Endocrinology of Pregnancy

Endocrinology of Pregnancy Indian Medical PG Question 1: Test done at sub-centre during pregnancy:

• A. Haemoglobin (Correct Answer)
• B. Triple test
• C. USG
• D. OGTT

Endocrinology of Pregnancy Explanation: ***Haemoglobin*** - **Haemoglobin testing** is a routine and essential screening measure performed at the subcenter level during pregnancy, primarily to detect and monitor **anaemia**. - Its simplicity, cost-effectiveness, and direct impact on maternal and fetal health make it suitable for primary healthcare settings. *Triple test* - The **triple test** (or multiple marker screen) is a prenatal diagnostic test for chromosomal abnormalities and neural tube defects, typically performed between weeks 15 and 20 of pregnancy. - This test requires specialized laboratory facilities and interpretation, which are usually not available or routinely performed at the subcenter level. *USG* - **Ultrasonography (USG)** is a vital imaging technique used to monitor fetal growth, development, and maternal health during pregnancy. - While crucial, USG requires specialized equipment and trained personnel (sonographers or radiologists) and is generally conducted in higher-level healthcare facilities, not routinely at a subcenter. *OGTT* - An **Oral Glucose Tolerance Test (OGTT)** is used to screen for **gestational diabetes mellitus**. - While it is a routine test in pregnancy, performing a full OGTT (which involves multiple blood draws over several hours after glucose ingestion) is often logistically challenging for routine performance at a subcenter; usually, only initial screening (like random blood sugar or fasting glucose) or a single-step glucose challenge test might be done at a primary level before referral.

Endocrinology of Pregnancy Indian Medical PG Question 2: Thyroxine binding globulin (TBG) is increased in:

• A. Pregnancy (Correct Answer)
• B. Cancer chemotherapy
• C. Nephrotic syndrome
• D. Glucocorticoid therapy

Endocrinology of Pregnancy Explanation: ***Pregnancy*** - Estrogen levels are elevated during **pregnancy**, which leads to an increase in the synthesis of **TBG** by the liver. - Increased TBG binds more thyroid hormone, reducing free thyroid hormone levels, which then stimulates the thyroid gland to produce more. *Cancer chemotherapy* - Many **chemotherapeutic agents** can damage the liver or interfere with protein synthesis, potentially leading to a *decrease* in TBG and other plasma proteins. - Chemotherapy can also induce **hypothyroidism** directly or indirectly, which may alter thyroid hormone binding. *Nephrotic syndrome* - **Nephrotic syndrome** is characterized by significant proteinuria, where plasma proteins, including **TBG**, are lost through the kidneys in the urine. - This leads to a *decrease* in serum TBG levels, which can affect total thyroid hormone measurements but typically does not cause overt thyroid dysfunction due to compensatory mechanisms. *Glucocorticoid therapy* - **Glucocorticoids** (e.g., prednisone, dexamethasone) are known to *decrease* the hepatic synthesis of **TBG**. - This reduction in TBG can lead to lower total thyroid hormone levels without necessarily indicating thyroid gland dysfunction, as free thyroid hormone levels often remain normal.

Endocrinology of Pregnancy Indian Medical PG Question 3: A 20 year old Primigravida, comes at 35 weeks of gestation with complaints of swelling of feet. On examination her blood pressure is 170/110 mm Hg on 2 occasions; urine examination shows proteinuria. Which one of the following statements regarding her management is NOT true?

• A. Injection Dexamethasone is to be given for fetal lung maturity (Correct Answer)
• B. Can be labelled as Preeclampsia
• C. Both maternal and fetal monitoring are required
• D. Requires urgent admission

Endocrinology of Pregnancy Explanation: ***Injection Dexamethasone is to be given for fetal lung maturity*** - At **35 weeks of gestation**, corticosteroids for fetal lung maturity are **traditionally NOT routinely indicated** according to classical obstetric teaching. - The primary indication for antenatal corticosteroids is between **24 and 34 weeks of gestation**, when the risk of respiratory distress syndrome is highest. - At 35 weeks, fetal lungs are generally considered sufficiently mature, and the risk-benefit ratio of routine steroid administration changes. - **Note**: Evolving evidence (post-2016) suggests potential benefits of late preterm steroids (34-36+6 weeks) in certain scenarios, but this was not standard practice at the time of this examination. - In the context of this question and examination year, this statement is **NOT true** as routine practice. *Can be labelled as Preeclampsia* - The patient presents with **severe hypertension** (BP 170/110 mmHg on two occasions) and **proteinuria**, which are the hallmark diagnostic criteria for **severe preeclampsia**. - BP ≥160/110 mmHg meets the criteria for severe features. - Swelling of the feet (**edema**) is a common, though not diagnostic, associated symptom. *Both maternal and fetal monitoring are required* - In severe preeclampsia, **close maternal monitoring** for signs of worsening disease is crucial: - Severe hypertension, headaches, visual disturbances, epigastric pain - Laboratory monitoring: liver enzymes, platelets, creatinine, LDH - **Fetal monitoring** is essential to assess fetal well-being: - Non-stress tests, biophysical profiles - Doppler velocimetry to assess placental insufficiency - Monitoring for IUGR or fetal distress *Requires urgent admission* - With BP 170/110 mmHg and proteinuria at 35 weeks, this is **severe preeclampsia** - a medical emergency. - **Urgent admission** is necessary for: - Continuous maternal and fetal monitoring - Blood pressure control with antihypertensives - Magnesium sulfate for seizure prophylaxis - Planning for timely delivery (delivery is the definitive treatment)

Endocrinology of Pregnancy Indian Medical PG Question 4: Intestinal absorption of calcium is mainly increased by?

• A. Calcitriol (Correct Answer)
• B. Parathormone
• C. Glucocorticoids
• D. ACTH

Endocrinology of Pregnancy Explanation: ***Calcitriol*** - **Calcitriol** (1,25-dihydroxyvitamin D3) is the hormonally active form of vitamin D, which is essential for increasing **calcium absorption** from the intestines. - It stimulates the synthesis of **calcium-binding proteins** in intestinal epithelial cells, facilitating active transport of calcium. *Parathormone* - **Parathormone (PTH)** primarily regulates calcium by increasing its reabsorption in the **kidneys** and stimulating its release from **bones**. - While it indirectly promotes calcitriol synthesis, its *direct* effect on intestinal calcium absorption is minimal compared to calcitriol. *Glucocorticoids* - **Glucocorticoids** generally have an *inhibitory* effect on calcium absorption in the intestine and can also increase renal excretion of calcium. - Prolonged use can lead to **osteoporosis** due to their negative impact on bone formation and calcium balance. *ACTH* - **ACTH (adrenocorticotropic hormone)** primarily stimulates the adrenal cortex to produce **cortisol** and other glucocorticoids. - It has **no direct role** in regulating calcium absorption from the intestines.

Endocrinology of Pregnancy Indian Medical PG Question 5: A 26-week pregnant female presents with hypertension for the first time. There is no proteinuria. What is the most likely diagnosis?

• A. Hypertension diagnosed before 20 weeks of gestation
• B. Hypertension diagnosed after 20 weeks of gestation without proteinuria (Correct Answer)
• C. Hypertension with proteinuria or end-organ damage
• D. Hypertension with seizures

Endocrinology of Pregnancy Explanation: ***Hypertension diagnosed after 20 weeks of gestation without proteinuria*** - This scenario describes **gestational hypertension**, defined as new-onset hypertension (≥140/90 mmHg) presenting *after* 20 weeks of gestation, without associated proteinuria or other signs of preeclampsia. - The patient's presentation at **26 weeks** with **no proteinuria** directly aligns with the diagnostic criteria for gestational hypertension. *Hypertension diagnosed before 20 weeks of gestation* - This description corresponds to **chronic hypertension**, meaning the hypertension was present *before* pregnancy or diagnosed *before* 20 weeks of gestation. - The question explicitly states the hypertension is presenting for the **first time** and the gestational age is **26 weeks**, ruling out chronic hypertension. *Hypertension with proteinuria or end-organ damage* - This definition describes **preeclampsia**, which involves new-onset hypertension *after* 20 weeks accompanied by significant **proteinuria** or signs of **end-organ damage** like renal insufficiency, liver dysfunction, or thrombocytopenia. - The patient specifically has **no proteinuria**, making preeclampsia an unlikely diagnosis based on the provided information. *Hypertension with seizures* - This refers to **eclampsia**, a severe complication of preeclampsia characterized by the development of **generalized tonic-clonic seizures** in a pregnant patient with preeclampsia, unrelated to other brain conditions. - The patient in this case is not experiencing seizures; therefore, eclampsia is not the correct diagnosis.

Endocrinology of Pregnancy Indian Medical PG Question 6: A patient presents with symptoms of hyperthyroidism. Thyroid function tests would probably reveal:

• A. Increased T4, Increased T3, decreased TSH (Correct Answer)
• B. Increased T4, normal T3, and increased TSH
• C. Increased T3, T4, and increased TSH
• D. Decreased T3 and T4, increased TSH

Endocrinology of Pregnancy Explanation: ***Increased T4, Increased T3, decreased TSH*** - In **primary hyperthyroidism**, the thyroid gland overproduces thyroid hormones (**T3 and T4**), leading to elevated levels [1]. - The high levels of T3 and T4 then **feedback negatively** on the pituitary gland, suppressing the release of **TSH** [1]. *Increased T4, normal T3, and increased TSH* - This pattern is inconsistent with primary hyperthyroidism, as elevated T3 and T4 should suppress TSH. - An isolated increase in T4 with normal T3 can occur in **subclinical hyperthyroidism** or **thyroxine (T4) resistance**, but increased TSH would suggest pituitary dysfunction or resistance to thyroid hormones. *Increased T3, T4, and increased TSH* - Elevated T3 and T4 accompanied by **increased TSH** is a rare presentation, usually indicating **TSH-secreting pituitary adenoma** (secondary hyperthyroidism) or **thyroid hormone resistance** [1], [2]. - In typical hyperthyroidism, high thyroid hormone levels would suppress TSH. *Decreased T3 and T4, increased TSH* - This profile is characteristic of **primary hypothyroidism**, where an underactive thyroid gland produces insufficient T3 and T4 [1]. - The low thyroid hormone levels stimulate the pituitary to release **more TSH** in an attempt to stimulate thyroid hormone production [1].

Endocrinology of Pregnancy Indian Medical PG Question 7: In a patient who has been in a state of starvation for 72 hours, which of the following is the primary mechanism for maintaining blood glucose levels?

• A. Increased gluconeogenesis (Correct Answer)
• B. Increased protein degradation
• C. Increased glycogenolysis
• D. Increased ketosis due to breakdown of fats

Endocrinology of Pregnancy Explanation: ***Increased gluconeogenesis*** - After 72 hours of starvation, **hepatic glycogen stores** are completely depleted, making gluconeogenesis the primary and essential mechanism to maintain **blood glucose levels**. - This process synthesizes glucose from non-carbohydrate precursors like **amino acids** (mainly alanine and glutamine), **lactate**, and **glycerol** to supply glucose for obligate glucose-dependent tissues like **red blood cells** and the **renal medulla**, and provides baseline glucose for the brain. - Gluconeogenesis occurs primarily in the **liver** and to a lesser extent in the **kidney cortex** during prolonged fasting. *Increased protein degradation* - While **protein degradation** does occur to supply amino acids for gluconeogenesis, the body actively minimizes this to preserve muscle mass, especially after prolonged starvation. - The initial phase of starvation (first 24-48 hours) sees more significant protein breakdown, but its rate decreases substantially after 72 hours as the body becomes increasingly **protein-sparing** and shifts to fatty acid oxidation and ketone body production. *Increased glycogenolysis* - **Hepatic glycogen stores** are typically depleted within **12-24 hours** of starvation. - After 72 hours, there is essentially no glycogen remaining to break down, so **glycogenolysis** cannot contribute to maintaining blood glucose at this stage. *Increased ketosis due to breakdown of fats* - **Ketosis** does dramatically increase after 72 hours of starvation as the body shifts to using **fatty acids** for energy and producing **ketone bodies** (β-hydroxybutyrate and acetoacetate) for the brain and other tissues. - However, while ketone bodies serve as an alternative fuel source for the brain (providing up to 60-70% of its energy needs), they **cannot replace glucose entirely** because certain tissues (red blood cells, renal medulla) are obligate glucose users and cannot utilize ketones. - The question specifically asks about maintaining **blood glucose levels**, which requires gluconeogenesis, not ketone production.

Endocrinology of Pregnancy Indian Medical PG Question 8: Estrogen is secreted during pregnancy, mostly by which organ?

• A. Placenta (Correct Answer)
• B. Fetal ovary
• C. Pituitary
• D. Hypothalamus

Endocrinology of Pregnancy Explanation: ***Placenta*** - During pregnancy, the **placenta** takes over the primary role of **estrogen production** from the ovaries, especially after the first trimester. - It synthesizes significant amounts of **estriol**, the main estrogen produced during pregnancy, using precursors from the fetal adrenal glands. *Fetal ovary* - The **fetal ovary** is not the primary source of estrogen synthesis during pregnancy. - While it has some hormonal activity, it does not produce the large quantities of estrogen needed to support the pregnancy. *Pituitary* - The **pituitary gland** produces hormones like **FSH and LH**, which regulate ovarian function, but it does not directly secrete estrogen itself. - Its role is supervisory, not secretory of sex steroids. *Hypothalamus* - The **hypothalamus** secretes **gonadotropin-releasing hormone (GnRH)**, which stimulates the pituitary, but it does not produce estrogen. - It is part of the central control system for reproductive hormones, not a direct estrogen secretor.

Endocrinology of Pregnancy Indian Medical PG Question 9: What is the preferred insulin regimen during pregnancy?

• A. Insulin Regular + NPH
• B. Insulin NPH + Lispro (Correct Answer)
• C. Insulin Degludec
• D. Insulin Lispro + Insulin regular

Endocrinology of Pregnancy Explanation: ***Insulin NPH + Lispro*** - **NPH insulin** is a preferred basal insulin during pregnancy due to its long-standing safety record and intermediate duration of action [1]. - **Insulin Lispro** is a rapid-acting insulin analog that is safe and effective for postprandial glucose control in pregnant women [1]. *Insulin Regular + NPH* - While NPH is safe, **regular insulin** has a slower onset and longer duration compared to rapid-acting analogs, making it less ideal for precise postprandial control [2]. - Achieving tight glycemic control with regular insulin can be challenging due to its peak action occurring later, potentially leading to **postprandial hyperglycemia** or **unpredictable hypoglycemia** [2]. *Insulin Degludec* - **Insulin Degludec** is a newer ultra-long-acting insulin analog, and while effective, there is currently limited data on its long-term safety during pregnancy. - Due to insufficient robust safety data, it is generally **not the preferred first-line basal insulin** for pregnant women. *Insulin Lispro + Insulin regular* - This combination lacks a dedicated **basal insulin** component, which is crucial for maintaining fasting and between-meal glucose levels [2]. - Relying solely on rapid-acting and short-acting insulins without basal coverage would likely result in **poor glycemic control** throughout the day and night [1].

Endocrinology of Pregnancy Indian Medical PG Question 10: Consider the following statements regarding HCG : 1. HCG is a glycoprotein with two subunits α and β. 2. HCG levels reach the maximum between the 60th and 70th day in a normal pregnancy. 3. HCG is secreted by the syncytiotrophoblast. Which of the statements given above is/are correct ?

• A. 2 and 3 only
• B. 1 and 2 only
• C. 1 and 3 only
• D. 1, 2 and 3 (Correct Answer)

Endocrinology of Pregnancy Explanation: ***Correct: 1, 2 and 3*** - **Human Chorionic Gonadotropin (HCG)** is a **glycoprotein hormone** composed of **alpha (α) and beta (β) subunits**, making statement 1 correct - HCG is primarily secreted by the **syncytiotrophoblast** cells of the placenta, confirming statement 3 - In a normal pregnancy, HCG levels typically **peak between 60-70 days (8-10 weeks)** after the last menstrual period, supporting statement 2 - All three statements are factually accurate regarding HCG structure, secretion, and physiological levels *Incorrect: 2 and 3 only* - This option incorrectly excludes statement 1 about HCG being a glycoprotein with α and β subunits - The structural composition of HCG as a heterodimeric glycoprotein is a fundamental characteristic *Incorrect: 1 and 2 only* - This option incorrectly excludes statement 3 about syncytiotrophoblast being the source of HCG - The syncytiotrophoblast is the outer layer of the trophoblast responsible for HCG secretion *Incorrect: 1 and 3 only* - This option incorrectly excludes statement 2 about HCG peak timing during pregnancy - Understanding that HCG peaks at 8-10 weeks (60-70 days) is crucial for monitoring early pregnancy

Endocrinology of Pregnancy Flashcard 1 of 7

Question: During the second and third trimesters, 16-OH DHEA-sulfate is converted to _____ via the enzymes aromatase and sulfatase

Answer: estriol

Endocrinology of Pregnancy Flashcard 2 of 7

Question: During the second and third trimesters, the fetal _____ converts DHEA-sulfate to 16-hydroxy DHEA-sulfate

Answer: liver

Endocrinology of Pregnancy Flashcard 3 of 7

Question: _____ system: Classification of diabetes in pregnancy

Answer: Priscilla White

Endocrinology of Pregnancy Flashcard 4 of 7

Question: Placental _____ deficiency can present with maternal virilization during pregnancy

Answer: aromatase

Endocrinology of Pregnancy Flashcard 5 of 7

Question: During the second and third trimesters, the fetal _____ converts pregnenolone to DHEA-sulfate

Answer: adrenal gland

Endocrinology of Pregnancy Flashcard 6 of 7

Question: When is the prenatal rx for CAH started in a mother who has a previous child with CAH?_____

Answer: As soon as pregnancy is diagnosed

Endocrinology of Pregnancy Flashcard 7 of 7

Question: A _____-gram, three-hour oral glucose tolerance test (GTT), is the diagnostic test for gestational diabetes mellitus.

Answer: 100