July 22, 2025

Most Missed Question in Internal Medicine Exam Prep Course This Week

By Challenger Corporation · 4 minute read

Don't Stop With Just One Question - Check Out Our Library of Over 35,000 Q&A With Remediation!

A 28-year-old gravida 3, para 2 woman at 13 weeks of gestation who is morbidly obese presents to you for a prenatal visit. Recent findings on ultrasonography revealed a single viable pregnancy at 13 weeks and 2 days of gestation. Her vital signs are remarkable for blood pressure of 150/100 mm Hg.

During her last visit before she became pregnant, which was 4 months ago, her blood pressure was 138/85 mm Hg; at that time, she was taking hydrochlorothiazide 25 mg. She discontinued the drug a few weeks ago when the result of her home pregnancy test was positive.

What drug, if any, should be started to control her hypertension?

Answers:

hydrochlorothiazide
lisinopril
propranolol
no treatment; close follow-up

IM is not doing well in hypertension questions this week. 🙂

This is a depth of knowledge question. Guideline thresholds for hypertension management inside and outside pregnancy differ. Some fundamental principles apply to management of hypertension in pregnancy. If the regimen is safe and effective with pregnancy (eg. labetalol, methyldopa, or nifedipine) then you don’t stop it, continuation avoids rebound hypertension. Thiazides like HCTZ could probably have been continued at a low dose, if the patient in the question stem hadn’t already discontinued it.

So in this question HCTZ is a distractor, your patient with HTN is effectively off medication, so you follow the ACOG guidelines (ACOG Practice Bulletin 203 (2019)).

Why This Question Is Often Missed

Many test-takers assume any blood pressure ≥140/90 in pregnancy warrants pharmacotherapy, overlooking guideline thresholds for treatment initiation.
Confusion between chronic hypertension management outside pregnancy and the more conservative approach in pregnant patients, leading to inappropriate drug re-starts.

What the Distractors Indicate

Option	What It Tests / Implies	Why It’s Wrong Here
Hydrochlorothiazide	Understanding that thiazides are sometimes used for chronic HTN	Diuretics are not first-line in pregnancy and mild chronic HTN < 160/110 is observed, not treated.
Lisinopril	Knowledge that ACE inhibitors are standard for chronic HTN	ACE inhibitors are teratogenic (fetal renal dysplasia) and contraindicated in pregnancy.
Propranolol	Recognition of β-blockers for hypertension	Propranolol is not preferred (can impair fetal growth); labetalol or methyldopa are first-line.
No treatment; close follow-up (✔)	Awareness of conservative management thresholds in pregnancy	—

High-Yield Pearl

Mild chronic hypertension in pregnancy (BP < 160/110 mm Hg) is managed expectantly; pharmacotherapy begins only when BP ≥ 160/110 mm Hg.

Core Learning Objectives

Recognize the blood pressure thresholds for initiating antihypertensive therapy in pregnant patients with chronic hypertension.
Identify which antihypertensive agents are safe or contraindicated during pregnancy.

The “Test Trick” at Play

This question exploits the common trap of treating any elevated blood pressure in pregnancy. Unlike non-pregnant guidelines (≥ 140/90), obstetric guidelines defer pharmacologic treatment of chronic hypertension until pressures reach ≥ 160/110 mm Hg to balance maternal benefit against potential fetal risks.

Additional Practice Questions and Remediation

Question 1

A 35-year-old G1P0 at 10 weeks’ gestation with known chronic hypertension presents with BP 165/105 mm Hg on two readings. She is not yet on any medication. What is the most appropriate management?

A. Labetalol

B. No treatment; close follow-up

C. Lisinopril

D. Hydrochlorothiazide

Answer and Remediation

If you chose A (Labetalol): Correct response! Labetalol is first-line for severe chronic hypertension (BP ≥ 160/110) in pregnancy.
If you chose B, C, or D:
- Review: BP ≥ 160/110 in pregnancy warrants treatment (so B is wrong).
- ACE inhibitors (lisinopril) are teratogenic.
- Thiazides are not first-line for severe HTN in pregnancy.

Question 2

A 30-year-old G2P1 at 28 weeks with baseline chronic HTN has a BP of 150/95 mm Hg today. She’s currently medication-naïve. What do you do?

A. Start methyldopa

B. No treatment; close follow-up

C. Start propranolol

D. Start hydrochlorothiazide

Answer and Remediation

If you chose B (No treatment; close follow-up): Correct response! Mild chronic HTN (< 160/110) in pregnancy is observed.
If you chose A, C, or D:
- Review: Therapy not indicated until ≥ 160/110 (so all medication starts are premature).
- Methyldopa is safe but unnecessary at this BP.
- Propranolol is less preferred and still unwarranted.
- Thiazides aren’t first-line for mild elevations.

Question 3

A 32-year-old woman with chronic hypertension controlled on lisinopril plans pregnancy. Preconception counseling should include:

A. Continue lisinopril until 12 weeks, then switch to methyldopa

B. Discontinue lisinopril and start labetalol

C. Stop all antihypertensives and observe

D. Switch to propranolol immediately

Answer and Remediation

If you chose B (Switch to labetalol): Correct response! ACE inhibitors must be stopped preconception; labetalol is first-line.
If you chose A, C, or D:
- Review: ACE inhibitors are teratogenic throughout the first trimester (so A wrong).
- Observational approach would risk uncontrolled HTN.
- Propranolol is less preferred than labetalol.

Question 4

A 26-year-old at 26 weeks’ gestation presents in triage with BP 162/112 mm Hg and headache. She denies visual changes or pain. Next step:

A. IV hydralazine

B. Oral labetalol

C. No treatment; repeat in 1 week

D. Continue home hydrochlorothiazide

Answer and Remediation

If you chose B (Oral labetalol): Correct response! For severe chronic HTN with symptoms, oral labetalol is appropriate.
If you chose A, C, or D:
- Review: Hydralazine IV is reserved for acute hypertensive emergencies; oral first.
- Mild expectant management (C) is unsafe at this BP.
- Thiazides aren’t first-line for severe elevations.

Question 5

A 40-year-old G1 at 20 weeks with chronic hypertension and type 2 diabetes has BP 145/92 mm Hg. Management?

A. No treatment; close follow-up

B. Start methyldopa

C. Start enalapril

D. Start propranolol

Answer and Remediation

If you chose A (No treatment; close follow-up): Correct response! Even with diabetes, mild chronic HTN (< 160/110) is observed.
If you chose B, C, or D:
- Review: Treatment threshold remains ≥ 160/110 even with comorbidities.
- ACE inhibitors (enalapril) are contraindicated.
- Propranolol not preferred early.

Mini Case Discussion Prompt

Compare and contrast the management of chronic hypertension versus gestational hypertension in pregnancy, focusing on treatment thresholds, choice of medication, and maternal–fetal risks associated with early pharmacologic intervention.

This question appears in Med-Challenger Internal Medicine Review with CME

Try for free and save. Ace your exams and meet your CME/MOC requirements for just $35 a month!

No matter your program, no matter the size, Med-Challenger for Groups and Institutions can better prepare your program or group, fulfill industry requirements, and increase test scores.