Prenatal care from the first visit to term

A patient with a certain last menstrual period (LMP) is 10 0/7 weeks by dates. Crown-rump length on her first ultrasound corresponds to 9 1/7 weeks. The estimated due date should be

1. averaged between the two dates
   Averaging the LMP and ultrasound dates is never recommended; one source is chosen by the size of the discrepancy.
2. left unchanged
   For a crown-rump length at 9 0/7 to 13 6/7 weeks, ACOG redates only when the difference from a certain LMP exceeds 7 days; here it is 6 days, so the LMP-based date stays unchanged.
3. changed to the ultrasound date
   Changing the date for a 6-day difference applies the stricter cutoff used before 9 weeks (more than 5 days) to a scan at 9 1/7 weeks.

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A patient at 11 weeks' gestation has chronic hypertension. The recommended regimen for preeclampsia prophylaxis is aspirin

1. 60 mg daily from 20 weeks until delivery
   Starting at 20 weeks loses much of the benefit, which is greatest when aspirin starts before 16 weeks, and 81 mg is the US dose.
2. 325 mg daily from 12 weeks until delivery
   Preeclampsia prophylaxis uses low-dose aspirin; 325 mg adds bleeding risk without proven extra benefit.
3. 81 mg daily from 12 weeks until delivery
   USPSTF and ACOG recommend low-dose aspirin 81 mg daily for patients at high risk of preeclampsia, such as those with chronic hypertension, starting at 12 to 28 weeks (ideally before 16) and continuing until delivery.

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At 30 weeks' gestation, a patient has aching leg varicosities by evening. There is no calf tenderness, swelling or skin change. The nurse practitioner should recommend

1. prophylactic enoxaparin
   Varicose veins alone are not an indication for anticoagulation; LMWH is reserved for patients with VTE risk factors or prior thrombosis.
2. compression stockings
   Uncomplicated varicose veins in pregnancy are managed with graduated compression stockings, leg elevation and avoiding long standing.
3. referral for sclerotherapy now
   Sclerotherapy is deferred until after pregnancy, because many varicosities improve postpartum and the procedure is not done in pregnancy.

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Besides aneuploidy, increased nuchal translucency with a normal karyotype is most strongly associated with

1. bilateral renal agenesis
   Renal agenesis shows up as absent kidneys and severe oligohydramnios in the second trimester; it is not a typical cause of raised nuchal translucency.
2. open neural tube defects
   Open neural tube defects are detected with ultrasound and maternal serum AFP; they are not the main association of a thick nuchal fold.
3. congenital heart defects
   With a normal karyotype, increased nuchal translucency is most strongly linked to structural heart defects, so a fetal echocardiogram is offered.

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Routine antenatal fetal surveillance (such as weekly NSTs from 32 weeks) is indicated for which patient?

1. Maternal age of 32 years
   Maternal age becomes an indication only from 35 (testing is considered at 35 to 39 and advised weekly from 36 weeks at 40 or older); 32 is not an indication.
2. Pregestational type 1 diabetes
   Pregestational diabetes raises the risk of stillbirth, so weekly or twice-weekly fetal testing from about 32 weeks is routine.
3. One prior low transverse cesarean
   A prior low transverse cesarean affects labor planning, not fetal well-being, and does not call for antenatal testing.

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Which second-trimester quad screen pattern suggests fetal trisomy 21?

1. High AFP, normal estriol, hCG and inhibin A
   An isolated high AFP suggests an open neural tube defect or abdominal wall defect, not aneuploidy.
2. Low AFP, low estriol, high hCG, high inhibin A
   Trisomy 21 lowers AFP and unconjugated estriol and raises hCG and inhibin A on the quad screen.
3. Low AFP, low estriol, low hCG, normal inhibin A
   All three markers low with normal inhibin A is the pattern of trisomy 18.

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At 32 weeks' gestation, the amniotic fluid index is 27 cm. A detailed ultrasound shows normal fetal anatomy and growth. She did not have the routine screening usually done at 24–28 weeks. The nurse practitioner should next order

1. a glucose tolerance test
   Polyhydramnios with normal anatomy and growth is most often linked to maternal diabetes, and she has not been screened, so a glucose tolerance test comes next.
2. maternal serum alpha-fetoprotein
   MSAFP screens for neural tube defects at 15 to 22 weeks; at 32 weeks with normal anatomy it adds nothing.
3. a urine drug screen
   Drug exposure is not a usual cause of excess amniotic fluid; diabetes is the treatable cause to exclude.

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At the 20-week anatomy scan, an isolated echogenic intracardiac focus is seen. Earlier cell-free DNA screening was low risk. The nurse practitioner should

1. advise no further evaluation
   An isolated echogenic intracardiac focus is a normal variant; with low-risk cell-free DNA it carries no added aneuploidy risk and needs no follow-up.
2. offer amniocentesis
   Offering invasive testing after low-risk cell-free DNA for a soft marker exposes her to procedure risk with essentially no gain.
3. arrange fetal echocardiography
   An isolated focus is a calcified papillary muscle, not a heart defect, so it is not an indication for fetal echo.

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At 30 weeks in September, a patient asks about protecting her newborn from respiratory syncytial virus. The nurse practitioner should plan to give the maternal RSV vaccine at

1. 32–36 weeks
   CDC recommends one dose of the maternal RSV vaccine (Abrysvo) at 32 0/7 to 36 6/7 weeks during September through January, so she is due as soon as she reaches 32 weeks.
2. 24–28 weeks
   Weeks 24 to 28 are when gestational diabetes screening is done; the RSV vaccine is not given that early.
3. 27–36 weeks
   Weeks 27 to 36 are the Tdap window; the RSV vaccine window is narrower and starts at 32 weeks.

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Which finding on the mid-trimester ultrasound should prompt transvaginal color Doppler evaluation for vasa previa?

1. Placental lakes
   Placental lakes are common and usually benign; they are not a risk factor for vessels over the os.
2. Single umbilical artery
   A single umbilical artery prompts a detailed anatomy scan and growth surveillance, but it does not by itself raise the risk of vasa previa.
3. Velamentous cord insertion
   With a velamentous insertion, vessels run through the membranes unprotected, and transvaginal color Doppler checks whether they cross the cervical os.

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At her first prenatal visit, an asymptomatic patient has a reactive RPR (1:16) and a reactive treponemal test. She has never been tested or treated for syphilis. Benzathine penicillin G 2.4 million units IM should be given

1. weekly for 3 doses
   A reactive RPR and treponemal test with no symptoms and unknown timing is latent syphilis of unknown duration, treated with benzathine penicillin G 2.4 million units IM weekly for 3 doses.
2. once as a single dose
   A single dose treats primary, secondary or early latent syphilis acquired within a year; without proof of recent infection, the 3-dose regimen is used.
3. weekly for 2 doses
   Two doses is not a standard regimen; stopping short leaves latent infection undertreated, and a missed dose in pregnancy means restarting the series.

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A pregnant patient who exercises most days should stop and seek care if she develops

1. Muscle soreness the next day
   Delayed muscle soreness is an expected response to training, not a reason to stop exercising in pregnancy.
2. Breathing hard but able to talk
   Being able to talk while breathing hard marks moderate intensity, which is the recommended level in pregnancy.
3. Regular painful contractions
   Regular painful contractions during or after exercise can mean preterm labor, which is a warning sign to stop and seek care.

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A primigravida at 36 weeks has intensely itchy papules and plaques that began in abdominal striae and spare the umbilicus. The most likely diagnosis is

1. Polymorphic eruption of pregnancy
   Intensely itchy papules starting in the striae and sparing the umbilicus in a first pregnancy near term is polymorphic eruption of pregnancy (PUPPP), which is benign for the fetus.
2. Pemphigoid gestationis
   Pemphigoid gestationis usually begins around the umbilicus and evolves into tense blisters; periumbilical sparing argues against it.
3. Atopic eruption of pregnancy
   Atopic eruption usually starts earlier in pregnancy in patients with atopy and favors flexural surfaces, not abdominal striae.

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At the first prenatal visit, an Rh-negative patient has a positive anti-D antibody titer. The nurse practitioner should

1. Recheck the titer after birth
   Waiting until after birth misses fetal anemia and hydrops, which develop during the pregnancy.
2. Give RhIG at 28 weeks as usual
   Routine RhIG prevents sensitization in patients who are antibody-negative; it has no effect once anti-D is present.
3. Refer to maternal-fetal medicine
   A positive anti-D titer means she is already alloimmunized, so RhIG cannot help; the pregnancy needs serial titers and MCA Doppler under maternal-fetal medicine care.

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At 32 weeks, a patient has severe itching of the palms and soles, worse at night, with no rash. The most useful diagnostic test is

1. Skin biopsy with immunofluorescence
   Immunofluorescence biopsy confirms pemphigoid gestationis, which has blisters; there is no rash here to biopsy.
2. Hepatitis B surface antigen
   Hepatitis B serology is routine prenatal screening, but it does not explain itching without jaundice; bile acids test the likely diagnosis.
3. Serum total bile acids
   Itching of the palms and soles without a rash in the third trimester suggests intrahepatic cholestasis, confirmed by raised total bile acids, which also guide delivery timing.

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