Postpartum hypertension and preeclampsia — structured oral station (12 minutes)

Opening prompt — "What are you going to do?"

Model response — say it in this order: ^[1][2]

• "This is severe hypertension with a headache on day 4 — day postnatal pressure peaks. I am treating this as preeclampsia with severe features until proven otherwise."
• "I want the pressure below 160/110 mmHg within one hour. I would give labetalol 20 mg intravenously over 2 minutes, then 40 mg, then 80 mg at 10-minute intervals to a cumulative maximum of 300 mg, or immediate-release nifedipine 10 mg orally, repeated every 20 to 30 minutes up to 3 doses if she has no intravenous access."
• "In parallel: intravenous access, full blood count, creatinine, transaminases and lactate dehydrogenase; a full symptom review; reflexes, clonus, fundi and chest; and fluid restriction to about 80 mL per hour. I would call my consultant and inform the anaesthetist."^[1][2]

Examiner is listening for: the one-hour target stated out loud, a named drug with a dose, parallel assessment, and the recognition that day 4 is the peak rather than the recovery. ^[3]

Probe 1 — "Why are you worried on day 4? She's had a baby, surely she's improving."

• "Because the postnatal blood pressure curve dips in the first 48 hours and then climbs. In a 1194-patient remote-monitoring cohort the peak was at days 5 to 7, with rapid decline only after day 7. Day 4 is the wrong day to be reassured."^[3]
• "And delivering the placenta does not clear the endothelial disease. Antiangiogenic imbalance takes days to weeks to resolve, so preeclampsia can worsen — or appear for the first time — after birth."^[2]

Probe 2 — "Would you give magnesium? Justify it."

• "Yes, if she has severe features or neurological symptoms, and a headache at 168/108 mmHg qualifies. Magpie showed magnesium sulfate more than halved eclampsia risk with a relative risk of 0.42."^[5]
• "4 grams intravenously over 15 to 20 minutes, then 1 gram per hour by infusion, with hourly reflexes, respiratory rate and urine output because it is renally cleared. Calcium gluconate available for toxicity. Conventionally 24 hours, with a recurrent seizure receiving a further 2 gram bolus and prompting me to question the diagnosis."^[1][5]
• "And I would tell her explicitly that magnesium does not stop her breastfeeding."^[4]

Probe 3 — "She is breastfeeding. What will you send her home on, and at what doses?"

This is the domain where candidates hesitate. Do not. ^[4]

• "Nifedipine modified release 20 mg twice daily, up to 60 mg twice daily; or labetalol 100 to 200 mg twice daily, up to 600 mg three times daily. Both are compatible with breastfeeding."^[4]
• "If she needs a second agent, enalapril 5 mg daily up to 20 mg. Angiotensin-converting enzyme inhibitors are contraindicated in pregnancy but are conventional lactation-compatible choices after birth — that reversal is worth stating explicitly."^[4]
• "I would move her off methyldopa if she were on it, because of the association with low mood at exactly the time we screen for postnatal depression."^[4]

Probe 4 — "When can she go home, and what happens then?"

• Discharge criteria, recited: blood pressure consistently under 150/100 mmHg with no severe readings in the last 24 hours; asymptomatic; bloods improving; a written plan naming agent, dose and reviewer; a measured blood pressure check arranged for day 3 to 7 after discharge; and written symptom advice with a number to call.^[1][3]
• "I would offer self-monitoring with clinician-guided titration. In POP-HT that produced a 24-hour mean diastolic pressure 5.8 mmHg lower and systolic 6.5 mmHg lower at around nine months — a short postnatal intervention with an effect nearly a year later."^[6]
• "And I would warn her about the four-week window: eclampsia can occur up to four weeks after birth, often in women who never had antenatal preeclampsia."^[8]

Probe 5 — "She is upset. She says she thought this was all over once the baby was born."

This is a scored domain. Demonstrate it out loud with actual words. ^[1]

• Sit down, eye level, use her name: "You are right that most of this settles — but the blood pressure often gets worse before it gets better, usually around the end of the first week. That is why we are keeping a close eye on you now rather than because something has gone wrong."
• Name the plan: "We are bringing the pressure down with a medicine that is safe while you are feeding. Your milk is not affected. We will check you again in a few days at home."
• Give the safety net in her words, not yours: "If you get a bad headache, see flashing lights, get pain under your ribs, or feel breathless, you ring this number and come straight in. Any hour."
• Acknowledge the feeling: "It is genuinely frustrating to be dealing with this now. I am sorry."^[1]

Probe 6 — "What do you tell her about the next twenty years?"

• "That a hypertensive pregnancy is a marker of future cardiovascular risk, not just a pregnancy event. After preeclampsia the relative risk of later hypertension is about 3.7 and of ischaemic heart disease about 2.2, and the excess persists for many years."^[7]
• "So the plan is annual blood pressure, lipids and glucose with her general practitioner, and a conversation about weight, activity and smoking. I would write this in the discharge letter so it does not depend on her remembering."^[7][6]