A 26-year-old gravida 2 para 1 presents at 30 weeks gestation with a complaint of severe itching. She has excoriations from scratching in various areas. She says that she had the same problem during her last pregnancy, and her medical records reveal a diagnosis of intrahepatic cholestasis of pregnancy.
Elevation of which one of the following is most specific and sensitive marker of this disorder?
Correct Answer B: Intrahepatic cholestasis of pregnancy (ICP) classically presents as severe pruritus in the third trimester. Characteristic findings include the absence of primary skin lesions and elevation of serum levels of total bile acids.
The most specific and sensitive marker of ICP is total serum bile acid (BA) levels greater than 10 micromol/L. In addition to the elevation in serum BA levels, the cholic acid level is significantly increased and the chenodeoxycholic acid level is mildly increased, leading to elevation in the cholic/chenodeoxycholic acid level ratio. The elevation of aminotransferases associated with ICP varies from a mild increase to a 10- to 25-fold increase.
Total bilirubin levels are also increased but usually the values are less than 5 mg/dL. Alkaline phosphatase (AP) is elevated in ICP up to 4-fold, but this is not helpful for diagnosis of the disorder since AP is elevated in pregnancy due to production by the placenta. Mild elevation of gamma glutamyltransferase (GGT) is seen with ICP but occurs in fewer than 30% of cases. However, if GGT is elevated in cases of ICP, that patient is more likely to have a genetic component of the liver disease.
A 28-year-old previously healthy female presents with a 2-day history of a painful mass on her vulva. On examination vital signs are normal. The patient is unable to sit normally because of the pain. She has an exquisitely tender red mass in the posterior right labia majora. It is oval in shape, with the largest dimension being about 6 cm.
The treatment of choice for this condition would be:
Correct Answer E:
The patient has a Bartholin’s abscess. Abscesses may present spontaneously or after a painless cyst with the following symptoms:
Incision of the lesion, followed by insertion of a Word catheter, creates a long-lasting drainage tract and usually cures the problem permanently.
→ Marsupialization can be used for a Bartholin’s cyst, but is not appropriate for an acutely infection lesion like the one presented. This procedure is reserved for recurrent abscesses.
→ Surgical excision is used for recurrent, but not acutely infected, cysts.
→ Incision and drainage alone relieves the immediate pain, but is associated with a very high recurrence rate.
→ Surgical gland removal is rarely used.
The most common cause of jaundice in pregnancy is:
Correct Answer D: Viral hepatitis is the most common cause of jaundice in pregnancy, accounting for 50% of all cases. This is important to recognize, as it should be considered first in the differential diagnosis of jaundice and elevated transaminase levels, in particular ALT. In this situation, the diagnosis can be made or excluded by ordering serologic tests for hepatitis. If these are negative, further evaluation for more infrequent causes of jaundice in pregnancy should be pursued.
HELLP syndrome is associated with preeclampsia and is rare, occurring in 0.1% of all pregnancies. It presents with hemolysis, elevated liver enzymes, and low platelets. Acute fatty liver of pregnancy presents as a complication of preeclampsia and occurs in 1 in 13,000 pregnancies. Acute cholelithiasis usually does not present with jaundice, but with right upper quadrant pain. Jaundice does occur, however, if choledocholithiasis is present. Intrahepatic cholestasis of pregnancy is also rare, occurring in 0.01% of all pregnancies. This presents with pruritis and/or jaundice.
Maternal parvovirus B19 poses which one of the following risks to the fetus?
Correct Answer A:
Maternal parvovirus B19 infection poses several risks to the fetus and newborn. The virus readily crosses the placenta, but transplacental transmission is not known to cause congenital defects, even during early pregnancy infections. Early pregnancy infection is associated with a high rate of spontaneous abortion, usually in 1-10 weeks after maternal infection. Infection later in pregnancy may destroy immature red blood cells in the fetus, causing anemia, which may lead to non-immune hydrops due to heart failure; it may also lead to fetal death. The degree of fetal illness is unpredictable, and most women with prenatal infection deliver healthy infants.
It would be appropriate to empirically treat asymptomatic bacteriuria in which one of the following patients?
Correct Answer B:
The treatment of asymptomatic bacteriuria in pregnancy reduces symptomatic urinary tract infections, pyelonephritis, low birth weight, and preterm delivery.
The guidelines recommend against the routine screening of men and nonpregnant women for asymptomatic bacteriuria. No benefit has been shown and there are potential harms associated with the overuse of antibiotics to treat asymptomatic patients with positive urine culture results.
Studies have not demonstrated that either age or underlying medical condition (other than pregnancy) are indications for treating asymptomatic bacteriuria.
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