A 25-year-old female at 36 weeks gestation presents for a routine prenatal visit. Her blood pressure is 118/78 mm Hg and her urine has no signs of protein or glucose. Her fundal height shows appropriate fetal size and she says that she feels well. On palpation of her legs, you note 2 + pitting edema bilaterally.
Which one of the following is true regarding this patient’s condition?
Correct Answer C:
Lower-extremity edema is common in the last trimester of normal pregnancies and can be treated symptomatically with compression stockings. Edema has been associated with preeclampsia, but the majority of women who have lower extremity edema with no signs of elevated blood pressure will not develop preeclampsia or eclampsia. For this reason, edema has recently been removed from the diagnostic criteria for preeclampsia. Disproportionate swelling in one leg versus another, especially associated with leg pain, should prompt a workup for deep venous thrombosis but is unlikely given this patient’s presentation, as are cardiac or renal conditions.
A 24-year-old primiparous female at 8 weeks gestation presents to your office for her initial prenatal visit. She has no identifiable risks for the pregnancy. You counsel her regarding her lifestyle choices modifications for healthy pregnancy.
Which one of the following would be appropriate advice?
Correct Answer D:
The recommended intake of calcium during pregnancy is 1000-1300 mg daily.
→ Air travel is discouraged in the 4 weeks prior to a patient’s due date, but no recommendations restrict intercontinental flights for the entire pregnancy.
→ Sexual intercourse is deemed safe during pregnancy (assuming a normal pregnancy).
→ Aspartame and sucralose are also generally considered safe.
→ Exposure to high levels of mercury in fish can lead to neurologic abnormalities in women and their infants. Therefore, pregnant women should avoid shark, swordfish, king mackerel, and tuna steak, and limit intake of other fish (including canned tuna) to 12 oz (2-3 meals) per week.
When evaluating the results of a human chorionic gonadotropin level in the maternal blood, the peak value occurs at which gestational week of the pregnancy?
Correct Answer B:
Human chorionic gonadotropin (hCG) doubles every 1.2-3 days in early pregnancy. Serum total hCG concentration peaks at about 93,000 mIU/mL (range 27,300-233,000 mIU/mL) at 8-11 weeks of gestation. It then declines to a plateau level for the remainder of the gestation.
During pregnancy, lactation is suppressed by the action of:
The high level of estrogen is inhibitory to the production of milk by the breast despite the extremely high level of prolactin. After delivery of the fetus and placenta, the level of estriol decreases until the inhibitory effect is removed, at which time significant milk production begins (2-3 days).
A. Insulin levels elevate in pregnancy. This hormone, however, does not suppress lactation.
C. Total T4 levels rise in pregnancy due to an increase in thyroid hormone binding globulin. Free T4 levels stay essentially unchanged.
D. HPL increases free fatty acids, allowing glucose and amino acids to be conserved for use by the fetus.
E. Inhibin is produced by the placenta. Levels rise during pregnancy, causing a suppression of maternal gonadotropins.
You are performing the admission history and physical on an otherwise healthy 17-year-old woman who presents to Labor and Delivery for induction at 41 weeks’ gestation. Her past medical history is unremarkable, and in reviewing her prenatal records, you note that no abnormalities were found on her initial prenatal physical exam at 8 weeks’ gestation. On your admission physical, you note subtle systolic ejection murmurs heard best over the aortic valve region, and you rate it a 1 on a scale of 6.
This murmur is most likely due to:
Maternal blood volume is up 40-50% by the start of the third trimester. Maternal stroke volume (choice B) and cardiac output are up by a similar fraction, leading to an increase in turbulent flow with ventricular emptying. This gives rise to a flow murmur at the aortic valve. The hematocrit in pregnancy should decrease since the red cell mass only goes up 30% (physiologic anemia of pregnancy).
→ Increased cardiac size (choice A) is an incorrect answer. Ejection murmurs are due to the increase in turbulent flow.
→ Although peripheral resistance decreases (choice C), reaching a nadir in the second trimester, the murmur is still due to turbulent flow secondary to the 50% increase in cardiac output.
→ Decreased cardiac valvular resistance (choice D) is incorrect. See answer to A.
→ Increased hematocrit in pregnancy (choice E) is incorrect because the hematocrit decreases in pregnancy due to a relative increase in plasma volume relative to red cell mass.
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