Hypertensive disorders of pregnancy — structured oral station (12 minutes)

Opening prompt — "Plan her pregnancy from today."

Model response — say it in this order: [3][2]

• "The single most urgent action today is to stop the perindopril. ACE inhibitors, angiotensin receptor blockers and direct renin inhibitors are fetotoxic — renal dysgenesis, oligohydramnios, skull hypoplasia and neonatal renal failure — so it stops at the positive pregnancy test."
• "I would substitute labetalol 100 to 200 mg orally twice daily, titrated every two to three days toward 200 to 400 mg two or three times daily, after checking she has no asthma. Nifedipine modified release is my alternative."[2][3]
• "I would start low-dose aspirin today, before 16 weeks — she has two independent high-risk factors, chronic hypertension and previous preeclampsia — and assess her dietary calcium intake."[6][2]
• "I would take a booking bundle: creatinine and electrolytes, full blood count, liver enzymes, urate, urine protein:creatinine ratio, and an ECG. That protein:creatinine ratio before 20 weeks is the only baseline I will ever get, and without it I cannot later call proteinuria new."[1][3]
• "I would arrange obstetric medicine co-care, dating and anomaly scans, and growth scans with umbilical artery Doppler from around 24 to 28 weeks."[2][1]

Examiner is listening for: the ACE inhibitor stopped first, a named substitute with a dose, aspirin before 16 weeks, and a baseline protein:creatinine ratio. [3]

Probe 1 — "What blood pressure will you treat her to, and why?"

• "Below 140/90 mmHg. CHAP randomised 2,408 women with mild chronic hypertension and showed that target reduced the composite of severe preeclampsia, indicated preterm birth before 35 weeks, abruption, or fetal or neonatal death from 37.0% to 30.2%, adjusted risk ratio 0.82."[4]
• "Critically, CHAP did not show an increase in small-for-gestational-age birth weight below the tenth centile — 11.2% versus 10.4% — which removes the old fear that treating mild hypertension starves the fetus."[4]
• "CHIPS came first and answered a slightly different question: less-tight versus tight control produced no difference in the primary composite, but severe hypertension developed in 40.6% of the less-tight group against 27.5% with tight control. So CHIPS told us tight control was safe, and CHAP told us it was better."[5][4]

Probe 2 — "At 29 weeks her blood pressure is 164/108 mmHg and her protein:creatinine ratio is well above the significant-proteinuria threshold. What now?"

• "This is superimposed preeclampsia with severe-range hypertension. I would treat the blood pressure within 30 to 60 minutes — labetalol 10 to 20 mg intravenously over 2 minutes, then 20 to 80 mg every 10 to 30 minutes to a cumulative 300 mg, or hydralazine or oral nifedipine."[1][2]
• "I would give magnesium sulfate 4 g intravenously over 15 to 20 minutes, then 1 g per hour, admit her, restrict fluid to about 80 mL per hour, give betamethasone for fetal lung maturity, and assess the fetus with cardiotocography and ultrasound."[2][1]
• "Then I would plan the birth with my consultant and neonatology, recognising that at 29 weeks the default is stabilise and expectant management in a tertiary unit with daily review, and that maternal instability overrides that at any gestation."[1][2]

Probe 3 — "She is worried the tablets will harm the baby. What do you say?"

This is a scored communication domain. Demonstrate it out loud. [2]

• Sit down, use her name, and ask what she has heard and what worries her most.
• "The tablet you were on, perindopril, is the one we do need to change — it can affect the baby's kidneys. The one I am swapping you to, labetalol, has been used in pregnancy for decades and is safe for the baby."
• "Treating your blood pressure is not just about you. A large trial published in 2022 showed that keeping it under 140 over 90 reduced serious complications for both of you, and did not make babies smaller."[4]
• Check understanding by asking her to tell you back the plan, offer written information, and use a professional interpreter rather than a family member if language is a barrier.[2]

Probe 4 — "Her pregnancy goes well. When would you deliver, and what happens afterwards?"

• "With chronic hypertension that stays controlled and a well-grown fetus, I would plan birth at 37 to 39 weeks, individualised, and bring it forward for uncontrolled hypertension, superimposed preeclampsia, deteriorating bloods or fetal compromise."[2][1]
• "Postnatally I would continue an antihypertensive compatible with breastfeeding — labetalol, nifedipine or enalapril — and stop methyldopa if she were on it because of postnatal depression risk."[8][2]
• "I would warn her and the community midwife that blood pressure peaks on days 3 to 6, arrange a check at one to two weeks, a full review at six weeks with repeat bloods and protein:creatinine ratio, and reclassification at 12 weeks."[8][1]

Probe 5 — "What do you tell her about her long-term health?"

• "A hypertensive pregnancy is a cardiovascular risk marker for life. After preeclampsia the relative risk of later hypertension is 3.70, of ischaemic heart disease 2.16, of stroke 1.81 and of venous thromboembolism 1.79, with overall mortality raised at 1.49."[7]
• "So I would write to her GP asking for annual blood pressure, lipids and glucose, and I would talk with her about weight, activity, smoking and diet — framed as something we do together, not a lecture."[7][2]
• "I would also flag that she is at high risk again in any future pregnancy and should book early for aspirin before 16 weeks."[6][2]