A 26-year-old G2P1 presents to your office for her first prenatal visit. Social history reveals that she smokes one pack of cigarettes each day.
Which of the following statements is true regarding tobacco and pregnancy?
There are many potential teratogens in cigarette smoke, including nicotine, carbon monoxide, cadmium, lead, and hydrocarbons. Smoking has been shown to cause fetal growth restriction and to be related to increased incidences of subfertility, spontaneous abortions, placenta previa, abruption, and preterm delivery. The mechanisms for these adverse effects include increased fetal carboxyhemoglobin levels, reduced uteroplacental blood flow, and fetal hypoxia. Most studies do not indicate that tobacco use is related to an increased risk of congenital malformations, mental retardation, or developmental delay. Almost half of women who smoke quit directly before or during pregnancy. An office-based protocol that offers treatment or referral for smoking cessation has been proven to increase quit rates. The 5A’s is an office based intervention to help pregnant women quit smoking. These are as follows: (1) Ask the patient about smoking, (2) Advise the patient to stop, (3) Assess the patient’s willingness to attempt to quit, (4) Assist the patient who is interested by providing smoking cessation materials, (5) Arrange follow-up visits to track the progress of the patient’s attempt to stop smoking. Patients should be encouraged to remain smoke free. Children born to mothers who smoke are at an increased risk of asthma, obesity, and colic.
A 36-year-old G0 who has been epileptic for many years is contemplating pregnancy. She wants to stop taking her phenytoin because she is concerned about the adverse effects that the medication may have on her unborn fetus. She has not had a seizure in the past 5 years.
Which of the following is the most appropriate statement to make to the patient?
Offspring of women with epilepsy have two to three times the risk of congenital anomalies even in the absence of anticonvulsant medications, because seizures cause a transient reduction in uterine blood flow and fetal oxygenation. When anticonvulsant medications are used, pregnant women have an even greater risk of congenital malformations. It is recommended that women undergo a trial of being weaned off their medications prior to becoming pregnant. If antiseizure medications must be used, monotherapy is preferred to minimize the risk to the fetus, since the incidence of fetal anomalies increases as additional anticonvulsants are consumed. Many anticonvulsants have been found to impair folate metabolism, and folate supplementation in pregnancy has been associated with a decreased incidence of congenital anomalies in epileptic women taking antiseizure medications. Fetal exposure to valproic acid has been associated with a 1% to 2% risk of spina bifida.
A 26-year-old P0 who works as a nurse in the surgery intensive care unit comes to see you for her annual gynecologic examination. She tells you that she plans to discontinue her oral contraceptives because she wants to become pregnant in the next few months. She has many questions regarding the immunizations required by her hospital and whether or not she can do this while pregnant.
Which of the following is the most appropriate recommendation regarding MMR vaccination?
In general, it is ideal for women to be up to date on routine adult vaccines before becoming pregnant. Live vaccines, such as MMR, should be given at least 1 month before pregnancy, due to theoretic risks to the fetus. Women should be offered testing for immunity to rubella during preconception counseling visits, and offered immunization prior to pregnancy if needed. Pregnant women who are found to be rubella nonimmune may be given the MMR vaccine immediately postpartum.
What is the most appropriate counseling regarding the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine during pregnancy?
The Tdap should be offered to all pregnant women during each pregnancy between 27 and 36 weeks, regardless of the patient’s prior history of receiving Tdap. Pertussis, or whooping cough, is a common vaccine-preventable disease that can be very serious for newborns. The level of pertussis antibodies decreases over time, hence the recommendation to administer during every pregnancy. In addition, all family members and caregivers of infants should be vaccinated with Tdap. Vaccinating pregnant women helps prevent the mother from acquiring the disease and passing it to her newborn, and also provides passive immunity to the infant. Tdap is an inactivated vaccine.
What should you tell this patient about the annual influenza vaccine that is required by her hospital?
Influenza is an inactivated vaccine that is recommended for all women who are pregnant or who may be pregnant during flu season. It may be given in any trimester. Pregnant women who get the flu are at increased risk for severe complications requiring hospitalization. Flu season in the United States is generally from early October to late March.
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