21

CHAPTER 4

Maternal Physiology

4–1. Which of the following accurately characterize 4–3. A 23-year-old presents for her initial prenatal care
Braxton Hicks contractions? visit. She undergoes an ultrasound and the findings
a. Are usually non-rhythmic are shown below. What is the adnexal mass seen
below?
b. Have an intensity of 5–25 mmHg
c. Can be detected by bimanual examination
d. All the above

4–2. Which of the following soluble receptors attenuates

vascular endothelial and placental growth factor in
vivo?
a. PIGF
b. sFlt-1
c. VEGF
d. Estrogen

a. Teratoma
b. Hydrosalpinx
c. Corpus luteum
d. Hemorrhagic cyst
 22 Maternal Anatomy and Physiology

4–4. The patient in Question 4–3 reports that she had
a cyst on her right ovary removed 3 years earlier
and asks if the cyst below needs to be removed as
well. You explain the function of the cyst and that
SECTION 2
4–6. A 26-year-old primigravida is in your office for
a prenatal care visit at 34 weeks’ gestation. Her
abdomen is pictured below. She comments that
her 36-year-old friend does not have these marks

excision of this cyst before what gestational age and wants to know why she does. Which of the
would lead to loss of the pregnancy? following is not a strong risk factor associated with
a. 5–6 weeks’ gestation the development of striae gravidarum?
b. 8–9 weeks’ gestation
c. 10–12 weeks’ gestation
d. 14 weeks’ gestation

4–5. A 32-year-old multigravida presents to triage

complaining of increasing vaginal discharge for the
last 24 hours. You perform a microscopic examination
of the discharge and see the image pictured below
under the slide. What is the diagnosis?

Used with permission from Amber Portley.

a. Family history
b. Prepregnancy weight
c. Younger maternal age
d. Class II maternal obesity

4–7. Which of the following statements is consistent

with findings published by the World Health
Used with permission from Dr. Barbara Hoffman. Organization?
a. Protein deposition is highest per day in the third
a. Bacterial vaginosis trimester.
b. Cervical shortening b. Fat deposition is highest per day in the third
c. Rupture of membranes trimester.
d. Normal physiologic discharge c. The total energy cost of pregnancy is about
50,000 kcal.
d. Maternal weight gain is highest per day in the
third trimester.
 Maternal Physiology 23

4–8. Which of the following is true about the patient in 4–11. Based on the graph below, which of the following is
the following picture? true?
300

CHAPTER 4
296

292

Posm (mOsmol/kg)
288

284

280

276

a. This is probably bilateral mastitis.

272
b. This is classic inflammatory breast carcinoma.
c. The patient should receive antepartum parlodel. MP MP LMP 4 8 12 16
d. Surgery may be required postpartum for Weeks of pregnancy
reduction.
a. Blood osmolality increases after 4–6 weeks’ gestation.
4–9. Which of the following is not a consequence of b. Blood osmolality decreases after 4–6 weeks’
vascular changes in women during pregnancy? gestation.
a. Angiomas c. Plasma osmolality stays about the same during
b. Palmar erythema pregnancy.
c. Melasma gravidarum d. Plasma osmolality decreases by about 10 mOsm/kg
d. Dissipate excess heat generated by increased during pregnancy.
metabolism
4–12. Which of the following statements regarding amino
4–10. The fetus gains the most weight proportionately acid concentration is accurate?
during which time period in pregnancy? a. It is highest in fetal compartment.
a. 10–20 weeks’ gestation b. It is highest in maternal compartment.
b. 20–30 weeks’ gestation c. The placenta is not involved with oxidation of
c. 30–40 weeks’ gestation amino acids.
d. 40–42 weeks’ gestation d. The placenta does not concentrate amino acids
into the fetal circulation.

4–13. Which of the following statements is true regarding

glucose and insulin levels in pregnant and nonpregnant
women?
a. Insulin levels decrease after meals in pregnancy.
b. Glucose levels decrease after meals in nonpregnant
women.
c. Glucose concentrations increase after meals in
pregnancy.
d. Insulin levels increase prior to meals in non-
pregnant women.
 24 Maternal Anatomy and Physiology

4–14. Which of the following is a safeguard provided by
pregnancy-induced hypervolemia?
a. Provides abundant nutrients and elements to
support the rapidly growing fetus and placenta.
SECTION 2
4–19. Which of the following statements regarding
hemodynamic changes from the third trimester to
the postpartum period is not accurate?
a. Heart rate decreases in the postpartum period.

b. Meets the metabolic demands of the enlarged b. Serum colloid oncotic pressure is lower during
uterus and its greatly hypertrophied vascular pregnancy.
system. c. Pulmonary capillary wedge pressure is higher
c. Protects the mother, and in turn the fetus, from during pregnancy.
deleterious effects of impaired venous return in d. Systemic vascular resistance decreases in the
the supine and erect positions. postpartum period.
d. All the above
4–20. This graphic suggests which of the following?
4–15. When are maternal iron stores used in pregnancy?
120 Supine
a. First trimester
b. Second trimester 110 SYSTOLIC
c. Third trimester

Blood pressure (mm Hg)

100
d. Latter half of pregnancy 90 Left lateral recumbent

4–16. Which of the following inflammatory markers are 80

unaltered in pregnancy?
70
a. Procalcitonin
DIASTOLIC
60
b. Erythrocyte sedimentation rate
c. Leukocyte alkaline phosphatase levels 50
d. All of the above are altered in pregnancy 40

4–17. Levels of which of the following coagulation factors 0

are unchanged in pregnancy? 0 4 8 12 16 20 24 28 32 36 40 PP
Gestation (weeks)
a. Protein C
Adapted with permission from Wilson M, Morganti AA, Zervoudakis I, et al: Blood pressure,
b. Fibrinogen the renin-aldosterone system and sex steroids throughout normal pregnancy, Am J Med
c. Factor VII 1980 Jan;68(1):97–104.

d. Antithrombin III
4–18. What is the relationship between stroke volume and
position in the pregnant woman when compared to
the nonpregnant woman?
a. Compared to the nonpregnant state, stroke
volume is increased when in the supine position
at all gestational ages.
b. Compared to the nonpregnant state, stroke
volume is increased when in the lateral position
at all gestational ages.
c. At 26–30 weeks’ gestation, stroke volume in
the supine position is equivalent to that of the
nonpregnant woman in the lateral position.
d. All of the above
a. Diastolic pressures decrease more than systolic
pressures.
b. Arterial pressure usually declines to a nadir at
24–26 weeks’ gestation.
c. Brachial artery pressure when supine is higher
than that when in the lateral recumbent position.
d. All the above
4–21. Which of the following statements are true?
a. Angiotensinogen is produced in the maternal
kidney.
b. Vascular refractoriness to angiotensin II may be
estrogen related.
c. Refractoriness to angiotensin II is characteristic of
mothers who develop preeclampsia.
d. None of the above
 Maternal Physiology 25

4–22. Which statement accurately describes the changes in 4–25. The following scatter plot depicting 24-hour total
respiratory physiology during pregnancy? urinary protein excretion by gestational age illus-
a. Respiratory rate increases. trates which of the following changes concerning
renal function in pregnancy?

CHAPTER 4
b. Tidal volume remains the same.
c. Inspiratory capacity rises by 5–10%. 1st Trimester
2nd Trimester
d. Functional residual capacity decreases by 300
3rd Trimester
approximately 50%.

Protein (mg/24 hr)

95%

4–23. Concerning acid–base equilibrium during pregnancy, 200

which of the following statements is true?
a. Bicarbonate levels are decreased to compensate
Mean
for the resulting alkalosis. 100
b. A physiological dyspnea results from greater tidal
volume that lowers the blood PCO2.
0
c. Progesterone acts centrally, where it lowers the
0 10 20 30 40
threshold and raises the sensitivity of the chemo-
Gestational age (weeks)
reflex to CO2.
Modified with permission from Higby K, Suiter CR, Phelps JY, et al: Normal values of
d. All of the above urinary albumin and total protein excretion during pregnancy, Am J Obstet Gynecol
1994 Oct;171(4):984–989.
4–24. A 32-year-old multigravida presents to you at 8 weeks’
gestation. Her baseline serum creatinine is 1.0 mg/dL, a. Proteinuria remains the same throughout
and her blood pressure is 145/105 mmHg. Which pregnancy.
test might you consider next?
b. Excretion of more than 200 mg/24 hours is
a. Kidney ultrasound abnormal in the third trimester.
b. 50-gram glucose screen c. Excretion of more than 300 mg/24 hours is
c. 24-hour total urine protein abnormal in the second trimester.
d. Serum anti-double-stranded DNA d. None of the above

4–26. Which of the following statements is true regarding

ureteral dilation in pregnancy?
a. Left-sided dilation is seen more often.
b. β-hCG is responsible for the ureteral dilation
seen in pregnancy.
c. Unequal dilation results from right ureteral
compression by the dextrorotated uterus.
d. None of the above

4–27. Concerning bladder function in pregnancy, which of

the following is true?
a. Urethral length increases to compensate for
decreased bladder capacity.
b. In primigravidas bladder pressure increases from
8 cm H2O to 20 cm H2O at term.
c. Maximal urethral pressure increases from 70 cm
H2O to 93 cm H2O to maintain continence.
d. All of the above
 26 Maternal Anatomy and Physiology

4–28. Concerning the gastrointestinal tract during 4–34. Regarding the thyroid gland during pregnancy,
pregnancy, which of the following is correct? which of the following is true?
a. Gastric emptying time increases during pregnancy. Mother
SECTION 2

b. Intraesophageal pressures are lower during pregnancy.

c. Lower esophageal sphincter tone is increased during
pregnancy.
TBG
d. None of the above
Total T4
4–29. Which of the following hepatic enzymes is increased
in normal pregnancy?
a. Alkaline phosphatase hCG
b. Alanine transaminase Free T4
c. Aspartate transaminase Thyrotropin
d. γ-Glutamyl transpeptidase

4–30. During normal pregnancy, which of the following is

true regarding gallbladder physiology and function?
a. Gallbladder contractility is increased Fetus
b. Decreased cholesterol saturation of bile
c. Impaired emptying and increased stasis TBG
d. None of the above

4–31. Your patient with previous diagnosis of pituitary Total T4

microadenoma presents at 15 weeks’ gestation
complaining of impaired vision. You suspect pituitary
enlargement. What is your next course of action?
Thyrotropin
a. Initiate bromocriptine
b. Collect a 24-hour urine collection Free T4
c. Refer to neurosurgery for excision Total T3
d. Refer to ophthalmology for visual field testing
Free T3
4–32. Which statement accurately reflects placental growth
hormone secretion in pregnancy? 10 20 30 40
a. After 20 weeks’ gestation the placenta is the main Week of pregnancy
source. Modified with permission from Burrow GN, Fisher DA, Larsen PR: Maternal and fetal
b. Primary source throughout pregnancy is the thyroid function, N Engl J Med 1994 Oct 20;331(16):1072–1078.

maternal pituitary gland.

c. It influences fetal growth by downregulation of a. The highest concentration of maternal free T4 is
early in gestation.
insulin-like growth factor 1.
d. Placental and maternally secreted growth hormone b. Fetal concentration of thyroxine-binding globulin
increases throughout pregnancy.
have the same amino acid composition.
c. Maternal concentration of thyroid-stimulating
4–33. Which of the following is true regarding the pituitary hormone reaches a plateau by the mid-second
gland? trimester.
a. Oxytocin is secreted from the anterior pituitary d. All the above
gland.
b. Prolactin is secreted from the posterior pituitary
gland.
c. Antidiuretic hormone is secreted from the anterior
pituitary gland.
d. Oxytocin and antidiuretic hormone are secreted
from the posterior pituitary gland.
 Maternal Physiology 27

4–35. Which of the following is inaccurate concerning fetal 4–38. A 33-year-old multigravida at 21 weeks’ gestation
and maternal skeletal metabolism? presents for her prenatal care visit. She reports that
a. All markers of bone turnover decrease during she is having difficulties at work doing her secretarial
and administrative duties. She is experiencing aching,

CHAPTER 4
pregnancy.
numbness, and weakness in her upper extremities.
b. Fetal skeletal mineralization requires approximately
What is the likely diagnosis?
30 grams of calcium.
c. Prevention of possible pregnancy-related maternal a. Rheumatoid arthritis
osteoporosis is difficult. b. Carpal tunnel syndrome
d. Greater maternal calcium absorption occurs c. Early-onset preeclampsia
and is mediated by elevated maternal d. Traction on the median and ulnar nerves from
1,25-dihydroxyvitamin D concentrations. lordosis

4–36. Which of the following is true about hormone 4–39. Pregnancy-related memory decline is limited to
physiology during pregnancy? which period in pregnancy?
a. Fetal levels of testosterone correlate with maternal a. First trimester
levels. b. Second trimester
b. The trophoblast incompletely converts testosterone c. Third trimester
to 17β-estradiol.
d. Postpartum
c. Maternal plasma levels of androstenedione and
testosterone are increased. 4–40. Which of the following is true regarding difficulties
d. The source of production of androstenedione and in sleep patterns in pregnancy?
testosterone is the placenta. a. Include difficulty awakening
b. Last up to 8 weeks postpartum
4–37. Concerning the musculoskeletal system, which of the
following is not true? c. Begin as early as 6 weeks’ gestation
a. Most relaxation takes place during the second half d. Are more common in multiparous women
of pregnancy.
b. Symphyseal separation greater than 1 cm may
cause significant pain.
c. Progressive lordosis is a characteristic feature of
normal pregnancy.
d. Sacroiliac, sacrococcygeal, and pubic joints have
increased mobility during pregnancy.