Chapter 1 (Obstetrics): Pregnancy and prenatal care Flashcards
What is suggestive of pregnancy? How can we confirm it?
Suggestive;
- In a sexually active patient with regular menstrual cycles, a period delayed more than a few days to a week is suggestive of pregnancy.
- Urine and serum assays test for β-HCG can also be taken (peaks at 100.000 mIU/mL by 10 weeks of gestations, and goes down to 20-30k at third trimester).
Confirmation;
- Pregnancy can be confirmed by transvaginal ultrasound (gestational sac is seen at week 5 and fetal heart motion at week 6).
What are the signs and symptoms of pregnacy?
Signs–>
- Chadwick sign (bluish discoloration of vagina and cervix)
- Goodell sign (softening and cyanosis of the cervix at or after 4wk)
- Ladin sign (softening of the uterus after 6wk)
- Breast swelling and tenderness
- Development of the linea nigra from umbilicus to pubis
- Telangiectasias, and palmar erythema.
Symptoms–>
- Amenorrhea
- Nausea and vomiting,
- Breast pain
- Quickening (fetal movement).
What is embryo, fetus and infant?
Embryo-> For the time of fertilization until the pregnancy is 8 weeks (10 weeks GA), the conceptus is called embryo.
Fetus-> After 8 weeks until the time of birth it is called fetus.
Infant-> From delivery to one year of age it is called infant
What is previable, preterm, term and postterm infant?
Previable-> Infant born before third trimester (23-24weeks)
Preterm-> Infant born before 37 weeks
Term-> Infant born between 37-42 weeks
Postterm-> Infant born after 42 weeks
What is gravidity and what is parity? what designation is most specific designation used for pregnancy outcomes?
- Gravidity (G) refers to number of times a women has been pregnant, and parity (P) refers to the number of pregnancies that led to a birth at or beyond 20 weeks GA or of an infant weighing more than 500g.
- TPAL (Term, preterm which is the ones born before 20 weeks, abortuses and living children).
What is the difference between gestational age and developmental age? In what ways can we determine the EDD?
Difference: GA is the age in weeks and days from the last menstrual period (LMP), while developmental age is the from fertilization (thus the latter is usually 2 weeks less).
EDD determine:
- Nagele rule (add 1 year and 7 days to the first day of LMP and then substracting 3 months)
- Ultrasound (decreases in accuracy as pregnancy progresses)
- Auscultation of the fetal heart at 20 weeks by nonelectronic fetoscopy or at 10 weeks by Doppler ultrasound.
What are the cardiovascular and pulmonary changes?
Cardiovascular->
- Increased cardiac output
- Decrease in SVR and BP (due to progresterone induced smooth muscle relaxation)
Pulmonary->
- Increased TV, but decreased TLC and ERV
- Increased alveolar and arterial O2 and decreased CO2
- Dyspnea of pregnancy
What are the GI and renal changes?
GI->
- Morning sickness (nausea vomiting and even hyperemesis gravidarum with weight loss and ketosis)
- Ptyalism (prolonged gastric emptying and decreased LES tone)
- Constipation (Decreased large bowel motility and increased water absorption)
Renal->
- Increased rate of pyelonephritis
- Increased GFR and thus decreased BUN and creatinine
What are the hematologic and endocrine changes?
Hematologic->
- Dilutional anemia
- Increased WBC count
- Decreased concentration of platelets
- Hypercoagulable state
Endocrine->
- Increased estrogen
- Increased hCG (double every 48h and peak at 10wk)
- Increased human placental lactogen (important for constant supply of nutrients to fetus by leading to lipolysis)
- Increased prolactin
- Increased thyroid hormones (but decreased TSH)
What are the musculoskeletal and dermatologic changes?
Musculoskeletal->
- Lower back strain (change of posture)
- Carpel tunnel syndrome
Dermatologic->
- Spider angiomas and palmar erythema (increased estrogen)
- Hyperpigmentation of different body parts (increased MSH and steroid hormones)
How much does the calorie intake increase during pregnancy and breastfeeding? and what is the daily requirement of protein, calcium and folate during pregnancy?
Calorie intake-> Increase by 300kcal/day during pregnancy and by 500kcal/day when breastfeeding
Protein-> 70-75 g/day
Calcium-> 1.5g/day
Folate-> 0.8mg/day
When is the initial visit and what should we screen for?
When–> Initial visit should take place between 6-10 week of gestation (1st trimester).
What–> CBC (including hematocrit), blood type, infections (venereal disease, HIV, TB and VZV), urinalysis + culture, and early screening for aneuploidy (Nuchal translucency with or without beta hCG and PAPP-A)
What should be measured in every routine visit? what should we ask about?
- BP, weight, urine dipstick, measurement of uterus + auscultation of FH
- Ask about symptoms of complications–> Vaginal bleeding, vaginal discharge, fluid leakage, urinary symptoms, and fetal movement (Irregular, regular or absent)
What should be discussed during second trimester visits?
- Elective termination of pregnancy if congenital abnormalities was found during early screening for aneuploidy
Week 15-18–> Do genetic testing;
- Maternal alpha fetoprotein
- Triple screen (by adding hCG and estradiol)
- Quad screen (by adding inhibin A)
- Ultrasound (screen for fetal abnormalities, amniotic fluid volume, placental location and GA)
- Cell free DNA (more sensitive)
How often should the visits be during third trimester? What should be done at third trimester visits?
- Increase visits from every 3rd in weeks 28-36 to every week after 36.
- Leopold maneuvers should be performed at week 32-34 to determine fetal presentation and US should be used at week 35 to confirm–> Offer external cephalic version at week 37 if fetus is in breech position.
- Lab tests–> Hematocrit, GLT and test for infections (venereal and group B streptococcus).
