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).
What are the common problems during pregnancy? What are their causes and management?
Problems–> Back pain, constipation, contractions, dehydration, edema, GERD, hemorrhoids, pica, round ligament pain, urinary frequency and varicose veins
- Back pain
Cause-> Change in posture
Management–>
- Mild pain: mild exercise, gentle massage and heating pads
- Severe pain: muscle relaxants or even narcotics - Constipation
Cause-> Decreased large bowel motility secondary to elevated progesterone levels and thus increased water reabsorption
Management–>
- Increased fluid intake, and the use of stool softeners or bulking agents (avoid laxatives in third trimester as they may lead to preterm labour) - Contractions
Cause–> Dehydration or delivery
Management–>
- Increase fluid intake in case of Braxton hicks
- Cervical examination should be done in case of regular contractions every 10min - Dehydration
Cause–> Increased third spacing of fluid
Management–> Increase fluid intake - Edema
Cause–> Compression of the IVC and pelvic veins by the uterus leads to increased hydrostatic pressure and edema of lower extremities
Management–>
- Elevation of the lower extremities above the heart
- Sleep on their sides to decrease compression (edema of the hands and face may indicate preeclampsia) - GERD
Cause–> Relaxation of LES and increased transit time in the stomach
Management–>
- Antacids, eating multiple small meals, and avoiding lying down within an hour of eating
- H2 blockers or PPIs can be given if symptoms are persistent - Hemorrhoids
Cause–> Venous stasis, compression of IVC and pelvic veins, and increased intraabdominal pressure secondary to constipation
Management–>
- Topical anesthetics and steroids for pain and swelling
- Treating constipation - Pica
Definition–> Craving to eat nonfood items
Management–> Toxicology consult if toxic substances are ingested - Round ligament pain
Cause–> Rapid expansion of the uterus leads to stretching of the round ligament and lower abdominal/groin pain.
Management–>
- Usually selflimited
- Warm compresses or paracetamol can be given - Urinary frequency
Cause–> Increased intravascular volume, increased GFR and compression of the bladder
Management–>
- Take urinalysis and culture to exclude infection
- Inform patient that its normal - Varicose veins
Cause–> Relaxation of venous smooth muscle and increased intravascular pressure
Management–>
- Elevation of the lower extremities or use of pressure stockings
- Surgical therapy can be done if problem does not resolve
Which tests are used for antenatal testing of fetal well-being? What are considered good in those tests?
- Nonstress test (NST), oxytocin challenge test (OCT) and biophysical profiles (BPP).
BPP (Using ultrasound):
- It measures following categories–> amniotic fluid volume, fetal tone, fetal activity, fetal breathing movements and nonstress test
- You can 0-2 points for each category and up to 10 points. A good score is between 8-10
NST:
- Reassuring sign is 2 or more 15x15 (15 beats above baseline, each lasting 15 seconds) in 20 minutes.
OCT:
- It is obtained by getting at least three contractions in 10 minutes and analyzing the FHR tracing during that time.
- The reactivity criteria are the same as in NST.
