Master the board step 3

Master the Boards: USMLE Step 3
Liver Diseases
A 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?
Answer: 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. Ursodeoxycholic acid reduces cholesterol
absorption and dissolves gallstones; however, gallstones re-form when the
patient stops taking the medication.
Urinary Tract Infections, Pyelonephritis, and Bacteriuria
Asymptomatic
Bacteriuria Acute Cystitis Pyelonephritis
1. Urine culture (+)
2. No urgency, frequency, or
burning
3. No fever
1. Urine culture (+)
2. Urgency, frequency, or
burning
3. No fever
1. Urine culture (+)
2. Urgency, frequency, or burning
3. Fever and CVA tenderness
Tx: Outpatient PO antibiotics (Nitrofurantoin is drug of
choice; alt: Cephalexin or amoxicillin)
Cx: 30% of cases develop acute pyelonephritis when
untreated
Tx: Admit to hospital; IV hydration, IV cephalosporins or
gentamicin, and tocolysis
Cx: Preterm labor and delivery;
Severe cases → sepsis, anemia, and pulmonary
dysfunction
Termination of Pregnancy
Induced Abortion
The more advanced the gestation, the higher the rate of complications.
First-Trimester Methods
··
Dilation and curettage (D&C) is the most common first trimester abortion
procedure and is performed before 13 weeks’ gestation. Give prophylactic
antibiotics, conscious sedation, and paravertebral block local anesthetic.
Rarely complicated by endometritis (outpatient antibiotic) and/or retained
products of conception (repeat curettage).
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