Pre-Conceptual Counselling

Question 1

A 23-year-old woman visits your office for pre-conceptual counselling. She has a ventricular septal defect (VSD) with bi-directional shunting across the VSD and pulmonary hypertension. Which of the following changes occurring in the peripartum period will place her at greatest risk?

a) Increase in cardiac output

b) Increase blood pressure after local with pushing CO = HR x SV

c) Increase blood coagulability

d) Decrease blood pressure

e) Bacteraemia associated with delivery

Answer 1

a) Increase in cardiac output

Question 2

Which of the following medications would be the most suitable first line treatment for a woman with chronic hypertension in early pregnancy?

a) Methyldopa

b) ACE inhibitor

c) Frusemide

d) Propranolol

e) Isosorbide dintrate

Answer 2

a) Methyldopa

Question 3

Women who have epilepsy and on treatment for this should be advised

a) The risk of a neural tube defect increases with the number of antiepileptic agents used

b) Folic acid should be avoided in pregnancy

c) They should discontinue their antiepileptic medication as soon as they have a positive pregnancy test

d) The risk of limb reduction abnormalities in their offspring is high

e) Neural tube defects can be picked up by maternal serum screening alone

Answer 3

a) The risk of a neural tube defect increases with the number of antiepileptic agents used

Question 4

With regard to pre-conceptual counselling, which of the following statements is true?

a) Childcare workers should be advised of increased risks in pregnancy if they contract childhood infections and to change jobs for the duration of pregnancy

b) In consultation with a neurologist, women with epilepsy should consider changing from sodium valproate to levateracitam prior to pregnancy

c) Measles-mumps-rubella vaccination should not be given as it can increase the risk of cognitive problems in subsequent offspring

d) Hepatitis B serology should not be tested until pregnancy is confirmed

e) Women with type 1 diabetes should not try to improve their blood glucose levels prior to pregnancy as this could cause their diabetic eye disease to deteriorate rapidly

Answer 4

b) In consultation with a neurologist, women with epilepsy should consider changing from sodium valproate to levateracitam prior to pregnancy

Question 5

Which of the following advice given pre conceptually has been shown to improve pregnancy outcomes:

a) Tight glycaemic control for diabetic women

b) Start folic acid after diagnosis of pregnancy

c) Reduce alcohol intake to 1-2 units per day

d) Maintain weight for women with BMI >40

e) Stop anti-epileptic medication at first positive pregnancy test

Answer 5

a) Tight glycaemic control for diabetic women

Question 6

Which of the following drugs is listed as a Category X drug in NZ?

a) Cisplatin

b) Quinapril

c) Ibuprofen

d) Isotretinoin

e) Rifampicin

Answer 6

d) Isotretinoin

Question 7

Min, a 23 year old woman, presents with symptoms of a urinary tract infection. She has noticed increased frequency and dysuria over the last 3 days. Her LMP was 5 weeks ago and she has a confirmed intrauterine pregnancy. She has no known allergies.

Her urine culture result is as follows:
E. coli 8.3x108 CFU/mL
Sensitive to: trimethoprim, co-trimoxazole,
nitrofurantoin, norfloxacin, gentamicin
Resistant to: amoxicillin, amoxicillin/clavulanic acid,
cephalexin

You advise that:

a) Amoxicillin should be trialled prior to other antibiotics as it is a category A drug

b) Nitrofurantoin can be given at a dose of 100mg BD when a woman is struggling with nausea in early pregnancy

c) Norfloxacin is generally contraindicated in pregnancy due to concerns about fetal arthropathy

d) She should take ural sachets and if her symptoms do not settle or worsen, she should return

e) Trimethoprim is the recommended first-line medication for E. coli infection but in pregnancy a 7 day course is required

Answer 7

c) Norfloxacin is generally contraindicated in pregnancy due to concerns about fetal arthropathy

Question 8

Which of the following complications are more common in pregnancies affected by maternal methamphetamine use?

a) Fetal cleft palate

b) Fetal growth restriction

c) Fetal limb deformities

d) Instrumental birth

e) Postpartum haemorrhage

Answer 8

b) Fetal growth restriction

Question 9

With regards to screening and alcohol consumption in pregnancy, which of the following statements are correct?

a) Fetal alcohol spectrum disorder only occurs with heavy drinking in the first trimester

b) 70% of women under the age of 25 stop drinking once they find out they are pregnant

c) Professional women in their 30’s are the social group most likely to continue drinking in pregnancy

d) Screening is only necessary for women at risk of heavy and continued drinking

e) Women should not drink during the first trimester, but can drink small amounts of alcohol throughout the remainder of pregnancy

Answer 9

c) Professional women in their 30’s are the social group most likely to continue drinking in pregnancy

Question 10

With regards to alcohol in pregnancy, which of the following statements is correct?

a) Alcohol is metabolised by the fetus and cleared quickly from the fetal circulation

b) Alcohol passes through the placenta and fetal blood alcohol levels can be nearly equivalent to maternal levels

c) Alcohol consumption during the second trimester increases the risk of structural abnormalities in the fetus

d) The amniotic fluid helps the fetus clear alcohol from the circulation more quickly, so the effect is less at greater gestations

e) There is a clear dose-response relationship between the amount of alcohol consumed by the mother and the damage to the infant

Answer 10

b) Alcohol passes through the placenta and fetal blood alcohol levels can be nearly equivalent to maternal levels

Question 11

With regards to cigarette smoking and cessation in pregnancy, which of the following is correct?

a) 35-75% of women stop smoking in pregnancy and rates are higher when women are counselled by health professionals

b) Nicotine replacement therapy has not been proven to be safe in pregnancy and should be discouraged

c) Smoking cessation after 20 weeks of pregnancy conveys no risk-reduction benefit to the pregnancy

d) Second-hand smoke exposure has no adverse effects on pregnancy and cessation for partners is not required

e) Varenicline (Champix) can be used as an adjunct for smoking cessation in the third trimester

Answer 11

a) 35-75% of women stop smoking in pregnancy and rates are higher when women are counselled by health professionals

Question 12

With regards to cigarette smoking in pregnancy, which of the following is correct?

a) Exposure to second-hand smoke does not increase the risk of stillbirth in pregnant women

b) Smoking at any time of pregnancy increases the risk of stillbirth by 50%

c) Smoking during pregnancy reduces the risk of childhood obesity in the offspring

d) Smoking in the second trimester has the greatest impact on birth weight

e) Smoking in the first trimester increases the risk of developing pre-eclampsia by 15%

Answer 12

b) Smoking at any time of pregnancy increases the risk of stillbirth by 50%

Question 13

Which of the following complications are more common in pregnancies affected by maternal opiate dependence?

a) Caesarean section

b) Excessive gestational weight gain

c) Fetal cardiac abnormalities

d) Gestational diabetes

e) Neonatal abstinence syndrome

Answer 13

e) Neonatal abstinence syndrome

Question 14

Which of the following complications are more common in pregnancies affected by maternal benzodiazepine dependence?

a) Fetal renal tract abnormalities

b) Gestational diabetes

c) Preeclampsia

d) Preterm birth

e) Postpartum haemorrhage

Answer 14

d) Preterm birth

Question 15

Which of the following statements is correct with regards to maternal marijuana use in pregnancy?

a) Chemical products from marijuana do not cross the placenta or into breast milk

b) Marijuana can be used sparingly for the treatment of nausea and vomiting in pregnancy

c) Marijuana use in pregnancy increases the risk of low birth weight in offspring

d) Marijuana use in pregnancy increases the risk of neurobehavioural problems in offspring

e) Regular marijuana use is of no risk during pregnancy

Answer 15

d) Marijuana use in pregnancy increases the risk of neurobehavioural problems in offspring

Question 16

Akari, a 29 year old woman, is planning a pregnancy. She has come to the clinic to discuss her medications. Akari has had a recent pulmonary embolism and is currently on dabigatran. She has long-standing epilepsy and takes sodium valproate and has not had a seizure in the last 3 months. She accepts a referral to the multi-disciplinary obstetric high-risk clinic for pre-pregnancy counselling. Which of the following may be one of the medication changes recommended at the clinic?

a) Change from dabigatran to aspirin

b) Change from dabigatran to warfarin

c) Change from sodium valproate to carbamazepine

d) Change from sodium valproate to levetiracetam

e) Change from sodium valproate to phenytoin

Answer 16

d) Change from sodium valproate to levetiracetam

Question 17

Kaia, a 26 year old woman, is planning a pregnancy in the next 2-3 months. She has primary generalised epilepsy and takes lamotrigine. Kaia has not had a seizure for one year. She accepts a referral to the multi-disciplinary obstetric high-risk clinic for pre-pregnancy counselling. Before she leaves, you advise her that:

a) She can stay on lamotrigine, at the same dose, throughout her pregnancy

b) She could stop her lamotrigine today as she has not had a seizure in a year

c) She should start taking folic acid supplements now and continue them throughout her pregnancy

d) She should switch her lamotrigine to carbamazepine as this has a better safety profile

e) She will need to have an amniocentesis at 16 weeks as her fetus is at high risk of a neural tube defect

Answer 17

c) She should start taking folic acid supplements now and continue them throughout her pregnancy

Question 18

Marie, a 22 year old woman, has come to clinic to see you as she is planning a pregnancy. Marie has a history of rheumatic fever as a child and subsequently developed rheumatic heart disease. She is taking no medication at present. She accepts a referral to the multidisciplinary team at the high-risk obstetric clinic for pre-pregnancy counselling. Which of the following complications is Marie at higher risk of in pregnancy due to her rheumatic heart disease?

a) Miscarriage

b) Myocardial infarction

c) Postpartum haemorrhage

d) Preeclampsia

e) Pulmonary oedema

Answer 18

e) Pulmonary oedema

Question 19

Samara, a 24 year old woman, has come to see you as she is planning a pregnancy. 3 months ago, Samara had a renal transplant. At present she is well and taking immunosuppression. She accepts a referral to the multidisciplinary team at the high-risk obstetric clinic for pre-pregnancy counselling. You also advise her that:

a) Most women planning a pregnancy who have stable graft function can stop their immunosuppressive drugs during the first trimester

b) Mycophenolate and sirolimus are the safest immunosuppressive drugs to take during pregnancy

c) Pregnancy is best delayed to 1 year after transplant, once graft function and medication levels are stable

d) There is no adverse effect on graft function during pregnancy, even if the creatinine level is >130umol/L

e) There is no increased risk of pre-eclampsia or fetal growth restriction in renal transplant recipients during pregnancy

Answer 19

c) Pregnancy is best delayed to 1 year after transplant, once graft function and medication levels are stable

Question 20

Waimarie, a 32 year old woman, has come to see you as she is planning another pregnancy. 2 years ago Waimarie was hospitalised with early-onset preeclampsia at 25 weeks. Her baby was born at 27 weeks via Caesarean section. She has had no other pregnancies. Her BMI is 38. Waimarie accepts a referral to the multidisciplinary team at the high-risk obstetric clinic for pre-pregnancy counselling. You also advise her that that:

a) Her recurrence risk for preeclampsia is approximately 70%

b) Uterine artery dopplers at 20-24 weeks may be useful in predicting preeclampsia recurrence

c) She should start low dose aspirin now as it will reduce her risk of recurrent preeclampsia by 50%

d) There is high quality evidence that all women with previous preeclampsia should start calcium supplementation

e) Weight loss is not necessary pre-pregnancy as this will not decrease her risk of recurrent preeclampsia

Answer 20

b) Uterine artery dopplers at 20-24 weeks may be useful in predicting preeclampsia recurrence

Question 21

Nozomi, a 29 year old woman, has come to see you as she is planning her second pregnancy. 3 years ago Nozomi had a spontaneous preterm birth at 25 weeks. She has no relevant past medical or surgical history and no obvious cause was found for her spontaneous preterm birth. She accepts a referral to the preterm birth clinic for pre-pregnancy counselling. Before she leaves, you advise her that:

a) Her cervical length should be measured first at 20 weeks, with her anatomy scan

b) Her risk of recurrent preterm birth is 50%

c) Quantitative FFN (fetal fibronectin) does not have a role in predicting risk in asymptomatic high-risk women

d) Progesterone supplementation reduces the risk of preterm birth by 30% in a subsequent singleton pregnancy

e) She should consider the use of a home uterine activity monitor in pregnancy to detect preterm labour early

Answer 21

d) Progesterone supplementation reduces the risk of preterm birth by 30% in a subsequent singleton pregnancy

Question 22

Daliah, aged 23, has been planning a pregnancy and comes to you for advice. Daliah is an elite triathlete and has recently begun running marathons. She asks you about the risks and benefits of exercise during pregnancy. Which of the following is correct?

a) Aerobic fitness will decline in pregnancy if she continues to exercise, so she should consider stopping her training early

b) Ligament laxity in pregnancy causes a reduction in sprains and strains in pregnant athletes

c) Regular exercise in pregnancy can worsen pregnancy-related low back pain and pelvic girdle pain and so exercise should be limited to walking and swimming

d) Running marathons on very hot days, hot yoga, or hot pilates should be avoided, particularly in the first trimester, due to the risk of maternal hyperthermia

e) Studies have shown that moderate maternal exercise causes fetal decelerations/bradycardias in 30% of cases in the second trimester

Answer 22

d) Running marathons on very hot days, hot yoga, or hot pilates should be avoided, particularly in the first trimester, due to the risk of maternal hyperthermia