Commonprobsofpregnancy-Table 1 Flashcards
Where are the areas most commonly affected by striae (stretch marks) during pregnancy?
Abdomen, thighs, breast
What is raccoon face?
Mask of pregnancy, melasma, cholasma
Hyperpigmentation of skin on forehead, upper lip, and cheeks caused by the steep rise in estrogen levels, which stimulate excess melanin
Should go away
what is PUPPP?
Pruritic urticarial papules and plaques of pregnancy
Itchy, raised rash most commonly appearing on the abdomen, thighs, arms, and butt
When is PUPPP more common?
Third trimester and in moms carrying multiple fetus’s
What are tx options for PUPPP?
Emollient creams, OTC antihistamine, compress etc
What are tx options for striae?
Creams, laser tx…all kinda depends
What is the rule of 3 in regards to asthma during pregnancy?
1/3 of women… get better, get worse, or stay the same
When should a serial US and antenatal testing be done in pregnant asthmatics?
At >/= 32 weeks to make sure baby is receiving enough O2
If HTN is present before 20 wks GA, is it caused by pregnancy?
NO, most likely chronic HTN and unrelated
What is hypertensive dz of pregnancy and when does is manifest?
Types of htn dz: Preclampsia, eclampsia, HELLP syndrome (severe pre-eclampsia)
After 20 wk GA
What is a common maternal arrhythmia? What do you need to rule out if this is present?
Paroxysmal atrial tachycardia (PAT)
r/o underlying pathology vs secondary strenuous exercise
When does peri-partum cardiomyopathy kick in? how long does it last?
Last month through the first 6 mo pp
What are the S/S of peri-partum cardiomyopathy?
fatigue, palpitations, nocturia, ankle edema, DOE, SOB/supine
How is peri-partum cardiomyopathy tx?
Tx the heart failure and hope heart returns to normal size….
Why does physiologic anemia happen in pregnancy?
d/t dilution effect on increasing plasma volume in greater amount than increasing RBC
What is in PN vitamins that helps to prevent iron def anemia?
60-65mg elemental iron
What should you make sure to remind mom about when giving ferrous sulfate tablets?
Black poops!
Why is folate supplementation so important in pregnancy?
To prevent NTD
When does the neural tube form?
5-6weeks GA
What are the types of NTD?
Spina bifida, encephalocele, anencephaly
What is a cyst containing only meninges with an intact neural tube?
Meningocele
What is myeloschisis?
Neural groove open at one or several thoracolumbar levels
What is the dome shaped cyst frequently at the lumbar level that can contain neural, leptomeninges, and glial tissue?
Myelomeningocele
What constitutes spina bifida occulta?
vertebral arches unfused & underdeveloped, vertebral canal is open but meninges & spinal cord in canal, site covered w/skin
What hx might your preggo lady present with if she is being evaluated for materal sickle cell disease?
pre-existent underlying organ dysfunction, prior multiple transfusions, VTE, spleen status, iron storage, acute chest syndrome
What are the fetal risks of maternal sickle cell disease?
utero-placental insufficiency, alloimmunization, asymmetric IUGR, anemia, stillbirth, opioid exposure/withdrawal
How is maternal sickle cell disease managed?
Materal-fetal and hem consutl/specialist
D/C: hydroxyurea, chelating agents and ACEI- cant use these if preggo
Switch to low dose ASA after 1st trimester or LMWH during and post partum if they have a hx of VTE
What should be done if preggo with maternal sickle cell disease has a vaso-occlusive episode?
- O2, opiod analgesia, fluids, and transfusion
What should be drawn monthly in maternal SCD?
Cbc to check ferritin level
What can happen to the tooth enamel during pregnancy?
Erosion from vomit
Use fluoride toothpaste and don’t brush immediately after
Can use 1 tsp baking soda in 8 oz water & rinse = neutralize acid
When does gingivitis occur in preggos?
2-8th mo
What are symptoms of gingivitis?
Bleeding w/brushing, erythema, mild tenderness
What is periodontitis?
Severe gingivitis involving the bone
Tx with abx, deep root scaling
What is a non-tender erythematous smooth/lobular growth at gumline?
Epulis gravidarum , aka pyogenic granuloma
What is the cause of pyogenic granuloma?
Benign Response to irritation from poor oral hygiene, tartar or trauma
When does pyogenic granuloma appear?
> /= 2nd trimester and recurrence is common
What are guidelines for normal weight gain n preggo?
•Normal wt. 25-35 lb •Under wt prior to conception 28-40 lb •Over wt. prior to conception 15-25 lb •Obese 11-20 lb •Twins –Normal wt. 37-54 lb –Over wt. prior to conception 31-50 lb –Obese 25-42 lb
When does morning sickness tend to happen?
Weeks 4-14, peaks weeks 7-12
How can you help adjust things to minimize or help morning sickness?
Small frequent meals, ice chips, ginger, B6, take PN vitamin at might with food or in different form
If severe Doxylamine succinate & B6 (Diclegis)
What are s/s of hyperemesis gravidarum?
Wt loss > 5% pre-pregnancy value
-Protracted vomiting, dehydration, ketonuria
What do you need to r/o with hyperemesis gravidarum?
Acute fatty liver of pregnancy
Appendicitis!
How is hyperemesis gravidarum tx?
IV hydration
If a pregnant woman gets appendicitis, where might the organ displace to?
Upward and laterally
What are symptoms and treatment for cholelithiasis?
F/V, RUQ pain
–Supportive: IV fluids, NG tube, analgesia
–Surgical w/obstruction or acute abdomen
What is Intrahepatic cholestasis of pregnancy?
Build up of bile acids in the liver
What are risk factors for Intrahepatic cholestasis of pregnancy?
Multi-fetal gestations, previous liver damage and or prior IUP with cholestasis
What is often the only symptom in Intrahepatic cholestasis of pregnancy?
Pruritus, esp in hands and feet
What are some other symptoms you should keep an eye out for in suspected Intrahepatic cholestasis of pregnancy?
dark urine color (like dark brown), light color BM, fatigue or exhaustion, loss of appetite, depression
How is Intrahepatic cholestasis of pregnancy tx? What needs to be monitored in mom?
Ursodeoxycholic acid
Monitor: serum bile and LFTs of mom and check non stress test in baby to check fetal HR
What are the most common traumas in pregnancy
MVA and DV/IPV (partner violence)
What are common outcomes of trauma in pregnancy?
Placental abruption, PROM, preterm labor, fetal-maternal hemorrhage, uterine rupture, maternal &/or fetal death
how are traumas managed?
Maternal stabilization and fetal US and electronic monitoring 2-6 hrs post trauma continuing for 24 hrs
How is the Rh status determined and assessed in trauma?
Kleihauer-Betke test
What is Asymptomatic bacteriuria?
Bacterial colonies on urine culture, commonly ecoli but no symtpoms are caused, can monitor and do periodic cultures without tx
What is the sequelae of Asymptomatic bacteriuria?
Cyctitis and UTI and pyelonephritis
Can do abx for 3 days and 7-10 days if high risk
What needs to happen if a pregnant women has pyelonephritis?
Hospital…. Risk of premature labor
What are s/s of calculi? How should they be tx?
CVA tenderness, microhematuria, malaise, dehydration, no fever
Rx: hydrate, strain urine, watch for infection or obstruction
What should you do if your pregnant pt is epileptic?
Send to neuro, have OB-neuro management…. No good DOC need more folate supplementation and more fetal monitoring
What is a very common disorder in pregnant women that completely resolves postpartum?
Carpal tunnel…late 2-3rd trimester
What are risk factors for antenatal depression?
unplanned/unwanted IUP, socioeconomic stressors (limited social network, relationship discord/DV/IPV, drug use); Hx current/past treatment depression, hx post-partum depression/blues or psychosis, FHx
What are the post partum (PP) blues attributed to?
Hormonal changes…. High levels during labor and delivery followed by large decrease within 48 hrs
When do pp blues tend to happen?
2-4days post birth, peaks at 5 days then resolved with in 2 weeks
What are the symptoms of pp blues?
Weepy, sad, lack of concentration, anxious, irritable all coming and going
What is PP depression?
More severe than PP blues, less serve and more prevalent that PP psychosis
Form of major depression
What is the major risk factor for PP depression?
Antenatal depression
What are symptoms of PP depression?
depressed mood, anhedonia (not enjoying baby), changes in sleep/appetite, crying spells, feeling guilty/worthless, fatigue, difficulty concentrating, interference w/ADLs & infant care
What are risk factors of PP psychosis?
preexisting bipolar or schizophrenia
What are symptoms of PP psychosis?
confusion, hallucinations, delusions, depressed mood, mania, disorganized thinking
What should be done immediately if PP psychosis is suspected?
Inpatient tx
When might you want to get TSH levels in a pregnant woman?
- Personal/FHx thyroid dz
- > 30 y/o; symptomatic for thyroid dz or have goiter
- Hx preterm delivery or SAB
- Hx H&N radiation or thyroid surgery
- Take amiodarone or lithium
- Infertility
- Iodine deficient
If your pregnant pt has stable hypothyroidism, when should you be monitoring TSH?
- at confirmation of pregnancy
- then q4 weeks for the 1st 20 weeks, then once in both 2nd and 3rd trimester
If taking thyroid meds and PN vitamins, do you need to give any education to your pts?
Yes, separate the PN vitamins and thyroid meds by 6hrs
What are maternal risks for non-euthyroid hyperthyroidism?
HF, uncontrolled HTN, atrial fib, thyroid storm; fetal hyperthyroid in mother w/Graves’ dz
What are s/s symptoms of graves in preggo pts?
fever, tachycardia, altered MS, V/D, arrhythmia thyroid storm: emergent admission !!!can lead to shock coma and death
What are the medical rx for stable hyperthyroid in preggo?
- 1st trimester: propylthiouracil (PTU) - ADE hepatotoxicity
* 2nd & 3rd trimesters: switch methimazole (MMI) & avoid fetal scalp defects/aplasia cutis in 1st trimester
What is a teratogen that leads to the most anomalies in the first 42 days of gestation?
Glucose!!! Mom needs tight glucose control if DM I and preggo!
What is the metabolic characteristic of GDM?
insufficient insulin secretion to counteract pregnancy related fall in insulin sensitivity
What is happening in GDM?
maternal pancreas produces as much insulin as possible but can’t overcome effect of HPL elevated maternal glucose d/t dec’d peripheral uptake
What 2 things happen to the fetus that lead to macrosomia and neonatal hypoglycemia in GDM?
Fetal hyperglycemia and increased fetal adiposity
What are risks the mother faces if she has GDM?
–Eclampsia
–Preterm delivery
–C-sec
–Macrosomia + shoulder dystocia &/or brachial plexus injury
–Fetal demise if uncontrolled, stillbirth
–Inc risk type 2 DM postpartum
What are fetal risks if mom has GDM?
–Sacral agenesis (rare) –PP •Neonatal hypoglycemia/ hyperinsulinemia •RDS •Later life obesity &/or type 2 DM
When should you screen moms for GDM?
•Risk factors/no overt DM
– 1 or 2 step approach: initially & again @ 28-32 wks
•No risk: fasting glucose as part initial lab work
–1 or 2 step approach @ 28-32 wks
What is the one step glucose screen for GDM?
Fasting glucose then drink 75 g oral solution & draw blood @ 1 & 2 hours (2 H GTT)
What abnormal labs are diagnostic of GDM?
–Abnormal fasting > 92
–Abnormal 1 H > 180
–Abnormal 2 H > 153
–If fasting > 125 or 2 H > 199 = DM (normal not G)
What is the 2 step glucose screen?
•Non fasting - drink 50 g oral solution & draw blood 1 H later
IF ABNORMAL at 1 hr, need a 3 hr GTT
–Fasting glucose then drink 100 g oral solution & draw blood @ 1, 2 & 3 hours
What constitutes and abnormal 1hr level?
> 130-140… depends on lab
For the 3 hr GTT in the 2 step glucose screen, what are the abnormal values? How many are needed to diagnose GDM?
–Abnormal fasting > 105 –Abnormal 1 H > 190 –Abnormal 2 H > 165 –Abnormal 3 H > 145 NEED 2/4 to DIAGNOSE
What PO agents can be used to control GDM?
Glyburide and metformin
What fetal monitoring needs to happen is GDM?
Daily: FM and kick counts
@ 32 weeks: NST/BPP, US: EFW
What are some rules for delivery if GDM?
NO POST DATE DELIVERY
Baby >4500g is C section
When should maternal glucose levels be rechecked?
After delivery and 6-12 weeks later
How should candida infection be tx during preggo?
Topical azoles x 7 days
Should bacterial vaginitis be treated in pregnancy?
Only is symptomatic… unclear risk of preterm delivery since flagyl crosses placenta
What is trichomonas infection associated with in pregnancy?
- Inc’d risk PROM, premature birth, LBW
* Associated w/vertical transmission HIV
How is trichomonas tx?
Flagyl PO 500mg BID x 7days…crosses placenta and gets into breast milk
If your pt has a hx of known exposure or prior tx for gonorrhea, when should they be rescreened?
1st antenatal visit and 3rd trimester
same screening as Chlamydia
What is 1t line tx for gonorrhea in preggo? What does the neonate have to receive at birth?
ceftriaxone (Rocephin) 250 mgIM/single dose & 1 g azithromycin
erythromycin ophthalmic ointment
If mom has Chlamydia what is first line tx?
Azithromycin 1g PO single dose
What should baby be monitored for if mother had Chlamydia/ was tx for?
neonate purulent conjunctivitis 5-12 days s/p birth or pneumonia 1-3 months
Is vaginal delivery ok if positive for HSV?
NO C section …RX doesn’t guarantee safe delivery.. recurrence rate high
What should be done 3rd trimester is partner has HSV?
Abstinence
What is tx for HSV? Suppressive Rx?
acyclovir (po or IV – if severe)
acyclovir 400 mg TID or valacyclovir 500 mg BID
What tx for HPV are contraindicated in pregnancy?
–Sinecatechins, podophyllin & 5-FU
Imiquimod
How should HPV be mamaged in preggo?
Elective c section, and defer tx until post partum
What can happen to neonates with mothers infected by HPV? Does C-section prevent?
rare laryngeal papillomatosis
NO it does not
What is the issue with T pallidum?
It crosses the placenta
What should screening for syph be and when should it be done?
RPR and FTA
Initial PN visit then again 3rd trimester
What is first line tx for preggo with syphilis?
benzathine LA 2.4 single or weekly x 3
What can be a complication of syphilis tx?
Jarisch- herxheimer rxn….Precipitate preterm labor or fetal distress due to febrile response 24 hrs post PCN
Make sure to get pt in stat
What would be s/s of congenital syphilis? ( if mom untreated)
Snuffles, saddle nose, Hutchinson teeth, mulberry molars, saber shins, chorioretinitis
When should HIV screening be done?
1st antenatal visit & & repeat 3rd trimester
What can be done antepartum to reduce transmission? Intrapartum?
Antiretroviral
c-section
What should you do if your preggo pt tests positive for hep b surface antigen?
Report to public health ad refer to specialist
Why is there universal screening for Group B strep? When is it performed?
To prevent neonatal sepsis, pneumonia, meningitis
35-37weeks recto vaginal culture
What happens if mom tests postitive for GBS?
IV antibiotic prophylaxis 4 hrs pre-delivery through ROM & L&D
PCN/ampicillin or cefazolin
What can happen to the fetus if there is 1st trimester exposure to rubella?
SAB, congenital rubella syndrome (deafness, cataracts, heart defects (PDA), mental retardation)
After receiving which vaccines should women try not to get pregnant for at least 4 weeks?
Rubella, varicella
What is congential varicella syndrome?
1st or early 2nd trimester maternal infection: LBW, scarring on skin, limb hypoplasia, microcephaly
If mom has exposure, what should happen>
VZIG within 72 hrs… doesn’t protect fetus
What if mom has exposure then develops a rash and or pneumonia?
acyclovir w/in 24 hrs (pneumonia associated w/inc’d maternal mortality)
What if mom developes rash 5 days prior to delivery up through 2 days pp?
Neonate at risk for varicella
Which pts should be screened for CMV?
w/short febrile illness, clinical suspicion, hx transfusions, HIV/AIDS
What lab findings indicate an acute infection with CMV?
4 fold increase in CMV titers 10-14 days apart
What are neonatal risks associated with CMV?
- Microcephaly, hydrocephaly, chorioretinitis, fetal hydrops
* Long term: hearing loss, neurological disabilities
How are moms infected with toxoplasmosis?
Contact w/infected cat feces
Improperly cooked meat or raw meat
When should mom be screened for toxo?
1st visit, if low or negative titers and hx of exposure, repeat at week 20 and pre-delivery
What will labs look like in acute infection with toxo?
•Elevated IgM
•IgG titers > 1:1000
•4 fold increase in IgG antibodies
Rapid rise in either titer
Toxoplasmosis has what kind of transmission? what does that mean?
Vertical….means damage to fetus is more severe the earlier the transmission occurs
What are potential risks associated with toxo infection?
SAB, stillbirth, congenital anomalies (blindness, brain damage)
What risks are associated with parvo virus B19 ?
risk SAB, hydrops or fetal death d/t hydrops
What is hydrops fetalis?
severe anemia, high-output cardiac failure, extramedullary hematopoiesis
What is congenital infection syndrome?
rash, anemia, hepatomegaly & cardiomegaly
If mom is positive IgM- acute infection, what should be done for fetal evaluation?
US and obtain amniotic fluid or fetal blood for B19 DNA
What needs to be done if fetus has hydrops?
Intrauterine transfusion and further evalv
