anastamosis
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A 31-year-old Caucasian woman who is in her 19th week of gestation comes to the office to discuss the results of a slightly elevated serum AFP. She has been followed since her seventh week of pregnancy. Ever since she learned that women must start taking folic acid before getting pregnant in order to avoid congenital defects, she has been concerned about the possibility of having a baby with neural tube defects. Because she just started taking folic acid during her second month of pregnancy and one of her friends had a child with spina bifida, she requested her alpha-fetoprotein (AFP) levels to be tested. She has no other medical problems. She does not use alcohol, tobacco or illicit drugs. Her family history is not significant. She is currently not taking any medications, except for folic acid. The physical examination reveals clear lung fields, and normal first and second heart sounds. The abdomen is soft and non-tender. The uterine size, fetal movements and fetal cardiac activity are all normal. Neurologic examination reveals no abnormalities. Her serum AFP level is slightly elevated, reaching 2.7 MoM (normal values: less than 2.5 MoM). Which of the following is the most appropriate next step in management?
A. Repeat the serum AFP test
B. Perform amniocentesis for chromosomal analysis
C. Perform amniocentesis and evaluate amniotic fluid AFP levels
D. Order an obstetric ultrasound
E. Order amniotic fluid acetylcholinesterase (AChE)
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| me007
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A
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| anastamosis
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Why is D not right? As per the texts the most common cause of elevated or decreased AFP is 'Wrong Dates'
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| MAGY17
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YES DO U/S
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| anastamosis
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USMLE world says do Repeat AFP levels. why do things change from step 2 ck to step 3?
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| Ivonne
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I will go with D, as you said, the most common cause is dating error therefore it is important to know exactly the gestational age.
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| nany
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I think you're right Ivonne
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| shigeyasu
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Then, when do you choose 'A'?
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| Ivonne
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After US, making sure that the gestational age is accurateby US, becuase the cause number one of increased maternal serum AFP is ERROR.
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| arlete
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If the question had mentioned she already had an US, done earlier during pregnancy (when the gestational date error is the smallest, meaning it would be the ideal) atesting it was really 19th week gestation, we would repeat serum AFP. Otherwise, US to be sure. US should show neural tube defect, too.
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| Ivonne
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hummmm the answer given by NBME is A too  any explanation? they are killing my built up knowledge.
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| farnsworth
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In real life you may do U/S (takes you 10min, compared to drawing another blood sample, send it to the lab and have the results returned in 30-60min). U/S also has the advantage to visualize the thickness of the nuchal fold, the spine, the heart etc...
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| Ivonne
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Just found out that the answer i found for the NBME is not  official DDDDDDDDDDDDDDDDDDD
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| Aashi
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Ivonne wrote:Just found out that the answer i found for the NBME is not official DDDDDDDDDDDDDDDDDDD
Yes its D
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| Korotkoff
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I will pick A because the woman has been followed since her 7th week. It is not her first visit. So U/S might have been done before. I am hoping the physician is sure about the gestational age at this time.
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