Female Reproductive Pregnancy and Childbirth

Question 1

Danger Signals

Placental A______

Placental P______

Severe Pre______

HELLP =

Answer 1

PLACENTAL ABRUPTION

PLACENTA PREVIA

SEVERE PREECLAMPSIA

HELLP (HEMOLYSIS, ELEVATED LIVER ENZYMES, AND LOW PLATELETS) SYNDROME

Question 2

PLACENTAL ABRUPTION (ABRUPTIO PLACENTAE)

Pregnant woman who is in the l____ few weeks of pregnancy complains of ______ onset of vaginal ______ accompanied by a _______ uterus that feels _____ (hypertonic) and is very ____ful; may have uterine contractions.

Associated with a _____ onset of _____-red-colored vaginal bleeding. Up to 20% of women do not have vaginal bleeding (blood is trapped between placenta and uterine wall; Figure 1).

If mild, blood is re______, and affected area reim____. Severe cases cause hem______ (e.g., DIC); fetus must be _____ to save mother’s life.

Higher risk in females with history of h___tension, pree_____, smoking, trauma, and co_____ use. Strongest risk factor is a _____ of placenta abruption.

Call 911. Requires ______ treatment and __-section. Placenta abruption accounts for 5% to 8% of maternal deaths.

Answer 2

Pregnant woman who is in the last few weeks of pregnancy complains of sudden onset of vaginal bleeding accompanied by a contracted uterus that feels hard (hypertonic) and is very painful; may have uterine contractions.

Associated with a sudden onset of dark-red-colored vaginal bleeding. Up to 20% of women do not have vaginal bleeding (blood is trapped between placenta and uterine wall; Figure 1).

If mild, blood is reabsorbed, and affected area reimplants. Severe cases cause hemorrhage (DIC); fetus must be delivered to save mother’s life.

Higher risk in females with history of hypertension, preeclampsia/eclampsia, smoking, trauma, and cocaine use. Strongest risk factor is a history of placenta abruption.

Call 911. Requires emergent treatment and C-section. Placenta abruption accounts for 5% to 8% of maternal deaths.

Question 3

PLACENTA PREVIA

=

A multipara woman who is in the late second to third trimester complains of new onset of pain____ vaginal bleeding that is worsened by inter_____. Blood is ____ red in color. From 10% to 20% present with both bleeding and uterine contractions. Uterus is s____ and nontender.

Any vaginal or rectal insertion or stimulation is an absolute _______ (can precipitate severe hemorrhage).

(1) to diagnose.

If cervix is not dilated, treatment is (1)*. Administer IV (1)* if there is uterine cramping. Uterus will usually reimplant itself if mild.

If cervix is dilated or if hemorrhaging, (1)*. Severe cases cause hemorrhage; fetus must be delivered to save mother’s life.

Strong association between placenta previa and amniotic fluid ______ (sudden respiratory distress, hypoxia, and/or seizures followed by DIC during labor or after delivery).

Answer 3

The placenta implants too low either on top of the cervix or on the cervical isthmus/neck.

A multipara woman who is in the late second to third trimester complains of new onset of painless vaginal bleeding that is worsened by intercourse. Blood is bright red in color. From 10% to 20% present with both bleeding and uterine contractions. Uterus is soft and nontender.

Any vaginal or rectal insertion or stimulation is an absolute contraindication (can precipitate severe hemorrhage).

Transabdominal ultrasound to diagnose.

If cervix is not dilated, treatment is strict bed rest. Administer IV magnesium sulfate if there is uterine cramping. Uterus will usually reimplant itself if mild.

If cervix is dilated or if hemorrhaging, fetus is delivered by C-section. Severe cases cause hemorrhage; fetus must be delivered to save mother’s life.

Strong association between placenta previa and amniotic fluid embolism (sudden respiratory distress, hypoxia, and/or seizures followed by DIC during labor or after delivery).

Question 4

SEVERE PREECLAMPSIA

A primigravida woman who is in the late ____ trimester of pregnancy (>34 weeks) complains of a sudden onset of severe recurrent ____aches, v____ abnormalities (blurred vision, scotomas), and pitting _____. Edema easily seen on the f____/eyes and fingers. Sudden rapid ______ gain within 1 to 2 days (>2–4 1b/wk). New onset of right upper quadrant ______ pain.

Blood pressure (BP) more than ___/___ mmHg. Urine _____ 1+ or higher.

Sudden decrease in urine output (____uria). Visual symptoms, headache, nausea, and vomiting are worrisome signs (_____opathy).

If seizures occur, condition is reclassified as ______. Earliest time period that preeclampsia/eclampsia can occur is at ___ weeks’ gestation (and up to 4 weeks postpartum).

_______ stroke accounts for 36% of pregnancy-associated stroke. Only known “cure” is ______of fetus or baby.

(1)* is drug of choice to prevent eclampsia.

Answer 4

A primigravida woman who is in the late third trimester of pregnancy (>34 weeks) complains of a sudden onset of severe recurrent headaches, visual abnormalities (blurred vision, scotomas), and pitting edema. Edema easily seen on the face/eyes and fingers. Sudden rapid weight gain within 1 to 2 days (>2–4 1b/wk). New onset of right upper quadrant abdominal pain.

Blood pressure (BP) more than 140/90 mmHg. Urine protein 1+ or higher.

Sudden decrease in urine output (oliguria). Visual symptoms, headache, nausea, and vomiting are worrisome signs (encephalopathy).

If seizures occur, condition is reclassified as eclampsia. Earliest time period that preeclampsia/eclampsia can occur is at 20 weeks’ gestation (and up to 4 weeks postpartum).

Hemorrhagic stroke accounts for 36% of pregnancy-associated stroke. Only known “cure” is delivery fetus or baby.

Magnesium Sulfate* is drug of choice to prevent eclampsia.

Question 5

HELLP SYNDROME

=

Classic patient is a multipara woman older than 25 years of age who is in the _____ trimester of pregnancy. Presents with the signs and symptoms of preeclampsia accompanied by ____ upper quadrant (or midepigastric) abdominal pain with n____/v_____and malaise (may be mistaken for viral illness). Symptoms can present suddenly.

Lab abnormalities are elevation of (2)*, total (1) (>1.2 mg/dL), and LDH with decreased number of (1)* (<100,000 cells/mcL) and ____, peripheral smear with schistocytes and burr cells, and hemoglobin and hematocrit.

If severe, right upper quadrant/epigastric pain may have h______ bleed or swelling, which may be signs of impending hepatic r______.

Answer 5

Serious but rare complication of preeclampsia/eclampsia (15% cases develop HELLP). (HEMOLYSIS, ELEVATED LIVER ENZYMES, AND LOW PLATELETS)

Classic patient is a multipara woman older than 25 years of age who is in the third trimester of pregnancy. Presents with the signs and symptoms of preeclampsia accompanied by right upper quadrant (or midepigastric) abdominal pain with nausea/vomiting and malaise (may be mistaken for viral illness). Symptoms can present suddenly.

Lab abnormalities are elevation of AST and ALT, total bilirubin (>1.2 mg/dL), and lactate dehydrogenase (LDH) with decreased number of platelets (<100,000 cells/mcL) and DIC, peripheral smear with schistocytes and burr cells, and hemoglobin and hematocrit.

If severe, right upper quadrant/epigastric pain may have hepatic bleed or swelling, which may be signs of impending hepatic rupture.

Question 6

Lab Tests During Pregnancy

Answer 6

Question 7

Urinalysis (Dipstick)

Obtain midstream urine _____ gynecologic exam (minimizes contamination from vaginal discharge). Check protein, leukocytes, nitrite, blood, glucose.

• Protein =
• If ___ weeks’ gestation or more, rule out (1) if protein ___ or higher
• If proteinuria present, order (1) urine for protein and creatinine

Answer 7

Obtain midstream urine before gynecologic exam (minimizes contamination from vaginal discharge). Check protein, leukocytes, nitrite, blood, glucose.

• Protein: Negative (trace, 1+ to 4+)
• If 20 weeks’ gestation or more, rule out preeclampsia if protein 1+ or higher
• If proteinuria present, order 24-hour urine for protein and creatinine

Question 8

Pregnancy and LFTS

What happens to LFT levels in pregnancy?

Why happens to the level alkaline phosphatase? why?

Answer 8

ALT, AST, bilirubin, and gamma glutamyl transpeptidase (GGT) remain the same except for alkaline phosphatase.

Expected to increase during pregnancy due to the growth of the fetal bones. Values higher in multiple gestation pregnancies.

Question 9

Pregnancy and WBCs

What happens to WBC levels in pregnancy? Why?

Levels may climb as high as?

Leukocytosis with ______ is “normal” during pregnancy (if it is not accompanied by signs of infection)

Answer 9

WBC is elevated throughout pregnancy, especially during the third trimester. This is because your body is going through a lot of stress just being pregnant

May climb as high as 16,000 cells/mm³ in the third trimester. (WBC in nonpregnant adults: range is 4,500–10,500 cells/mm³.)

Leukocytosis with neutrophilia is “normal” during pregnancy (if it is not accompanied by signs of infection).

Question 10

Pregnancy and Hemoglobin and Hematocrit

What happens to the levels of Hgb and Hct during pregnancy?

Why does this happen?

Levels may be as low as?

What should you rule out?

Answer 10

Both values go down during pregnancy due to hemodilution. Called physiologic or dilutional anemia of pregnancy.

The hemoglobin value may be as low as 10.5 g/dL, and the hematocrit value may go down to about 30% (by the third trimester).

To rule out iron-deficiency anemia, check the mean corpuscular volume (MCV). It is not affected by pregnancy.

Question 11

Pregnancy and Erythrocyte Sedimentation Rate

What happens to the levels of ESR?

• Normal range =*
• Rate in pregnancy =*

Answer 11

ESR increases during pregnancy.

• Normal Range:* 0 to 20 mm/hr
• Range in Pregnancy=* 13-70 mm/hr by the third trimester

Question 12

Pregnancy and TFTs

=

why?

Answer 12

T3 elevated

T3 higher bc of increased levels of thyroid-binding globulin (TBG)

TSH, free T3, free T4 remains unchanged

Question 13

Serum Alpha-Fetoprotein

What is it used to detect? Would levels be low or high? When to check?

Where does it produced?

Answer 13

A biochemical marker used to estimate a pregnant woman’s risk of having a fetus with DOWN SYNDROME. LOW levels of AFP (check btwn 15-18 weeks)

Serum alpha-fetoprotein (AFP) is manufactured by the liver of the fetus and mother. Majority of maternal AFP comes from the fetus (liver, fetal yolk sac, gastrointestinal [GI] tract).

Question 14

Serum Alpha-Fetoprotein

AFP levels by race white, asian, black?

Indications to check serum alpha-fetoprotein include (2)

Answer 14

AFP levels are adjusted for weight and race; slightly higher levels are found in Black women and lower levels in Asian women (compared with Whites).

Indications include advanced maternal age and previous births or family history of chromosomal or birth defects (e.g., neural tube defects).

Question 15

Low Alpha Fetoprotein

Most common risk factor?

If AFP is low order a triple or quadruple screen test that includes?

Answer 15

Mature maternal age _>_35yo “geriatric pregnancy” is the most common risk factor for Down syndrome (35-year-old or older woman has a 1:350 at term).

Low AFP → order (AFP, HCG, estriol, inhibin-A) to eval for Down Syndrome (trisomy 21)

Question 16

High Alpha-Fetoprotein

Rule out (2)

• Most common reason for a high AFP is pregnancy d_____ error.
• If AFP is high (e.g., neural tube defects, omphalocele, gastroschisis), order the (1) + (1) to rule out neural tube abnormalities (higher sensitivity than AFP alone).
• To prevent neural tube defects: Ingest (1)* 400 mcg (0.4 mg) per day (found in ____ green vegetables, fortified ______). To reduce risk, advise patients to take _____ vitamins when planning to become pregnant.

Answer 16

Neural Tube Defects or Multiple Gestation

• Most common reason for a high AFP is pregnancy dating error.
• If AFP is high (e.g., neural tube defects, omphalocele, gastroschisis), order the triple screen or the quad screen test and sonogram to rule out neural tube abnormalities (higher sensitivity than AFP alone).
• To prevent neural tube defects: Ingest folic acid 400 mcg (0.4 mg) per day (found in leafy green vegetables, fortified cereals). To reduce risk, advise patients to take prenatal vitamins when planning to become pregnant.

Question 17

Triple Marker Screen Test

=
The hormone level results are used in a formula to figure out the ____ for a _____ syndrome infant.

Diagnostic test for genetic anomalies is ______ testing.

Answer 17

AFP, beta HCG, and estriol serum level values

The hormone level results are used in a formula to figure out the risk for a Down syndrome infant.

Diagnostic test for genetic anomalies is chromosome testing.

Question 18

Quadruple Marker Screen Test

Combination of the triple screen + (1)

What is inhibin A?

The triple or quadruple screen tests are more sensitive than the AFP alone (but have a higher rate of false positives).

Gold Standard Test for genetic disorders =

Answer 18

Combination of the triple screen hormones (AFP, beta-HCG, estradiol) plus inhibin-A

Inhibin A is a hormone released by the placenta

Gold Standard test for genetic disorders = fetal chromosomes/DNA.

Question 18

Screening For Genetic Disorders

What genetic disorder should be screened for in these populations?

1. Jewish descent (Ashkenazi Jews)
2. Whites
3. African Americans

Answer 18

1. Tay–Sachs disease; this fatal neurological disease, with no known cure, is more common among Eastern Europeans of Jewish descent (Ashkenazi Jews)
2. Cystic Fibrosis - whites
3. Sickle Cell Anemia - African Americans

Question 18

Amniocentesis And Chorionic Villus Sampling

When can these tests be done

• Chorionic villus sampling =*
• Amniocentesis =*
• Specimens contain _____ cells
• Fetal ch_____/D____ is tested for abnormalities

Answer 18

• Chorionic villus sampling =* 10-12 weeks
• Amniocentesis =* 15-18 weeks
• Specimens contain fetal cells
• Fetal chromosomes/DNA is tested for abnormalities

Question 18

Beta Human Chorionic Gonadotropin

Manufactured by the chorion (early _____) by day __ to day __.

High-quality urine home pregnancy tests (e.g., First Response, EPT) can detect pregnancy as early as the first missed _____ (__ weeks after conception).

There are ______ levels of HCG with twins/multiple fetuses.

Answer 18

Manufactured by the chorion (early placenta) by day 8 to day 10.

High-quality urine home pregnancy tests (e.g., First Response, EPT) can detect pregnancy as early as the first missed period (2 weeks after conception).

There are higher levels of HCG with twins/multiple fetuses.

Question 19

Beta-HCG Doubling Time

Why do we care about doubling time? (Useful only in 1st trimester)

• Normal finding:* HCG doubles every ___ hours during the first __ weeks (first trimester) in a normal pregnancy.
• Ectopic pregnancy:* The HCG has _____ values than normal. Values increase _____ and do not double as expected.
• Inevitable abortion:* Values of HCG start decreasing r______; there is ___ doubling. Cervix is _____.

Answer 19

Doubling time is an important indicator of the viability of a pregnancy.

• Normal finding:* HCG doubles every 48 hours during the first 12 weeks (first trimester) in a normal pregnancy.
• Ectopic pregnancy:* The HCG has lower values than normal. Values increase slowly and do not double as expected.
• Inevitable abortion:* Values of HCG start decreasing rapidly; there is no doubling. Cervix is dilated.

Question 20

Vaginal Cultures

(1) tested for at 35 to 37 weeks.

Swab ____ introitus and _____ (insert up to anal sphincter) for culture and sensitivity (C&S).

If positive, administer intrapartum antibiotic _____ with (1)Rx* 5 million units IV, followed by 2.5 to 3 million units IV every __ hours until delivery.

Penicillin allergy: Use ___/___mycin instead

Answer 20

Group B Streptococcus (GBS) is tested for at 35 to 37 weeks

Swab vaginal introitus and rectum (insert up to anal sphincter) for culture and sensitivity (C&S).

If positive, administer intrapartum antibiotic prophylaxis with penicillin G 5 million units IV, followed by 2.5 to 3 million units IV every 4 hours until delivery.

Penicillin allergy: Use clindamycin or erythromycin instead

Question 21

Sexually Transmitted Diseases

Screen for (1) surface antigen, H__, g_____, ch_____, s_____, (1) types 1 and 2.

Answer 21

Screen for hepatitis B surface antigen (HBsAg), HIV, gonorrhea, chlamydia, syphilis, herpesvirus types 1 and 2.

Question 22

Titers

(2) to check in pregnancy

Answer 22

Rubella

Varicella (if no proof of infection)

Question 23

Drugs And Vaccines During Pregnancy

The new Food and Drug Administration (FDA) Pregnancy and (1) will eventually replace the pregnancy letter categories (A, B, C, D, and X) with new labeling.

Since most of the drugs on the exam were released before the PLLR, the FDA letter categories will still be covered in this edition. Most of the drugs used in pregnancy are FDA category __ drugs.

Because it is unethical to experiment on pregnant women, a number of drugs used during pregnancy are found to be safe only through many years of use by pregnant women (e.g., penicillins, macrolides).

Answer 23

The new Food and Drug Administration (FDA) Pregnancy and Lactation Labeling Rule (PLLR) will eventually replace the pregnancy letter categories (A, B, C, D, and X) with new labeling.

Since most of the drugs on the exam were released before the PLLR, the FDA letter categories will still be covered in this edition. Most of the drugs used in pregnancy are FDA category B drugs.

Because it is unethical to experiment on pregnant women, a number of drugs used during pregnancy are found to be safe only through many years of use by pregnant women (e.g., penicillins, macrolides).

Question 24

Category A Drugs

=

Prenatal (1)

In_____

(1) hormone
(1) (vitamin B9), (1) (vitamin B6)

Answer 24

Animal and human data show no risk to pregnant women.

Prenatal vitamins (high-dose multivitamins are not used during pregnancy)

Insulin

Thyroid hormone (levothyroxine)

Folic acid (vitamin B9), pyridoxine (vitamin B6)

Question 25

Category B Drugs

=

• Antacids (T___, M____) are safe for pregnant women.
• (1) stool softener and is approved for pregnant women. It is not a laxative.
  
  • ______ laxatives (e.g., ex-lax, Bisacodyl), especially in the third trimester (may induce labor).
• Analgesics ( (1) preferred to nonsteroidal anti-inflammatory drugs [NSAIDs] especially in the third trimester; see “Category D Drugs.”

Answer 25

Animal studies show no risk. No human data available.

• Antacids (Tums, Maalox) are safe for pregnant women.
• Docusate sodium (Colace). Colace is a stool softener and is approved for pregnant women. It is not a laxative.
  
  • Avoid laxatives (e.g., ex-lax, Bisacodyl), especially in the third trimester (may induce labor).
• Analgesics (acetaminophen preferred to nonsteroidal anti-inflammatory drugs [NSAIDs] especially in the third trimester; see “Category D Drugs.”

Question 26

Antibiotics for Pregnant Women

Penicillins?

Cephalosporins?

Only 1 macrolide is category C

Nitrofurantoin (Furadantin, Macrobid) - Do not use with (1) deficiency and contraindicated during (1)

Answer 26

Pencillins are safe to use

Cephalosporins are safe to use

XX Clarithromycin (Biaxin) XX is the only macrolide that is Category C (avoid in pregnancy, consult with physician before use and discuss risk and benefits)

XX Nitrofurantoin (Furadantin, Macrobid) XX - Do not use with G6PD deficiency bc will cause hemolysis (anemia, jaundice, dark urine), Contraindicated during labor and delivery (or near tearm dt increased risk of hemolytic anemia)

Question 27

Antihypertensives for Pregnant Women

(3)

Used for women with __existing hypertension or for moderate-to-severe (1). Use of antihypertensive drugs to control mild hypertension does not alter the course of the disease or diminish perinatal morbidity or mortality of preeclampsia. Refer to obstetrician.

Answer 27

Methyldopa (Aldomet)

Calcium channel blockers (Procardia)

Labetalol (Normodyne)

Used for women with preexisting hypertension or for moderate-to-severe preeclampsia or eclampsia. Use of antihypertensive drugs to control mild hypertension does not alter the course of the disease or diminish perinatal morbidity or mortality of preeclampsia. Refer to obstetrician.

Question 28

Category C Drugs

(3)

Answer 28

Sulfa drugs - Trimethoprim–sulfamethoxazole (e.g., Bactrim DS, Septra)

Clarithromycin (Biaxin)

Pseudoephedrine (Sudafed)

Question 29

Category C Drugs

• Sulfa Drugs (Bactrim)= can cause?
• Clarithromycin (Biaxin) = only category C macrolide abx
• Pseudoephedrine (Sudafed) = increases risk of?

Answer 29

• Sulfa Drugs (Bactrim)= can cause hemolytic anemia which results in hyperbilirubinemia. Sulfa drugs displace bilirubin from albumin → high levels of unconjugated bilirubin can cross blood brain barrier and cause brain damage (kernicterus)
• Clarithromycin (Biaxin) = only category C macrolide abx
• Pseudoephedrine (Sudafed) = increases risk of gastroschisis (intestines protrude through abdominal wall defect) - ideally should not be used in pregnancy and breastfeeding (may interfere with lactation, crosses breast milk)

Question 30

Category D Drugs

Evidence of ____ risk. Benefits should outweigh the risk of using the drug.

A___/A____

Fl______

T________

N_____

S____ Drugs

Answer 30

Evidence of fetal risk. Benefits should outweigh the risk of using the drug.

ACEI/ARBS

Fluoroquinolones

Tetracyclines

NSAIDs

Sulfa Drugs

Question 30

Category D Drugs

What these drugs can cause

ACE/ARBS =

Fluoroquinolones =

Tetracyclines =

NSAIDS =

Sulfa Drugs =

Answer 30

ACE/ARBS = Causes fetal renal abnormalities, renal failure, and hypotension

Fluoroquinolones = Affect fetal cartilage development; a rare side effect is Achilles tendon rupture in athlete; contraindicated in pregnant or lactating women and children younger than 18 years

Tetracyclines = Stain growing tooth enamel

NSAIDS = Block prostaglandins and may cause premature labor; avoid using especially in the last 2 weeks of pregnancy

Sulfa Drugs = Risk of hyperbilirubinemia (neonatal jaundice or kernicterus); sulfa drugs displace bilirubin from albumin; high levels of unconjugated bilirubin will cross the blood–brain barrier and cause brain damage (mental retardation, seizures, deafness, etc.)

Question 31

Category X Drugs

=

A_______ (isotretinoin, a vitamin A derivative)

M_______ (antimetabolite) and anticancer drugs

F______ (Proscar (antiandrogen))

_____prostol (prostaglandin analog)

Evista and Tamox_____ (selective estrogen receptor modulator [SERM])

All ______ drugs (estrogen, testosterone, finasteride (proscar), mifepristine (RU-86)

Depo _____ (blocks hormone synthesis and is used for infertility, hormone-dependent cancers, and endometriosis)

Answer 31

Proven fetal risks outweigh the benefits.

Accutane (isotretinoin, a vitamin A derivative)

Methotrexate (antimetabolite) and anticancer drugs

Proscar (antiandrogen)

Misoprostol (prostaglandin analog)

Evista and tamoxifen (selective estrogen receptor modulator [SERM])

All Hormonal drugs (estrogen, testosterone, finasteride (proscar), mifepristine (RU-86)

Depo Lupron (blocks hormone synthesis and is used for infertility, hormone-dependent cancers, and endometriosis)

Question 32

Category X Drugs

Accutane (isotretinoin, a vitamin A derivative)

• Used for severe c____ and nodular acne recalcitrant to treatment; it is highly teratogenic.
• Also avoid vitamin ___ derivative topicals such as ____nol/retinoid, tretinoin (Retin-A), adapalene

Methotrexate (antimetabolite) and anticancer drugs

• Used for some types of auto_____ diseases (psoriasis, rheumatoid arthritis) and certain c______

Proscar (antiandrogen)

• Used for benign (1) and (1) cancer

Misoprostol (prostaglandin analog)

• Used as one of the drugs in medical ____ (a component of the “abortion pill”)

Answer 32

Accutane (isotretinoin, a vitamin A derivative)

• Used for severe cystic and nodular acne recalcitrant to treatment; it is highly teratogenic.
• Also avoid vitamin A derivative topicals such as retinol/retinoid, tretinoin (Retin-A), adapalene

Methotrexate (antimetabolite) and anticancer drugs

• Used for some types of autoimmune diseases (psoriasis, rheumatoid arthritis) and certain cancers

Proscar (antiandrogen)

• Used for BPH and prostate cancer

Misoprostol (prostaglandin analog)

• Used as one of the drugs in medical abortion (a component of the “abortion pill”)

Question 33

Category X Drugs

Evista and tamoxifen (selective estrogen receptor modulator [SERM])

• Use reduces risk of reoccurrence of _____ receptor–positive _____ cancer

All hormonal drugs (natural or synthetic) are category X in pregnancy—all forms of e_____, tes______, fin______ (Proscar), mifepristone (RU-86).

Any drug that blocks hormone synthesis or binding (D____ Lupron)

Depo Lupron is used for in______, hormone-dependent cancers, and end______.

Answer 33

Evista and tamoxifen (selective estrogen receptor modulator [SERM])

• Use reduces risk of reoccurrence of estrogen receptor–positive breast cancer

All hormonal drugs (natural or synthetic) are category X in pregnancy—all forms of estrogens, testosterone, finasteride (Proscar), mifepristone (RU-86).

Any drug that blocks hormone synthesis or binding (Depo Lupron)

Depo Lupron is used for infertility, hormone-dependent cancers, and endometriosis.

Depo Lupron lowers the amount of testosterone in a person’s body, which helps slow the growth of cancer cells**.

Question 34

Drugs to Avoid (Third Trimester of Pregnancy)

(1)* (blocks prostaglandin)

A____ and salicylates (affect platelets). Bismuth subsalicylate (____-Bismol) contains salicylates.

_____-containing drugs (2)) near term: Higher risk of hyperb_____emia, jaundice, k____icterus, _____hydramnios, premature closure ductus arteriosus.

Answer 34

NSAIDs (blocks prostaglandin)

Aspirin and salicylates (affect platelets). Bismuth subsalicylate (Pepto-Bismol) contains salicylates.

Sulfa-containing drugs (trimethoprim–sulfamethoxazole, nitrofurantoin) near term: Higher risk of hyperbilirubinemia, jaundice, kernicterus, oligohydramnios, premature closure ductus arteriosus.

Question 35

Live Vaccines

Which Vaccines are contraindicated in pregnancy?

(4)

Notes: If a reproductive aged woman gets a live virus vaccine, what should you advise them to do?

Answer 35

MMR, Oral Polio, Varicella, and Flumist

Note: If a reproductive aged woman gets a live virus vaccine - advise them not to get pregnant (use reliable birth control) the next 4 weeks for MMR or 3 months (varicella and shingles)

Question 36

Vaccines and Pregnancy

(2) Vaccines are recommended for pregnant women

Answer 36

Inactivated flu vaccine and Tdap vaccines are recommended for pregnant women.

Influenza vaccine is an inactivated virus and is safe to use in pregnant women.

• Recommend for pregnant women, especially if they are pregnant during the fall and winter seasons. Only use the injectable inactivated flu vaccine.
• Live attenuated influenza virus (LAIV) vaccine and flu vaccine via nasal spray (FluMist) are contraindicated.

Question 37

Teratogens

Agents that can cause structural abnormalities during pregnancy:

• (1) (Paxil):* Taking drug during the first trimester increases risk of birth defects, particularly ____ defects (others are anencephaly, abdominal wall defects). FDA category D drug.
• (1) (Prozac):* ____ wall defects and cranio______ (premature closure of skull sutures).
• Other SSRIs (citalopram, escitalopram, sertraline):* ____-trimester exposure may be associated with a low risk of teratogenicity

Chronic ______ during pregnancy (poorly controlled diabetes or gestational diabetes mellitus [GDM]) is a teratogenic state. It increases the risk of neural tube defects and craniofacial defects.

Answer 37

• Paroxetine (Paxil):* Taking drug during the first trimester increases risk of birth defects, particularly heart defects (others are anencephaly, abdominal wall defects). FDA category D drug.
• Fluoxetine (Prozac):* Heart wall defects and craniosynostosis (premature closure of skull sutures).
• Other SSRIs (citalopram, escitalopram, sertraline):* First-trimester exposure may be associated with a low risk of teratogenicity

Chronic hyperglycemia during pregnancy (poorly controlled diabetes or gestational diabetes mellitus [GDM]) is a teratogenic state. It increases the risk of neural tube defects and craniofacial defects.

Question 38

Teratogens

• Alcohol:* (1) syndrome
• Aminoglycosides:* ____ness
• C_______:* Intrauterine growth retardation (IUGR), prematurity
• C______:* Cerebro_____ accidents (CVAs), mental retardation, abruptio placentae
• _______ (Accutane):* Central nervous system (CNS)/craniofacial/ear/cardiovascular defects
• Lithium:* Cardiac defects (_____ anomalies are malformations of tricuspid valve and right atrium that can cause heart failure, sudden death, transient ischemic attack (TIA), stroke; presentation is middle teenager years).

Answer 38

• Alcohol:* Fetal alcohol syndrome
• Aminoglycosides:* Deafness
• Cigarettes:* Intrauterine growth retardation (IUGR), prematurity
• Cocaine:* Cerebrovascular accidents (CVAs), mental retardation, abruptio placentae
• Isotretinoin (Accutane):* Central nervous system (CNS)/craniofacial/ear/cardiovascular defects
• Lithium:* Cardiac defects (Ebstein’s anomalies are malformations of tricuspid valve and right atrium that can cause heart failure, sudden death, transient ischemic attack (TIA), stroke; presentation is middle teenager years).

Question 39

Health Education

Take ______ vitamins with 400 mcg of (1) daily (start 2–3 months before conception).

Always wear seat____ (lap-style seatbelt _____ uterine fundus).

Avoid ____ cheeses (blue cheese, brie), uncooked m____, raw m____ (Listeria bacteria).

Sex is ___ except during vaginal bl_____, incom____ cervix, placenta previa, or preterm labor.

Cat ____or r___/undercooked ____ can cause toxo______ (congenital infection).

Answer 39

Take prenatal vitamins with 400 mcg of folic acid daily (start 2–3 months before conception).

Always wear seatbelt (lap-style seatbelt below uterine fundus).

Avoid soft cheeses (blue cheese, brie), uncooked meats, raw milk (Listeria bacteria).

Sex is safe except during vaginal bleeding, incompetent cervix, placenta previa, or preterm labor.

Cat litter or raw/undercooked meat can cause toxoplasmosis (congenital infection).

Question 40

Health Education

Do not eat raw ____fish or raw oy____ (Vibrio vulnificus infection).

Be careful with cold ____, uncooked hot ____, and “d____” meat (L______ bacteria). Pregnant women are 20 times more likely to become infected and die from Listeria monocytogenes.

Sm____ (vasoconstriction causes IUGR) and al____ (fetal alcohol syndrome) are contraindicated.

Regular coffee (8 oz/d) is ____. Do not consume an excessive amount of caffeine (premature labor).

Do not use hot ___ or sa____ or expose oneself to excessive heat.

Answer 40

Do not eat raw shellfish or raw oysters (Vibrio vulnificus infection).

Be careful with cold cuts, uncooked hot dogs, and “deli” meat (Listeria bacteria). Pregnant women are 20 times more likely to become infected and die from Listeria monocytogenes.

Smoking (vasoconstriction causes IUGR) and alcohol (fetal alcohol syndrome) are contraindicated.

Regular coffee (8 oz/d) is okay. Do not consume an excessive amount of caffeine (premature labor).

Do not use hot tubs or saunas or expose oneself to excessive heat.

Question 41

Zika Virus

Zika infection during pregnancy can cause severe birth defects (e.g., micro_____) and n____developmental abnormalities.

The only way to completely prevent Zika infection during pregnancy is to?

If travel is necessary, the Centers for Disease Control and Prevention (CDC) recommends the following special pre______ for pregnant women and women (and their partners) who are trying to become pregnant

Answer 41

Zika infection during pregnancy can cause severe birth defects (e.g., microcephaly) and neurodevelopmental abnormalities.

The only way to completely prevent Zika infection during pregnancy is to not travel to areas with Zika outbreak/risk and to use condoms or avoid sex with someone who has recently traveled to a risk area.

If travel is necessary, the Centers for Disease Control and Prevention (CDC) recommends the following special precautions for pregnant women and women (and their partners) who are trying to become pregnant

Question 42

Zika Virus Pregnant Women

Use Environmental Protection Agency (EPA)-registered insect rep____ and cover skin.

Stay in places with air _____, sc____, and mosquito n___.

Use c_____ or ab____ from sex during pregnancy.

Be alert for symptoms after travel.

Answer 42

Use Environmental Protection Agency (EPA)-registered insect repellents and cover skin.

Stay in places with air conditioning, screens, and mosquito nets.

Use condoms or abstain from sex during pregnancy.

Be alert for symptoms after travel.

Question 43

Zika Virus Women and Partners Trying to Become Pregnant

Use condoms or abstain from sex according to the following time frames:

• Both partners or only the male partner traveled to an outbreak/risk area: ___ months after return or from the start of symptoms or date of diagnosis
• Only the female partner traveled to an outbreak/risk area: __ months after return or from the start of symptoms or date of diagnosis

Answer 43

Use condoms or abstain from sex according to the following time frames:

• Both partners or only the male partner traveled to an outbreak/risk area: 3 months after return or from the start of symptoms or date of diagnosis
• Only the female partner traveled to an outbreak/risk area: 2 months after return or from the start of symptoms or date of diagnosis

Question 44

Weight Gain

• Best Weight Gain Total =* ___ -____ lb
• Underweight patients (BMI <18.5):* Gain a total of __ to __lb
• Obese patients (BMI >30):* Gain a total of up to __ to __ lb

Answer 44

• Best weight gain Total:* 25 - 35 lb
• Underweight patients (BMI <18.5):* Gain a total of 28 to 40 lb
• kg).Obese patients (BMI >30):* Gain a total of up to 11 to 20 lb

Question 45

Weight Gain

What trimester is the most weight gained per week? how many lb per week?

• After delivery:* Loss of up to __ to __ lb in first few weeks is appropriate.
• Twins:* Increased weight gain __–__ lb is appropriate, but weight gain should not be double that for a single fetus.

Answer 45

Most weight gain is gained in the third trimester (about 1-2 lb per week)

• After delivery:* Loss of up to 15 to 20 lb in first few weeks is appropriate.
• Twins:* Increased weight gain 37–54 lb is appropriate, but weight gain should not be double that for a single fetus.

Question 46

Geriatric Pregnancy

Women who are pregnant at age 35 years have a “geriatric pregnancy.” At higher risk of:

Ch________ abnormalities (e.g., Down syndrome), birth defects

Pre______

___-birth-weight infants

Mis______, ___mature birth

Complications during delivery (e.g., stillbirth); more likely to have C______ delivery

Answer 46

Women who are pregnant at age 35 years have a “geriatric pregnancy.” At higher risk of:

Chromosomal abnormalities (e.g., Down syndrome), birth defects

Preeclampsia

Low-birth-weight infants

Miscarriage, premature birth

Complications during delivery (e.g., stillbirth); more likely to have Cesarean delivery

Question 47

Positive Signs of Pregnancy

______ of fetus by health provider

U______ and visualization of fetus

Fetal ____ tones (FHTs) auscultated by health provider

• 10 to 12 weeks by D____/Doptone
• 20 weeks by fetoscope/st______

Answer 47

Palpation of fetus by health provider

Ultrasound and visualization of fetus

Fetal heart tones (FHTs) auscultated by health provider

• 10 to 12 weeks by Doppler/Doptone
• 20 weeks by fetoscope/stethoscope

Question 48

Probable Signs of Pregnancy

• (1) sign (4 weeks):* Cervical softening
• (1) sign (6–8 weeks):* Blue coloration of the cervix and vagina
• (1) sign (6–8 weeks):* Softening uterine isthmus

En_____ uterus

(1) (seen in midpregnancy): When the fetus is pushed, it can be felt to bounce back by tapping the palpating fingers inside the vagina

Urine or blood pregnancy tests (beta ____)

Answer 48

• Goodell’s sign (4 weeks):* Cervical softening
• Chadwick’s sign (6–8 weeks):* Blue coloration of the cervix and vagina
• Hegar’s sign (6–8 weeks):* Softening uterine isthmus

Enlarged uterus

Ballottement (seen in midpregnancy): When the fetus is pushed, it can be felt to bounce back by tapping the palpating fingers inside the vagina

Urine or blood pregnancy tests (beta HCG)

Question 49

Presumptive Signs of Pregnancy

The following are the “softest” and least objective signs (from mother). Can be caused by many other conditions besides pregnancy.

• ____orrhea
• N___/v____ (most common in first trimester in the morning, usually disappears by the second trimester)
• Br____ changes (swollen and tender)
• Fat____
• Urinary fr______
• Slight ___crease in body temperature
• “Q_______”: Mother feels the baby’s movements for the first time; starts at 16 weeks

Answer 49

The following are the “softest” and least objective signs (from mother). Can be caused by many other conditions besides pregnancy.

• Amenorrhea
• Nausea/vomiting (most common in first trimester in the morning, usually disappears by the second trimester)
• Breast changes (swollen and tender)
• Fatigue
• Urinary frequency
• Slight increase in body temperature
• “Quickening”: Mother feels the baby’s movements for the first time; starts at 16 weeks

Question 50

Signs of Pregnancy

Answer 50

Question 51

Exam Tips

The signs with surnames (Goodell, Chadwick, Hegar) are all _____ signs.

Palpation of fetal movements by the mother is not considered a positive sign of pregnancy (“quickening”). It is classified as a “______ sign.”

Urine/serum pregnancy tests are considered _____ signs (do not confuse them as “positive signs”). Beta HCG also presents in molar pregnancy and ovarian cancer.

Answer 51

The signs with surnames (Goodell, Chadwick, Hegar) are all probable signs.

Palpation of fetal movements by the mother is not considered a positive sign of pregnancy (“quickening”). It is classified as a “presumptive sign.”

Urine/serum pregnancy tests are considered probable signs (do not confuse them as “positive signs”). Beta HCG also presents in molar pregnancy and ovarian cancer.

Question 52

Exam Tips

Exam questions asking for one of the signs will mix them up (e.g., mix a positive sign with a probable sign). Ensure that the answer option contains the two signs from the ____ category.

Memorize the (3) positive signs of pregnancy. This is the shortest list to memorize. By the process of elimination, you can rule out (or in) the correct answer choice.

Answer 52

Exam questions asking for one of the signs will mix them up (e.g., mix a positive sign with a probable sign). Ensure that the answer option contains the two signs from the same category.

Memorize the three positive signs of pregnancy. This is the shortest list to memorize. By the process of elimination, you can rule out (or in) the correct answer choice.

1. Palpation of fetus
2. US/Visualization of Fetus
3. Auscultation of Fetal Heart Tones (10-12 wks by Doppler, 20 weeks by stethoscope)

Question 53

Clinical Methods for Dating Pregnancy

Fundal Heights

(1) weeks = Uterine fundus first rises above symphysis pubis
(1) weeks = Uterine fundus between symphysis pubis and umbilicus
(1) weeks = Uterine fundus at level of umbilicus

FHTs are heard by Doppler at how many weeks?

FHTs are heard by fetoscope or Stethoscope by how many weeks?

Answer 53

12 weeks = Uterine fundus first rises above symphysis pubis

16 weeks = Uterine fundus between symphysis pubis and umbilicus

20 weeks = Uterine fundus at level of umbilicus

FHTs are heard by Doppler by 10 to 12 weeks.

FHTs are heard with fetoscope or stethoscope by 20 weeks.

Question 54

Fundal Height 20-35 Weeks Gestation

Measure the distance between upper edge of (1) and the top of the uterine (1) using a paper tape measure.

Past 20 weeks the fundal height equals what in cm?

For example, a 32-week-gestation fetus should have a fundal height of between ___ and __ cm.

Answer 54

Measure the distance between upper edge of pubic symphysis and the top of the uterine fundus using a paper tape measure.

Fundal height in centimeters equals the number of weeks of gestation (±2 cm).

For example, a 32-week-gestation fetus should have a fundal height of between 30 and 34 cm.

Question 55

Size and Date Discrepancy

The size of the uterus does not match gestational age. Defined as a difference of plus or minus __ (or +/− 2) from number of weeks of gestation.

If the uterine fundus is ≤2 cm (fetus smaller than expected), it can be caused by d_____ error, IU_ _ , or other problem.

If fundus size is ≥2 cm (fetus larger than expected), it can be due to dating error, m____somia, or other problem.

Order an (1).

Answer 55

The size of the uterus does not match gestational age. Defined as a difference of plus or minus 2 (or +/− 2) from number of weeks of gestation.

If the uterine fundus is ≤2 cm (fetus smaller than expected), it can be caused by dating error, IUGR, or other problem.

If fundus size is ≥2 cm (fetus larger than expected), it can be due to dating error, macrosomia, or other problem.

Order an ultrasound.

Question 56

Size and Date Discrepancy

Screening ultrasound to check gestational age:

At 10 to 14 weeks’ gestation, will measure nuchal ______, maternal serum beta ____, and pregnancy-associated plasma ____-A (PAPP-A)

Answer 56

Screening ultrasound to check gestational age:

At 10 to 14 weeks’ gestation, will measure nuchal translucency, maternal serum beta HCG, and pregnancy-associated plasma protein-A (PAPP-A)

Question 57

Physiologic Changes During Pregnancy: Cardiovascular System

Position of the Heart

• Heart is shifted anteriorly toward the ____.
• It rotates toward a trans_____ position as the uterus enlarges.

Heart Rate

• ___creases during pregnancy by 15 to 20 beats/min. Resting heart rate starts to rise during the first trimester.

Heart Sounds

• Heart sounds are _____ in pregnancy.
• The ___ heart sound is common (80%) in pregnant women (but not S4).
• There is wide ____ of S1.
• In the third trimester, splitting of S__ may be heard

Answer 57

Position of the Heart

• Heart is shifted anteriorly toward the left.
• It rotates toward a transverse position as the uterus enlarges.

Heart Rate

• Increases during pregnancy by 15 to 20 beats/min. Resting heart rate starts to rise during the first trimester.

Heart Sounds

• Heart sounds are louder in pregnancy.
• The S3 heart sound is common (80%) in pregnant women (but not S4).
• There is wide splitting of S1.
• In the third trimester, splitting of S2 may be heard

Question 58

Physiologic Changes During Pregnancy: Cardiovascular System

Murmurs

• A ___tolic ej____ murmur (grade II/IV) over the pulmonary and tricuspid areas is common.
• A mammary _____ (systole or continuous) is heard over the breasts later in pregnancy and during lactation (breastfeeding).

Cardiac Output

• ___creases by 30% to 50% and peaks at about 28 to 34 weeks’ gestation
• ___creases of systemic vascular resistance and systolic BP

Plasma Volume

• Plasma volume ___creases by almost 50% by the end of the second trimester.
• Hemo_____ results in physiologic _____ of pregnancy (hematocrit decreased).

Answer 58

Murmurs

• A systolic ejection murmur (grade II/IV) over the pulmonary and tricuspid areas is common.
• A mammary soufflé (systole or continuous) is heard over the breasts later in pregnancy and during lactation (breastfeeding).

Cardiac Output

• Increases by 30% to 50% and peaks at about 28 to 34 weeks’ gestation
• Reduction of systemic vascular resistance and systolic BP

Plasma Volume

• Plasma volume increases by almost 50% by the end of the second trimester.
• Hemodilution results in physiologic anemia of pregnancy (hematocrit decreased).

Question 59

Physiologic Changes During Pregnancy: Cardiovascular System

Physiologic Anemia of Pregnancy

• Physiologic _____of pregnancy is most obvious from 6 to 9 months (second and third trimesters).
• Hemoglobin and hematocrit are creased because of the hemo___ from increased plasma ____. The hemoglobin can decrease to as low as ____ g/dL.

Preload and Afterload

• Preload ____creases because of higher blood volume.
• Afterload goes _____ because of the decrease in peripheral vascular resistance that occurs during pregnancy.

Answer 59

Physiologic Anemia of Pregnancy

• Physiologic anemia of pregnancy is most obvious from 6 to 9 months (second and third trimesters).
• Hemoglobin and hematocrit are decreased because of the hemodilution from increased plasma volume. The hemoglobin can decrease to as low as 10.5 g/dL.

Preload and Afterload

• Preload increases because of higher blood volume.
• Afterload goes down because of the decrease in peripheral vascular resistance that occurs during pregnancy.

Question 60

Physiologic Changes During Pregnancy: Cardiovascular System

Blood Pressure

• Systolic and diastolic BP starts to __crease in the first trimester and continues in the second trimester. Many mothers who are hypertensive before pregnancy can be off prescription antihypertensives at this time.
• By the third trimester, BP gradually returns back to ____pregnancy levels. Antihypertensives used for pregnant women are (1) (Aldomet) and(1) (Normodyne; beta-blocker).

Vena Cava

• Com______ by enlarged uterus (20 weeks’ gestation till labor) of the inferior vena cava ___creases blood return to the brain, resulting in _______ hypotension (postural hypotensive syndrome).
• Advise women to lie on the ____ side and change positions _____.

Answer 60

Blood Pressure

• Systolic and diastolic BP starts to decrease in the first trimester and continues in the second trimester. Many mothers who are hypertensive before pregnancy can be off prescription antihypertensives at this time.
• By the third trimester, BP gradually returns back to prepregnancy levels. Antihypertensives used for pregnant women are methyldopa (Aldomet) and labetalol (Normodyne; beta-blocker).

Vena Cava

• Compression by enlarged uterus (20 weeks’ gestation till labor) of the inferior vena cava decreases blood return to the brain, resulting in orthostatic hypotension (postural hypotensive syndrome).
• Advise women to lie on the left side and change positions slowly.

Question 61

Physiologic Changes During Pregnancy: Cardiovascular System

Coagulation Factors

• Pregnancy is a ___coagulable state (clotting factors go __ ), especially ____ labor (puerperium or postpartum period).

Varicose Veins

• Varicose veins become ____ severe during pregnancy.

Edema

• Peripheral edema is considered _____ in pregnancy. Mild edema of the lower extremities and the feet is most noticeable in the third trimester.

Answer 61

Coagulation Factors

• Pregnancy is a hypercoagulable state (clotting factors go up), especially after labor (puerperium or postpartum period).

Varicose Veins

• Varicose veins become more severe during pregnancy.

Edema

• Peripheral edema is considered normal in pregnancy. Mild edema of the lower extremities and the feet is most noticeable in the third trimester.

Question 62

Respiratory System in Pregnancy

Presence of basal r____ that disappear with coughing or deep breathing

Feeling of breath______ (inn_____ hyperpnea) and __creased exercise tolerance

Physiologic ___pnea in pregnancy has a ____ onset. ____-onset dyspnea is abnormal; rule out pulmonary _____ (pleuritic chest pain, tachypnea, hemoptysis).

The gravid uterus pushes up the dia_____ as it gets larger; the diameter of the thorax is increased.

___ change in forced expiratory volume in one second (FEV1), but total lung capacity ____ slightly from 4.2 to 4 L.

Answer 62

Presence of basal rales that disappear with coughing or deep breathing

Feeling of breathlessness (innocent hyperpnea) and decreased exercise tolerance

Physiologic dyspnea in pregnancy has a slow onset. Sudden-onset dyspnea is abnormal; rule out pulmonary emboli (pleuritic chest pain, tachypnea, hemoptysis).

The gravid uterus pushes up the diaphragm as it gets larger; the diameter of the thorax is increased.

No change in forced expiratory volume in one second (FEV1), but total lung capacity drops slightly from 4.2 to 4 L.

Question 63

Physiologic Changes in Pregnancy

Endocrine System

• Diffusely en_____ (size up to 15% larger), with ______ metabolic activity.

Gastrointestinal System

• ___creased peristalsis from progesterone effects (constipation, heartburn)

Answer 63

Endocrine System

• Diffusely enlarged (size up to 15% larger), with higher metabolic activity.

Gastrointestinal System

• Decreased peristalsis from progesterone effects (constipation, heartburn)

Question 64

Integumentary System (Skin and Hair) in Pregnancy

Pigmentary Changes

• Pigmentary changes from increase in _____cyte-stimulating hormone from higher levels of _____. Causes the (1) (dark pigmented “line” that extends from the mons pubis to the umbilicus located midline).
• The nipples and areola get ______.

(1)

• Blotchy hyperpigmentation on forehead, cheeks, nose, and upper lip seen in pregnant women and some birth control pill users. Usually gets lighter and regresses within 1 year; however, in some women, hyperpigmentation may be permanent.
• Condition is more common in darker skins (olive skins and darker).

Answer 64

Pigmentary Changes

• Pigmentary changes from increase in melanocyte-stimulating hormone from higher levels of estrogen. Causes the linea nigra (dark pigmented “line” that extends from the mons pubis to the umbilicus located midline).
• The nipples and areola darken.

Chloasma (Melasma)

• Blotchy hyperpigmentation on forehead, cheeks, nose, and upper lip seen in pregnant women and some birth control pill users. Usually gets lighter and regresses within 1 year; however, in some women, hyperpigmentation may be permanent.
• Condition is more common in darker skins (olive skins and darker).

Question 65

Integumentary System (Skin and Hair) in Pregnancy

(1) (Stretch Marks)

• Most common locations are abdomen, breasts, and thighs. Other less common areas are upper arms, lower back, and buttocks.

(1) (Hair Loss)

• During the postpartum period, hair loss may accelerate, but it is temporary.

Answer 65

Striae Gravidarum (Stretch Marks)

• Most common locations are abdomen, breasts, and thighs. Other less common areas are upper arms, lower back, and buttocks.

Telogen Effluvium (Hair Loss)

• During the postpartum period, hair loss may accelerate, but it is temporary.

Question 66

Renal System in Pregnancy

What happens to kidney size? Ureters and Renal Pelvis?

What happens to the Glomerular filtration rate (GFR)?

Answer 66

Kidney size increases during pregnancy. The ureters and renal pelvis become dilated (physiologic hydronephrosis).

Glomerular filtration rate (GFR) is much higher in pregnancy because of higher cardiac output and renal blood flow.

Question 67

Ear, Nose, and Throat in Pregnancy

Some women develop nasal _____ and/or ep_____ due to increased blood flow to the nasopharynx during pregnancy.

Rule out acute ___itis if purulent mucus seen in posterior pharynx.

Answer 67

Some women develop nasal congestion and/or epistaxis due to increased blood flow to the nasopharynx during pregnancy.

Rule out acute sinusitis if purulent mucus seen in posterior pharynx.

Question 68

Musculoskeletal System in Pregnancy

Weight gain, enlarged uterus, and hormonal changes contribute to joint ligamentous ___ity and exaggerated ____osis of the lumbar spine.

Up to 60% of pregnant women experience back ____(not related to labor).

Gait changes to w_____ stance.

Answer 68

Weight gain, enlarged uterus, and hormonal changes contribute to joint ligamentous laxity and exaggerated lordosis of the lumbar spine.

Up to 60% of pregnant women experience back pain (not related to labor).

Gait changes to wider stance.

Question 69

Naegele’s Rule*

=

Used to estimate date of (1) during the first trimester.

Assumes regular 28- to 30-day menstrual cycle. Not as useful for irregular menstrual cycles. A full-term pregnancy is ___ weeks (280 days).

Answer 69

LMP - 3 months + 7 days

Used to estimate date of delivery (EDD) during the first trimester.

Assumes regular 28- to 30-day menstrual cycle. Not as useful for irregular menstrual cycles. A full-term pregnancy is 40 weeks (280 days).

Question 70

Naegele’s Rule Practice Question

A 28-year-old woman who is at 8 weeks’ gestation reports that her LMP was on February 20, 2021. Using Naegele’s rule, which of the following dates is correct for her expected EDD?

A. November 10, 2021

B. November 27, 2021

C. December 10, 2021

D. December 27, 2021

Answer 70

B. November 27, 2021

LMP - 3 months + 7 days

Question 71

Exam Tips

There is usually one question about the EDD (use _____ rule).

The LMP month on the exam will either be January (01), February (02), or March (03).

• LMP → EDD
  
  • January → ________
  • February → _______
  • March → _______

___ heart murmur is normal finding in pregnancy.

Chloasma/_____ is due to high _____ level.

Answer 71

There is usually one question about the EDD (use Naegele’s rule).

The LMP month on the exam will either be January (01), February (02), or March (03).

• LMP → EDD
  
  • January → October
  • February → November
  • March → December

S3 heart murmur is normal finding in pregnancy.

Chloasma/melasma is due to high estrogen level.

Question 72

Exam Tips

Placenta _____ is vaginal bleeding (bright red) without a hypertonic tender uterus.

Placenta ______ is vaginal bleeding that is intermittent with hypertonic, hard, and tender uterus.

Fundus at 12 weeks is =

Fundus at 16 weeks is =

Fundus at 20 weeks is =

Answer 72

Placenta previa is vaginal bleeding (bright red) without a hypertonic tender uterus.

Placenta abruptio is vaginal bleeding that is intermittent with hypertonic, hard, and tender uterus.

Fundus at 12 weeks is above symphysis pubis.

Fundus at 16 weeks is between the symphysis pubis and the umbilicus.

Fundus at 20 weeks is at the umbilicus.

Question 73

Exam Tips

Ashkenazi Jews (European Jews) should be screened for (1) disease.

Sexually active females with hypertension who do not use birth control who get pregnant should avoid (2) to treat hypertension (category C/D).

Preferred medications for hypertension in pregnancy are _____ (Aldomet), ______ (beta-blocker), hy______, and long-acting nif______.

For methyldopa, check ____ at baseline and periodically (contraindicated if active hepatic disease). Discontinue if j_____, abnormal ____, or unexplained f_____ occur.

Answer 73

Ashkenazi Jews (European Jews) should be screened for Tay–Sachs disease.

Sexually active females with hypertension who do not use birth control who get pregnant should avoid ACE inhibitors and ARBs to treat hypertension (category C/D).

Preferred medications for hypertension in pregnancy are methyldopa (Aldomet), labetalol (beta-blocker), hydralazine, and long-acting nifedipine.

For methyldopa, check LFTs at baseline and periodically (contraindicated if active hepatic disease). Discontinue if jaundice, abnormal LFTs, or unexplained fever occur.

Question 74

Obstetric History

G-T-P-A-L

Answer 74

Gravida

Term

Preterm

Abortion

Living Children

Question 75

GTPAL Practice Question

28-Year-Old G5T3P1A1L5

=

Answer 75

G: 5 (five pregnancies total)

T: 3 (three pregnancies full term)

P: 1 (one twin pregnancy preterm born at 34 weeks)

A: 1 (one abortion)

L: 5 (five living children)

Question 76

Postpartum (or Puerperium) Period

=

Answer 76

Occurs immediately after delivery and generally lasts about 6 weeks

Question 77

Uterine Involution

Takes how long?

Is it normal for women to continue to have contractions after giving birth?

What is the size of the uterus after delivery?

What are signs that the uterus atony (inadequate contraction)?

Answer 77

Uterine Involution takes about 6 weeks

It is normal for postpartum women to have uterine contractions (spontaneous or with breastfeeding) during the first 2 to 3 days after giving birth.

After delivery, the uterus is the size of a 20-week pregnancy (fundi at the umbilicus)

A soft boggy uterus accompanied by heavy vaginal bleeding is a sign of atony (inadequate contraction).

Question 78

Oligohydramnios

=

• Amniotic fluid index (AFI*) < __cm
• Normal AFI = ___-___* cm
• The uterus is _____ in size than expected.
• It may occur in what trimester?
• Multiple causes; it can be idiopathic or have maternal, fetal, or placental causes. Refer to _____ for management.
• At higher risk of fetal malfo____, p_____ hypoplasia, umbilical cord com______, and fetal or neonatal d______.

Answer 78

Amniotic fluid volume is less than expected for gestational age.

Amniotic fluid index (AFI) < 5 cm

Normal AFI = 5-25 cm

• The uterus is smaller in size than expected.
• It may occur in the first, second, or third trimester.
• Multiple causes; it can be idiopathic or have maternal, fetal, or placental causes. Refer to obstetrician for management.
• At higher risk of fetal malformation, pulmonary hypoplasia, umbilical cord compression, and fetal or neonatal death.

Question 79

Polyhydramnios

=

• Occurs in approximately __% of pregnancies.
• F_____ anomalies (usually associated with g____ abnormality or syndrome) are the most common causes of polyhydramnios.
• Refer to ______ for management.

Answer 79

An excessive volume of amniotic fluid that is more than expected for gestational age.

• Occurs in approximately 1% of pregnancies.
• Fetal anomalies (usually associated with genetic abnormality or syndrome) are the most common causes of polyhydramnios.
• Refer to obstetrician for management.

Question 80

RH-Incompatibility Disease

Mother is Rh (1) and Fetus is Rh (1)

What happens?

When should you give RhoGAM to Rh-negative mothers?

Answer 80

Rh-negative mothers with Rh-positive fetuses

The maternal immune system develops antibodies against Rh-positive blood if not given RhoGAM (gamma globulin against Rh factor).

Give RhoGAM for all pregnancies of Rh-negative mothers—even if they terminate in miscarriages, abortions, or tubal or ectopic pregnancies

Question 81

Rhogam

Also known as anti-__ immune globulin.

It is made from pooled Ig__ antibodies against Rh (rhesus) factor. It is an immunoglobulin that helps prevent maternal __immunization (self-immunization) or ___immunization (immunity against another individual of the same species).

If RhoGAM is not given to Rh-______pregnant women, this will result in fetal h_____and fetal an____ in her f_____ pregnancies.

Answer 81

Also known as anti-D immune globulin.

It is made from pooled IgG antibodies against Rh (rhesus) factor. It is an immunoglobulin that helps prevent maternal isoimmunization (self-immunization) or alloimmunization (immunity against another individual of the same species).

If RhoGAM is not given to Rh-negative pregnant women, this will result in fetal hemolysis and fetal anemia in her future pregnancies.

Question 82

(1) Test

Detects presence of Rh _____ in the mother (indirect test) and the infant (direct test). This test is done as part of the labs performed early in pregnancy.

Answer 82

Coombs Test

Detects presence of Rh antibodies in the mother (indirect test) and the infant (direct test). This test is done as part of the labs performed early in pregnancy.

Question 83

Rhogam Injection Schedule

(2)

MOA: RhoGAM decreases the risk of ___immunization of the maternal immune system by des_____ fetal Rh-____ (1) that have cr____ the placenta.

Answer 83

RhoGAM 300 mcg IM first dose is at 28 weeks.

Give second dose within 72 hours after delivery.

MOA: RhoGAM decreases the risk of isoimmunization of the maternal immune system by destroying fetal Rh-positive red blood cells (RBCs) that have crossed the placenta.

Question 84

Gestational Diabetes

GDM is diabetes that occurs during pregnancy.

GDM mothers are at high risk for type 2 diabetes. GDM has high rates of re_____ (33%–50% chance) in future pregnancies.

GDM has concomitant higher rates of (1) defects (anencephaly, microcephaly), congenital h____ disease, birth trauma (shoulder _____), pre_____, and neonatal ____glycemia.

Risk factors are history of GDM in a previous pregnancy, ob____, ethnicity (3), m____somic infant (>9 1bs), and age (older than __ years).

If there is a history of GDM, check for prediabetes or diabetes at __ to __ weeks postpartum and advise lifelong screening at least every __ years.

Answer 84

GDM is diabetes that occurs during pregnancy.

GDM mothers are at high risk for type 2 diabetes. GDM has high rates of reoccurrence (33%–50% chance) in future pregnancies.

GDM has concomitant higher rates of neural tube defects (anencephaly, microcephaly), congenital heart disease, birth trauma (shoulder dystocia), preeclampsia, and neonatal hypoglycemia.

Risk factors are history of GDM in a previous pregnancy, obesity, ethnicity (Asian, American Indian, Pacific Islander, African American, Hispanic), macrosomic infant (>9 1bs), and age (older than 35 years).

If there is a history of GDM, check for prediabetes or diabetes at 4 to 12 weeks postpartum and advise lifelong screening at least every 3 years.

Question 85

Gestational Diabetes Evaluation

Screen at the ____ visit if history of GDM and/or presence of risk factors.

If not high risk for GDM, screen at ___ to ___ weeks’ gestation.

There are two methods of testing for GDM =

Answer 85

Screen at the first visit if history of GDM and/or presence of risk factors.

If not high risk for GDM, screen at 24 to 28 weeks’ gestation.

There are two methods of testing for GDM = one-step or two-step strategy

Question 86

• One-Step Method*
• =*

. Overnight fast of at least __ hours. Perform test in the ____.

Diagnostic criteria

• Fasting: ≥__ mg/dL
• 1 hour: ≥___ mg/dL
• 2 hours: ≥___ mg/dL

If ___ value is elevated in this test, it is diagnostic of GDM.

The 75-gram OGTT is the ______ test.

Answer 86

Administer 75-g oral glucose tolerance test (OGTT; check fasting, 1 hour, and 2 hours).

Overnight fast of at least 8 hours. Perform test in the morning.

Diagnostic criteria

• Fasting: ≥92 mg/dL
• 1 hour: ≥180 mg/dL
• 2 hours: ≥153 mg/dL

If one value is elevated in this test, it is diagnostic of GDM.

The 75-gram OGTT is the preferred test.

Question 87

• Two-Step Method*
• Screening:* ___-g glucose load (___fasting), check plasma glucose at __ hour.
• If ≥____mg/dL:* Rule out GDM. Order ____-g OGTT (fasting, 1 hour, 2 hours, and 3 hours).

Diagnostic criteria

• Fasting: ≥__ mg/dL
• 1 hour: ≥___ mg/dL
• 2 hours: ≥___ mg/dL
• 3 hours: ≥____ mg/dL

Answer 87

• Screening:* 50-g glucose load (nonfasting), check plasma glucose at 1 hour.
• If ≥140 mg/dL:* Rule out GDM. Order 100-g OGTT (fasting, 1 hour, 2 hours, and 3 hours).

Diagnostic criteria

• Fasting: ≥95 mg/dL
• 1 hour: ≥180 mg/dL
• 2 hours: ≥155 mg/dL
• 3 hours: ≥140 mg/dL

Question 88

Clinical Pearls

GDM is diagnosed in the ____-____ trimester.

A woman with diabetes in the first trimester has (1)

An A1C

Answer 88

GDM is diagnosed in the second to third trimester.

A woman with diabetes in the first trimester has type 2 diabetes.

An A1C <6% (second to third trimester) has the lowest risk for large-for-gestational-age infants.

Question 89

Glycemia Targets in Pregnancy

• Preprandial:* ≤__ mg/dL
• 1-hour postmeal*: ≤___ mg/dL
• 2-hour postmeal:* ≤___ mg/dL
• A1C goal:*

Answer 89

• Preprandial:* ≤95 mg/dL
• 1-hour postmeal*: ≤140 mg/dL
• 2-hour postmeal:* ≤120 mg/dL
• A1C goal:* <6%

Question 90

Gestational Diabetes Treatment Plan

First-line treatment is _____ (follow a meal plan and scheduled physical activity).

• Eat ____ meals per day plus two or three ____. Limit ca_____.
• Exercise ___ minutes per day at least ___ days a week (total of 2 hours per week).

Answer 90

First-line treatment is lifestyle (follow a meal plan and scheduled physical activity).

• Eat three meals per day plus two or three snacks. Limit carbohydrates.
• Exercise 30 minutes per day at least 5 days a week (total of 2 hours per week).

Question 91

Gestational Diabetes Treatment Plan

____-impact exercises such as walking and swimming are preferred.

• Perform frequent home glucose monitoring (____ to six times per day).
• If medication needed, human _____ is the preferred agent. Insulin injections needed if unable to control blood glucose with diet and exercise.
• May need to self-inject insulin from three to six times per day.
• American Diabetes Association (ADA) and American Congress of Obstetricians and Gynecologists (ACOG) have endorsed use of oral antihyperglycemic drugs gly____ and met____.

Glucose monitoring: Check blood glucose at least ____ times per day (fasting, 1 or 2 hours after the first bite of each meal).

Answer 91

Low-impact exercises such as walking and swimming are preferred.

• Perform frequent home glucose monitoring (four to six times per day).
• If medication needed, human insulin is the preferred agent. Insulin injections needed if unable to control blood glucose with diet and exercise.
• May need to self-inject insulin from three to six times per day.
• American Diabetes Association (ADA) and American Congress of Obstetricians and Gynecologists (ACOG) have endorsed use of oral antihyperglycemic drugs glyburide and metformin.

Glucose monitoring: Check blood glucose at least four times per day (fasting, 1 or 2 hours after the first bite of each meal).

Question 92

Follow up GDM

Test for prediabetes or diabetes at ___ to __ weeks postpartum and at least every _ years afterward (future).

NOTE

The lowest rates of adverse fetal outcomes (large-for-gestational age infant, preterm delivery, preeclampsia) occur with an A1C

Answer 92

Test for prediabetes or diabetes at 4 to 12 weeks postpartum and at least every 3 years afterward (future).

NOTE

The lowest rates of adverse fetal outcomes (large-for-gestational age infant, preterm delivery, preeclampsia) occur with an A1C <6% to 6.5%

Question 93

Exam Tips

There are ____ methods of screening for GDM.

One-step method uses the ___-g OGTT (both for screening and diagnosis).

Two-step method uses ___-g OGTT test (__fasting) as the screening test.

If 50-g OGTT is abnormal (postprandial >___mg/dL or fasting >___g/dL), follow-up test is _____-g OGTT (must ____ for at least 8 hours).

Answer 93

There are two methods of screening for GDM.

One-step method uses the 75-g OGTT (both for screening and diagnosis).

Two-step method uses 50-g OGTT test (nonfasting) as the screening test.

If 50-g OGTT is abnormal (postprandial >140 mg/dL or fasting >95 g/dL), follow-up test is 100-g OGTT (must fast for at least 8 hours).

Question 94

Exam Tips

First-line treatment for GDM is_______ change (correct d___ and scheduled ex_______).

Learn the risk factors for GDM =

Learn action of RhoGAM =

Answer 94

First-line treatment for GDM is lifestyle change (correct diet and scheduled exercises).

Learn the risk factors for GDM = hx of GDM, obesity, asian/indian/AA/hispanic ethnicity, macrosomic infant >9lb, >35 yo

Learn action of RhoGAM = Rh antibodies that hemolyze Rh-positive fetal RBCs

Question 95

Urinary Tract Infections

Acute cystitis can occur alone, or it may be complicated by acute pyelonephritis. The most common organism is (1) (75%–95%). Signs and symptoms include ___uria, fr_____, ur____, and ___turia. Higher risk of ____term birth and ____ birth weight is observed.

Answer 95

Acute cystitis can occur alone, or it may be complicated by acute pyelonephritis. The most common organism is Escherichia coli (75%–95%). Signs and symptoms include dysuria, frequency, urgency, and nocturia. Higher risk of preterm birth and low birth weight is observed.

Question 96

Asymptomatic Bacteriuria

Pregnant women with asymptomatic bacteriuria do we treat? why?

Diagnosis is based on ____stream urine __&__results. Obtain specimen _____ antibiotic treatment and ____(to check for eradication of infection).

Urinary tract infections (UTIs) increase the risk of ___term birth, ___birth weight, and perinatal mor_____.

Answer 96

Pregnant women with asymptomatic bacteriuria are always treated because they are at high risk for acute pyelonephritis (25%).

Diagnosis is based on midstream urine C&S results. Obtain specimen before antibiotic treatment and after (to check for eradication of infection).

Urinary tract infections (UTIs) increase the risk of preterm birth, low birth weight, and perinatal mortality.

Question 97

Asymptomatic Bacteriuria Treatment Plan

Urine dipstick

• WBCs (leukocyte esterase): _____
• Nitrite: May be positive or negative

Send ___stream urine for urinalysis (UA) and urine _&_.

Document resolution of infection by ordering ____treatment urine C&S __ week after completing antibiotic therapy.

If suspect pyelonephritis, refer to ___ or a physician.

Answer 97

Urine dipstick

• WBCs (leukocyte esterase): Positive
• Nitrite: May be positive or negative

Send midstream urine for urinalysis (UA) and urine C&S.

Document resolution of infection by ordering posttreatment urine C&S 1 week after completing antibiotic therapy.

If suspect pyelonephritis, refer to ED or a physician.

Question 98

Asymptomatic Bacteriuria Medications

N_________ BID × 5 to 7 days (avoid using during the last trimester)

• Do not use sulfa drugs (e.g., (2) near term because of the risk of hyper______; causes hemo_____ if the mother (or both mother and baby) has G____ anemia.

Aug_____ BID x 3 to 7 days

Am______ BID x 3 to 7 days

Ce______ BID x 3 to 7 days

Fos______ 3-g single dose

Answer 98

Nitrofurantoin (Macrobid) BID × 5 to 7 days (avoid using during the last trimester)

• Do not use sulfa drugs (e.g., Bactrim) or nitrofurantoin near term because of the risk of hyperbilirubinemia; causes hemolysis if the mother (or both mother and baby) has G6PD anemia.

Amoxicillin–clavulanate (Augmentin) BID x 3 to 7 days

Amoxicillin BID x 3 to 7 days

Cephalexin BID x 3 to 7 days

Fosfomycin 3-g single dose

Question 99

Sulfa Drugs

Sulfa drugs, including n______, should be avoided n____ term (__–__ weeks), during l____, and during del______. They are also contraindicated in neonates younger than __ weeks of age.

These drugs increase the risk of hyper______ (bilirubin is toxic to n____ and C_ _).

Complication of hyperbilirubinemia is called “_______” (serious nerve/brain damage).

Do not use if ______ anemia is suspected (causes hemolysis).

Nitrofurantoin causes serious adverse effects, such as p_____reactions (interstitial pneumonitis, pulmonary fibrosis), l____ damage, n___pathy, and others.

Answer 99

Sulfa drugs, including nitrofurantoin, should be avoided near term (38–42 weeks), during labor, and during delivery. They are also contraindicated in neonates younger than 4 weeks of age.

These drugs increase the risk of hyperbilirubinemia (bilirubin is toxic to nerves and CNS).

Complication of hyperbilirubinemia is called “kernicterus” (serious nerve/brain damage).

Do not use if G6PD anemia is suspected (causes hemolysis).

Nitrofurantoin causes serious adverse effects, such as pulmonary reactions (interstitial pneumonitis, pulmonary fibrosis), liver damage, neuropathy, and others.

Question 100

Exam Tips

Asymptomatic bacteriuria and UTIs in pregnant women =

UTIs in pregnant women are classified as “______ UTIs.”

A count of ___ cfu/mL or higher in a symptomatic pregnant woman is considered a UTI.

In a nonpregnant healthy adult, a UTI is defined as 100,000 CFU, or ___ CFU, of one organism.

Answer 100

Always treat asymptomatic bacteriuria and UTIs in pregnant women.

UTIs in pregnant women are classified as “complicated UTIs.”

A count of 10³ cfu/mL or higher in a symptomatic pregnant woman is considered a UTI.

In a nonpregnant healthy adult, a UTI is defined as 100,000 CFU, or 10⁵ CFU, of one organism.

Question 101

Exam Tips

Signs and symptoms of UTI in pregnant women are the ____ as in those in a nonpregnant state.

_____ is not the first-line drug for empiric UTI treatment (high resistance rates).

There are usually only a few questions that address pregnancy. Do not ___study this subject area for the exam, because the number of questions has decreased over the past few years.

Answer 101

Signs and symptoms of UTI in pregnant women are the same as in those in a nonpregnant state.

Amoxicillin is not the first-line drug for empiric UTI treatment (high resistance rates).

There are usually only a few questions that address pregnancy. Do not overstudy this subject area for the exam, because the number of questions has decreased over the past few years.

Question 102

(1)

Also known as a miscarriage. Spontaneous loss of the fetus before it is viable (<20 weeks).

Answer 102

Spontaneous Abortion

Question 103

(1)

Vaginal bleeding occurs, but cervical os remains closed. Most of these cases will result in an ongoing pregnancy.

Answer 103

Threatened Abortion

Question 104

(1)

Cervix is dilated and unable to stop process. Fetus will be aborted.

Answer 104

Inevitable Abortion

Question 105

(1)

Vaginal bleeding with cramping occurs. Placenta and fetus are expelled completely. Cervical os will close, and bleeding stops.

Answer 105

Complete Abortion

Question 106

(1)

Vaginal bleeding with cramping occurs. Placental products remain in the uterus. Cervical os remains dilated, and bleeding persists; pieces of tissue may be seen at the cervical os. Vaginal discharge is foul smelling (bacterial ______). Treatment is di_____ and c____ (D&C) and anti_____.

Answer 106

Incomplete Abortion (Abortion with Retained Products of Conception)

Vaginal bleeding with cramping occurs. Placental products remain in the uterus. Cervical os remains dilated, and bleeding persists; pieces of tissue may be seen at the cervical os. Vaginal discharge is foul smelling (bacterial vaginosis). Treatment is dilation and curettage (D&C) and antibiotics.

Question 107

(1)

Pregnancy loss that occurs at 20 weeks’ gestation or later or weight of 350 grams or greater.

Answer 107

Stillbirth or Fetal Death

Question 108

Preeclampsia (Pregnancy-Induced Hypertension)

Most cases of preeclampsia occur in the late ____ trimester (34 weeks’ gestation or later). It can occur up to 4 weeks ____ childbirth (postpartum period). Mild cases of preeclampsia may not have symptoms such as _____aches, _____ vision, or ____ upper quadrant _____ pain.

Answer 108

Most cases of preeclampsia occur in the late third trimester (34 weeks’ gestation or later). It can occur up to 4 weeks after childbirth (postpartum period). Mild cases of preeclampsia may not have symptoms such as headaches, blurred vision, or right upper quadrant abdominal pain.

Question 109

Preeclampsia

Risk factors include p___gravida, m___para, >__ years of age, obesity, prior history of preeclampsia, hyper____, or k____ disease.

Will cause multi____ damage to the brain (1); kidneys (acute renal _____); lungs (pulmonary ______); liver (hepatic r_____), as well as D__; and fetal and/or maternal d_____.

Older name is “toxemia.” The exact etiology of preeclampsia is unknown. If ____ develop, the woman will be diagnosed with eclampsia.

Answer 109

Risk factors include primigravida, multipara, >35 years of age, obesity, prior history of preeclampsia, hypertension, or kidney disease.

Will cause multiorgan damage to the brain (stroke); kidneys (acute renal failure); lungs (pulmonary edema); liver (hepatic rupture), as well as DIC; and fetal and/or maternal death.

Older name is “toxemia.” The exact etiology of preeclampsia is unknown. If seizures develop, the woman will be diagnosed with eclampsia.

Question 110

Diagnostic Criteria Preeclampsia

Classic triad of (3) that occur after ___ weeks’ gestation and up to __ weeks postpartum. Take at least ____ separate readings (at least 6 hours apart).

• BP: Systolic ≥___ mmHg or diastolic ≥___ mmHg
• Proteinuria: >0.__ g protein in a 24-hour urine specimen. Proteinuria ranges from trace to __ to 4+ (severe cases).
• Rapid _____ gain of 2 to 5 lb per week. The ed____ is most obvious in the f___, around the eyes, and on the h_____.

Answer 110

Classic triad of hypertension, proteinuria, and edema that occur after 20 weeks’ gestation and up to 4 weeks postpartum. Take at least two separate readings (at least 6 hours apart).

• BP: Systolic ≥140 mmHg or diastolic ≥90 mmHg
• Proteinuria: >0.3 g protein in a 24-hour urine specimen. Proteinuria ranges from trace to 1+ to 4+ (severe cases).
• Rapid weight gain of 2 to 5 lb per week. The edema is most obvious in the face, around the eyes, and on the hands.

Question 111

Preeclampsia Treatment Plan

Refer to (1) for management.

The only definitive “cure” for preeclampsia and eclampsia is?

Answer 111

Refer to obstetrician for management.

The only definitive “cure” for preeclampsia and eclampsia is delivery of the placenta/fetus.

Question 112

Preexisting/Chronic Hypertension

Definition =

Do not confuse this condition with preeclampsia.

May be on a prescription. If on an (1) or (1), discontinue as soon as possible and monitor BP closely.

Most pregnant women with preexisting hypertension can usually get ___ their BP medications (temporarily) during the first to second trimester because of the physiologic _____ of BP during pregnancy (less peripheral vascular resistance).

Answer 112

Defined as the presence of an elevated BP (>140/90 mmHg) before the 20th week of gestation.

Do not confuse this condition with preeclampsia.

May be on a prescription. If on an ACE inhibitor or ARB, discontinue as soon as possible and monitor BP closely.

Most pregnant women with preexisting hypertension can usually get off their BP medications (temporarily) during the first to second trimester because of the physiologic lowering of BP during pregnancy (less peripheral vascular resistance).

Question 113

(1)

Premature partial to complete separation of a normally implanted placenta from the uterine bed. Rupture of the maternal blood vessels from the decidua basalis. Bleeding ranges from mild to hemorrhage. Controllable risk factors are smoking, cocaine use, hypertension, and encouraged seatbelt use.

Answer 113

Placenta Abruptio (Placental Abruption)

Question 114

Classic Case of Placenta Abruptio

Sudden onset of vaginal bleeding (mild to hem_____) with abdominal and/or b____ pain. Painful uterine con______. Uterus is rigid (____tonic) and very t_____.

Answer 114

Sudden onset of vaginal bleeding (mild to hemorrhage) with abdominal and/or back pain. Painful uterine contractions. Uterus is rigid (hypertonic) and very tender.

Question 115

Placenta Abruptio Treatment Plan

Refer to the ___.

Initial ED labs are CBC, prothrombin time (PT)/partial thromboplastin time (PTT), blood type, cross-match, Rh factor, and so on.

Abdominal (1) and blood ______ needed.

If mild contractions, give (1) IV. Strict bed ____ is needed.

Deliver fetus by (1) if mother’s life is threatened. Give st_____ if fetus is viable.

Answer 115

Refer to the ED.

Initial ED labs are CBC, prothrombin time (PT)/partial thromboplastin time (PTT), blood type, cross-match, Rh factor, and so on.

Abdominal ultrasound and blood transfusion needed.

If mild contractions, give magnesium sulfate (MgSO₄) IV. Strict bed rest is needed.

Deliver fetus by C-section if mother’s life is threatened. Give steroids if fetus is viable.

Question 116

(1)

This is an abnormally implanted placenta. The placenta implants too low either on top of the cervix or on the cervical isthmus/neck. Most cases get better spontaneously (will reimplant). Some cases are __symptomatic. Higher risk if previous history of placenta previa or C-section, multipara, older age, smoking, fibroids, or cocaine use.

Answer 116

Placenta Previa

This is an abnormally implanted placenta. The placenta implants too low either on top of the cervix or on the cervical isthmus/neck. Most cases get better spontaneously (will reimplant). Some cases are asymptomatic. Higher risk if previous history of placenta previa or C-section, multipara, older age, smoking, fibroids, or cocaine use.

Question 117

Classic Case of Placenta Previa

A multipara woman who is in the late ___ or ____ trimester of pregnancy complains of a sudden onset of br____-___ vaginal bleeding (light to heavy) accompanied by mild contractions. The uterus feels ___ and is ___ tender.

Answer 117

A multipara woman who is in the late second to third trimester of pregnancy complains of a sudden onset of bright-red vaginal bleeding (light to heavy) accompanied by mild contractions. The uterus feels soft and is not tender.

Question 118

Placenta Previa Treatment Plan

Refer to ___.

______ bimanual examination, because _____ of the uterus may cause severe hemorrhage.

Use abdominal ______ only. No i___vaginal ultrasound. No r___exams.

Avoid any vaginal/rectal ____ intercourse.

Bed ____ required. Close fetal and maternal mon_____.

If contractions, give (1) IV. If mild case, pregnancy can be salvaged, and the placenta will reimplant. Perform (1) if mother’s life is in danger.

Answer 118

Refer to ED.

Avoid bimanual examination, because palpation of the uterus may cause severe hemorrhage.

Use abdominal ultrasound only. No intravaginal ultrasound. No rectal exams.

Avoid any vaginal/rectal sexual intercourse.

Bed rest required. Close fetal and maternal monitoring.

If contractions, give magnesium sulfate (MgSO₄) IV. If mild case, pregnancy can be salvaged, and the placenta will reimplant. Perform C-section if mother’s life is in danger.

Question 119

Breastfeeding

Colostrum and Breast Milk

During the first few days (days 1–2) of breastfeeding, _____ is produced (thick yellow color), which contains maternal _____ (passive immunity).

By the third to the fourth day, mature breast ____ is produced (contains fat, sugar/lactose, water, protein, and antibodies).

The full-term healthy infant can be exclusively breastfed for the first ___ months of life, with no supplemental fluids unless ill or dehydrated.

Answer 119

During the first few days (days 1–2) of breastfeeding, colostrum is produced (thick yellow color), which contains maternal antibodies (passive immunity).

By the third to the fourth day, mature breast milk is produced (contains fat, sugar/lactose, water, protein, and antibodies).

The full-term healthy infant can be exclusively breastfed for the first 6 months of life, with no supplemental fluids unless ill or dehydrated.

Question 120

Vitamin D

All breastfed infants need?

Formula-fed infants should only be given ____-fortified formula (has vitamin D).

Answer 120

All breastfed infants need vitamin D supplementation started within the first few days.

Formula-fed infants should only be given iron-fortified formula (has vitamin D).

Question 121

Iron

All exclusively _____ infants require iron (ferrous sulfate) supplementation starting at age ___ months at a dose of __ mg/kg of body weight. Breast milk contains very __ iron.

Most full-term newborns have sufficient iron ____ in their bodies for at least __ months.

At about 6 months, infants’ iron needs can be met through introduction of iron-rich foods, iron-fortified _____, or iron supplement drops.

Infants on iron-fortified f_____ do not need additional iron supplementation.

Answer 121

All exclusively breastfed infants require iron (ferrous sulfate) supplementation starting at age 4 months at a dose of 1 mg/kg of body weight. Breast milk contains very little iron.

Most full-term newborns have sufficient iron stores in their bodies for at least 4 months.

At about 6 months, infants’ iron needs can be met through introduction of iron-rich foods, iron-fortified cereals, or iron supplement drops.

Infants on iron-fortified formula do not need additional iron supplementation.

Question 122

Breastfeeding Technique

Breastfeed within the first ____ of birth. It provides the baby with col_____ and helps the uterus _____.

A new mother should be taught proper breastfeeding technique. Refer to lactation specialist if having problems; follow up at home.

If n____, assess for improper latch on (check positioning, sucking, clicking noises). Swallowing noises are normal, but not cl_____ noises.

For clicking, advise the mother to use her in____ finger to pull down the baby’s ____ so that the baby’s lower lip will be outside. The baby should have the _____ nipple and most of the areola inside its mouth.

Newborns will nurse about __ to __ times per 24 hours.

Answer 122

Breastfeed within the first hour of birth. It provides the baby with colostrum and helps the uterus contract.

A new mother should be taught proper breastfeeding technique. Refer to lactation specialist if having problems; follow up at home.

If noisy, assess for improper latch on (check positioning, sucking, clicking noises). Swallowing noises are normal, but not clicking noises.

For clicking, advise the mother to use her index finger to pull down the baby’s chin so that the baby’s lower lip will be outside. The baby should have the entire nipple and most of the areola inside its mouth.

Newborns will nurse about 8 to 12 times per 24 hours.

Question 123

Steps to a Good Latch

Infant’s chest and stomach should rest _____ body; head is st_____ and not turned to the side.

Tickle infant’s lips with nipple and aim nipple just ____ infant’s ___ lip.

Ensure (1) and (1) are inside the infant’s mouth (baby’s tongue will cup under the breast with lips turned ____; Figure 1).

May hear/see swallowing, and the infant’s ears may w____ slightly.

Breast ____ness is normal the first few days of breastfeeding; a pr_____ latch on will help make it more comfortable.

If improper latch on, gently place a clean finger in the ____ of the infant’s mouth to break the seal (suction) and start again.

Answer 123

Infant’s chest and stomach should rest against body; head is straight and not turned to the side.

Tickle infant’s lips with nipple and aim nipple just above infant’s top lip.

Ensure nipple and areola are inside the infant’s mouth (baby’s tongue will cup under the breast with lips turned out; Figure 1).

May hear/see swallowing, and the infant’s ears may wiggle slightly.

Breast soreness is normal the first few days of breastfeeding; a proper latch on will help make it more comfortable.

If improper latch on, gently place a clean finger in the corner of the infant’s mouth to break the seal (suction) and start again.

Question 124

Sore Nipples

Advise the mother ___ to stop breastfeeding. This causes breast eng_____ (painful).

If p____ latch, the infant may have to suck h_____, which causes pain.

This results from babies having difficulty “latching on” to an en_____ breast.

Nipple ____ is worse during the first week and usually disappears by the _____ week.

If nipple pain persists, assess nipples for fi____ and inf____.

Answer 124

Advise the mother not to stop breastfeeding. This causes breast engorgement (painful).

If poor latch, the infant may have to suck harder, which causes pain.

This results from babies having difficulty “latching on” to an engorged breast.

Nipple pain is worse during the first week and usually disappears by the second week.

If nipple pain persists, assess nipples for fissures and infection.

Question 125

Sore Nipples

Start nursing on the ____ painful breast first.

Initiate “letdown reflex” of milk by m____/w____ shower.

Apply lan___ or breast milk to nipple after nursing to protect from skin breakdown.

____ using plastic nipple shields, alcohol, and soap. Wear nursing bras with good supp____.

May need referral to a _____ specialist (e.g., La Leche League)

Answer 125

Start nursing on the less painful breast first.

Initiate “letdown reflex” of milk by massage/warm shower.

Apply lanolin or breast milk to nipple after nursing to protect from skin breakdown.

Avoid using plastic nipple shields, alcohol, and soap. Wear nursing bras with good support.

May need referral to a lactation specialist (e.g., La Leche League)

Question 126

Maternal Benefits of Breastfeeding

Stimulates uterine contractions (speeds up uterine in_____ after delivery).

Increases maternal b_____ with infant (ox____ effect).

Speeds up w____ loss after pregnancy.

Lowers risk of breast/ovarian _____

Can _____ ovulation if mother breastfeeds exclusively.

Answer 126

Stimulates uterine contractions (speeds up uterine involution after delivery).

Increases maternal bonding with infant (oxytocin effect).

Speeds up weight loss after pregnancy.

Lowers risk of breast/ovarian cancer.

Can delay ovulation if mother breastfeeds exclusively.

Question 127

Fetal Health Benefits of Breastfeeding

Lowers risk of inf_____ (necrotizing enterocolitis, acute otitis ____).

Lowers risk of bacterial and viral inf______ such as otitis media and diarrhea.

Lower incidence of as____ and all____ in breastfed babies.

Young infants who are exclusively breastfed get enough fluids and do not need extra w____. Juices should be ____, because they increase the risk of dental c_____.

Lowers risk of (1) syndrome and future ob______.

Answer 127

Lowers risk of infections (necrotizing enterocolitis, acute otitis media).

Lowers risk of bacterial and viral infections such as otitis media and diarrhea.

Lower incidence of asthma and allergies in breastfed babies.

Young infants who are exclusively breastfed get enough fluids and do not need extra water. Juices should be avoided, because they increase the risk of dental caries.

Lowers risk of sudden infant death syndrome (SIDS) and future obesity.

Question 128

Exam Tips

S______ noises may be heard in breastfeeding, especially in younger babies.

If _____ noises are heard during breastfeeding, it is abnormal. Advise the mother to use her ____ finger to pull down the baby’s ____ so that the baby’s lower lip will latch better onto the areola.

If a question describes a mother who complains of sore nipples, can she stop breastfeeding? Best answer is to advise her that?

Answer 128

Swallowing noises may be heard in breastfeeding, especially in younger babies.

If clicking noises are heard during breastfeeding, it is abnormal. Advise the mother to use her index finger to pull down the baby’s chin so that the baby’s lower lip will latch better onto the areola.

If a question describes a mother who complains of sore nipples, do not advise her to stop breastfeeding, to supplement with formula, or to use formula at nighttime feedings. The best answer is to advise the mother that it is a common problem during the first 2 weeks and will resolve and to continue breastfeeding.

Question 129

Lactational Mastitis (Breastfeeding Mastitis)

Most common in the first 2 months of breastfeeding. Skin f____ on the nipple(s) allow bacterial entry.

Most common organism is (1) (gram positive).

Consider (1) bacterial infection (becoming more common). If severe or toxic, refer to ED or admit to the hospital.

Answer 129

Most common in the first 2 months of breastfeeding. Skin fissures on the nipple(s) allow bacterial entry.

Most common organism is Staphylococcus aureus (gram positive).

Consider methicillin-resistant S. aureus (MRSA) bacterial infection (becoming more common). If severe or toxic, refer to ED or admit to the hospital.

Question 130

Lactational Mastitis Prevention

=

Answer 130

Frequent and complete emptying of breast and proper breastfeeding technique. Breast engorgement and poor technique increase risk of mastitis.

Question 131

Classic Case of Lactational Mastitis

Patient who is breastfeeding complains of a sudden onset of a r__, f___, and tender area (induration) on one breast. May also have f____/chills and malaise (flu-like symptoms). May have _____pathy on the axilla by the affected breast. Most common in the ____ 3 months of breastfeeding.

Answer 131

Patient who is breastfeeding complains of a sudden onset of a red, firm, and tender area (induration) on one breast. May also have fever/chills and malaise (flu-like symptoms). May have adenopathy on the axilla by the affected breast. Most common in the first 3 months of breastfeeding.

Question 132

Lactational Mastitis Labs

Do you need labs for diagnosis?

CBC shows (1)

C&S of milk? but can be useful to guide (1)

Imaging (1) if mastitis does not respond in 48-72 hours

Answer 132

Usually not needed; this is a clinical diagnosis.

CBC shows leukocytosis

C&S of milk is usually not required, but it can be useful to guide antibiotic selection, particularly if hospital acquired, severe, or not responding to antibiotic treatment.

Ultrasound may be useful if mastitis does not respond in 48 to 72 hours.

Question 133

Lactational Mastitis Treatment Plan

• If Low Risk of* Methicillin-Resistant S. aureus
• (1) Rx or (1) Rx*

Do not use (1) during the newborn period, due to increased risk of kernicterus.

Answer 133

Dicloxacillin 500 mg PO QID or Cephalexin (Keflex) 500 mg PO QID for 10 to 14 days.

Do not use sulfas during the newborn period, due to increased risk of kernicterus.

Question 134

Lactational Mastitis Treatment Plan

If High Risk of Methicillin-Resistant S. aureus

(1)Rx one to two tablets PO BID (can be used if healthy infant is 1 month or older, no jaundice) or (1)Rx 300 mg PO QID for 10 to 14 days.

______ to breastfeed on affected breast during antibiotic treatment. If unable to breastfeed, pump milk from infected breast (and discard) to prevent engorgement. Complete _____ of the breast is important during the infection.

If breast abscess is suspected, order an (1) and refer for (1) and (1).

(1) for pain and fever as needed. Apply ____ compresses on indurated breast area.

Refer to _____ consultant if suspect poor breastfeeding technique.

Answer 134

Trimethoprim–sulfamethoxazole (Bactrim) one to two tablets PO BID (can be used if healthy infant is 1 month or older, no jaundice) or clindamycin 300 mg PO QID for 10 to 14 days.

Continue to breastfeed on affected breast during antibiotic treatment. If unable to breastfeed, pump milk from infected breast (and discard) to prevent engorgement. Complete emptying of the breast is important during the infection.

If breast abscess is suspected, order an ultrasound and refer for incision and drainage.

NSAID for pain and fever as needed. Apply cold compresses on indurated breast area.

Refer to lactation consultant if suspect poor breastfeeding technique.

Question 135

Postpartum Contraception

Lactational Amenorrhea Method =

In women who do not breastfeed, ovulation resumes (average) how many days postpartum?

During the postpartum period and with breastfeeding, birth control pills or any contraceptive method containing _____ (pregnancy category X) is contraindicated.

Answer 135

Women who exclusively breastfeed (at least every 4 hours daily) with amenorrhea and who are <6 months postpartum are much less likely to ovulate than a woman who does not breastfeed exclusively

In women who do not breastfeed, ovulation resumes (average) at 39 days postpartum.

During the postpartum period and with breastfeeding, birth control pills or any contraceptive method containing estrogen (pregnancy category X) is contraindicated.

Question 136

Postpartum Contraception

Postpartum women or women who cannot take estrogens can use methods such as?

Answer 136

IUDs (copper or levonorgestrel) or progesterone-only contraception such as etonogestrel (Nexplanon), depot medroxyprogesterone (Depo-Provera), progestin-only pills, or barrier methods (condoms, diaphragm, cervical cap).

Question 137

Postpartum Contraception

The progestin-only contraceptive pill nor_____ (Micronor) contains 28 active pills that are taken daily (no pill-free week).

For maximum effectiveness, pill must be taken at the ____ time each day (very important). If more than __ hours late, take dose as soon as possible and use backup (_____) for the next 2 days. Will probably have vaginal sp_____ for the next few days.

Answer 137

The progestin-only contraceptive pill norethindrone (Micronor) contains 28 active pills that are taken daily (no pill-free week).

For maximum effectiveness, pill must be taken at the same time each day (very important). If more than 3 hours late, take dose as soon as possible and use backup (condom) for the next 2 days. Will probably have vaginal spotting for the next few days.

Question 138

Uncomplicated Chlamydia Infection (Cervicitis, Urethritis)

• ______ Chlamydia trachomatis* infection in the mother will help to prevent the transmission (_____transmission) of the infection to the newborn through the birth canal.
• Example:* Trachoma (or inclusion ____itis of the newborn) and pn______

Answer 138

Treating Chlamydia trachomatis infection in the mother will help to prevent the transmission (vertical transmission) of the infection to the newborn through the birth canal.

Example: Trachoma (or inclusion conjunctivitis of the newborn) and pneumonia

Question 139

Uncomplicated Chlamydia Infection (Cervicitis, Urethritis) Labs

Obtain (1) test such as the Gen-Probe, Amplicor, or ProbeTec.

Gen-Probe can only be used on the (1) and (1). Do not use to collect specimens from the eyes.

Test of cure needed in __ weeks after completing treatment.

Answer 139

Obtain nucleic acid amplification tests (NAATs) such as the Gen-Probe, Amplicor, or ProbeTec.

Gen-Probe can only be used on the cervix and urethra. Do not use to collect specimens from the eyes.

Test of cure needed in 3 weeks after completing treatment.

Question 140

Chlamydia in Pregnancy Treatment Plan

• First-line:* (1) (single dose)
• Alternative:* (1) 500 mg PO TID × 7 days (lower cure rate than azithromycin)

Answer 140

• First-line:* Azithromycin 1 g orally (single dose)
• Alternative:* Amoxicillin 500 mg PO TID × 7 days (lower cure rate than azithromycin)

Question 141

Chlamydia Infection in Pregnancy Treatment of Sexual Partners

• First-line:* (1) 1 g orally (single dose)
  (1) 100 mg PO BID × 7 days (do not use if breastfeeding stains tooth enamel, category D)

Avoid _____ activity for 7 days; avoid unprotected intercourse until both partners are treated; test for other ____ (gonorrhea, syphilis, HIV)

Answer 141

First-line: Azithromycin 1 g orally (single dose)

Doxycycline 100 mg PO BID × 7 days (do not use if breastfeeding stains tooth enamel, category D)

Avoid sexual activity for 7 days; avoid unprotected intercourse until both partners are treated; test for other STDs (gonorrhea, syphilis, HIV)