Renal disease in pregnancy — MCQs

10 questions

A 24-year-old primigravida presents to her physician for regular prenatal care at 31 weeks gestation. She has no complaints and the antepartum course has been uncomplicated. Her pre-gestational history is significant for obesity (BMI = 30.5 kg/m2). She has gained a total of 10 kg (22.4 lb) during pregnancy, and 2 kg (4.48 lb) since her last visit 4 weeks ago. Her vital signs are as follows: blood pressure, 145/90 mm Hg; heart rate, 87/min; respiratory rate, 14/min; and temperature, 36.7℃ (98℉). The fetal heart rate is 153/min. The physical examination shows no edema and is only significant for a 2/6 systolic murmur best heard at the apex of the heart. A 24-hour urine is negative for protein. Which of the following options describe the best management strategy in this case?

A 35-year-old woman, gravida 2, para 1, at 16 weeks' gestation comes to the office for a prenatal visit. She reports increased urinary frequency but otherwise feels well. Pregnancy and delivery of her first child were uncomplicated. Her vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 16-week gestation. Urinalysis shows mild glucosuria. Laboratory studies show a non-fasting serum glucose concentration of 110 mg/dL. Which of the following is the most likely explanation for this patient's glucosuria?

A 36-year-old woman, gravida 2, para 1, at 30 weeks' gestation comes to the physician for evaluation of increased urinary frequency. She has no history of major medical illness. Physical examination shows no abnormalities. Laboratory studies show an increased serum C-peptide concentration. Ultrasonography shows polyhydramnios and a large for gestational age fetus. Which of the following hormones is predominantly responsible for the observed laboratory changes in this patient?

A 22-year-old primigravida is admitted to the obstetrics ward with leg swelling at 35 weeks gestation. She denies any other symptoms. Her pregnancy has been uneventful and she was compliant with the recommended prenatal care. Her vital signs were as follows: blood pressure, 168/95 mm Hg; heart rate, 86/min; respiratory rate, 16/min; and temperature, 36.7℃ (98℉). The fetal heart rate was 141/min. The physical examination was significant for 2+ pitting edema of the lower extremity. A dipstick test shows 1+ proteinuria. On reassessment 15 minutes later without administration of an antihypertensive, her blood pressure was 141/88 mm Hg, and the fetal heart rate was 147/min. A decision was made to observe the patient and continue the work-up without initiating antihypertensive therapy. Which of the following clinical features would make the suspected diagnosis into a more severe form?

A 36-year-old primigravida woman visits her gynecologist during the 28th week of her pregnancy. Physical examination reveals pitting edema around her ankles and elevated systolic blood pressure. 24-hour urine collection yields 4 grams of protein. If left untreated, the patient is most at increased risk for which of the following:

A 27-year-old woman presents to her primary care physician for a concern about her pregnancy. This is her first pregnancy, and she is currently at 33 weeks gestation. She states that she has experienced diffuse swelling of her ankles and legs and is concerned that it is abnormal. Otherwise, she has no concerns. The patient has a past medical history of obesity and diabetes. Her temperature is 98.5°F (36.9°C), blood pressure is 147/92 mmHg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 97% on room air. Physical exam reveals bilateral edema of the lower extremities. Which of the following is the best next step in management?

A 32-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the physician for a prenatal visit. She reports that she has had frequent headaches and dizziness recently. Pregnancy and delivery of her first child were uncomplicated. There is no personal or family history of serious illness. Medications include folic acid and a multivitamin. Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 170/100 mm Hg. Pelvic examination shows a uterus consistent in size with a 32-week gestation. Physical examination shows 2+ edema in the lower extremities. Laboratory studies show: Hematocrit 37% Leukocyte count 9000/mm3 Platelet count 60,000/mm3 Serum Na+ 140 mEq/L Cl- 104 mEq/L K+ 4.4 mEq/L Creatinine 1.0 mg/dL Aspartate aminotransferase 20 U/L Alanine aminotransferase 20 U/L Which of the following is the most appropriate next step in management?

A 25-year-old woman presents to her physician with a missed mense and occasional morning nausea. Her menstrual cycles have previously been normal and on time. She has hypothyroidism resulting from Hashimoto thyroiditis diagnosed 2 years ago. She receives levothyroxine (50 mcg daily) and is euthyroid. She does not take any other medications, including birth control pills. At the time of presentation, her vital signs are as follows: blood pressure 120/80 mm Hg, heart rate 68/min, respiratory rate 12/min, and temperature 36.5℃ (97.7℉). The physical examination shows slight breast engorgement and nipple hyperpigmentation. The gynecologic examination reveals cervical softening and increased mobility. The uterus is enlarged. There are no adnexal masses. The thyroid panel is as follows: Thyroid stimulating hormone (TSH) 3.41 mU/L Total T4 111 nmol/L Free T4 20 pmol/L Which of the following adjustments should be made to the patient’s therapy?

A 28-year-old woman at 28 weeks gestation seeks evaluation at her obstetrician’s office with complaints of a severe headache, blurred vision, and vomiting for the past 2 days. Her pregnancy has been otherwise uneventful. The past medical history is unremarkable. The blood pressure is 195/150 mm Hg and the pulse is 88/min. On examination, moderate pitting edema is present in her ankles. The urinalysis is normal except for 3+ proteinuria. The obstetrician orders a complete blood count (CBC), liver function tests (LFTs), creatinine, and a coagulation profile. The obstetrician transfers her to the hospital by ambulance for expectant management. Which of the following medications would be most helpful for this patient?

Q10

A 25-year-old woman, gravida 2, para 1, at 25 weeks' gestation comes to the emergency department because of a 1-day history of fever and right-sided flank pain. During this period, she also had chills, nausea, vomiting, and burning on urination. Her last prenatal visit was 10 weeks ago. Pregnancy and delivery of her first child were uncomplicated. Her temperature is 39°C (102.2°F), pulse is 110/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Physical examination shows costovertebral angle tenderness on the right. The abdomen is soft and nontender, and no contractions are felt. Pelvic examination shows a uterus consistent in size with a 25-week gestation. Fetal heart rate is 170/min. Laboratory studies show: Leukocyte count 15,000/mm3 Urine Nitrite 2+ Protein 1+ Blood 1+ RBC 5/hpf WBC 500/hpf Blood and urine samples are obtained for culture and drug sensitivity. Which of the following is the most appropriate next step in management?

Renal disease in pregnancy US Medical PG Practice Questions and MCQs

Question 1: A 24-year-old primigravida presents to her physician for regular prenatal care at 31 weeks gestation. She has no complaints and the antepartum course has been uncomplicated. Her pre-gestational history is significant for obesity (BMI = 30.5 kg/m2). She has gained a total of 10 kg (22.4 lb) during pregnancy, and 2 kg (4.48 lb) since her last visit 4 weeks ago. Her vital signs are as follows: blood pressure, 145/90 mm Hg; heart rate, 87/min; respiratory rate, 14/min; and temperature, 36.7℃ (98℉). The fetal heart rate is 153/min. The physical examination shows no edema and is only significant for a 2/6 systolic murmur best heard at the apex of the heart. A 24-hour urine is negative for protein. Which of the following options describe the best management strategy in this case?

A. Treatment in outpatient settings with labetalol
B. Treatment in the outpatient settings with nifedipine
C. Observation in the outpatient settings (Correct Answer)
D. Treatment in the inpatient settings with methyldopa
E. Admission to hospital for observation

Explanation: ***Observation in the outpatient settings*** - The patient's blood pressure is 145/90 mmHg, which meets the criteria for **gestational hypertension** according to ACOG (systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg on two occasions at least 4 hours apart after 20 weeks gestation in a previously normotensive woman, without proteinuria). - Since this is a single elevated blood pressure reading (not yet confirmed by a second reading after 4 hours) and there is no evidence of **proteinuria** or **severe features** (e.g., severe headache, visual disturbances, epigastric pain, elevated liver enzymes, thrombocytopenia, pulmonary edema), **close outpatient monitoring** is the appropriate initial step. *Treatment in outpatient settings with labetalol* - **Antihypertensive medication** is typically initiated for gestational hypertension if BP is consistently ≥160/110 mmHg, or if there are signs of severe features. - While labetalol is a safe and common first-line agent, starting treatment based on a **single, non-severe elevated BP reading** without confirmed gestational hypertension or severe features is premature. *Treatment in the outpatient settings with nifedipine* - Similar to labetalol, **nifedipine** is an appropriate antihypertensive if medication is warranted for gestational hypertension. - However, initiating medication is not the **first step** for an isolated, non-severe elevated blood pressure reading without confirmed diagnosis or severe features. *Treatment in the inpatient settings with methyldopa* - **Inpatient treatment** is reserved for patients with severe gestational hypertension, preeclampsia with severe features, or uncontrollable hypertension. - While methyldopa is a safe antihypertensive in pregnancy, inpatient treatment is **not indicated** for this patient's presentation. *Admission to hospital for observation* - **Hospital admission** for observation is generally reserved for patients with more severe hypertension, suspected preeclampsia with severe features, or concerns about fetal well-being. - Given the patient's **asymptomatic state**, normal fetal heart rate, and lack of proteinuria or severe features, inpatient admission is **unnecessary** at this stage.

Question 2: A 35-year-old woman, gravida 2, para 1, at 16 weeks' gestation comes to the office for a prenatal visit. She reports increased urinary frequency but otherwise feels well. Pregnancy and delivery of her first child were uncomplicated. Her vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 16-week gestation. Urinalysis shows mild glucosuria. Laboratory studies show a non-fasting serum glucose concentration of 110 mg/dL. Which of the following is the most likely explanation for this patient's glucosuria?

A. Decreased SGLT2 expression
B. Increased glomerular filtration barrier permeability
C. Decreased insulin production
D. Decreased insulin sensitivity
E. Increased glomerular filtration rate (Correct Answer)

Explanation: ***Increased glomerular filtration rate*** - During pregnancy, the **glomerular filtration rate (GFR)** significantly increases, leading to a higher filtered load of glucose. - This increased load can exceed the reabsorptive capacity of the renal tubules, resulting in **glucosuria** despite normal blood glucose levels. *Decreased SGLT2 expression* - **SGLT2 inhibitors** are medications that decrease glucose reabsorption in the renal tubules, but there is no physiological decrease in SGLT2 expression during normal pregnancy that would cause glucosuria with normal blood glucose. - SGLT2 expression itself is generally not altered in a way that leads to isolated glucosuria in healthy pregnancy. *Increased glomerular filtration barrier permeability* - Increased permeability of the **glomerular filtration barrier** would primarily lead to **proteinuria**, not glucosuria. - Glucosuria implies glucose passing through the barrier normally but being uncleared by the tubules. *Decreased insulin production* - **Decreased insulin production** would lead to **hyperglycemia** in addition to glucosuria, which is not seen here as the non-fasting glucose is 110 mg/dL, well within the normal range. - The patient's blood glucose is normal, ruling out significant insulin deficiency. *Decreased insulin sensitivity* - **Decreased insulin sensitivity** (insulin resistance) is a hallmark of gestational diabetes, but it would primarily cause **hyperglycemia**, which is not present in this patient (non-fasting glucose 110 mg/dL). - While some insulin resistance occurs in pregnancy, it wouldn't cause glucosuria with normal blood glucose in the absence of other factors.

Question 3: A 36-year-old woman, gravida 2, para 1, at 30 weeks' gestation comes to the physician for evaluation of increased urinary frequency. She has no history of major medical illness. Physical examination shows no abnormalities. Laboratory studies show an increased serum C-peptide concentration. Ultrasonography shows polyhydramnios and a large for gestational age fetus. Which of the following hormones is predominantly responsible for the observed laboratory changes in this patient?

A. Human placental lactogen (Correct Answer)
B. Adrenocorticotropic hormone
C. Human chorionic gonadotropin
D. Progesterone
E. Estrogen

Explanation: ***Human placental lactogen*** - **Human placental lactogen (hPL)**, also known as **chorionic somatomammotropin**, is produced by the placenta and has **anti-insulin effects**, increasing maternal blood glucose to prioritize fetal nutrient supply. - This **insulin resistance** leads to increased maternal insulin production (reflected by **elevated C-peptide**) to compensate, and if inadequate, results in **gestational diabetes mellitus (GDM)**, which explains the **polyhydramnios** and **large for gestational age fetus**. *Adrenocorticotropic hormone* - **ACTH** stimulates the **adrenal cortex** to produce **cortisol**, which also has diabetogenic effects. - However, **hPL** is the primary hormone responsible for the **insulin resistance** of pregnancy and the associated elevated C-peptide and GDM features (polyhydramnios and large for gestational age fetus) in this context. *Human chorionic gonadotropin* - **hCG** is crucial for maintaining the **corpus luteum** in early pregnancy, stimulating **progesterone** production, and is used as a marker for pregnancy. - It does not directly cause the **insulin resistance** or significantly elevate C-peptide that leads to the observed findings of **polyhydramnios** and a **large for gestational age fetus**. *Progesterone* - **Progesterone** is essential for maintaining pregnancy by promoting **endometrial growth** and suppressing uterine contractions. - While it plays a role in some metabolic changes during pregnancy, it is not the primary hormone responsible for the **insulin-antagonistic effects** that lead to the elevated C-peptide and signs of GDM described. *Estrogen* - **Estrogen** promotes uterine growth, maintains the **endometrium**, and plays a role in fetal development and the development of maternal secondary sexual characteristics. - While it contributes to metabolic changes in pregnancy, it is not the main hormone responsible for the **insulin resistance** and related features like elevated C-peptide, polyhydramnios, and a large for gestational age fetus seen in this patient.

Question 4: A 22-year-old primigravida is admitted to the obstetrics ward with leg swelling at 35 weeks gestation. She denies any other symptoms. Her pregnancy has been uneventful and she was compliant with the recommended prenatal care. Her vital signs were as follows: blood pressure, 168/95 mm Hg; heart rate, 86/min; respiratory rate, 16/min; and temperature, 36.7℃ (98℉). The fetal heart rate was 141/min. The physical examination was significant for 2+ pitting edema of the lower extremity. A dipstick test shows 1+ proteinuria. On reassessment 15 minutes later without administration of an antihypertensive, her blood pressure was 141/88 mm Hg, and the fetal heart rate was 147/min. A decision was made to observe the patient and continue the work-up without initiating antihypertensive therapy. Which of the following clinical features would make the suspected diagnosis into a more severe form?

A. Serum creatinine 0.98 mg/dL
B. 24-hour urinary protein of 5 g/L (Correct Answer)
C. Hematocrit of 0.55
D. Platelet count 133,000/μL
E. Blood pressure of 165/90 mm Hg reassessed 4 hours later

Explanation: ***24-hour urinary protein of 5 g/L*** - A 24-hour urine protein collection exceeding **5 g/L (or 5000 mg)** is a criterion for **severe preeclampsia**, indicating significant renal involvement. - This level of proteinuria suggests extensive **glomerular damage** and impaired renal function beyond what is seen in mild preeclampsia. *Serum creatinine 0.98 mg/dL* - A serum **creatinine of 0.98 mg/dL** is within the normal range for this patient and does not indicate renal insufficiency or severe preeclampsia. - Renal dysfunction in severe preeclampsia is typically defined by a **creatinine >1.1 mg/dL** or a doubling of baseline creatinine. *Hematocrit of 0.55* - A **hematocrit of 0.55 (55%)** might indicate hemoconcentration, but not necessarily severe preeclampsia. **Hemoconcentration** is common in preeclampsia due to plasma volume contraction but is not a primary diagnostic criterion for severity. - Severe preeclampsia is often associated with **microangiopathic hemolytic anemia**, which would typically manifest as a *decreasing* hematocrit due to red blood cell destruction. *Platelet count 133,000/μL* - A **platelet count of 133,000/μL** is within the normal range or slightly below, but it is not indicative of severe **thrombocytopenia**. - **Severe thrombocytopenia** in preeclampsia is defined as a platelet count **<100,000/μL**. *Blood pressure of 165/90 mm Hg reassessed 4 hours later* - This blood pressure reading, while elevated, does not meet the criteria for severe preeclampsia on its own, as **severe hypertension** is defined as **systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg on two occasions at least 4 hours apart** while the patient is on bed rest. - The initial reading improved, and this single elevated reading after 4 hours requires another confirming reading to classify as severe hypertension.

Question 5: A 36-year-old primigravida woman visits her gynecologist during the 28th week of her pregnancy. Physical examination reveals pitting edema around her ankles and elevated systolic blood pressure. 24-hour urine collection yields 4 grams of protein. If left untreated, the patient is most at increased risk for which of the following:

A. Thrombocytosis
B. Gestational diabetes
C. Hemolysis (Correct Answer)
D. Placenta accreta
E. Eclampsia

Explanation: **Hemolysis** - The patient's presentation with **new-onset hypertension** (elevated systolic blood pressure), **proteinuria** (>300 mg/24 hours or 4 grams in this case), and **edema** strongly suggests **preeclampsia**. - If left untreated, preeclampsia can progress to **HELLP syndrome** (**H**emolysis, **E**levated **L**iver enzymes, **L**ow **P**latelets), where **hemolysis** is a primary component. *Thrombocytosis* - **Preeclampsia** and its severe forms, like HELLP syndrome, are associated with **thrombocytopenia** (low platelets), not thrombocytosis (elevated platelets). - **Thrombocytosis** is generally not a complication of severe preeclampsia or eclampsia. *Gestational diabetes* - While **gestational diabetes** is a common pregnancy complication, it is characterized by **glucose intolerance** and is not directly linked to the patient's symptoms of hypertension and proteinuria. - The primary risk from gestational diabetes is for macrosomia, neonatal hypoglycemia, and increased future risk of type 2 diabetes, not the direct complications of severe preeclampsia. *Placenta accreta* - **Placenta accreta** is a condition where the placenta abnormally adheres to the uterine wall, typically presenting with **heavy bleeding during delivery**. - It is not a direct complication of untreated preeclampsia, although both can increase maternal morbidity. *Eclampsia* - **Eclampsia** is defined by the occurrence of **new-onset grand mal seizures** in a woman with preeclampsia, without a history of epilepsy. - While eclampsia is a severe complication of untreated preeclampsia, **hemolysis** (as part of HELLP syndrome) is also a critical and direct potential consequence that can occur with severe preeclampsia, even before seizures manifest.

Question 6: A 27-year-old woman presents to her primary care physician for a concern about her pregnancy. This is her first pregnancy, and she is currently at 33 weeks gestation. She states that she has experienced diffuse swelling of her ankles and legs and is concerned that it is abnormal. Otherwise, she has no concerns. The patient has a past medical history of obesity and diabetes. Her temperature is 98.5°F (36.9°C), blood pressure is 147/92 mmHg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 97% on room air. Physical exam reveals bilateral edema of the lower extremities. Which of the following is the best next step in management?

A. Urinalysis and urine protein
B. Echocardiography
C. Reassurance and followup in 1 week
D. A 24 hour urine protein
E. Spot protein to creatinine ratio (Correct Answer)

Explanation: ***Spot protein to creatinine ratio*** - The patient presents with **hypertension** (147/92 mmHg) and **edema** in the third trimester of pregnancy, raising suspicion for **preeclampsia**. - A spot urine protein-to-creatinine ratio is a **rapid** and **convenient screening test** to assess for significant proteinuria, which is a diagnostic criterion for preeclampsia. *Urinalysis and urine protein* - While a urinalysis can detect protein, it is **qualitative** and less precise than quantitative methods for diagnosing preeclampsia. - A plain urine dipstick for protein can yield **false positives** or **false negatives**, making it an unreliable sole diagnostic test for proteinuria in this context. *Echocardiography* - Echocardiography is primarily used to evaluate **cardiac function** and structure, and there are no signs or symptoms in this patient suggesting primary cardiac pathology. - While preeclampsia can affect the heart, an echocardiogram is **not the initial diagnostic step** for suspected preeclampsia itself. *Reassurance and followup in 1 week* - Given the elevated blood pressure and edema, **preeclampsia is a serious concern** that requires immediate evaluation, not delayed follow-up. - Delaying assessment could lead to progression of the condition, increasing risks for both the mother and the fetus. *A 24 hour urine protein* - A 24-hour urine collection for protein is considered the **gold standard** for quantifying proteinuria. - However, it is **time-consuming** and less practical as an initial rapid assessment tool compared to a spot protein-to-creatinine ratio when immediate evaluation for preeclampsia is warranted.

Question 7: A 32-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the physician for a prenatal visit. She reports that she has had frequent headaches and dizziness recently. Pregnancy and delivery of her first child were uncomplicated. There is no personal or family history of serious illness. Medications include folic acid and a multivitamin. Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 170/100 mm Hg. Pelvic examination shows a uterus consistent in size with a 32-week gestation. Physical examination shows 2+ edema in the lower extremities. Laboratory studies show: Hematocrit 37% Leukocyte count 9000/mm3 Platelet count 60,000/mm3 Serum Na+ 140 mEq/L Cl- 104 mEq/L K+ 4.4 mEq/L Creatinine 1.0 mg/dL Aspartate aminotransferase 20 U/L Alanine aminotransferase 20 U/L Which of the following is the most appropriate next step in management?

A. Magnesium sulfate and labetalol therapy (Correct Answer)
B. Lisinopril therapy
C. Platelet transfusion
D. Perform C-section
E. Admit the patient to the ICU

Explanation: ***Magnesium sulfate and labetalol therapy*** - This patient presents with **severe preeclampsia** (new-onset hypertension with systolic BP ≥160 or diastolic BP ≥110, or hypertension with proteinuria and features of end-organ damage such as headache, vision changes, thrombocytopenia, and elevated liver enzymes). - **Magnesium sulfate** is crucial for **seizure prophylaxis** in severe preeclampsia, while **labetalol** is an appropriate **antihypertensive** to manage the dangerously high blood pressure. *Lisinopril therapy* - **ACE inhibitors** like lisinopril are **contraindicated in pregnancy** due to their potential for serious fetal adverse effects, including renal dysfunction and oligohydramnios. - While it lowers blood pressure, its use in pregnancy would be harmful to the fetus. *Platelet transfusion* - Although the patient has **thrombocytopenia** (platelet count 60,000/mm3), a transfusion is generally **not indicated acutely** unless there is active bleeding or the platelet count is critically low (e.g., <10,000-20,000/mm3) or before an invasive procedure. - The primary issue is the underlying severe preeclampsia, which needs to be addressed first. *Perform C-section* - While **delivery** is the definitive treatment for severe preeclampsia, the patient is at **32 weeks' gestation**, and immediate C-section might not be necessary if the condition can be stabilized. - The priority is to **magnesium sulfate for seizure prophylaxis** and **control the blood pressure** before considering the timing and mode of delivery, which would typically be after stabilization and potentially a course of corticosteroids for fetal lung maturity if time permits. *Admit the patient to the ICU* - Although severe preeclampsia warrants close monitoring, **initial management often occurs on a labor and delivery unit** with appropriate nursing and medical staff experienced in obstetric emergencies. - ICU admission might be considered for cases with more severe complications or multi-organ failure, but the immediate next step is to initiate specific therapies for preeclampsia.

Question 8: A 25-year-old woman presents to her physician with a missed mense and occasional morning nausea. Her menstrual cycles have previously been normal and on time. She has hypothyroidism resulting from Hashimoto thyroiditis diagnosed 2 years ago. She receives levothyroxine (50 mcg daily) and is euthyroid. She does not take any other medications, including birth control pills. At the time of presentation, her vital signs are as follows: blood pressure 120/80 mm Hg, heart rate 68/min, respiratory rate 12/min, and temperature 36.5℃ (97.7℉). The physical examination shows slight breast engorgement and nipple hyperpigmentation. The gynecologic examination reveals cervical softening and increased mobility. The uterus is enlarged. There are no adnexal masses. The thyroid panel is as follows: Thyroid stimulating hormone (TSH) 3.41 mU/L Total T4 111 nmol/L Free T4 20 pmol/L Which of the following adjustments should be made to the patient’s therapy?

A. Increase levothyroxine dosage by 20%–30% (Correct Answer)
B. Decrease levothyroxine dosage by 30%
C. Discontinue levothyroxine
D. The patient is euthyroid, so no adjustments should be made
E. Increase levothyroxine dosage by 5% each week up to 50%

Explanation: ***Increase levothyroxine dosage by 20%–30%*** - The patient's symptoms (missed menses, nausea, breast changes, enlarged uterus, cervical changes) are highly suggestive of **pregnancy**. During pregnancy, **thyroid hormone requirements increase significantly** due to increased levels of **thyroid-binding globulin (TBG)** stimulated by estrogen, and the production of **human chorionic gonadotropin (hCG)** which has TSH-like activity. - The recommended management for pregnant women with hypothyroidism is to **increase the levothyroxine dose by approximately 25-50%** and monitor TSH and free T4 levels every 4-6 weeks to maintain a TSH level within the goal range for pregnancy (typically <2.5 mU/L in the first trimester). *Decrease levothyroxine dosage by 30%* - Decreasing levothyroxine would lead to **hypothyroidism**, which is detrimental in pregnancy and associated with adverse outcomes such as **preeclampsia**, **gestational hypertension**, **low birth weight**, and **neurocognitive impairment** in the offspring. - Thyroid hormone requirements increase, not decrease, during pregnancy. *Discontinue levothyroxine* - **Discontinuing levothyroxine** would result in severe hypothyroidism, posing significant risks to both the mother and the developing fetus. - Hypothyroidism must be treated throughout pregnancy to ensure proper fetal development. *The patient is euthyroid, so no adjustments should be made* - While the patient's thyroid panel currently shows euthyroid values (TSH 3.41 mU/L is within normal range but slightly elevated for first-trimester pregnancy goals), the **onset of pregnancy** rapidly increases thyroid hormone demand. - Failure to adjust the dose can lead to **maternal and fetal hypothyroidism** as pregnancy progresses, even if the patient is currently euthyroid. *Increase levothyroxine dosage by 5% each week up to 50%* - A gradual increase of 5% each week may be too slow and insufficient to meet the rapidly increasing thyroid hormone demands of early pregnancy. - The standard recommendation is to make a more substantial initial adjustment (20-30%) as soon as pregnancy is confirmed, followed by close monitoring and further adjustments.

Question 9: A 28-year-old woman at 28 weeks gestation seeks evaluation at her obstetrician’s office with complaints of a severe headache, blurred vision, and vomiting for the past 2 days. Her pregnancy has been otherwise uneventful. The past medical history is unremarkable. The blood pressure is 195/150 mm Hg and the pulse is 88/min. On examination, moderate pitting edema is present in her ankles. The urinalysis is normal except for 3+ proteinuria. The obstetrician orders a complete blood count (CBC), liver function tests (LFTs), creatinine, and a coagulation profile. The obstetrician transfers her to the hospital by ambulance for expectant management. Which of the following medications would be most helpful for this patient?

A. Olmesartan
B. Lisinopril
C. Nifedipine (Correct Answer)
D. Hydrochlorothiazide
E. Metoprolol

Explanation: ***Nifedipine*** - The patient presents with **severe preeclampsia** (hypertension, proteinuria, and symptoms like headache and blurred vision), necessitating immediate **blood pressure reduction**. [1] - **Nifedipine** is a **calcium channel blocker** that is effective and safe for acute blood pressure control in pregnancy, and is a first-line agent in this context. [1] *Olmesartan* - **Olmesartan** is an **angiotensin receptor blocker (ARB)**, which is **contraindicated in pregnancy** due to the risk of fetal renal toxicity and other adverse outcomes. - ARBs can cause **fetal growth restriction**, oligohydramnios, and neonatal renal failure during the second and third trimesters. *Lisinopril* - **Lisinopril** is an **ACE inhibitor**, which, like ARBs, is **contraindicated in pregnancy** due to its teratogenic effects, particularly in the second and third trimesters. - It can lead to **fetal renal dysfunction**, oligohydramnios, and other severe birth defects. *Hydrochlorothiazide* - **Hydrochlorothiazide** is a **thiazide diuretic**; while sometimes used in chronic hypertension in pregnancy, it is **not appropriate for acute, severe hypertension** in preeclampsia. - Diuretics can reduce maternal intravascular volume, which is already compromised in preeclampsia, potentially worsening placental perfusion and fetal well-being. *Metoprolol* - **Metoprolol** is a **beta-blocker** sometimes used for chronic hypertension in pregnancy, but it may not be the optimal choice for **acute, severe hypertension** in preeclampsia. - While generally considered safe, it can be associated with **fetal growth restriction** and **neonatal bradycardia** or hypoglycemia, and other agents like nifedipine or labetalol are often preferred for acute management.

Question 10: A 25-year-old woman, gravida 2, para 1, at 25 weeks' gestation comes to the emergency department because of a 1-day history of fever and right-sided flank pain. During this period, she also had chills, nausea, vomiting, and burning on urination. Her last prenatal visit was 10 weeks ago. Pregnancy and delivery of her first child were uncomplicated. Her temperature is 39°C (102.2°F), pulse is 110/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Physical examination shows costovertebral angle tenderness on the right. The abdomen is soft and nontender, and no contractions are felt. Pelvic examination shows a uterus consistent in size with a 25-week gestation. Fetal heart rate is 170/min. Laboratory studies show: Leukocyte count 15,000/mm3 Urine Nitrite 2+ Protein 1+ Blood 1+ RBC 5/hpf WBC 500/hpf Blood and urine samples are obtained for culture and drug sensitivity. Which of the following is the most appropriate next step in management?

A. Inpatient treatment with intravenous ceftriaxone (Correct Answer)
B. Perform a renal ultrasound
C. Outpatient treatment with oral ciprofloxacin
D. Inpatient treatment with intravenous ampicillin and gentamicin
E. Admit the patient and request an emergent obstetrical consult

Explanation: ***Inpatient treatment with intravenous ceftriaxone*** - The patient presents with classic signs of **pyelonephritis** (fever, flank pain, nausea, vomiting, CVA tenderness) in pregnancy, which warrants **inpatient admission** and **IV antibiotics** to prevent complications such as sepsis, preterm labor, and fetal compromise. - **Ceftriaxone** is a broad-spectrum cephalosporin that is safe and effective in pregnancy for treating urinary tract infections, including pyelonephritis. *Perform a renal ultrasound* - While a **renal ultrasound** may be considered in cases of persistent fever after 48-72 hours of antibiotic therapy or if there's suspicion of obstruction or abscess, it is **not the immediate next step**. - The priority is to initiate antibiotics promptly to treat the acute infection and prevent further complications. *Outpatient treatment with oral ciprofloxacin* - **Outpatient treatment** is inappropriate for **pyelonephritis in pregnancy** due to the high risk of complications for both the mother and the fetus. - **Ciprofloxacin** (a fluoroquinolone) is generally **contraindicated in pregnancy** because of potential adverse effects on fetal cartilage development. *Inpatient treatment with intravenous ampicillin and gentamicin* - Although **ampicillin and gentamicin** are effective for many UTIs and safe in pregnancy, they are often reserved for cases where local resistance patterns favor this combination or as a second-line option. - **Ceftriaxone** is a preferred first-line empiric choice for pyelonephritis in pregnancy due to its broad coverage and once-daily dosing. *Admit the patient and request an emergent obstetrical consult* - While admitting the patient is correct, **immediately requesting an emergent obstetrical consult** is premature as the primary issue is an acute infection requiring medical management. - Obstetrics consultation is important in managing high-risk pregnancies or complications like preterm labor, but antibiotics for pyelonephritis should be initiated first, and then an obstetrician can be consulted for comanagement.

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