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Respiratory renal system - Maternal medicine Module part2

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A woman developed severe pre-eclampsia at 35 weeks of gestation and her labour was
induced. She needed an emergency caesarean section for suspected fetal compromise. She
developed sudden onset of breathlessness 6 hours post delivery. She has no history of chest pain,
palpitation or cough and no past history of chest or cardiac disease. She is on labetalol 200 mg TDS.
On examination she looks unwell; her heart rate is 100/min, BP is 130/80 mmHg, respiratory rate is
28/min, SpO2 is 94% on air and she is apyrexial. There are reduced breath sounds on chest
auscultation and normal heart sounds. There is poor urine output. There is no calf tenderness.
The results of the investigations are:
• haemoglobin = 95 gm/l
• platelet count = 110 x 109/l
• raised urea
• raised creatinine
• normal ALT
• low albumin
• CXR = bilateral infiltrates
• ABG on air = respiratory failure, PaO2 (kPa):FiO2= 24
• CTPA = no evidence of pulmonary embolism
• ECHO = pulmonary oedema with PCWP 15 mmHg; no evidence of cardiomyopathy.
She was reviewed by critical care team and a diagnosis of Acute Respiratory Distress Syndrome
(ARDS) was made.

1) Which of the following is not part of the diagnostic criteria for ARDS?

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.

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

3)

A 28 yr old woman is 18 weeks pregnant and is a known to hav ephenylketonuria, all are
included in her management plan except;

4)

A 25-year-old lady presents to the GP 10 weeks into her first pregnancy. She has recently
arrived from Belarus. She complains of night sweats and a productive cough. She has lost 2kg since
the beginning of the pregnancy. What is the most appropriate investigation?

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

5) • trimethoprim = S

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

6)

A 32-year-old woman presents at 16 weeks of gestation with a dry cough that is worse at night
for the last 4 weeks. She wakes up coughing once per night on average. She also complains of
breathlessness and wheeze with exertion. She is known to have asthma and takes a salbutamol
inhaler. Recently she has been using the inhaler up to three times per day. Examination shows that
she is well at rest, and there is wheeze scattered throughout the chest. Peak flow is 65% of
predicted. What is the most appropriate first-line management?

7)

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?

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.

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

9)

An obese 38 year old primigravida undergoes an emergency caesarean section under general
anaesthetic for fetal bradycardia. Two days later she becomes acutely unwell with pyrexia,
tachycardia, tachypnoea and a productive cough. Chest X-ray shows left lower lobe consolidation.
What is the most likely causative organism?

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.

10) Which of the following statement is correct regarding physiological renal adaptation to pregnancy?

A 31-year-old woman at 38 weeks of gestation presents with purulent sputum, chest pain and
cough.

Her pulse is 110/min, respiratory rate is 24/min and temperature is 39°C.
Her chest X-ray shows consolidation.

11) What is the most likely diagnosis?

12)

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?

13)

A 30-year-old woman presents at 38 weeks of gestation with fever, myalgia, arthralgia, cough
and dyspnoea that began yesterday evening. She also has symptoms of vomiting. She was previously
fit and well. On examination she has a respiratory rate of 28, oxygen saturations of 90% on air, and
her pulse is 110. Blood pressure is 120/70 mmHg. Her chest has widespread wheeze and reduced air
entry. Chest X-ray shows patchy consolidation throughout both lungs. What is the most appropriate
initial treatment?

14)

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?

Sarah is a 38-year-old primigravida who works as a nursery nurse. She has no significant past
medical history. She smokes ten cigarettes per day. She presents at 32 weeks of gestation with fever,
cough and increasing breathlessness. On examination, her statistics are as follows:
• pulse = 95 bpm
• blood pressure = 105/68 mmHg
• temperature = 38.1°C
• saturations = 94% on air.
Auscultation shows reduced air entry and crackles in the left lower zone. Her X-ray shows
consolidation in the left lower lobe.

15) What is the most likely causative organism?

A 25-year-old nulliparous woman is referred to the obstetric medicine clinic at 14 weeks of
gestation with a history of asthma. She takes an inhaled corticosteroid twice daily (400 micrograms)
and reports using her short-acting beta-agonist inhaler twice a month. She has had no recent
hospital admissions due to exacerbations of her asthma, and has never been admitted to ICU.
She is extremely concerned regarding the maternal and fetal effects of her asthma and medication.

16) Which of the following is the most important advice regarding her ongoing management?

17) The following statements about pregnancy in women with renal allografts are true except;

18) For a woman with phenylketonuria , preconceptional target levels of Phe should be

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.

19) Which of the following statement is correct regarding asymptomatic bacteriuria in pregnancy?

20)

A 23-year-old woman who is 11 weeks pregnant presents to her GP because her grandfather has
recently been diagnosed with pulmonary tuberculosis. He lives in Pakistan and she stayed with him
about a month ago. She has never been vaccinated against tuberculosis, and is concerned that she
may be at risk. She is fit and well with no past medical history. What is the most appropriate next
step in her management?

A 28-year-old multiparous woman at 37 weeks of gestation attends her GP surgery with a rash
(developed 6 hours ago) and feeling unwell – her toddler was diagnosed with chickenpox 1 week
ago. She has no recollection of previous varicella infection and the booking bloods revealed varicella
IgG was negative.
Her past medical history includes moderate asthma, with an infective exacerbation treated with
steroids and oral antibiotics 4 weeks ago.

21) Which of the following is the most appropriate next step in her management?

A 25-year-old nulliparous woman attends the labour ward at 32 weeks of gestation. She is a
known asthmatic and has recently had a 'chesty cough'. She has been non-compliant with her
inhalers (inhaled corticosteroids and long acting beta agonist) for fear of fetal side effects. She has a
widespread wheeze on auscultation of the lung fields.
Her vital signs are as follows:
• temperature = 36.9°C
• pulse = 110 bpm
• BP = 105/65 mmHG
• respiratory rate = 10/min
• SaO2 is 92% (on 5l O2).
The arterial blood gas (ABG) results are as follows:
• pH 7.32 (7.35–7.45)
• pO2 7.8 kPa (>10.6 kPa)
• pCO2 7.2 kPa (4.7–6.0 kPa)
• BE –4.2 (+/– 2).

22) What is the most appropriate next stage of her management?

A 23-year-old primigravida attends the emergency department at 34 weeks of gestation with
shortness of breath and wheeze. She has a history of asthma for which she takes salbutamol,
salmeterol and beclometasone inhalers.
She complains of symptoms of the common cold but has become increasingly breathless despite
increased used of her salbutamol inhalers.
Respiratory system Questions
06 April 2020 11:09
New Section 31 Page 1
increased used of her salbutamol inhalers.
The baby is moving well and the pregnancy has been uncomplicated. On examination, her pulse is
118 bpm, respiratory rate is 32, oxygen saturation is at 92% and she is unable to complete sentences
in one breath. Auscultation reveals widespread wheeze.

23) What is the most important initial treatment?

24)

The following statements are true about pregnancy in women with chronic renal disease
except;

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