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
Appraoch to Testing for Decrease Fetal Movement
Decreased Fetal Movement
- can be a sign of impending fetal death
- what can mom do: count fetal kicks, lay on side in cool dark room and feel : 10 kicks in 2 hours is reassuring of fetal well being
Decreased fetal movement: warrents further eval with nonstress testing and biophysical profile testing
majority of decreased fetal movement is due to sleep/wake cycles
Multiple Gestations
- chrionicity v amnionicity
- different types of twins in utero
- highest and lowest risk twins
Chorion: the “outer” or moms side; placenta
Amnion: the fluid or “inner” amniotic fluid
Risk Factors for Twins
- family history of dizygotic twins (two zygotes)
- increase materal age
- materal size increased
- mutliple pregnanies (increase parity)
Dizygotic
- 2 eggs and 2 sperm
- fertalized at the same time
- result in 2 amniotic fluid & 2 placenta
- can result in same placenta (monochorionic) two amniotic fluid (diamniotic)
Monochorionic/monoamniotic = highest risk for cord entanglement
- shared placenta = communication between vessel
Dichroionic (separate placentas)/diamnionitc = lowest risk of complications
dichorionic can have two separate placentas OR the placenta can fuse: still separate supply but fused
Multiple Gestations
US signs to clue you into
US Signs
- lambda or twin peak sign :shows the dividng membrane
Multiple Gestations: Complications to be on the look out for
Complications
Materal: GDM, HTN, preeclamspia, PPH, maternal death
Fetal: SAB, IUGR, preterm, TTTS (twin transfusion), fetal malformations, entagelemtn and perinatal mortality
Surveillence early and often is key!
increased number of fetus: increased and earlier premature labor
Twin-Twin Transfusion Syndrome
TTTS
- occurs when fetuses share the same placenta: so one becomes “donor” and one becomes “recieving” twin
- recieving twin: becomes fluid overloaded and has CHF< hydrops fatalis, etc.
Routine Care of Twins
what to include in your visits
Routine Twin Care
- first trimester US
- dietary counceling
- frequent visits
- serial growth US
- NST and BPP
- doppler
- no bed rest
- corticosteroids given for lung maturation to decreased premature birth risk
OB guidance of delivery for twins: by twin type
OB Guidance of Delivery
Di:Di twins: early term (38wk.-38 6/7)
mono:di: late preterm/early term (34-37 6/7) (1 placenta 2 sac)
mono: mono: C section between 32-32 weeks (need to protect the cord!)
mode of delivery
- depends on th epresentation of the fetuses
- vagianl possible, c section , vbac
lost of considerations with devleiry: patient-provider decision!
Maternal Changes in Pregnancy:
- Cardiac
- blood volume
- cardiac output
Cardiac Changes
- heart rotates on axis: long-ways
- size: increses by 12%
- vascular: hypertrophy of the smooth mucles in the cardiac tissue and decreases of collagen
Blood Volume
- volume expands early on: within the first trimester
- increase in plasma volume by 50% due to pregnancy hormones
- results in state of hypervolemia
Cardiac Output
- increases by 40%
- stroke volume: increases by 25-30% (amount leaving the L ventricle per beat)
- cardiac output directly dependent on the rise in maternal heart rate
- this output: decrease when laying supine
Maternal Changes in Pregnancy:
- Blood Pressure
- Blood flow distrubution
- murmues/rhythm changes
Blood Pressure
- declines with lowest the second trimester
- pulse pressure widens
- BP returns to pre-pregnancy levels by 36 weeks
- LE edema seen
Blood Flow Distrubtuion
- increased flow to the uterus, kidneys, skin and breasts
Murmus/Rhythm
- systolic ejection murmurs are common
- first heart sounds can/could be split
Maternal Changes in Pregnancy: Respiration
Anatomical
- diaphragm rises by 4cm
- angle of ribs with spine increased
- respriration becomes diaphragm dependent
- capillaries dilate
Physiologically: Airflow
Lung Volume & Capacity (becomes more efficient)
- FEV1/FVC remain unchaged
- respiratory rate remains unchanged
- tidal volume and inspiratory capacity increses (taking more in)
- decreased functional residual capactiy (less remains after breathing out)
dyspena in pregnancy is normal: air hunger
Maternal Changes in Pregnancy:
Renal
Renal Anatomy
- kidney size increases
- dilation of the renal calyces and ureters
- bladder positioning changes
Renal Function (filter a lot and more better)
- plasma flow and GFR increases (increase filtering)
- glycosuria and proteinuria can occur normally
- increased bicarb secretion
- hyponatremia can occur
- plasma Cr drops
Bladder: increased frequency
Maternal Changes in Pregnancy:
GI
- oral
- esophagus and stomach
Anatomic
- shift in the organs
Oral Cavity Changes
- salivation : increased (ptyalism)
- gum hyperemia
Esophagus & Stomach
- reflux symptoms
- esophageal peristalsis
- blunted respons of teh LES
- decreased motility
- increased acidity of the gastric secretion
- delayed gastric empying
Intestines
- transit time and GI motility decreased
- slower transit
- increased water absorbtion
Gallbladder
- emptying is slowed
- appears dilated and atonic
Liver
- albumin levels decrease
- ALP elevated
Maternal Changes in Pregnancy:
Hematologic
Red Blood Cells
- the mass of the RBCs increases: but the plasms volume also increases
- anemia is common
- enchanced erythropoeiesis
- make more RBC: make them bigger (mass) to carry more o2
- but with not enough iron = anemia
White Blood Cells
- leukocytes increased
- reduced PMN chemotaxis
Platlets
- increase production of platlets clotting risk
- consumption decreased
- getational throbocytopenia can happen
Clotting Factors
- significnat rise in facto VIII (8) & fibrinogen
- less of a significant increase in VII,IX,X,XII
- risk of thrombotic events
- protein S drops, protein C stays the same
Maternal Changes in Pregnancy: Skin/derm
Dermatologic
- hyperpigmentation: melasma & linea nigra
- straie gravidarum (stretch marks)
- spider anigomas, plamar erythema
- brittle nails
- hair thickening
Maternal Changes in Pregnancy:
Breast Changes
Breast Changes
- tenderness and parasthesias: common early on
- increased size
- veins become pronounced
- nipples and arela become larger and deeply pigmented
- colostrum: production begins around 20 weeks
Maternal Changes in Pregnancy: MSK
MSK
- lordosis: flexure in the small back (lumbar)
- increased mobility of hip and pubic joints
- pubic symphysis separation possible
- pain, numbeness and weakness commone
- joint strengthening is completed by 3-5 months postpartum (back to normal)
Maternal Changes in Pregnancy:
Reproductive Tract
uterual, cervical, and vaginal changes
Uterus
- increases in size, blood flow and contractility
Cervix
- softening and cyanosis
Vaginal
- chadwick’s sign (blue/purple discoloration) due to increased venous flow
Maternal Changes in Pregnancy: Endocrine
Endorcine
- pitutiary gland increase in Size and function
- prolactin, oxytocin release
- thyroid changes
- insulin resistance possible
prolactin: creates milk, oxytocin: milk let down
