Exam 1 Flashcards
What are the recommended office visits for a low-risk client throughout the pregnancy?
-Up to 28 weeks: Every 4 weeks
-28 to 36 weeks: Every 2 weeks**
-36 weeks and on: every week or more as necessary
What are common discomforts for each trimester?
1st: breast pain/enlargement, constipation, ptyalism/bad taste in mouth, fatigue, flatulence, headache, hemorrhoids, nausea and vomiting, urinary frequency/incontinence, varicosities of vulva and legs
2nd: backache, epistaxis, leukorrhea, ligament pain, leg muscle cramps, PICA, syncope
3rd: Braxton-Hicks, dyspnea, discomfort in upper extremities, edema, heartburn, insomnia, joint or pelvic pain
What are the normal, non-worrisome complaints during each trimester?
-N/V, heartburn, constipation
-Leg cramps, lower leg swelling
-Urinary frequency
-Backache
-Dyspnea (3rd trimester)
-Leukorrhea (white, thin vaginal discharge with no odor)
What are complaints from the pregnant patient that would be needed to be further evaluated?
-Fever
-Vaginal irritation/discharge that is large amount or odorous
-Vaginal bleeding
-Palpitations
-Breathlessness at rest
-Swelling of upper extremities or face
-Oliguria
-Decreased or absent fetal movement
What OCP can be given to breastfeeding women?**
-Progesterone only pill
What immunizations can be given in pregnancy?
-TDAP, HepB, inactivated influenza vaccine- no active vaccines during pregnancy
S&S of mastitis
flu-like symptoms. malaise, fever and chills, erythema and swelling of affected breast with possible pitting edema
Treatment for mastitis
-Milk culture, bed rest, continue breastfeeding; ice packs, warm packs, increased fluids
-Meds: NSAIDS, first choice is dicloxacillin sodium 250-500 mg QID for 10-14 days, also cephalexin (if breastfeeding); if PCN allergy: erythromycin or clindamycin
How would you treat mastitis if you suspect MRSA?
-Bactrim: do not give if mom is breastfeeding and baby is under 2 months old
What should the fundal height be at various prenatal visits?
-16 weeks: halfway b/t symphysis pubis and umbilicus
-20-36 weeks: uterine fundus at umbilicus; fundal height= gestational age (give or take 2 cm)
-Term: Fundal height drops r/t fetal head engagement into pelvis
Describe fetal development during pregnancy
-Major milestones during first trimester: beginning of fetal heart movements at 6 weeks gestation, closure of the neural tube at 7 weeks gestation, rapid head and brain growth starting at week 7
What week can you hear fetal heart tones on a Doppler?
by 10-12 weeks gestation
What to tell patients to do about N/V during pregnancy?
-Often N/V is limited to first trimester
-Diclegis and vitamin B6 can help; Dramamine, benadryl, zofran are all pregnancy category B
-Adequate hydration
-Small, frequent meals to avoid stomach from being to empty or full
-Ginger is natural and effective
Recommended weight gain during pregnancy
Based off of BMI:
<18.5 = 28-40 pounds
18.5-24.9= 25-35 pounds
25-29.9= 15-25 pounds
>30 = 11-20 lbs
Recommended blood testing/labs for all patients during pregnancy
-Blood type and antibody screening
-CBC
-Rubella titer
-Syphilis screening
-Hep B surface antigen
-UA
-Chlamydia//gonorrhea
-Cervical cytology
-HIV anibody
How do you prevent neural tube defects?
Folic acid
How do you differentiate between Trich, BV, and Candida infections?
On wet mount:
Candida-hyphae/pseudohyphae
BV: clue cells**
Trich: Protozoa with tails
Treatment for Trich, BV, Candida infections
Candida- miconazole, diflucan 150 mg single dose
Trich- metronidazole BID for 7-10 dyas
BV- metronidazole
S&S of Trichomoniasis
-Grey/yellow thin, foamy discharge
-Itchy/burning
S&S of chlamydia
-Yellow discharge
-Burning/itching
-Male: itching/burning, penile discharge
Treatment for chlamydia
-CDC first line: Doxy 100 mg BID for 7 days** -or-
-azithromycin 1 gram single dose -or-
-Levofloxacin 500 mg PO for 7 days
What STIs are reportable to the health department?
Chlamydia, gonorrhea, syphillis
S&S of gonorrhea
-Yellow, thin discharge
-Itching/burning
Treatment for gonorrhea
-Ceftriaxone 500 mg IM injection single dose
-If weight >150kg treat with 1 gram instead
Symptoms of pelvic inflammatory disease
-Dull, continuous lower abdominal or pelvic pain
-Fever, vomiting, vaginal discharge, irregular vaginal bleeding
-Lateral motion tenderness of cervix and adnexal
Labs to test if suspecting PID
-WBC-leukocytosis
-ESR- elevated
-CRP- elevated
What is one of the biggest concerns of PID?
-Can cause infertility if travels to tubes and causes abscess
Causes of PID
-Gonnorhea, chlamydia, trichomonas
-BV or cytomegalovirus
Treatment for PID
Ceftriaxone 500 mg IM once + doxycycline 100 mg BID for 14 days + metronidazole 500 mg BID for 14 days (regiment treats multiple different causes)
Treatment of HPV
For genital warts- Cryotherapy, topical creams/lotions (imiquimod 5% cream, podofilox 0.5% solution/gel), surgery
Treatment for HSV during pregnancy
-If pregnant and at risk start suppressive therapy at or after 36 weeks gestations acyclovir 400 mg TID or valacyclovir 500 mg BID until delivery
Complications of syphilis
-Neurosyphilis- infection of CNS, this can occur AT ANY STAGE OF INFECTION
S&S of different phases of syphilis
Primary: one or more chancres that resolve after a few weeks and appear about 3 weeks after exposure
Secondary: Starts 1-2 months after primary infection; maculopapular rash on palms and soles, hypertrophic papular lesions on vulva and anus, lymphadenopathy with flu-like symptoms
Tertiary: 15-30 years after infection; aortitis or gummatous changes to skin, bone, or viscera
Treatment for Syphillis
-Treatment differs based on phase of disease
-Primary: PCN G 2.4 million units IM once, repeat dose in 1 week IF pregnant
-Secondary: Same as primary
-Tertiary: Late latent is 2.4 million units IM every week for 3 weeks; early latent the same as primary/secondary
What are the guidelines for PAP smears for ACOG?
-Start at age 21years
-Every 3 years until 65 if cytology alone
-Every 5 years for age 21-65 if cytology +HPV or HPV alone
What are the guidelines for PAP smears for ACS (American Cancer Society)?
-Start at age 25-29 years**
-HPV alone or HPV +Cytology every 5 years
-Cytology every 3 years
Exceptions to pap smear screening guidelines
-Abnormal pap: need annual till 2 normal, then follow guidelines
-Hx of cervical or uterine cancer- continue screening past 65 years until 20 years cancer free
-Hysterectomy- no screening unless cancer
Management for abnormal pap smear
-Refer for colposcopy if HPV +, guidelines are different depending on what is found but most guidelines recommend this; repeat testing in 1 year
What is a colposcopy and when is it indicated?
Procedure that can be done in office that collects biopsy of cervix; indicated if PAP is positive for certain strains of HPV that cause cervical cancer
What is a bimanual exam?
-Palpation of pelvic organs
-Examines size, controur, shape, note any masses and location
-Not recommended to be performed by AAFM
-Recommended by ACOG to continue performing
How to perform a bimanual exam?
-Use prominent hand in vaginal vault, push on cervical OS
-With nondominant hand palpate downward to locate uterus, bladder, and ovaries
What is the best way to palpate the ovaries and what is the purpose of this procedure?
-Rectovaginal exam
-Rule out ovarian abnormalities such as cancer
-Not often done due to discomfort
What is a wet prep and what is it used to test for?
-Testing of vaginal discharge under microscope
-Bacterial vaginitis, Candida infections (yeast) and Trichomoniasis
Treatment for bacterial vaginosis
Metronidazole 500 mg BID for 7 days ~or**
-Metrogel 0.75% for 5 nights ~or
-Clindamycin cream 2% for 7 nights
Recommendations for screening for HIV
-Annual testing with antibody or antibody/antigen testing and RNA test
-If positive- follow-up testing to confirm
-Once confirmed- Viral load, CD4 count
What are the guidelines for breast cancer screening?
-Mammography every 2 years starting at age 40 for women with low-moderate risk women
-Age >75 years- offer screening if life expectancy >10 years
-High risk: every 6 month to year; MRI also used in combination**
Benefits of the combination oral pill for birth control
-Relatively inexpensive, easy to obtain and not long-term
-Can be stopped at any point
-Regular cycles that tend to be shorter and lighter
-Help with acne
Use of combination birth control pills increase risk factors for what?
-Blood clots
-Elevated BP
-Increased risk of estrogen/progestin dependent Ca
-HAs
Contraindications for combination BC pills
-HTN
-DVT or thrombus of any kind
-CA (especially breat or endometrial)
-Smoker
-Age >35years
-Migraines
-Pregnancy
-Depression
-Caution in seizures
What to tell patients about missing their birth control pills
-Effectiveness rate drops when pills are missed
-1 pill missed = take as soon as you remember, OK to take 2 in one day
-Do not take more than 2 pills in one day
-Use backup contraceptive or abstain from sex until 7 days of no missed pills
Benefits and risks of the 3-mo oral pill for birth control
-Benefits: cycle every 3 months, good for women who have dysmenorrhea or menorrhagia
-Risk: also a combination pill and therefore same risks as other estrogen/progestin pills
How do you use the NuvaRing? What are the risks and contraindications?
-Inserted into vaginal opening and lies around the cervix; remains in place for 3 weeks and removed for 1 week
-Combination contraceptive: same side effects and contraindications as oral contraceptives
What are the progestin based contraceptives?
-Pill
-Intradermal (Nexplanon)
-Injection (Depo-provera)
-IUD
Pros and Cons for progestin-based contraceptives
-Cons: Breast tenderness, headaches, nausea, weight gain, may have more vaginal discharge
Pros: Safe for women with HTN and age over 35, lower risk of blood clots (but still a risk)
Instructions for patients taking progestin only pill
-Safe for breastfeeding
-Take at same time every day and use backup contraceptive if even 3 hours late
-Cycles are regular and lighter
Patient education when using nexplanon
-Transdermal, placed under skin between elbow and shoulder
-Lasts 3 years
-Irregular to no cycles
Treatment for abnormal bleeding with nexplanon or mirena
-Ibuprofen 600 mg q 6 hours
-Doxycycline 100 mg BID for 10 days
-Add oral combination pill for 1 cycle
-Removal
What is the biggest risk factor for using Depo-Provera IM injection birth control?
-Weight gain of 10-15 pounds or higher if African American
What is the best birth control method for women with a history of thromboembolism or cancer?
-Paragard= copper IUD
Education for women with Paragard
-Regular cycles, may have heavier than normal bleeding
-Changes cervical mucus (may have more discharge)
How long is Paragard good for?
10 years
How long is mirena good for?
5 years
Name and describe the forms of contraceptive that are not pharmacological
-Diaphragm- remove hours after sex, must be custom fit
-Sponge- remove 6 hours after sex
-Male/female condoms
-Tubal ligation
What are the benefits of breastfeeding for infants?
-1st few days of infants life- mom is producing colostrum which is HIGH IN CALORIES and baby would only need a few drops (good because they have a small stomach)
-Maternal antibodies
-Decreased incidence of diarrhea, respiratory infections, otitis media, meningitis, botulism, UTI, necrotizing entercholitis, obesity, SIDS, Type I DM, Crohn’s, leukemia
-Breastfeeding is BEST choice for preterm infants
Benefits of breastfeeding for mothers
-Assists in involution- quicker recovery
-Decreases risk of ovarian, uterine, and breast cancer
-Weight control
-Lower cost, convenient, fewer clinic visits
-Increased bonding with the infant
-Helps with postpartum depression due to hormones that are released
Name some contraindications for breastfeeding
-HIV- only MAJOR contraindications
-Precautions: breast reconstruction/reduction, certain medications, tobacco and alcohol use
What are the benefits of bottle feeding?
-Iron fortified
-Ready to feed
-No additional fluids or vitamins needed
Describe the concept of supply and demand in regard to breastfeeding
-The more mom stimulates with feeding baby or pumping, the more milk she will produce and vice versa
Differentiate between: Goodell’s sign, Chadwick’s sign, Hegar’s sign, Braxton Hicks
Goodell’s: a probable sign of pregnancy characterized by a softening of the cervix
Chadwick’s: bluish appearance of the vaginal part of the cervix**
Hegar’s: compressibility and softening of the cervical isthmus
Braxton-Hicks: sporadic contractions and relaxation of the uterine muscles; also known as “false labor” pains; begin around 6 weeks gestation but are not felt until 2nd or 3rd trimester
Describe Naegele’s rule to estimate date of delivery**
-Assumes 28-day cycle
-Subtract 3 months from first day of last menstrual period, add 7 days, and add a year depending on month of LMP
What to tell patients about missing their birth control pills
-Effectiveness rate drops when pills are missed
-1 pill missed = take as soon as you remember, OK to take 2 in one day
-Do not take more than 2 pills in one day
-Use backup contraceptive or abstain from sex until 7 days of no missed pills
What is the best birth control method for women with a history of thromboembolism or cancer?
-Paragard= copper IUD
How are TSH levels affected during pregnancy?
Often TSH levels are lower
What cardiac changes can be expected during pregnancy?
-Increase in plasma and RBC volume, HGB drop due to dilution
-Cardiac output increases
-Peripheral resistance decreases, decreasing diastolic BP in 1st and 2nd trimesters by 10-20 mmHg
-Varicose veins= increased pressure
What are the respiratory changes that can be expected during pregnancy?
-Tidal volume and RR increases
-Oxygen consumption increases
-All of this can cause dyspnea
-Fetus can push against diaphragm
Timing of each trimester in pregnancy
1st: 1-13 weeks
2nd: 14-27 weeks
3rd: 28th week-delivery
What labs should be drawn at the initial prenatal visit?
-Pap smear
-Blood type and antibody screen
-Rubella/Hep B titer
-STIs: GC, syphilis, HIV, Hep C
-CBC
-UA (if concern present)
-UDS (if concern present)
What would you check at every subsequent prenatal visit?
-Weight
-BP
-Fetal movement/quickening
-Urine: blood, ketones, protein, glucose
-Fundal height: after 17 weeks
-Fetal heart tones: after 12 weeks
What are some concerning symptoms during pregnancy?**
-Fever
-Vaginal discharge that is a large amount or odorous with itching
-Vaginal bleeding
-Palpitations
-Dyspnea at rest
-Swelling of arms or face
-Oliguria
-Decreased or absent fetal movement
What could sudden weight gain in the third trimester indicate?
impending Pre-eclampsia
What vitamins and supplements should be given during pregnancy?
-Folic acid: 400 micrograms per day**
-Iron: dosage based on patient’s anemic status:
non-anemic: 30 mg/day
anemic: 120 mg/day for at least 6 weeks and then recheck
When is sexual intercourse NOT ok during pregnancy?**
-If patient has vaginal bleeding: nothing in vagina for 2 weeks after bleeding stops
-Symptoms of preterm labor or placenta previa
Which immunizations are not safe during pregnancy?**
Live vaccines such as MMR and Varicella
What is the Quad screen?
-A screening test offered between 12-24 weeks during pregnancy that tests for birth defects
When is the postpartum visit for mom?
-6 weeks for vaginal birth
-1 week for C-sections to check incision
How long should a woman abstain from sex after delivery?
6 weeks
What are the problems mothers encounter that cause them to stop breastfeeding?
-Problems latching
-Milk supply issues
-Pain and lack of support
-Lack of training/education/experience
-Limited time
What are the recommendations for breastfeeding from Healthy People and American Academy of Pediatrics?
-Exclusive breastfeeding till 6 months of life
What are some recommendations for nipple care for the breastfeeding mother?
-Proper latch technique
-Ensure nipples are clean and dry after feeding
-Moisturize - lanolin or breast milk
-Avoid heat
-Watch for cracking, peeling, bleeding, and yeast
-Treat mom if baby has thrush and mom is breastfeeding
What are some concerning signs in the infant if mom is breastfeeding?
-Poor weight gain
-Lack of voids and stools (3-4 wet diapers, stool every few days at least)
-Infant fussy after feedings (sign they are still hungry)
-Lack of milk (soft breast, unable to express milk)
-Sore nipples (thrush, latch is wrong)
Different positioning for breast feeding
-Cradle hold: good for full term infants, may be uncomfortable if C-section
-Cross cradle: good for small infants or who have a hard time latching
-Football: good for C-section, small infants or those who have a hard time latching, mom with large breasts, twins
-Reclining: good for C-section or difficult delivery, be careful NOT to fall asleep in this position
Recommendations for pumping
-Best to exclusively breastfeed during first 2 weeks
-Slowly introduce pumping
-Stimulate breast every 3 hours (8-12 times a day)
-Clean equipment after each pumping in warm soapy water
Recommendations for storage of milk
-Good for 4 hours at room temperature
-Good in fridge for 7 days
-Good in freezer for 3 months
-Good in deep freezer for 1 year (once thawed good for 24 hours)
Medications considerations for breastfeeding moms
-Quinolones are always contraindicated
-<1% of drug taken by mom is delivered to infant
-Best meds are those that can be given to the infant
Describe the lactation risk categories for medications
L1- safest: tylenol, PCN, depo-provera
L2- safer- macrolides, cephalosporins, SSRIs, antihistamines, prednisone
L3- moderately safe: bactrim, 1st generation antihistamines, doxycycline
L4- hazardous: lithium, corticosteroids
What is the usual amount of bottle feeding for an infant at first?
15 mLs and steadily increase
Education for bottle feeding moms
-Feed every 3-4 hours
-Hold infant, don’t prop bottle, burp after each feeding
-Clean equipment with warm, soapy water
-Do not warm bottle in microwave
-Mix per formula, usually 1 scoop per 2 oz of water
Risks/things to consider with formula feeding
-More problems with allergies
-Requires clean water (check rural wells)
What are the leading causes of death for women in pregnancy?
-HTN
-PE
-Hemorrhage
-Infection
-Mental health (according to the CDC this is the primary cause of deaths)
What factors increase a pregnant woman’s risk of death or complications?
-Age: over 35/under 20 years
-Poverty
-Single
-Nonwhite (specifically AA)
-No prenatal care
Why do you get a UA on pregnant women on every prenatal visit?
-Due to the risk of UTI with atypical symptoms or no symptoms
-UA would show positive leukocytes and MAY or MAY NOT positive nitrites
-ALWAYS culture if positive leukocytes
-Also good to check for proteinuria (sign of preeclampsia) or glucosuria (sign of GDM)
Which antibiotic would we not want to prescribe during the first and third trimesters for women?
Bactrim
What are the effects of pre-existing DM on mom and baby?
-Mom: PIH, cystitis, DKA, spontaneous abortion
-Infant: NTD’s, cardiac defects, macrosomia (larger/increased weight), IUGR (decreased nutrients/blood supply- intrauterine growth restriction), hyperbilirubinemia
What is the main causative factor of delayed lung maturation in infants?
-Hyperglycemia
Normal metabolic changes during pregnancy
-Hormones stimulate insulin production in 1st trimester
-Hormones cause insulin resistance in 2nd and 3rd trimester
-Postpartum- return to pre-pregnancy glucose sensitivity 7-10 days after delivery
When should you refer a pregnant woman with pre-existing DM to a specialist?
-Immediately refer to high-risk OB
-Would need to follow up with endocrine
What are the risks of developing gestational diabetes?
-Age 35+
-Overweight
-Previous FBS 110-125
-Previous GD
-Infant >9lbs
-Unexplained stillbirth
-FH of DM
Describe the glucose tolerance test
-Done at 24-28 weeks of pregnancy
-Mom drinks 50g glucose: if 1 hour BS is > 130 than do a 3 hour GTT
-Screening test, not diagnostic
Describe the 3-hour glucose tolerance test (GGT)***
Have patient be NPO after midnight:
—> FBS prior to test, drink 100g glucose, check BS hourly for 3 hours
-GB diagnosed if FBS is >95 or if 1 hour glucose >180, 2 hour is > 155, or 3 hour is >140
-Diagnostic
What is PIH?
-Pregnancy induced hypertension or gestational hypertension
-Occurs after 20 weeks
-Resolves within 48 hours after delivery
-Risk factors: DM, HTN, renal disease, multiple gestation, primigravida
Tx for PIH
-Prevention: exercise, increased protein, 8 glasses of water per day, rest
-Tx: labetalol, nifedipine, methyldopa (only if severe= SBP > 160 or DBP >110**), weekly OB visits, kick counts (best way to mntr fetal well being), refer to high-risk OB
Triad of symptoms for preeclampsia
-HTN
-Edema
-Proteinuria
S&S of preeclampsia
-Rapid weight gain
-Hyperreflexic DTRs
-HA, visual disturbances
-Epigastric pain (late sx, concern for HELLP)
Sx of mild versus severe preeclampsia
Mild: SBP >140, DBP <90, 1+ proteinuria, no HA
Severe: SBP >160, DBP >110, 3+ proteinuria, decreased UOP, HA, visual disturbance, thrombocytopenia
Tx for mild versus severe preeclampsia
Mild: increase protein in diet, document fetal activity, weekly NST
Severe: rest, decreased stimuli, meds- apresoline for severe HTN, MgSO4 (antivonvulsant & antihypertensive), delivery
S&S of eclampsia versus HELLP
Eclampsia: facial twitching, tonic-clonic seizures, pulmonary edema, renal/circular failure
HELLP**: RUQ pain, N/V, edema, decreasing H&H, decreased PLT, increased liver enzymes
Tx for eclampsia/HELLP
-Bedrest in hospital
-Meds: MgSO4, valium or phenobarb (if mag not effective, not within 2 hours of delivery), hydralazine, steroids to increase fetal lung maturity in prep of delivery
Labs to draw when evaluating for PIH/eclampsias/HELLP
-CBC- increase H&H and low PLT
-Uric acid- increased
-Protein to creatinine ratio- increased
-Urine 1+ to 4+ proteins
What is hyperemesis gravidarum?
Excessive vomiting with dehydration, ketoacidosis, electrolyte imbalance
Tx for hyperemesis gravidarum
-Avoid zofran if possible due to risk of cardiac abnormalities**
-B-complex vitamins if mild
-High protein/carb, low fat, advance as tolerated; slow, frequent meals
-Natural remedies: ginger, pressure point bracelets
-Oral hygiene
What can early bleeding in pregnancy signify?
-Could be benign
-Miscarriage
-Ectopic pregnancy
-Incompetent cervix
Spontaneous abortion management
-Threatened: Check fetus by U/S; not much to do to prevent it; bedrest, no sexual activity and nothing in vagina for 2 weeks after bleeding stops, support & education
-Inevitable: Check with U/S for complete vs. incomplete, analgesics for D&C, RhoGAM
Incomplete or missed abortion management
-Hospitalization
-Before 14 weeks: D&C + IV pitocin
-After 14 weeks: Pitocin or Prostaglandins
-Monitor for DIC
Post-abortion education
-Bleeding & cramping for 1-2 weeks
-Vaginal rest for 1 week
-Check temp BID
-F/U 2 weeks
S&S of incompetent cervix
-advanced cervical dilation
-lower abdominal pressure
-bloody show
-urinary frequency
Tx of incompetent cervix
-Cerclage placed in-hospital under anesthesia; cerclage kept in until term
What are the risk factors for ectopic pregnancy?
-History of salpingitis
-Prior ectopic pregnancy
-Assisted reproduction
-IUD
-Cigarette smoking
S&S of ectopic pregnancy
-Missed period
-Abdominal pain- severe if rupture
-Vaginal spotting
-Lower HCG/progesterone level than normal pregnancy
Tx of ectopic pregnancy
-Salpingectomy- surgical
-Methotrexate if unruptured and early on
What can late pregnancy bleeding be indicative of?
Placenta previa and abruptio placenta
What is placenta previa and what are the risk factors?
-Placenta covers cervix
-Rx factors: HTN, tobacco use, cocaine use, previous C-section, multifetal pregnancy, Asian or AA
S&S of placenta previa
-bleeding after 24 weeks
-Abdomen is soft, nontender, relaxed
-Diagnosed by US
Management of placenta previa
-Avoid pelvic exam unless done in OR
-Bed rest until 36 weeks
-Antenatal testing: US, NST,
-L/S ratio prior to early delivery (lung maturity)
-C-section
What is abruptio placenta and risk factors?
-Premature separation of placenta
-Rx factors: HTN, DM, poor nutrition, cocaine or tobacco use, blunt trauma
S&S of abruptio placenta
-Sudden onset of intense pain with or without bleeding
-Hard abdomen
-Decreased fetal HR and movement
-Shock
How do you assess fetal well-being during pregnancy?
-Kick counts: about 3x per hour
-Can be used in all pregnancies in 3rd trimester
-Left lying position- more blood going to fetus = more movement
-US- abdominal or transvaginal
What would an elevated S/D (systolic/diastolic) ratio on doppler flow study indicate?
poorly perfused placenta
What would a low amniotic fluid volume indicate?
Anomalies, IUGR, fetal distress, post-term pregnancy
What would a high AFI indicate?
Anomalies (primarily kidney), DM
What is the normal AFI?
5-19 cm
What are we looking for in a non-stress test?
-2 or more episodes of accelertation (>15 BPM) in 20 minutes, at least 15 seconds long–> indicator of fetal movement
-Usually do this weekly or twice weekly on moms that have DM or HTN
What is a biophysical profile (BPP)?
-Real-time ultrasound/physical of the fetus
-Looks at: fetal breathing, gross body movements, fetal tone, reactive fetal heart rate, quality of amniotic fluid volume
-Each receives a score of 0 or 2: Normal score is 8-10, Abnormal is <4
What is completed at the 28-34 week prenatal visits?
-RhogGam administration if indicated
-STI testing if indicated
-Continued feeding discussions
-Administer Tdap
-preterm labor assessment/education
When should mom begin performing fetal movement counts (FMCs)
-Daily starting at 28 weeks gestation
Name some positive signs of pregnancy
-Auscultation of fetal heart sounds
-Palpation of fetal movements
-Radiological and/or ultrasonic verification of gestation
What is leopold’s maneuver?
-Used to determine the baby’s positioning and can also be used to help determine where to find the fetal heart rate
Where do you find fetal heart tones?
-1st trimester: lower pelvic region
-2nd trimester: upwards toward umbilicus (easier to find)
What are the presumptive signs of pregnancy?**
-Amenorrhea
-N/V
-Fatigue
-Urinary frequency
-Breast changes
-Quickening
What are the probable signs of pregnancy?
-Positive urine pregnancy
-Enlarged abdomen
-Hegar’s sign
-Chadwick’s sign
-Goodell’s sign
-Ballotement
-Fetal outline
Treatment for nausea in pregnancy
-Small, frequent meals
-Low fat meals
-Bland foods
-Unisom/B6
-Acupuncure
-Getting away from using Zofran in first trimester due to fetal anomalies
What to tell patients that are experiencing back pain during pregnancy- management & education
-Exercise- at least walking
-Massage
-Physical therapy
-Pregnancy belt- sits below uterus and helps relieve weight off of pelvis
36-wk pregnant woman presents to clinic. BP is 150/92. UA shows proteinuria. Weight gain 6 pounds since last visit. She also has edema in LE. What are you most concerned for and what would you do for management?
-Preeclampsia
-Assess DTRs, HA
-Instruct to closely monitor kick counts
-US for placental blood flow
-Diet high in protein
-Weekly NSTs
-Bedrest
-Hydralazine/nifedipine
-Delivery if severe
Screening in 2nd trimester
-1 hour glucose tolerance test
-Quad test
-Anatomy US
Patient presents 2-weeks post-partum with c/o lochia becoming brighter red with clots. What do you suspect?
-Subinvolution
How would you diagnose subinvolution?
-Emergency
-VS for signs of sepsis
-Pelvic exam
-Fundus: soft, larger than expected
-Diagnostics: US for retained placental parts
How to treat subinvolution?
Methergine for 2-3 days and antibiotics
How do you perform a fundal height measurement?
-Make sure patient’s bladder is empty
-Mother should be lying supine with pillow under head/shoulder
-Locate highest point of the fundus (may or may not be midline)
-Measure down to the symphysis pubis
How do you perform leopold’s maneuvers?
-1st: palpate upper abdomen using both hands: head is firm and round, buttox is symmetric and soft
-2nd: Identify the fetus’s back by palpating deeply with palms of hands using one hand to support the uterus while palpating the other side with the other hand
-3rd: Identify the part of the fetus that is above the inlet by using fingers and thumb of hand to grasp the lower abdomen
-4th: Examiner faces patients feet to locate the fetus’ brow: move both hands toward the pubis by sliding the hands of the sides of the uterus
What is the leading cause of morbidity and mortality for moms during the postpartum period?
Hemorrhage
What are some common causes of late hemorrhage in postpartum women?
-Subinvolution
-Uterine atony- uterus remains flaccid
-Lacerations- firm uterus with lacerations
-Hematoma
When to suspect a postpartum hematoma?
Patient complains of persistent perineal or rectal pain and pressure with a palpable mass OR may present in shock with little pain due to hidden bleed
What puts a patient at risk for uterine atony?
-High parity
-Multifetal pregnancy
-Hydramnios
-Large fetus
-Oxytocin use during delivery
-Mag sulfate use
-Long labor
Treatment for uterine atony
Uterine massage or Hemabate (prostaglandins)
What are some common postpartum thromboembolic problems?
DVTs and PEs
Treatment for DVT vs PE
DVT: IV heparin, bed rest 5-7 days and then ambulate with TED hose
PE: IV heparin, bed rest initially; Later: Coumadin or lovenox for 3-6 months (coumadin is contraindicated in pregnancy)
What is the most common form of postpartum infection?
Endomyometritis
What are some S&S of endomyometritis?
Fever, chills, anorexia, nausea, fatigue, pelvic pain, and foul-smelling lochia
Diagnostic workup for endomyometritis
-CBC- elevated WBC
-Sed rate
-Blood and cervical cultures
Management of endomyometritis
-Triple ABX therapy IV
-Hydration, rest, nutrition
