Part 41

Question 1

If a patient has sex with 2 different men 3 days apart can you tell who the father is?

Answer 1

No its too close together with too much variablility, will need genetic testing upon birth

Question 2

Goals of prenatal care

Answer 2

To have all patients receive some form, and preferably in the first trimester

Question 3

4 stages of prenatal care

Answer 3

• Preconception care (basic medical care esp. for those with chronic medical conditions and staying up to date on vaccines)
• prompt diagnosis of pregnancy (confirm they didn’t read an at home test wrong)
• initial presentation for pregnancy care (initial pelvic exam, height of fundus, etc)
• followup prenatal visits

Question 4

Supplementing with folic acid prior to conception (typically done in all bread purchased) has allowed for a decrease in…

Answer 4

….neural tube defects (spinal bifida)

Question 5

1 and #2 structural birth defects

Answer 5

congenital heart anomalies, neural tube defects

Question 6

Tdap in pregnancy

Answer 6

Used in every pregnant woman for every pregnancy to help lower prevalence of whooping cough in infants as infants don’t receive Dtap until 6 months of age, given at 27-36 weeks to promote passive antibody transfer

Question 7

Signs and symptoms of pregnancy (4)

Answer 7

• cessation of menses (not as reliable now due to obesity and birth control)
• changes in cervical mucus and softening
• breast tenderness
• urine or serum pregnancy tests gold standard

Question 8

Parturient definition

Answer 8

Meaning just having delivered

Question 9

Estimation of duration of pregnancy

Answer 9

Mean is 266 days from conception, 279-282 from first day of last menstrual period

Neagle rule
Estimated date of delivery = 1st day of last menstrual period + 7 days, - 3 months + 1 year

Question 10

If the uterus fails to grow as expected, what should be considered?

Answer 10

Intrauterine growth restriction (IUGR)

Question 11

1st trimester ultrasound

Answer 11

Best method possible to predict due date by measuring crown rump length, when done earlier in pregnancy more accurately predicts due date*** (further in gestation more biological variation we get)

Question 12

Pelvimetry

Answer 12

Measurement of the diagonal conjugate from posterior inferior edge of symphysis pubis to sacral promontory to estimate the inlet of the pelvis, normally >12.5cm, can determine if a lady can deliver a baby at term without complication

Question 13

Lab tests in prenatal care (11)

Answer 13

• pap smear (not before 21 regardless of pregnancy status)
• GC and chlamydia screen (regardless if monogomous)
• HIV screen
• syphilis screening
• hepatitis screening
• rubella antibody titer (congenital rubella syndrome)
• ABO and antibody screen
• urinalysis and culture
• cystic fibrosis screen
• fifth disease (in high risk populations, mother can get it from being around kids)
• glucose tolerance tests (determine diabetes)
• thyroid studies
• Quad screen (oh lawdy)

Question 14

Signs of fetal life (3)

Answer 14

• Transvaginal ultrasound 6-8 weeks gestation
• doppler ultrasound 10-12 weeks gestation
• palpation of fetal movements

Question 15

Diagnosis of fetal death (5)

Answer 15

• more common early in pregnancy (1/6 ends in miscarriage)
• regression of signs of pregnancy despite hCG remaining high for weeks after
• failure of uterine growth
• ultrasound primary method**
• failure to feel fetal movement after having felt it before

Question 16

Scheduling of routine prenatal visits

Answer 16

Every 4 weeks thru week 28, every 2 weeks weeks 28-36, every week from 36 to delivery, 2x per week for postdates >42 weeks

Question 17

12, 14-16, 20, 24, 28, 32-36, 36-40, 40+ week visits

Answer 17

• 12 (review prenatal lab tests, assess fetal heart beat with doppler)
• 14-16 (assess growth, order some genetic tests and order amniocentesis)
• 20 (auscultate fetal heart with fetoscope (old school) ultrasound for fetal anatomy)
• 24 (maternal education and review signs and symptoms for preterm labor)
• 28 (repeat antibody screens, administer Rh immune globulin, perform glucose screen, perform cervical assessment, TDaP administration)
• 32-36 (assess the cervix, GBS culture)
• 36-40 (assess fetal position, cervical exam for dilation each visit)
• 40+ (perform cervical assessment, institute fetal surveillance, typically WILL induce by end of 41 weeks)

Question 18

Weight gain during pregnancy

Answer 18

a woman at ideal body weight requires total 24-28 lb weight gain, less for those over or more for those under ideal weight to meet goal requirements (might have to modify diet)

Question 19

Weight loss during pregnancy is not advised except in those with…

Answer 19

…very high BMI

Question 20

Weight retention after pregnancy

Answer 20

Average retained pregnancy weight of 3 lbs, see loss over 6 months progressively due to natural diuresis of excess volume

Question 21

Smoking and pregnancy complications (6)

Answer 21

• bleeding
• premature birth
• low birth weight
• neonatal absence syndrome
• congenital anomalies
• low IQ of childhood

Question 22

Alcohol and pregnancy complications (2)

Answer 22

• low birth weight
• fetal alcohol syndrome

Question 23

Best advice regarding alcohol and pregnancy

Answer 23

Complete abstience

Question 24

Fetal alcohol syndrome features (6)

Answer 24

• growth restriction
• behavioral disturbances
• brain defects
• cardiac defects
• spinal defects
• broad upper lip, facial distortions

Question 25

Caffeine in pregnancy

Answer 25

Ideally none, but risks not as obvious as smoking and alcohol

Question 26

Cell free fetal DNA (cffDNA)

Answer 26

A maternal phlebotomy study that is often done on screening in the first trimester to determine sex of child and test for aneuploidy, these DNA fragments increase in conc. in bloodstream thruout pregnancy and quickly diminishes upon delivery

Question 27

Nucchal fold translucency

Answer 27

Ultrasound screen done most often in the first trimester to visualize fetus, can be found alone in 62% of down syndromes and 30% of spontaneous abortions

Question 28

AFP testing

Answer 28

Alpha fetoprotein, a sometimes recommended 2nd trimester screen that finds 20% of down syndrome patients and neural tube defects

Question 29

Pregnancy associated protein A (PAPPA)

Answer 29

Screening done during first trimester alongside nucchal fold translucency on ultrasound to increase rate of determining presence of down syndrome (positive in both up to 73% certainty)

Question 30

Amniocentesis

Answer 30

a relatively low risk .5% of fetal loss test done during 2nd trimester for chromosome analysis, AFP, DNA markers, etc, not done as screening but for diagnosis and evaluation

Question 31

Work conditions which increase risk of low birth weight, preterm labor, and delivery (4)

Answer 31

- physically intensive employment - standing for long periods of time - increased pulling, pushing, or lifting - decreased rest periods

Question 32

Recommended favorable working conditions for pregnant women (4)

Answer 32

- only 8 hour shifts - no more than 48 hrs a week - limit work between 6am and midnight - avoid jobs that require good sense of balance

Question 33

Saunas, hot tubs, and whirlpools use while pregnant

Answer 33

Advise not to use while pregnant, temp already elevated by the baby

Question 34

Travel while pregnant

Answer 34

Best taken during 2nd trimester, many airlines have regulations

Question 35

Common pregnancy complaints and how are they treated? (8)

Answer 35

- nausea and vomiting (first trimester usually resolves 16 weeks, morning sickness), treated with zofran - constipation, treated with bulking agents (mirilax) - hemorrhoids, treated with prevention or topical anesthetic - fatigue (particularly early on), supplemental iron if anemic - urinary frequency or incontinence (differentiate from rupture of amnion also known as water breaking), treated with kegals - headaches, treated with acetaminophen - syncope (due to blood flow to fetus does see drastic drop in blood pressure), treated with resting in lateral recumbent position, change position gradually, hydrate - edema (common, as long as bilateral can be physiologic and not concern for DVT or heart failure and is relieved by raising legs)

Question 36

Live vaccines and pregnancy

Answer 36

Contraindicated (MMR, V, and live influenza!)

Question 37

Nulligravida

Answer 37

Never having been pregnant

Question 38

Nullipara

Answer 38

Never having given birth

Question 39

In measuring the fundus, if smaller than expected may be due to these 2 conditions. If larger, than these 3

Answer 39

- earlier gestation - oligohydraminos - later gestation - polyhydramnios - twins

Question 40

Intrauterine growth restriction

Answer 40

When the unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb, putting it at risk of certain health problems and complications during pregnancy (potentially even death), delivery, and after birth

Question 41

Quad screen

Answer 41

One lab test performed in patients prenatal care based on history at 15-19 weeks, includes AFP, hCG, estriol, and inhibin A to assess neural tube defects and genetic defects

Question 42

Group B infection in neonates vs 1 month old

Answer 42

Because it is ubiquitous and commensal with mother not generating antibodies, the 1 month old is too often colonized and asymptomatic but neonates do not have immune function and can get septic from infection

Question 43

Standard of care for screening in first trimester (2)

Answer 43

- ultrasound - blood test for pregnancy associated protein A

Question 44

Chorionic villous sampling

Answer 44

Removal of part of the placenta to take for chromosomal testing either abdominally or vaginally, NOT often utilized because of high risk of fetal loss and is pretty much obsolete

Question 45

Exercise while pregnant

Answer 45

Good 3-4x a week but not starting anything new they haven't already been doing, should avoid hot humid conditions or when febrile, sports injuries much higher due to ligmaent tissue loosening due to circulating relaxin levels

Question 46

Round ligament pain in pregnancy

Answer 46

Prior to 28 weeks can have a lot of pain especially on the right side as it is pulled and hurts with activity but subsides with rest differentiating it from acute appendicitis