Antepartum Care and Maternal/Fetal Physiology Flashcards
The Preconception Visit
what does it entail
Pregnancy: a biopsychosocial and medial combination of care: physiologically and medically; thus it needs to be approached as one!
Preconception Visit
40% of pregnancies are unplanned, thus this visit is often missed; hense the importance of most of these topics during each routine visit
Maternal and Paternal History
- ask about pmhx., social, family, OBGYN, genetic
- current medications & need to switch
- substance use, IPV
Identifity pre-exisitng conditions
- those which can affect pregnancy or delivery
- DM, autoimmune, HTN, IBD, mental health d/o
Nutrtion
- optimize exercise and eating habits
- provide folic acid or a multivitamin
Environmental/Occupation
- expsoures, hazards
- travel history
Immunization status
- flu & covid: high risk in preg.
- HPV
Blood Type, STI and PE
Goals of Care in a Prenatal Visit
how often to have prenatal vistis depending on gestational weeks
Prenatal visit
- diagnosis of pregnanct: and establishment of the gestational age
- monitor pregnancy with periodic visits and appropriate screenings
- assess materal and fetal well being
- patient education: labor, devleiry and PP period care
- detection of medicaion or psychsocial complications
Overall Outcomes: health newborn and mom!
Visit Schedule
- every 4 weeks until 28weeks gestation
- every 2 week from 28 weeks - 36 weeks
- weekly from 36 weeks until delivery
increased frequency of visits as gestational age increases: more risk for HTN and pre-eclapsemia, DM, bleeding occur after 20 weeks
the Inital Prenatal Visit
history to collect
labs to be done
The Initial Prenatal Visits
comprehensive history
- obstetrical: pregnancy hx.
- past GYN hx.
- Pmhx., social and family hx.
- socail risk assessment
- better history obtained when you personalize it!
- Genetic Screening: 3 generation pedigree assessment
- Discussion of the course of care: frequency of visitis with OB provider
- Complete Physical Exam: including GYN exam
Labs
- blood type
- Rh factor
- antibody screen
- CBC
- syphilis antibody (two test process)
- HIV
- Hepatitis B antigen: they can get full hepB panel if warrented
- hemoglobin electrophoresis
- CF
- SMA
- Rubella
- Varicella
Urine: UA and culutre because we treat asymptomatic UTI in pregnancy
Vaginal: Gc/ct/trich, pap if indicated
earyl glucose for some women
for chronicHTN: baseline LFTs, BMP, 24 hours urine protein + Cr clearance
specific panels avalible for those of specific heritage
Glucose Testing in the Prenatal period
what typ of glucose test & when
who is at an increased risk of GDM
Glucose Test:
who is at risk (aka do it earlier than res of population)
- laundry list but: those overweight/obsese, family history, previous GDM, high lipids, HTN, etc.
Testing
- 1 hour glucose test: conducted in a nonfasting manner : this is a screening test
if this 1 hour test come back positive: follow up with 3 hour fasting glucose test
- if 2 of the 3 hour readins are abnormal = diagnosis of GDM
Labs to Obtain at subsequent prenatal visits
not just the first one
from 24-28 weeks
from 35-37 weeks
at the 24-28 week period Labs
- 1 hr. glucose test (if not already completed)
- CBC (for anemia)
- syphilis antibody
- antibody screen
at the 35-37 week period Labs
- HIV
- group B strep sensitivities
- gc/ct if needed
- repeat CBC if needed
Prenatal Visits
besides labs, what other topics are of conversation at these visits
when to start monitoring BP
(not just the first prenatal)
how to assess fundal height
Prenatal visit Topics
- symptoms & management of them
- BP: begin monitoring after 20 weeks
- weight: assess fluid retention & adequate weight gain
- urinalysis: not recommended but frequently done
- assessment of fetal well being: quickenin can occur 18weeks (16weeks if second pregnancy)
- Fundal height
- fetal presentation
Fundal Height Assessment: tape measure in cm starting at pubic symphisis
12 weeks: fundus just above the pubic bone
14-16 weeks: between pubic bone & umbilicus
20 weeks: at the umbilicus
22 weeks: umbilicus & filling out the sides
36-38 weeks: the fundus usually at the upper sterum
40 weeks: the fundus drops below the 38 week level, as it begins to decend into the pelvis
between 20-30 weeks: fundal height should be about equal to the week of gestation; if 1-2cm off; warrents an US
Establishment of Gestational Age & EDD
EDD = estimate date of delivery (EDC)
Estimation of Getational Age
- helps to determine timeing of due date, growth and health of fetus
- determines when to screen for genetic conditions
- first timester US is best time to assess growth
Calcuations of EDD
Naegle rule
- add 7 days to the first day of last mentrual peroid, subtract 3 monts & add 1 year = estimated date
- can also track serial b-HCG
Using US to determine Gestational Age
US determination of age
Goals of US
- confirm a interuterine pregnancy
- estimate GA
- confirm cardiac activity
- diagnosis mutliple gestations
- evaluate pelvic mass or uterin abnormalities
US can detect pregnancy as early as 5-6 weeks
TVUS: can detect as early as 3-4 weeks
US to Date
- < 12 weeks gestation: measure fetus from crown to rump: CTR
- > 12 weeks: measurement of the fetus’s femur can determine age
if there is discrepency between FDMLP and US dating: warrents redating of the pregnancy to determine gestational age
Rhogam (RhIG) & its uses; when is it given
Rhogam: Rh immunoglobulin
- given if mother is Rh negative and pregnant
because, if mom is Rh negative; she will subsequently attack (via the antigens in her blood) any Rh positivity from baby (in baby blood)
- if any of moms blood crosses to baby; risk of attacking fetus and create hemolytic disease in the fetus
- only after secondary expoure: so risk is of moms antigens attacking second pregnancy if baby is +
SO: Rhogam given to any Rh negative pregnant mothers unsensitized
- given at 28 weeks gestation and then again
- within 72 hours of delivery if infant is postitive
- baby Rh negative? no cascase strated and no need for this second dose
Additional indications for administering rhogam outside of the 28 weeks and 72 hours post delivery
Additiona Rhogam Indications
- spontaneous abortion
- elective, thereaten abortions
- ectopic pregnancy
- hydatidiform mole
- amniocentesis (disrupted placenta: bleed risk(
- CVS (cyclical vomiting)
- placenta previa or bleeding
- IUFD: fetal death in utero
- blunt abd. trauma: CVA, IPV, fall
- ECV: breech baby attempted to fix
- fetal blood sampling: periumbilical
Recommedations for exercise in pregnancy
Exercise in Pregnancy
- ACOG: 30 minutes or more daily is recommended
helpful to..
- decrease risk of GDM
- decrease pre-eclapsia risk
- decrease low back pain/peliv pain
if women is sedintary from start: advocate for 5-15 minutes, walking, etc. and building up to the 30 minutes recommendation
“Talk Test” = should be able to hold a conversation while exercising
women should not take up new exercsie, but stick to their routine or begin light exercise
exercsie: strengthens joints and can help prevent injury of joints via the release of relaxin that is loosening connective ligamnets during pregnancy
advise that their center of gravity has changed!!
Nutrition in Pregnancy : Recommendations for
- iron
- folic acid
- calcium and phosphorous
- B6
- protein
- calories and increase
Nutrition: a key in pregnancy!!!
Recommendations for
Iron
- harder to obtain iron; but in pregnancy its more readily absorbed
- red meat, dark leafy greens, eggs
- take with vit. C to increase absorbtion
- cast iron pan!
Folic Acid
- continue taking; can take daily prenatal
iron, folic acid and vitamin D needs double!!
Calcium and Phosphrous
- increase intake by 1/2
B6 & thiamine
- increase by 1/3
Protein
- increase intake from 46g to 71 grams daily (aim for 60g)
Calories
- increased intake to about 300+ additional calories a day not eating for two!
Guidelines for Weight Gain
underweight BMI
normal BMI
overweight BMI
Obese
Morbid obese
Underweight BMI: < 18.5
- gain up to 40 lbs.
Normal Weight BMI: 18-24
- gain up to 25-35 lbs.
Overweight BMI: 25-30
- gain 15-25 lbs.
Obese: BMI > 30
- gain 10-15 if BMI 31-34
- gain 0-10 if BMI 35-39
Morbid Obesity : BMI > 40
No weight gain
Assessing Fetal Well Being
4 ways to measure
Ways to Measure Fetal Well Being
- Non-stress test : wave forms on the monitor
- Biophysical profile test (Scoring out of 10, < 8 = abnormal)
- Growth US
- Doppler: measure flow of blood through umbilical arteries
fetal kicks is one of the best measures for fetal well being
FGR (IGUR): < 10%tile
Macrosomia: > 90%tile
Fetal Behavioral States: 1F-4F
Fetal Behavior States
should be assesed at every visit with fetal movement
State 1F: quiet sleep: narrow bandwidth of fetal HR
State 2F: indcludes frequent gross moevements, eye movements, fetal heart rate oscillations; like REM!
most babies are 1F or 2F
State 3F: continuous eye movement in the absense of fetal body mvoement or HR accelerations
State 4F: vigorous movement with continuous eye moevement and HR accelerations = like the awak state of newborns
