13.1 Contraception, Preconception Care & Teratogenicity

ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)

11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

13.1 Contraception, Preconception Care & Teratogenicity

Key Takeaways Explain This Topic AI

Family planning and reproductive health is a named blueprint subsection, and hormonal therapy is enumerated under ovarian disorders and female reproductive health.

Combined hormonal contraception is contraindicated in women 35 or older who smoke, and in migraine with aura, because of stroke and thromboembolic risk.

Long-acting reversible contraception has the lowest typical-use failure rates and few medical contraindications.

Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, valproate, isotretinoin, methotrexate and warfarin are teratogens that must be changed before conception.

Folic acid supplementation should begin before conception, at higher doses for women with prior neural tube defect or on antiseizure medication.

Last updated: August 2026

Internal medicine physicians frequently manage women of reproductive age who present with complex chronic medical conditions requiring effective contraception, preconception counseling, or acute obstetric-medical co-management during pregnancy. Mastery of the CDC Medical Eligibility Criteria, teratogenic pharmacology, hypertensive disorders of pregnancy, gestational diabetes, gestational thyroid physiology, and peripartum anticoagulation is essential for the ABIM examination.

1. Contraception Selection & CDC Medical Eligibility Criteria (US MEC)

The Centers for Disease Control and Prevention (CDC) publishes the United States Medical Eligibility Criteria for Contraceptive Use (US MEC) to guide safe contraceptive prescribing across diverse medical comorbidities:

Category 1: A condition for which there is no restriction for the use of the contraceptive method.

Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks .

Category 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method; method not recommended unless more suitable methods are unavailable or unacceptable.

Category 4: A condition that represents an unacceptable health risk if the contraceptive method is used ( absolute contraindication ).

Absolute Contraindications to Combined Hormonal Contraception (US MEC Category 4)

Combined hormonal contraceptives (CHCs)—including combined oral contraceptive pills (COCPs), the transdermal norelgestromin/ethinyl estradiol patch, and the etonogestrel/ethinyl estradiol vaginal ring—contain an estrogen component (typically ethinyl estradiol) that increases hepatic synthesis of clotting factors (fibrinogen, factors VII, VIII, X) and decreases antithrombin III, substantially amplifying the baseline risk of venous thromboembolism (VTE), stroke, and myocardial infarction.

Clinical Condition Rationale & Pathophysiology Safe Alternative Methods

Age >= 35 and smoking >= 15 cigarettes/day Synergistic, exponential increase in myocardial infarction, stroke, and arterial thrombosis Progestin-only pills (POPs), Nexplanon implant, LNG-IUD, Copper IUD

Migraine with Aura (at any age) 2- to 4-fold elevated baseline risk of ischemic stroke multiplied up to 7-fold by exogenous estrogen POPs, Progestin implant, LNG-IUD, Copper IUD

Current or prior Venous Thromboembolism (DVT / PE) High risk of recurrent thrombosis due to estrogen-induced hypercoagulability Copper IUD, LNG-IUD, Etonogestrel implant, POPs

Known Thrombogenic Mutations (Factor V Leiden, Prothrombin G20210A, Protein C/S/Antithrombin deficiency, Antiphospholipid Syndrome) Profound prothrombotic state; high risk of fatal PE or extensive venous infarction Copper IUD (preferred non-hormonal), LNG-IUD, Nexplanon, POPs

Ischemic Heart Disease, Stroke, or Complicated Valvular Heart Disease Estrogen increases arterial thrombosis, vasospasm, and volume retention; high risk in pulmonary HTN or SBE history Copper IUD, LNG-IUD, Nexplanon, POPs

Breast Cancer (current or past <5 years) Estrogen and progestin stimulate hormone-receptor-positive neoplastic proliferation Copper IUD (ParaGard) is Category 1; all hormonal methods are Category 4

Severe Decompensated Cirrhosis, Hepatocellular Adenoma, or Malignant Liver Tumors Impaired estrogen metabolism; hepatic adenomas are estrogen-dependent and risk rupture/hemorrhage Copper IUD, LNG-IUD (Category 2 for cirrhosis, Category 3 for adenoma)

Uncontrolled Hypertension (SBP >= 160 or DBP >= 100 mmHg, or with vascular disease) Estrogen stimulates angiotensinogen synthesis, worsening HTN and precipitating hemorrhagic/ischemic stroke Copper IUD, LNG-IUD, Nexplanon, POPs

Diabetes Mellitus with Microvascular Complications (Nephropathy, Retinopathy, Neuropathy) or Duration > 20 years Accelerated systemic endothelial dysfunction, microvascular damage, and heightened atherothrombotic risk Copper IUD, LNG-IUD, Nexplanon, POPs

Safe Contraceptive Alternatives in High-Risk Patients

Progestin-Only Pills (POPs):

Norethindrone (0.35 mg daily): Thickens cervical mucus and thins the endometrium. Requires strict compliance: taking a dose >3 hours late requires back-up barrier contraception for 48 hours.

Drospirenone (4 mg daily, 24/4 regimen): Inhibits ovulation with a forgiving 24-hour missed-pill window. Has mild anti-mineralocorticoid activity (monitor potassium if co-administered with ACEi/ARBs or spironolactone).

Subdermal Progestin Implant (Etonogestrel 68 mg / Nexplanon):

Single rod inserted subdermally into the inner upper arm; highly effective (failure rate <0.05%), approved for 3 to 5 years.

Primary mechanism: Suppresses ovulation and thickens cervical mucus. Most common side effect is unscheduled, irregular spotting.

Levonorgestrel Intrauterine Devices (LNG-IUD: Mirena 52 mg, Kyleena 19.5 mg, Liletta 52 mg, Skyla 13.5 mg):

Highly effective (failure rate <0.2%), provides 3 to 8 years of continuous contraception.

Mechanism: Intense local endometrial decidualization and glandular atrophy, cervical mucus thickening. Mirena/Liletta 52 mg reduces menstrual blood loss by >80-90% and is FDA-approved for heavy menstrual bleeding.

Copper Intrauterine Device (ParaGard T 380A):

100% non-hormonal, effective for up to 10 to 12 years.

Mechanism: Continuous release of copper ions creates a sterile, inflammatory, spermicidal environment in the uterine cavity and fallopian tubes.

Ideal for patients with breast cancer, active liver disease, or multiple cardiovascular comorbidities. May increase menstrual blood loss and dysmenorrhea in the first 3 to 6 months.

Emergency Contraception (EC) Comparison

Copper IUD (ParaGard): Most effective emergency contraception (>99.8% efficacy). Must be inserted within 120 hours (5 days) of unprotected intercourse. Efficacy is completely unaffected by maternal body weight/BMI and provides ongoing long-term contraception.

Ulipristal Acetate (Ella, 30 mg single oral dose): Selective progesterone receptor modulator (SPRM). Delays follicular rupture even after the luteinizing hormone (LH) surge has begun. Highly effective when taken within 120 hours (5 days) . Superior efficacy compared to levonorgestrel in overweight and obese women (BMI >25-30 kg/m2). Requires holding hormonal contraception for 5 days after administration (to prevent competitive receptor antagonism).

Oral Levonorgestrel (Plan B One-Step, 1.5 mg single oral dose): Over-the-counter progestin that prevents or delays ovulation if taken before the LH surge begins. Must be taken within 72 hours (3 days) of intercourse. Has significantly reduced efficacy in women with BMI >=25 kg/m2 and is largely ineffective in women with BMI >30 kg/m2 .

Loading diagram... CDC US MEC Contraceptive Safety & Method Selection Algorithm

2. Preconception Optimization & Teratogenicity

Optimizing chronic medical therapy prior to conception is essential to prevent structural congenital malformations, fetal loss, and maternal decompensation. Organogenesis occurs primarily between weeks 3 and 8 post-conception, often before pregnancy is recognized.

Teratogenic Medications & Recommended Substitutions

Drug Class / Medication Teratogenic Effects / Fetal Toxicity Recommended Safe Pregnancy Substitute

ACE Inhibitors & ARBs (e.g., Lisinopril, Losartan, Valsartan) ACEi fetopathy: Renal tubular dysgenesis, oligohydramnios, neonatal anuria, pulmonary hypoplasia, calvarial/skull bone defects, fetal growth restriction Labetalol , Extended-Release Nifedipine , or Methyldopa

HMG-CoA Reductase Inhibitors (Statins: Atorvastatin, Rosuvastatin) Disruption of fetal cholesterol biosynthesis essential for cell membrane and steroidogenesis formation; potential skeletal/CNS anomalies Discontinue preconception ; bile acid sequestrants (Cholestyramine) if severe familial hypercholesterolemia

Methotrexate Aminopterin-methotrexate syndrome: Craniofacial anomalies (craniosynostosis, hypertelorism), limb/skeletal hypoplasia, spontaneous abortion, neural tube defects Azathioprine (<=2 mg/kg/day), Hydroxychloroquine , or Sulfasalazine (with 4 mg/d folic acid)

Mycophenolate Mofetil (MMF) Mycophenolate embryopathy: Microtia/external ear canal atresia, cleft lip/palate, ocular coloboma, congenital heart defects Switch to Azathioprine or Tacrolimus at least 3 to 6 months prior to conception

Valproic Acid / Divalproex Fetal valproate syndrome: Neural tube defects (spina bifida in 1-2%), craniofacial clefts, cardiovascular malformations, dose-dependent autism spectrum and cognitive delay Switch to Levetiracetam or Lamotrigine preconception; co-prescribe Folic Acid 4 mg daily

Warfarin Warfarin embryopathy: Nasal hypoplasia, depressed nasal bridge, stippled epiphyses (chondrodysplasia punctata), optic atrophy, microcephaly, intracranial hemorrhage Switch to Low-Molecular-Weight Heparin (LMWH) preconception or before 6 weeks gestation

Glycemic Optimization

Elevated maternal blood glucose during the first 8 weeks of gestation is directly teratogenic. Hyperglycemia increases the risk of caudal regression syndrome (sacral agenesis) , transposition of the great arteries, ventricular septal defects, neural tube defects, and spontaneous abortion.

Target: Preconception HbA1c < 6.5% (ideally <6.0% if achievable without severe hypoglycemia).

Folic Acid Supplementation Guidelines

Average-Risk Women: 400 to 800 mcg (0.4 to 0.8 mg) daily orally starting at least 1 month prior to conception and continuing through the first trimester to prevent neural tube defects (anencephaly, spina bifida).

High-Risk Women (4 mg [4,000 mcg] daily):

• Prior pregnancy complicated by a neural tube defect
• Personal history of neural tube defect (patient or partner)
• Patients taking antiseizure medications (valproate, carbamazepine)
• Pregestational diabetes mellitus (Type 1 or Type 2)
• Malabsorption syndromes (celiac disease, post-bariatric bypass surgery)

High-dose folic acid (4 mg daily) should be initiated at least 1 to 3 months prior to conception and continued through 12 weeks gestation, then reduced to 0.4-0.8 mg daily.