Chapters 19 & 21 Flashcards
acoustic stimulation test
Antepartum test to elicit fetal heart rate response to sound; performed by applying sound source (laryngeal stimulator) to the maternal abdomen over the fetal head.
alpha-fetoprotein (AFP)
Fetal antigen; elevated levels in amniotic fluid and maternal blood are associated with neural tube defects
amniocentesis
procedure in which a needle is inserted through the abdominal and uterine walls to obtain amniotic fluid; used for assessment of fetal health and maturity.
amniotic fluid index (AFI)
Estimation of amount of amniotic fluid by means of ultrasound to determine excess or decrease.
biophysical profile (BPP)
Noninvasive assessment of the fetus and its environment using ultrasonography and fetal monitoring; includes fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume
chorionic villus sampling (CVS)
Removal of fetal tissue from the placenta for genetic diagnostic studies.
contraction stress test (CST) (also called oxytocin challenge test (OCT)
Test to stimulate uterine contractions for the purpose of assessing fetal response; a healthy fetus does not react to contractions, whereas a compromised fetus demonstrates late decelerations in the fetal heart rate that are indicative of uteroplacental insufficiency.
daily fetal movement count (DFMC)
Maternal assessment of fetal activity; the number of fetal movements within a specified time are counted; also called “kick count”
Doppler blood flow analysis
use of ultrasound for noninvasive measurement of blood flow in the fetus and placenta.
magnetic resonance imaging (MRI)
Noninvaseive nuclear procedure for imaging tissues with high fat and water content; in obstetrics, uses include evaluation of fetal structures, placenta, and amniotic fluid.
nonstress stest (NST)
evaluation of fetal response (fetal heart rate) to natural contractile uterine activity or to an increase in fetal activity
percutaneous umbilical blood sampling (PUBS)
AKA cordocentesis
procedure during which a fetal umbilical vessel is accessed for blood sampling or for transfusions
uteroplacental insufficiency (UPI)
Decline in placental function (exchange of gases, nutrients, and wastes) leading to fetal hypoxia and acidosis; evidenced by late decelerations of the fetal heart rate in response to uterine contractions.
abruptio placentae
partial or complete prematures separation of a normally implanted placenta
cerclage
use of nonabsorbable suture to keep a premature dilating cervix closed; usually removed when pregnancy is at term
cervical funneling
effacement of the internal cervical os
chronic hypertension
systolic pressure of 140 mmHg or higher or diastolic pressure of 90 mmHg of higher that is present preconceptionally or occurs before 20 weeks of gestation and/or is persistent after 6 weeks postpartum
clonus
spasmodic alternation of muscular contraction and relaxation; counted in beats
couvelaire uterus
interstitial myometrial hemorrhage after premature separation (abruption) of placenta; purplish-blue discoloration of the uterus is noted.
disseminated intravascular coagulation (DIC)
Pathologic form of coagulation in which clotting factors are consumed to such an extent that generalized bleeding can occur; associated with abruptio placentae, eclampsia, intrauterine fetal demise, amniotic fluid embolism, and hemorrhage.
eclampsia
severe complication of pregnancy of unknown cause and occurring more often in the primigravida than in multiparous women characterized by new-onset grand mal seizures in a woman with preeclampsia occurring during pregnancy or shortly after birth.
ectopic pregnancy
implantation of the fertilized ovum outside of the uterine cavity; locations include the uterine tubes, ovaries, and abdomen.
gestational hypertension
the new onset of hypertension without proteinuria after week 20 of pregnancy
HELLP syndrome
A laboratory diagnosis for a variant of severe preeclampsia that incolces hepatic dysfunction, characterized by hemolysis, elevated liver enxymes, and low platelet count
hydatidiform mole (molar pregnancy)
gestational trophoblastic neoplasm usually resulting from fertilization of an egg that has no nucleus or an inactivated nucleus.
hyperemesis gravidarum
abnormal condition of pregnancy characterized by protracted vomiting, weight loss, and fluids and electrolyte imbalance.
miscarriage
loss of pregnancy that occurs naturally without interference or known cause; also called spontaneous abortion.
placenta previa
placenta that is abnormally implanted in the thin, lower uterine segment. The condition is further classified as complete placenta previa, marginal placenta previa, or low-lying placenta according to gestational age and placental location in relation to the internal cervical os.
preeclampsia
disease encountered after 20 weeks of gestation or early in the puerperium; a vasospastic disease process characterized by hypertension and proteinuria.
premature dilation of the cervix
cervix that is unable to remain closed until a pregnancy reaches term because of a mechanical defect in the cervix; also called incompetent cervix
superimposed preeclampsia
new-onset proteinuria in a woman with hypertension before 20 weeks for gestation, sudden increase in proteinuria if already present in early gestation, sudden increase in hypertension, or the development of HELLP syndrome
TORCH infections
infections caused by organisms that damage the embryo or fetus; acronym for toxoplasmosis, other (e.g., syphilis), rubella, cytomegalocirus, and herpes simplex virus.
Risk Factors for Polyhydramnios
- Diabetes mellitus
- Fetal congenital anomalies
Risk Factors for IUGR
- Maternal Causes: Hypertensive disorders, diabetes, chronic renal disease, collagen vascular disease, thrombophilis, cyanotic heart disease, poor weight gain, smoking, alcohol/drug use, living at high altitude, multiple gestation.
- Fetoplacental causes: chromosomal abnormalities, congenital malformations, intrauterine infection, genetic syndromes, abnormalplacental development.
Risk factors for Oligohydramnios
- renal agenesis (potter syndrome)
- PROM
- Prolonged pregnancy
- Uteroplacental insufficiency
- Maternal hypertensive disorders
Risk factors for chromosomal abnormalities
- maternal age 35 years or older
- balanced translocation (maternal and paternal)
Common maternal and fetal indications for antepartum testing.
- Diabetes
- Chronic hypertension
- preeclampsia
- fetal growth restriction
- multiple gestation
- oligohydramnios
- preterm PROM
- postdate or postterm gestation
- previous still birth
- decreased fetal movement
- systemic lupus erythematosus
- renal disease
- cholestasis of pregnancy
Fetal alarm signal
fetal movements cease entirely for 12 hours. A kick count lower than 3 movements an hour warrants further evaluation
Indications for standard ultrasonography
detect fetal viability, determine presentation of fetus, assess gestational age, locate the placenta,examine the fetal structure for anomalies, and determine amniotic fluid volume
Limited examination ultrasound indications
ID fetal presentation during labor or evaluating FHR activity when its not detected by other methods
Specialized or target examinations indications
woman is suspected of carrying ananatomically or physiologically abnormal fetus
Indications for comprehensive ultrasound
abnormal clinical exam, polyhytramnios, oligohydramnios, elevated AFP, history of offspring with anomalies
When can Fetal heart activity first be seen and heard?
as early as 6-7 weeks by Echo scanners, and 10-12 weeks by doppler
nuchal translucency
screening tool using ultrasound measurement of fluid in the nap of the fetal neck between 10 and 14 weeks of gestation to ID possible fetal abnormalities. Fluid greater than 3mm is considered abnormal
What does an elevated NT (nuchal translucency) indicate.
Increased risk of fetal cardiac disease. Genetic testing is recommended.
When combined with a low maternal serum marker, increased risk of chromosomal abnormalities occurs (trisomy 13,18,21)
Placenta previa diagnosed during 2nd trimester. (facts)
more than 90% of cases diagnosed during the 2nd trimester will have resolved by term, primarily because of elongation of the lower uterine segment.
Calculating AFI
Take the largest pocket of amniotic fluid in each quadrant and measure their vertical depth in cm and add all 4 together.
Normal AFI
10 cm or greater, with the upper range of normal around 25 cm
Low normal AFI
5 - 10 cm
Oligohydramnios
AFI less than 5 cm
Associated with congenital anomalies (renal agenesis), grown restriction, and fetal distress during labor
Polyhydramnios
AFI >25 cm
associated with neural tube defects, obstruction of the fetal gastrointestinal tract, multiple fetuses, and fetal hydrops.
Biophysical profile scoring categories
Fetal breathing movements Gross body movement Fetal tone Reactive fetal heart rate Qualitative amniotic fluid volume
Normal Score for Biophysical Profile
2 Pts per category
Fetal breathing: at least 1 episode of >30 sec in 30 mins
Gross body: 3 discrete body movements in 30 mins
Fetal tone: at least 1 episode of active extension with return to flexion
Reactive FHR: 2 accelerations in 30 mins
Fluid volume: at least 1 pocket measuring 2 cm in 2 planes
Abnormal Biophysical Categories
Fetal breathing: absent or no episodes > 30 sec
Gross body: up to 2 episodes of movement
Fetal tone: absent movement, slow extension, or no return
Reactive FHR: less than 2 accelerations
Fluid volume: either no fluid pockets or less than <2cm in two planes
Score 10 (biophysical profile interpretation and management)
Normal infant; low risk of chronic asphyxia.
Repeat testing at weekly intervals; repeat twice weekly in diabetic patients and patients at 41 weeks of gestation.
Score 8 (biophysical profile interpretation and management)
Normal infant; low risk of chronic asphyxia
Repeat testing at weekly intervals; repeat testing twice weekly in diabetic patients and patients at 41 weeks gestation; oligohydramnios is an indication for delivery
Score of 6
BPP interpretation & management
Suspect chronic asphyxia
If 36 weeks of gestation and conditions are favorable, deliver; if at > 36 weeks and L/S <2.0, repeat rest in 4-6 hours; deliver if oligohydramnios is present
Score 4
BPP Interpretation and Management
Suspect chronic asphyxia
If 36 weeks of gestation, deliver; if <32 weeks of gestation repeat score
Score 0-2
BPP interpretation and management
Strongly suspect chronic asphyxia
Extend testing time to 120 minutes; if persistent score of <4, deliver, regardless of gestational age.
presence of ______ almost always indicates a fetal defect
acetylcholinesterase
MSAFP can be performed when?
Between 15 - 22 weeks (16 - 18 weeks is ideal)
Triple marker tests for
MSAFP, unconjugated estriol, and HCG
Quad screen test for
the same as triple screen + inhibin A
Oxytocin contraction tests (looks for what kind of contractions)
3 uterine contractions of good quality, lasting 40 - 60 seconds within a 10 minute period.
Four most common types of hypertensive disorders during pregnancy
- gestational hypertension
- preeclampsia
- chronic hypertension
- preeclampsia superimposed on chronichypertension
Mild Preeclampsia
- BP>or = 140/90 x2 at least 4-6 hrs apart but within a week
- proteinuria >= 1+or 300mg in 24 hour
- Output matches intake
- No visual problem, epigastric pain, or pulmonary edema
- Transient irritability/ changes in affect
- normal liver function
- reduced placental perfusion.
Severe preeclampsia
- BP rise >= 160/110 on 2 separate occasions 6 hrs apart while on BR
- Proteinuria >= 3+ dip, >= 5g 24 hour
- <400-500 mL in 24 hrs
- persistent severe headache
- blurred vision, photophobia
- severe irritability
- epigastric pain, thrombocytopenia, impaired liver function, pulmonary edema may be present.
- decreased placental perfusion expressed as IUGR
Hemoglobin
normal
12 - 16
Hematocrit
normal
37 - 47%
Platelets
normal
150,000 - 400,000
PT
normal
12-14 sec
PTT
normal
60 - 70 sec
Fibrinogen
normal
200 - 400
Fibrin split products
normal
Absent
BUN
10 - 20
Creatinine
normal
0.5 - 1.1
LDH
normal
45 - 90
AST
normal
4 - 20
ALT
normal
3 - 21
Creatinine clearance
80 - 125
Burr cells or schistocytes
normal
Absent
Uric acid
normal
2 - 6.6
Bilirubin (total)
normal
0.1-1
Preeclampsia lab value changes
Hgb, Hct: may increase
Plt:normal or 5
Bili: unchanged or slightly increased
HELLP lab value changes
HGB, HCT, PLTs: decreased Fibrinogen: decreased Fibrin split products: present BUN, Creat, AST, ALT: increased AST and ALT very increased Creat Clear: decreased Burr cells: present Uric acid: >10 Bili: increased
HELLP acronym
Hemolysis
Elevated Liver
Low Platelets
Assessing Deep Tendon Reflexes
0 - No response
1+ - Sluggish or diminished
2+ - Active or expected response
3+ - More brisk than expected, slightly hyperactive
4+ - Brisk, hyperactive, with intermittent or transient clonus
Pitting Edema grades
+1 - 2mm
+2 - 4mm
+3 - 6mm
+4 - 8mm
Therapeutic serum magnesium for preeclampsia
4 - 7 mEq/L
Expected side effects of magnesium sulfate
feeling of warmth, flushing, and burning at IV site
Symptoms of mag toxicity
Mild: lethargy, muscle weakness, decreased or absent DTRs and slurred speech.
Increasing toxicity:maternal hypotension, brady cardia, bradypnea, and cardiac arrest.
Reversal agent for Mag Sulfate
Calcium gluconate
Treatment of patient after seizure
Suction food and fluid from glottis, and administer 10 L of oxygen by non-rebreather. Insert 18G IV, replace old IV because its likely displaced. Loading dose of 6G mg over 15-30 mins followed by 2G hourly
types of miscarriage
threatened, inevitable, incomplete, complete, and missed
threatened miscarriage
include spotting of blood but with the cervical os closed.
-mild cramping
-No passage of tissue, no cervical dilation
Management: bed rest, sedation, avoidance of stress, sexual stimulation and orgasm usually recommended
Inevitable miscarriage
Moderate bleeding mild to severe cramping No passage of tissue Cervical dilation Treatment: acetaminophen, further treatment depends of woman's response to treatment, bedrest if no pain, fever or bleeding. If ROM bleeding, pain, or fever is present, the prompt termination of pregnancy is accomplished usually by D&C
Incomplete Miscarriage
Heavy, profuse bleeding Severe uterine cramps Passage of tissue Cervical dilation with tissue in cervix Management: May or may not require additional cervical dilation before curettage.
Complete miscarriage
Slight bleeding
Mild uterine cramping
Passage of tissue
No cervical dilation (cervix already closed after tissue passed)
Management: Suction curettage may be performed to ensure no retained fetal or maternal tissues
Missed miscarriage
No bleeding, possible spotting No cramps No tissue passed No dilation Management: If spontaneous evacuation of the uterus does not occur within 1 month, uterus is emptied by method appropriate to duration of pregnancy.
Septic miscarriage
blood amount varies, usually malodorus cramps vary tissue passage varies cervical dilation usually passes Management: The uterus is emptied immediately by a method appropriate for the gestational age
Recurrent miscarriage
bleeding varies cramping varies passage of tissue dilation is usually present management: Varies depending on type. Prophylactic cerclage may be performed if premature cervical dilation is the cause.
cerclage placement
offered if the cervical length falls to less than 20 to 25 mm before 23 to 24 weeks. Risks of the procedure include PROM, preterm labor, and chorioamnionitis.
removal of the entire tube
salpingectomy
“cleaning”of the fallopian tube after tubal pregnancy
salpingostomy
How long should the woman wait to get pregnancy after miscarriage?
At least 3 menstral cycles to allow for healing.
What medication can be given to dissolve an ectopic pregnancy
methotrexate
How long should pregnancy be postponed after a molar pregnancy
6 months - 1 year to ensure no cancer cells are forming.
GTD
gestational trophoblastic disease
ex. molar pregnancy
types of molar pregnancies
complete or partial mole
complete mole
fertilization of an egg in which the nucleus has been lost or inactivated. It resembles a bunch of white grapes.
Usually contains no fetus, placenta,amniotic membranes, or fluid.
Maternal blood has no placenta to receive it; therefore hemorrhage into the uterine activity and vaginal bleeding occur.
Partial mole
two sperm fertilizing 1 egg.
often have embryonic or fetal parts and an amniotic sac.
Congenital anomalies are usually present.
Potential for malignant transformation if 5 - 10%
Abruptio placentae
Grade 1 mild seperation
- minimal bleeding, dark red blood
- <500 mL blood loss
- shock rare
- tenderness usually absent
abruptio placentae
grade 2 - moderate seperation
Absent to moderate bleeding
- dark red
- 1000-1500 mL
- mild shock
- increased uterine tonicity
- pain present
abruptio placentae
grade 3 - severe
absent to moderate bleeding >1500 blood loss dark red blood Shock is common pain - agonizing tetanic, persistent uterine contractions
placenta previa
minimal to severe and life threatening bleeding
- amount varies
- bright red blood
- Normal uterine tonicity
- absent pain.
Chlamydia
effects on mother and baby
Maternal: PROM, preterm labor, postpartum endometritis, miscarriage
Fetal: Low birth weight
Gonorrhea
affects on mother/baby
Maternal: miscarriage, preterm labor, PROM, amniotic infection syndrome, chorioamnionitis, postpartum endometritis,postpartum sepsis
Fetal: Preterm birth, IUGR
Group B Strep
Affects on Mom/baby
Maternal: UTI, chorioamnionitis, postpartum endometritis, sepsis, meningitis (rare)
Fetal: preterm birth
HSV
effects on Mom/Baby
Maternal: Intrauterine infection (rare)
Fetal: Congenital infection (rare)
HPV
affects on mother/baby
Maternal: Dystocia from large lesions, excessive bleeding from lesions after birth trauma
Syphilis
affects on Mom/baby
Maternal: Miscarriage, Preterm labor
Fetal: IUGR, Preterm birth, Stillbirth, Congenital Infection
Chlamydia
treatment
Azithromycin
Amoxicillin
HSV
treatment
Acyclovir
Gonorrhea
treatment
Ceftriaxone
Cefixime + Azithromycin or Amoxicillin
Group B Strep
treatment
Penicillin G
Syphillis
treatment
Penicillin G
Trichomonas
treatment
Metronidazole
Candidiasis
treatment
butoconazole, clotrimazole, miconazole, or terconazole
Bacterial vaginosis
treatment
metronidazole
CABS
compressions, airway, breathing, and defibrilation
