MC 9 Prenatal and PPcare

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Stem & Answers A 23-year-old primiparous patient at 8 weeks' gestation reports abdominal cramping and moderate vaginal bleeding which has now stopped. Which of the following statements is most accurate? First trimester vaginal bleeding without pain essentially rules out ectopic pregnancy. Almost all first trimester miscarriages arise from high risk maternal behaviors. The cervix should be gently probed with a small cotton swab to determine if the internal os is closed. The presumptive diagnosis is completed miscarriage. Half of all women with first trimester bleeding will ultimately miscarry. Remediation Correct! It is widely estimated that approximately 50% of all females who have bleeding during early pregnancy will miscarry, possibly higher in the ED population. Of greatest concern in the differential diagnosis is ectopic pregnancy, which may present as vaginal bleeding with or without pain. Most miscarried fetuses are nonviable up to 2 weeks prior to clinical signs of miscarriage; therefore measures aimed at prevention are not useful. Moderate daily activities do not increase the risk of miscarriage. Completed miscarriage can only be diagnosed after expulsion of an intact gestational sac or identification of products of conception after dilation and curettage, or by ultimate conversion of the pregnancy test to negative. References: Marx: Rosen’s Emergency Medicine, Concepts and Clinical Practice, 6th ed., 2006, Chpt 177: Acute Complications of Pregnancy Question 2 Stem & Answers Which of the following is the most accurate statement regarding Rh immunization? Rh sensitization can occur during threatened miscarriage even without fetal loss. Pregnant Rh-negative patients should not receive anti-D immune globulin if the father's Rh status is unknown. The standard dose of anti-D immune globulin is the same regardless of gestational age. The Kleihauer-Betke test is sensitive to as little as 0.1 ml of fetal blood in the maternal circulation. Ectopic pregnancy does not require anti-D immune globulin therapy. Remediation

Correct! Anti-D immune globulin is indicated if the patient is Rh negative, unless the father is known to also be Rh negative. Sensitization occurs most commonly at delivery, but also can occur during threatened miscarriage with or without fetal loss, at surgery for ectopic pregnancy and amniocentesis. The Kleihauer-Betke test of maternal blood is only sensitive enough to detect 5 ml or more of fetal cells in the maternal circulation, while sensitization may occur with as little as 0.1 ml of fetal blood. In general, the dose of anti-D immune globulin is 50 mg before 12 weeks gestation and 300 mg thereafter. References: Marx: Rosen’s Emergency Medicine, Concepts and Clinical Practice, 6th ed., 2006, Chpt 177: Acute Complications of Pregnancy Question 3 Stem & Answers A patient early in her first trimester complains of severe lower abdominal pain. Which of the following most significantly decreases the likelihood of ectopic pregnancy? Blood visible at the cervical os An intrauterine gestational sac with a double decidual sac sign visible on transvaginal sonography A previous history of pelvic inflammatory disease or other STD Doubling of the quantitative HCG in 72 hours A history of prior tubal sterilization Remediation Identification of an intrauterine gestational sac with a double decidual sac sign significantly reduces the likelihood of an ectopic pregnancy (though it does NOT rule it out!). HCG levels normally double every 1.8 to 3 days for the first 6 to 7 weeks. The ectopic pregnancy sometimes results in abnormally low HCG production, however, normally rising HCG levels are commonly seen during early ectopic pregnancy. Slow leakage of blood or abrupt rupture of the pregnancy may lead to vaginal bleeding or blood in the peritoneum or pelvis. Factors predisposing to ectopic pregnancy include previous tubal infections or surgeries, use of an IUD, smoking or older maternal age. Reference:

Marx: Rosen’s Emergency Medicine, Concepts and Clinical Practice, 6th ed., 2006, Chpt 177: Acute Complications of Pregnancy Question 4 Stem & Answers Which of the following statements is most accurate regarding ectopic pregnancy? Direct sonographic evidence of ectopic pregnancy, such as an adnexal mass, is usually visible. A normally rising HCG level rules out ectopic pregnancy. The rate of heterotopic pregnancy among patients undergoing embryonic transfer techniques is about 1 in 4000. Methotrexate is used to treat early ectopic pregnancies less than 4 cm in diameter. Peritoneal signs and cervical motion tenderness decrease the likelihood of ectopic pregnancy. Remediation Correct! Methotrexate causes destruction of rapidly dividing fetal cells and involution of the pregnancy. The presence of peritoneal signs, cervical motion tenderness or lateral or bilateral abdominal or pelvic tenderness greatly increases the likelihood of ectopic pregnancy. Pelvic sonography rarely demonstrates direct evidence of ectopic pregnancy in the adnexa. About half the sonographic studies are indeterminate. Early ectopic pregnancies may demonstrate a normal doubling of HCG approximately every 48 to 72 hours. The reported rate for heterotopic pregnancy is undergoing change in the literature as clinicians are realizing that the condition may be more common that once suspected. In the general population, the rate is reported to be anywhere from 1 in 30,000 to about 1 in 4000. Several authors report this rate to rise to about 1 in 100 or 1 in 500 (depending on author) with patients undergoing embryo implantation or other in vitro proecdures. The rate is also elevated from the that of the general population in patients with fallopian tube damage. References: Marx: Rosen's Emergency Medicine, Concepts and Clinical Practice, 6th ed., 2006, Chpt 177: Acute Complications of Pregnancy Barnhart KT. Ectopic pregnancy. N Engl J Med. July 2009;361(4):379-387. Hassani KIM; Heterotopic pregnancy: A diagnosis we should suspect more often. J Emerg Trauma Shock. 2010 Jul-Sep; 3(3): 304. Question 5

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Stem & Answers A patient at 12 weeks' gestation presents with prolonged nausea and vomiting. A diagnosis of hyperemesis gravidarum was made on a prior ED visit. Which of the following best supports a diagnosis of molar pregnancy? Abnormal appearance of the uterus on pelvic ultrasound Starvation, weight loss and dehydration Presence of normal fetal heart tones Uterine fundal height palpable just at the pelvic outlet Presence of serum or urine ketones Remediation The diagnosis of gestational trophoblastic disease (molar pregnancy) is based on the characteristic "snowstorm" appearance of hydroptic vesicles within the uterus. Absence of fetal heart tones during the second trimester is a common presenting sign. The uterine size is larger than expected by dates by 4 weeks or more. Severe nausea and vomiting, with resultant starvation ketosis and dehydration, are present in both hyperemesis gravidarum and molar pregnancy. References: Marx: Rosen’s Emergency Medicine, Concepts and Clinical Practice, 6th ed., 2006, Chpt 177: Acute Complications of Pregnancy Dhanda, Sunita, Subhash Ramani, and Meenkashi Thakur. "Gestational trophoblastic disease: A multimodality imaging approach with impact on diagnosis and management." Radiology research and practice 2014 (2014). DiSaia, Philip J., and William T. Creasman. Clinical gynecologic oncology. Elsevier Health Sciences, 2012. Seckl, M. J., et al. "Gestational trophoblastic disease: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up." Annals of oncology 24.suppl 6 (2013): vi39-vi50. Question 6

Stem & Answers A patient at 24 weeks' gestation presents with vaginal bleeding. Which of the following statements is most accurate regarding abruptio placentae? Vaginal bleeding late in pregnancy can usually be managed in the outpatient setting. Abruptio placentae is associated with primi gravidity and young maternal age. The absence of vaginal bleeding rules out significant abruptio placentae. Uterine tenderness and pain are common in abruptio placentae, and uterine contractions are present 1/3 of the time. Sonography is sensitive for detection of small abruptions. Remediation Uterine tenderness or pain is seen in about two thirds of patients with abruptio placentae, with about one third experiencing uterine contractions. Sonography is insensitive in the diagnosis of abruption, because initially the echogenicity of fresh blood is similar to that of the placenta itself. Abruption may result in significant bleeding that is self-contained. Even small abruptions without vaginal bleeding that occur rapidly may cause significant fetal distress. The incidence of abruptio placentae increases with parity, maternal age and hypertension, cigarette smoking and cocaine use. Patients with suspected abruptio placentae require fetal monitoring and consideration for early delivery. References: Ananth, Cande V., et al. "Severe placental abruption: clinical definition and associations with maternal complications." American journal of obstetrics and gynecology (2015). Boisrame, T., et al. "Placental abruption: risk factors, management and maternal–fetal prognosis. Cohort study over 10 years." European Journal of Obstetrics & Gynecology and Reproductive Biology 179 (2014): 100-104. Marx: Rosen’s Emergency Medicine, Concepts and Clinical Practice, 6th ed., 2006, Chpt 177: Acute Complications of Pregnancy Question 7 Stem & Answers Which of the following statements is the most accurate regarding placenta previa?

Uterine contractions and pain are hallmarks of placenta previa. Digital probing of the cervix should be avoided in the second half of pregnancy. Sonography is not a sensitive diagnostic procedure. Most cases identified in the second trimester go on to spontaneous miscarriage. Prolonged passage of dark vaginal blood is characteristic of placenta previa. Remediation Correct! Digital or instrument probing of the cervix should never be done in the second half of pregnancy, as it may precipitate hemorrhage from otherwise asymptomatic placenta previa. Most cases identified in the second trimester resolve as the lower uterine segment elongates and the placenta no longer overlaps the cervical os. Painless passage of bright red blood is the hallmark of placenta previa. Sonography is very accurate in identifying placenta previa. References: Marx: Rosen’s Emergency Medicine, Concepts and Clinical Practice, 6th ed., 2006, Chpt 177: Acute Complications of Pregnancy Question 8 Edited: Aug 30, 2020 Stem & Answers What is the minimum definition of preeclampsia? BP > 140/90 mmHg at 20 or more weeks, and proteinuria BP > 140/90 mmHg at 20 weeks, proteinuria, and abnormal liver function tests Blood pressure (BP) > 140/90 mmHg at 20 or more weeks of pregnancy BP > 130/85 mmHg at 20 or more weeks Remediation Educational Objective: Define preeclampsia.

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Key Point: Hypertension (after the 20th week of pregnancy) and proteinuria are the hallmarks of preeclampsia. Explanation: It is important to note that gestational hypertension is defined as high blood pressure that develops after week 20 in pregnancy and resolves after delivery. However, both chronic hypertension and gestational hypertension can lead to a more severe condition known as preeclampsia. (BP>140/90 mmHg and proteinuria > 0.3 Gm/24 hrs.). Preeclampsia can lead to serious complications and should be treated quickly. HELLP syndrome (Hemolysis, Elevated liver enzymes and Low platelets) is a severe form of pregnancy induced hypertension (PIH), affecting up to 10% of patients with preeclampsia. These findings may be accompanied by cerebral (i.e. seizures) or visual disturbances, pulmonary congestion/edema, renal insufficiency or right upper quadrant tenderness not relieved by analgesics. Risk factors for severe preeclampsia include age less than 20 years, primigravidity, twin or molar gestation, and cigarette smoking. References: Smith RP, Preeclampsia and Eclampsia, Nelson’s Textbook of Obstetrics and Gynecology, 2018; 238: 494- 497 Lisonkova, Sarka, and K. S. Joseph. "Incidence of preeclampsia: risk factors and outcomes associated with early-versus late-onset disease." American journal of Obstetrics and Gynecology 209.6 (2013): 544-e1. Question 9 Stem & Answers Which of the following best describes the use of magnesium sulfate for the treatment of eclampsia? Hypermagnesemia can be treated with intravenous calcium gluconate. Magnesium is an effective antihypertensive. The intramuscular route is preferred over the intravenous route.

Serum magnesium levels are the best method to monitor toxicity. Hyperventilation is a late sign of magnesium toxicity. Remediation Correct! Calcium gluconate, 1 gram given intravenously, will reverse the adverse effects of hypermagnesemia. Magnesium administration should always be accompanied by close clinical observation for loss of reflexes or respiratory depression that occur with toxic levels of magnesium. Both intramuscular and intravenous protocols exist for administration of magnesium. The intravenous route is preferred for better control of the medication and shorter time to therapeutic effect. Magnesium has little direct antihypertensive effect. Controlling the seizures in eclampsia usually aids in controlling hypertension as well. References: Marx: Rosen’s Emergency Medicine, Concepts and Clinical Practice, 6th ed., 2006, Chpt 177: Acute Complications of Pregnancy Question 10 Edited: Sep 12, 2016 Stem & Answers Which of the following is the most appropriate drug for a patient with eclampsia and a diastolic pressure of 115 mm Hg? Nitroglycerine Losartan Lisinopril Hydralazine Nitroprusside Remediation Hydralazine 5 mg IV should be given and repeated in a dose of 5 to 10 mg IV every 20 minutes as needed to keep the diastolic blood pressure below 110 mm Hg. Angiotensin receptor blockers (ARBs) such as Losartan should be avoided as should ACE inhibitors (lisinopril). Several antihypertensive agents, including methyldopa, calcium channel blockers, hydralazine, and labetalol, have a good safety profile for use in pregnant women. In contrast, animal and human data suggest that angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are associated with increased risk of fetopathy. Nitroprusside has been assigned to pregnancy category C by the FDA. Animal studies have shown that

nitroprusside readily crosses the placenta. Nitroglycerine falls under US FDA pregnancy category C: Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. References: Abalos, Edgardo, Lelia Duley, and D. Wilhelm Steyn. "Antihypertensive drug therapy for mild to moderate hypertension during pregnancy." The Cochrane Library (2014). Al Khaja, Khalid AJ, et al. "Drug treatment of hypertension in pregnancy: a critical review of adult guideline recommendations." Journal of hypertension 32.3 (2014): 454-463. Magee, Laura A., et al. "Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy." Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health 4.2 (2014): 105-145. Question 11 Report Question Stem & Answers Which of the following statements best describes appendicitis in pregnancy?   The incidence of appendicitis increases in pregnancy compared to the nonpregnant patient.   The appendix is in the right upper quadrant by the end of the second month of gestation.  Sonography is sufficiently accurate to diagnose appendicitis in pregnancy.   Peritoneal signs are most prevalent late in pregnancy.   Sterile pyuria without bacteruria essentially rules out appendicitis.

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Remediation Correct! Sonography has been reported to be over 90% accurate in diagnosing appendicitis in pregnant patients. The incidence of appendicitis in pregnancy is no higher than in nonpregnant females, but delayed diagnosis contributes to a higher rate of perforation. During the second half of pregnancy, the presentation and clinical examination become less classic. Peritoneal signs are often absent and the gravid uterus obscures normal physical findings. The appendix is located deep in the right upper quadrant by the third trimester. During its migration, the appendix takes a position very near the kidney, leading to flank pain and sterile pyuria. Pyelonephritis is the most common condition confused with appendicitis in the pregnant patient. References: Marx: Rosen’s Emergency Medicine, Concepts and Clinical Practice, 6th ed., 2006, Chpt 177: Acute Complications of Pregnancy Question 12 Report Question Stem & Answers A 26 year-old G1P0 presents at 32 weeks gestation with extreme pruritis, worse at night, and predominantly on the palms and soles. She has aminotransferases that are moderately elevated and her serum bilirubin is 3.1 mg/dL. She does not have abdominal pain. An ultrasound shows no cholelithiasis and her intrahepatic bile ducts are not dilated. What is the most likely etiology?   Hepatitis C.   Acalculous cholecystitis.   Primary biliary cirrhosis   Acute fatty liver of pregnancy  Intrahepatic cholestasis Remediation Intrahepatic cholestasis is characterized by pruritis and elevated bile acid levels. Jaundice is present in only 10% or so of patients. Bile ducts are not typically dilated, and the patient does not have abdominal pain. Pruritis in second and third trimester should raise the possibility of intrahepatic cholestasis.

Reference: Pathak B, Sheibani L, Lee RH. Cholestasis of pregnancy. Obstet Gynecol Clin North Am . 2010 Jun. 37(2):269-82 Question 13 Edited: Apr 17, 2019 Report Question Stem & Answers Which of the following best describes thromboembolic disease and pregnancy?   Mild respiratory alkalosis supports the diagnosis of pulmonary embolism.   Leg pain and swelling are good predictors of deep vein thrombosis.  Technetium-labeled ventilation-perfusion (VQ) scans are safe in pregnancy.   Doppler sonography for venous flow should be done in the supine position. Remediation Technetium-labeled VQ scans carry less than 50 mrads of fetal exposure and are considered safe in pregnancy. Late in pregnancy, venous flow may be abnormal in the supine position due to the gravid uterus compressing the vena cava. Venous Doppler studies should be performed in the left lateral decubitus position. Arterial blood gas analysis in pregnancy normally shows a respiratory alkalosis and A- a gradient as high as 20 mm Hg. Clinical signs are rarely good predictors in deep venous thrombosis, and leg pain and swelling are nonspecific findings in the pregnant patient. The clinical diagnosis of DVT and VTE is unreliable during pregnancy. Just suspecting the diagnosis requires a high degree of clinical suspicion because the suggestive symptoms and signs, such as leg swelling and dyspnea also appear with the physiologic changes of pregnancy itself. Another challenge to diagnosis is the propensity during pregnancy towards proximal thrombosis in the pelvic veins. This may present with symptoms not normally associated with DVT, such as lower abdominal pain, and a complete absence of the more familiar presentation with calf pain and swelling. Reference: Venous Thromboembolism in Pregnancy: Greer IA. Clinical Practice. Pregnancy complicated by venous thrombosis. N Engl J Med 2015 Aug;373(6):540-7

Question 14 Edited: Mar 16, 2017 Report Question Stem & Answers Which of the following statements best describes sexually transmitted diseases of the genital tract during pregnancy?   Cesarean section is mandatory in patients with first time genital herpes simplex (HSV) infections.  Maternal Chlamydia trachomatis causes preterm labor and neonatal pneumonia.   Pelvic inflammatory disease (PID) is most prevalent after the first trimester.   Vaginal imidazoles are contraindicated when treating Candida infections in pregnancy.   The most common complication of third trimester gonococcal infections is chorioamnionitis. Remediation Suppressive acyclovir therapy can reduce the need for cesarean section in women whose first genital HSV infection occurs during pregnancy. Candidal infections are preferentially treated with vaginal imidazoles with an 85% to 100% cure rate. Transmission of gonococcal infection from mother to neonate occurs in up to 50% of untreated cases and the most prevalent complication of third trimester gonococcal infections is neonatal gonococcal ophthalmia. Pelvic inflammatory disease is rare in pregnancy and does not occur after the first trimester. References: Marx: Rosen’s Emergency Medicine, Concepts and Clinical Practice, 6th ed., 2006, Chpt 177: Acute Complications of Pregnancy Question 15 Report Question Stem & Answers

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A 26-year-old G1P0 at 32 weeks’ gestation presents with shortness of breath. Her oxygen saturation is 98%; respiratory rate is increased, and diffuse wheezing with fair aeration is audible on auscultation of the lungs. She has used her albuterol inhaler at home with little relief. Which of the following is true about asthma in pregnancy?   Cromolyn sodium is considered category D during pregnancy.  Supplemental oxygen should be administered to pregnant patients during an acute asthma exacerbation.   Systemic corticosteroids are contraindicated during pregnancy because they are associated with cleft deformiti   During normal pregnancy, both the tidal volume and the minute ventilation decrease.   Inhaled corticosteroids are not recommended for use during pregnancy. Remediation Correct! Acute asthma affects the mother and fetus during pregnancy. If the mother is hypoxic, the fetus is hypoxic as well. The fetus is more sensitive to hypoxia; therefore, a normal maternal oxygen saturation during an acute asthma exacerbation does not preclude decreased oxygenation of the fetus. It is therefore critical that all pregnant patients with acute asthma exacerbation receive supplemental oxygen. The other treatment aspects of asthma are largely the same for nonpregnant and pregnant asthmatic patients. Even during pregnancy, inhaled beta-agonists are the first-line drugs for an acute exacerbation, and oral or parenteral steroids should be administered if the patient fails to respond to beta-agonists or if the patient is already taking inhaled or oral steroids. Inhaled and systemic corticosteroids are considered safe in pregnancy and should be used if clinically indicated. Corticosteroids have a possible association with cleft deformities, preterm delivery, low birth weight, and preeclampsia; however, the link is not clear--these complications may also be related to uncontrolled asthma. During normal pregnancy, both the tidal volume and minute ventilation increase to up to 50% over baseline at term. Cromolyn sodium and the newer leukotriene receptor antagonists are considered category B (presumed safe) in pregnancy. References: Calder KK and Newton EJ. Chronic Medical Illness During Pregnancy. In: Rosen’s Emergency Medicine. 7th ed. Mosby; 2009:2298-2312.

Question 16 Report Question Stem & Answers A 40-year-old G3P2 presents at 33 weeks’ gestation reporting a headache. Her blood pressure is 170/100 mm Hg. Urine assessment for proteinuria is positive at 1+. Fetal heart tones are audible by Doppler ultrasound at 150 bpm. Her lower legs are significantly swollen with edema extending above the knee. Further clarification of her medical history reveals that she has had elevated blood pressure prior to and throughout pregnancy, although it is usually 150/90 mm Hg. Which of the following is true about hypertension in pregnancy?   The primary risks to the fetus from hypertension in pregnancy are intrauterine growth restriction and fetal dea   Placental abruption is unlikely because the patient has not described any recent vaginal bleeding.   Due to the edema, hydrochlorothiazide is the first-line agent to lower blood pressure in this patient.   This patient’s blood pressure should be immediately reduced to 140/90 mm Hg or lower.   Laboratory studies of platelet count and liver function are not indicated at this point. Remediation The definition of chronic hypertension in pregnancy is a blood pressure of 140/90 mm Hg or higher prior to pregnancy or prior to 20 weeks’ gestation. The risks of hypertension in pregnancy to the fetus include intrauterine growth restriction (IUGR) and fetal death. The risks of hypertension in pregnancy to the mother include progression of end organ damage and placental abruption. Pregnant patients with chronic hypertension are at increased risk for developing preeclampsia and eclampsia; therefore, any signs of preeclampsia (headache, increased blood pressure, proteinuria as described in this case) warrant further investigation, which includes platelet count and liver function testing. Acute lowering of blood pressure in pregnant patients with chronic hypertension may significantly decrease uteroplacental blood flow and compromise perfusion of the fetus. If acute blood pressure reduction is indicated, the agents of first choice in a pregnant patient are typically hydralazine or labetolol. Diuretics are not preferred because these patients typically have intravascular volume depletion despite their noted edema. The new criteria for preeclampsia are: A. Blood Pressure Criteria:

o Greater than or equal to 140 mm Hg systolic or greater than or equal to 90 mm Hg diastolic on two occasions at least 4 hours apart after 20 weeks of gestation in a woman with a previously normal blood pressure o Greater than or equal to 160 mm Hg systolic or greater than or equal to 110 mm Hg diastolic, hypertension can be confirmed within a short interval (minutes) to facilitate timely antihypertensive therapy. AND B. Proteinuria Criteria: o Greater than or equal to 300 mg per 24-hour urine collection (or this amount extrapolated from a timed collection) or o Protein/creatinine ratio greater than or equal to 0.3 o Dipstick reading of 1+ (used only if other quantitative methods not available) OR in the absence of proteinuria, new-onset hypertension with the new onset of any of the following: C. Alternative Criteria in the Absence of Proteinuria: o Platelet count less than 100,000/microliter (thrombocytopenia) o Serum creatinine concentrations greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease (renal insufficiency) o Elevated blood concentrations of liver transaminases to twice normal concentration (impaired iiver function) o Pulmonary edema o Cerebral or visual symptoms References: Calder KK and Newton EJ. Chronic Medical Illness During Pregnancy. In: Rosen’s Emergency Medicine. 7th ed. Mosby; 2009:2298-2312. Hypertension, Pregnancy-Induced—Practice Guideline. American College of Obstetricians and Gynecologists. Nov. 2013. RG575.5 618.3'6132—dc23 Question 17 Report Question Stem & Answers A 26-year-old G1P0 at 29 weeks’ gestation presents after a “dizzy spell” at work when she was walking the stairs in order to exercise. Her laboratory studies show a hemoglobin concentration of 7 g/dL. The patient is asymptomatic and denies chest pain, fatigue, abdominal symptoms, vaginal bleeding, or shortness of breath. Which of the following is true regarding the various types of anemia in pregnancy?

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  Patients with sickle cell anemia should routinely be given iron supplementation during pregnancy.   This patient should not be given supplemental iron, because she is asymptomatic and the noted anemia is likel physiologic dilution of pregnancy.   The primary adverse effect on the fetus of a mother with sickle cell disease is limb deformity.   The most common anemia during pregnancy is megaloblastic anemia, which is treated with iron and vitamin B  Anemia is the most common medical complication of pregnancy. Remediation Correct! Anemia is the most common medical complication of pregnancy. Iron-deficiency anemia affects approximately 25% of pregnancies because of low iron stores in women and because of diversion of maternal iron to the fetus for development of its own red blood cells. Pregnant patients do experience a dilutional physiologic anemia as well because of the expansion of plasma volume in excess of the increase in red blood cell mass. Dilutional anemia is usually reflected by hemoglobin levels of 9 to 11 g/dL. Lower levels should be supplemented with iron to increase maternal stores, although patients with iron deficiency anemia usually have good pregnancy outcomes. Folate deficiency (a type of megaloblastic anemia) is found in 4% of pregnancies and is associated with neural tube defects. Folate supplementation is recommended for all pregnant women in a dose of 0.4 to 1 mg daily, with higher doses recommended for those with folate deficiency. Sickle cell disease in pregnancy is associated with placental microinfarcts and fetal growth restriction (small-for-gestational-age and low-birth-weight infants due to placental insufficiency). This is more common in women homozygous for the sickle cell gene (SS). Limb deformities are not associated with sickle cell disease. Management of sickle cell disease during pregnancy is similar to that of the nonpregnant patient. Folate supplementation is standard even in the nonpregnant state because of the increased turnover of red blood cells, although the recommended daily dose of folate increases to 4 mg during pregnancy. Supplemental iron is controversial because of the potential for iron overload. Pearl: An incidental complication of sickle cell disease is that the Kleihauer-Betke test to distinguish fetal from maternal blood will yield false-positive results because of the persistence of hemoglobin F in the mother. References: Calder KK and Newton EJ. Chronic Medical Illness During Pregnancy. In: Rosen’s Emergency Medicine. 7th ed. Mosby; 2009:2298-2312.

Question 18 Report Question Stem & Answers A 30-year-old G1P0 who is at 10 weeks’ gestation is brought in by coworkers after having suffered a brief seizure, from which she has recovered, at work. She has a known seizure disorder and has been stable on valproic acid for years with rare breakthrough seizures. Which of the following reflects how this patient should be counseled regarding the use of antiepileptic medication during pregnancy?   She is at increased risk of eclampsia because of her known seizure disorder.   Her baby will be vitamin K deficient at birth.  The primary concern with use of valproic acid in pregnancy is neural tube defects.   If she experiences status epilepticus during pregnancy, it will not be treated with medication because of terato fetus.   A dose of 400 micrograms of supplemental folate is recommended during pregnancy. Remediation Correct! Epilepsy affects less than 1% of all gestations. Unintentional pregnancy can be seen in epileptic patients taking oral contraceptives because antiepileptic medications can cause increased clearance of oral contraceptives and thereby reduce their efficacy. The primary concern with valproic acid and carbamazepine is neural tube defects, and the primary concern with phenytoin and barbiturates is cleft palates/cardiac anomalies. There is a 2- to 3-fold increase in the incidence of serious congenital malformations in children of epileptic mothers taking these drugs, and the risk is higher if the mother is taking more than 1 agent. Because of the risk of neural tube defects, women taking valproate during pregnancy should be advised to take 4 mg of folate (not 0.4 mg, which is the minimum recommended dose for all pregnant women). If a pregnant woman presents to the emergency department in status epilepticus, she should be treated according to standard protocols with care taken to consider eclampsia as an etiology in addition to other causes. The risk of status epilepticus to both the mother and the fetus clearly outweighs the potential for adverse teratogenic effects. Proper positioning to avoid supine hypotensive syndrome and measurement of fetal heart tones should also occur.

Patients with underlying seizure disorder are not at increased risk of eclampsia during pregnancy. Vitamin K is given orally to mothers with seizure disorders during the last month of pregnancy, and parenteral vitamin K is routinely given to all newborns at birth, although vitamin K deficiency and associated bleeding problems are more commonly associated with the use of carbamazepine, phenytoin, and phenobarbital. References: Calder KK and Newton EJ. Chronic Medical Illness During Pregnancy. In: Rosen’s Emergency Medicine. 7th ed. Mosby; 2009:2298-2312. Question 19 Edited: Oct 13, 2021 Report Question Stem & Answers A 31-year-old G4P3 known to be human immunodeficiency virus (HIV) positive presents in active labor to the emergency department at 39 weeks’ gestation with no prenatal care. Her cervix is 4 cm dilated, and her membranes are intact. Her viral load is unknown. Which of the following is the best strategy for delivery to prevent vertical transmission of HIV to her newborn?   Administer intrapartum antiretroviral therapy and allow the patient to deliver vaginally in the emergency depa   Allow the patient to deliver vaginally in the emergency department with no interventions until after delivery.  Contact the obstetric team for intrapartum antiretroviral therapy and emergent cesarean section.   Test the patient’s viral load, if her load is under 1,000 copies/mL, allow vaginal delivery to proceed; if the load i copies/mL, contact the obstetric team for intrapartum antiretroviral therapy and emergent cesarean section Remediation Educational Objective: Discuss management of an HIV positive mother who presents without prenatal care to the emergency department for imminent delivery. Key Point: The viral load of the patient in this case is unknown; therefore, a cesarean section is the recommended mode of delivery. Administration of antiretroviral therapy should be standard in all HIV patients during labor and would be appropriate for the patient in this case.

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Explanation: Human immunodeficiency virus (HIV) transmission during pregnancy is thought to occur primarily through exposure to maternal blood and secretions. Other means of transmission are in utero and during breastfeeding. The most important factor is maternal viral load, with the desired maternal viral load being under 1,000 copies/mL. Patients with viral loads under 1,000 can be allowed to deliver vaginally; however, they still should be offered elective cesarean as an option, given the possibility of vertical transmission at even lower levels. Use of antiretroviral agents during pregnancy and during labor has decreased the rate of vertical transmission and should be routinely given to all pregnant HIV positive women. Neonates born to HIV-positive mothers generally all test positive for HIV antibodies because of placental transfer of maternal antibodies. These antibodies may be present for up to 18 months and are not necessarily indicative of newborn infection. Optimal therapy to prevent vertical transmission includes antepartum administration of highly active antiretroviral therapy (HAART), intrapartum antiretroviral dosing, and treatment of the infant with 6 weeks of zidovudine. Women with known HIV should be advised to avoid breastfeeding. References: Salhi BA, Nagrani S. Acute Complications of Pregnancy (Chapter 178). Marx JA, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice, 9th ed., 2018. Question 20 Report Question Stem & Answers Which of the following best describes normal respiratory physiology in pregnancy?  Resting pCO2 is decreased by an average of 10 mm Hg.   Slight respiratory acidosis occurs.   Minute ventilation decreases.   Tidal volume decreases. 

 There is a compensatory decrease in the renal excretion of bicarbonate. Remediation A physiologic state of hyperventilation is present during pregnancy caused by progesterone stimulation of the medullary respiratory center. Minute ventilation increases by about 50% during the first trimester of pregnancy. This is thought to result from increased circulating progesterone. Progesterone directly stimulates ventilation by sensitizing the central respiratory center to carbon dioxide. As a consequence, the pregnant woman takes larger tidal volumes to eliminate carbon dioxide. This causes an increase in minute ventilation and a decrease in the PaCO2 from 40mmHg to 30mmHg References: Hegewald MJ(1), Crapo RO. Respiratory physiology in pregnancy. Clin Chest Med. 2011 Mar;32(1):1-13, vii. doi: 10.1016/j.ccm.2010.11.001. Morrison LJ. General Approach to the Pregnant Patient. In: Rosen’s Emergency Medicine. 7th ed. Mosby; 2009. Calder KK and Newton EJ. Chronic Medical Illness During Pregnancy. In: Rosen’s Emergency Medicine. 7th ed. Mosby; 2009:2298-2312. Question 21 Edited: Oct 15, 2018 Report Question Stem & Answers A 19-year-old primigravida presents at 28 weeks gestation just after a new-onset seizure. Her pregnancy has previously been uncomplicated with no history of fever, drug use, or head trauma. However, she has not attended any of her prenatal appointments since 20 weeks. Which of the following would be most helpful in diagnosing eclampsia in this patient?   Peripheral edema  Proteinuria   Papilledema   Disorientation Remediation Educational Objective

Discuss diagnostic criteria for eclampsia Key Point Although proteinuria is no longer mandatory for diagnosis of pre-eclampsia, its presence in the setting of seizures is highly suggestive of eclampsia. Explanation Eclampsia is defined by the American Congress of Obstetricians and Gynecologists (ACOG, Nov. 2013) as the new onset of grand mal seizure in a woman with preeclampsia. Even though the presence of proteinuria no longer is mandatory for a diagnosis of preeclampsia (see below), it will be present in the vast majority of women with preeclampsia and indeed is the single most helpful diagnostic clue in the scenario of a seizing pregnant patient with unknown medical history (as in the above scenario). At the time of seizure due to eclampsia, 40% of women have severe hypertension and 40% have mild-to- moderate hypertension, but 20% remain normotensive. Disorientation is common following a seizure, regardless of the cause. Many normal pregnancies may have mild pedal edema. Proteinuria may be the only differentiating factor in the initial diagnosis of eclampsia. Non-eclamptic patients will revert to normal or low blood pressure after a period of observation. If the patient remains hypertensive or manifests other signs of a preexisting preeclampsia, magnesium sulfate and other agents are indicated to prevent further seizures and to control blood pressure. The criteria for diagnosing eclampsia (grand-mal seizure in the context of preeclamspia) or the HELLP syndrome (Hgmolysis + Elevated Liver enzymes + Low Platelets) have remained the same, but the criteria for diagnosing "preecclampsia" and "severe preeclamspia" changed in 2013. The new criteria for preeclampsia are:  Blood Pressure Criteria: o Greater than or equal to 140 mm Hg systolic or greater than or equal to 90 mm Hg diastolic on two occasions at least 4 hours apart after 20 weeks of gestation in a woman with a previously normal blood pressure o Greater than or equal to 160 mm Hg systolic or greater than or equal to 110 mm Hg diastolic, hypertension can be confirmed within a short interval (minutes) to facilitate timely antihypertensive therapy. AND  Proteinuria Criteria: o Greater than or equal to 300 mg per 24-hour urine collection (or this amount extrapolated from a timed collection) or o Protein/creatinine ratio greater than or equal to 0.3* o Dipstick reading of 1+ (used only if other quantitative methods not available) OR in the absence of proteinuria, new-onset hypertension with the new onset of any of the following:  Alternative Criteria in the Absence of Proteinuria:

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o Platelet count less than 100,000/microliter (thrombocytopenia) o Serum creatinine concentrations greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease (renal insufficiency) o Elevated blood concentrations of liver transaminases to twice normal concentration (impaired iiver function) o Pulmonary edema o Cerebral or visual symptoms In addition, the 2013 ACOG removed the criterion of "fetal growth restriction" from the diagnostic criteria of "severe preeclampsia". The presence of any ONE of the following criteria now is sufficient to establish the diagnosis of "severe preeclampsia": • Systolic blood pressure of 160 mm Hg or higher, or diastolic blood pressure of 110 mm Hg or higher on two occasions at least 4 hours apart while the patient is on bed rest (unless antihypertensive therapy is initiated before this time) • Thrombocytopenia (platelet count less than 100,000/microliter) References: Alvero R. Eclampsia. Book Chapter in Ferri's Clinical Advisor, 2017. 405-405.e1. Bassily-Marcus, Adel M., et al. "Pulmonary hypertension in pregnancy: critical care management." Pulmonary medicine 2012 (2012). Hypertension, Pregnancy-Induced—Practice Guideline. American College of Obstetricians and Gynecologists. Nov. 2013. RG575.5 618.3'6132—dc23 Question 22 Report Question Stem & Answers Which of the following often worsens during pregnancy?   Myasthenia gravis   Multiple sclerosis   Rheumatoid arthritis 

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Diabetes mellitus   Grave's disease Remediation Correct! As pregnancy progresses there is an insulin resistance up to peak demand at 28 weeks. All pregnant women with diabetes are "brittle" and must be followed closely to avoid wide swings in glucose control. Autoimmune diseases such as Grave's disease, multiple sclerosis, rheumatoid arthritis, and myasthenia gravis often may transiently improve during pregnancy because of the relative immunosuppression. After delivery, however, there is a high likelihood of rebound exacerbation of these diseases. Reference: Calder KK and Newton EJ, Rosens Emergency Medicine, 7th Ed. 2009. Chronic Medical Illness during Pregnancy. Chapter 177 (2298-2312) Question 23 Report Question Stem & Answers A 21-year-old insulin dependent diabetic is found comatose at home. She is 17 weeks pregnant and is found to have a serum glucose of 386 mg/dl (normal: 70-110 mg/dl). Which of the following is most accurate regarding diabetic ketoacidosis (DKA) in pregnancy?   Glucose levels tend to be higher in pregnant than non-pregnant patients with DKA.   Fetal mortality is unusual.   Serum pH tends to be lower in pregnant than non-pregnant patients with DKA.   Maternal insulin and counter-regulatory hormones cross the placenta.  Hyperemesis is one of the most common precipitants. Remediation Correct!

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Hyperemesis and noncompliance or errors in insulin dosage are the most common precipitants of diabetic ketoacidosis in the pregnant patient. Admission is often indicated to correct dehydration and more carefully adjust glucose control. The serum pH may be deceptively normal in the pregnant patient, because the initial pH tends to be higher in pregnancy due to physiologic hyperventilation. DKA is rare in patients with gestational diabetes, and insulin and counter-regulatory hormones do not cross the placenta. But serum glucose may be only moderately elevated because the fetus continues to secrete insulin and use glucose. Maternal mortality is rare in appropriately treated DKA. Fetal mortality rates are relatively high, ranging from 10 to 35%. Reference: Calder KK and Newton EJ, Rosens Emergency Medicine, 7th Ed. 2009. Chronic Medical Illness during Pregnancy. Chapter 177 (2298-2312) Question 24 Report Question Stem & Answers What is the first priority when treating a pregnant patient with suspected hyperthyroidism?  Adrenergic blockade with propranolol   Inhibition of thyroid synthesis with propylthiouracil   Ablation of the thyroid with radioactive iodine   Inhibition of thyroid release with iodide   Decrease conversion of T4 to T3 with hydrocortisone Remediation The first priority in treatment of hyperthyroidism is the stabilization and reversal of the end-organ and hemodynamic effects of sympathetic stimulation. Typically, this is accomplishe with a beta-blocker. Reduction of thyroid hormone synthesis and release can then follow. Both propylthiouracil (PTU) and methimazole at the lowest effective dose are acceptable during pregnancy for decreasing production of thyroid hormones t4 and T3; PTU will also inhibit the conversion of the less potent T4 to the more potent T3.. Surgical therapy (thyroidectomy) is useful in refractory cases. Because the fetal thyroid is extremely sensitive to iodide, giving any iodide products may result in a large goiter and it should be reserved for only severe cases. I131 radionuclide to ablate the maternal thyroid is absolutely contraindicated because

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it will simultaneously destroy the fetal thyroid gland. Pearl: Hydrocortisone decreases peripheral conversion of T4 to the more active T3 and can be used during pregnancy. General Review: Hyperthyroidism results in an overproduction of thyroid hormone by the cells. The two thyroid hormones manufactured by the thyroid gland, thyroxine (T4 ) and triiodothyronine (T3), are formed by combining iodine and a protein called thyroglobulin with the assistance of an enzyme called peroxidase. PTU inhibits iodine and peroxidase from their normal interactions with thyroglobulin to form T4 and T3. This action decreases production of thyroid hormone. PTU also interferes with the conversion of T4 to T3, and, since T3 is more potent than T4, this also reduces the activity of thyroid hormones. While either PTU or methimazole (MMI) are acceptable, PTU is preferred during the first trimester due to concern of possible congenital abnormalities associated with the use of MMI in the first trimester. Reference: Calder KK and Newton EJ, Rosens Emergency Medicine, 7th Ed. 2009. Chronic Medical Illness during Pregnancy. Chapter 177 (2298-2312) Question 25 Report Question Stem & Answers What is the most important factor contributing to the frequency of vertical transmissions and neonatal morbidity of syphilis and hepatitis B?   Immunosuppression   Inadequate diagnostic tests   Resistant organisms  Inadequate screening   Ineffective drug therapy Remediation Correct! Screening for syphilis and/or hepatitis B virus infection should be performed in all pregnant patients and repeated at various intervals in high-risk populations. Treatment with penicillin before 20 weeks gestation can result in a negligible rate of vertical transmission; largely, inadequate prenatal screening

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causes the current cases of congenital syphilis. Vertical transmission of the hepatitis B virus approaches 90% in untreated cases, and up to 90% of infected neonates will become chronic carriers as adults. Routine screening for HBV during early pregnancy is recommended because treatment with hepatitis B immunoglobulin and hepatitis B vaccine is very effective in reducing the rate of vertical transmission. Unvaccinated, HBsAg-negative gravidas who are exposed during the pregnancy to HBV should receive both hepatitis B immuno- globulin and vaccine. Reference: Calder KK and Newton EJ, Rosens Emergency Medicine, 7th Ed. 2009. Chronic Medical Illness during Pregnancy. Chapter 177 (2298-2312) Question 26 Edited: Feb 15, 2021 Report Question Stem & Answers A woman with a preexisting C7 spinal cord injury (SCI) presents at 34 weeks gestation. She is alert and does not perceive respiratory distress, but complains of a pulsatile headache. She is afebrile, tachycardic, hypertensive, and diaphoretic, with blotching of the skin. Which of the following choices is most likely?   Subarachnoid hemorrhage   Pulmonary embolism  Onset of labor   Urinary tract infection with sepsis Remediation Educational Objective Discuss signs of labor onset in a pregnant woman with a low cervical SCI. Key Point:

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The patient is exhibiting signs of autonomic dysreflexia. The response is nonspecific and may be precipitated by distention of the bowel or bladder or any of the other causes listed. Thus, the clinical interpretation of autonomic dysreflexia in a patient with high-level SCI is heavily context-dependent. It also heralds the onset of labor, which would be most likely in the above scenario. Explanation: Autonomic dysreflexia is the most serious complication of SCI and occurs in up to 85% of women with high lesions (above T5-T6) and occurs with increased frequency during pregnancy. Autonomic dysreflexia presents as severe paroxysmal hypertension, headache, tachycardia, diaphoresis, piloerection, mydriasis, and nasal congestion. It is often precipitated by afferent stimuli from a hollow viscus such as the bladder, bowel, or uterus. Autonomic dysreflexia is triggered in particular by uterine contractions during labor. For patients with lesions above T10, labor may be imperceptible or experienced as mild abdominal discomfort, thus not enabling them to communicate the onset of labor, leaving an episode of autonomic dysreflexia as the only warning sign of premature labor. Pregnant women with SCI are twice as likely to have preterm labor and are at increased risk of having a low-birth-weight infant. By contrast, patients with spinal cord lesions below T10 to T12 have an intact uterine nerve supply and will experience – and be able to communicate - labor pains. Pregnant patients with SCI with symptoms of autonomic dysreflexia should be assessed for signs of labor, such as cervical dilation, and should receive monitoring for uterine contractions. Other ED treatments are directed at the restoration of normal blood pressure with standard agents. Definitive therapy is with regional anesthesia. Epidural anesthesia obliterates (and also prevents) this response and should be used as soon as possible during labor for all women with SCI. In autonomic dysreflexia, symptoms such as hypertension will resolve once the stimuli to the skin or hollow viscus have been relieved; in preeclampsia, the symptoms and laboratory abnormalities are more likely to persist. Other problems to consider AFTER checking for signs of imminent delivery are deep vein thrombosis (DVT) and urosepsis. DVT is as high as 8% in pregnant women with SCI, due to immobilization in combination with the hypercoagulable state of pregnancy. The incidence of urinary tract infection is also increased during pregnancy and may progress to pyelonephritis, with subsequent maternal sepsis and fetal loss. References: Gorgas DL. Comorbid Medical Emergencies During Pregnancy. (Chapter 179) In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018: 2259-2276.e4 Question 27 Report Question Stem & Answers

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A 23-year-old woman presents with shortness of breath and chest pain. She is 4 days postpartum. Which of the following statements is true about deep venous thrombosis (DVT) and pulmonary embolus in pregnancy?   Spontaneous pneumothorax is common postpartum due to the dramatic change in hormone levels.   DVT in pregnancy is almost never genetic in etiology.  DVT is 7-10 times more common during pregnancy and peaks after delivery.   DVT is 50% less common during pregnancy.   Chest pain during pregnancy is common due to diaphragmatic irritation by the gravid uterus. Remediation Correct! The risk of DVT is increased by 7-10 times during pregnancy and is highest following delivery. It is often the first manifestation of hereditary thrombophilia, which accounts for approximately 50% of DVT cases during pregnancy. Chest pain is not common during pregnancy. There is no increased risk of spontaneous pneumothorax. References: Robertson L, Wu O, Langhorne P, et al; Thrombosis: Risk and Economic Assessment of Thrombophilia Screening (TREATS) Study. Thrombophilia and pregnancy: a systematic review. Br J Haematol. 2006;132(2):171-196. Lensen R, Rosendaal F, Vandenbroucke J, Bertina R. Factor V Leiden: the venous thrombotic risk in thrombophilic families. Br J Haematol. 2000;110(4):939-945. Tchaikovski SN, Rosing J. Mechanisms of estrogen-induced venous thromboembolism. Thromb Res. 2010;126(1):5-11. Question 28 Edited: Oct 6, 2022 Report Question Stem & Answers

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A 32-year-old woman who is 7 months pregnant presents with increasingly severe and debilitating fatigue. On physical examination, you note a red facial rash. Which of the following is the most likely diagnosis?   chronic fatigue syndrome   influenza   none; severe fatigue is normal during the third trimester   multiple sclerosis  systemic lupus erythematosus Remediation Pregnancy is a Th2 dominant state. Because of this, a Th2-dependent disease such as systemic lupus erythematosus often becomes more severe, while Th1-dominant diseases, such as multiple sclerosis, often ameliorate. There is no known correlation between pregnancy and chronic fatigue syndrome or influenza. Severe fatigue is not normal at any time during pregnancy. References: Muller AF, Drexhage HA, Berghout A. Postpartum thyroiditis and autoimmune thyroiditis in women of childbearing age: recent insights and consequences for antenatal and postnatal care. Endocr Rev. 2001;22(5):605-630. Wegmann TG, Lin H, Guilbert L, Mosmann TR. Bidirectional cytokine interaction in the maternal-fetal relationship: is successful pregnancy a Th2 phenomenon? Immunol Today. 1993;14(7):353-356. Rahman A, Isenberg DA. Systemic lupus erythematosus. N Engl J Med. 2008;358(9):929-939. Question 29 Report Question Stem & Answers A 32-year-old woman 6 months pregnant presents with wheezing, tachypnea, and perioral cyanosis. She reports that she has not used her steroid inhaler during this pregnancy because she is afraid of harming the fetus. Which of the following statements is true about asthma during pregnancy? 

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 Uncontrolled asthma is less dangerous to the fetus than current treatment options.   Steroids may cause fetal harm so they should be discontinued until the third trimester.   Asthma invariably improves during pregnancy due to immune response changes.   Inhaled steroids and albuterol are the recommended first-line treatment options for asthma during pregnancy.   Asthma is most likely to worsen in people with mild symptoms. Remediation Correct! Untreated asthma poses a greater risk to the fetus than the medications used for treatment. Currently, most patients with asthma are treated with either albuterol or inhaled steroids. During pregnancy, one- third of patients have increased symptoms, one-third experience improved symptoms, and the remaining one-third experience no change in symptoms at all. Symptoms tend to worsen in those with the most severe disease. Uncontrolled asthma is considered more dangerous to the fetus than the medications used for treatment. References: Louik C, Schatz M, Hernández-Díaz S, MM Werler, Mitchell AA. Asthma in pregnancy and its pharmacologic treatment. Ann Allergy Asthma Immunol. 2010;105(2):110-117. Syed RZ, Zubairi AB, Zafar MA, Qureshi R. Perinatal outcomes in pregnancy with asthma. J Pak Med Assoc. 2008;58(9):525-527. National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007. J Allergy Clin Immunol. 2007;120(5 Suppl):S94-138. Question 30 Edited: Apr 3, 2019 Report Question Stem & Answers A 28-year-old woman who is 27 weeks pregnant complains of epigastric pain and difficulty swallowing. Her past medical/surgical history is significant for bariatric surgery for weight management 2 years ago. Which of the following statements is true concerning bariatric surgery and pregnancy? 

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Bariatric surgery reduces pregnancy complications among morbidly obese patients   Bariatric surgery is usually performed outside of the reproductive age group.   Caesarean section is more common in those who have had bariatric surgery.   Nutritional requirements are identical in those who have had surgery and those who have not. Remediation Educational Objective Review the impact of bariatric surgery on pregnancy outcomes. Key Point Bariatric surgery reduces maternal complications of pregnancy among morbidly obese patients. Explanation Bariatric surgery among morbidly obese women reduces the incidence of gestational diabetes, large-for- gestational age infants, hypertension, post-partum hemorrhage, and Cesarean delivery in pregnancy. Surgery does increase the risk of delivering an infant who is small for gestational age, as well as preterm delivery. Fifty percent of all bariatric surgery is performed in women between the ages of 18 and 45 years. Nutritional requirements do change in those who have had weight reduction surgery. Monitoring of patients throughout pregnancy, for deficiencies of Vitamin B-12, Folic acid and minerals, is essential. References: Kwong W, Tomlinson G, Feig DS. “Maternal and neonatal outcomes after bariatric surgery: a systematic review and meta-analysis: do the benefits outweigh the risks?” Am J Obstet Gynecol 2018, 218(6):53. Maggard MA, Yermilov I, Li Z, et al. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA. 2008;300(19):2286-2296. Question 31 Report Question Stem & Answers A 19-year-old woman presents with diarrhea. She is 8 months pregnant. She is known to be HIV positive, but she has never received treatment with antiretrovirals (ARVs). Which of the following statements is true about ARV therapy? 

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 ARVs should never be withheld unless there are known adverse events to the mother, fetus, or infant that outw to the patient.   ARVs should never be used during pregnancy due to their extreme teratogenic potential.   In women who present with HIV infection late in pregnancy, it is better to wait until after delivery to begin ARV   No change in the toxicity of ARVs is present during pregnancy. Remediation Correct! ARV therapy is routinely used during pregnancy. Although some ARVs have known teratogenic effects, this fact is not a contraindication to use. Unless known adverse events to the mother or fetus outweigh the potential benefit to the patient, therapy should be initiated. There are some changes in toxicity of ARV agents depending on the stage of pregnancy, so thoughtful consideration of the treatment options is mandatory. Question 32 Edited: Jan 19, 2018 Report Question Stem & Answers A 27-year-old woman 4 months pregnant presents to you with epilepsy. She is visiting her parents from out of town and is currently being treated with antiepileptic drugs (AEDs). Which of the following statements is true concerning epilepsy and pregnancy?   There is rarely a need to change dosages of AEDs during pregnancy.   Tonic-clonic seizures during pregnancy pose no increased risk to the fetus.  Seizure control using monotherapy during pregnancy is considered ideal.   In general, there is a 50% decrease in seizures during pregnancy. Remediation

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Correct! Seizure control during pregnancy is important because seizures carry a distinct risk to the fetus, particularly premature delivery. Monotherapy is considered to be the ideal treatment option. Although studies vary wildly, there is an approximately 25% increase of seizures during pregnancy. The metabolism of AEDs changes in unpredictable ways during pregnancy, so monitoring plasma drug levels is important. Protein binding in AEDs is inversely related to breast milk, so increases in protein binding result in a decreased concentration in breast milk. References: Sabers A, Tomson T. Managing antiepileptic drugs during pregnancy and lactation. Curr Opin Neurol. 2009;22(2);157-161. Samrén EB, van Duijn CM, Koch S, et al. Maternal use of antiepileptic drugs and the risk of major congenital malformations: a joint European prospective study of human teratogenesis associated with maternal epilepsy. Epilepsia. 1997;38(9):981-990. Pennel PB. Antiepileptic drug pharmacokinetics during pregnancy and lactation. Neurology. 2003;61(Suppl 2):35-42. Question 33 Report Question Stem & Answers A 29-year-old woman gravida 3, para 2 presents at 29 weeks’ gestation with a chief complaint of frequent urination. You note pitting ankle edema on her physical examination. Her urine is 1+ for protein, and her blood pressure is 180/100 mm Hg. Her past medical history is unremarkable. Three months ago her blood pressure was 125/70 mm Hg. What is the most likely diagnosis?   patient is normal for this stage of pregnancy   gestational hypertension   preeclampsia superimposed on chronic hypertension   chronic hypertension  preeclampsia Remediation

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Gestational hypertension is defined as new-onset hypertension without proteinuria after 20 weeks’ gestation. Chronic hypertension is defined as a maternal blood pressure of 140/90 mm Hg on two occasions before 20 weeks’ gestational age. Preeclampsia is new onset hypertension with either proteinuria or another sign of end organ damage after 20 weeks’ gestation (see below). The vast majority of women with preeclampsia will have proteinuria. But a few will present with other signs of severe preeclampsia and the ABSENCE of proteinuria. The preeclampsia guidelines were adjusted in 2013 to capture this small group of women without proteinuria. The November 2013 guidelines of the American Congress of Obstetricians and Gynecologists state: DIAGNOSTIC CRITERIA FOR PREECLAMPSIA: 1. Blood Pressure Criteria: o Greater than or equal to 140 mm Hg systolic or greater than or equal to 90 mm Hg diastolic on two occasions at least 4 hours apart after 20 weeks of gestation in a woman with a previously normal blood pressure o Greater than or equal to 160 mm Hg systolic or greater than or equal to 110 mm Hg diastolic, hypertension can be confirmed within a short interval (minutes) to facilitate timely antihypertensive therapy AND 2. Proteinuira Criteria: o Greater than or equal to 300 mg per 24-hour urine collection (or this amount extrapolated from a timed collection) or o Protein/creatinine ratio greater than or equal to 0.3 o Dipstick reading of 1+ (used only if other quantitative methods not available) OR in the absence of proteinuria, new-onset hypertension with the new onset of any of the following: 3. Alternative Criteria in the Absence of proteinuria: o Thrombocytopenia: Platelet count less than 100,000/microliter o Renal Insufficiency: Serum creatinine concentrations greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease o Impaired Liver Function: Elevated blood concentrations of liver transaminases to twice normal concentration o Pulmonary Edema 5. Cerebral or visual symptoms The AGOC has also altered the criteria for severe preeclampsia (the requirement for fetal growth retardation has been removed). The 2013 practice guidelines for diagnosing severe preeclampsia are as follows: SEVERE FEATURES OF PREECLAMPSIA (Any one of these findings) :

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 Systolic blood pressure of 160 mm Hg or higher, or diastolic blood pressure of 110 mm Hg or higher on two occasions at least 4 hours apart while the patient is on bed rest (unless antihypertensive therapy is initiated before this time) • Thrombocytopenia (platelet count less than 100,000/microliter)  Impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes (to twice normal concentration), severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses, or both  Progressive renal insufficiency (serum creatinine concentration greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease)  Pulmonary edema  New-onset cerebral or visual disturbances References: Houry DE, Salhi BA. Acute complications of pregnancy. In: Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed, 2009. von Dadelszen P, Magee LA. Antihypertensive medications in management of gestational hypertension- preeclampsia. Clin Obstet Gynecol. 2005;48(2):441-459. Esplin MS, Fausett MB, Fraser A, et al. Paternal and maternal components of the predisposition to preeclampsia. N Engl J Med. 2001;344(12):867-872. Hypertension in pregnancy—Practice Guideline Nov. 2013. . American College of Obstetricians and Gynecologists. RG575.5 618.3'6132—dc23 Question 34 Report Question Stem & Answers A 23-year-old woman who is 35 weeks pregnant presents in acute respiratory failure secondary to tonic- clonic seizures. She has a history of anemia and preeclampsia. On physical examination, her blood pressure is 170/110 mm Hg. Which of the following statements is true about eclampsia?   Its incidence is approximately one in 400.   Intravenous diazepam is recommended for seizure control.   Beta blockers are contraindicated in pregnant patients because they may induce labor. 

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Eclampsia will always include seizures.   The maternal death rate is approximately one in 10. Remediation Correct! Seizure not attributed to other causes is a defining characteristic of eclampsia. In the United States, eclampsia occurs in about one in 2500 pregnancies. Maternal deaths occur in about one in 100 cases. The classic triad of eclampsia also includes hypertension and preeclampsia. The treatment of choice is magnesium sulfate. Beta blockers are useful for helping to control hypertension. References: Sibai BM. Diagnosis, prevention, and management of eclampsia. Obstet Gynecol. 2005;105(2):402-410. Lew M, Klonis E. Emergency management of eclampsia and severe pre-eclampsia. Emerg Med (Fremantle). 2003;15(4):361-368. Hypertension in pregnancy—Practice Guideline Nov. 2013. . American College of Obstetricians and Gynecologists. RG575.5 618.3'6132—dc23 Question 35 Edited: Aug 26, 2020 Report Question Stem & Answers A 31-year-old woman gravida 3, para 2, and at 34 weeks gestation presents to you with generalized severe itching. Upon physical examination, you note that her sclera are slightly icteric. What is the most likely diagnosis?   Preeclampsia  Intrahepatic cholestasis of pregnancy 

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 Cholelithiasis   Hemolytic anemia Remediation Educational Objective: Discuss the diagnosis of jaundice and cholestasis during pregnancy. Key Point: When Jaundice and generalized pruritis appear in a patient in the 2nd or 3rd trimester of pregnancy, the diagnosis of intrahepatic cholestasis of pregnancy should be the presumptive diagnosis. Explanation: ICP is characterized by pruritus and an increase in bile acids. It begins in the second or third trimester and rapidly resolves after delivery. Its etiology is unclear, although both genetic and hormonal factors appear to contribute, and it occurs in approximately one in 100 pregnancies in the United States. A high index of suspicion for ICP is essential, as the condition is associated with a significant incidence of fetal demise. Prompt diagnosis with the initiation of ursodeoxycholic acid and consideration of early delivery may protect the fetus Preeclampsia does not cause pruritus. Hemolytic anemia can cause jaundice, but this is unlikely. Cholelithiasis is common in pregnancy, and it is increased in those with ICP; however, this patient does not have a history of upper abdominal pain. An allergic reaction could result in pruritus, but this does not explain the jaundice. References: Geenes, Victoria, et al. "Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: A prospective population-based case-control study." Hepatology 59.4 (2014): 1482-1491. Rigby FB, Intrahepatic Cholestasis of Pregnancy Workup., emedicine, medscape.com., Updated Jan 14, 2019 Question 36 Edited: Nov 11, 2016 Report Question Stem & Answers A 27-year-old woman gravida 2, para 1 undergoes screening for gestational diabetes with a 50g oral glucose load. Her 1-hour glucose is 240 mg/dL. She does not have a personal history of diabetes. What is the beginning recommended treatment for this patient?

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 nutritional counseling, exercise, blood glucose surveillance   none; gestational diabetes is self-limiting and presents no concern   aggressive postpartum treatment since she has type 2 diabetes   start oral hypoglycemic agents   immediately start insulin Remediation Gestational diabetes is a common condition and has an incidence of up to 14% in the United States. It has been traditionally diagnosed with a 3-hour glucose tolerance test. In 2014, the U.S. Preventive Services Task Force updated its 2008 statement to recommend that asymptomatic pregnant women be screened for GDM after 24 weeks of gestation (B recommendation). Most clinicians in the United States use a two-step approach, first administering a 50-g non-fasting oral glucose challenge test at 24 to 28 weeks, followed by a 100-g fasting test for women who have a positive screening result. Women who do not pass this simpler (and less time consuming!) screening test go on to the standard 100g/3 hour glucose tolerance test for diagnosing gestational diabetes. For the first test, a blood glucose level of either 135 mg/dL or 140 mg/dL is considered abnormal. This serum glucose level on the first test is sufficient to move on the second test. For the three hour test, there are two different sets of diagnostic criteria that are acceptable to use. The values for diagnosis at fasting, one hour, two hours, and three hours are 95-105 mg/dL, 180-190 mg/dL, 155-165 mg/dL, and 140-145 mg dL respectively. Treatment includes diet and exercise as well as insulin, if necessary. It has been shown that women treated for even mild gestational diabetes have smaller, leaner babies who are less likely to experience shoulder dystocia. Treated mothers were also found to be less likely to develop gestational hypertension or preeclampsia. Developing postpartum type 2 diabetes is variable and is found in up to 10% of patients. Oral hypoglycemic agents may be used as treatment options, but they generally are not required. References: Garrison, Andrew. "Screening, diagnosis, and management of gestational diabetes mellitus." Am Fam Physician 91.7 (2015): 460-7. Sukumaran, S., et al. "Screening, diagnosis and management of gestational diabetes mellitus: A national survey." Obstetric Medicine: The Medicine of Pregnancy (2014): 1753495X14536891.

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Question 37 Edited: Dec 27, 2017 Report Question Stem & Answers A 23-year-old woman is 9 weeks pregnant and presents with lethargy and weight gain. Which of the following statements is true concerning hypothyroidism and pregnancy?   Short-term hypothyroidism has no effect on the fetus.   Normal thyroid-stimulating hormone (TSH) levels are the same throughout pregnancy.   In a healthy patient, thyroid-stimulating hormone (TSH) levels decrease in the first trimester and, then return t second and third trimester.   It is diagnosed by measuring free T4.   In a healthy patient, thyroid-stimulating hormone (TSH) levels increase each trimester in pregnancy. Remediation There is a physiological and transient reduction in TSH seen usually between 8 and 14 weeks of gestation. This is due to the thyroid stimulating effects of the physiological increase in hCG in early in pregnancy. In around 20% of women, the TSH may drop below the normal range. After 14 weeks, the TSH usually returns to normal. Free T4 is an unreliable measure of thyroid status in pregnancy. Due to the increased circulating estrogen levels, there is an increase in thyroid binding globulin (TBG) which first appears in the first half of pregnancy and continues to term. The increase in TBG results in lower levels of free T3 and T4 which stimulates the hypothalamic-pituitary-thyroid axis and results in higher levels of total T3 and T4. In addition, the abundance of deiodinase enzymes found in the placenta result in an increase in the metabolism of T4 to T3. It is worth noting that even short-term hypothyroidism can pose a risk to this patient; therefore, she should receive appropriate treatment. References: Nader S. Thyroid Disease and Pregnancy. Book Chapter in Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice, 60, 1022-1037.e4

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Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, Grobman WA, Laurberg P, Lazarus JH, Mandel SJ, Peeters RP, Sullivan S. “2017 Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum.” Thyroid 2017, 27(3):315- 389. Vaidya B, Hubalewska-Dydejczyk A, Laurberg P, Negro R, Vermiglio F, Poppe K. Treatment and screening of hypothyroidism in pregnancy: results of a European survey. Eur J Endocrinol. 2012;166(1):49-54. Question 38 Report Question Stem & Answers A 26-year-old woman who is 25 weeks pregnant presents with heat intolerance, anxiety, and the inability to gain weight. Which of the following statements is true concerning hyperthyroidism in pregnancy?   The most common form of hyperthyroidism is Hashimoto disease.   There are no maternal or fetal consequences of hyperthyroidism.   Carbimazole is the drug of choice in early pregnancy.   Hyperthyroidism in pregnancy has an incidence of approximately 1:45000.   Gestational transient thyrotoxicosis results from the direct stimulation effects of human chorionic gonadotroph Remediation Correct! The incidence of hyperthyroidism during pregnancy is approximately 0.5%. The most common form of hyperthyroidism is Graves disease. About 10% of those with hyperthyroidism have gestational transient thyrotoxicosis due to direct stimulation by hCG. This is generally a self-limiting condition and does not require treatment. Untreated hyperthyroidism may increase the risk of hypertension or preeclampsia, and it may cause low birth weight in the fetus. Propylthiouracil is the drug of choice for women early in their pregnancy because it is less teratogenic than carbimazole. References: Poppe K, Hubalewska-Dydejczyk A, Laurberg P, Negro R, Vermiglio F, Vaidya B. Management of hyperthyroidism in pregnancy: results of a survey among members of the European Thyroid Association. Eur Thyroid J. 2012;1(1):34-40.

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Bowman P, Osborne NJ, Sturley R, Vaidya B. Carbimazole embryopathy: implications for the choice of antithyroid drugs in pregnancy. QJM. 2012;105(2):189-193. Anselmo J, Cao D, Karrison T, Weiss RE, Refetoff S. Fetal loss associated with excess of thyroid hormone exposure. JAMA. 2004;292(6):691-695. Question 39 Edited: Sep 1, 2017 Report Question Stem & Answers A 36-year-old woman who is 31 weeks pregnant presents with fever, nausea, urinary frequency, and back pain. Which of the following is true concerning urinary tract infection (UTI) and pregnancy?   No risks to the fetus from UTI have been documented.   There is no associated maternal morbidity.   UTI is rare in pregnancy.  UTI in pregnancy requires treatment to avoid adverse pregnancy outcomes.   Mild dilation of the ureter should be treated with external drainage or internal stents. Remediation UTI in pregnancy is a common condition and has an overall incidence of about 8%. Hormonal differences coupled with stasis and mild urinary tract dilation secondary of pressure from the gravid uterus increase the likelihood of this condition. Complications of untreated UTI can be serious and include prematurity, low birth weight, and increased perinatal mortality. Maternal complications include preterm labor, increased incidence of hypertension, and chorioamnionitis. References: McCormick T, Ashe RG, Kearney PM. Urinary tract infection in pregnancy. Obstet Gynaecol. 2008;10(3):156-162. Mazor-Dray E, Levy A, Schlaeffer F, Sheiner E. Maternal urinary tract infection: is it independently associated with adverse pregnancy outcome? J Matern Fetal Neonatal Med. 2009;22(2):124-128.

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Question 40 Report Question Stem & Answers A woman who is 2 months postpartum presents with new onset of severe intermittent joint pain. Which of the following statements is true concerning the postpartum period and rheumatoid arthritis (RA)?   The risk for RA is highest after four or more pregnancies.   Joint pain is normal postpartum due to the effects of oxytocin.   The postpartum period is generally a time of diminished inflammatory activity.   RA is generally worse during pregnancy.  There is a five times greater incidence of new onset RA. Remediation Correct! RA is one of three autoimmune diseases that tend to improve, or at least stabilize, during pregnancy. The postpartum period can be regarded as a time of heightened inflammatory activity. Most women are likely to relapse after delivery and there is a fivefold risk of new onset RA in the year following delivery. This risk is highest after the first pregnancy. References: O'Dell JR. Therapeutic strategies for rheumatoid arthritis. N Engl J Med. 2004;350(25):2591-2602. Silman A, Kay A, Brennan P. Timing of pregnancy in relation to the onset of rheumatoid arthritis. Arthritis Rheum. 1992;35(2):152-155. Question 41 Edited: May 1, 2017 Report Question Stem & Answers

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Which of the following statements is most accurate?   Fertilization occurs in the fallopian tube up to 10 days after follicular ovulation   Gestational age refers to the number of completed weeks after the reported date of conception   Gravidity refers to the number of prior pregnancies, excluding the current pregnancy   Parity refers to the number of full term live births  Preterm labor is defined as uterine contractions before 37 weeks gestation that cause cervical change Remediation Preterm labor is defined as uterine contractions occurring before 37 weeks of gestation that cause cervical change. Cervical change can be diagnosed if an initial examination reveals a cervix that is at least 2 cm dilated or 80% effaced, or if interval cervical examinations document progression of effacement or dilation. Preterm contractions without cervical advancement can also occur; these do not require intervention. The distinction may be difficult, in particular at the onset of contractions. Gravidity refers to the number of pregnancies, including all normal and abnormal pregnancies, as well as the current one. Parity is the total number of times the patient has given birth, regardless of the outcome. Gestational age refers to the number of completed weeks of pregnancy from the last menstrual period. Fertilization occurs within minutes to hours of follicular ovulation as the unfertilized ovum is only viable for up to 24 hours after ovulation. Implantation of the blastocyst occurs 6 days after fertilization. References: Morrison LJ, Toma A, & Gray, SH. General Approach to the Pregnant Patient (Chapter 177). Marx JA, et al. 8's Emergency Medicine. 7th ed. 2014. Question 42 Report Question Stem & Answers Human chorionic gonadotropin (hCG):   Stimulates estrogen production by the ovarian follicle 

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 Levels peak at 20 weeks' gestation  Stimulates progesterone production by the corpus luteum   Is measured clinically in nanograms per deciliter   Is produced by the cells of the corpus luteum Remediation Correct! Human chorionic gonadotropin (hCG) originates in the trophoblasts and augments corpus luteal production of progesterone, until the trophoblastic production of progesterone is capable of maintaining pregnancy. HCG levels peak at 7 to 10 weeks of pregnancy and hCG is measured in international units per liter (IU/L). Question 43 Edited: Jul 8, 2019 Report Question Stem & Answers Which of the following are abnormal physical examination findings in the pregnant patient?   Reddish linear striae on the abdomen, breasts, and thighs   Reddish velvety epithelium extending into the ectocervix   Spider nevi on the face, neck and upper chest  Diastolic murmurs, and systolic murmurs of III/VI or greater Remediation A third heart sound and systolic murmurs are common in pregnancy. All diastolic murmurs and systolic murmurs greater than or equal to III/VI warrant further investigation. In pregnancy, normal extension of columnar epithelium of the endocervix into the ectocervix appears as a red velvety lesion known as

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pseudoerosion. Striae gravidarum commonly appear as linear markings on the breast, thighs, and abdomen in the third trimester. Spider nevi are frequently seen in pregnancy on the face, neck, upper chest, and arms. Question 44 Report Question Stem & Answers Which of the following are expected (normal) laboratory findings in the pregnant patient?   Hemoglobin less than 10 gm/dL   Elevated creatinine  Glucosuria   Elevated arterial PCO 2   Fasting hyperglycemia Remediation Correct! The CDC defines anemia in pregnancy as hemoglobin less than 11 gm/dL in the first and third trimesters and less than 10.5 gm/dL in the second trimester. Pregnancy induces a state of peripheral resistance to insulin, resulting in hyperinsulinemia, mild fasting hypoglycemia, postprandial hyperglycemia and glucosuria. Glomerular filtration rate increases by the second trimester resulting in a decrease in urea nitrogen and creatinine. Tidal volume increases, thus creating a mild respiratory alkalosis and decreased arterial PCO 2 . Question 45 Edited: Nov 28, 2016 Report Question Stem & Answers

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Which of the following statements is most accurate regarding pregnant patients?   Braxton-Hicks contractions are painless, irregular contractions that occur early in ectopic pregnancy   Accurate obtainedblood pressure measurement is best obtained with the patient in the left lateral decubitus p   The urine beta HCG test is more sensitive than the serum test.   Nearly all pregnant women will become hypotensive in the left lateral decubitus position  Fetal heart activity can be detected using transvaginal ultrasonography as early as 6 weeks' gestational age Remediation Fetal heart activity can be detected using transvaginal sonography at 6 weeks' gestation. Braxton-Hicks contractions are painless contractions that occur spontaneously and irregularly in early pregnancy. They do not occur in ectopic pregnancy. Some pregnant women become hypotensive in the supine position, referred to as the supine hypotensive syndrome, due to the enlarging pregnant uterus compressing the vena cava, particularly in the latter half of pregnancy. An accurate blood pressure measurement is best obtained with the patient seated comfortably with the back and arm supported. When the patient is in the left lateral position, the blood pressure cuff on the arm is elevated above the level of the heart and this may lead to false low readings. The urine beta HCG test is less sensitive than the serum one Reference: American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol . 2013;122(5):1122-1131. Question 46 Report Question Stem & Answers Which of the following statements is most accurate regarding physical examination of the gravid uterus?   Hegar's sign is an abnormal softening of the lower uterine segment 

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 At six weeks, the top of the fundus should be at the level of the symphysis pubis   Reproducible ballottement of the midterm fetus is considered abnormal  At 38 weeks, the top of the fundus is approximately at the level of the xiphoid process   At 12 weeks, the top of the fundus is approximately at the level of the umbilicus Remediation Correct! Hegar's sign is the normal softening of the lower uterine segment caused by hyperemia. At 6 to 8 weeks, the uterus is about the size of an orange and is contained within the pelvis. At 12 weeks, the top of the fundus should be at the level of the pubic symphysis. At 16 to 20 weeks it is at the level of the umbilicus. At 36 to 38 weeks, the fundus is at the level of the xiphoid process of the sternum. Thereafter the fetus descends and the fundal height may decrease. At midpregnancy, the fetus floats in a large volume of amniotic fluid and can be perceived by ballottement through the maternal abdominal wall. Question 47 Report Question Stem & Answers Which of the following statements is most accurate regarding hCG testing?   HCG can be detected as early as 48 hours after conception   Following spontaneous abortion, hCG levels are normally expected to return to zero within 2 to 3 weeks  False-positive hCG results may be attributable to postmenopausal state   HCG levels peak at 16 to 20 weeks of pregnancy   Most bedside qualitative hCG tests are sensitive at 10 mIU/mL Remediation

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Correct! HCG may be detected as early as 6 to 8 days after fertilization. In 98% of patients, HCG testing becomes positive 7 days after implantation, or around the time of the expected period. Levels peak around 7 to 10 weeks gestation, with a range of 20,000 to 200,000 IU/L. The small number of false positive HCG tests can be attributed to post-menopausal state, post-abortion in the first trimester, exogenous HCG for induction of ovulation or an HCG-secreting tumor. Levels may take as long as 60 days to return to zero after abortion. Most bedside tests are sensitive to levels of between 25 and 50 mIU/L. Question 48 Report Question Stem & Answers Which of the following statements is most accurate regarding sonography in pregnancy?  Transvaginal sonography can identify an intrauterine pregnancy at 5 weeks' gestation   Intrauterine pregnancy is confirmed by the presence of a single decidual ring   A full bladder is required to perform transvaginal sonography   The normal gestational sac is centrally placed in the uterine cavity surrounded by symmetrically thickened end   Fetal heart motion can be identified with transvaginal sonography at a gestational age correlating with an hCG Remediation Correct! Transvaginal sonography (TVS) can identify an intrauterine gestational sac at 5 weeks gestation, which correlates with a quantitative HCG value of more than 1800 IU/L. Fetal heart motion can be detected with TVS at 6 weeks gestation, which correlates with a quantitative HCG level of 6770. Intrauterine pregnancy can be diagnosed sonographically by demonstration of a double ring sign, an eccentrically placed gestational sac, an intrauterine fetal pole, and fetal heart activity. A full bladder is usually required for transabdominal sonography, but not for TVS. References: Marx: Rosen's Emergency Medicine, 7th ed.: Mosby; 2009. CHAPTER 175 - General Approach to the Pregnant Patient

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Question 49 Edited: Jan 28, 2019 Report Question Stem & Answers Which of the following statements is most accurate?  The most common cause of death in eclampsia is cerebral hemorrhage   The incidence of venous thromboembolism in pregnant patients is half that of nonpregnant patients   The most common cause of death in patients with eclampsia is renal failure   Symptoms of carpal tunnel syndrome will usually improve with the onset of pregnancy Remediation In patients with eclampsia, the most common cause of death is cerebral hemorrhage. While the most common cause of headache during pregnancy is muscle contraction headache, serious causes of headache that may be exacerbated by pregnancy include pseudotumor cerebri, subarachnoid hemorrhage, and certain brain tumors. Pregnant patients are at a five-fold increased risk of venous thromboembolism.While acute kidney injury is common in patients with eclampsia, death is rare since the advent of peritoneal dialysis and renal transplantation, Carpal tunnel syndrome can worsen with pregnancy and subside post-partum. References: Mackay AP, Berg CJ, Atrash HK, Pregnancy related mortality from preeclampsia and eclampsia, ObstetGynecol 2001; 97: 533-538 Liu Y, et al.Pregnancy outcomes in patients acute kidney injury during pregnancy: a systematic review and meta-analysis, BMC Pregnancy Childbirth, 017; 17: 235 Jido TA, Eclampsia: maternal and fetal outcome. AFR Health Sci 2012; 12: 148-152 Question 50 Report Question

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Stem & Answers Which of the following statements is most accurate regarding domestic violence (DV) in pregnancy?   Domestic violence is not correlated with other unhealthy or high-risk behaviors   Direct questioning about DV may further traumatize the victim and should be avoided   DV affects about 2% of all pregnant women in the U.S.   Facial trauma is the most common type of DV-related injury in the pregnant patient  Physically abused pregnant patients may present with vague symptoms such as fatigue, insomnia or backache Remediation Correct! Blunt abdominal trauma is the most common domestic violence-related injury among pregnant patients, in contrast to facial trauma in nonpregnant patients. Abused women are more commonly prone to social instability, unhealthy lifestyles and physical health problems, including drug and alcohol abuse. It is important to include direct questioning about domestic abuse in the clinical history, with the patient separated from her partner during the interview. In several studies, at least 20% of pregnant patients reported some form of domestic violence. Symptoms may be directly related to trauma, or may be nonspecific, including headache, fatigue, insomnia, gastrointestinal complaints, pelvic pain and backache. Question 51 Report Question Stem & Answers A 26-year-old G1P0 at 32 weeks’ gestation presents with shortness of breath. Her oxygen saturation is 98%; respiratory rate is increased, and diffuse wheezing with fair aeration is audible on auscultation of the lungs. She has used her albuterol inhaler at home with little relief. Which of the following is true about asthma in pregnancy?   Cromolyn sodium is considered category D during pregnancy. 

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Supplemental oxygen should be administered to pregnant patients during an acute asthma exacerbation.   Inhaled corticosteroids are not recommended for use during pregnancy.   During normal pregnancy, both the tidal volume and the minute ventilation decrease.   Systemic corticosteroids are contraindicated during pregnancy because they are associated with cleft deformiti Remediation Educational Objective: Treat acute asthma exacerbation in a pregnant patient. Key Point: Acute asthma exacerbations in pregnant and non-pregnant patients are treated similarly. Explanation: Acute asthma affects the mother and fetus during pregnancy. If the mother is hypoxic, the fetus is hypoxic as well. The fetus is more sensitive to hypoxia; therefore, normal maternal oxygen saturation during an acute asthma exacerbation does not preclude decreased oxygenation of the fetus. It is therefore critical that all pregnant patients with acute asthma exacerbation receive supplemental oxygen. The other treatment aspects of asthma are largely the same for non-pregnant and pregnant asthmatic patients. Even during pregnancy, inhaled beta-agonists are the first-line drugs for an acute exacerbation, and oral or parenteral steroids should be administered if the patient fails to respond to beta-agonists or if the patient is already taking inhaled or oral steroids. Inhaled and systemic corticosteroids are considered safe in pregnancy and should be used if clinically indicated. Corticosteroids have a possible association with cleft deformities, preterm delivery, low birth weight, and preeclampsia; however, the link is not clear--these complications may also be related to uncontrolled asthma. During normal pregnancy, both the tidal volume and minute ventilation increase to up to 50% over baseline at term. Cromolyn sodium and the newer leukotriene receptor antagonists are considered category B (presumed safe) in pregnancy. Reference: Calder KK and Newton EJ. Chronic Medical Illness During Pregnancy. In: Rosen’s Emergency Medicine. 7th ed. Mosby; 2009:2298-2312. Question 52 Report Question

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Stem & Answers A 40-year-old woman, G3P2, presents at 33 weeks’ gestation reporting a persistent headache. Her blood pressure is 170/100 mm Hg. Abnormal findings on physical examination are limited to 3+ pitting edema of the legs to the knees. Fetal heart tones are audible by Doppler ultrasound at 150 bpm. Urinalysis shows 1+ protein. Her blood pressure was elevated before and throughout this pregnancy at a level of 140/90 mm Hg. Which of the following comments is correct?   The primary risks to the fetus from hypertension in pregnancy are intrauterine growth restriction and fetal dea   An immediate reduction in blood pressure is essential.   Hydrochlorothiazide is indicated to lower the patient’s blood pressure.   Placental abruption is unlikely in this patient because she has not described any recent vaginal bleeding. Remediation Educational Objective: Recognize preeclampsia risks in pregnancy. Key Point: Preeclampsia is characterized by the new onset of hypertension and proteinuria after 20 th week gestation. It is associated with intrauterine growth restriction (IUGR), preterm birth, fetal death as well as life-threatening maternal complications. Explanation: The definition of chronic hypertension in pregnancy is a blood pressure of 140/90 mm Hg or higher prior to pregnancy or prior to 20 weeks’ gestation. This patient meets the criteria for preeclampsia and close attention to blood pressure control is in order. The risks of hypertension in pregnancy to the fetus include intrauterine growth restriction (IUGR) and fetal death. The risks of hypertension in pregnancy to the mother include progression of end organ damage and placental abruption. Abrupt lowering of blood pressure in pregnant patients with chronic hypertension may significantly decrease utero-placental blood flow and compromise perfusion of the fetus. If acute blood pressure reduction is indicated, the agents of first choice in a pregnant patient are typically hydralazine or labetolol. Diuretics are contraindicated because these patients typically have intravascular volume depletion despite their noted edema. References:

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Calder KK and Newton EJ. Chronic Medical Illness During Pregnancy. In: Rosen’s Emergency Medicine. 7th ed. Mosby; 2009:2298-2312. Hypertension, Pregnancy-Induced—Practice Guideline. American College of Obstetricians and Gynecologists. Nov. 2013. RG575.5 618.3'6132—dc23 Question 53 Report Question Stem & Answers A 26-year-old woman, G1P0, at 29 weeks’ gestation presents after a “dizzy spell” when she was exercising. She is otherwise free of symptoms and denies chest pain, fatigue, abdominal symptoms, vaginal bleeding, or shortness of breath. Physical examination reveals marked pallor with blood pressure of 118/70 mm Hg, Pulse of 92 and regular and fetal heartbeat of 110. Her hemoglobin is noted to be 7 g/dL., hematocrit 22%, and MCV 73 um 3 . Which of the following is true regarding anemias in pregnancy?   The most common anemia during pregnancy is megaloblastic anemia.   Supplemental iron is not indicated in this patient since the anemia is likely related to physiologic dilution of pre   Iron deficiency is uncommon in pregnancy.  Anemia is the most common medical complication of pregnancy. Remediation Educational Objective: Diagnose anemias in pregnancy. Key Point: Common anemias occurring in pregnant patients are dilutional (physiologic), iron deficiency and megaloblastic anemia due to folate deficiency. Standard evaluation is recommended. Explanation: Anemia is the most common medical complication of pregnancy. Iron-deficiency anemia is noted in approximately 25% of pregnancies, the result of low iron stores in women and the diversion of maternal iron to the fetus. Pregnant patients experience a dilutional anemia as the result of an expansion of plasma volume. Dilutional anemia is usually reflected by hemoglobin levels of 9 to 11 g/dL. Lower levels

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should be supplemented with iron to increase maternal stores. Megaloblastic anemia due to Folate deficiency is found in 4% of pregnancies and is associated with neural tube defects. Folate supplementation is recommended for all pregnant women in a dose of 0.4 to 1 mg daily, with higher doses recommended for those with megaloblastic anemia. References: Calder KK and Newton EJ. Chronic Medical Illness During Pregnancy. In: Rosen’s Emergency Medicine. 7th ed. Mosby; 2009:2298-2312. Kilpatrick S. Anemia and Pregnancy. In Creasy and Resnik’s Maternal Fetal Medicine: Principles and Practice. 2014; 55: 918-931 Question 54 Report Question Stem & Answers A 30-year-old woman, G1P0, at 10 weeks’ gestation, is brought in by coworkers after having suffered a brief seizure. She has a known seizure disorder and has been stable on valproic acid for years with rare breakthrough seizures. Which one of the following statements is true regarding seizures in pregnancy?   There is no association between the use of valproic acid during pregnancy and the presence of neural tube def newborns.  The primary concern with use of valproic acid in pregnancy is neural tube defects.   Most epileptic patients have an increase in the frequency of seizures during pregnancy.   There is an increased risk of eclampsia in pregnant patients who have epilepsy. Remediation Educational Objective: Recognize risks of anticonvulsants in pregnancy. Key Point: Valproic acid should be avoided during pregnancy if possible. Folic acid supplementation is recommended. Explanation:

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The primary concern with the use of valproic acid or carbamazepine during pregnancy is the increased risk of neural tube defects. Women taking valproate during pregnancy should be advised to take 4 mg of folate daily to minimize the risk of congenital malformations. Patients with underlying seizure disorder are not at increased risk of eclampsia during pregnancy. A minority of pregnant patients with seizure disorder will experience an increase in frequency of seizures during pregnancy. Reference: Calder KK. Chronic Medical Illness During Pregnancy. In Rosen’s Emergency Medicine. 2014; 179: 2300- 2315 Question 55 Report Question Stem & Answers A 31-year-old woman, G4P3, known to have human immunodeficiency virus (HIV) infection, presents in active labor at 39 weeks’ gestation. She has received no prenatal care. Her cervix is 4 cm dilated, and her membranes are intact. Her viral load is unknown. Which of the following is the best strategy for delivery to prevent vertical transmission of HIV to her newborn?   Test the patient’s viral load, and decide how to proceed when results of the testing are available.   Administer intrapartum antiretroviral therapy and allow the patient to deliver vaginally.   Proceed with immediate cesarean delivery and give antiretroviral therapy to the newborn.  Administer intrapartum antiretroviral therapy and proceed with cesarean section.   Allow the patient to deliver vaginally with no interventions. Remediation Educational Objective: Prevent vertical transmission of HIV during pregnancy. Key Point:

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Antiretroviral therapy, delivery via caesarian section and avoiding breastfeeding are recommended to decrease transmission of HIV from mother to infant. Explanation: Human immunodeficiency virus (HIV) transmission during pregnancy is thought to occur primarily through exposure to maternal blood and secretions. Other means of transmission are in utero and during breastfeeding. The most important factor is maternal viral load, with the desired maternal viral load being <1,000 copies/mL. Patients with viral loads under 1,000 can be allowed to deliver vaginally; however, they still should be offered elective cesarean as an option, given the possibility of vertical transmission at even lower levels. The viral load of the patient in this case is unknown; therefore, a cesarean section is the recommended mode of delivery. Use of antiretroviral agents during pregnancy and during labor has decreased the rate of vertical transmission. Administration of antiretroviral therapy should be standard in all HIV patients during labor and would be appropriate for the patient in this case. Neonates born to HIV-positive mothers generally all test positive for HIV antibodies because of placental transfer of maternal antibodies. These antibodies may be present for up to 18 months and are not necessarily indicative of newborn infection. Optimal therapy to prevent vertical transmission includes antepartum administration of highly active antiretroviral therapy (HAART), intrapartum antiretroviral dosing, and treatment of the infant with 6 weeks of zidovudine. Women with known HIV should be advised to avoid breastfeeding. Reference: Calder KK. Chronic Medical Illness During Pregnancy. In Rosen’s Emergency Medicine. 2014; 179: 2300- 2315 Question 56 Edited: Dec 20, 2016 Report Question Stem & Answers A 19-year-old primigravida presents at 28 weeks gestation just after a new-onset seizure. Her pregnancy has previously been uncomplicated with no history of fever, drug use, or head trauma. However, she has not attended any of her prenatal appointments since 20 weeks. Her physical examination is normal for her gestation age with the exception of blood pressure of 160/100 in both arms. Which of the following would be most helpful in establishing a diagnosis of eclampsia in this patient?   Disorientation   Hypertension 

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Proteinuria   Papilledema   Peripheral edema Remediation Educational Objective: Diagnose eclampsia. Key Point: Eclampsia is defined as the new onset of grand mal seizure in a patient with preeclampsia. Presence of proteinuria is helpful in confirming the diagnosis of preeclampsia in which up to 20% of women may be normotensive. Explanation: Eclampsia is defined by the American Congress of Obstetricians and Gynecologists (ACOG, Nov. 2013) as the new onset of grand mal seizure in a woman with preeclampsia. The presence of proteinuria in the face of hypertension is sufficient for the diagnosis of pre-eclampsia. Even though proteinuria is no longer a requirement for the diagnosis of preeclampsia, it will be present in the vast majority of women with preeclampsia and indeed is the single most helpful diagnostic clue in a pregnant patient who has had a seizure and whose medical history is unknown. At the time of a seizure due to eclampsia, about 80% of women have hypertension; half of these are severe. About 20% of patients in eclampsia are normotensive. Disorientation is common following a seizure, regardless of the cause. Many normal pregnancies may have mild pedal edema. Proteinuria may be the only differentiating factor in the initial diagnosis of eclampsia. Non-eclamptic patients will revert to normal or low blood pressure after a period of observation. If the patient remains hypertensive or manifests other signs of a preexisting preeclampsia, magnesium sulfate and other agents are indicated to prevent further seizures and to control blood pressure. References: Alvero R. Eclampsia. Book Chapter in Ferri's Clinical Advisor, 2017. 405-405.e1. Bassily-Marcus, Adel M., et al. "Pulmonary hypertension in pregnancy: critical care management." Pulmonary medicine 2012 (2012). Hypertension, Pregnancy-Induced—Practice Guideline. American College of Obstetricians and Gynecologists. Nov. 2013. RG575.5 618.3'6132—dc23 Question 57 Report Question

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Stem & Answers What is the first priority when treating a pregnant patient with suspected hyperthyroidism?   Ablation of the thyroid with radioactive iodine   Inhibition of thyroid synthesis with propylthiouracil  Adrenergic blockade with propranolol   Inhibition of thyroid release with iodide Remediation Educational Objective: Treat hyperthyroidism in pregnancy. Key Point: Treatment of symptomatic hyperthyroidism includes beta-blockers for severe hyperadrenergic symptoms, and methimazole or propylthiouracil. Radioactive iodine is contraindicated in pregnancy. Explanation: The first priority in the treatment of hyperthyroidism is stabilization and reversal of the end-organ and hemodynamic effects of sympathetic stimulation. Typically, this is accomplished with a beta-blocker. Reduction of thyroid hormone synthesis and release can then follow. Both propylthiouracil (PTU) and methimazole at the lowest effective dose are acceptable during pregnancy for decreasing production of thyroid hormones T4 and T3. PTU will also inhibit the conversion of the less potent T4 to the more potent T3. Surgical therapy (thyroidectomy) is useful in refractory cases. Because the fetal thyroid is extremely sensitive to iodide, giving any iodide products may result in a large goiter and it should be reserved only for severe cases. I131 radionuclide to ablate the maternal thyroid is absolutely contraindicated because it will simultaneously destroy the fetal thyroid gland. Reference: Calder KK. Chronic Medical Illness During Pregnancy. Rosen’s Emergency Medicine. 2014; 179: 2300- 2315 Question 58 Report Question

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Stem & Answers What is the most important factor contributing to the frequency of vertical transmissions and neonatal morbidity of syphilis and hepatitis B?   Resistant organisms   Ineffective drug therapy  Inadequate screening   Immunosuppression   Inadequate diagnostic tests Remediation Educational Objective: Reduce risk of vertical transmission of syphilis and hepatitis B. Key Point: Treatment of syphilis and vaccination against hepatitis B in early pregnancy are very effective for reducing the risk of vertical transmission. Screening for syphilis and hepatitis B virus infection should be performed in all pregnant patients. Explanation: Screening for syphilis and/or hepatitis B virus infection should be performed in all pregnant patients and repeated at various intervals in high-risk populations. Treatment with penicillin before 20 weeks gestation can result in a negligible rate of vertical transmission. Inadequate prenatal screening is at the root of most current cases of congenital syphilis. Vertical transmission of the hepatitis B virus approaches 90% in untreated cases, and up to 90% of infected neonates will become chronic carriers as adults. Routine screening for HBV during early pregnancy is recommended because treatment with hepatitis B immunoglobulin and hepatitis B vaccine is very effective in reducing the rate of vertical transmission. Unvaccinated, HBsAg-negative gravidas who are exposed during the pregnancy to HBV should receive both hepatitis B immuno- globulin and vaccine. Reference: Calder KK, Chronic Medical Illness During Pregnancy. In Rosen’s Emergency Medicine. 2014; 179: 2300- 2315

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Question 59 Report Question Stem & Answers A 23-year-old woman presents with shortness of breath and pleuritic chest pain. She is 4 days postpartum. Which of the following statements is true about deep venous thrombosis (DVT) and pulmonary embolus in pregnancy?  DVT is 7-10 times more common during pregnancy and peaks after delivery.   DVT in pregnancy is almost never genetic in etiology.   Chest pain during pregnancy, worse on inspiration, is common due to diaphragmatic irritation by the gravid ute   DVT is 50% less common during pregnancy.   Spontaneous pneumothorax is common in the postpartum period due to the dramatic change in hormone leve Remediation Educational Objective: Recognize increased risk for venous thromboembolism in pregnancy. Key Point: Risk for DVT and pulmonary embolism is increased during pregnancy and the first six weeks of postpartum period. Low molecular weight heparin is the anticoagulant of choice. Explanation: The risk of DVT is increased by 7-10 times during pregnancy and is highest following delivery. It is often the first manifestation of hereditary thrombophilia, which accounts for approximately 50% of DVT cases during pregnancy. Chest pain is not common during pregnancy. There is no increased risk of spontaneous pneumothorax. The use of coumadin anticoagulants during early pregnancy is discouraged. Warfarin crosses the placenta and an increase in the incidence of nasal hypoplasia is noted among infants whose mothers were treated with warfarin between 6 and 12 weeks’ gestation. Either unfractionated or low molecular weight heparin is recommended instead. References:

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Robertson L, Wu O, Langhorne P, et al; Thrombosis: Risk and Economic Assessment of Thrombophilia Screening (TREATS) Study. Thrombophilia and pregnancy: a systematic review. Br J Haematol. 2006;132(2):171-196. Lensen R, Rosendaal F, Vandenbroucke J, Bertina R. Factor V Leiden: the venous thrombotic risk in thrombophilic families. Br J Haematol. 2000;110(4):939-945. Tchaikovski SN, Rosing J. Mechanisms of estrogen-induced venous thromboembolism. Thromb Res. 2010;126(1):5-11. Gallahue F, Postpartum Emergencies. Emergency Medicine 2013; 123: 1061-1068 Question 60 Report Question Stem & Answers A 29-year-old woman gravida 3, para 2 presents at 29 weeks’ gestation with a chief complaint of frequent urination. You note pitting ankle edema on her physical examination. Her urine is 1+ for protein, and her blood pressure is 180/100 mm Hg. Her past medical history is unremarkable. Three months ago her blood pressure was 125/70 mm Hg. What is the most likely diagnosis?   patient is normal for this stage of pregnancy   gestational hypertension   preeclampsia superimposed on chronic hypertension   chronic hypertension  preeclampsia Remediation Educational Objective: Diagnose preeclampsia. Key Point:

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Preeclampsia is new onset hypertension with either proteinuria or another sign of end organ damage after 20 weeks’ gestation. Gestational hypertension is new-onset hypertension without proteinuria after 20 weeks’ gestation. Explanation: Gestational hypertension is defined as new-onset hypertension without proteinuria after 20 weeks’ gestation. Chronic hypertension is defined as a maternal blood pressure of 140/90 mm Hg on two occasions before 20 weeks’ gestational age. Preeclampsia is new onset hypertension with either proteinuria or another sign of end organ damage after 20 weeks’ gestation. The vast majority of women with preeclampsia will have proteinuria. The preeclampsia guidelines were adjusted in 2013 to capture this small group of women without proteinuria. The 2013 practice guidelines for diagnosing severe preeclampsia are as follows: SEVERE FEATURES OF PREECLAMPSIA (Any one of these findings):  Systolic blood pressure of 160 mm Hg or higher, or diastolic blood pressure of 110 mm Hg or higher on two occasions at least 4 hours apart while the patient is on bed rest (unless antihypertensive therapy is initiated before this time)  Thrombocytopenia (platelet count less than 100,000/microliter)  Impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes (to twice normal concentration), severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses, or both  Progressive renal insufficiency (serum creatinine concentration greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease)  Pulmonary edema  New-onset cerebral or visual disturbances References: Houry DE, Salhi BA. Acute complications of pregnancy. In: Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed, 2009. von Dadelszen P, Magee LA. Antihypertensive medications in management of gestational hypertension- preeclampsia. Clin Obstet Gynecol. 2005;48(2):441-459. Esplin MS, Fausett MB, Fraser A, et al. Paternal and maternal components of the predisposition to preeclampsia. N Engl J Med. 2001;344(12):867-872. Hypertension in pregnancy—Practice Guideline Nov. 2013. American College of Obstetricians and Gynecologists. RG575.5 618.3'6132—dc23

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Question 61 Report Question Stem & Answers A 31-year-old woman gravida 3, para 2 and at 34 weeks gestation presents to you with generalized severe pruritus. On physical examination, you note that her sclera are slightly jaundiced. What is the most likely diagnosis?   cholelithiasis   hemolytic anemia  intrahepatic cholestasis of pregnancy (ICP)   preeclampsia Remediation Educational Objective: Diagnose intrahepatic cholestasis of pregnancy. Key Point: Intrahepatic cholestasis of pregnancy is a benign condition occurring in the second or third trimester and characterized by generalized pruritus and elevated serum bile acids and aminotransferases. Explanation: ICP is typically a benign condition that occurs in approximately one in 100 pregnancies in the United States. In addition to bilirubin, other liver function tests are elevated, particularly alkaline phosphatase. Pruritus results from retention of bile salts. Symptoms and signs of cholestasis generally subside within 48 hours of delivery. Preeclampsia does not cause pruritus. Hemolytic anemia may result in jaundice, but, again, pruritus would be unlikely. Cholelithiasis is common in pregnancy but jaundice, from bile duct obstruction, without pain, would be highly unusual. References: Geenes V, Williamson C. Intrahepatic cholestasis of pregnancy. World J Gastroenterol. 2009;15(17):2049- 2066 Grone AK, Smith JF Jr. Intrahepatic cholestasis of pregnancy Neo Rev. 2012;13(3):e145--e150.

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Geenes, Victoria, et al. "Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: A prospective population based case control study." Hepatology 59.4 (2014): ‐ ‐ 1482-1491. Question 62 Report Question Stem & Answers A 36-year-old woman who is 31 weeks pregnant presents with fever, nausea, urinary frequency, and back pain. Which of the following is true concerning urinary tract infection (UTI) and pregnancy?   Mild dilation of the ureter should be treated with external drainage or internal stents.   No risks to the fetus from UTI have been documented.  The UTI should be treated, and treatment standards are unchanged.   UTI is rare in pregnancy.   There is no associated maternal morbidity. Remediation Educational Objective: Manage UTI during pregnancy. Key Point: Treatment is required for pregnant women with either UTIs or asymptomatic bacteriuria. Explanation: UTI in pregnancy is a common condition and has an overall incidence of about 8%. Hormonal differences coupled with stasis and mild urinary tract dilation secondary to pressure from the gravid uterus increase the likelihood of this condition. Complications of untreated UTI can be serious and include prematurity, low birth weight, and increased perinatal mortality. Maternal complications include preterm labor, increased incidence of hypertension, and chorio-amnionitis. References:

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McCormick T, Ashe RG, Kearney PM. Urinary tract infection in pregnancy. Obstet Gynaecol. 2008;10(3):156-162. Mazor-Dray E, Levy A, Schlaeffer F, Sheiner E. Maternal urinary tract infection: is it independently associated with adverse pregnancy outcome? J Matern Fetal Neonatal Med. 2009;22(2):124-128. Easter SR, Cantonwine DE, Zera CA, Urinary Tract Infection During Pregnancy; angiogenic factor profiles and risk of preeclampsia. American Journal of Obstetrics and Gynecology. 2016; 214: 381. e1-381. e7 Question 63 Report Question Stem & Answers A 26-year-old primigravida presents with a complaint of severe abdominal pain. She reports that initially she had a few days of a vague, aching sort of pain, but it has culminated today in extremely severe pain. Her only gynecologic history is an episode of pelvic inflammatory disease, 2 years ago, requiring hospitalization and intravenous antibiotics. She says that she is late for her menstrual cycle, but she is currently experiencing some irregular vaginal bleeding. You suspect ectopic pregnancy. Which is the most likely location?   abdominal cavity   heterotopic   cervix  fallopian tube   ovary Remediation Educational Objective: Recall pathology of ectopic pregnancy. Key Point: The fallopian tube is the most common site of ectopic pregnancy. Explanation:

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The most common site for an ectopic pregnancy is the fallopian tube (96% of all cases). The fallopian tube is composed of 4 portions, and an ectopic pregnancy can occur, with differing frequency, in any of them. The portions and the incidence of ectopics are the infundibulum (5%), ampulla (80%), isthmus (12%), and the interstitium (1%-2%), which inserts into the cornua. Although most ectopic pregnancies occur in the tubes, other sites are possible: 1.5% of sites are abdominal and less than 1% are cervical or ovarian. Heterotopic pregnancy refers to a concurrent intrauterine and ectopic pregnancy. Although it is rare, a woman's risk is increased if she uses ovulation-inducing agents. Reference: Lobo RA. Ectopic pregnancy. Lentz GM, et al. Comprehensive Gynecology. 6th ed., 2012:361-382. Question 64 Report Question Stem & Answers Which of the following are risk factors for ectopic pregnancy?  history of pelvic inflammatory disease, prior tubal surgery, ovulation induction, and smoking   multiple gestations, excessive first trimester weight gain, and history of streptococcal illness   obesity, diabetes, and alcohol use   oral contraceptives, younger age, and irregular periods   hyperlipidemia, congenital heart disease, and natural pregnancy (no in vitro fertilization or assisted reproductiv Remediation Educational Objective: Recognize risk factors for ectopic pregnancy. Key Point: Previous ectopic pregnancy and abnormal tubal anatomy from previous surgery, infection or other pathology are major risks factors for ectopic pregnancy. Explanation:

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There are many risk factors for ectopic pregnancy; however, 50% of all ectopic pregnancies occur in the absence of any risk factor. Major risk factors are those conditions that impede the passage of the fertilized ovum to the uterus. The most clearly proven risk factor is prior pelvic inflammatory disease, especially if caused by the sexually transmitted infection, chlamydia. Other risk factors include:  Previous ectopic pregnancy  Failed sterilization  Prior tubal surgery  Tubal reanastomosis  Contraceptive failure: Progesterone intrauterine device  Ovulation inductions/in vitro fertilization  Salpingitis isthmica nodosa  Diethylstilbestrol exposure in utero  Increased age  Infertility  Smoking  Prior abdominal or pelvic surgery References: Hoover RN. Adverse health outcomes in women exposed in utero t diethylstilbestrol. N Engl J Med. 2011;365:1304-1314. Lobo RA. Ectopic pregnancy. Lentz GM, et al. Comprehensive Gynecology. 6th ed., 2012:361-382. Question 65 Report Question Stem & Answers A 37-year-old G2P0010 presents with abdominal pain. The pain came on suddenly, is very severe, and is located in the left lower quadrant. She had a positive pregnancy test 1 week ago after a missed period, but she is now having some vaginal bleeding. On examination, she appears uncomfortable, but she has normal vital signs. Her pelvic examination is remarkable for scant vaginal bleeding and L adnexal tenderness. Human chorionic gonadotropin level is positive. What is the next step in the diagnosis of this patient?   progesterone level

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 ultrasonography to look for intrauterine pregnancy   dilation and curettage   culdocentesis   urgent laparoscopy Remediation Educational Objective: Diagnose ectopic pregnancy. Key Point: Suspect ectopic pregnancy in a woman presenting withabdominal pain, missed menses, vaginal bleeding and testing positive for pregnancy. Confirm the diagnosis with ultrasound. Explanation: This patient has signs and symptoms of an ectopic pregnancy until proven otherwise. She has risk factors, which include her age and a previous miscarriage, and she has the classic symptoms of abdominal pain, missed menses, and vaginal bleeding. She also has a positive human chorionic gonadotropin level. Her examination appears to show a stable patient, so the best course of diagnosis is now ultrasonography. Ultrasonography is useful for viewing intrauterine pregnancies, assessing fetal size and viability, and excluding ectopic pregnancy, except in rare cases of heterotopic pregnancies, which may be missed on ultrasound. An unstable patient should be taken directly to the operating room for laparoscopy, which is the most effective and efficient means of diagnosing and treating ectopic pregnancy in an emergency situation. Progesterone levels will be low in ectopic pregnancy, but they will also be low in spontaneous abortions; these levels are also not particularly sensitive in distinguishing between the two conditions. Culdocentesis is rarely used instead of ultrasonography because it is less sensitive and specific and is frequently not diagnostic. Dilation and curettage should never be used in the absence of a definitive diagnosis. Reference: Haury DE, Salhi BA. Acute complications of pregnancy. Marx JA, et al. Rosen's Emergency Medicine. 7th ed., 2009:2279-2297. Question 66 Report Question

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Stem & Answers A 37-year-old G2P0010 presents with severe abdominal pain. The pain came on suddenly and was initially colicky in nature, but it has since localized to the L side and has become severe. She had a positive pregnancy test 1 week ago after a missed period, but she is now having some vaginal bleeding. On examination, she appears extremely uncomfortable, pale, and her blood pressure is 78/51 mm Hg. Her abdominal examination is significant for marked tenderness to palpation about the entire abdomen, and the pelvic examination is remarkable for scant vaginal bleeding and significant L adnexal tenderness. Her human chorionic gonadotropin level is positive. A complete blood count shows a hemoglobin level of 7.1 g/dL. Despite aggressive volume resuscitation with fluids and blood products, her blood pressure remains low, her heart rate rises to 120 beats/minute, and her pain continues. What is the next step in management of this patient's condition?   single dose of methotrexate 50 mg/m2 given intramuscularly   obtain a progesterone level to look for viable intrauterine pregnancy  surgically remove the ectopic pregnancy   ultrasonography to confirm location of pregnancy Remediation Educational Objective: Manage ectopic pregnancy. Key Point: Treatment of ectopic pregnancy may be either medical (methotrexate) when patient is stable and has no contraindications, or surgical (laparoscopic salpingostomy or salpingectomy). Explanation: For women with a ruptured ectopic pregnancy or in cases when methotrexate or other medical therapy is contraindicated or refused by the patient, laparoscopy is the procedure of choice. When an accurate diagnosis cannot be made, it may also be used. This patient is unstable so surgery is in order to remove the ectopic pregnancy. In stable patients who desire future fertility, salpingostomy can be performed, which is the removal of the tubal pregnancy through an incision in the fallopian tube that is then closed by secondary intention. Salpingectomy may also be performed in women who do not desire future fertility or in unstable patients; however, in these cases, both the tube and the ectopic pregnancy are removed during the procedure.

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References: Haury DE, Salhi BA. Acute complications of pregnancy. Marx JA, et al. Rosen's Emergency Medicine. 7th ed., 2009:2279-2297. Lobo RA. Ectopic pregnancy. Lentz GM, et al. Comprehensive Gynecology. 6th ed., 2012:361-382.

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MC 9 Prenatal and PPcare

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