A 26-year-old woman comes to the emergency department because of a 3-day history of nausea and vomiting. Her last menstrual period was 9 weeks ago. A urine pregnancy test is positive. Ultrasonography shows an intrauterine pregnancy consistent in size with a 7-week gestation. The hormone that was measured in this patient's urine to detect the pregnancy is also directly responsible for which of the following processes?
Q62
A 26-year-old woman, gravida 2, para 1, at 9 weeks' gestation comes to the physician with her 16-month-old son for her first prenatal visit. Her son has had low-grade fever, headache, and arthralgia for 5 days. He has also had a generalized rash that started on the cheeks 2 days ago and has since spread to his body. The woman has some mild nausea but is feeling well. Her first pregnancy was uneventful. Her son was delivered at 40 weeks' gestation via lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Current medications include prenatal vitamins with folic acid. Preconception rubella and varicella titers were recorded as adequate. His immunizations are up-to-date. His temperature is 36.8°C (98.2°F), pulse is 85/min, respirations are 13/min, and blood pressure is 114/65 mm Hg. Pelvic examination of the woman shows a uterus consistent in size with a 9-week gestation. An image of the woman's son is shown. A complete blood cell count is within normal limits. Which of the following is the most appropriate next step in management?
Q63
A 26-year-old G1P0 woman comes to her maternal and fetal medicine doctor at 15 weeks of gestation in order to be evaluated for fetal developmental abnormalities. Her family has a history of congenital disorders leading to difficulty walking so she was concerned about her child. Amniocentesis shows normal levels of all serum proteins and circulating factors. Despite this, the physician warns that there is a possibility that there may be a neural tube abnormality in this child even though the normal results make it less likely. If this child was born with a neural tube closure abnormality, which of the following findings would most likely be seen in the child?
Q64
A 17-year-old girl comes to the physician because she had unprotected sexual intercourse the previous day. Menses have occurred at regular 28-day intervals since menarche at the age of 13 years. Her last menstrual period was 12 days ago. Physical examination shows no abnormalities. A urine pregnancy test is negative. She does not wish to become pregnant until after college and does not want her parents to be informed of this visit. Which of the following is the most appropriate step in management?
Q65
A 14-year-old girl is brought to the pediatrician by her mother. The girl's mother states that she began having her period 6 months ago. The patient states that after her first period she has had a period every 10 to 40 days. Her menses have ranged from very light flow to intense and severe symptoms. Otherwise, the patient is doing well in school, is on the track team, and has a new boyfriend. Her temperature is 98.1°F (36.7°C), blood pressure is 97/58 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam demonstrates an obese girl but is otherwise within normal limits. Which of the following is the most likely diagnosis?
Q66
A 26-year-old woman, G1P0, at 22 weeks of gestation presents to the clinic for a prenatal visit. Her recent pregnancy scan shows a single live intrauterine fetus with adequate fetal movements. Facial appearance shows the presence of a cleft lip. The rest of the fetal development is within normal limits. The fetal heart rate is 138/min. Her prenatal screening tests for maternal serum α-fetoprotein (MSAFP) concentration, pregnancy-associated plasma protein-A (PAPP-A), and free β-human chorionic gonadotropin (β-hCG) are within normal ranges respectively. Her past medical and surgical histories are negative. She is worried about the health of her baby. The baby is at increased risk for which of the following birth defects?
Q67
A 19-year-old female complains of abnormal facial hair growth. This has been very stressful for her, especially in the setting of not being happy with her weight. Upon further questioning you learn she has a history of type 2 diabetes mellitus. Her height is 61 inches, and weight is 185 pounds (84 kg). Physical examination is notable for facial hair above her superior lip and velvety, greyish thickened hyperpigmented skin in the posterior neck. Patient is started on a hormonal oral contraceptive. Which of the following is a property of the endometrial protective hormone found in this oral contraceptive?
Q68
A 25-year-old G1P0 woman at 22 weeks’ gestation presents to the emergency department with persistent vomiting over the past 8 weeks which has resulted in 5.5 kg (12.1 lb) of unintentional weight loss. She has not received any routine prenatal care to this point. She reports having tried diet modification and over-the-counter remedies with no improvement. The patient's blood pressure is 103/75 mm Hg, pulse is 93/min, respiratory rate is 15/min, and temperature is 36.7°C (98.1°F). Physical examination reveals an anxious and fatigued-appearing young woman, but whose findings are otherwise within normal limits. What is the next and most important step in her management?
Q69
A 28-year-old primigravid woman comes to the physician at 27 weeks' gestation with increased urinary frequency, a burning sensation when urinating, flank pain, and nausea. Her pregnancy has been uncomplicated. Glucose tolerance testing performed at 25 weeks' gestation was normal. She is sexually active with her husband. Her only medication is a prenatal vitamin. Her pulse is 90/min, respirations are 16/min, and blood pressure is 125/75 mm Hg. Physical examination shows marked tenderness in the right costovertebral area. Pelvic examination shows a uterus consistent with 27 weeks' gestation. Her urine dipstick is positive for leukocyte esterase and nitrites. The urine is sent for bacterial culture. Which of the following changes most likely contributed to this patient's condition?
Q70
A 27-year-old woman, gravida 2, para 1, at 36 weeks' gestation comes to the physician for a prenatal visit. She feels well. Fetal movements are adequate. This is her 7th prenatal visit. She had an ultrasound scan performed 1 month ago that showed a live intrauterine pregnancy consistent with a 32-week gestation with no anomalies. She had a Pap smear performed 1 year ago, which was normal. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 36-week gestation. Her blood group and type is A negative. Which of the following is the most appropriate next step in management?
Prenatal Care US Medical PG Practice Questions and MCQs
Question 61: A 26-year-old woman comes to the emergency department because of a 3-day history of nausea and vomiting. Her last menstrual period was 9 weeks ago. A urine pregnancy test is positive. Ultrasonography shows an intrauterine pregnancy consistent in size with a 7-week gestation. The hormone that was measured in this patient's urine to detect the pregnancy is also directly responsible for which of the following processes?
A. Development of breast tissue
B. Preparation of the uterine endometrium for implantation
C. Inhibition of preterm uterine contractions
D. Maintenance of the corpus luteum (Correct Answer)
E. Inhibition of ovulation
Explanation: ***Maintenance of the corpus luteum***
- The hormone measured in the urine pregnancy test is **human chorionic gonadotropin (hCG)**.
- **hCG** acts like **luteinizing hormone (LH)** to maintain the **corpus luteum** in early pregnancy, ensuring continued progesterone production until the placenta takes over.
*Development of breast tissue*
- **Estrogen** and **progesterone** are the primary hormones responsible for the development of breast tissue during pregnancy, preparing the breasts for lactation.
- While hCG indirectly supports these hormones, it does not directly cause breast tissue development.
*Preparation of the uterine endometrium for implantation*
- The **preparation of the uterine endometrium** for implantation is primarily driven by **progesterone**, produced by the corpus luteum initially and later by the placenta.
- hCG’s role is to maintain the corpus luteum, thus indirectly supporting progesterone production.
*Inhibition of preterm uterine contractions*
- **Progesterone** is the main hormone responsible for **inhibiting uterine contractions** during pregnancy to prevent preterm labor.
- While hCG supports progesterone production, it does not directly inhibit uterine contractions itself.
*Inhibition of ovulation*
- High levels of **estrogen** and **progesterone** during pregnancy suppress the hypothalamic-pituitary-gonadal axis, thereby **inhibiting ovulation**.
- While hCG maintains the corpus luteum which produces these hormones, hCG itself is not the direct inhibitor of ovulation.
Question 62: A 26-year-old woman, gravida 2, para 1, at 9 weeks' gestation comes to the physician with her 16-month-old son for her first prenatal visit. Her son has had low-grade fever, headache, and arthralgia for 5 days. He has also had a generalized rash that started on the cheeks 2 days ago and has since spread to his body. The woman has some mild nausea but is feeling well. Her first pregnancy was uneventful. Her son was delivered at 40 weeks' gestation via lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Current medications include prenatal vitamins with folic acid. Preconception rubella and varicella titers were recorded as adequate. His immunizations are up-to-date. His temperature is 36.8°C (98.2°F), pulse is 85/min, respirations are 13/min, and blood pressure is 114/65 mm Hg. Pelvic examination of the woman shows a uterus consistent in size with a 9-week gestation. An image of the woman's son is shown. A complete blood cell count is within normal limits. Which of the following is the most appropriate next step in management?
A. Antibiotics for the child
B. Serial fetal ultrasounds
C. Report the disease to health authorities
D. Maternal serologic assays for virus-specific IgG and IgM (Correct Answer)
E. Isolation precautions for the child
Explanation: **Maternal serologic assays for virus-specific IgG and IgM**
- The child's symptoms (low-grade fever, headache, arthralgia, and a rash starting on the cheeks and spreading to the body, often described as a "slapped cheek" appearance) are highly suggestive of **Erythema Infectiosum** (fifth disease), caused by **Parvovirus B19**.
- Since the mother is pregnant and has been exposed, assessing her **immune status** (IgG) and recent infection (IgM) with Parvovirus B19 is crucial due to the potential for significant fetal complications, such as **hydrops fetalis**, anemia, and even fetal death.
*Antibiotics for the child*
- Erythema Infectiosum is a **viral infection**, therefore, antibiotics are **ineffective** and inappropriate for treatment.
- The clinical presentation clearly points away from a bacterial cause for the rash and systemic symptoms.
*Serial fetal ultrasounds*
- While **serial fetal ultrasounds** would be indicated if the mother tested positive for acute Parvovirus B19 infection to monitor for **fetal hydrops**, this is not the immediate **first step**.
- The first step is to confirm maternal infection status before initiating these more invasive and resource-intensive monitoring measures.
*Report the disease to health authorities*
- **Parvovirus B19 infection** is generally not a **nationally notifiable disease** that requires immediate reporting to public health authorities, unlike conditions such as measles or rubella.
- The primary concern here is the potential **vertical transmission** and fetal risk, which is managed clinically rather than through public health reporting.
*Isolation precautions for the child*
- By the time the characteristic rash of Erythema Infectiosum appears, the child is typically **no longer contagious**.
- Therefore, isolation precautions for the child at this stage would be unnecessary and would not prevent further spread.
Question 63: A 26-year-old G1P0 woman comes to her maternal and fetal medicine doctor at 15 weeks of gestation in order to be evaluated for fetal developmental abnormalities. Her family has a history of congenital disorders leading to difficulty walking so she was concerned about her child. Amniocentesis shows normal levels of all serum proteins and circulating factors. Despite this, the physician warns that there is a possibility that there may be a neural tube abnormality in this child even though the normal results make it less likely. If this child was born with a neural tube closure abnormality, which of the following findings would most likely be seen in the child?
A. Protrusion of the meninges and spinal cord through a bony defect
B. Protrusion of the meninges through a bony defect
C. Spinal cord able to be seen externally
D. Tuft of hair or skin dimple on lower back (Correct Answer)
E. Absence of the brain and calvarium
Explanation: ***Tuft of hair or skin dimple on lower back***
- This finding, particularly a **tuft of hair**, **skin dimple**, or **subcutaneous lipoma** on the lower back, is characteristic of **spina bifida occulta**.
- **Spina bifida occulta** is the least severe form of neural tube defect, where there is a bony defect in the vertebrae but the spinal cord and meninges remain within the spinal canal and are not externally evident.
*Protrusion of the meninges and spinal cord through a bony defect*
- This describes a **myelomeningocele**, which is a more severe form of spina bifida where the **spinal cord** and **meninges** protrude through a bony defect.
- Myelomeningocele typically presents with a visible sac on the back containing neural tissue, often leading to neurological deficits.
*Protrusion of the meninges through a bony defect*
- This describes a **meningocele**, where only the **meninges** protrude through a defect in the vertebral column, forming a fluid-filled sac.
- While it involves a visible sac, it does not contain neural tissue, and neurological symptoms are often absent or less severe compared to myelomeningocele.
*Spinal cord able to be seen externally*
- This is characteristic of **myeloschisis** or **rachischisis**, the most severe open neural tube defects where the **spinal cord** is open and exposed to the environment.
- This condition is often incompatible with life or leads to profound neurological impairment.
*Absence of the brain and calvarium*
- This describes **anencephaly**, a severe neural tube defect resulting from failure of closure of the anterior neural tube.
- Anencephaly is a lethal condition where the forebrain and cranial vault are absent, which is distinctly different from a spinal defect.
Question 64: A 17-year-old girl comes to the physician because she had unprotected sexual intercourse the previous day. Menses have occurred at regular 28-day intervals since menarche at the age of 13 years. Her last menstrual period was 12 days ago. Physical examination shows no abnormalities. A urine pregnancy test is negative. She does not wish to become pregnant until after college and does not want her parents to be informed of this visit. Which of the following is the most appropriate step in management?
A. Administer ulipristal acetate
B. Insert copper-containing intra-uterine device
(Correct Answer)
C. Administer mifepristone
D. Insert progestin-containing intra-uterine device
E. Administer combined oral contraceptive
Explanation: ***Insert copper-containing intra-uterine device***
- This is the **most effective form of emergency contraception**, offering >99% effectiveness and can be inserted up to 5 days after unprotected intercourse.
- It also provides highly effective long-term contraception, aligning with the patient's desire not to become pregnant until after college.
*Administer ulipristal acetate*
- While effective as emergency contraception, **ulipristal acetate** is less effective than the copper IUD, especially five days after intercourse.
- It provides only **short-term contraception** and would require the patient to return for long-term birth control.
*Administer mifepristone*
- **Mifepristone** is primarily an abortion pill used to terminate an existing pregnancy, not for emergency contraception.
- It would be inappropriate for a situation where pregnancy has not been confirmed and the goal is prevention.
*Insert progestin-containing intra-uterine device*
- **Progestin-containing IUDs** are excellent for long-term contraception but are **not approved or effective as emergency contraception**.
- Their mechanism of action primarily involves thickening cervical mucus and thinning the uterine lining, which takes time to become effective.
*Administer combined oral contraceptive*
- Combined oral contraceptives can be used as emergency contraception (the **Yuzpe method**) but are **less effective** than the copper IUD or ulipristal acetate.
- This method is associated with more side effects like nausea and vomiting, and requires multiple doses, which decreases compliance.
Question 65: A 14-year-old girl is brought to the pediatrician by her mother. The girl's mother states that she began having her period 6 months ago. The patient states that after her first period she has had a period every 10 to 40 days. Her menses have ranged from very light flow to intense and severe symptoms. Otherwise, the patient is doing well in school, is on the track team, and has a new boyfriend. Her temperature is 98.1°F (36.7°C), blood pressure is 97/58 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam demonstrates an obese girl but is otherwise within normal limits. Which of the following is the most likely diagnosis?
A. Normal development (Correct Answer)
B. Pregnancy
C. Polycystic ovarian syndrome
D. Premenstrual tension
E. Premenstrual dysphoric disorder
Explanation: ***Normal development***
- In the first 1-2 years after **menarche**, menstrual cycles are often **irregular** due to the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, leading to anovulatory cycles.
- The patient's presentation of varied cycle lengths (10-40 days) and flow intensity within 6 months of menarche is consistent with this common physiological phenomenon.
*Pregnancy*
- Although **amenorrhea** is a hallmark of pregnancy, the patient is experiencing periods, albeit irregular.
- There are no other signs or symptoms suggestive of pregnancy like nausea, breast tenderness, or abdominal enlargement.
*Polycystic ovarian syndrome*
- While **irregular menses** and **obesity** are features of PCOS, the patient's symptoms have only been present for a short time (6 months post-menarche).
- PCOS typically involves additional signs of **hyperandrogenism** (e.g., hirsutism, acne, alopecia) or characteristic ovarian morphology on ultrasound, which are not mentioned here.
*Premenstrual tension*
- **Premenstrual tension (PMT)**, often referred to as PMS, involves a constellation of emotional and physical symptoms that cyclically occur in the late luteal phase of the menstrual cycle and resolve with menses.
- The primary concern in this case is the **irregularity of her periods** and menstrual symptoms, rather than a consistent pattern of premenstrual mood or physical complaints separate from the flow itself.
*Premenstrual dysphoric disorder*
- **Premenstrual dysphoric disorder (PMDD)** is a severe form of PMS characterized by significant mood disturbances such as irritability, depression, and anxiety that profoundly affect daily functioning.
- The patient's reported symptoms focus on variability in her menstrual cycle and flow, not on severe, debilitating mood shifts occurring consistently before her menses, and she is otherwise noted to be "doing well."
Question 66: A 26-year-old woman, G1P0, at 22 weeks of gestation presents to the clinic for a prenatal visit. Her recent pregnancy scan shows a single live intrauterine fetus with adequate fetal movements. Facial appearance shows the presence of a cleft lip. The rest of the fetal development is within normal limits. The fetal heart rate is 138/min. Her prenatal screening tests for maternal serum α-fetoprotein (MSAFP) concentration, pregnancy-associated plasma protein-A (PAPP-A), and free β-human chorionic gonadotropin (β-hCG) are within normal ranges respectively. Her past medical and surgical histories are negative. She is worried about the health of her baby. The baby is at increased risk for which of the following birth defects?
A. Down syndrome
B. Neural tube abnormalities
C. Ocular abnormalities
D. Trisomy 13
E. Cleft palate (Correct Answer)
Explanation: ***Cleft palate***
- A **cleft lip** may occur in isolation or with a **cleft palate**, as both result from incomplete fusion of facial structures during embryonic development.
- The presence of a cleft lip strongly increases the likelihood of an associated cleft palate, forming a **cleft lip and palate (CLP)** spectrum of defects.
*Down syndrome*
- **Down syndrome (Trisomy 21)** is associated with facial dysmorphia but not typically isolated cleft lip.
- Additionally, maternal serum markers (MSAFP, PAPP-A, free β-hCG) were reported as **normal**, making Down syndrome less likely.
*Neural tube abnormalities*
- **Neural tube defects (NTDs)**, like **spina bifida** or **anencephaly**, are primarily associated with abnormal MSAFP levels, which are normal in this case.
- They involve defects of the brain or spinal cord and are not directly linked to cleft lip.
*Ocular abnormalities*
- While some genetic syndromes can involve both facial and ocular abnormalities, an isolated **cleft lip** does not specifically point to a higher risk of ocular defects compared to other associated anomalies.
- There is no direct anatomical or developmental connection between isolated cleft lip and increased risk of ocular abnormalities.
*Trisomy 13*
- **Trisomy 13 (Patau syndrome)** is often associated with a **cleft lip** and palate, but it also presents with severe multi-organ anomalies like **microphthalmia**, **polydactyly**, and significant developmental delays.
- The fetal development, apart from the cleft lip, is described as **otherwise normal**, and the maternal serum markers would likely be abnormal in Trisomy 13, making this diagnosis less probable.
Question 67: A 19-year-old female complains of abnormal facial hair growth. This has been very stressful for her, especially in the setting of not being happy with her weight. Upon further questioning you learn she has a history of type 2 diabetes mellitus. Her height is 61 inches, and weight is 185 pounds (84 kg). Physical examination is notable for facial hair above her superior lip and velvety, greyish thickened hyperpigmented skin in the posterior neck. Patient is started on a hormonal oral contraceptive. Which of the following is a property of the endometrial protective hormone found in this oral contraceptive?
A. Enhances tubal motility
B. Thickens cervical mucus (Correct Answer)
C. Increases bone fractures
D. Decreases LDL
E. Decreases thyroid binding globulin
Explanation: ***Thickens cervical mucus***
- The endometrial protective hormone in this oral contraceptive is **progestin**, which acts by **thickening cervical mucus**, making it impenetrable to sperm and thus preventing fertilization.
- This action is a key mechanism by which combined oral contraceptives prevent pregnancy, along with inhibiting ovulation.
*Enhances tubal motility*
- **Estrogen**, found in combined oral contraceptives, generally enhances tubal motility, but progestin's primary action for contraception is not tubal enhancement but rather making the cervical mucus inhospitable.
- Increased tubal motility could theoretically aid sperm transport or ovum capture, which is counterproductive to contraception.
*Increases bone fractures*
- **Hormonal contraceptives**, particularly combined oral contraceptives, are not typically associated with an **increased risk of bone fractures**; in fact, some studies suggest a protective or neutral effect on bone mineral density.
- **Estrogen** in combined oral contraceptives generally has a protective effect on bone density.
*Decreases LDL*
- While some hormonal therapies can impact lipid profiles, **oral contraceptives**, particularly those with certain progestins, can sometimes lead to a **slight increase in LDL** (low-density lipoprotein) and triglycerides, while estrogen components can elevate HDL.
- The net effect on LDL is not typically a decrease; therefore, this is not a property of the progestin component providing endometrial protection.
*Decreases thyroid binding globulin*
- **Estrogen** in oral contraceptives **increases the synthesis of thyroid-binding globulin (TBG)**, leading to higher total thyroid hormone levels, although free thyroid hormone levels usually remain normal.
- Progestins do not decrease TBG; therefore, this statement is incorrect.
Question 68: A 25-year-old G1P0 woman at 22 weeks’ gestation presents to the emergency department with persistent vomiting over the past 8 weeks which has resulted in 5.5 kg (12.1 lb) of unintentional weight loss. She has not received any routine prenatal care to this point. She reports having tried diet modification and over-the-counter remedies with no improvement. The patient's blood pressure is 103/75 mm Hg, pulse is 93/min, respiratory rate is 15/min, and temperature is 36.7°C (98.1°F). Physical examination reveals an anxious and fatigued-appearing young woman, but whose findings are otherwise within normal limits. What is the next and most important step in her management?
A. Begin treatment with vitamin B6
B. Begin treatment with metoclopramide
C. Obtain a basic electrolyte panel
D. Obtain a beta hCG and pelvic ultrasound
E. Admit and begin intravenous rehydration (Correct Answer)
Explanation: ***Admit and begin intravenous rehydration***
- The patient exhibits signs of **hyperemesis gravidarum**, including persistent vomiting, **significant weight loss** (5.5 kg), and inability to maintain hydration orally.
- **Intravenous rehydration** is crucial to correct dehydration and electrolyte imbalances, which can lead to serious complications if left untreated.
*Begin treatment with vitamin B6*
- While **pyridoxine (vitamin B6)** is a first-line treatment for **mild to moderate nausea and vomiting of pregnancy**, it is insufficient for severe cases involving significant weight loss and dehydration.
- This patient's symptoms are beyond what can be effectively addressed with vitamin B6 alone and require more aggressive management.
*Begin treatment with metoclopramide*
- **Metoclopramide** is an antiemetic that can be used for nausea and vomiting in pregnancy, but it is typically reserved for cases where first-line therapies (like vitamin B6) are ineffective.
- Before starting medication, especially in a severely dehydrated patient, addressing the immediate fluid and electrolyte deficits is paramount.
*Obtain a basic electrolyte panel*
- While obtaining an **electrolyte panel** is an important diagnostic step to assess the degree of electrolyte disturbance, it is not the *most important first step* in management.
- The patient's clinical presentation of persistent vomiting and weight loss clearly indicates the need for immediate intravenous rehydration regardless of initial electrolyte results.
*Obtain a beta hCG and pelvic ultrasound*
- A **beta hCG level** and **pelvic ultrasound** might be indicated later to rule out other causes of hyperemesis, such as **multiple gestation** or **molar pregnancy**.
- However, given the patient's acute symptoms of dehydration and weight loss, immediate stabilization with intravenous fluids takes precedence over diagnostic imaging.
Question 69: A 28-year-old primigravid woman comes to the physician at 27 weeks' gestation with increased urinary frequency, a burning sensation when urinating, flank pain, and nausea. Her pregnancy has been uncomplicated. Glucose tolerance testing performed at 25 weeks' gestation was normal. She is sexually active with her husband. Her only medication is a prenatal vitamin. Her pulse is 90/min, respirations are 16/min, and blood pressure is 125/75 mm Hg. Physical examination shows marked tenderness in the right costovertebral area. Pelvic examination shows a uterus consistent with 27 weeks' gestation. Her urine dipstick is positive for leukocyte esterase and nitrites. The urine is sent for bacterial culture. Which of the following changes most likely contributed to this patient's condition?
A. Increased body temperature
B. Decreased ureteral smooth muscle tone (Correct Answer)
C. Decreased urine volume
D. Increased urinary pH
E. Decreased urine glucose concentration
Explanation: ***Decreased ureteral smooth muscle tone***
- Hormonal changes during pregnancy, particularly elevated **progesterone**, lead to **relaxation of smooth muscle** in the ureters. This causes **ureteral dilation** and **stasis of urine**, increasing the risk of ascending infection.
- The resulting **hydroureteronephrosis** allows bacteria to ascend more easily from the bladder to the kidneys, predisposing the patient to **pyelonephritis**, as suggested by her symptoms of flank pain, fever (implied by symptoms), and costovertebral angle tenderness.
*Increased body temperature*
- While an increased body temperature (fever) is a symptom of infection, it is a **result** of the pyelonephritis, not a predisposing factor for it.
- An underlying infection leads to systemic inflammatory responses that cause fever, but higher baseline body temperature does not directly contribute to the development of the condition.
*Decreased urine volume*
- **Decreased urine volume** (e.g., dehydration) would lead to more concentrated urine, which can sometimes be associated with a higher risk of infection due to less frequent flushing of bacteria from the urinary tract.
- However, in pregnancy, women typically have **increased GFR** and often **increased urine volume**, and the primary predisposing factor for pyelonephritis is urinary stasis due to ureteral changes, not reduced volume.
*Increased urinary pH*
- An **increased urinary pH** can favor the growth of certain bacteria (e.g., *Proteus mirabilis*), which can produce urease and create an alkaline environment.
- However, in pregnancy, the hormonal and anatomical changes leading to **urinary stasis** are the more significant and direct contributors to the development of ascending UTIs like pyelonephritis.
*Decreased urine glucose concentration*
- A **decreased urine glucose concentration** is not a known risk factor for urinary tract infections or pyelonephritis.
- Women with **gestational diabetes** or uncontrolled diabetes (leading to increased urine glucose) are at higher risk for UTIs due to glucose providing a substrate for bacterial growth, so a *decreased* concentration would theoretically be protective or irrelevant.
Question 70: A 27-year-old woman, gravida 2, para 1, at 36 weeks' gestation comes to the physician for a prenatal visit. She feels well. Fetal movements are adequate. This is her 7th prenatal visit. She had an ultrasound scan performed 1 month ago that showed a live intrauterine pregnancy consistent with a 32-week gestation with no anomalies. She had a Pap smear performed 1 year ago, which was normal. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 36-week gestation. Her blood group and type is A negative. Which of the following is the most appropriate next step in management?
A. Transabdominal doppler ultrasonography
B. Rh antibody testing
C. Swab for GBS culture (Correct Answer)
D. Serum PAPP-A and HCG levels
E. Complete blood count
Explanation: ***Swab for GBS culture***
- All pregnant women should be screened for **Group B Streptococcus (GBS)** between **36 weeks 0 days and 37 weeks 6 days** of gestation.
- A positive GBS culture requires **intrapartum antibiotic prophylaxis** to prevent early-onset neonatal GBS disease.
*Transabdominal doppler ultrasonography*
- **Doppler ultrasonography** is primarily used to assess **fetal well-being** in cases of **fetal growth restriction**, preeclampsia, or other high-risk conditions.
- This patient has a **normal-sized uterus** and **adequate fetal movements**, indicating no immediate need for fetal Doppler assessment.
*Rh antibody testing*
- **Rh antibody testing** (indirect Coombs test) is performed early in pregnancy for Rh-negative women and typically repeated at **28 weeks' gestation** before anti-D immune globulin administration.
- Repeating this test at 36 weeks is not the most appropriate *next* step as the routine schedule for Rh immune globulin would typically be managed prior to this point.
*Serum PAPP-A and HCG levels*
- **Serum PAPP-A and HCG levels** are components of **first-trimester screening** for chromosomal abnormalities, performed between 11 and 14 weeks of gestation.
- At 36 weeks' gestation, these markers are not relevant for current fetal assessment.
*Complete blood count*
- A **complete blood count (CBC)** is routinely performed in the first trimester and often repeated in the **late second or early third trimester** (around 28 weeks) to check for anemia.
- While a CBC might be done as part of general prenatal care, it is not the most urgent or specifically indicated test at 36 weeks in the absence of symptoms.
