Exam 1: Modules 1-3 and self paced module #1 5/12/23 Flashcards
outer uterine muscle layer
longitudinal - expulsion of the fetus
middle muscle layer
interlacing- constricts blood vessels
FSH
low levels of estrogen and progesterone toward end of cycle stimulates hypothalamus to secrete GnRH. FSH stimulates development of graafian follicales and their production of estrogen.
FSH surges before LH to mature a follicle, secreted by the anterior pituitary.
three cycles happening simultaneously
hypothalamus - pituitary ovary cycle
ovarian cycle - follicle maturation/ovulation, corpus luteum formation - degeneration
endometrial cycle - thickening and sloughing
inner muscle layer uterus
circular - forms sphincters at the fallopian tubes, key in maintaining cervical integrity during pregnancy/dilation in labor
blastocyst
inner mass cells (stem cells) -
become:
embryo
amnion
yolk sac
all or none period
first 2 weeks after conception - not susceptible to teratogens
damage - embryo dies or recovers and develops normally
implantation
trophoblast day 6-10
burrow into endometrium
early placenta
formation of chorionic villi - secrete hCG, maintains estrogen and progesterone (inhibits menstrual and ovarian cycles)
embryo’s critical development stage
begins 10-14 days after conception, week 3-8
3 primary germ layers develop - ectoderm, mesoderm, endoderm –> organogenesis
embryo most likely to be damaged during this time
trophoblast
outer layers
trophoblast and blastocyst formation day 4-5
become:
chorion
placenta
luteal stage
second ovarianstage - constant - 14 days
chorionic villi
important for transfer between fetus and mother
secrete hCG - maintains estrogen and progesterone - inhibits ovarian and menstrual cycles
maternal and fetal blood should not mix - nutrition, fluid, waste return - happening at the cellular level
cellular differentiation days 10-14
primary germ layers - ectoderm, endoderm, mesoderm - determine all organ systems
embryonic membranes form - chorion, amnion
amniotic fluid
yolk sac for primitive RBCs
umbilical cord
ectoderm
epidermis, hair, teeth, nose and CNS
mesoderm
dermis, muscles, bones, kidneys, CVS, lymphatic tissue, spleen
endoderm
resp & digestive tract linings, bladder, liver, pancreas
heart beats
28 days after conception (6 weeks gestational age)
able to see on US at 6 weeks,
do US at 7-8 weeks because days make a difference
male differentiation
4-6 weeks
typically not detectable on US until 16-20 weeks gestation
organ structures formed
by 8 weeks after conception - 10 weeks gestation
fetal breathing movements and fetal hearing
~16 weeks
youngest preterm survivor
21 4/7 weeks
ductus arteriosis
pulmonary artery/lung bypass
duct between pulmonary artery and descending aorta
foramen ovale
hole between right and left atria - right ventricle bypass
ductus venosus
liver bypass
umbilical vein to IVC
Oxytocin
stimulate contractions
milk letdown
LH
released by anterior pituitary - a marked surge of LH and a smaller peak of estrogen day 12 precede the expulsion of the ovum from the follicle
After ovulation, converts the empty follicle into the corpus luteum and supports this structure(which in turn supports an early pregnancy until the placenta forms)
Estrogen
dominates the follicular ovarian phase - days 1-14 (variable phase), dominates the proliferative uterine phase
moody, breast tenderness midcycle surge
stimulates the thickening of the endometrium after menstruation and before ovulation
ovulation
14 days prior to period. In a 21 day cycle it happens on day 7 for example. 28 day cycle happens on day 14
optimum time for conception - 14 days before next period, when LH, estrogen and FSH spike
begins luteal ovarian phase,
Progesterone
dominates the 2nd, luteal ovarian phase (relatively constant phase avg 14 days),
dominates the uterine secretory phase - ready for EGG, drops and lining sheds
ovarian hormone, responsible for the changes in the endometrium that occur after ovulation to prepare the uterine lining for implantation of a fertilized ovum
Positive Signs of Pregnancy
Can’t be anything else:
Fetal Heartbeat per doppler
fetal movement
- palpated
- visualized
visualization of fetus on ultrasound
delivery
1st trimester
0-12 6/7
organogenesis, cellular hyperplasia
second trimester
13-27 6/7
cellular hyperplasia and hypertrophy
third trimester
28 weeks till delivery
cellular hypertrophy
ampulla
outer 1/3 of fallopian tube - where mature eggs meets sperm
egg survival 12-24 hours
sperm - 72 hours +
acrosomal reaction
removal of sperm’s plasma membrane allows for rxn
production of enzymes to weaken carona radiata
morula
12-16 cells - inner and outer cell mass
amniotic fluid
early pregnancy - diffusion from maternal blood
after 20 weeks - largely fetal urine
fxns:
temp stablity, prevents adherence to membranes, allows for growth and development, breathing practice, protection, keeps umbilical from crimping
placenta
part maternal (decidua), part fetal (chorion)
endocrine fxn: hPL, hCG, progesterone, estrogen production
facilitates hydostatic and osmotic pressure gradients for active/facilitated transport
fetal surface - shiny side
maternal surface - meaty
umbilical cord
2 arteries + 1 vein
arteries away from fetus, vein to fetus
foramen ovale
hole between right and left atria - right ventricle bypass
difference between dizygotic and monozygotic twins
dizygotic - two eggs, two sperm, two amnions, two chorions
monozygotic - one egg, one sperm, two amnions, one chorion
maternal serum/quad screen
trisomy 18 and 21
collected between 15 and 23 weeks (ideal b/t 16-18)
covered by most insurance
rarely used - more accurate testing options - available for patients who miss 1st trimester screen and cost preference
1st trimester screen
11-13 weeks - nuchal translucency and maternal serum
trisomy 13, 18, 21 and cardiac, neural tube defects
2nd trimester screen
2nd draw of meternal serum alphafetoprotein to screen for neural tube defects and abdominal wall defects
–> spina bifida and gastroschisis
covered by most insurance plans
Free Fetal DNA ffDNA
most accurate screening option
trisomy 13, 18, 16, 29, 21 and se chromosome aneuploidies and micro-deletions
after 10 weeks
most accurate in high-risk women, advance age (>35yr)
gender!
US 2nd or 3rd trimester
fetal presentation and number
AFI
placental location
presence of cardiac activity
fetal biometry
anatomy - review of systems
uterine/pelvic anatomy
detects: cranio-spinal defect, GI malformations, cardiac defects, renal malformations, skeletal
transabdominal after 12 weeks ga
tests used to confirm chromosomal abnormality/inherited disorder
chorionic villus sampling - 10-12 weeks - transabd or transcervical
- does not detect neural tube defects, many risks, but allows for termination before fetal movement felt
amniocentesis - 15 - 18 weeks - needle guided aspiration of amniotic fluid
percutaneous umbilical cord blood sampling - hemophilia, hemolytic disorders, fetal infections, chromosomal
not gaining enough weight
more likely to deliver low birth weight - inc risk for respiratory distress syndrome, PDA
increased lifelong risk for HTN, DM, CVD
Reasons:
Anorexia/body image disorders
Nausea, “morning sickness”
Substance abuse, smoking
Insufficient means: poverty, homelessness, etc.
Pica (filling up on non-nutritive foods)
obesity
inc risk of birth defects, HTN, GDM & DM, sleep disordered breathing
inc risk of primary, rpt CS
medical induction, prolonged first stage, blood loss, prolonged operative time
neonate - macrosomia, IUGR, stillbirth, preterm
normal BMI weight gain
total: 25-35lb
1st trimester: .5-3 lb
2nd/3rd: 1lb/week
or 5-10 lb by 20wks, then 1lb/week
relaxin
loosening of joints (combo with estrogen and progesterone)
vena cava syndrome
Enlarged uterus compresses the inferior vena cava and the lower aorta when patient is supine
Reduced venous return to heart
Symptoms include decreased BP, light headedness, syncope, racing heart, sweating, fetal heart rate changes
implications for labor - keep at a tilt and monitor
Naegle’s Rule
LMP + 1 year - 3 months + 7 days
not always exactly 280 days from LMP, need known LMP
late - term
post - term
late - 41w0d
post - 42w0d
preterm
> 37w
give Rogam
Rh-negative woman:
- 28 weeks prophylactically (half-life 14 weeks)
- instances mixing suspected
- within 72 hours of delivery if baby Rh+ (via umbilical blood sample) or unknown (miscarriage/abortion)
Can omit Rogam if:
- women Rh-positive
- partner DOCUMENTED history of Rh negative
Toxoplasmosis
avoid raw/undercooked meat
contact with cat feces
Parvovirus (aka 5th’s, Coxsackie, Hand Foot Mouth)
check status for high exposure risks - precautions if non-immune
Listeria
avoid eating unpasteurized cheese
Rubella, Varicella
immunization available but not given in pregnancy (live attenuated)
check status, precautions if non-immune
immunize postpartum
rubella - isolate infants w/ rubella - 12 mo virus shedding
hep B
bathe asap
baby vaccine
all family members tested/vaccinated
Toxoplasmosis
cat feces, soil, uncooked meat
transplacental
highest risk of infection 3rd trimester, death 1st trimester
Syphillis
all women screened
treat penicillin G
immunizations safe to give during pregnancy
influenza (not nasal spray), tdap - booster 27-36wks - antibodies pass placenta, protect baby first 2 months b4 Dtap
, covid
underweight weight gain
BMI <18.5
28-40 lbs
if underweight, inc risk of PTL, low birth weight
inadequate weight gain - inc risk of fetal growth restriction
Normal weight - weight gain
BMI 18.5-24.9
25-35 lbs
Overweight weight gain
BMI 25-29.9
15-25 lbs
Obese weight gain
BMI >30
11-20 lbs
inc risk of HTN, DM/GDM, macrosomia, injury, c/s, postpartum hemorrhage, stillbirth, miscarriage
Morbid Obesity weight gain
BMI >40
no weight gain
normal symptoms during pregnancy
braxton-hicks
leukorrhea - estrogen
SOB - should be manageable
visual changes -
slightly elevated WBCs - look for s/s
nausea vomiting (esp 1st trim)
nausea - which hormone?
hCG
heartburn - which hormone?
progesterone - valve stomach esophagus softens
constipation - which hormone?
progesterone - slowed gut motility
swollen ankles/feet - which hormone?
estrogen, progesterone - hormones trigger fluid retention + mechanical - pelvic congestion
Leukorrhea/mucus plug - which hormone?
estrogen
bleeding gums/nosebleeds - which hormone?
estrogen and progesterone - capillary engorgement and swelling nasal passages
epistaxis - estrogen
fetal heartbeat/ movement
SEEN on US after 6 wks
HEARD doppler 10-12 weeks (organs formed ~10 wks)
FELT 18-22 wks
prenatal care visits
initial 8-12wks
visits Q4 until 28 weeks
visits Q2 weeks until 36 week
Visits Q1 week until birth
prenatal care visits
initial 8-12wks
visits Q4 until 28 weeks
visits Q2 weeks until 36 week
Visits Q1 week until birth
phyisologic anemia
treat:
1st & 3rd trimester hemaglobin <11g/dL
2nd trimester <10.5
fetus begins to store iron after 20 wks
gravidity
any pregnancy, regardless of duration
parity
of times the uterus has emptied after 20 weeks
primipara “premip”
has given birth once to a fetus >20 weeks
grand multipara
five or more births >20 weeks
Nullipara “nullip”
never given birth to a fetus >20 wks
primigravida
pregnant for the first time
5 digit system
G - number of pregnancies of any length
P- TPAL
T - term births >37 wks, regardless outcome
P - preterm - # of births 20 wks - 37 wks
A - loss of pregnancy <20wks
L - number of currently living children
Stage 1 Early Phase
0-5cm
contractions q5-10min 30-60 seconds
other symptoms: loose stools, backache
support:
encourage alternative rest/activity. Distraction, hydrate, light meals, shower
empty bladder q2
Stage 1 Active Phase
6-10cm
contractions - stronger, more regular q3-5 min 60 seconds
late active 8-9 cm q1-3 min 90 seconds
apprehensive, engrossed in contractions
other sx: inc bloody show, inc pelvic pressure
support: active support with position changes, breathing, massage, focus
empty bladder q2
false labor
no rupture of membranes
irregular contractions, space out when lying down
no cervical changes
true labor
↑ in U/C
Frequency
Duration
Intensity (strength)
Progressive cervical dilation, effacement & descent of presenting part
Rupture of membranes
lie
relationship of long axis of fetus to long axis of mother
-longitudinal
- transvers
Presentation
what part enters pelvis 1st
-cephalic (vertex)
-breech
-shoulder
attitude
relationship of the fetal parts to one another
flexed, military, brow, face
Position
probable signs pregnancy
Objective
Those things the provider can observe/measure
eg. linea negra, palpation fetal outline, positive pregnancy test
Goodell’s, Hegar’s sign - changes to the uterus
Chadwick’s sign - cervix becomes blue
Braxton Hicks - false contractions (lower back pain, pelvic pain)
Uterine souffle - wooshing maternal pulse
Linea nigra -
Abdominal striae - stretch marks
Ballottement - bimanual cervical check reveals firmness (could be fibroids)
Palpation of fetal outline - fibroids
Abdominal enlargement - weight gain, ascites
Positive pregnancy test - can be false, rare Hcg secreting ovarian tumors
Presumptive signs pregnancy
Subjective
Those things the woman experiences and reports
eg. amenorrhea, nausea, vomiting
all have other possible causes
amenorrhea (can also be caused by birth control,
nausea
vomiting
urinary frequency
breast tenderness
darkened areola
quickening - feeling fetus move
weight gain
fatigue
engagement
baby at 0 station - presenting part is at ischial spine
above this is negative number, below is positive number (-5 - +5)
caput
natural generalized swelling of soft tissue - cone head
molding
overriding of the bones without damage to the brain
prevent hemorrhage - active mgmt 3rd stage
(after delivery of anterior shoulder or cord clamped)
Pitocin 10-40 U in IV 500-1000 ml LR fast
Pitocin 10 Units IM - not ideal - last resort
patients with placenta accreta:
Tranexamic Acid (TXA) after cord clamped
fundal massage AFTER the placenta is out (before can cause partial separation -> postpartum hemorrhage)
> 1000 mls blood loss
hemorrhage
pitocin
methergine 0.2 mg IM
cytotec (misoprostol) 800-1000mcg sublingual or rectally
hemabate 250 mcg IM, intracervical, intrauterine
TXA 1g in 100 ml NS IV of 10 minutes - first 3 hrs
urinary catheter to empty bladder
lacerations degrees -1st
vaginal mucosa and perineal skin
lacerations degrees - 2nd
1st degree + bulbocavernosus muscle, transverse & deep transverse muscles & fascia
lacerations degrees - 3rd
1st + 2nd + anterior anal sphincter
lacerations degrees - 4th
1st + 2nd + 3rd + anterior rectal mucosa
Lacerations heal as well or better than episiotomies
Chlamydia gonorhea
1st and 2nd most common
ophthalmic neonatorum
chlamydia –> pneumonia
e-mycin ointment asap postpartum
HSV
50-60% mortality w/ exposure to primary lesion - neuro complications, sepsis
prophylactic antiviral beginning wks 35-36, if 2-3 outbreaks during pregnancy
c-section of active lesions (vag safe if no active lesions 7 days)
