View source for WBR0181

{{WBRQuestion
|QuestionAuthor=Mugilan Poongkunran
|ExamType=USMLE Step 3
|SubCategory=Musculoskeletal/Rheumatology
|SubCategory=Musculoskeletal/Rheumatology
|SubCategory=Musculoskeletal/Rheumatology
|SubCategory=Musculoskeletal/Rheumatology
|SubCategory=Musculoskeletal/Rheumatology
|SubCategory=Musculoskeletal/Rheumatology
|SubCategory=Musculoskeletal/Rheumatology
|SubCategory=Musculoskeletal/Rheumatology
|Prompt=A 24 year old female comes to your office with 3 month H/O amenorrhea.  She is sexually active and says she and her husband has been planning pregnancy.  She does not smoke or consume alcohol or use any illicit drugs.  An urine pregnancy test done at the office turns positive.  She reveals her past history about cold intolerance for 1 year and has been taking nifedipine for that.  Physical examinations are well within normal limits. What is the best step in the line of management of her past medical condition during her pregnancy period?

A.      Continue the same doze of oral nifedipine
B.      Reduce the dose of nifedipine by half
C.      Double up the dose of nifedipine
D.	Stop nifedipine 
E.	Do a nailfold capillaroscopy
|Explanation=The goals of therapy in [[Raynaud's phenomenon]] patients are to improve quality of life and to prevent ischemic tissue injury.  At least a moderate reduction in the intensity of attacks and the prevention of digital ulcers or tissue injury are achievable in most patients.  The initial treatment of patients with the Raynaud phenomenon includes, patient education, general measures to maintain body warmth and to avoid other triggers of RP, pharmacotherapy with calcium channel blockers for vasodilation, if general nonpharmacologic measures are inadequate, behavioral therapies, the use of which depends upon patient preference and upon the availability and cost to the individual patient.
|AnswerA=Continue the same doze of oral nifedipine
|AnswerAExp='''Incorrect''' : [[Calcium channel blockers]] can be discontinued during pregnancy.  If required, in cases of digital ischemia during pregnancy, we prefer to use CCBs rather than angiotensin receptor blockers.
|AnswerB=Reduce the dose of nifedipine by half
|AnswerBExp=There is no need to titrate the dose for patients on constant therapy for a long time.  We generally titrate the dose slowly in nonurgent situations, usually adjusting the dose every four weeks and no more frequently than every 7 to 10 days while starting the therapy.  This patient doesnt require CCBs during her pregnancy period and after that would require the same dose of [[nifedipine]].
|AnswerC=Double up the dose of nifedipine
|AnswerCExp='''Incorrect''' : When there is no response to treatment, we generally titrate the dose slowly, usually adjusting the dose every four weeks and no more frequently than every 7 to 10 days.  This patient has been symptom free and since pregnancy itself would improve her condition, the best option is to discontinue the drug during the pregnancy period.
|AnswerD=Stop nifedipine 
|AnswerDExp='''Correct''' : We generally discontinue CCBs and other vasodilators during pregnancy if possible,  as Raynaud's phenomenon often improves during pregnancy in association with increased blood volume.  If beta blockers are needed for blood pressure control, the selective agents are preferred, as some studies suggest that non-selective [[beta blockers]] sometimes worsen the symptoms of Raynaud's phenomenon.
|AnswerE=Do a nailfold capillaroscopy
|AnswerEExp='''Incorrect''' : There is no requirement for a diagnostic tool in a clinically diagnosed patient.
|RightAnswer=D
|Approved=Yes
}}