ATI CCRN CERTIFICATION
MODULE 8
HEMATOLOGY AND IMMUNOLOGY
4 PRACTICE TESTS
2024
1. A pregnant woman at 32 weeks of gestation presents with severe epigastric
pain, nausea, and vomiting. Her blood pressure is 170/110 mmHg, and her urine
dipstick shows 3+ proteinuria. Her blood tests reveal hemoglobin of 9 g/dL,
platelet count of 60 x 10^9/L, AST of 120 U/L, ALT of 150 U/L, LDH of 800 U/L,
and serum creatinine of 1.5 mg/dL. Her peripheral blood smear shows
schistocytes. What is the most likely diagnosis?
A) Acute fatty liver of pregnancy
B) HELLP syndrome
C) Thrombotic thrombocytopenic purpura
D) Disseminated intravascular coagulation
**B) HELLP syndrome**
Rationale: HELLP syndrome is a severe form of preeclampsia characterized by
hemolysis, elevated liver enzymes, and low platelets. It typically occurs in the
third trimester and presents with hypertension, proteinuria, and symptoms such
as epigastric pain, nausea, vomiting, and headache. The diagnosis is based on
laboratory findings of hemolytic anemia, elevated liver enzymes, and
thrombocytopenia. The peripheral blood smear may show schistocytes due to
microangiopathic hemolysis. Acute fatty liver of pregnancy is a rare condition that
usually occurs in the third trimester and presents with nausea, vomiting,
,abdominal pain, jaundice, and hepatic encephalopathy. It causes severe liver
dysfunction and coagulopathy but does not cause hemolysis or hypertension.
Thrombotic thrombocytopenic purpura is a rare disorder that causes
microangiopathic hemolytic anemia and thrombocytopenia due to deficiency or
inhibition of ADAMTS13, a metalloproteinase that cleaves von Willebrand factor
multimers. It can occur in pregnancy and present with fever, neurological
symptoms, renal impairment, and jaundice. However, it does not cause
hypertension or proteinuria. Disseminated intravascular coagulation is a condition
that causes widespread activation of coagulation and consumption of clotting
factors and platelets, leading to bleeding and thrombosis. It can occur as a
complication of various conditions such as sepsis, trauma, malignancy, obstetric
emergencies, or severe preeclampsia. It causes prolonged coagulation tests (PT,
aPTT), low fibrinogen level, high D-dimer level, and schistocytes on peripheral
blood smear.
2. A pregnant woman at 28 weeks of gestation is diagnosed with HELLP
syndrome and is started on magnesium sulfate infusion for seizure prophylaxis.
She also receives corticosteroids for fetal lung maturation and antihypertensive
medication for blood pressure control. Her platelet count is 50 x 10^9/L and her
liver enzymes are mildly elevated. She has no signs of bleeding or organ
dysfunction. What is the best management option for her condition?
A) Immediate delivery by cesarean section
B) Expectant management until 34 weeks of gestation
C) Platelet transfusion and expectant management until 37 weeks of gestation
D) Delivery within 24 to 48 hours after corticosteroid administration
**D) Delivery within 24 to 48 hours after corticosteroid administration**
Rationale: The definitive treatment for HELLP syndrome is delivery of the fetus
and placenta, which usually leads to resolution of the maternal condition.
However, the timing of delivery depends on the gestational age, the severity of the
maternal condition, and the fetal status. In general, delivery is recommended for
women with HELLP syndrome who are at or beyond 34 weeks of gestation or who
have evidence of severe maternal or fetal complications such as eclampsia,
pulmonary edema, renal failure, liver hematoma or rupture, disseminated
intravascular coagulation, abruption placentae, or fetal distress. For women who
are less than 34 weeks of gestation and have mild or stable HELLP syndrome
without severe complications, expectant management may be considered to allow
for fetal maturation. However, this should be done in a tertiary care center with
close maternal and fetal monitoring and availability of intensive care facilities.
Corticosteroids should be given to enhance fetal lung maturation and may also
improve maternal platelet count and liver function. Delivery should be planned
within 24 to 48 hours after corticosteroid administration or earlier if maternal or
, fetal deterioration occurs. Platelet transfusion is not routinely indicated for women
with HELLP syndrome unless they have active bleeding, severe thrombocytopenia
(platelet count less than 20 x 10^9/L), or require an invasive procedure such as
cesarean section or epidural anesthesia. The mode of delivery depends on the
obstetric indications and maternal preference. Cesarean section is not mandatory
for women with HELLP syndrome unless there are other contraindications to
vaginal delivery.
3. A pregnant woman at 30 weeks of gestation develops sudden onset of chest
pain, dyspnea, and hypoxia. She has a history of immune thrombocytopenic
purpura (ITP) and is on prednisone therapy. Her platelet count is 80 x 10^9/L and
her coagulation tests are normal. Her chest X-ray shows bilateral pulmonary
infiltrates and her arterial blood gas shows a PaO2 of 50 mmHg and a PaCO2 of 40
mmHg. What is the most likely diagnosis?
A) Pulmonary embolism
B) Acute respiratory distress syndrome
C) Pneumonia
D) Amniotic fluid embolism
**B) Acute respiratory distress syndrome**
Rationale: Acute respiratory distress syndrome (ARDS) is a condition that causes
acute hypoxemic respiratory failure due to increased permeability of the alveolar-
capillary membrane, leading to pulmonary edema and inflammation. It can occur
as a complication of various conditions such as sepsis, trauma, aspiration,
transfusion, pancreatitis, or drug overdose. In pregnancy, ARDS can be associated
with preeclampsia, eclampsia, HELLP syndrome, amniotic fluid embolism, or
postpartum hemorrhage. The diagnosis is based on clinical criteria of acute onset
of respiratory symptoms, bilateral pulmonary infiltrates on chest imaging, and
hypoxemia (PaO2/FiO2 ratio less than 300 mmHg) that is not fully explained by
cardiac failure or fluid overload. The treatment involves supportive care with
mechanical ventilation, fluid management, and treatment of the underlying cause.
Corticosteroids are not routinely recommended for ARDS but may be considered
in selected cases such as refractory shock or severe asthma. Pregnant women with
ARDS have a high mortality rate and may require early delivery depending on the
maternal and fetal condition. Pulmonary embolism is a condition that causes acute
obstruction of the pulmonary arteries by a thrombus or other material, leading to
impaired gas exchange and hemodynamic instability. It can occur in pregnancy
due to hypercoagulability, venous stasis, and vascular injury. The diagnosis is
based on clinical suspicion, risk factors, biomarkers (D-dimer), and imaging tests
(computed tomography pulmonary angiography or ventilation-perfusion scan).
The treatment involves anticoagulation therapy with low molecular weight
heparin or unfractionated heparin. Pregnant women with pulmonary embolism
MODULE 8
HEMATOLOGY AND IMMUNOLOGY
4 PRACTICE TESTS
2024
1. A pregnant woman at 32 weeks of gestation presents with severe epigastric
pain, nausea, and vomiting. Her blood pressure is 170/110 mmHg, and her urine
dipstick shows 3+ proteinuria. Her blood tests reveal hemoglobin of 9 g/dL,
platelet count of 60 x 10^9/L, AST of 120 U/L, ALT of 150 U/L, LDH of 800 U/L,
and serum creatinine of 1.5 mg/dL. Her peripheral blood smear shows
schistocytes. What is the most likely diagnosis?
A) Acute fatty liver of pregnancy
B) HELLP syndrome
C) Thrombotic thrombocytopenic purpura
D) Disseminated intravascular coagulation
**B) HELLP syndrome**
Rationale: HELLP syndrome is a severe form of preeclampsia characterized by
hemolysis, elevated liver enzymes, and low platelets. It typically occurs in the
third trimester and presents with hypertension, proteinuria, and symptoms such
as epigastric pain, nausea, vomiting, and headache. The diagnosis is based on
laboratory findings of hemolytic anemia, elevated liver enzymes, and
thrombocytopenia. The peripheral blood smear may show schistocytes due to
microangiopathic hemolysis. Acute fatty liver of pregnancy is a rare condition that
usually occurs in the third trimester and presents with nausea, vomiting,
,abdominal pain, jaundice, and hepatic encephalopathy. It causes severe liver
dysfunction and coagulopathy but does not cause hemolysis or hypertension.
Thrombotic thrombocytopenic purpura is a rare disorder that causes
microangiopathic hemolytic anemia and thrombocytopenia due to deficiency or
inhibition of ADAMTS13, a metalloproteinase that cleaves von Willebrand factor
multimers. It can occur in pregnancy and present with fever, neurological
symptoms, renal impairment, and jaundice. However, it does not cause
hypertension or proteinuria. Disseminated intravascular coagulation is a condition
that causes widespread activation of coagulation and consumption of clotting
factors and platelets, leading to bleeding and thrombosis. It can occur as a
complication of various conditions such as sepsis, trauma, malignancy, obstetric
emergencies, or severe preeclampsia. It causes prolonged coagulation tests (PT,
aPTT), low fibrinogen level, high D-dimer level, and schistocytes on peripheral
blood smear.
2. A pregnant woman at 28 weeks of gestation is diagnosed with HELLP
syndrome and is started on magnesium sulfate infusion for seizure prophylaxis.
She also receives corticosteroids for fetal lung maturation and antihypertensive
medication for blood pressure control. Her platelet count is 50 x 10^9/L and her
liver enzymes are mildly elevated. She has no signs of bleeding or organ
dysfunction. What is the best management option for her condition?
A) Immediate delivery by cesarean section
B) Expectant management until 34 weeks of gestation
C) Platelet transfusion and expectant management until 37 weeks of gestation
D) Delivery within 24 to 48 hours after corticosteroid administration
**D) Delivery within 24 to 48 hours after corticosteroid administration**
Rationale: The definitive treatment for HELLP syndrome is delivery of the fetus
and placenta, which usually leads to resolution of the maternal condition.
However, the timing of delivery depends on the gestational age, the severity of the
maternal condition, and the fetal status. In general, delivery is recommended for
women with HELLP syndrome who are at or beyond 34 weeks of gestation or who
have evidence of severe maternal or fetal complications such as eclampsia,
pulmonary edema, renal failure, liver hematoma or rupture, disseminated
intravascular coagulation, abruption placentae, or fetal distress. For women who
are less than 34 weeks of gestation and have mild or stable HELLP syndrome
without severe complications, expectant management may be considered to allow
for fetal maturation. However, this should be done in a tertiary care center with
close maternal and fetal monitoring and availability of intensive care facilities.
Corticosteroids should be given to enhance fetal lung maturation and may also
improve maternal platelet count and liver function. Delivery should be planned
within 24 to 48 hours after corticosteroid administration or earlier if maternal or
, fetal deterioration occurs. Platelet transfusion is not routinely indicated for women
with HELLP syndrome unless they have active bleeding, severe thrombocytopenia
(platelet count less than 20 x 10^9/L), or require an invasive procedure such as
cesarean section or epidural anesthesia. The mode of delivery depends on the
obstetric indications and maternal preference. Cesarean section is not mandatory
for women with HELLP syndrome unless there are other contraindications to
vaginal delivery.
3. A pregnant woman at 30 weeks of gestation develops sudden onset of chest
pain, dyspnea, and hypoxia. She has a history of immune thrombocytopenic
purpura (ITP) and is on prednisone therapy. Her platelet count is 80 x 10^9/L and
her coagulation tests are normal. Her chest X-ray shows bilateral pulmonary
infiltrates and her arterial blood gas shows a PaO2 of 50 mmHg and a PaCO2 of 40
mmHg. What is the most likely diagnosis?
A) Pulmonary embolism
B) Acute respiratory distress syndrome
C) Pneumonia
D) Amniotic fluid embolism
**B) Acute respiratory distress syndrome**
Rationale: Acute respiratory distress syndrome (ARDS) is a condition that causes
acute hypoxemic respiratory failure due to increased permeability of the alveolar-
capillary membrane, leading to pulmonary edema and inflammation. It can occur
as a complication of various conditions such as sepsis, trauma, aspiration,
transfusion, pancreatitis, or drug overdose. In pregnancy, ARDS can be associated
with preeclampsia, eclampsia, HELLP syndrome, amniotic fluid embolism, or
postpartum hemorrhage. The diagnosis is based on clinical criteria of acute onset
of respiratory symptoms, bilateral pulmonary infiltrates on chest imaging, and
hypoxemia (PaO2/FiO2 ratio less than 300 mmHg) that is not fully explained by
cardiac failure or fluid overload. The treatment involves supportive care with
mechanical ventilation, fluid management, and treatment of the underlying cause.
Corticosteroids are not routinely recommended for ARDS but may be considered
in selected cases such as refractory shock or severe asthma. Pregnant women with
ARDS have a high mortality rate and may require early delivery depending on the
maternal and fetal condition. Pulmonary embolism is a condition that causes acute
obstruction of the pulmonary arteries by a thrombus or other material, leading to
impaired gas exchange and hemodynamic instability. It can occur in pregnancy
due to hypercoagulability, venous stasis, and vascular injury. The diagnosis is
based on clinical suspicion, risk factors, biomarkers (D-dimer), and imaging tests
(computed tomography pulmonary angiography or ventilation-perfusion scan).
The treatment involves anticoagulation therapy with low molecular weight
heparin or unfractionated heparin. Pregnant women with pulmonary embolism
