67.4 Routine Prenatal Care & Longitudinal Pregnancy Management

ABFM Family Medicine Certification Study Guide Exam

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1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

2.1 Practice Management, Billing, Coding & Documentation 2.2 Quality Improvement, Patient Safety & Diagnostic Stewardship 2.3 Interprofessional Team-Based Care & Care Coordination

3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

3.1 Medical Ethics, Informed Consent & Surrogate Decision-Making 3.2 Biostatistics, Clinical Epidemiology & Diagnostic Test Interpretation 3.3 Social Determinants of Health, Health Equity & Cultural Humility 3.4 Physician Wellness, Burnout Prevention & Professionalism

4 Chapter 4: Lifestyle Counseling & Behavior Change

4.1 Alcohol Use Screening & Brief Intervention 4.2 Illicit Drug & Cannabis Counseling 4.3 Tobacco & Vaping Cessation Counseling

5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

5.1 Dietary Counseling for Obesity & Chronic Disease Prevention 5.2 Exercise Prescription & Physical Activity Counseling 5.3 Genetic Risk Assessment & Family History Counseling

6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

9.1 Cardiovascular Disease & Hypertension Screening 9.2 Type 2 Diabetes Screening & Prediabetes Risk Stratification 9.3 Abdominal Aortic Aneurysm & Osteoporosis Screening

10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

67.4 Routine Prenatal Care & Longitudinal Pregnancy Management

Key Takeaways Explain This Topic AI

Routine prenatal visits occur every 4 weeks until 28 weeks, every 2 weeks from 28 to 36 weeks, and weekly from 36 weeks to delivery, yielding roughly 12 to 14 visits in an uncomplicated pregnancy.

First-trimester crown-rump length redates a pregnancy when it differs from the LMP by more than 7 days before 14 0/7 weeks; a third-trimester size discrepancy raises growth abnormality rather than justifying redating.

The gestational-age anchors are aspirin from 12 to 28 weeks, anatomy ultrasound at 18 to 22 weeks, gestational diabetes screening at 24 to 28 weeks, Tdap and anti-D immune globulin at 27 to 36 and 28 weeks, and GBS culture at 36 0/7 to 37 6/7 weeks.

Low-dose aspirin 81 mg daily is a USPSTF Grade B recommendation for patients with one high-risk factor or two or more moderate-risk factors for preeclampsia, started ideally before 16 weeks.

MMR, varicella, and live attenuated influenza vaccines are contraindicated in pregnancy and given postpartum, while Tdap, inactivated influenza, COVID-19, and maternal RSV (Abrysvo at 32 0/7 to 36 6/7 weeks, September through January) are recommended.

Last updated: September 2026

Prenatal Care as Longitudinal Chronic Care

The blueprint separates acute pregnancy management issues (Acute Care & Diagnosis) from pregnancy management issues as a Chronic Care Management activity. The distinction is deliberate: ectopic pregnancy and miscarriage are episodic problems, while routine prenatal care is a structured 9-month program of scheduled visits, timed laboratory testing, timed immunizations, and timed prophylaxis. The examination tests what is done, and when — gestational-age anchors are the single highest-yield content in this section.

Family medicine remains a maternity care specialty, and even physicians who do not attend deliveries must recognize the schedule to co-manage patients and to identify when a pregnancy has fallen off it.

The Visit Schedule

The traditional schedule yields roughly 12 to 14 visits for an uncomplicated nulliparous pregnancy:

• Gestational age Visit frequency
• First visit through 28 weeks Every 4 weeks
• 28 to 36 weeks Every 2 weeks
• 36 weeks to delivery Weekly

Reduced-frequency schedules, telehealth-supplemented models, and group prenatal care (CenteringPregnancy) are acceptable alternatives for low-risk patients and are associated with comparable or improved outcomes and higher patient satisfaction. High-risk pregnancies are individualized and seen more often.

Every visit includes: blood pressure, weight, urine dipstick when indicated, fundal height (after ~20 weeks), fetal heart tones (after ~10–12 weeks by Doppler), fetal movement inquiry (third trimester), and presentation assessment near term.

Dating: Get It Right Once

Naegele's rule : estimated due date = first day of the last menstrual period − 3 months + 7 days , assuming a regular 28-day cycle.

First-trimester ultrasound crown-rump length is the most accurate method (± 5–7 days) and should redate the pregnancy when it differs from the LMP by more than 7 days before 14 0/7 weeks .

Accuracy degrades with advancing gestation; second-trimester biometry is accurate only to ± 10–14 days and third-trimester to ± 21–30 days. A pregnancy is not redated in the third trimester based on size discrepancy alone — that finding raises growth restriction or macrosomia instead.

First-Visit Laboratory Panel

• Test Purpose / note
• Blood type, Rh(D), antibody screen Identifies Rh(D)-negative and alloimmunized patients
• CBC Baseline anemia, platelets; hemoglobinopathy evaluation as indicated

Rubella IgG; varicella immunity Non-immune patients are vaccinated postpartum — MMR and varicella are live and contraindicated during pregnancy

• HBsAg Perinatal hepatitis B transmission prevention (repeat in third trimester if risk)
• HIV Opt-out testing; repeat in third trimester in high-prevalence settings
• Syphilis Universal; many jurisdictions mandate repeat testing in the third trimester and at delivery
• Hepatitis C Universal screening in each pregnancy

Chlamydia (± gonorrhea) All patients under 25 and older patients with risk factors; retest in the third trimester if positive or at continued risk

Urine culture For asymptomatic bacteriuria — a USPSTF Grade B screen, typically at 12–16 weeks or the first visit; treat because untreated bacteriuria progresses to pyelonephritis and preterm birth

• Cervical cytology Per standard age-based intervals if due
• TSH Not universal; obtain for symptoms, known thyroid disease, or high-risk features
• The Gestational-Age Timeline 0 ──── 12 ──── 16 ──── 20 ──── 24 ──── 28 ──── 32 ──── 36 ──── 40 weeks
• │ │ │ │ │ │ │ │
• │ │ │ │ │ │ │ └─ GBS culture 36 0/7 – 37 6/7
• │ │ │ │ │ │ └───────── Maternal RSV (Abrysvo) 32 0/7 – 36 6/7,
• │ │ │ │ │ │ seasonally September – January
• │ │ │ │ │ └───────────────── Tdap every pregnancy, 27 – 36 weeks
• │ │ │ │ │ Anti-D immune globulin at 28 weeks
• │ │ │ │ │ Repeat antibody screen (Rh-negative)
• │ │ │ │ └───────────────────────── GDM screening 24 – 28 weeks
• │ │ │ └───────────────────────────────── Anatomy ultrasound 18 – 22 weeks
• │ │ └───────────────────────────────────────── MSAFP / quad screen 15 – 22 weeks
• │ └───────────────────────────────────────────────── Low-dose aspirin started 12 – 28 weeks
• │ (ideally before 16 weeks)
• └───────────────────────────────────────────────────────── Dating US, first-visit labs,
• cfDNA screening from 10 weeks
• Aneuploidy screening

Screening must be offered to all pregnant patients regardless of age . Options include cell-free DNA (from 10 weeks; the most sensitive screen for trisomy 21, but still a screen — a positive result requires diagnostic confirmation by chorionic villus sampling at 10–13 weeks or amniocentesis at 15 weeks or later), first-trimester combined screening with nuchal translucency at 11–14 weeks, and the second-trimester quadruple screen at 15–22 weeks. Carrier screening and a discussion of diagnostic testing are offered alongside.

Gestational diabetes screening at 24 to 28 weeks

Approach Step 1 Step 2

Two-step (most common in the U.S.) Non-fasting 50 g glucose challenge; positive at ≥ 130–140 mg/dL depending on the threshold chosen Fasting 100 g 3-hour OGTT; two or more abnormal values confirm

One-step Fasting 75 g 2-hour OGTT; any one abnormal value confirms —

Patients with obesity, prior gestational diabetes, a first-degree relative with diabetes, prior macrosomic infant, or polycystic ovary syndrome should be screened early (first visit) and rescreened at 24–28 weeks if the early screen is normal.

Rh(D) alloimmunization prophylaxis

For every unsensitized Rh(D)-negative patient: repeat the antibody screen and give anti-D immune globulin 300 µg at 28 weeks , and again within 72 hours of delivery if the newborn is Rh(D) positive. Additional doses follow sensitizing events — miscarriage, ectopic pregnancy, termination, amniocentesis or CVS, external cephalic version, antepartum bleeding, or abdominal trauma.

Immunizations in Pregnancy

Vaccine Timing Note

Tdap 27 to 36 weeks of every pregnancy , preferably early in that window Maximizes transplacental pertussis antibody transfer; given regardless of prior Tdap history

Influenza (inactivated) Any trimester during influenza season Live attenuated intranasal vaccine is contraindicated

COVID-19 Any trimester Recommended in pregnancy

RSV (Abrysvo only) 32 0/7 to 36 6/7 weeks , seasonally September through January Protects the infant for the first 6 months; substitutes for infant nirsevimab when given at least 14 days before birth. Arexvy is not used in pregnancy

MMR, varicella, live attenuated influenza Contraindicated during pregnancy Administer postpartum to non-immune patients, including before hospital discharge

Preeclampsia Prevention and Recognition

Low-dose aspirin 81 mg daily is a USPSTF Grade B recommendation, started between 12 and 28 weeks — optimally before 16 weeks — and continued until delivery, for patients with one high-risk factor or two or more moderate-risk factors .

High-risk factors : prior preeclampsia, multifetal gestation, chronic hypertension, pregestational type 1 or 2 diabetes, chronic kidney disease, autoimmune disease (SLE, antiphospholipid syndrome).

Moderate-risk factors : nulliparity, obesity (BMI > 30), family history of preeclampsia in a mother or sister, age 35 or older, sociodemographic factors, prior adverse pregnancy outcome, and an interpregnancy interval longer than 10 years.

Diagnostic anchors after 20 weeks : gestational hypertension is systolic ≥ 140 or diastolic ≥ 90 mm Hg on two occasions at least 4 hours apart, without proteinuria. Preeclampsia adds proteinuria or , in its absence, thrombocytopenia (< 100,000/µL), serum creatinine > 1.1 mg/dL or doubling, transaminases at twice the upper limit of normal, pulmonary edema, or new-onset headache or visual symptoms. Severe features include BP ≥ 160/110 mm Hg and any of those end-organ findings.

Nutrition, Weight and Screening

Folic acid 400–800 µg daily preconception and in the first trimester; 4 mg daily for a prior neuroepithelial defect–affected pregnancy.

Gestational weight gain (NASEM/IOM ranges by prepregnancy BMI): underweight 28–40 lb , normal weight 25–35 lb , overweight 15–25 lb , obesity 11–20 lb .

Perinatal depression : USPSTF Grade B for screening pregnant and postpartum patients, and a separate Grade B for referring patients at increased risk to counseling interventions. The Edinburgh Postnatal Depression Scale is the most-used instrument.

Universal screening for intimate partner violence, substance use (including tobacco, alcohol, cannabis, and opioids), and food and housing insecurity should be built into the schedule.

Avoid : ACE inhibitors and ARBs, warfarin, isotretinoin, methotrexate, valproate, and live vaccines. Continue most needed chronic medications after risk–benefit review — abrupt discontinuation of antiseizure or psychiatric medication frequently causes more harm than continuation.

Board Exam Traps

LMP-based due date differs by 9 days from a 9-week crown-rump length → redate by ultrasound; the 7-day rule applies before 14 0/7 weeks.

Third-trimester ultrasound "measuring small" → evaluate for growth restriction; do not redate .

Rh(D)-negative patient with first-trimester bleeding → anti-D immune globulin now, in addition to the routine 28-week dose.

"She had Tdap two years ago" → Tdap is repeated in every pregnancy at 27–36 weeks.

Non-immune rubella on first-visit labs → vaccinate postpartum , not during pregnancy.

Asymptomatic bacteriuria on prenatal urine culture → treat; this is one of the few settings where asymptomatic bacteriuria is treated.

Nulliparous 37-year-old with obesity, at 13 weeks → two moderate-risk factors qualify her for low-dose aspirin now.