Clinical: Diagnosis of Pregs and Prenatal care Flashcards
what are the symptoms of preggers
amenorrhea urinary frequency fatigue n/v breast tenderness quickening
what is quickening
date of initial perception of fetal activity
what are the signs of preggers
Chadwick’s sign
Chloasma
Fetal heart tones
what is Chadwick’s sign
blue-ing/purple hue of the vagina and cervix
what is chloasma
hyperpigmentation (face, nose)
raccoon look d/t changes in hormones
what are the four tests that can be done to confirm pregnancy
*Beta hCG - gold standard
serum progesterone
US
Doppler
what are two different type of beta hCG test
Qualitative - tells YES/NO
Quantitative - gives more specific numbers and used when there’s concern for the pregnancy (ie. bleeding/ectopic)
Tell me more about quantitative beta hCG, GO!
Used to assess how the pregs is going
usually normal pregs hCG will double in count in about 2.5 days so you need to do another one in 3 days to compare values
what does it mean if there’s a 40% drop in hCG levels when you compare day1 and day2-3
failing pregnancy
when is serum progesterone used and what do the results mean
with quantitative hCG
25 = rules out ectopic pregs
around what week should you start using ultrasound to see how the pregs is going
5-6 weeks
how is EDD (estimated date of delivery) determined
either by FDLMP or the earliest fetal ultrasound
the “gestational wheel” is used for which method of EDD
FDLMP
- can also use Naegele’s Rule 9but almost never used)
Is the FDLMP or the earliest fetal ultrasound more reliable
it depends …. foo!
when is fetal ultrasound most effective for EDD
when its performed early in pregs:
6-11 weeks: +/- 5-7 days
12-20 weeks: +/- 10 days
Third trimester: +/- 3 weeks
What are some other factors that make fetal U/S more reliable
- if the FDLMP is not known to certainty
- menstrual cycle is irregular
- the EDD by the FDLMP and the EDD by early U/S differ by MORE than the range of U/S confidence (based upon gestational age)
when is FDLMP more reliable
- when FDLMP is known
- menstrual cycel is regular
- the EDD by the FDLMP and the EDD by early U/S DO NOT differ by MORE than the range of U/S confidence (based upon gestational age)
gestational age is based upon…
FDLMP
embryonic age is based upon…
Conception
how many week(s) difference are there btwn gestational and embryonic age
2 weeks
most patients more likely know their … than their …
FDLMP …. date of conception
OB/GyN’s use which type of age the most
GESTATIONAL, even though it includes 2 weeks where no pregnancy exisits
what is considered “full term”
37-42 weeks
T/F: Ob/Gyns use number of weeks to determine how far along the pregs is
TRUE
pts often refer to months which is CLEARLY confusing, huh? dumbass
the interval from FDLMP to EDD is …
40 weeks
here we go again:
miscarriage is aka…
spontaneous abortion (ab)
threatened ab
bleeding and/or cramping and NOT passing any tissue
-50/50 chance of going to full term
incomplete ab
bleeding and/or cramping and tissue HAS passed, BUT not sure if ALL passed
most common in 1st trimester
complete ab
bleeding and/or cramping, passed ALL the tissue, and beginning the healing process
missed ab
there’s no symptoms at all
-body hasn’t recognized the pregs failed, so it still thinks its pregnant thus the ab fetus needs to be taken out
inevitable ab
threatened ab, no tissue, but cervix is dilated
which ab is most common in the 1st trimester
incomplete ab
which ab is most common in the 2nd trimester
complete ab
And again:
what is an ectopic pregnancy
Includes a pregnancy located anywhere OUTSIDE the endometrial cavity.
Can be in the part of the tube contained within the myometrium, fallopian tube, ovary, or on the bowel or the peritoneum
How is ectopic pregs diagnosed
absence of an intrauterine gestational sac on a TRANSVAGINAL U/S once the quantitative hCG level reaches 1500
which diagnostic tech RARELY identifies a gestational sac outside the endometrial cavity
U/S
what happens during a preconception consultation
- identify risk factors (personal or in family)
- optimize pt medical status if medical risk factors are found (diabetes, HTN)
- current meds and safety in pregs
- Give prenatal vitamins prior to conception
what risk factors from pt reproductive history is important to note bc of risk of REOCURRENCE
- preterm labor or delivery
- low birth weight
- pre-eclampsia
- stillbirth
- congential anomalies
- gestational diabetes
what is the prenatal visit schedule like
Every 4 weeks until 28 weeks
Every 2-3 weeks at 28-36 weeks
Weekly from 36 weeks until delivery
Appointments may be closer if risk factors or ongoing medical conditions need closer monitoring
which risk factor are most common in first pregnancy and should be check
HELLP/pre-eclampsia
what do you except at a first prenatal visit
- complete HnP
- cultures and blood work
- everything in preconception counseling if not done before
- if previous cesarean - discuss circumstances and current delivery options
- if >35 at EDD - discuss risks/testing
what is prenatal care mostly about
TRENDS! if pt is falling off the normal curve of trend, bring them back asap!
Lab tests at first visit
CBC, blood type/Rh, GC/Chlamydia, pap smear, HBsAG, TSH, Urinalysis, HIV and Cystic fibrosis(if pt agrees for both), RPR (syphilis)
Rubella titer - can protect baby, but can’t vaccinate
Antibody screen
why is antibody screening an important lab test
Erythroblastic fetalis: Tx for exposure of mother and fetal blood (trauma etc..) even if you don’t know baby’s blood type
what needs to be done in subsequent visits
maternal weight urine dipstick -for protein and glucose BP fundal height fetal heart tones fetal presentation after 30 weeks --> Leopold's maneuvers
whats the importance of maternal weight
average gain. body habitus effects on weight gain
- underweight women gain weight to get to optimal preggers weight
- overweight women actually LOSE weight to get to that optimal preggers weight
when to measure fundal height
1st 12 weeks, 12-20wks, after 20 wks
what is screened during the 1st trimester
blood work (10-13wks gestation) U/S (11-13 wks gestation)
what do you look for in blood work in the 1st trimester
- PAPP-A (lower than usual with fetal Down’s)
- Inhibin A, free beta subunit hCG, total hCG (higher than usual with fetal Down’s)
what do you look for on U/S in the 1st trimester
nuchal lucency –> naturally occurring fluid space at the back of the neck
(thickening in this area associated with Down’s)
what is screened during the 2nd trimester
2nd trimester (15-20weeks)
- fasting blood sugar
- trisomies and open neural tube defects
- fetal U/S
what is the screening test for trisomies and neural tube defects
- Serum Alpha fetoprotein – still used for twins
- Triple Screen (Alpha fetoprotein, HCG, Estriol)
- Quad Screen (same as triple screen + inhibin A)
- Penta Screen (same as Quad + ITA: invasive trophoblast antigen)
what is combined screening
serum sequential, integrated (non-disclosure) screening.
This replaces 2nd trimester screening
when do you use a diagnostic test for trisomies/ONTD (open neural tube defects)
screening tests for these are replaced by Diagnostic testing if there are high risk factors for these conditions
- advanced maternal age
- previously affected babies
also used when screening comes back with a higher than normal risk status
so what is diagnostic testing for trisomies/ONTD
- amniocentesis at 15-20 wks
- chorionic villi sampling at 12-14 wks
1. transabdominal
2. transcervical
what is cell-free fetal DNA
analyses fetal DNA in Maternal serum
it’s non-invasive - reliability that approaches amniocentesis or CVS (Chorionic villus sampling)
when is cell-free fetal DNA done and why
can be done as early as 10 wks gestation
checks for trisomy 21, 18, 13
what labs are done at 24-28 weeks
CBC
1hr 50gm Glucola test
Rhogram, if Rh neg (regardless of baby’s blood type)
vaginal culture (optional)
what do you do if 1hr 50gm Glucola test is abnl
3 hr GTT, 100gm loading dose
when do you give Rhogam
antepartum at 28 weeks, it has a 12 week lifesapn
post-partum if infant is Rh pos.
Rh incompatibility occurs in …
Rh neg mothers
what is Rh incompatibility
when maternal exposure to Rh pos. blood from teh fetus causes an antibody response in teh mother
T/F; Rh incompatibility effects the first (exposure) pregnancy
FALSE; it effects future pregnancies
erythroblastosis fetalis (destruction of fetal red blood cells) => fatal fetal hydrops
Rh incompatibility:
what are some feto-maternal hemorrhage sufficient to cause sensitization (alloimmunization)
At the time of delivery – most common Abruptio placenta Bleeding placenta previa Abdominal trauma Amniocentesis Ectopic pregnancy Miscarriage
RhoGam is passive or active immunity
passive immunity
when should group B beta strep be cultured
35-36 weeks
where is group B beta strep cultured from
lower 1/3 of vagina and rectum in the same culture medium
T/F: group B beta strep should be treated in labor
TRUE; treatment in labor
what are the risk factors of group B beta strep (GBBS)
- preterm labor
- preterm premature rupture of the membranes
- rupture of the membranes > 18 hrs
- temp >38C (100.4F)
T/F: treat only those effected with GBBS
TRUE; treat ALL women, regardless of strategy who have:
- GBBS bacteriuria at ANY time in preggers
- given birth to an infant with GBBS
intrapartum prophylaxis for GBBS
- IVPB penicillin G 5 million units initially and 2.5 million units every 4hrs until delivery
- IVPB Ampicillin, 2 gm initially and 1 gm every 4 hrs until delivery
what do you give to moms who have GBBS but is allergic to penicillin
Now: request sensitivites as teh efficacy of Clindamycin and Erythromycin have been drawn into question
used to: empirically use Clinda and Erythro
what are the older testing methods for fetal well-being
non-stress test (NST)
contraction stress test (CST)
Biophysical profile (BPP)
what is NST
testing thats done after 28 weeks
fetal heart beat will go up 15 beats for a few seconds with movement and that’s normal
-this test means that adequate oxygen is required for fetal activity and heart rate to be within normal ranges. When oxygen levels are low, the fetus may not respond normally
what is CST
The aim is to induce contractions (usually 3) and monitor the fetus to check for heart rate abnormalities.
stimulate uterine contractions:
- nipple stimulation
- IV pitocin (oxytocin)
what is the newest testing for fetal well-being
Cord Doppler Velocimetry (CDV) :
-Used largely in pregnancies at risk for FGR (fetal growth restriction, AKA IUGR).
What does a normal CDV mean
Normal cord doppler studies indicate forward motion of blood flow both in systole and diastole.
What does an abnormal CDV mean
Abnormal cord doppler studies indicate increased placental resistance to blood flow that results in either absent or reversed blood flow during the end-diastolic phase
whats the damn purpose of pre-natal visit
- pt education
- evaluation for presence/development of preg risk factor
- assuring fetal well-being
- look at developing trends**
What should you be thinking when approaching preg pt
dang you HUGE!
- Proving to yourself that the baby is better off left in-utero,
- The benefits of leaving the baby in-utero outweigh the risks of delivery.
- It’s not just about the numbers and the trends!
