Preeclampsia diagnosis and management — structured oral station (12 minutes)

Opening prompt — "Set out her inpatient plan."

Model response — say it as a plan with numbers. ^[1][2]

• "This is preeclampsia at 30+2 weeks with uteroplacental dysfunction — she meets ISSHP 2021 on proteinuria at 64 mg/mmol and again on fetal growth restriction with an abnormal umbilical artery Doppler. She is not currently in the severe range and her bloods are not yet deranged."^[1]
• "Admit to a high-dependency antenatal area. Blood pressure four-hourly or more often, daily symptom review, strict fluid balance, and a defined escalation trigger written in the notes."^[2][3]
• "Antihypertensives: she is on labetalol three times daily. I would uptitrate per the current protocol toward the local ceiling, and add nifedipine modified release per protocol if she remains above target."^[3][2]
• "Corticosteroids: betamethasone per the current protocol dosing, because birth within seven days is plausible at this gestation."^[9]
• "Bloods every 24 to 48 hours, and immediately with any new symptom: full blood count, creatinine and electrolytes, liver enzymes, urate, lactate dehydrogenase, and repeat protein:creatinine ratio."^[1][2]
• "Fetal surveillance: daily or alternate-day cardiotocography, umbilical artery Doppler twice weekly given the raised pulsatility index, and growth reassessed in two weeks."^[1][3]
• "And I would ask neonatology to meet her and her partner now, not on the day she delivers."^[3]

Examiner is listening for: the ISSHP criteria named, a drug uptitration with numbers, steroids, a monitoring interval, and early neonatal involvement. ^[1]

Probe 1 — "Would you give magnesium sulfate today?"

• "Not today. Her blood pressure is not in the severe range and she has no neurological features beyond a headache that has not escalated. ISSHP and SOMANZ support magnesium where eclampsia risk is judged high — severe hypertension or neurological signs — and it is mandatory once she has seized."^[1][3]
• "I would have the threshold explicit in her notes: severe-range blood pressure, worsening headache, visual disturbance, clonus, epigastric pain or a decision to deliver. At that point, magnesium per the current protocol loading and maintenance doses, continued 24 hours after birth or the last seizure, whichever is later."^[8][3]
• "The evidence is Magpie: 10,141 women, eclampsia cut by 58%, from 1.9% to 0.8%, with a probable reduction in maternal death."^[8]

Probe 2 — "Her placental growth factor comes back low and the sFlt-1:PlGF ratio is 210. How does that change things?"

• "Angiogenic markers are best understood as rule-out and triage tools, not as a trigger for delivery on their own. Zeisler showed a ratio of 38 or lower has a negative predictive value of 99.3% for not developing preeclampsia within a week; a ratio above 38 has a positive predictive value of only 36.7% for preeclampsia within four weeks."^[4]
• "In her case the diagnosis is already made clinically, so a high ratio does not diagnose anything new. What it does is mark her as high risk for progression and justify the intensity of surveillance I have set out."^[4][5]
• "PARROT showed that revealing placental growth factor results cut the median time to clinical confirmation of preeclampsia from 4.1 days to 1.9 days and was associated with fewer maternal severe adverse outcomes. But PARROT-2 showed that repeat testing did not improve perinatal outcomes, so I would not test her serially by reflex."^[5][6]

Probe 3 — "On day 4 her platelets have fallen, her transaminases have trebled, her creatinine has risen and her blood pressure is in the severe range. She is vomiting. What now?"

• "Multi-organ deterioration with severe-range hypertension — platelets 96 x 10^9/L, ALT 118 IU/L, creatinine 98 micromol/L, blood pressure 176/116 mmHg. Treat the pressure within 30 to 60 minutes per the current protocol doses and ceilings."^[2][1]
• "Magnesium sulfate per the current protocol loading and maintenance doses, with hourly reflexes, respiratory rate and urine output, and calcium gluconate per protocol available as the antidote."^[8][2]
• "Restrict fluid per the current protocol rate, catheterise, and do not give a bolus for oliguria unless the creatinine is rising and I have excluded pulmonary oedema."^[1][2]
• "Deliver. At 30+4 weeks with a falling platelet count, rising transaminases, rising creatinine and uncontrolled hypertension, expectant management is no longer safe. I would apply fullPIERS to articulate that — gestational age, chest pain or dyspnoea, oxygen saturation, platelet count, creatinine and aspartate transaminase, area under the ROC curve 0.88 for adverse maternal outcomes within 48 hours."^[7][2]
• "Consultant, anaesthetist and neonatal team involved now; I would expect caesarean given the gestation, the growth restriction and an unfavourable cervix."^[2][3]

Probe 4 — "Her partner asks why you cannot just wait until 34 weeks."

This is the communication and rapport domain. Answer him, not the examiner. ^[3][10]

• Sit down, use their names, and check what they already understand.
• "I know how much every extra week matters for your baby, and if it were safe I would give you those weeks. What has changed today is that her liver, her kidneys and her platelets are all being affected, and her blood pressure is at the level where we worry about a stroke."
• "The only treatment that reverses this is delivering the baby. Waiting now risks her having a fit, a bleed into the brain, or the placenta separating — and none of those help the baby either."^[2][1]
• "The steroid injections she had on admission have already done most of their work for the baby's lungs. The neonatal team will meet you before we go to theatre."^[9]
• Pause, allow silence, invite questions, and offer a follow-up conversation after delivery.^[3]

Probe 5 — "What happens after birth?"

• "Continue magnesium for 24 hours, continue and expect to escalate antihypertensives around days 3 to 6 when blood pressure peaks, and repeat bloods until platelets and transaminases are clearly improving."^[2][1]
• "Choose breastfeeding-compatible agents — labetalol, nifedipine or enalapril — reassess venous thromboembolism prophylaxis once haemostasis is secure, and use non-steroidal anti-inflammatory drugs cautiously."^[3][1]
• "Then the follow-up: blood pressure at one to two weeks, full review with bloods and protein:creatinine ratio at six weeks, reclassification at 12 weeks, and a debrief plus a documented plan for the next pregnancy."^[1][3]