PANCE Sample Questions: Prenatal Care and Gestational Diabetes
Question 1: Preconception Counseling for Type 2 Diabetes
A 28-year-old woman with type 2 diabetes presents for preconception counseling. Her current A1C is 7.8%, and she takes metformin, lisinopril for hypertension, and atorvastatin. What is the MOST important immediate action?
A) Continue current medications and schedule follow-up in 3 months B) Discontinue lisinopril and atorvastatin immediately, prescribe effective contraception, and optimize glycemic control to A1C <6.5% C) Start insulin therapy and continue all current medications D) Refer to maternal-fetal medicine only after pregnancy is confirmed
Correct Answer: B
Explanation: Immediately discontinue ACE inhibitors (lisinopril) and statins (atorvastatin) as they are teratogenic, prescribe effective contraception until A1C is optimized to <6.5%, and transition to pregnancy-safe antihypertensives like extended-release nifedipine. 1 ACE inhibitors and statins are absolutely contraindicated in pregnancy due to risks of congenital malformations. 1 The target A1C before conception should be <6.5% to reduce congenital malformations from 1.4-10.9% to 1.0-1.7%. 1, 2 Long-acting reversible contraception should be prescribed immediately to prevent pregnancy until optimization is achieved. 1, 3
Question 2: Preeclampsia Prophylaxis Timing
A 32-year-old G2P1 woman at 10 weeks gestation has a history of preeclampsia in her first pregnancy at 34 weeks. She has chronic hypertension (BP 145/92 mmHg) and BMI of 36. When should low-dose aspirin be initiated?
A) At 20 weeks gestation B) Immediately, before 16 weeks gestation C) At 24 weeks with gestational diabetes screening D) Only if blood pressure remains elevated at 16 weeks
Correct Answer: B
Explanation: Start low-dose aspirin (81-150 mg daily) immediately, before 16 weeks gestation, as she has multiple major risk factors for preeclampsia including prior preeclampsia, chronic hypertension, and BMI >35. 2, 4 The American College of Obstetricians and Gynecologists recommends aspirin initiation before 16 weeks for maximum efficacy in preventing preeclampsia. 2, 4 Her history of gestational hypertension from 34 weeks confers a 25% risk of superimposed preeclampsia in subsequent pregnancy. 3 Aspirin should be continued until 36 weeks gestation. 2
Question 3: Gestational Diabetes Screening Timing
A 38-year-old woman presents for her first prenatal visit at 8 weeks gestation. She has a BMI of 32, history of gestational diabetes in her previous pregnancy, and is of South Asian descent. When should gestational diabetes screening be performed?
A) Only at 24-28 weeks with standard screening B) Immediately at first visit, then repeat at 24-28 weeks if initially normal C) At 20 weeks gestation only D) Defer screening until third trimester due to early gestational age
Correct Answer: B
Explanation: Screen immediately at the first prenatal visit using standard diagnostic criteria (fasting glucose ≥126 mg/dL or A1C ≥6.5%) to detect preexisting type 2 diabetes, then repeat oral glucose tolerance test at 24-28 weeks if initial results are normal. 5, 6 Women at increased risk (history of GDM, obesity, age >35 years, South Asian ethnicity) require early screening to identify undiagnosed type 2 diabetes. 5, 7 The 75g oral glucose tolerance test is mandatory between 24-28 weeks for all pregnant women with previously normal glucose metabolism. 5 Early-onset gestational diabetes represents a high-risk subgroup with higher rates of hypertension (18.46% vs 5.88%), greater insulin requirements (33.85% vs 7.06%), and increased perinatal complications. 7
Question 4: Glycemic Targets in Pregnancy
A 30-year-old woman with type 1 diabetes at 14 weeks gestation is checking her blood glucose 4 times daily. What are the appropriate target glucose levels?
A) Fasting <110 mg/dL, 1-hour postprandial <160 mg/dL B) Fasting <95 mg/dL, 1-hour postprandial <140 mg/dL OR 2-hour postprandial <120 mg/dL C) Fasting <100 mg/dL, 2-hour postprandial <140 mg/dL D) Fasting <90 mg/dL, 1-hour postprandial <130 mg/dL
Correct Answer: B
Explanation: Target fasting plasma glucose <95 mg/dL and either 1-hour postprandial <140 mg/dL OR 2-hour postprandial <120 mg/dL to minimize maternal and fetal complications. 1, 2 These specific targets are recommended by the American Diabetes Association for both gestational and pregestational diabetes in pregnancy. 1 The A1C target during pregnancy should ideally be <6% (42 mmol/mol) if achievable without significant hypoglycemia, but may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia. 1 Fasting and postprandial blood glucose monitoring are essential, with some individuals also requiring preprandial checks. 1
Question 5: Diabetic Retinopathy Screening in Pregnancy
A 27-year-old woman with type 1 diabetes for 10 years is planning pregnancy. She has no known diabetic complications. What is the appropriate ophthalmologic screening schedule?
A) Eye exam only if visual symptoms develop during pregnancy B) Dilated eye exam before pregnancy or in first trimester, then every trimester and for 1 year postpartum C) Single dilated eye exam in second trimester only D) Annual eye exam as per routine diabetes care, no additional screening needed
Correct Answer: B
Explanation: Perform dilated eye examination ideally before pregnancy or in the first trimester, then monitor every trimester throughout pregnancy and for 1 year postpartum, as pregnancy can accelerate diabetic retinopathy progression. 1 Women with preexisting diabetes should be counseled on the risk of development and/or progression of diabetic retinopathy during pregnancy. 1 Close monitoring is essential as individuals with preexisting diabetic retinopathy need assessment for progression and treatment if indicated. 1 The frequency should be adjusted based on the degree of retinopathy and recommendations from the eye care provider. 1
Question 6: Multidisciplinary Care for Pregestational Diabetes
A 33-year-old woman with type 2 diabetes (A1C 7.2%) presents at 6 weeks gestation. Which team members should be involved in her prenatal care?
A) Obstetrician only B) Obstetrician and endocrinologist only C) Endocrinologist, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes care and education specialist D) Maternal-fetal medicine specialist only
Correct Answer: C
Explanation: Establish multidisciplinary care including an endocrinologist, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes care and education specialist for optimal management of pregestational diabetes in pregnancy. 1, 4 This interprofessional approach should ideally begin in the preconception period. 1 The Society for Maternal-Fetal Medicine emphasizes that pregnancy in women with pregestational diabetes carries increased risks of maternal complications (preeclampsia, worsening retinopathy, diabetic ketoacidosis) and perinatal complications (miscarriage, stillbirth, congenital anomalies, macrosomia, neonatal hypoglycemia). 1 Multidisciplinary care is mandatory for intensive monitoring throughout pregnancy given increased rates of gestational diabetes, hypertensive disorders, preterm birth, and fetal growth restriction. 3
Question 7: Fetal Surveillance in Pregestational Diabetes
A 29-year-old woman with well-controlled type 1 diabetes on insulin is now at 32 weeks gestation. What fetal assessments are indicated?
A) No additional testing needed if glucose control is good B) Fetal echocardiogram only C) Begin antepartum fetal surveillance; fetal echocardiogram should have been performed at 16-22 weeks D) Biophysical profile at 36 weeks only
Correct Answer: C
Explanation: Begin antepartum fetal surveillance at 32-34 weeks for high-risk pregnancies including pregestational diabetes, and note that fetal echocardiogram should have been scheduled between 16-22 weeks gestation. 2, 4 Women with pregestational diabetes require detailed fetal anatomy ultrasound between 16-22 weeks to detect congenital anomalies. 2 Fetal echocardiogram is specifically recommended between 16-22 weeks for women with pregestational diabetes to detect cardiac anomalies, as recommended by the American Heart Association. 2 Third-trimester fetal surveillance is essential even with good glycemic control due to increased risks of stillbirth and fetal complications. 4
Question 8: Supplementation in Preconception Period
A 26-year-old woman with type 2 diabetes is planning pregnancy. Which supplements should be prescribed?
A) Folic acid 400 mcg daily only B) Folic acid 400-800 mcg daily and potassium iodide 150 mcg daily C) Prenatal vitamins without specific supplementation D) Iron supplementation only
Correct Answer: B
Explanation: Prescribe folic acid 400-800 mg daily and potassium iodide 150 mg daily prior to conception or as soon as pregnancy is confirmed to reduce the risk of congenital malformations, particularly neural tube defects. 1, 2 The American College of Obstetricians and Gynecologists specifically recommends these supplements for women with preexisting medical conditions. 2 Folic acid supplementation decreases the risk of neural tube defects. 6 These supplements should be initiated in the preconception period for maximum benefit. 1
Question 9: Medication Review in Preconception Diabetes Care
A 35-year-old woman with type 2 diabetes and hypertension is planning pregnancy. She currently takes metformin, lisinopril, and atorvastatin. Which medications must be discontinued?
A) Metformin only B) Lisinopril only C) Lisinopril and atorvastatin D) All three medications
Correct Answer: C
Explanation: Immediately discontinue lisinopril (ACE inhibitor) and atorvastatin (statin) before conception, as both are pregnancy category X medications associated with severe fetal malformations. 1, 2 ACE inhibitors and angiotensin receptor blockers cause fetal renal abnormalities and are absolutely contraindicated. 1 Statins cause severe CNS and other fetal malformations and must be stopped immediately if present. 3 Special attention should be paid to reviewing the medication list for potentially harmful drugs during preconception care. 1 Metformin can be continued and is often used in pregnancy for gestational diabetes management. 8
Question 10: Postpartum Follow-up for Gestational Diabetes
A 31-year-old woman delivered at 39 weeks after being diagnosed with gestational diabetes at 26 weeks, managed with insulin. What postpartum testing is recommended?
A) No follow-up needed if blood glucose normalizes immediately postpartum B) 75g oral glucose tolerance test at 4-12 weeks postpartum, then glucose assessment every 2-3 years C) A1C testing only at 6 months postpartum D) Fasting glucose at annual physical examination
Correct Answer: B
Explanation: Perform 75g oral glucose tolerance test using WHO criteria at 4-12 weeks postpartum to reassess glucose tolerance, then continue glucose assessment (fasting glucose, random glucose, A1C, or optimally OGTT) every 2-3 years if glucose tolerance is normal. 1, 5 Women with gestational diabetes should have lifelong screening for development of diabetes or prediabetes at least every 3 years. 1 All women must be counseled about their increased risk of type 2 diabetes and cardiovascular disease at follow-up. 5 Insulin resistance typically resolves after delivery; however, patients with GDM have significantly increased risk of developing overt diabetes. 8 Continued lifestyle modifications, breastfeeding, and use of metformin can reduce this risk. 8