Antepartum Normal Flashcards
Name the stages from sex to implantation?
Sex–>Fertilization–>zygote–>blastomeres–>morula–>blastocyst–>implantation
What period is the first 7 days after conception
Zygotic period (1-2 weeks)
What and when is the embryonic period?
week 3-7 after conception. 3 layers of cells (ectoderm, endoderm, and mesoderm) makes up all tissues and organogenesis at this time.
How does Teratogens affect this time period
May be lethal (cause SAB) or cause major congenital malformations.
Fetal development week 2 (after conception)
endo and ectoderm development
Fetal development week 3 (ac)
mesoderm development and notochord
Fetal development week 4 (ac)
heart beat begins, neural tube closes, beginning organ system, CRL 4-6mm
FD week 5 (ac)
rapid brain development, head enlarges, eyes, CRL 7-9mm
FD week 6 (ac)
nose, mouth, limb differentiation, ears, CRL 11-14
FD week 7 (ac)
Neck established, intestines herniated in umbilical cord, distinct human characteristics, CRL 16-18mm
FD week 8 (ac)
All structured present, eyelids closed, genitalia evident CRL 27-31mm
When does the fetal period begin
Week 9 (after conception) 11 weeks from LMP
FD week 9-12 (ac)
Body/limb growth accelerate, ears lowset, intestines back in abdomen, erythropoiesis shifts to spleen, swallows, breathe, urinates moves limbs (11-14 wks GA)
FD week 13-16 (ac)
Rapid growth, ossification of skeleton, ovaries differentiated, genitals recognizable, eyes/ears move to normal position, wt 3.5-4oz (15-18 wks GA)
FD week 17-20 (AC)
Movements stronger (mother feels now) Brown fat deposited, by 20wks body is covered in vernix; wt 1 lb (19-22 wks GA)
FD week 21-26 (ac)
Fetus gains wt, surfactant production, skin w/o SQ fat, lanugo present, crying and sucking, can make fist or grip, wt 1.25lbs (23-28 wks GA)
FD week 26 - 29 (ac)
Lungs capable of breathing air, CNS controls breathing, some fat storage begins, eyes open/shut, fingernails, wt 2.25 lbs (28 - 31 wks GA)
FD week 30-32 (ac)
Lanugo on face disappear, rhythmic breathing, can control body temp, wt 3.75 lbs (32-34 wks GA)
FD week 33-36 (ac)
Testes descended, more fat, less wrinkles, rounder body, wt 5.5 lbs (35-37 wks GA)
FD week 37 - 40 (ac)
Protuberant mammary glands, testes in scrotum, no lanugo, nails beyond fingers/toes, pulmonary, GI and renal permit extrauterine survival 7.5 lbs (39-42 wks GA)
Teratogens effect on weeks 1-4 after fertilization
either SAB or no reaction (all or nothing principle)
Teratogens effect of week 3-8 after fertilization
most critical for structural defects (during organogenesis)
Heart, arms/legs susceptible and neural tube defects w/o enough folic acid.
Teratogen effects what after 1st trimester
eyes, ears teeth CNS and genitalia
Which system has the longest sensitivity to teratogens? and how long
CNS and for a 16week window can be effected.
Increased teratogens (amount) has…
1) Decreased in effect
2) no change in the effect
3) increase in effect
Increase in effect. The more teratogen, the more likely more severe the defect.
Teratogen effect from week 8 - Term
functional defects and/or minor abnormalities
Placental development of the primary structure begins…
8 to 10 wks after conception
When does the placenta achieve full thickness
4 months
Function of placenta
Protection of fetus from pathogens
Allows passage of nutrients, waste and drugs and IgG antibodies, late in pregnancy
When does formation of the placenta begin
At invasion of trophoblast into endometrium 6-7 days after conception
Decidua
Name of endometrium during pregnancy
Decidua basalis
beneath implantation site (maternal contribution)
Decidua capsularis
covering the embryo
Decidua parietales
lines the rest of the uterus
Placental development day 14
chorionic villi begin to form, placental septa, and cotyledons
Role of placental septa and cotyledons
Septa- restrict exchange of blood between cotyledons (keeping problems localized)
Cotyledons- main stem of chorionic villi and its branches
Describe placental circulation
Mothers’ blood enter from spiral arteries and bath chorionic villi, so no mixing of maternal and fetal blood.
What happens to blood transfer when placenta matures
It degenerates somewhat allowing passage of more nutrients and IgG from mom. However more passage of fetal blood cells enter into maternal circulation (hence the importance of RhoGAM)
Amnion
The inner fetal portion of fetal membranes
End of 3rd month its in contact with chorion
together with chorion, forms the amniotic sac
What hormones are produced by placenta
HCG - maintains corpus luteum and endometrium
HPL - produced early for lactogenic and metabolic processes
Estrogen and Progesterone
Production and function of estrogen in pregnancy
Produced in ovaries and placenta.
Function promotes breast tissue growth,
-increased myometrial activity and vasodilation,
-softens cervical collegen,
-increases secretion of prolactin, but decreases sensitivity to receptors
-ductal system development (glandular tissue mammary growth)
-decrease plasma proteins,
-increase fibrinogen and clotting factors
Production and function of progesterone in pregnancy
Produced- corpus luteum til 5 wks after fertilization and the placenta thereafter (drops in late pregnancy)
Function - fetal synthesis of cortiocosteroids
- decreases myometiral activity (quiets uterus) and constricts myometiral blood vessels,
-inhibits prolactin
-aveolar system development contributin to mammary growth
-suppresses mom’s immune response to fetal antigens,
-relaxees smooth muscle in GI and Urinary tracts
Production and Function of HCG
Produced- placenta (detected 7 days after fertilization)
concentration rises by 66% q 48 hrs during first 2-3 months after feritlization
Function Maintains Corpus lutuem for progesterone
stimulates fetal testes and adrenals for testosterone and corticosteroid secretion
suppress lymphocyte responses to prevent fetal rejection
HCG levels in molar pregnancy
increased > 100K
when is HCG decreased
ectopic preg,
abnormal preg, or impending SAB
production and function of HPL
Produced - placenta begins 5-10 days after fertilization, increases and levels off 34-36 weeks GA
concentration proportional to placenta
Function- promotes fetal growth by diverting mom’s metabolism
-regulated by glucose for lipolysis and anti insulin for constant nutrients to fetus.
-Stimulates mammary growth
Prolactin
Produced, by the pituitary
Function- increased secretion in the presence of estrogen, but not responsive until progesterone decreases by end of pregnancy
causes milk production.
Changes in breast (3)
2 fold increase in blood flow,
Wt increased to 12 oz (hyperplasia)
Increase size and pigmentation of areola
Respiratory changes
Diaphragm increases 4 cm and widening of ribcage leads to diaphramatic breathing
- Hgb and CO increase
- decrease in PCO2
- incrase awareness of a desire to breathe
What happens to blood volume during pregnancy
increases 30-50%, starting 1st trimester, expands rapidly during 2nd and slows during 3rd, plateaus last few weeks during pregnancy
Physiologic anemia
plasma volume increase more rapidly than erythrocyte production
What happens to erythrocyte production during pregnancy
increases by 33%, but not as much as plasma volume, thus a slight decrease in Hgb and Hct
CDC definition of anemia in pregnancy
< 11g/dL in 1st and 3rd trimesters and <10.5g/dL in the 2nd trimester
What happens to blood coagulation during pregnancy
increase in fibrinogen by 50% (and other clotting factors) and increase in PT and PTT
Cardio changes during pregnancy
Pulse rate increases 10-15 bpm
systolic murmor heard in 90% of pregnancies
Exaggerated S1 splitting.
CO increases by as much as 22%
BP changes during pregnancy
BP in brachial... higher while sitting lower in the lateral recumbant intermittent while supine decreases during 2nd and early 3rd trimesters and returns to baseline by end of term.
Circulatory changes during pregnancy
blood flow to legs impeded (more venous return when lying on side,
more dependent edema closer to term
more varicosities in legs, vulva, and rectum
GI changes during pregnancy
stomach and intestines displaced,
GI motility decreased (thx to progesterone)
Prolonged gastric emptying time
Pyrosis (heartburn) caused by acid reflux in lower esophagus
Liver/gall bladder changes during pregnancy
Not much
gallbladder has decreased tone, causing increased stasis of bile leading to more gall stones in pregnancy and after.
Kidney changes in pregnancy
Kidneys increase in size
Uterus presses on ureters and bladder, causing ureteral dilation (hydroureter) and hydronephrosis mostly on right side (86% of women) (colon on left protects left for excess pressure.
Increased GFR
Bladder changes in pregnancy
Decreased bladder capacity
increased urinary stasis and compression of uterus on ureters, leading to increased asymptomatic bacteriuria. if it travels to kidneys, then increased chance of Pyelonephritis (also seen mostly on the right side
Glucosuria due to increased GFR
Proteinuria (not usual) except in trace amounts, caused by preeclampsia, UTI or increased leukkorea
Uterine changes during pregnancy
Hyperplasia during 1st 6 weeks due to estrogen,
Hypertrophy after 1st trimester due to uterine stretching by fetal mechanical pressure
Asymmetric shape at site of implantation (Piskecek’s sign)
Pear shaped at 12 weeks
Dextrorotation to the right at about 12 weeks due to pressure from colon on the left.
Contractility of uterus
never quiescent
contracts irregularly once every 2-3 hrs initially after 25 weeks 2-3 ctx every hour.
Braxton-Hicks brings more rhythm to contractions
Estrogen effects on uterus
increased action potentials, contractile proteins, gap junctions formation, SR development increasing calcium movement, and increased energy production by increased mitochondria for more ATP
Cervical changes during pregancy
increase in water, mass and vascularity
Hegar’s sign: Neck of cervix compressible
Goodall’s sign: softer Consistency
Chadwick’s sign: bluish color of os and vagina, due to increased vascularity and edema
Ovarian changes during preganncy
Annovulatory due to alteration of feedback loop
Corpus Luteum source of progesterone until 12 weeks
Relaxin secreted by c. luteum, myometrium, deciduas and placenta
Vaginal changes during pregnancy
increased vascularity, increased thickness of mucosa, increased leukorrhe
Musculoskeletal changes during pregnancy
Relaxin and progesterone affect cartilage and connective tissue,
Lordosis later in pregnancy
Separation of Diastasis recti muscle
Bone mineralization due to decrease in calcium, magnesium, phosphorus
Rate of bone turnover increases.
Probable signs of preg
- ballottment
- positive preg test
- Piskecek’s sign
- Goodall’s sign
- Hegar’s sign
- increased abdomen size
- increased uterine size
- abdomina palpation of fetus
- Braxton-Hicks ctx
Positive signs of preg
- Fetal heart tones
- Fetal movement felt by examiner
- US showing intrauterine preg
Surgical Abortion procedures
Dilation and suction curettage < 14 wks GA
D&E (with suction and/or surgical instruments) >16wks GA
Hystorectomy or hystorotomy
Medical abortion procedure
Before 8-9 wks gestation
Mexotrexate: Folic acid inhibitor causing cell death
Mifipristone: (RU 486) anti-progesterone
Misoprostol: synthetic prostiglandin causing expulsion of POC
Instillation injection of a hyperosmotic to induce labor and still birth (later in preg)
Category A
Adequate studies in pregnant women have shown no risk to fetus
Category B
Animal studies fail to show risk, but no adequate studies done in preg women
Category C
Animal studies shown some adverse effects, but no adequate studies done in preg women
Category D
Positive evidence of human fetal risk
Category X
Animal or Human studies have shown fetal anomalies or toxcity
Inlet: anterior-posterior and transverse diameters
AP: 9.5cm
Transverse: 13.5 cm
Interspinous diameter
> 10cm
Diagonal congjugate
> 11.5cm
Gynecoid Pelvis (female pelvis)
Engages in transverse or oblique diameter Good flexion Early and complete internal rotation spontaneous delivery wide pubic arch decreases perineal tears
Android Pelvis (male)
Engages in transverse or posterior diameter
Asynclitism
Extreme Molding
Deep transverse arrest common
Arrest as OP with failure of rotation
Frequent forceps delivery
Narrow pubic arch, increases perineal tears
Anthopoid Pelvis
Engages in AP or oblique
OP common
Adequate for vaginal delivery
Platypelloid Pelvic
Short AP diameter
Engages in transverse diameter
Market asynclitism
Delay at inlet
Rh negative
Absence of an antigen expressed on RBCs which means that moms have to be monitored during each pregnancy to prevent Isoimmunization
Conditions when fetal blood may enter maternal blood stream
SAB or EAB, 3rd trimester bleeding (eg previa), amniocentesis, external version or maternal trauma, delivery
Problem with Rh isoimmunization in subsequent pregnancy
antibodies pass through placenta of new fetus causing hemolysis and hydrops (generalized edema)
Prevention of isoimmunization
RhoGAM given within 72 hrs of fetal/maternal bleed, can prevent in 98% of women,
Should not be withheld if after 72 hrs
May be given in 3rd trimester usually 28 -30wks GA
Protection usually lasts 12 wks
What determines vaginal delivery in HIV+ mom
viral load.
many women who received antivirals during preg will be candidates
Consultation
When should Rubella non-immune women be vaccinated?
after delivery and breastfeeding is NOT contraindicated.
How much RhoGAM should be given
50mcg in 1st trimester and 300mcg thereafter
When is triple screen done and what does it consist of
15-19 6/7 wks GA
MSAFP, hCG, uE3
What is additionally tested in the quad screen above the triple screen
inhibin A
When reading the quad screen what indicates Downs syndrome
MSAFP decreased
hCG increased
Estriol decreased
inhibin A increased
MSAFP is increased in
neural tube defects
Glucose screening guidelines
Random >/= 130 order 1hr GTT 1hr >/= 140 order 3hr GTT diagnostic Any value >/=200 treat as GDM 3hr reference points if 2 or more values elevated = GDM diagnosed Fasting >/= 105 1hr >/= 190 2hr >/=165 3hr >/=145
RBCs in Iron deficiency anemia
Micorcytic (small) and hypochromic (lack color)
MCV < 80fl
B12 or Folate deficiency
Macrocytic anemia (MCV > 95 fL)
GBS and abx
Test at 35-37 wks GA
If found in urine treat bactiuria and treat again intrapartum
If previous GBS affected INFANT treat intrapartum regardless of culture outcome
Pap guidelines in preg (6)
ASCUS w/ HPV-: repeat postpartum/annual visit
ASCUS w/ HPV+: colpo
ASC-H: colpo
LSIL: repeat postpartum, get HPV type or colpo
HSIL: colpo
AGUS: colpo
Weight gain BMI < 18.5
28-40 lbs; 1-1.3 lbs/wk in 2nd and 3rd trimester
Weight gain BMI 18.5 - 24.9
25-35 lbs; 1lb/wk in 2/3 trimesters
Weight gain BMI 25 -29.9
15-25 lbs; .5 - .7lbs/wk
Wt gain BMI >30
11-20 lbs; .4 - .6lbs/wk
Risks for being overweight/obese during pregnancy
HTN, preeclampsia, GDM, macrosomia, C/S, SD, 2-fold increase in NTD and late intrauterine fetal demise
How to do Fetal Kick counts
Woman relax on left side after eating or light activity
Count all movments except hiccups
5-10 movements in 1 hr if < then count for another hour.
Uterine size at 8, 10 and 12wks GA
8- size of a tennis ball
10- size of an orange
12- size of a grapefruit
Leopold’s 1st manuver
Lie and presentation: facing woman’s head and palpating fundus with both hands
Leopold’s 2nd manuver
Position: facing woman’s head, palpating both sides of the uterus, assessing which side spine is on
Leopold’s 3rd manuver
Confirms lie, presentation and determines engagement: facing woman’s head, grabbing presenting part with thumb and middle finger, above pubic symphysis and wiggle
Leopold’s 4 manuver
attitude and descent of presenting part: face woman’s feet, press inward and down toward pelvic inlet; evaluate cephalic prominence and degree of descent
Reactive NST
2 or more accelerations, FHR >/= 15bpm, lasting 15 seconds w/in 20 min
Non-reactive NST
Reactive criteria NOT met within 40 min, must do BPP
Variable decels on NST
may indicate oligohydramnios
inconclusive NST
repeat
Factors effecting NST (5)
sleeping fetus, medications fetal hypoxia CNS anomolies smoking prior to testing
Define contraction stress test (CST)
fetal surveillance of FHR during contractions while continuous fetal monitoring
Indications for CST: non-reactive NST and abnormal BPP
Describe CST w/ contraindications
inducing contractions either manually or with oxytocin; an acceptable test is 3 contractions lasting 40-60 sec w/in 10 min
CI: any contradictions to labor (i.e. previa)
Negative CST
no late or variable decels
Equivocal/suspicious CST
no long term variability or non-repetative decels
Positive CST
persistant late decels (>50% of contractions)
Define AFI
adding vertical depths of pockets of amniotic fluid in 4 equal uterine quadrants via ultrasound
Polyhydramnios
AFI >25cm
Oligohydramnios
AFI < 5cm
BPP definition
fetal surveillance of 5 parameters of fetal well being, giving 2 pts for each parameter.
- NST = reactive
- Fetal Breathing = 1+ episode lasting 30 sec in 30 min
- Fetal Movement = 3+ in 30 min
- Fetal tone = 1+ extension/flexion of extremity or with hand open/close
- AFI = single pocket > 2cm (further exam is needed if <2cm despite overall score
Absolute Contraindications to exercise in preg (7)
heart and lung disease, incompetent cervix/cerclage multiple gestation 2nd or 3rd trimester bleeding, or previa premature labor (current gestation) ruptured membranes preeclampsia
Relative contraindications to exercise (7)
Severe anemia undiagnosed maternal cardiac arrhythmia BMI <12 IUGR (current gestation) poorly controlled, HTN, bronchitis, seizure disorder, hyperthyroidism, Type 1 diabetes Orthopedic limitations heavy smoker
Folic acid: how much and MOA
400-800 mcg/day; women with Hx of NTD 4mg/day
MOA: needed for protein metabolism and production of RBCs. Involved in almost all aspects of DNA and RNA Synthesis
Psychological stages of preg: 1st trimester (3)
Growing awareness of ovum
fetus seen as an outsider
fetus is merged with self (mother)
Major developmental tasks of 1st trim (3)
Incorporation of intruding fetus
Gradual alteration of body image and ego identification
Acceptance of fetus/infant by sig other
1st trim cognitive/affective/behavioral processes (3)
Increase in introversion, somatization, narcissism, and dependancy
Initial ambivalence and rejection of preganncy
Major cognitive focus is on self and changed body
Psych stages of 2nd trim (3)
Beginning separation of fetus as object, rather than self
Shift of major object relations from mother to mate
Secondary objects are peers
Major developmental tasks of 2nd trim (2)
Acceptance of growing fetus by self and others
Willingness to “house” fetus with resulting body/role/ego changes
2nd trim cognitive/affective/behavioral processes (7)
Slight decrease in introversion, dependancy and anxiety
Rising attachment to fetus
Acute openness to environment
Increase in susceptibility to suggestions
Increase in emotional liability
Increase in transient compulsions and ruminations
Acquisition of maternal roll: mimicry, role play, introjection, Identificaiton
Phych stages 3rd trim (3)
Fetus seen as separate object with own identity
Sometimes increase in confusion between sefl and mother
Major significant object- mate
3rd trim cognitive/affective/behavioral processes (3)
Increase introversion
Increase in dependency and ego rigidity
Increased preoccupation with impending birth
major developmental tasks of 3rd trim (2)
separation of fetus and self
Mastery and integration of primitive anxieties and fantasies regarding birth
Labor and Birth developmental tasks (4)
Safe passage for self and baby
Identification of infant as own
Association and differentiation of infant
Major sig object: fetus/baby
Labor and birth cognitive/affective/behavioral processes (3)
Extreme ego constriction during labor
Sense of void immediately after birth
Recognition and attachment to infant
Natural child birth and prep classes
By: Grantly Dick-Read
Premise: rejected the need for pain relieving drugs during childbirth; perception of pain brought on by fear-tension-pain syndrome
Lamaze
Modified Dick-Read, breathing and controlled relaxation techniques for various stages of labor as psycho-prophylaxis.
Bradley
drug free birth, husband participation, relaxation and deep breathing.
LeBoyer
traditional delivery rooms caused infant trauma; babies delivered in dimly lit/quiet rooms and placed immediately on mom’s abdomen until cord stops pulsing and then in a warm bath.
Birthing from within
Classes in 3 parts;
- multi sensory activity; like learning Birth art or singing lullabies
- building pain coping mindset through techniques
- practical information; like how to push your baby out.
What % of TOLACs end in successful VBAC
60-80%
Biggest risk with VBAC
uterine rupture; continuous fetal monitoring required incidence is .4-1.2%
No use of prostaglandins for cervical ripening
