EBCOG P1 – 3 month May 2022 – Maternal Medicine Part 1 – Thyroid disorder – Day 6

1.You are asked to review a 32-year-old woman in the antenatal clinic who is currently 13 weeks into her fourth pregnancy. She had an uncomplicated vaginal delivery at term 7 years ago followed by two first-trimester miscarriages. She was diagnosed with IgA nephropathy and needed a renal transplant (allograft) 2 years ago. There is no other medical and no surgical history of note. She is not a smoker. Currently, she is on prednisolone, azathioprine and tacrolimus. Her BMI is 26, her blood pressure is 130/84 mmHg and she is not on any antihypertensive treatment. Her recent blood test results are:

haemoglobin = 10.2 g/dl

serum albumin = 32 g/dl

serum creatinine level = 110 micromol/l

eGFR = 53

urine protein:creatinine ratio = 15

Her CMV titres were negative 4 months ago.

Which of the following statement is most appropriate in her case regarding pregnancy outcome and management?

2.You are asked to review 21-year-old woman in the maternity assessment unit who is currently at 26 weeks of gestation. She had been feeling unwell for the last 24 hours and presented with fever with rigor, right loin pain, urinary frequency and vomiting. There is no history of abdominal tightenings or vaginal loss and she reports normal fetal movements.

On examination:

pulse rate = 106 bpm

blood pressure = 110/70 mmHg

respiratory rate = 16 breaths per minute

temperature = 38.2ºC

moderate right renal angle tenderness

well-grown baby with normal fetal heart rate on auscultation with hand-held Doppler.

Urinalysis reveals ++ proteinuria, ++ red cells, +++ leucocytes and nitrite positive.

You have made a diagnosis of pyelonephritis.

Which of the following statement is correct regarding pyelonephritis in pregnancy?

3.You are asked to review the renal scan for Mrs Smith who is currently at 35 weeks of gestation and has presented with right loin pain, which started 1 week ago. She is haemodynamically stable, apyrexial with minimal right renal angle tenderness. Urinalysis is negative. Her renal function is normal, with serum urea at 3.4 mmol/l and serum creatinine at 40 micromol/l. There is mild hydronephrosis of right kidney, probably secondary to gravid uterus, but it is an otherwise normal-looking kidney on renal scan.Which of the following statement is correct regarding physiological renal adaptation to pregnancy?

4.Mrs S is referred by her GP to the antenatal clinic for her booking visit as she had a caesarean section in the past. She is otherwise fit and healthy with no significant past medical history. She is currently 11 weeks pregnant by her dating scan. She reports no problems with her pregnancy so far. You were looking through her booking bloods and MSU results done by her midwife 5 days ago. The MSU showed growth of E. coli >105 colony forming units per millilitre. She denies any urinary symptoms.You have made a diagnosis of asymptomatic bacteriuria.Which of the following statement is correct regarding asymptomatic bacteriuria in pregnancy?

5.You are asked to review a 36-year-old woman in a joint obstetric–renal clinic who is currently 16 weeks pregnant into her second pregnancy. She had an uncomplicated caesarean section at term for breech presentation 13 years ago.She was diagnosed with reflux nephropathy and has been on haemodialysis for last 2 years. There is no other medical and surgical history of note. She is not a smoker. Currently she is on calcium and vitamin D supplements, erythropoietin injection and pregnancy vitamins.Her BMI at her booking visit is 20. Her BP is 120/78 mm Hg and she is not on any antihypertensives.

A recent blood test showed:

haemoglobin = 102 gm/l

serum potassium level = 4.8 mmol/l

serum creatinine level = 210 micromol/l

serum urea level = 10 mmol/l

eGFR = 10 ml/min/1.73m2

normal bone profile

normal plasma bicarbonate levels

urine protein creatinine ratio: 95.

Which of the following statement is most appropriate in her case regarding pregnancy outcome and management?

6.You are asked to review a 28-year-old woman in the obstetric-renal clinic with chronic kidney disease stage 3 secondary to reflux nephropathy and recurrent urinary tract infections (UTIs). She has a BMI of 22, is a non-smoker and is planning her first pregnancy.She has hypertension that is well controlled with ramipril. She takes nitrofurantoin 100 mg once daily at night as antibiotic prophylaxis for her recurrent UTIs.Her blood pressure is 135/85 mmHg and on urinalysis she has proteinuria 3+. Her most recent serum creatinine is 150 and her eGFR is 38. Her most recent protein:creatinine ratio was 350 mg/mmol creatinine.What is the most appropriate medication addition or change at this stage in her prepregnancy planning?

7.A 30-year-old woman is seen in the antenatal clinic. She is 24 weeks into her first pregnancy. She has a history of recurrent urinary tract infections outside of pregnancy. Renal ultrasound and baseline renal function tests were normal. She has been treated for three urinary tract infections in pregnancy so far. She is allergic to nitrofurantoin. The most recent MSU result shows:

white blood cells = 277/ul (0–40)

red blood cells = 4/ul (0–44)

epithelial cells = 17/ul (0–55)

Culture: >105 organisms/ml of Enterococcus species:

co-amoxiclav = S

cefalexin = R

ciprofloxacillin = R

pivmecillinam = R

nitrofurantoin = S

trimethoprim = S

You decide that prophylactic antibiotics are indicated. What is the most appropriate antimicrobial regimen to prescribe?

8.You are part of the team managing a 24-year-old pregnant woman who developed acute kidney injury at 28 weeks of gestation following a road traffic accident. What will be the pregnancy-specific indication for considering renal replacement in this woman?

9.Mrs.Fathima, 34year old , is here for pre conceptional counseling .she is known case of renal transplant .she is on Mycophenolate Mofetil .How Long she  is advised  to wait before conceiving

10.All are true regarding  Thyroid dysfunction in pregnancy except

11..Mrs, Jiya, 24 year old primigravida is her for anomaly scan ,on examination

What’s the most common cause for this ?

12.The fetus is dependent on maternal thyroid hormone until autonomous fetal thy- roid function begins at around  ——weeks’ gestation.

4.mrs, Reena , primigravida 22 weeks gestation  with hypothyroidism she is on eltroxin 25mcg , as her Hemoglobin is 90g/l , she is on iron (ferrous sulphate )which she takes sling with Eltroxin 25mcg ,

14.In overt hypothyroidism, thyroxine should be commenced and adjusted in what increments?

15.Mrs, x , A 27-year-old woman with Graves’ disease,. She is currently on 40 mg daily and has had a previous miscarriage presented with labour pain .she delivers normally .on examination Baby has this .

Which drug she might be on?

17.A 27-year-old woman with Graves’ disease attends your clinic for pre-pregnancy care. She is currently on carbimazole 40 mg daily and has had a previous miscarriage. Compliance has been an issue in the past. Thyroid function tests were performed by her general practitioner, which showed fT4 = 32 and TSH <0.1.She asks you about the risk of her baby having an overactive thyroid.

17.You are the Consultant responsible for an 18-year-old nulliparous woman with pre-existing Graves’ disease. She is 28 weeks pregnant on PTU 50 mg daily with TFTs of fT4 = 27 and TSH <0.1.

Her fetus is small for dates with a fetal tachycardia of 170 bpm.

What is the risk of mortality rate of baby in utero without treatment ?

18.Mrs, g A 36-year-old woman in her third pregnancy visits your antenatal clinic at 16 weeks of gestation. She complains of lethargy and TFTs show a fT4 = 10.8 with a TSH = 10.she has no significant past history .The commonest cause encountered in pregnancy ia

19.You are the Consultant responsible for a 29-year-old woman with no previous history of thyroid disorders.  She is type 1 DM on insulin You see her at her postnatal visit at 6 weeks of gestation when she complains of palpitations, sweats and tremors.

TFTs are measured and show fT4 = 31 and TSH <0.1.

thyroid peroxidase (TPO) antibodies positive .

What’s the probable diagnosis ?