skip to main content

Diabetic kidney disease in early pregnancy — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

HardNephrologyDiabetic kidney disease in early pregnancyMSRA

A 34-year-old woman attends after a positive pregnancy test at 7+4 weeks' gestation. She has type 2 diabetes with diabetic kidney disease (eGFR 44 mL/min/1.73 m² and urine ACR 220 mg/mmol, both stable over 8 months) and chronic hypertension. Her current medicines are ramipril 10 mg once daily, dapagliflozin 10 mg once daily and metformin 1 g twice daily. HbA1c last week was 52 mmol/mol. Her BP today is 146/92 mmHg. She has no wheeze, bradycardia, heart block, symptomatic hypotension, vomiting or features of diabetic ketoacidosis. What is the most appropriate immediate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Stop ramipril and dapagliflozin, start labetalol, continue metformin pending specialist review, and arrange immediate contact with the joint diabetes and antenatal clinic.

This is established diabetic kidney disease with chronic hypertension, newly recognised in early pregnancy. Ramipril must be stopped promptly: NICE advises stopping ACE inhibitors or ARBs in pregnancy, preferably within 2 working days of notification, despite their pre-pregnancy albuminuria-lowering benefit. Dapagliflozin should also be discontinued when pregnancy is detected; NICE recommends stopping oral glucose-lowering agents other than metformin before pregnancy and using insulin where required. Metformin may be continued in pregnancy when its glycaemic benefit outweighs potential harm, pending the specialist glycaemic plan. Her BP of 146/92 mmHg meets the treatment threshold for chronic hypertension in pregnancy (140/90 mmHg). In the absence of asthma, bradycardia or other contraindication, labetalol is the preferred first option; the target is 135/85 mmHg. Pregnant women with pre-existing diabetes require immediate contact with a joint diabetes and antenatal clinic, which can rapidly establish insulin requirements, arrange renal assessment and coordinate high-risk obstetric care. A wrongly delays withdrawal of two unsuitable medicines. C misses dapagliflozin discontinuation. D incorrectly applies the severe-hypertension threshold rather than the chronic-hypertension treatment threshold. E uses a less preferred antihypertensive without a reason that labetalol or nifedipine is unsuitable, and incorrectly delays specialist contact.

Reference: NICE NG133: Hypertension in pregnancy: diagnosis and management, recommendations 1.3.1-1.3.10 (2019) — https://www.nice.org.uk/guidance/ng133/chapter/recommendations NICE NG3: Diabetes in pregnancy: management from preconception to the postnatal period, recommendations 1.1.21 and 1.3.28-1.3.37 (2020) — https://www.nice.org.uk/guidance/ng3/chapter/recommendations Dapagliflozin 10 mg film-coated tablets Summary of Product Characteristics, section 4.6 (2026) — https://www.medicines.org.uk/emc/product/100996/smpc