628 Obstetrics and Gynecology Board Review •••
❍ Patient comes to the office complaining that she got pregnant with her recently placed intrauterine device
(IUD). How do you advise her?
Among IUD users, there are on average about 6 pregnancies per 1000 woman-years. The rare intrauterine pregnancies
that occur in women using an IUD generally end in miscarriage. About 25% of these pregnancies end in a live birth
if the device is left in place, compared with about 90% if the device is removed. Early IUD removal appeared to
improve outcomes but did not entirely eliminate risks. Ectopic pregnancies are rarer in IUD users than in women
who do not use contraception. However, about 1 in 20 pregnancies that occur in women using an IUD is ectopic.
❍ Is the spermicide nonoxynol-9 a teratogen?
No. Literature demonstrates that vaginal spermicide use before or during pregnancy is not associated with
increased rates of pregnancy loss or abnormal offspring.
❍ Your patient with a history of infertility conceived with clomiphene citrate (CC) and now she is concerned
the potential risk of birth defect associated with the use of medication. How do you counsel her?
In the United States an estimated 1.6% of pregnancies are conceived with the use of CC, reflecting >67,000
exposed pregnancies per year. Two types of birth defects that have been most commonly reported to be associated
with CC exposure are neural tube defects and hypospadias; however, results regarding the association between CC
and these birth defects have been inconsistent. Because of the small number of cases, the inconsistency of some
findings and the potential unknown reason of subfertility, these associations should be interpreted cautiously.
❍ What is pica?
Pica is an appetite for non-nutritive substances or food ingredients (eg, ice, coal, soil, chalk, flour, raw potato, and
starch). Symptoms must persist for >1 month. Pica is seen in all ages, particularly common in pregnant women. The
condition’s name comes from the Latin word for the magpie, a bird that is reputed to eat almost anything.
❍ Does the month of contraception matter in the United States in respect to birth defect?
Birth defect rates in the Unites States were found to be highest for women conceiving in the spring and summer
(maternal LMPs in April–July). This increase was significant for 11 of the 22 categories of birth defects reported
in the CDC natality database from 1996 to 2002. This has been attributed to elevated concentrations of
agrichemicals (nitrates, atrazine, and other pesticides) in surface water during those months.
❍ What advice do you give pregnant women about fish consumption?
According to the U.S. Food and Drug Administration and the Environmental Protection Agency, a pregnant
woman can safely eat up to 12 ounces (two average meals) a week of a variety of fish and shellfish. Nearly all fish
contain trace amounts of methyl mercury, which are not harmful to humans. However, long-lived, larger fish that
feed on other fish accumulate the highest levels of methyl mercury and pose the greatest risk to people who eat them
regularly. Hence, pregnant and nursing women and also young children should not eat the following fish:
Shark
Swordfish
King mackerel
Tilefish
❍ What are the major adverse effects of smoking during pregnancy?
The Surgeon General warns women of the dangers of smoking on every pack they buy. Smoking causes
intrauterine growth restriction (IUGR) and increases the incidence of preterm delivery in a dose-dependent
manner. The incidence of placenta previa, abruptio placentae, and spontaneous abortion also increased in smokers.