A 29-year-old woman, gravida 2, para 1, at 32 weeks gestation comes to the clinic for a sc… — USMLE Step 2 CK

A $29$ -year-old woman, gravida $2$ , para $1$ , at $32$ weeks gestation comes to the clinic for a scheduled prenatal visit. She reports increased urinary frequency over the last few weeks but denies dysuria, hematuria, or urgency. She feels well, reports active fetal movements, and has no itching or abdominal pain. At $26$ weeks gestation, her $50$ -g, $1$ -hour oral glucose challenge test result was $110$ mg/dL. Vital signs are within normal limits. Fundal height is $32$ cm, and the fetal heart rate is $145$ /min.

Laboratory Test	Result
Hemoglobin	$11.4$ g/dL
Leukocytes	$13,800$ /mm $^3$
Platelets	$195,000$ /mm $^3$
Alkaline phosphatase	$320$ U/L
Aspartate aminotransferase (AST)	$20$ U/L
Alanine aminotransferase (ALT)	$18$ U/L

Urinalysis	Result
Glucose	$1+$
Protein	Negative
Leukocyte esterase	Negative
Nitrites	Negative

Which of the following is the most appropriate next action?

A
Order fasting serum bile acid levels
B
Administer a 3-hour oral glucose tolerance test
Schedule the next routine prenatal visitAnswer
D
Prescribe oral nitrofurantoin therapy
E
Request a peripheral blood smear

Answer

Schedule the next routine prenatal visit

The correct action is to schedule the next routine prenatal visit. This patient's clinical presentation and laboratory findings are entirely consistent with normal physiologic changes of pregnancy. Urinary frequency without dysuria is common in the third trimester due to the mechanical compression of the bladder by the enlarging uterus. Mild leukocytosis (typically up to

15,000

/mm

^3

) is a normal physiological stress response during pregnancy. Furthermore, alkaline phosphatase (ALP) levels normally double or triple in the third trimester due to the synthesis of a placental ALP isoenzyme; an isolated ALP elevation with normal transaminases and no severe pruritus is not pathological. Finally, a trace amount of glucose (

1+

) in the urine frequently occurs because the pregnancy-induced increase in glomerular filtration rate exceeds the reabsorptive capacity of the proximal tubules. Since this patient already passed her gestational diabetes screening and shows no signs of infection or biliary pathology, no additional testing or treatment is required.

Step-by-Step Solution

Analyze the patient's clinical symptoms.

The patient has increased urinary frequency without dysuria or urgency in the third trimester.

This helps differentiate between a physiological mechanical effect of the gravid uterus and a pathological urinary tract infection.

Evaluate the laboratory panel.

The alkaline phosphatase is elevated, leukocytes are mildly elevated, and urinalysis shows trace glucose.

Each laboratory abnormality must be weighed against expected baseline changes during pregnancy.

Synthesize the findings to determine the management plan.

All findings represent normal physiologic adaptations to pregnancy, requiring no further workup.

Recognizing physiologic changes prevents unnecessary, costly, or harmful interventions in healthy pregnant patients.

Key Concept

Physiologic maternal adaptations to pregnancy

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