165 Preconception & Prenatal Care: What Actually Shows Up On Your Exam

Hello and welcome to episode 165 of the Physician Assistant Exam Review Podcast. Today we’re going to be covering preconception and prenatal care. My name is Brian Wallace. I’m the hosting creator here at Physician Assistant Exam Review, and I’m excited to be back behind the microphone. I’ve been very, very busy getting things ready for the next 33 days cohort, wrapping up the April cohort, getting ready for the June cohort, working with students. Some have done amazing. Some who needed a little extra help, all those things. So I’ve been a little behind on the podcast, but here we go. And speaking of the 33 days program and the June cohort coming up, I just got literally 15 hours ago, there’s a post in the April cohort from a student who I didn’t ask permission for, so I’m not going to share her name, but she says, “Hey, everyone, I passed. Honestly, I still can’t believe it won’t be… I can’t believe it and won’t…had gotten here without everyone’s help and support.” It was a retest taker and improved by 119 points. Thank you, thank you, thank you. Just unbelievable results we get inside of this program. And the reason is that we’re unlocking what you do, right? It’s a transition course. It’s not a content course. I’ve identified five areas of what I call five areas of focus. I’m working out exactly the map here, but over time I’ve discovered that everyone comes to me thinking it’s pure content, pure content, pure content. And sometimes it is, but they don’t even know, right, is the problem. Students aren’t even sure if it’s pure content. So I’m working out, as I work with these students, different ways to test if it’s pure content. If it is clinical reasoning, if it’s peak performance and anxiety, if it’s how you approach your studying for these high-stakes exams, if it’s how you work through multiple-choice-pants type questions to squeeze out the most points, to get the most out of your study time so that you’re efficient and not just sitting in a chair. These are all things that we teach inside of 33 Days to Pass. The pants, it’s why you see scores move routinely, 119 points. That’s not shocking to me anymore. It wasn’t when we first started the program. I see so many students come into the program, though, who have failed the pants, tried one review course, then tried another review course, then tried another review course. And their scores don’t move. And it’s the same thing in PA School. Students struggle on EORs. They struggle on EORs. They fail one. Then they study harder. Then they get a tutor. Then they kind of just barely pass. Then they drift back. That’s not what we do inside of 33 Days. We train the whole process. We don’t just pound content. We teach you how to do it better. We teach you how to get the squeeze the most out of it once you have it. And the next cohort begins June 1st. That’s when we’re running them every other month this year. We’re actually increasing the number because we’ve had such good outcomes and so many students reaching out for help that we’re going to do every other month this year, going up from five to six cohorts. And what the coach is helping me, it really isn’t a problem because the coaches are so amazing inside the program. And so helpful for our students that it takes less of my time. So it becomes that I can run a cohort every other year. Anyway, the next cohort begins June 1st. You can go to www.physicianassisttings.com/33 to find out more there and then to sign up right now for the– waiting, let’s just give you some information about what’s coming when exactly the launch is going to be and all that so that you’re ready to go if that’s something that interests you. Anyhow, let’s jump in and get started with our primary questions for today.

What folic acid dose is recommended for a patient with a prior neural tube defect affected pregnancy? What folic acid dose is recommended for a patient with a prior neural tube defect affected pregnancy?

A pregnant patient’s quad screen shows API low, HCG high, unconjugated estriol low, inhibited high. What does this suggest? Let me go through that one more time. Quad screen, AFP low, HCG high, unconjugated estriol low, inhibited high. What does this suggest?

At what gestational age is the GBS rectovaginal culture obtained? At what gestational age is the GBS rectovaginal culture obtained?

An RH-antibody negative patient is at 28 weeks with no complications. What’s the next step? An RH-antibody negative patient is at 28 weeks with no complications. What’s the next step?

A patient at 24 weeks has a one-hour glucose challenge test results of 155 milligrams per deciliter. What’s next? A patient at 24 weeks has a one-hour glucose challenge test result of 155 milligrams per deciliter. What do you do next?

And we’ll get into all of that. Hopefully you’ll keep an eye out for those as we go. Again, the primary questions are designed to give you something to pay attention to, something to hook the information to as you go. We’re trying to build out these strong neural networks as part of how we study better to take less time and retain more.

Alright, so let’s jump into preconception and prenatal care. So prenatal care is just the structured care before and during pregnancy to optimize maternal health and fetal outcomes. You’re going to need to know prenatal screening timelines, polyg acid dosing, and which labs belong at which visits. To me, that’s how this stuff is going to come. And that’s again how we want to focus our energies, is how is this going to come on your exam? What do you actually need to know? I’m going to be asking you. Let’s run through first some risk factors. So why we would move things up quicker. Indications for early or enhanced screening. So obvious one is advanced paternal age, which is what? Greater than 35. With an increased risk of aneuploidy. And you’re just going to want to keep a closer eye on people who are older than 35. If patients have chronic conditions like diabetes, hypertension, thyroid disease, epilepsy, all kinds of stuff, you want to make sure all of that is well controlled, at least as best as it can be before they get pregnant. And obviously if they’ve had prior pregnancy complications, so preeclampsia, preterm birth, their old tube defect, effective pregnancy, all of that stuff is going to require increased early screening, enhanced screening, etc. And you’re going to want to keep an eye on that list. I don’t think you’re going to get it just straight forward though, right? You’re not going to get real clean lines. You’re going to get questions that are a little bit more drawn out. You know, patient 38 years old with some, with a history of diabetes, blah, blah, blah, blah, blah. And that’s going to be how it comes to you, I think, anyway, in a test question. So you have to be aware.

Let’s talk about medications. Again, the boards, I don’t think that your pants is going to say, “Hey, they’re on this drug. What should you do?” I don’t think that’s going to happen. Instead, what I think is going to happen is it’s going to say, “You have a mother with epilepsy or a seizure disorder. What do you do? What’s the next best step? What’s the folic acid level?” Well, in this case, you have to be concerned because they may be on valparate or carbazepine, which then can lead to neural tube defects. So the folate acid goes to four milligrams per day from 400 to 800 micrograms per day. Does that make sense? I hope that makes sense. So I don’t think they’re going to say a patient comes in, comes into your office, who’s pregnant on carbazepine. What’s the folic acid dose? I think they’re going to give you the second step and say, “Pay attention with epilepsy comes in. What’s your folic acid dose?” So if I’m making up flashcards, if I’m making up my own questions, if I’m working on this, I have that order mapped out. Seizure disorder, epilepsy equals valparate or carbazepine. Those equal an increase to folic acid to four milligrams per day because of neural tube defects.

Another one would be warfarin because you can get fetal warfarin syndrome. I’m not going to get into the details of that. I don’t think you need to know the details of that. But if mom comes in presenting on anticoagulation, so if she’s got a mechanical heart valve, history of dbt or pe, aphib, I’m not sure how many moms come in in aphib, but you never know. I hope you don’t get a question where your mother comes in in aphib, but you have to be in the lookout, is all I’m trying to say.

Or another good one is severe nodular acne. Right if they’re on an isotarotin, to nion, which I can’t pronounce at all. This leads to central nervous system cardiac defects. So they have to have a negative pregnancy test before starting it. But you just want to have that, you want to have that flag go off. You want to have those alarm bells go off when you see a patient come in who is talking about getting pregnant and has severe acne. And if they mention that in a question, there’s no reason they would just mention as a red herring. They’re not just going to say, you know, a 27-year-old comes in with severe acne talking about getting pregnant, how should you counsel her and just ignore the acne part. You have to consider that. So I don’t think these are going to be a huge part of your exam, but I do think you’re going to get one question on these.

You know, same thing if a mother has a history of bipolar. You know, lithium can be a real problem. It leads to ebbsen’s anomaly, which is a tricuspid valve displacement, which we’re not going to, again, not going to get into. I think that’s deeper than you need, but I think you need to know that lithium is a problem and you need to know that bipolar disorder patients are going to, maybe on lithium, so you need to ask about it.

Another one is autoimmune diseases. Rheumatoid arthritis. So those rheumatoid disease modifying agents can be teratogenic, right? We use methotrexate in ectopic pregnancies. So you need to be aware of all that again. So what I would counsel you is that when you’re reading the questions, understand that they don’t usually put words in the questions that don’t matter at all. They’re usually what I call the breadcrumbs push you either closer to an answer choice or further away from an answer choice. One or the other. Most words will do that. So if they’re giving you a time of year, if they’re giving you a specific disease state, if they’re giving you past medical history, if they’re giving you an age range, if they’re giving you an ethnicity, a lot of times those are, I’d say 80% of the time, maybe not 100% of the time, but 80, 85% of the time, those are pushing you down one path or another or away from one path or another.

Another one would be hypertension. You know, ACE inhibitors can be a problem, right? They lead to fetal renal dysplasia. So just be aware. And then there’s an antibiotic that we don’t want to give that comes up a lot. Remember what it is. Tetracycline for it leads to bone and tooth staining is what they say.

All right, preconception counseling. So that was our risk factors. We’ll touch back on those as we go. And I wasn’t sure whether to include them up front or after we go through normal. So it’s always hard. I don’t know which is better. Just those are things I want you to keep an eye out. So we’ll hit preconception, preconception counseling and visits in just a second. But the risk factors, we want to increase our screening, right? So we want to look if they’ve got chronic conditions. That makes sense. Diabetes, hypertension, thyroid, epilepsy, on and on and on. We’re going to have to look a little closer. If they have advanced maternal age greater than 35, we have to look a little closer. Obviously, if they’ve had a previous pregnancy with a problem, there’s a good chance they’re going to have a problem again. So we need to pay attention there. And then again, keep in mind, I would maybe keep a list of these diagnoses, these diseases that if a mother has, I need to ask about certain medications. I need to be worried about medications. I need to increase my folic acid dose in the one case that we talked about.

Preconception counseling. So folic acid is 400 to 800 milligrams micrograms per day, starting at least one month before conception and through the first trimester. This prevents neural tube defects. So I like that before part of emphasize that because I think that’s an easy thing to test. It’s an easy thing to know. If I have a high risk patient, so if they’ve had a prior neural tube defect, affected pregnancy or they’re on valparate or carbazepine, we’re going to bump that up to four milligrams per day. That’s a big bounce, right? Four milligrams per day. And then preconception counseling. Again, this is all before you get pregnant. When someone just comes in to talk to you about getting pregnant, we’re going to talk about alcohol, we’re going to talk about smoking, we’re going to talk about drug use, we’re going to talk about making sure that everything is as tuned up as we can get it. So you want the person to be, you want to talk about weight optimization, you want to talk about vaccination status, you want everything to be as good as it can be before they get pregnant.

Now here’s something that I just, I died on. I just couldn’t remember because it’s pure memorization stuff and that’s what always killed me. Prenatal visit schedules. So it’s every four weeks until 28 weeks, every two weeks from 28 to 36, and every week from 36 until delivery. You can find that in lots of places, but if you want to head over to the website at www.physicianassistanceexamereview.com/165, it will be listed in the notes there for you. I always post the notes so everything’s available to you. Some people like to read through the notes as I do this. As they listen to the podcast, it has a player right there, so that’s good for some people to do.

Your first prenatal visit is ideally 8 to 12 weeks out. So out there you’re going to do labs, you’ve CBC, blood type, an RH antibody screen, rubella titer, hepatitis B, surface antigen. You’re going to look for syphilis, you’re going to do HIV testing, you’re going to do kind of reoclamedia, your analysis, your enculture, pap smear if it’s due, and you may offer genetic screening based on age, family history, ethnicity, and on and on and on. So that first visit, 8 to 12 weeks, we’re going to do all our labs. We’re going to get a baseline for all of our labs.

Now our prenatal screening, in the first trimester, so now we’re talking like in the 10 to 13 week range, we’re going to do cell-free fetal DNA, non-invasive prenatal testing. It’s got a long acronym I’m not going to read. This is most sensitive and specific for tri-cell amnesia 21, 18, 13, and sex chromosome abnormalities. So this is screening, not diagnostic, that’s important. It’s a screening, not diagnostic, which means we can’t actually tell anything from that, we just get indicators. First trimester combined screen is the nucleotranslucency ultrasound, plus PAPPA and beta HCG, screens for tri-cell amnesia 21 and 18, again screening. Diagnostic though, a little bit different, and I need you to see the difference here. So those are screening tests, and I’m sure if you’ve covered this you understand this, but I’m just going to touch on it. Screening tests are indicators of a problem. They do not diagnose the problem. For diagnosis, you need either chronic bill of sampling at 10 to 13 weeks, or amniocentesis at 15 to 20 weeks to actually need that tissue. Everything else is an indicator, a screening tool. So if you want to, if you have trouble understanding that, you can think about a mammogram, right? A mammogram screens for breast cancer. It does not diagnose breast cancer. So you can get calcifications, you can get indications, you can get things that really make you think the patient may have breast cancer, you can get things that really make you think the patient doesn’t have breast cancer on a mammogram. It’s a screening tool. The way to really diagnose it though is with the biopsy, right, and sending tissue to pathology so they can look at the tissue. That’s the same thing we’re talking about here. The getting the tissue, the amniocentesis or the chronic bill of sampling, that’s going to be the tissue sample that’s going to give you a clear diagnosis. But we don’t want to do an amniocentesis on everyone. We don’t want to do a tissue biopsy on every woman with breasts to see if they have breast cancer. So we do the screening test, which is good but not perfect, so that we’re not doing invasive things on people who are perfectly healthy. We’re trying to only do the invasive things on people who have higher concerns about.

In the second trimester, 15 to 20 weeks, we’re going to have a quad screen, the alpha-fita protein, HGG uncondigrate estriol, inhibiting A, looking for Down syndrome, which is trisomy 21, which would be the AFP low, HGG high, estriol low, inhibiting A high on the quad screen. You know what it would be for trisomy 18 issues? AFP low, HGG low, estriol low. And what about open neural tube defect? Like encephalofi and encephalhe in spina bifida. This would be an AFP high. Again, this is a hard thing to listen to. Go back, look at the notes, check out the results for quad screen. You’re going to have to know that. To me, 100%, I would absolutely know that. I would know that cold, because it’s just a pure memorization. You can just do flash cards or something to get you that.

Anatomy, ultrasound is usually at 18 to 20 weeks. This evaluates fetal anatomy, will send a location, amniotic fluid. And patients find out what sex the child is, or at least they can.

At 24 to 28 weeks, we do a one hour glucose challenge. Yes, this is 50 grams of oral glucose. No fasting cutoff is 130 to 140. It’s greater than that. You do the three hour glucose tolerance challenge. And again, we’re screening here for gestational diabetes. We’re going to do Rogam at 28 weeks for all Rh negative antibody negative patients.

In the third trimester, 35 to 37 weeks, we’re going to do group B strep with a right to vaginal culture. If it’s positive, you’re going to do intrapartum, IP, penicillin. What about if they’re penicillin allergic? What do you give? What about if they’re penicillin allergic? We’re going to repeat syphilis HIV in high risk populations.

At 27 to 36 weeks, we can do a Tdap. We might give it influenza vaccine, RSV vaccine is recommended between 32 and 36 weeks. But here may be the key or a key question you might get. You want to avoid live vaccines during pregnancy. You want to avoid live vaccines. It’s just such an easy thing to hold on to. The hard part is remembering which are the live vaccines. So MMR, varicella, yellow fever. That to me is the hard part. I understand that I don’t want to give live vaccines.

This sounds funny, but we’re going to go into diagnostics for pregnancy. Guarant serum beta-HTG and the transvaginal ultrasound for location and dating is how it works. But you would need a little bit more than that. That’s not a bad start, but I think you need just a touch more. HTG is positive. Serum HTG is positive greater than 5. Detectable at 6 to 8 days post-conception. That’s probably not super relevant. What is super relevant is that the urine HTG is positive at 20 to 25, about 12 to 14 days post-conception. So maybe those are. I’m not sure. Honestly, I don’t know. I think that the serum HTG is more accurate. It is positive earlier. Let’s go with that. It’s positive earlier.

Okay, next we move into the discriminatories on. This is the HTG level where you should be able to see and interview in pregnancy on ultrasound. The transvaginal ultrasound is going to be a little sooner than trans-abdominal. Again, this is things that just should make sense. The gestational sex should be seen when HTG is 1,500 to 2,000. Trans-abdominal ultrasound would be the gestational sex should be seen at 6,000, oh, greater than 6,500. So there’s just a progression there. We can see more clearly through a transvaginal ultrasound than an abdominal ultrasound. If you have a HTG that’s high enough to be in the discriminatory zone, but you don’t see any intrauterine pregnancy, you have to be thinking of a topic.

The one thing that seems to pop up as like a key term or a high yield fact is the doubling time. So HTG should approximately double every 48 to 72 hours in an early, viable intrauterine pregnancy. If it’s not doubling or it’s plateauing or worse if it’s declining, you’re thinking of a topic or non-viable pregnancy. Peak HTG is around 100,000 at about 10 weeks. Then it declines through the second trimester. And abnormally high HTG, you might consider a molar pregnancy, which we’ll get to later, or multiple gestations. Gestational age confirmed by trimester ultrasound, crown-rump-rump-rump length. These are your most accurate methods. So there’s just measurements during the ultrasound, right? So what is your questions on the exam going to look like? They’re going to be something about describe the preanial screening result or ask what indicates or what does not indicate for the next patient, which marker you should use, maybe something about gestational age, those kind of things like we’ve been talking about all throughout.

Let’s talk a little bit about treatments and measurements. We’ll get into a lot more of this as we move into more issues in the upcoming weeks. GBS positive 35 to 37 weeks. We’re going to do IV penicillin G, intrapartum. RH negative patients are going to get ROGAM at 28 weeks. That’s a big one, right? That seems like an easy one to remember. And within 72 hours of delivery, write that down on an index card somewhere. Memorize that. It’s an easy, easy question. You get it? I don’t know. You might not. That’s a straight memorization question. You should be able to nail that. ROGAM at 28 weeks, if they’re all right, negative, and that 72 hours after delivery. Or within, I’m sorry, within 72 hours of delivery.

What else do we want to talk about? You know, again, we just need to optimize everything before you get pregnant. The other thing I’d look at is look at the full of gas level issues we talked about earlier. It’s normally 400 to 800 micrograms, but if you have a reason that moves up to 4 milligrams, I’m not going to go back through all of this stuff, but a lot of things in there that you are memorizable facts. Things that you can just be questioned on. You know, what is the quad screen for Down syndrome? What’s the quad screen for Trisomy? What’s the live versus attenuated vaccinations? What’s the glucose challenge stuff? All that stuff should just be memorized. You should really be all over that.

All right. This week, let’s talk a little bit about study tips. One of the things I want to point out is my definition of studying. I hesitate to say study tips because I feel like students’ eyes glaze over immediately. They roll in the back of their heads like, “Geez, I’m in a master’s level program. I know how to study, and I’m stunned at the number of students who come to me after failing the pants who have no idea what they’re doing.” And I don’t mean that to be rude. I mean that because no one’s ever shown them. What I mean is I teach the first few lessons on studying, and I have people reach out to me and say, “Holy crap, how come no one ever told me this before? How come I don’t know this? This would have made PA school so much easier.” I have student after student finish the 33-days program and say, “Man, if I could have taken this before PA school, life would have been so much easier, so much better.” So when I talk about study tips, I don’t mean– I need to come up with a better terminology, and maybe if you have one, email me. But when I talk about study skills, study philosophies, what I’m talking about is getting the most points out of the time you’re working. Getting the most points out of the time you’re working. That’s it. So how can we improve? So even if you think you’re really good at it, this is an area you can focus on and get better. If you’re still doing what you did a month ago, you probably could be doing better. If you’re still doing what you did in middle school, I guarantee you could be doing better.

So most people talk about working harder, staying up later, getting a tutor, studying more. Few people address how you approach the studying, and some courses talk about studying a little bit. Some review courses touch on it. Most don’t talk about it at all. I’m not going to say this is the most important of the five focus areas, but it’s a tremendously important area. Because everyone wants to come to me and talk about how they spend eight hours studying, how they’re up till midnight studying, how they get home from school and they’re studying, and they’re not sure what else they can do. They’ve tried everything, and it’s just simply not true. Measuring it in time is a terrible way to measure the work you’re doing. Terrible way. Now we’re all trained to measure time, measure work that way, right? You work an hourly job. You get paid for the time you put in, but it’s not true. You’ll get fired if you don’t put any work into that time you’re there. You don’t just get paid to show up. You get paid for the work you accomplish during that time. You don’t see it directly when you’re working an hourly job, but that’s the way the owner sees it. It’s the same thing here. You get paid for the work you do during the time you’re sitting there. You get paid for the work you do during the time you’re studying. You don’t get paid for the time. And I think there’s a huge disconnect there. Because too many people think they’re paid for the time. They sit in the chair for eight hours and then they wonder why they don’t do well. Sitting in the chair doesn’t do anything. Nothing. It’s working that does something and then working more efficiently, then working better. Now more efficiently doesn’t mean faster. A lot of times it means slower. I’m finding more and more in the age of Google and ChatGTP, people are moving too fast. In the age of question banks, people are doing hundreds of questions and getting nothing out of them.

So today’s study tip is evaluate what you’re doing. I’m not saying you should be jumping from idea to idea, to idea, from thing to thing to thing, from method to different method. But I think you should be looking at what’s your philosophy for studying. How do you think about the work you’re doing? How do you consider what to work on when you’re finished, what it looks like? When you don’t know something, do you have a system for reviewing it later? When you see something that you definitely need to know, like I pointed out the Rogam situation, you definitely have to know that without a doubt. But you’re not going to remember it from this discussion. You’re not going to remember it from one lecture. So where does that go? Where’s your system for touching that again? You can see some of these things coming and you have to have a system. So this is my overall idea behind study skills, right? So again, when I say study skills, I just, that term is so, such a negative connotation. And what I mean by study skills is how do you get better in the time that you have? And we can all do that.

So today’s study tip is just a, the way I want you to look at how you do your work. The way I want you to look at how you’re studying. If you’re just listening to this podcast and then clicking the off button when you’re done, you’re getting about half the value. If you’re doing the priming questions, which we’re about to get to, you’re getting a little more value. If you’re creating your own notes or study guides out of this, you’re getting even more value. If you’re jotting down a handful of index cards out of this, even better. There’s so many things you could do, but if you’re just listening to it in a car and then never coming back to it again, it’s a refresher. It’s helpful. But it’s not changing anything long term.

Let’s do our priming questions.

What folic acid doses recommend for a patient with a prior neural tube defect affected pregnancy? It’s hard to say. Here we jump to four milligrams per day, right? Their standard dose was 400 to 800. Here we jump to four.

A quad screen shows AFP low, HCG high, unconjugated estriol low, inhibit A high. What are we talking about here? This is trisomy 21 down syndrome. That’s hard to do in your head. Without looking at it, I couldn’t do it.

At what gestational age is the GBS recto-vaginal culture obtained? 35 to 37 weeks. You know what you do if it’s positive? Well, add one piece to this. What do you do if it’s positive? IV penicillin G, interpartum.

Rh negative antibody, negative patient. Is that 28 weeks with no complications? What’s the next step? We give them a roguem, right? And then when do we repeat it? 72 hours after delivery if the infant is Rh positive.

Patient 24 weeks has a one hour glucose challenge test of 155 milligrams per decolleter. What do you do next? We move to the three hour glucose tolerance test. What’s the one hour cutoff? 130, maybe 140. 155 is over though for short. So we move on.

All right, we’re moving through reproduction. Fantastic. This has been just a ton of fun for me. Happy to be back here behind the microphone. Happy to have you guys coming along with me. I’ve been hearing a lot of emails recently from people who are finding this stuff helpful. I really do appreciate that. I’m really happy to help to keep me going. I’ve been at this for 15 years now. So the encouragement definitely helps. The fact that you’re getting something out of it definitely helps.

Don’t forget that the June cohort of the 33 days passed to pass the pants. Registration is coming up soon. It’s early next week. I think it’s the 21st that we open the doors for that. You can find out more at physicianassistancexamrg.com/33. You can get all the information there and you can get on the email list. You find out exactly when it opens, all the information that you can get, or what will be there.

Alright, best of luck this week. Can’t wait to hear from you guys. I’ll be back next week to continue with reproduction.