Exam 1 Flashcards
1
Q
What should all women be taking regardless of pregnancy status? why?
A
Folic Acid 0.4mg/day—reduce risk of NTD (hx. NTD pregnancy should take 4mg/day)
2
Q
What should the fundal height be at various prenatal visits?
10
12
16
20-36
term
A
10 weeks
Baseball
FHT via doppler b/t 10-12 weeks
12 weeks
Softball
Fundus rising above symphysis pubis, palpable at this time
16 weeks
Half way b/t symphysis pubis and umbilicus Quickening first noted: earlier with 2nd or subsequent pregnancies: about 18-20 weeks with 1st pregnancy
20-36 weeks
1 cm increase weekly Uterine fundus at umbilicus; fundal height – gestational age (+ or – 1cm)
Term Fundal height drops r/t fetal head engagement into pelvis Vertex position in 95% of pregnancies by 36 weeks
3
Q
What are the recommended office visits for a low-risk client throughout the pregnancy?
A
o Up to 28 weeks—every 4 weeks
o 28-36 weeks—every 2 weeks
o 36 weeks to delivery—every week
o 40+ weeks—bi-weekly
4
Q
What vaccines can be given while pregnant?
A
TDapt
influenza
5
Q
Presumptive signs of pregnancy
A
Amenorrhea
Breast tenderness/enlargement
Chadwick’s sign
Fatigue
Hyperpigmentation
Chloasma
Linea nigra
Fetal movements
Urinary frequency
Nausea/Vomiting
6
Q
Probable sign of pregnancy
A
Abdominal enlargement
Ballottement
Braxton-Hicks contractions
Goodell’s sign
Hegar’s sign
Palpation of fetal contours
Positive pregnancy test
Uterine enlargement
7
Q
Positive sign of pregnancy
A
Auscultation of FHTs
Palpation of fetal movements
Radiologic or US verification of gestation
8
Q
What is the Chadwick’s Sign
A
Chadwick’s Sign—bluish discoloration of cervix, vagina, & labia
9
Q
What is the Goodell’s Sign
A
Goodell’s Sign—softening of the vaginal portion of the cervix—4 weeks gestation
10
Q
What is the Hegar’s Sign
A
Hegar’s Sign—softening of lower portion of uterus on palpation—6-12 weeks gestation
11
Q
What hormone detects pregnancy?
A
hCG (human chorionic gonadotropin)
- detected at time of implantation
- Levels double every 1.4 to 2 days; peak at 60-90 days post-fertilization; decrease/plateau at 16 weeks
- Quant β-hCG used to determine viability of pregnancy
12
Q
What are you going to do at the prenatal visit
1)
2)
3)
4)
5)
A
- Confirmation of pregnancy—hCG, FHTs or ulstrasound
o History—menstrual, contraceptive, OB/GYN, sexual, surgical
o Physical exam—VS, head to toe, pelvic
o Lab Testing, Education Materals, Anticipatory guidance
o Expected date of delivery (EDD)—LMP and Naegele’s rule
13
Q
How to calculate Naegele rule
A
Naegele’s Rule
* Add 7 days to the date of LMP (1st day), subtract 3 months, and 1 year
* (First day LMP + 7 days) – 3 months + 1 year = EDD
14
Q
Anticipatory test/guidance at 12-21 weeks gestation
A
quad marker screening
start discussing newborn feeding options
15
Q
Anticipatory test/guidance at 18-22 weeks gestation
A
Routine anatomy OB ultrasound
16
Q
Anticipatory test/guidance at 24-28 weeks gestation
A
1 hour glucose test
Rh neg-type and screen (repeat)
17
Q
Anticipatory test/guidance at 28-34 weeks gestation
A
RhoGam administered
STI testing
review newborn feedings
administer Tdap (if needed)
preterm labor assessment and education each visit
18
Q
Anticipatory test/guidance at 34-36 weeks gestation
A
GBS swab,
Review s/s of labor and review labor pains
19
Q
Anticipatory test/guidance at 36-40+ weeks gestation
A
fetal position assessment
cervical exam
review s/s of labor vs false labor
20
Q
what is
1st
2nd
3rd
trimester
A
1st 1-13
2nd 14-27
3rd 28-40
21
Q
What are some common 1st trimester complaints
A
Breast Pain/Enlargement & Pigmentation changes
Constipation
Salivation/Bad Taste
Fatigue
Flatulence
Headache
Hemorrhoids
N/V
Urinary Freq/Incontinence
Varicosities
22
Q
What are some common 2nd trimester complaints
A
Backache
Dyspnea - lay LR side
Epistaxis
Leukorrhea
Ligament Pain
Muscle cramps
PICA (eating non-food items)
Syncope
23
Q
What are some common 3rd trimester complaints
A
Braxton-Hicks contractions
Discomfort of ↑extremities
Edema in lower extremities
Heartburn
joint/ pelvic gridle pain
24
Q
Advanced maternal age is considered what age?
A
- Advanced maternal age (AMA)—greater than 35yoa
- More likely to experience complications with pregnancy, especially after 40
25
Anticipatory Guidance During Pregnancy
Accidents / blows to abdomen
bathing
chemical use
alcohol
Accidents & blows to the abdomen
o Danger signs—vaginal bleeding, leaking fluid, new/persistent/severe abdominal pain, uterine contractions, decreased/no fetal movement
Bathing
o May take warm (not hot) tub baths if ROM is not suspected; watch for syncope, overheating, dehydration
Chemical Use & Safety
o Tobacco—increased risk infertility, spontaneous abortion, preterm labor, delivery, IUGR, PROM, placenta previa, placental abruption, LBW, prenatal death, SIDS
Alcohol—complete abstinence—FAS, IUGR, microcephaly, congenital anomalies, fetal demise & birth defects of internal organs
26
Danger Signs and Symptoms in the 1st trimester
Spotting/bleeding (bright red blood)
Cramping
Painful Urination
Severe vomiting/diarrhea
Fever >100.4F
Vaginal infection or STI
Persistent/severe low abdominal pain
Lightheadedness/Dizziness
27
Danger Signs and Symptoms in the 2nd trimester
1st trimester concerns plus:
Regular uterine contractions
Unilateral leg/calf pain
Sudden gush or consistent leaking of fluid
Absence of fetal mvt >24 hours
Sudden weight gain
Sif edema of face and/or hands
Severe upper abdominal pain
Headache w/ visual changes and/or photophobia
28
Danger Signs and Symptoms in the 3rd trimester
1st & 2nd trimester concerns plus:
Decrease in daily fetal mvt
Menstrual-like bleeding
Constant, severe contractions
Abdominal pain w/o relief
PROM
29
signs and symptoms of preterm labor
* Lightening, dropping or engagement when presenting part descends into the pelvis
* Easier breathing but increased pelvic pressure, cramping, low back pain, more frequent urination
* 2-4 weeks before labor or as late as during labor
* Vaginal discharge increases or thickens; loss of mucous plug
* Braxton-Hicks increase or become more intense
* Softening of cervix, effacement, and some dilation up to 4cm
30
Signs and symptoms of active labor
when is it a medical emergency
* True labor contractions in the back, legs, or lower abdomen
* Menstrual-like or GI cramping sensations
Doppler FHT, tocometer (to monitor baby)
* 4-6cm dilation or greater with regular, painful contractions causing progressive cervical change
* Palpation of umbilical cord during pelvic exam is life-threatening emergency
31
routine exams include
* Bimanual exam or Fundal height measurement
* FHR depending on gestational age
* Advise mother on availability of prenatal tests
32
What test can they do first trimester to test for downs
* Traditional Aneuploidy Screening
o Between 9 & 13 weeks gestational age
o Trisomy 18 (Edwards Synd.) & Trisomy 21 (Downs Synd.)
33
What does the Quadruple Screening & MSAFP for NTDs
test
looking for
greatest accuracy
___ levels are associated with downs
* Quadruple Screening & MSAFP for NTDs
o MSAFP, hCG, diametric inhibin A, estriol
o NTDs, Trisomies 13, 18, 21
o Greatest accuracy if performed during 16-18 weeks GA
o If elevated MSAFP—ultrasound to identify possible causes
o Low levels MSAFP—associated with Down syndr.
34
Ultrasound
4-5 weeks
6 weeks
7-8 weeks
9-12 weeks
11-14 weeks
18-22 weeks
* Identification of gestational sac at 4-5 weeks
heart beat can be detected 6 weeks
* Fetal limbs at 7-8 weeks
* Fetal movement, stomach, bladder, umbilical cord, spin at 9-12 weeks
* Anatomic assessment at 11-14 weeks
* Universal recommendation for standard US at 18-22 weeks
35
During the 2nd and 3rd trimesters ultrasound is used for
US for Fetal Age/Growth/Well-being
* Gestational Age
* Growth Assessment
* Amniotic Fluid Volume
* Post-term Pregnancy monitoring
* Maternal/Fetal Exposures monitoring
* Documentation of Fetal Viability
36
fetal mvmt starts at
noticeable to mom at
Fetal Movement
* Passive mvt starts as early as 7 weeks; noticeable by the mother at 16-20 weeks
37
When to start kick counts
what is normal?
* Kick counts—28 weeks till end of pregnancy—10 movements in 2 hours is normal
38
Fetal heart rate
is doppler by
normal HR is
Bradycardia
Tachycardia
Fetal Heart Rate
* Doppler by 10-12 weeks
* Normal 110-160
* Bradycardia—less than 110 for 10 minutes; 80-100 is non-reassuring; persistent <80 ominous
* Tachycardia—greater than 160 for 10 minutes
39
FHR variability
Undetectable—
o Minimal—
o Moderate—
o Marked—
o Accelerations—
o Deceleration—
* FHR Variability
o Undetectable—FHR changes are absent or undetectable
o Minimal—FHR changes are undetectable up to or <5 bpm
o Moderate—6-25 bpm
o Marked—changes >25 bpm
o Accelerations—increased in FHR over baseline
o Deceleration—decreases in FHR below baseline
40
Nonstress test
FHR monitored by
assess
with
o FHR monitor transducer and Tocometer over fundus
o Assess over 20 minutes with mother marking events for each fetal movement
41
* Contraction Stress Test
purpose
similar to ____ but adds:
o Positive—
o Negative—
* Contraction Stress Test
o Induced stress to assess placental insufficiency
o Similar procedure to NST, add maternal BP every 10-15, nipple stimulation to induce contractions
o Positive—abnormal—late decelerations present
o Negative—normal—no late decelerations
42
Biophysical Profile
* Real-time ultrasound assessing fetal tone, breathing, motion, & AFV while doing a NST at the same time
* Score 0-10 (fetal asphyxia more certain closer to 0 and cesarean deliver required)
43
Intrauterine Growth Restriction
definition
based on
attempt to
Intrauterine Growth Restriction—fetal weight below 10th percentile for age with evidence of abnormal or dysfunctional growth
o Based on 2 ultrasounds, 3 weeks apart
o Attempt to determine cause from maternal history and physical exam; schedule delivery at 38-39 or 34-37 weeks if additional risk factors are present
44
Small for Gestational Age
definition
Small for Gestational Age—
birth weight less than 10th percentile for GA without reference to etiology
45
Macrosomia
definition
* Macrosomia—
estimated fetal weight >4000g (greater than 90th percentile)—high risk for birth trauma
o Plan cesarean delivery
46
What can be given to mom to promote fetal lung maturity?
* Maternal steroids to promote fetal lung maturity
47
Signs of Effective Breastfeeding:
Signs of Effective Breastfeeding:
Feeds well at least 8 times a day
Appropriate weight gain
5-10 wet diapers daily w/ 2-3 BMs
Sleeps or content between feedings
48
What contraceptives can you use when breastfeeding?
Progestin only OCP
Nexplanon implant
Depo-Provera injection
IUD (Mirena)
49
What will you see with Hep B
how is it treated?
Jaundice, Hepatomegaly
tx -
A—IgG
B—HBIG
50
How do you get Rubella
symptoms
tx
* Direct contact with urine, stool, or nasopharyngeal secretion; incubation 2-3 weeks
Postauricular & occipital lymphadenopathy
Fever, conjunctival erythema
Maculopapular rash on face spreads to trunk and disappears by the 3rd day
If none, vaccination 3 months prior to conception during preconception period or during immediate postpartum
If 1st trimester counsel on risks to fetus (Teratogenic effects in early pregnancy)
51
Chicken pox
symptoms
tx
Characteristic rash; fluid filled vesicles
Medications for symptomatic relief
Acetaminophen
Acyclovir
Vaccination
Prevent spread of infection
52
Most common intrauterine infection & leading infectious cause of mental retardation & hearing loss
cytomegalovirus
53
cytomegalovirus
how is it spread
symptoms
tx
Acquired mostly from sexual contact, blood transfusions, contact with daycare children
Lymphadenopathy, hepatosplenomegaly
Leukocytosis, Lymphocytosis
Elevated LFTs
No treatment
Good hygiene & handwashing
Protected sex
54
* Primary infection during pregnancy associated with stillbirth or congenital infection, permanent neurological damage
Toxoplasmosis
55
how is Toxoplasmosis contracted?
* Ingestion of contaminated meat, feces of infected cats/farm animals, unwashed fruit/veg
Ultrasound to r/o defects
Wear gloves when handling cat litter or gardening; good handwashing
No undercooked or raw meats
Sulfadiazine, Pyrimethamine, Folinic acid
56
HIV interventions for mom and baby
Prenatal screening
Newborn screening
HIV can be spread through breast milk
Postpartum contraception
57
Pyelonephritis
what antibiotics are okay
not okay
okay
3rd gen cephalosporin drug of choice
Typically hospitalized for IV Abx and hydration
caution
Nitrofurantoin is a good drug to suppress infection—do not use in last few weeks of pregnancy
Sulfa drugs should be avoided in late pregnancy (neonatal hyperbilirubinemia)
avoid
Fluoroquinolones should be completely avoided in pregnancy
58
Intra-Amniotic Infection is typically caused by
tx
Group B Strep Disease—leading cause of neonatal infection in US; maternal illness, UTI, GI infection, endometritis, bacteremia
Colonizes in vagina when present during pregnancy
IV penicillin or ampicillin for intrapartum
59
* Spontaneous Abortion—
o Threatened Abortion—
o Inevitable Abortion—
o Incomplete Abortion—
o Complete Abortion—
o Missed Abortion—
o Habitual Abortion—
* Spontaneous Abortion—termination of pregnancy before the point of fetal viability
o Threatened Abortion—possible pregnancy loss—slight bleeding, some contractions, prognosis unpredictable
o Inevitable Abortion—pregnancy that cannot be salvages—moderate bleeding, moderate to severe cramping, dilated cervix, prognosis poor
o Incomplete Abortion—some products of conception are passed, moderate to severe cramping, heavy bleeding, prognosis poor
o Complete Abortion—all products of conception are expelled, bleeding minimal, contractions subsided
o Missed Abortion—embryo is not viable but retained in utero for at least 6 weeks, spotting that later becomes heavier
o Habitual Abortion—3 or more consecutive spontaneous abortions—recurrent pregnancy loss
60
What can help prevent an abortion?
progesterone supplementation (vaginal supp.)
61
What is an Ectopic Pregnancy
how to tx
Ectopic Pregnancy - Implantation of fertilized ovum outside the uterine cavity. OB emergency!
Stable, non-ruptured—IM methotrexate or laparoscopic surgery
Unstable—immediate surgical intervention
62
What is placenta previa
subjective
objective
plan
* Placenta Previa—placenta becomes implanted in the lower segment of uterus and obstructs presenting part prior to or during labor; placenta is pulled away from endometrial wall
Subjective
Painless bright red bleeding
Objective
Dx by ultrasound; avoid pelvic exams
Plan
Early detection and appropriate referral
<36 weeks—bed rest
May require early delivery—cesarean is best
63
What is Abruptio Placentae
Subjective
plan
Abruptio Placentae—partial or complete detachment of a normally implanted placenta at any time prior to delivery
Subjective
Acute, severe abdominal pain, dark red bleeding
Immediate detection and appropriate referral
ABCs, IV fluids, expedient transport to hospital, blood transfusion
Emergent delivery
64
Iron-Deficiency Anemia occurs because
normal H&H levels each trimester
what is the highest sensitivity
Iron-Deficiency Anemia—decreased RBC production due to inadequate iron supply, usually secondary to poor dietary intake
* 1st trim: <11/33%
* 2nd trim: <10.5/32%
* 3rd trim: <11/33%
o Ferritin level highest sensitivity
plan -
Well-balanced diet, iron rich foods & foods the enhance iron absorption
Avoid taking iron supplements with milk, tea or antacids
Repeat Hgb in 2 weeks; monitor for infection and s/sx intrauterine growth retardation; following delivery should remain on iron therapy for at least 3 months
65
most common cause of macrocytic anemia
requirement during pregnancy
folic acid deficiency
Folic acid requirement during pregnancy 400mcg/day
Most common cause of macrocytic anemia (pernicious anemia); usually diet related
Leads to neural tube defects
plan -
Daily intake 1mg; if previous hx neural tube defect should take 4mg/day 2-3 months prior to and during pregnancy
Repeat labs in 2 weeks; same follow up as IDA
66
Plan for mothers with sickle cell anemia
Preconception counseling, Genetic referral
Reinforce avoiding triggers (cold environments, heavy physical exertion, dehydration, stress) and recognize symptoms of crisis
Folic Acid 4mg daily (d/t continued turnover of RBCs)
Crisis—hospitalization, transfusions, oxygen, IV hydration, sedation and analgesia
67
what is HYPEREMESIS GRAVIDARUM
s/sx
tx
Severe nausea and vomiting; most common causes of early hospitalization in pregnancy
S/Sx of dehydration—high urine specific gravity, ketones in urine, weight loss of 5% or more; 1st trimester with typical resolution by 20 weeks
Begin with prevention—1 mo before pregnancy start MVI; dietary mods (avoid spicy, fatty; small frequent meals, bland, high protein)
Antihistamines—diphenhydramine; Antiemetics—chlorpromazine; Benzamides—metoclopramide; SRA—ondansetron
68
Chronic hypertension in pregnancy def
Chronic hypertension in pregnancy
Hx of HTN prior to conception or HTN diagnosed prior to 20 weeks
69
what is preeclampsia
gestational HTN with/without proteinuria
Proteinuria—24 hour urine collection—300mg or more of proteinuria
If absent proteinuria
HTN with: 1—thrombocytopenia; 2—renal insufficiency; 3—pulmonary edema; 4—visual disturbances; 5—elevated liver enzymes
70
normal BP
preeclampsia BP
sever preeclampsia BP
normal BP <140/90
preeclampsia BP 140-159/ 90-109
sever preeclampsia BP >160/ 110
71
Eclampsia symptoms
treatment
Eclampsia
Facial twitching
Tonic-clonic seizures
Pulmonary edema
Circulatory/renal failure
Bedrest, MgSO4, Valium, Phenobarb
Hydralazine
Steroids
Delivery
72
Preeclampsia tx
Delivery of fetus is only cure for preeclampsia.
If less that 34 weeks—corticosteroids for lung development, OB management rather than primary care
Hospitalization if severe—apresoline; Mag Sulfate
ACEIs & ARBs are contraindicated in pregnancy
73
Obesity during pregnancy
Lifestyle interventions—diet & exercise, labs, sonogram
Avoid weight loss during pregnancy; attempt weight gain only 11-20 lbs
74
How to screen for diabetes when pregnant?
Screening vs diagnostic
o 1—50 gm 1 hour glucose tolerance test (<130-140 mg/dL)
o 2—100 gm 3 hour glucose tolerance test (2 elevated levels during 3 hour test indicate Gestational Diabetes)
Fasting blood sugar levels should be lower than 95 mg/dL.
After one hour, blood sugar levels should be lower than 180 mg/dL.
After two hours, blood sugar levels should be lower than 155 mg/dL.
After three hours, blood sugar levels should be lower than 140 mg/dL.
75
Plan for gestational diabetes
o Control glucose levels; home self-monitoring; exercise; insulin if diet & exercise fail
Those with GDM are at higher risk of DM2 later in life & with future pregnancies
76
What are sign of preterm labor/birth
what to do?
Cervical changes
20-37 weeks: 4 contractions 20 minutes apart or 8 contractions per hour with progressive cervical changes, dilation greater than 1 cm and effacement >80%
premature rupture of membrane (PROM) before 37 weeks
Plan
Immediate referral to OBGYN
