{"id":37096,"date":"2026-06-25T13:45:20","date_gmt":"2026-06-25T08:15:20","guid":{"rendered":"https:\/\/atsixty.com\/?p=37096"},"modified":"2026-06-25T13:46:14","modified_gmt":"2026-06-25T08:16:14","slug":"medical-disorders-in-pregnancy","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/obg\/medical-disorders-in-pregnancy\/","title":{"rendered":"Medical Disorders in Pregnancy"},"content":{"rendered":"\n\n\n<meta charset=\"UTF-8\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n<title>Morning Rounds \u00b7 Medical Disorders in Pregnancy<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n#obs06 *,#obs06 *::before,#obs06 *::after{box-sizing:border-box;margin:0;padding:0}\n#obs06{\n  --ob:#4B3A6E;\n  --ob-light:#5F4D85;\n  --ob-pale:#EFE9F5;\n  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font-family=\"Georgia,serif\" font-weight=\"bold\">Antiepileptic Drugs in Pregnancy \u2014 Relative Teratogenic Risk<\/text>\n      <rect x=\"10\" y=\"26\" width=\"160\" height=\"22\" rx=\"3\" fill=\"#4B3A6E\"\/>\n      <text x=\"90\" y=\"41\" text-anchor=\"middle\" fill=\"#F3EFFA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Drug<\/text>\n      <rect x=\"180\" y=\"26\" width=\"180\" height=\"22\" rx=\"3\" fill=\"#4B3A6E\"\/>\n      <text x=\"270\" y=\"41\" text-anchor=\"middle\" fill=\"#F3EFFA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Major Malformation Risk<\/text>\n      <rect x=\"370\" y=\"26\" width=\"180\" height=\"22\" rx=\"3\" fill=\"#4B3A6E\"\/>\n      <text x=\"460\" y=\"41\" text-anchor=\"middle\" fill=\"#F3EFFA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Notable Concern<\/text>\n      <rect x=\"10\" y=\"50\" width=\"160\" height=\"26\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"90\" y=\"67\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Valproate<\/text>\n      <rect x=\"180\" y=\"50\" width=\"180\" height=\"26\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"270\" y=\"67\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.3\" font-family=\"Georgia,serif\">Highest (~9&ndash;10%); dose-dependent<\/text>\n      <rect x=\"370\" y=\"50\" width=\"180\" height=\"26\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"460\" y=\"67\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.3\" font-family=\"Georgia,serif\">NTDs + cognitive impairment<\/text>\n      <rect x=\"10\" y=\"78\" width=\"160\" height=\"26\" rx=\"2\" fill=\"#fdf6e4\"\/>\n      <text x=\"90\" y=\"95\" text-anchor=\"middle\" fill=\"#8a6d1a\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Carbamazepine<\/text>\n      <rect x=\"180\" y=\"78\" width=\"180\" height=\"26\" rx=\"2\" fill=\"#fdf6e4\"\/>\n      <text x=\"270\" y=\"95\" text-anchor=\"middle\" fill=\"#8a6d1a\" font-size=\"7.3\" font-family=\"Georgia,serif\">Intermediate (~3&ndash;4%)<\/text>\n      <rect x=\"370\" y=\"78\" width=\"180\" height=\"26\" rx=\"2\" fill=\"#fdf6e4\"\/>\n      <text x=\"460\" y=\"95\" text-anchor=\"middle\" fill=\"#8a6d1a\" font-size=\"7.3\" font-family=\"Georgia,serif\">Spina bifida, craniofacial<\/text>\n      <rect x=\"10\" y=\"106\" width=\"160\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"90\" y=\"123\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Lamotrigine<\/text>\n      <rect x=\"180\" y=\"106\" width=\"180\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"270\" y=\"123\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\">Lower (~2&ndash;3%)<\/text>\n      <rect x=\"370\" y=\"106\" width=\"180\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"460\" y=\"123\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\">Preferred where seizure type allows<\/text>\n      <rect x=\"10\" y=\"134\" width=\"160\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"90\" y=\"151\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Levetiracetam<\/text>\n      <rect x=\"180\" y=\"134\" width=\"180\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"270\" y=\"151\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\">Lower (~2&ndash;3%)<\/text>\n      <rect x=\"370\" y=\"134\" width=\"180\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"460\" y=\"151\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\">Favourable profile, increasingly first-line<\/text>\n    <\/svg>\n  <\/figure>\n<\/div>\n\n<div id=\"obs06\">\n\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds &middot; Obstetrics Series &middot; Round 06<\/div>\n    <div class=\"mr-title\">\n      Medical Disorders<br><em>in Pregnancy<\/em>\n    <\/div>\n    <div class=\"mr-subtitle\">Five cases &middot; GDM, anemia, cardiac, thyroid &amp; epilepsy &middot; Trust your instinct<\/div>\n    <div class=\"mr-chips\">\n      <span class=\"mr-chip\">5 Cases<\/span>\n      <span class=\"mr-chip\">+4 \/ &minus;1 scoring<\/span>\n      <span class=\"mr-chip\">Options reshuffled<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-sentinel\" id=\"obs06-sentinel\"><\/div>\n\n  <div class=\"mr-progress\" id=\"obs06-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"obs06-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"obs06-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"obs06-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"obs06-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"obs06-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"obs06-pct\">0%<\/span>\n            <span class=\"mr-ring-sub\">net<\/span>\n          <\/div>\n        <\/div>\n        <div class=\"mr-score-title\">Your Debrief<\/div>\n        <div class=\"mr-score-net\" id=\"obs06-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"obs06-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"obs06-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"obs06-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"obs06-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"obs06-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n\n<\/div><!-- end #obs06 -->\n\n<script>\n(function () {\n  'use strict';\n\n  var NS    = 'obs06';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  var QS = [\n\n    {\n      id:      1,\n      tag:     'Medical Disorders &mdash; GDM Screening',\n      stem:    'A <strong>28-week pregnant<\/strong> woman with no identifiable risk factors undergoes screening by the <strong>DIPSI single-step method<\/strong>: a 75 g oral glucose load given <em>without prior fasting<\/em>, with venous plasma glucose measured at 2 hours. The result is <strong>148 mg\/dL<\/strong>. What is the correct interpretation and immediate next step?',\n      correct: 'This meets the DIPSI diagnostic threshold (2-hour value &ge;140 mg\/dL) for gestational diabetes; start medical nutrition therapy first and review glycaemic control in 1&ndash;2 weeks before considering pharmacotherapy',\n      opts: [\n        'This value cannot be used for diagnosis since no fasting plasma glucose was measured beforehand; a confirmatory fasting OGTT is mandatory before GDM can be labelled under any Indian protocol',\n        'This meets the DIPSI diagnostic threshold (2-hour value &ge;140 mg\/dL) for gestational diabetes; start medical nutrition therapy first and review glycaemic control in 1&ndash;2 weeks before considering pharmacotherapy',\n        'This value falls short of the diagnostic threshold, since the relevant IADPSG fasting cut-off of 92 mg\/dL was not met; she should be reassured and rescreened only if symptoms develop later',\n        'This is diagnostic of gestational diabetes, and oral hypoglycaemic agents such as metformin should be started immediately as first-line therapy, reserving insulin only for cases where metformin fails'\n      ],\n      exp:     'The <strong>DIPSI (Diabetes in Pregnancy Study Group India) single-step test<\/strong> was specifically designed to avoid the logistical burden of fasting OGTTs in Indian field conditions: a <strong>75 g glucose load is given regardless of fasting status<\/strong>, and a <strong>2-hour value &ge;140 mg\/dL<\/strong> alone is diagnostic of GDM &mdash; no fasting value or confirmatory test is required. This is the entire point of the test, so demanding a fasting value defeats its purpose. <br><br>Confusing this with the <strong>IADPSG criteria<\/strong> (fasting &ge;92, 1-hr &ge;180, 2-hr &ge;153 on a fasting 75g OGTT, any one value diagnostic) is a common error &mdash; that protocol requires fasting; DIPSI deliberately does not. <br><br><strong>Management sequencing:<\/strong> medical nutrition therapy (MNT) and exercise are first-line for all newly diagnosed GDM; <strong>insulin<\/strong>, not oral agents, is the standard pharmacological step-up in Indian national protocols (FOGSI\/MOHFW) if glycaemic targets are not met on MNT within 1&ndash;2 weeks &mdash; metformin\/glyburide are used in some international guidelines but are not the default first pharmacologic choice domestically.',\n      imgId:   null\n    },\n\n    {\n      id:      2,\n      tag:     'Medical Disorders &mdash; Anemia in Pregnancy',\n      stem:    'A woman at <strong>32 weeks<\/strong> gestation has <strong>Hb 7.8 g\/dL<\/strong>, microcytic hypochromic picture, and low serum ferritin. She reports breathlessness on climbing one flight of stairs but no resting dyspnoea, chest pain, or pedal oedema. What is the most appropriate next step in management?',\n      correct: 'Parenteral iron (e.g. ferric carboxymaltose) is preferred over oral iron at this Hb and gestational age, given the limited time remaining before delivery and the slower, less reliable response to oral therapy',\n      opts: [\n        'Oral iron alone remains appropriate, since her anemia &mdash; though symptomatic on exertion &mdash; is not severe enough at this Hb level to justify escalating to parenteral therapy',\n        'Parenteral iron (e.g. ferric carboxymaltose) is preferred over oral iron at this Hb and gestational age, given the limited time remaining before delivery and the slower, less reliable response to oral therapy',\n        'Immediate blood transfusion is indicated, since any symptomatic anemia in pregnancy &mdash; regardless of the specific Hb value &mdash; warrants transfusion rather than a trial of iron therapy first',\n        'Parenteral iron should be avoided due to teratogenic risk in pregnancy, so oral iron must be continued despite her poor response, with reassessment deferred until after delivery'\n      ],\n      exp:     'At <strong>Hb 7.8 g\/dL and 32 weeks<\/strong>, the combination of moderate-to-severe anemia and a <strong>narrow window before delivery<\/strong> tips management toward <strong>parenteral iron<\/strong> (ferric carboxymaltose or iron sucrose) rather than oral iron &mdash; oral absorption is slow, GI side effects reduce compliance, and there isn\\'t enough time left in pregnancy to reliably correct Hb orally. <strong>Parenteral iron is safe in the second and third trimesters<\/strong> and is not teratogenic; it is generally avoided only in the first trimester out of caution, not because of proven harm. <br><br><strong>Blood transfusion<\/strong> is reserved for more severe or decompensating anemia &mdash; classically Hb &lt;7 g\/dL with symptoms of cardiac compromise (resting tachycardia, dyspnoea, oedema) or Hb approaching the 4&ndash;5 g\/dL range, or when delivery is imminent and rapid correction is needed. Her current symptoms (exertional breathlessness only, no resting symptoms) do not yet meet that threshold &mdash; transfusion is not automatic for any symptomatic anemia, regardless of Hb. <br><br>Oral iron is undertreatment here, not appropriate conservative management &mdash; the question deliberately separates \"symptomatic but not decompensating\" from \"asymptomatic\" to test correct triage between the three options.',\n      imgId:   null\n    },\n\n    {\n      id:      3,\n      tag:     'Medical Disorders &mdash; Cardiac Disease &amp; Anticoagulation',\n      stem:    'A woman with a <strong>mechanical mitral valve<\/strong> on long-term warfarin discovers she is <strong>6 weeks pregnant<\/strong> (incidental finding; conception was unplanned). Regarding anticoagulation and the disclosure obligations this raises, which approach is correct?',\n      correct: 'Switch to therapeutic-dose LMWH for the remainder of the first trimester given the peak warfarin embryopathy risk window (6&ndash;12 weeks), while explicitly discussing with her the trade-off of higher valve thrombosis risk on LMWH versus continuing teratogenic exposure, and documenting this informed discussion',\n      opts: [\n        'Continue warfarin unchanged throughout pregnancy, since switching anticoagulants in a woman with a mechanical valve is never justified given the elevated thrombosis risk associated with any alternative regimen',\n        'Switch to therapeutic-dose LMWH for the remainder of the first trimester given the peak warfarin embryopathy risk window (6&ndash;12 weeks), while explicitly discussing with her the trade-off of higher valve thrombosis risk on LMWH versus continuing teratogenic exposure, and documenting this informed discussion',\n        'Stop all anticoagulation immediately, since the embryo has already been exposed to warfarin and continuing any anticoagulant at this stage would only compound the existing teratogenic harm without added benefit',\n        'Switch to unfractionated heparin alone rather than LMWH, since LMWH is contraindicated in pregnancy due to insufficient data on placental transfer and fetal safety'\n      ],\n      exp:     '<strong>Warfarin embryopathy<\/strong> (nasal hypoplasia, stippled epiphyses, limb defects) risk is highest with exposure between <strong>6 and 12 weeks<\/strong> &mdash; she is already in this window. The standard approach is to <strong>switch to therapeutic LMWH<\/strong> for this period, accepting a somewhat higher valve thrombosis risk than warfarin in exchange for avoiding further fetal exposure, and to have an explicit, <strong>documented discussion<\/strong> with the patient about this trade-off &mdash; this is precisely the kind of medication-risk disclosure that mechanical-valve pregnancies require as part of informed consent, since neither option is risk-free. <br><br><strong>Stopping anticoagulation entirely<\/strong> is dangerous regardless of prior exposure &mdash; mechanical valves carry a high baseline thrombosis risk, and \"damage is already done\" reasoning ignores the ongoing risk of valve thrombosis, which can be fatal. <br><br><strong>LMWH is not contraindicated<\/strong> in pregnancy &mdash; it does not cross the placenta in clinically significant amounts and is the preferred alternative to warfarin in this exact scenario; unfractionated heparin is reserved for situations needing rapid reversal (e.g. peri-delivery) rather than as a routine substitute. <br><br>This case is a recurring theme on this topic: the correct answer always involves <strong>switching plus disclosure<\/strong>, never blanket continuation or blanket cessation.',\n      imgId:   null\n    },\n\n    {\n      id:      4,\n      tag:     'Medical Disorders &mdash; Hypothyroidism',\n      stem:    'A woman with known hypothyroidism on <strong>levothyroxine 50 mcg\/day<\/strong> is found to be <strong>10 weeks pregnant<\/strong>. Repeat TSH is <strong>6.2 mIU\/L<\/strong>. What is the correct adjustment to her levothyroxine dose and target?',\n      correct: 'Increase the levothyroxine dose by approximately 25&ndash;30% from her pre-pregnancy dose, targeting a trimester-specific TSH below 2.5 mIU\/L in the first trimester, with TSH rechecked roughly every 4 weeks',\n      opts: [\n        'Continue the same dose unchanged, since a TSH of 6.2 mIU\/L would be considered within acceptable limits using standard non-pregnant reference ranges, which still apply during pregnancy',\n        'Increase the levothyroxine dose by approximately 25&ndash;30% from her pre-pregnancy dose, targeting a trimester-specific TSH below 2.5 mIU\/L in the first trimester, with TSH rechecked roughly every 4 weeks',\n        'Decrease the dose moderately, since pregnancy reduces overall thyroid hormone requirements as placental clearance of thyroxine-binding globulin lowers circulating demand on the maternal thyroid axis',\n        'Switch part of her regimen to liothyronine (T3), since levothyroxine (T4) does not cross the placenta effectively and the fetus depends on direct maternal T3 for early neurodevelopment'\n      ],\n      exp:     'Pregnancy <strong>increases<\/strong> thyroxine requirements &mdash; not decreases them &mdash; due to rising thyroxine-binding globulin (oestrogen-driven), increased renal clearance, and active placental\/fetal demand for maternal T4 before the fetal thyroid becomes functional (~12&ndash;14 weeks). The standard approach for a known hypothyroid woman found to be under-replaced in pregnancy is to <strong>increase the levothyroxine dose by 25&ndash;30%<\/strong>, targeting trimester-specific TSH goals &mdash; <strong>&lt;2.5 mIU\/L in the first trimester<\/strong> &mdash; tighter than the non-pregnant reference range, because even modest maternal hypothyroidism in early pregnancy is linked to adverse neurodevelopmental and obstetric outcomes. <br><br><strong>Maternal T4<\/strong> does cross the placenta, and is the dominant source of thyroid hormone for the fetus before its own thyroid gland becomes functional &mdash; this is precisely why correcting maternal levothyroxine dosing matters so much in the first trimester. There is no role for T3 supplementation; T3 crosses the placenta poorly and is not part of standard management. <br><br>Using <strong>non-pregnant TSH reference ranges<\/strong> is a common and clinically consequential error &mdash; trimester-specific targets exist precisely because the non-pregnant \"normal\" range underestimates the degree of replacement pregnancy requires.',\n      imgId:   null\n    },\n\n    {\n      id:      5,\n      tag:     'Medical Disorders &mdash; Epilepsy &amp; Drug Disclosure',\n      stem:    'A woman with epilepsy on <strong>sodium valproate monotherapy<\/strong> is found to be <strong>5 weeks pregnant<\/strong>; the pregnancy was unplanned. Regarding antiepileptic drug management and the disclosure obligation this raises, which approach is correct?',\n      correct: 'Do not abruptly stop valproate; refer urgently for specialist neurology review to weigh a supervised switch to a lower-risk agent (e.g. lamotrigine or levetiracetam), continue high-dose folic acid, and ensure the teratogenic risk discussion and rationale are explicitly documented',\n      opts: [\n        'Stop valproate immediately at this visit, since continuing a drug with established teratogenic risk once pregnancy is confirmed would itself amount to a failure of the duty of care toward the fetus',\n        'Do not abruptly stop valproate; refer urgently for specialist neurology review to weigh a supervised switch to a lower-risk agent (e.g. lamotrigine or levetiracetam), continue high-dose folic acid, and ensure the teratogenic risk discussion and rationale are explicitly documented',\n        'Continue valproate at the same unchanged dose throughout pregnancy, since altering antiepileptic therapy at any stage of pregnancy carries a greater risk of breakthrough seizures than the teratogenic risk of the drug itself',\n        'Valproate carries no meaningful teratogenic risk at doses below 600 mg\/day, so no change in management and no specific disclosure beyond routine antenatal counselling is required at this dose'\n      ],\n      exp:     '<strong>Valproate<\/strong> carries the <strong>highest teratogenic risk<\/strong> among commonly used antiepileptics &mdash; neural tube defects, cardiac and craniofacial anomalies, and a well-documented association with long-term cognitive and neurodevelopmental impairment, with risk rising with dose but <strong>no dose established as fully \"safe.\"<\/strong> Regulatory drug-safety bodies (including those followed in Indian practice) require that this risk be specifically disclosed to any woman of reproductive potential before valproate is prescribed, and that disclosure obligation does not disappear once pregnancy is already underway. <br><br>The correct response is <strong>not<\/strong> to stop the drug outright at this visit &mdash; abrupt valproate withdrawal risks breakthrough seizures or status epilepticus, which itself endangers mother and fetus and can be more immediately dangerous than continued exposure for the short interval needed to arrange specialist review. The correct path is an <strong>urgent, supervised transition plan<\/strong> with neurology input, not a unilateral stop-or-continue decision made at a single antenatal visit. <br><br>Equally wrong is treating \"switching carries seizure risk\" as a reason to make <strong>no change at all<\/strong> &mdash; that conflates the risk of an unsupervised abrupt stop with the risk of a planned, monitored switch, which is the actual standard of care here.',\n      imgId:   'obs06-img1'\n    }\n\n  ];\n\n  var answers  = {};\n  var answered = 0;\n  var shuffled = {};\n  var done     = false;\n\n  function byId(id) { return document.getElementById(id); }\n  function gid(suffix) { return byId(NS + '-' + suffix); }\n\n  function shuffleArr(arr) {\n    var a = arr.slice(), i, j, tmp;\n    for (i = a.length - 1; i > 0; i--) {\n      j = Math.floor(Math.random() * (i + 1));\n      tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n    }\n    return a;\n  }\n\n  function countVal(val) {\n    var k, n = 0;\n    for (k in answers) {\n      if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n    }\n    return n;\n  }\n\n  function buildPips() {\n    var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n    cont.innerHTML = '';\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      if (i > 0) {\n        wLine = document.createElement('div');\n        wLine.className = 'mr-pip-wrap';\n        line = document.createElement('div');\n        line.className = 'mr-pip-line';\n        line.id = NS + '-pl' + q.id;\n        wLine.appendChild(line);\n        cont.appendChild(wLine);\n      }\n      wPip = document.createElement('div');\n      wPip.className = 'mr-pip-wrap';\n      pip = document.createElement('div');\n      pip.className = 'mr-pip';\n      pip.id = NS + '-pip' + q.id;\n      pip.textContent = String(q.id);\n      wPip.appendChild(pip);\n      cont.appendChild(wPip);\n    }\n  }\n\n  function build() {\n    var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n        rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n        optEl, ltrSpan, txtSpan;\n\n    cont = gid('cases');\n    cont.innerHTML = '';\n    answers = {}; answered = 0; shuffled = {}; done = false;\n    gid('score').style.display = 'none';\n    buildPips();\n\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      opts = shuffleArr(q.opts);\n      shuffled[q.id] = opts;\n\n      card = document.createElement('div');\n      card.className = 'mr-case';\n\n      top = document.createElement('div');\n      top.className = 'mr-case-top';\n\n      numDiv = document.createElement('div');\n      numDiv.className = 'mr-num';\n      numDiv.textContent = q.id < 10 ? 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The endocrinologist and the neurologist both sign off.'],\n      [4, 'Strong round \\u2014 one dosing or disclosure nuance to revisit.'],\n      [3, 'Solid base \\u2014 the debrief will sharpen the thresholds.'],\n      [2, 'Halfway there \\u2014 review the missed cases carefully.'],\n      [0, 'Medical disorders in pregnancy reward close re-reading \\u2014 the thresholds are unforgiving.']\n    ];\n    gid('verdict').textContent = verdicts[4][1];\n    for (vi = 0; vi < verdicts.length; vi++) {\n      if (c >= verdicts[vi][0]) {\n        gid('verdict').innerHTML = verdicts[vi][1];\n        break;\n      }\n    }\n\n    gid('ct-c').textContent = '\\u2705 ' + c + ' Correct';\n    gid('ct-w').textContent = '\\u274C ' + w + ' Wrong';\n    gid('ct-s').textContent = '\\u23ED ' + s + ' Skipped';\n\n    sc = gid('score');\n    sc.style.display = 'block';\n    sc.scrollIntoView({ behavior: 'smooth', block: 'center' });\n  }\n\n  function tryInit() {\n    var sentinel = document.getElementById(NS + '-sentinel');\n    var submit   = document.getElementById(NS + '-submit');\n    var retry    = document.getElementById(NS + '-retry');\n    if (!sentinel || !submit || !retry) {\n      setTimeout(tryInit, 80);\n      return;\n    }\n    submit.addEventListener('click', showScore);\n    retry.addEventListener('click', function () {\n      build();\n      window.scrollTo(0, 0);\n    });\n    var bar = document.getElementById(NS + '-progress');\n    if (bar && window.IntersectionObserver) {\n      new IntersectionObserver(function (entries) {\n        bar.className = entries[0].isIntersecting ? 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