    Give an IV crystalloid to correct dehydration and an antiemetic such as ondansetron if protocol allows, and check glucose. Encouraging oral fluids fails a patient who cannot keep them down, and an antiemetic alone does not correct her tachycardia and orthostasis. Antiemetics are not withheld in the first trimester when vomiting is this severe.

21. Which electrolyte problem is most important to anticipate in a pregnant patient with prolonged vomiting?

    1. A. Hypernatremia
    2. B. Hypokalemia
    3. C. Hypercalcemia
    4. D. Hyperkalemia
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    Answer: B. Hypokalemia

    Repeated vomiting loses potassium and acid, causing hypokalemia and metabolic alkalosis, which can provoke dysrhythmias. Hyperkalemia is the opposite of what vomiting produces.

22. A pregnant woman with chronic hypertension is at increased risk of developing:

    1. A. A low-lying placenta previa
    2. B. Hyperemesis gravidarum
    3. C. Superimposed preeclampsia
    4. D. Spontaneous twin gestation
    Show answer

    Answer: C. Superimposed preeclampsia

    Women with hypertension before pregnancy have a much higher risk of preeclampsia, as well as abruption and growth restriction. Placenta previa relates to uterine scarring and implantation site, not blood pressure.

23. A woman at 28 weeks has fever, chills, flank pain, and costovertebral angle tenderness. You should suspect:

    1. A. Pyelonephritis
    2. B. Placenta previa
    3. C. Preeclampsia
    4. D. Round ligament pain
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    Answer: A. Pyelonephritis

    Urinary stasis in pregnancy raises the risk of a kidney infection, which can cause sepsis and preterm labor. Round ligament pain is brief and sharp, without fever or flank tenderness.

24. A pregnant woman with known asthma has a moderate exacerbation. The best approach is to:

    1. A. Withhold albuterol until she is at the ED
    2. B. Treat as usual with bronchodilators
    3. C. Give oxygen but no inhaled drugs
    4. D. Avoid steroids until after the delivery
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    Answer: B. Treat as usual with bronchodilators

    Uncontrolled asthma and maternal hypoxia threaten the fetus far more than standard drugs, so treat her as any adult: inhaled albuterol (with ipratropium if severe), oxygen to keep SpO2 at 95% or higher, and systemic steroids per protocol. Withholding albuterol delays the treatment that relieves bronchospasm. Oxygen without bronchodilators does not open the airways. Systemic steroids are recommended in pregnancy for a significant exacerbation; delaying them until delivery leaves the attack untreated. (NAEPP asthma in pregnancy.)

25. A woman at 33 weeks has a seizure. She has no history of epilepsy and her BP is 150/96 mmHg. Until proven otherwise you should treat this as:

    1. A. A febrile seizure
    2. B. A pseudoseizure
    3. C. Simple syncope
    4. D. Eclampsia
    Show answer

    Answer: D. Eclampsia

    A new seizure after 20 weeks with elevated blood pressure should be treated as eclampsia even if the pressure is only moderately raised. Labeling it a pseudoseizure would delay magnesium and could be fatal.