MSII Sample Quizzes [NEJM Case 30-1998]

Quiz #1: Physiology of Pregnancy and Preeclampsia (February 24, 2006)

Single best answer for items 1-8.

1. In normal pregnancy there is increased:

A.	Afterload	D.	Both A and B
B.	Cardiac contractility	E.	Both A and C
C.	Preload

2. Normal pregnancy is characterized by decreased:

	A.	Cardiac output	C.	Both
	B.	Peripheral vascular resistance	D.	Neither

3. Normal pregnancy is characterized by a relative excess of:

	A.	Fluid retention compared to red blood cell production	C.	Both
	B.	Sodium retention compared to water retention	D.	Neither

4. Normal pregnancy is characterized by an:

	A.	Altered hypothalamic osmolar set point	C.	Both
	B.	Increased vascular sensitivity to pressors	D.	Neither

5. During the second trimester of pregnancy the accepted normal range for blood pressure compared to non-pregnant women should be:

	A.	Higher	C.	The same
	B.	Lower

6. In preeclampsia, compared to normal pregnancy, there is decreased:

	A.	Effectiveness of the size/charge barrier in the glomerular filtration surface	C.	Both
	B.	Renal blood flow and glomerular filtration rate	D.	Neither

7. Preeclampsia is characterized by:

	A.	Hyperuricemia	C.	Both
	B.	Proteinuria	D.	Neither

8. Relative to normal pregnancy, preeclampsia is characterized by increased:

	A.	Cardiac contractility	C.	Both
	B.	Cardiac output	D.	Neither

Quiz #2: Case 30-1998 (February 26, 2006)

Single best answer for items 1-13.

1. Findings supportive of Lupus nephritis at the time of this patient’s hospitalization during her second pregnancy included her serum levels of:

	A.	Anti-nuclear antibodies	C.	Both
	B.	Complement	D.	Neither

2. Findings suggesting thrombophilia in this patient included:

A.	Abnormal levels of coagulation inhibitors	D.	All of the above
B.	Genetic abnormality of coagulation factor V	E.	None of the above
C.	Past medical history of thromboembolism

3. The baby was delivered at 28 weeks gestation because at that time the patient developed:

	A.	Hemolysis	C.	Both
	B.	Thrombocytopenia	D.	Neither

4. The reason Betamethasone was given in this case was to achieve an effect on:

A.	Adrenal	D.	Kidney
B.	Brain	E.	Lung
C.	Heart

5. During the course of her illness this patient had autoantibodies known to be associated with:

	A.	Congenital heart block	C.	Both
	B.	Recurrent miscarriages	D.	Neither

6. The patient had 2.2 grams/day proteinuria at 17 weeks gestation. The discussant suggests that this is at least partly related to:

A.	Autoantibodies against the glomerular basement membrane (GBM)	D.	Preeclampsia
B.	Eclampsia	E.	Renal scarring
C.	Normal finding of uncomplicated pregnancy

7. Evaluation of this patient at the time of admission showed:

	A.	Fetal compromise (low biophysical profile score)	C.	Both
	B.	Placental insufficiency (decreased diastolic flow by ultrasound)	D.	Neither

8. Evaluation of this patient at the time of admission showed:

	A.	Hematuria	C.	Both
	B.	Nephrotic range proteinuria	D.	Neither

9. The past medical history of this patient includes a previous pregnancy with:

	A.	Preeclampsia	C.	Both
	B.	Spontaneous abortion	D.	Neither

10. Proteinuria in this patient 8 years before the current pregnancy was proven to be due to:

A.	Glomerular endotheliosis	D.	Reflux nephropathy
B.	Glomerular hyperfiltration	E.	Use of nonsteroidal antiinflammatory drugs (NSAIDs)
C.	Immune complex glomerulonephritis

11. At one minute after birth the fetus had abnormal:

	A.	Pulse	C.	Both
	B.	Respiration	D.	Neither

12. Normal physiologic changes of pregnancy NOT seen in this patient at the time of the current admission include increased:

	A.	Renal clearance of uric acid	C.	Both
	B.	Vascular sensitivity to angiotensin II	D.	Neither

13. The main lesion seen in the renal biopsy in this patient during the current admission affected the glomerular:

	A.	Basement membranes	C.	Mesangium
	B.	Endothelium	D.	Podocytes

Quiz #3: Preeclampsia (March 3, 2006)

Select the most proximate cause for each of the findings in this patient listed in items 1-7

	A.	Abnormal trophoblast invasion
	B.	Microvascular thrombi
	C.	Systemic Lupus Erythematosus
	D.	Was a finding in this case but not likely a consequence of any of the above
	E.	Was not a finding in this case

1. Maternal hypertension at 27 weeks gestation
2. Seizures
3. Hemolysis
4. Immune complex glomerulonephritis
5. Glomerular endotheliosis
6. Spontaneous abortion in first pregnancy
7. Intrauterine fetal growth retardation

Single best answer for item 8–17.

8. Soluble fms-like tyrosine kinase 1 (sFlt-1) is a growth factor receptor:

	A.	Found in abnormally low levels in glomerular endothelium of preeclamptic patients
	B.	Inhibiting apoptosis allowing endothelial cell survival
	C.	Splice variant that functions as an inhibitor of vascular endothelial growth factor (VEGF)
	D.	Triggering a phosphorylation signal cascade in normal trophoblast cells
	E.	All of the above

9. The synthesis of sFlt-1 occurs in the:

	A.	Dysfunctional endothelial cell	C.	Both
	B.	Hypoxic placenta	D.	Neither

10. Glomerular endotheliosis can be induced by injection of:

	A.	Placental growth factor (PlGF)	C.	Both
	B.	Vascular endothelial growth factor (VEGF)	D.	Neither

11. Compared to normal pregnancy, preeclamptic women have increased circulating:

	A.	PlGF	C.	Both
	B.	sFlt-1	D.	Neither

12. In the uteroplacental unit, paternal genes are expressed in the:

	A.	Cytotrophoblast	C.	Both
	B.	Natural killer cells	D.	Neither

13. With regard to the immune interaction in the uteroplacental unit, the major determinants of successful placentation include:

A.	Inhibition of cytotoxic CD8 T lymphocytes	D.	All of the above
B.	Tolerance to mixed lymphocyte culture defined HLA-D antigens	E.	None of the above
C.	Tolerance to serologically defined HLA-A and HLA-B antigens

14. Of the entire pregnancy, the first trimester is characterized by the highest:

	A.	Oxygen tension in the trophoblast cells	C.	Both
	B.	Susceptibility to teratogenesis	D.	Neither

15. Risk factors for preeclampsia include all of the following EXCEPT:

A.	Diabetes	D.	Smoking
B.	Obesity	E.	Thrombophilia
C.	Primiparity

16. In the preeclampsia/HELLP/eclampsia spectrum, “endothelial dysfunction” is a reasonable explanation for the finding of a decrease in all of the following EXCEPT:

A.	Glomerular filtration size barrier function	D.	Prostaglandin synthesis
B.	Nitric oxide synthesis	E.	Sensitivity to vasopressors
C.	Platelet count

17. In the last two months of pregnancy, maternal levels of sFlt-1 increase in:

	A.	Normal pregnancy	C.	Both
	B.	Preeclampsia	D.	Neither