Section 3: Obstetrics 3

Question 1

Hypertension (BP ≥ 140/ 90 mm Hg) during pregnancy can be classified as chronic hypertension or gestational hypertension. Both types of hypertension predispose the mother and the fetus to more serious conditions

List the differential diagnosis of hypertension that is accompanied by signs and symptoms of end-organ damage or neurological sequelae

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12867-12887). Kaplan Publishing. Kindle Edition.

Answer 1

• Preeclampsia
• Eclampsia
• HELLP syndrome

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12867-12887). Kaplan Publishing. Kindle Edition.

Question 2

Warning signs of maternal jeopardy in HTN in pregnancy

Answer 2

1. Hallmark symptoms:
   
   • Headache
   • Epigastric pain
   • Changes in vision
2. Signs:
   
   • Pulmonary edema
   • Oliguria (Peripheral edema is not a warning sign.)
3. Labs:
   
   • Thrombocytopenia
   • Elevated liver enzymes

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12867-12887). Kaplan Publishing. Kindle Edition.

Question 3

Risk of sustained maternal HTN on the fetus

Answer 3

IUGR

Hypoxia

Abruptio placenta

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12888-12906). Kaplan Publishing. Kindle Edition.

Question 4

Define:

Chronic HTN

Gestational HTN

Preeclampsia

Mild preeclampsia

Severe preeclampsia

Answer 4

Chronic hypertension is the diagnosis when there is a history of elevated blood pressure before pregnancy or before 20 weeks’ gestation

Gestational hypertension is the diagnosis when blood pressure develops after 20 weeks’ gestation and returns to normal baseline by 6 weeks post-partum. It occurs more commonly in multifetal pregnancy

Preeclampsia is the diagnosis when there is proteinuria and/ or presence of “warning signs.”

Mild preeclampsia is indicated with:

• Sustained BP elevation > 140/ 90 mm Hg
• Proteinuria of 1– 2 + (on dipstick) or > 300 mg (on a 24-hour urine)

Severe preeclampsia is indicated by mild preeclampsia plus one of the following:

• Sustained BP elevation > 160/110 mm Hg
• Proteinuria of 3– 4 + (on dipstick) or > 5 g (on 24-hour urine)
• Presence of “warning signs”

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12888-12906). Kaplan Publishing. Kindle Edition.

Question 5

List the risk factors for preeclampsia

Answer 5

• Primiparas are most at risk.
• Multiple gestation
• Hydatidi-form mole
• Diabetes mellitus
• Age extremes
• Chronic hypertension
• Chronic renal disease

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12906-12927). Kaplan Publishing. Kindle Edition.

Question 6

A 19-year-old primigravida presents at 32 weeks’ gestation for routine follow-up. She denies headache, epigastric pain, or visual disturbances. She has gained 2 pounds since her last visit 2 weeks ago. On examination, her blood pressure is 155/ 95, which is persistent on repeat BP check 10 minutes later. She has only trace pedal edema. Which of the following is the next step in management?

a. Begin methyldopa
b. Begin labetalol
c. Perform an electrocardiogram
d. Perform a fetal ultrasound
e. Perform urinalysis

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12906-12927). Kaplan Publishing. Kindle Edition.

Answer 6

E. Always rule out preeclampsia in a hypertensive pregnant patient. Even if she is asymptomatic, proteinuria indicates preeclampsia and a worse prognosis

** Seizure disorder is not a risk factor for eclampsia.**

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12906-12927). Kaplan Publishing. Kindle Edition.

Question 7

Define:

Chronic hypertension with superimposed preeclampsia

Eclampsia

HELLP

Answer 7

Chronic hypertension with superimposed preeclampsia is the diagnosis when there is chronic hypertension with increasingly severe hypertension, proteinuria, and/ or “warning signs.”

Eclampsia is the diagnosis when the case describes unexplained grand mal seizures in a hypertensive and/ or proteinuric pregnant woman in the last half of pregnancy. Patients present with same signs and symptoms as in pre-eclampsia with the addition of unexplained tonic-clonic seizures. Seizures from severe diffuse cerebral vasospasm cause cerebral perfusion deficits and edema.

HELLP syndrome is the diagnosis when there is hemolysis (H), elevated liver (EL) enzymes, and low platelets (LP).

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12906-12927). Kaplan Publishing. Kindle Edition.

Question 8

Outline the diagnostic tests to be done in HTN in pregnancy

Answer 8

1. CBC
   
   • ↑ hemoglobin, ↑ hematocrit
2. Chem-12 panel
   
   • ↑ blood urea nitrogen (BUN), ↑ serum creatinine, and ↑ serum uric acid
3. Coagulation panel
   
   • DIC, elevated liver enzymes (severe preeclampsia)
4. Urinalysis with urinary protein
   
   • Proteinuria

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12927-12946). Kaplan Publishing. Kindle Edition.

Question 9

Rx of HTN in pregnancy

Blood pressure control

Answer 9

The only definitive cure is delivery and removal of all fetal-placental tissue

Blood pressure control:

1. Don’t treat unless BP > 160/ 100 mm Hg (antihypertensives decrease uteroplacental blood flow)
2. Goal SBP is 140– 150 mm Hg and DBP is 90– 100 mm Hg
3. Maintenance therapy:
   
   • First line therapy is methyldopa
   • Second line therapy is β-blockers (labetalol, atenolol). Watch out for intrauterine growth restriction (IUGR), which is associated with β-blocker use in pregnancy
4. Acutely elevated BP/ treatment of severe preeclampsia or eclampsia:
   
   • Intravenous hydralazine or labetalol
5. Never give ACE inhibitors or start thiazide diuretics during pregnancy

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12947-12974). Kaplan Publishing. Kindle Edition.

Question 10

**HTN in pregnancy **

Seizure management and prophylaxis

Monitoring

Answer 10

Seizure management and prophylaxis:

• Protect the patient’s airway and tongue
• Give IV MgSO4 (magnesium sulfate) bolus for seizure and infusion for continued prophylaxis

Monitoring:

• Serial sonograms (evaluate for intrauterine growth restriction [IUGR])
• Serial BP monitoring and urine protein

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12947-12974). Kaplan Publishing. Kindle Edition.

Question 11

HTN in pregnancy

Mgnt of labor

Answer 11

• Induce labor if ≥ 36 weeks with mild preeclampsia: attempt vaginal delivery with IV oxytocin if mother and fetus are stable
• Aggressive, prompt delivery is the best step for severe/ superimposed pre-eclampsia or eclampsia at any gestational age
• Give intrapartum IV MgSO4 and hydralazine and/ or labetalol to manage BP

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12947-12974). Kaplan Publishing. Kindle Edition.

Question 12

A 32-year-old multigravida at 36 weeks’ gestation was found to have BP 160/ 105 on routine prenatal visit. Previous BP readings were normal. She complained of some right-upper-quadrant abdominal pain. Urinalysis showed 3 + proteinuria. She is emergently induced for labor and delivers an 8 lb. 3 oz. boy. Two days after delivery, routine labs reveal elevated total bilirubin, lactate dehydrogenase, alanine aminotransferase (ALT), and aspartate aminotransferase (AST). Platelet count is 85,000. Postpartum evaluation reveals that she has no complaints of headache or visual changes. Which of the following is the most likely diagnosis?

a. Cholecystitis
b. HELLP syndrome
c. Hepatitis
d. Gestational thrombocytopenia
e. Preeclampsia

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12974-12995). Kaplan Publishing. Kindle Edition.

Answer 12

B. Patient has evidence of hemolysis (elevated LDH), elevated liver enzymes, and thrombocytopenia

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12974-12995). Kaplan Publishing. Kindle Edition.

Question 13

List the features of gestational thrombocytopenia

Answer 13

• Most common cause of thrombocytopenia in pregnancy
• Mild: Counts > 70,000
• Not associated with other abnormalities, and no symptoms
• Usually develops in third trimester

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12974-12995). Kaplan Publishing. Kindle Edition.

Question 14

HELLP syndrome occurs in 5– 10 percent of preeclamptic patients. It typically presents in the third trimester but may occur in the postpartum period,commonly presenting 2 days after delivery. Risk factors differ from preeclampsia, since HELLP syndrome is more common in whites, multigravids, and women of older maternal age.

Outline the treatment

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12996-13007). Kaplan Publishing. Kindle Edition.

Answer 14

• Schedule immediate delivery at any gestational age
• Give IV corticosteroids (dexamethasone) when platelets < 100,000/mm3 both antepartum and postpartum; continue until platelet count is > 100,000/mm3 and liver function normalizes
• Give platelet transfusion if platelet count < 20,000/mm3 or platelet count < 50,000/mm3 if cesarean section will be performed
• IV MgSO4 for seizure prophylaxis, even if BP is normal
• Steroids may also need to be considered for assistance with fetal lung maturation if prior to 36 weeks

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12996-13007). Kaplan Publishing. Kindle Edition.

Question 15

List the complications of HELLP syndrome

Answer 15

• DIC
• Abruptio placenta
• Fetal demise
• Ascites
• Hepatic rupture

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 12996-13007). Kaplan Publishing. Kindle Edition.

Question 16

1. True or False: Heart disorders account for about 10 percent of maternal obstetric deaths
2. True or False: Women with high-risk disorders (e.g., pulmonary hypertension, Eisenmenger syndrome, severe valvular disorders, prior postpartum cardiomyopathy) should be advised to become pregnant
3. Cardiovascular changes in pregnancy (30– 50 percent ↑ cardiac output [CO]) may unmask or worsen underlying cardiac conditions. When are these changes maximal?
4. Most dangerous seizure medication
5. What seizure medication is/are proven safe in pregnancy

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13009-13018). Kaplan Publishing. Kindle Edition.

Answer 16

1. True
2. False. They should be advised not to become pregnant due to risk of sudden death
3. These changes are maximal at 28 and 34 weeks’ gestation
4. Valproate
5. None

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13009-13018). Kaplan Publishing. Kindle Edition.

Question 17

Peripartum Cardiomyopathy

Heart failure with no identifiable cause can develop between the last month of pregnancy to 5 months postpartum.

List the risk factors

What is the 5 year mortality rate?

Answer 17

Risk factors

• Multiparity
• Age ≥ 30
• Multiple gestations (i.e., twins or triplets, etc.), and preeclampsia

The 5-year mortality rate is 50 percent.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13009-13018). Kaplan Publishing. Kindle Edition.

Question 18

1. True or False: Risk of maternal or fetal death is associated with class III or IV heart failure
2. Medications NOT to use
3. Medications to continue using
4. True or False: Digoxin may be used in pregnancy to improve symptoms, but it does not improve outcome

Answer 18

1. True
2. ACE inhibitor or aldosterone antagonist
3. Loop diuretics, nitrates, and ß-blockers
4. True

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13020-13030). Kaplan Publishing. Kindle Edition.

Question 19

True or False:

1. Arrhythmias: Continue rate control as with nonpregnant patients
2. Arrhythmias: Do not give amiodarone or warfarin
3. Endocarditis Prophylaxis: Indications are the same as for nonpregnant patients
4. Endocarditis Prophylaxis: Give daily prophylaxis in patients with rheumatic heart disease
5. Endocarditis Prophylaxis: Do not give prophylactic antibiotics during uncomplicated vaginal/ cesarean delivery in patients with valvular disease or prosthetic valves
6. Valvular Disease: Regurgitant lesions are well tolerated and do not require therapy
7. Valvular Disease: Stenotic lesions have an increased risk of maternal/ fetal morbidity and mortality
8. Valvular Disease: Mitral stenosis has an increased risk of pulmonary edema and atrial fibrillation

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13020-13030). Kaplan Publishing. Kindle Edition.

Answer 19

1. True
2. True
3. True
4. True
5. True
6. True
7. True
8. True

Question 20

Pulmonary embolus is the leading cause of maternal death in the United States. Fifty percent of pregnant women who develop thromboemboli have an underlying thrombophilic disorder.

indications for anticoagulation in pregnancy?

Answer 20

• DVT or PE in pregnancy
• Atrial fibrillation (AF) with underlying heart disease, but not atrial fibrillation alone
• Antiphospholipid syndrome
• Severe heart failure (ejection fraction [EF]) < 30 percent)
• Eisenmenger syndrome

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13030-13051). Kaplan Publishing. Kindle Edition.

Question 21

1. Anticoagulant of choice in pregnancy
2. What are the advantages to answer to (1)
3. Why is warfarin contraindicated in preganncy

Answer 21

1. LMWH.
2. LMWH does not cross the placenta (warfarin does cross the placenta and is contraindicated in pregnancy) and isn’t associated with osteopenia (unfractionated heparin causes osteopenia)
3. Because it causes fetal abnormalities and even death. Patients with a history of DVT or PE in a previous pregnancy or a history of underlying thrombophilic condition should receive prophylactic LMWH throughout pregnancy,

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13030-13051). Kaplan Publishing. Kindle Edition.

Question 22

Management of patients with a history of DVT or PE in a previous pregnancy or a history of underlying thrombophilic

True or False: Thrombolytics are used in pulmonary embolism with the same indications as in the nonpregnant patient

Answer 22

Management:

• Prophylactic LMWH throughout pregnancy
• Unfractionated heparin during labor and delivery
• Warfarin for 6 weeks postpartum

True

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13051-13067). Kaplan Publishing. Kindle Edition.

Question 23

List the most common underlying thrombophilias

Answer 23

• Factor V Leiden mutation
• Prothrombin gene mutation
• Antiphospholipid syndrome
• Hyperhomocysteinemia (MTHFR)
• Antithrombin III deficiency

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13051-13067). Kaplan Publishing. Kindle Edition.

Question 24

1. Effect of hyperthyroidism on the fetus
2. Effect of hypothyroidism on the fetus
3. True or False: Pregnancy does not change the symptoms of hypothyroidism or hyperthyroidism or the normal values and ranges of free serum thyroxine (T4) and thyroid-stimulating hormone (TSH)
4. True or False: Hormone replacement should be continued in patients with hypothyroidism during pregnancy
5. True or False: The dose of levothyroxine should be incresed by 50 - 60 percent when hypothyroid patients become pregnant
6. True or False: Triiodothyronine or desiccated thyroid are alternative medications in hypothyroidism
7. True or False: Beta blockers are the drug of choice for symptomatic hyperthyroidism
8. True or False: Radioactive iodine is never given in pregnancy

Answer 24

1. Fetal growth restriction and stillbirth
2. Intellectual deficits in offspring and miscarriage
3. True
4. True
5. False. Increment should be by 25-30%
6. False
7. True
8. True

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13051-13067). Kaplan Publishing. Kindle Edition.

Question 25

1. Drug of choice for Graves disease in pregnancy 2. True or False: PTU crosses the placenta and may cause goiter and hypothyroidism in the fetus 3. True or False: Congenital Graves’ disease in the fetus may be masked until 7 to 10 days after birth, when the drug’s effect subsides 4. True or False: Maternal thyroid-stimulating immunoglobulins (Igs) and thyroid-blocking Igs can cross the placenta 5. Effects of (4) on the fetus if any

Answer 25

1. Propylthiouracil (PTU). (methimazole is the second line therapy). 2. True 3. True 4. True 5. Fetal tachycardia, growth restriction, and goiter Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13067-13080). Kaplan Publishing. Kindle Edition.

Question 26

Diabetes in Pregnancy 1. What are the target values for FBS and serum glucose 1 hour after meal 2. Initial management of gestational diabetes (GD) 3. Management of GD if (2) fails 4. True or False: Insulin requirements increase throughout the course of the pregnancy including the immediate post-partum period 5. Avoid oral hypoglycemics while breastfeeding, as they can cause hypoglycemia in neonates

Answer 26

1. FBS \< 90 mg/ dL and \< 120 mg/ dL for 1 hour after a meal 2. Diet and light exercise 3. Insulin 4. False. Insulin requirements increase throughout the course of the pregnancy **but decrease** as soon as the placenta is delivered 5. True Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13067-13080). Kaplan Publishing. Kindle Edition.

Question 27

List the routine monitoring in diabetic patients

Answer 27

* ** HbA1c** in each trimester * **Triple-marker screen at 16– 18 weeks** to assess for neural tube defects (NTD) **Monthly sonograms** to assess fetal macrosomia or IUGR * **Monthly biophysical profiles** * **Start weekly nonstress test (NST)** and amniotic fluid index (AFI) at 32 weeks if taking insulin, macrosomia, previous stillbirth, or hypertension * **Start NSTs and AFIs at 26 weeks if small vessel disease is present** or there is poor glycemic control. * For gestational diabetes mellitus (GDM) patients, order a 2-hour 75 g OGTT 6– 12 weeks postpartum to determine if diabetes has resolved. – Thirty-five percent of women with GDM will develop overt diabetes within 5 to 10 years after delivery. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13080-13095). Kaplan Publishing. Kindle Edition.

Question 28

True or False: 1. Caudal regression syndrome is a common congenital abnormality associated with overt DM 2. Congenital malformations (especially NTDs) are strongly associated with HbA1c \> 8.5 in the first trimester 3. GDM is not associated with congenital anomalies, since hyperglycemia is not present in the first half of pregnancy.

Answer 28

1. True 2. True 3. True Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13096-13110). Kaplan Publishing. Kindle Edition.

Question 29

Outline the management of labor in a diabetic patient

Answer 29

* Larget delivery gestational age is 40 weeks because of delayed fetal maturity * Induce labor at 39– 40 weeks if \< 4,500 g or earlier if there is poor glycemic control. **A lecithin/ sphingomyelin (L/ S) ratio of 2.5 and presence of phosphatidyl glycerol ensures fetal lung maturity** * Schedule cesarean section if **\> 4,500 g** because of the risk of **shoulder dystocia** * Maintain maternal blood glucose levels between **80 and 100 mg/ dL using 5 percent dextrose in water and an insulin drip**. * Turn off any insulin infusion after delivery, because insulin resistance decreases with rapidly falling levels of hPL after delivery of the placenta. Maintain blood glucose levels with a sliding scale Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13096-13110). Kaplan Publishing. Kindle Edition.

Question 30

Complications of IODM

Answer 30

* **Hypoglycemia** (maternal hyperinsulinemia) * **Hypocalcemia** (PTH synthesis failure) * **Polycythemia** (hypoxia) * **Hyperbilirubinemia** (excessive neonatal RBCs breakdown) * **Respiratory distress syndrome** (delayed surfactant production)

Question 31

Describe the symptoms, diagnosis, and Rx of intrahepatic cholestasis of pregnancy

Answer 31

**Symptoms**: Classic symptoms include i**ntractable nocturnal pruritus** on the palms and soles of the feet without skin findings **Diagnosis**: ***_10- to 100-fold increase in serum bile acids_*** **Treatment**: **Ursodeoxycholic acid** is the treatment of choice. Symptoms may be relieved by antihistamines and cholestyramine. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13110-13127). Kaplan Publishing. Kindle Edition.

Question 32

31-year-old primigravida woman presents at 20 weeks’ gestation with dizygotic twins of different genders. She is of Swedish descent and complains of intense skin itching. Her sister experienced similar complaints when she was pregnant and delivered her baby prematurely. No identifiable rash is noted on physical examination. She states that her urine appears dark colored. What is the diagnosis? Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13110-13127). Kaplan Publishing. Kindle Edition.

Answer 32

The diagnosis is **intrahepatic cholestasis of pregnancy**. It occurs in genetically susceptible women (of **European heritage**) and is associated with **multiple pregnancies**. Symptoms: Classic symptoms include intractable nocturnal pruritus on the palms and soles of the feet without skin findings. Diagnosis: 10- to 100-fold increase in serum bile acids Treatment: Ursodeoxycholic acid is the treatment of choice. Symptoms may be relieved by antihistamines and cholestyramine. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13110-13127). Kaplan Publishing. Kindle Edition.

Question 33

A 29-year-old primigravida is at 33 weeks’ gestation. She is brought to the maternity unit by her husband, who states she is becoming confused. She developed nausea, vomiting, and anorexia 3 days ago associated with a lack of appetite. Fundal height is 30 cm. Fetal heart rate is 145/ min with nonreactive nonstress test. Mother’s BP is 150/ 95 mm Hg. Random blood glucose is 52 mg/ dL. Platelet count is 75,000. PTT is prolonged at 64.7 seconds. Creatinine is 2.1 mg/ dL. Uric acid is 11.9 mg/ dL, LDH is 1063 U/ I, ALT is 220 U/ I, AST is 350 U/ I, total bilirubin is 8.4 mg/ dL. Serum ammonia is elevated. Urine protein dipstick is 3 +. What is the diagnosis?

Answer 33

The diagnosis is **acute fatty liver**. This rare condition is related to disordered metabolism of fatty acids by mitochondria in the fetus. Hypertension, proteinuria, and edema can mimic preeclampsia Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13128-13160). Kaplan Publishing. Kindle Edition.

Question 34

How is the diagnosis of acute fatty liver made?

Answer 34

* Elevated liver enzymes (e.g., ALT, AST, GGT) * Hyperbilirubinemia * DIC * Hypoglycemia * Increased **serum ammonia** **Hypoglycemia and increased serum ammonia are unique laboratory abnormalities.** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13128-13160). Kaplan Publishing. Kindle Edition.

Question 35

Rx of acute fatty liver

Answer 35

Admit to the ICU for **aggressive IV fluid** treatment and **prompt delivery** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13128-13160). Kaplan Publishing. Kindle Edition.

Question 36

State the diagnosis, Rx and complication of the following: * Urine culture (+) * No urgency, frequency, or burning * No fever

Answer 36

Diagnosis: **Asymptomatic bacteriuria** Rx: Outpatient PO antibiotics (**Nitrofurantoin** is drug of choice; alt: Cephalexin or amoxicillin) Cx: 30% of cases develop acute pyelonephritis when untreated Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13128-13160). Kaplan Publishing. Kindle Edition.

Question 37

State the diagnosis, Rx and complication of the following: * Urine culture (+) * Urgency, frequency, or burning * No fever

Answer 37

Diagnosis: **Acute cystitis** Rx: Outpatient PO antibiotics (**Nitrofurantoin** is drug of choice; alt: **Cephalexin** or **amoxicillin**) Cx: 30% of cases develop acute pyelonephritis when untreated Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13128-13160). Kaplan Publishing. Kindle Edition.

Question 38

State the diagnosis, Rx and complication (Cx) of the following: * Urine culture (+) * Urgency, frequency, or burning * Fever and CVA tenderness

Answer 38

Diagnosis: Pyelonephritis Rx: * Admit to hospital * IV hydration * IV cephalosporins or gentamicin * Tocolysis Cx: * Preterm labor and delivery * Severe cases → sepsis, anemia, and pulmonary