Antepartum care, preterm labour, and postpartum hemorrhage Flashcards
1
Q
UTIs in Pregnancy
A
- UTIs are common in pregnancy. Can be either lower tract (acute cystitis) or upper tract (acute pyelonephritis)
- Although the incidence of UTIs in the same in pregnant and non-pregnant women there is a high rate of recurrent bacteriuria and pyelonephritis.
2
Q
Incidence of UTIs in Pregnancy
A
- 2-7% of pregnant women develop amsyptomatic bacteriura.
- Risk factors include: prior UTI, pre-existing diabetes, increased parity, low SES.
- Without treatment 30-40% of pregnant women will go on to develop symptomatic UTI
- Acute cystitis occurs in 1-2% or pregnant women
- Pyelonephritis occurs in 0.5-2% of pregnant women
3
Q
Pregnancy outcomes with UTI
A
- Untreated bacteriruia is associated with increase risk of preterm birth, low birth weight, and perinatal mortality.
- There seems to be no major adverse effects to acute cystitis. This is likely because these women receive treatment.
- Pyelonephritis is associated with adverse pregnancy outcomes, such as preterm birth, anemia, sepsis, and respiratory distress.
4
Q
Pathogenesis UTIs in pregnancy
A
- The same organisms that cause bacteriuria and UTI in non-pregnant women cause them in pregnant women (E. Coli)
- However, certain physical changes in pregnancy may facilitate bacteria entery and increase risk of pyelonephritis.
- Specificially, in pregnancy women experience smooth muscle relaxation and ureteral dilation that can make it easier for bacteria to move up the kidney. Furthermore, pressure on the bladder from enlarging uterus and immunosuppression of pregnancy may contribute
5
Q
Asymptomatic Bacteriuria in Pregnancy
A
- Finding of a high-level of bacterial growth on urine culture in absence of symptoms consistent with UTI.
- Screening - recommended to screen pregnant women for this at least once early on (12-16 weeks gestation) with a urine culture. Generally, there is no need to retest women unless they have certain risk factors (history of UTI, diabetes, etc).
- Diagnostic criteria - 2 consective voided urine specimens with isolation of the same bacterial strain in quantitative counts ≥ 105cfu
- If bacteria strain is group B streptococcus diagnosis can be made at >104cfu
- Rapid screening like dipstick should not be used
- Management - antibotic therapy tailored to culture results. Important to do a follow-up culture to test for clearance.
6
Q
Acute cystitis Pregnancy
A
- Symptomatic infection of the bladder
- Symptoms = urinary urgency, urinary frequency, and dysuria
- Acute cystitis should be suspected in women who complain of dysuria (urgency and frequency are common in all pregnant women). Urinalysis and urine culture should be preformed. Cultures as low as 102cfu are indicative of UTI in symptomatic patients
- Management - empiric antiboitic therapy that is tailored once cultures are available. Follow up cultures should be done afterwards to confirm treatment success.
7
Q
Acute Pyelonephritis Pregnancy
A
- Manfestation of infection of the upper urinary tract and kindeys.
- Most cases occur during second or third trimester.
- Symptoms - fever, flank pain, nausa, vomiting, and/or costovertebral angle tenderness
- Severe complications are assoicated with pyelonephritis in pregnancy - septic shock, respiratory distess, anemia, bacteremia, and renal dysfunction.
- Management - hospital admission for perenterla antibotics. Can be converted to oral following clinical improvement. These women can be given prophylatic antiboitics for remainder of the pregnancy.
8
Q
Preconception Care
A
- Set of interventions that aim to identify and modify biomedical, behavioural, and social risks to a women’s health or pregnancy outcome through prevention and management
- Ex. Smoking cessation, health weight, infections and immunizations, genetic screening, family history, nutritinal assessment, substance abuse, psychosocial concerns, etc.
9
Q
Basics of Prenatal Care
A
- Early and continuing risk assessment - history and physical exam, lab tests, assessment of fetal growth and well-being
- Health and promotion - providing information on care, increase knowledge on pregnancy and parenting, promoting healthful behaviours
- Medical and psychosocial interventions and follow up treatment of existing illness, provision of social and financial resources, referral to consultation with other specialized providers
10
Q
First Prenatal Visit (8-12weeks)
A
- Review medical, reproductive, family, genetic, nutritional, and psychosocial histories
- Reproductive history - preterm birth, low birth weight, preeclampsia, stillbirth, congenital abnormalities, and gestational diabetes (Important to know about these because of high risk of reoccurance).
- Type of delivery in previous pregnancy
- A complete physical exam - certain physical finding are normal during pregnancy (systolic murmurs, exaggerated splitting, S3, spider angioma, palmar erythemia, linear nigra, striae). A pelivc exam should be done and Pap status determined.
- Lab - screening and treatment for asymptomatic bacteriruia, syphilis testing, hepatitis B surface antigen, HIV testing, STI testing, TB screen if high risk
- Rh - women should recieve Rho(D) immune globulin at 28 weeks gestation and postpartum if needed.
11
Q
Alleviating unpleasant symptoms during pregnancy
A
- Nausea and vomiting - affects up to 70% of pregnances. Eating small, frequent meals, and avoiding greasy or spicy foods may help. If medication is necessdary antihistamines are recommended.
- Heartburn - affects 2/3rds of pregnant women due to progesterone induced relaxaion of esophageal spincter. patients should be tuaght about the behavioural factors that can help eliminate symptoms - not lying down imediately after a meal, elevating head of bed. If these dont work patient can take an antacid.
- Constipation - increase fiber and water intake. Stool softeners can be used with bulking agents
- Hemorrhoids - Caused by increase venous pressure in the rectum. To avoid this, patients should be encouraged to rest with legs elevated. Constipation should also be avoided.
- Leg cramps - affects 50% of pregnant women- especially at night and later months of pregnancy. Massage and stretching may help. Calcium and sodium chloride may also reduce cramps.
- Backaches - common in pregnancy. Can be avoided by preventing excessive wieght gain, exercising, wearing comfortable shoes, and having special pillows.
12
Q
Prenatal Nutitional Counselling
A
- Women should eat a balanced diet and avoid harmful and unsafe foods
- Recommended rates of weight gain in 2nd and 3rd trimester per week is 1.1, 0.9, and 0.66 pounds in underweight, normal weight, and overweight women respectively.
- Excessive weight gain is associated with fetal macrosomia and maternal obesity
- Inadequate weight gain is associated with low birth weight
- Women should avoid fasting (>13hrs) or skipping meals - increase risk of ketosis and preterm delivery
- pregnant women should eat 5 times per day - breakfast, lunch, afternoon snack, dinner, and bedtime snack
13
Q
Follow up prenatal visits
A
- First prenatal visit - 8-12 weeks
- Additional prenatal visits tend to be scheduled every 4 weeks until 30 weeks gestation, every 2 weeks until 36 weeks gestation, and then weekly until delivery
- Visits should be regular enough to monitor progession, provide education and recommended screening, assess well-being of fetus and mother, reassure the mother, and detect and treat medical and psychosocial complications
- Physician should evaluate BP, weight, urine protein and glucose, uterine size for progressive growth, and fetal heart rate.
- Mother should have first sensatation of fetal movement ~20 weeks and should be asked about fetal movements at subsequent visits
- At 24-34 weels women should be taught the warning symptoms of preterm labour - uterine contractions, leakage of fluids, vaginal bleeding, low pelvic pain, and low back pain.
- Screening for gestation diabetes should be preformed between 24-28 weeks
- Starting at 28 weeks systemic examination of the abdomen is done to identify lie, presentation, and position of the fetus
- Mother can be retested for STIs are 32-36 weeks if women has risk factors.
- Recommended for women to have universal screening for Group B Streptococcous at 35-37 weeks
14
Q
Preterm Labour
A
- Regular contractions of the uterus resulting in changes in the cervix that start before 37 weeks (but after 20 weeks).
15
Q
Pathogenesis of Preterm Labour
A
- Involved at least 4 primary pathogenic processes that ultimately result in a final common pathway ending in spontaneous preterm labour and delivery
- Activation of maternal or fetal HPA axis associated with either maternal anxiety and depression or fetal stress
- Inflammation and infection
- Decidual hemorrhage
- Pathological uterine distension
- Clinical findings of true labour are the same whether labour occurs preterm or at term
- Cramping; mild irregular contractions; low back ache; pressure sensation in vagina or pelvic; bloody show; spotting
