Musculoskeletal, Skin & Subcutaneous Tissue, Physiology, USMLE Step 1 - Full Vignette with Extended

Описание: A 29-year-old pregnant woman with a history of axial spondyloarthritis, psoriasis, and stable cardiomyopathy now presents at 22 weeks gestation with worsening inflammatory pain, persistent morning stiffness, sacroiliac tenderness, and active peripheral arthritis. How should clinicians approach disease-modifying management when standard non-systemic measures prove insufficient, particularly considering maternal comorbidities, gestational stage, and fetal safety? What makes this scenario especially challenging compared to other rheumatologic cases?

VIDEO INFO
Category: Musculoskeletal, Skin & Subcutaneous Tissue, Physiology, USMLE Step 1
Difficulty: Expert - Expert level - For those seeking deep understanding
Question Type: Treatment - Evaluate therapeutic interventions and management
Case Type: Pregnant Patient

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QUESTION
A 29-year-old gravida 2 para 1 at 22 weeks gestation presents with escalating axial and peripheral inflammatory pain despite non-systemic measures. Her last menstrual period began on June 28, 2025; estimated due date is April 4, 2026. She reports 3 hours of morning stiffness, nocturnal awakenings from low-back pain, alternating buttock pain, and difficulty turning in bed....

OPTIONS
A. Start certolizumab pegol subcutaneously with a loading regimen of 400 mg at weeks 0, 2, and 4, then 200 mg every 2 weeks in the outpatient setting throughout pregnancy and postpartum as needed, leveraging minimal placental transfer of this Fc-free TNF inhibitor.
B. Resume adalimumab subcutaneously 40 mg every 2 weeks and continue through delivery because tumor necrosis factor inhibitors have trivial third-trimester placental passage and do not require timing adjustments.
C. Initiate secukinumab subcutaneously 150 mg at weeks 0, 1, 2, 3, and 4, then 150 mg every 4 weeks in the outpatient setting as a first-line biologic during pregnancy on the basis of emerging observational registries (e.g., OTIS/MotherToBaby) suggesting outcomes comparable to TNF inhibitors.
D. Begin etanercept subcutaneously 50 mg weekly through 36 weeks gestation with plans to hold thereafter, assuming fetal exposure remains negligible compared with certolizumab and thus offers equivalent late-gestation safety.

CORRECT ANSWER
A. Start certolizumab pegol subcutaneously with a loading regimen of 400 mg at weeks 0, 2, and 4, then 200 mg every 2 weeks in the outpatient setting throughout pregnancy and postpartum as needed, leveraging minimal placental transfer of this Fc-free TNF inhibitor.

EXPLANATION
Certolizumab pegol is the optimal disease-modifying agent to initiate now because it is an Fc-free PEGylated Fab fragment with negligible active placental transfer even in late gestation. The CRIB study found minimal to undetectable cord-blood levels when mothers received certolizumab close to delivery, supporting continued dosing throughout pregnancy without the timing constraints required for IgG1 monoclonal antibodies....


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