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Repro > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Three Cycles related to Pregnancy

A

Endometrial Cycle—thickening of the endometrium for pregnancy; shed 2 weeks after ovulation if no pregnancy

Hypothalamic-Pituitary Cycle—pituitary sends signals to the ovaries to develop and mature eggs

Ovarian Cycle—ovarian follicles are stimulated to mature and release an egg; implantation of fetus 7-10 days after ovulation

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2
Q

3 phases of ovarian cycle

A

Follicular: begins with the onset of menses; 1st day of menstrual cycle

Ovulatory: begins when estrogen levels peak and ends with release of oocyte (egg)

Luteal: begins on day of LH surge-Lasts approx. ~ 14 days (If pregnancy occurs, releases progesterone and estrogen until placenta matures; if no pregnancy; corpus luteum degenerates and progesterone decreases

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3
Q

Menstrual Cycle

Length
Duration
Total blood loss
Regularity impacted by (3)

A

Length: 24-36 days (average is 28; but varies cycle to cycle)

Duration: 3-6 days (average 5 days)

Total Blood loss: 20-80 mL (average 50 mL)

Regularity impacted by stress, exercise, nutrition

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4
Q

Prostaglandins

Action
Effects (7)

A

Action: oxygenated fatty acids; hormones

Effects
- Ovulation (ovum trapped if prostaglandin does not increase w/ LH surge)
- Fertility
- Changes in cervix and cervical mucus
- Tubal and uterine motility
- Sloughing of endometrium (menstruation)
- Onset of abortion (spontaneous and induced)
- Onset of labor (term and preterm)

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5
Q

Three ovulation indicators

A
  • Basal body temperature: drops 1 day (< 37 C) prior to ovulation then rises 1 degree at ovulation for 10 -12 days
  • Spinnbarkeit: Change in cervical mucus (abundant, watery, clear, more alkaline, ferns under microscope)
  • Mittleschmerz- localized abdominal pain that coincides with ovulation
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6
Q

Most cost-effective genetic test

A

Obtaining a family history going back 3 generations on both maternal and paternal sides
(most other genetic tests are not done unless risk factors)

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7
Q

Risk factors for miscarriages (9)

A
  • chromosomal abnormalities (25% of first trimester losses)
  • Prior pregnancy loss
  • Advanced maternal age (> 35 yrs)
  • Endocrine abnormalities (DM, luteal phase defects)
  • Drug use or environmental toxins
  • Autoimmune disorders (SLE)
  • Infections
  • Uterine or cervical abnormalities
  • black woman
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8
Q

How to obtain karyotype of fetus? (4)

A
  • amniocentesis (cells from amniotic fluid)- risk for miscarriage
  • cells from fetal blood
  • cells from fetal skin
  • CVS-Chorionic Villi sampling (sample from placenta b/w 9-11 weeks)
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9
Q

Autosomal Recessive Disorders

5 disorders

A
  • Sickle Cell Anemia- abnormal hgb molecule reducing oxygen carrying capacity; present among AA and Mediterranean
  • Tay Sachs Disease- hexosaminidase deficiency affecting lipid storage usually dead by 2 yrs; among Ashkenazi Jews and French Canadians in Quebec
  • Cystic Fibrosis- exocrine glands produce excessive viscous secretions leading to respiratory and digestive problems; among Caucasians
  • Phenylketonuria (PKU)- phenylalanine hydroxylase deficiency so limit phenylalanine (amino acid) in diet; among Northern Europeans
  • Thalassemia
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10
Q

Autosomal Dominant Disorders

2 disorders

A
  • xeroderma pigmentation
  • huntington’s disease ( uncontrollable muscle contractions b/w 30-50 yrs then loss of memory and personality)
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11
Q

Autosomal Recessive vs Autosomal Dominant

A

Autosomal Dominant-If one parent carries the gene, 50% chance of child being affected.

Autosomal Recessive Inheritance - both parents must be carriers and both pass on abnormal gene to child for trait, disorder, or disease to be present (1 in 4 chance each pregnancy)

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12
Q

Risk factors for chromosomal abnormalities (6)

A
  • maternal age > 35 yrs by due date (esp trisomy 21)
  • paternal age 50 or older
  • History of miscarriage or stillbirth
  • Diabetes in mom (not fam hx)
  • Family history of birth defects/genetic diseases (Huntington’s, Down Syndrome, Muscular dystrophy, hemophilia, cystic fibrosis, intellectual disability)
  • Family history of hypercholesterolemia and PKU
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13
Q

4 Tips for coping with prenatally diagnosed genetic disorder

A
  • Provide ongoing info on genetic disorder (including appropriate websites)
  • Refer couple to support group for parents w/ children w/ same genetic disorder
  • Encourage open communication b/w couple about feelings and concerns
  • Let couple know that it is normal for them to grieve over the loss of their “dream child”
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14
Q

Sex-linked abnormalities

Disorders (4)

A

Turner syndrome (short stature, risk for cardiac defect, failure of ovaries to develop) in Females=45, X.

Klinefelter Syndrome (infertility) in Males= 47, XXY

X-Linked- hemophilia (Lack of factor VIII impairs chemical clotting)

X-linked- Duchenne’s-muscular dystrophy (replace muscle tissue w/ adipose or scar tissue so progressive loss of muscle function; fatal by 20 yrs)

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15
Q

3 Conditions for Fertilization

A

Ovulation occurs -> mature ovum enters a patent fallopian tube (fimbriae of fallopian tube capture ovum and cilia propel ovum to uterus)

Sperm cells are deposited in vagina & travel to fallopian tube surviving 48 hrs (max 5 days)

One sperm cell must penetrate ovum usually in outer third of fallopian tube (ampulla) within 24 hours of ovulation.

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16
Q

Pre-embryonic fetal development

Zygote (3)
Morula (3)

A

Zygote
- secretes BhCG to signal pregnancy
- has 46 chromosome
- single fertilized oocyte

Morula
- develops by day 3
- 16-cell sphere
- outer cells secrete fluid creating blastocyst

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17
Q

Pre-embryonic fetal development

Blastocyst (4)

A

Blastocyst
- develops by day 5
- fetus develops from inner cell mass (embryoblast)
- placenta and membranes develop from outer layer (trophoblast)
- trophoblast becomes chorion and secretes enzymes for implantation around 6-10 days

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18
Q

Embryonic Period (3)

A
  • Week 3 through 8 of pregnancy
  • Period of organogenesis - highest risk of structural damage by teratogens (chemicals, drugs, viruses, fever)
  • rapid hyperplasia of fetal cells
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19
Q

Pregnancy Lengths

Total Pregnancy
Conception
1st trimester
2nd trimester
3rd trimester

A

Total Pregnancy: 40 weeks, 280 days
Conception: 2 weeks after 1st day of menstrual cycle
1st trimester: 1st day of LMP through 13 weeks
2nd trimester: Week 14 through 26
3rd trimester: Week 27 through 40+

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20
Q

Teratogenic Effects: 3-8 weeks (9)

A
  • Neural tube defects (anencephaly, spina bifida) at 4 wks due to inadequate folic acid
  • Limb defects
  • Intellectual disability
  • Cleft lip, cleft palate
  • Deafness
  • Microphthalmia (small eyes), cataracts, glaucoma
  • Enamel hypoplasia, staining
  • Masculinization of female genitalia
  • Heart Defects (Truncus arteriosus, VSD, ASD (heart problems)
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21
Q

Teratogenic Effects: 9 weeks to delivery (3)

A
  • Functional defects (IUGR or reduced organ size)
  • Minor anomalies( ears, eyes, teeth, palate, external genitalia)
  • CNS (vulnerable throughout pregnancy
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22
Q

Fetal Alcohol Syndrome characteristics (4)

A
  • low birth weight
  • microcephaly and mental retardation
  • unusual facial features due to midfacial ­hypoplasia
  • cardiac defects.
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23
Q

Teratogens (10)

A
  • Tobacco (IUGR, preterm, SIDS, nicotine = vasoconstrictor so decreased perfusion)
  • Heroin, methadone (IUGR, prematurity, Neonatal abstinence syndrome)
  • cocaine (increases maternal BP, IUGR, placental abruption, prematurity; organ defects)
  • alcohol (> 1 drink/day– fetal alcohol syndrome)
  • ionizing radiation (>10 rads)
  • radioiodine
  • Tetracycline
  • carbamazepine (NTDs)
  • ACE inhibitors (renal tubular dysplasia, IUGR)
  • warfarin (spontaneous abortion, hemorrhage)
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24
Q

Infections and Fetal Anomalies (11)

A
  • Toxoplasmosis (protozoan)- fetal demise, blindness, mental retardation
  • Cytomegalovirus- hydrocephaly, microcephaly, cerebral calcification, mental retardation, hearing loss
  • Syphilis (RPR)- skin, bone, or teeth defects; fetal demise
  • Varicella- hypoplasia of hands and feet, blindness or cataracts, mental retardation
  • Zika - microcephaly, blindness, hearing defects
  • HSV
  • Influenza
  • HIV
  • Chlamydia
  • HPV
  • Rubella
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25
Q

Prenatal Screening: Fetal Anomalies

Offered to?
Types (2)
Results for quad (2)

A
  • offered to all expectant women

Types
- Multiple Marker Screen (Triple, Quad or Penta Screen)– during 2nd trimester for Trisomy 21, Trisomy 18, NTD
- Cell free DNA (cfDNA) blood test for gender, trisomy 21 and 18 but not NTD

Results (quad screen)
- Alpha-Fetoprotein (AFP) is high = increased risk for NTDs
- Low AFP levels = increased risk for Trisomy 21 (Down Syndrome)

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26
Q

Prenatal Diagnostics: Fetal Anomalies

Offered to? (2)
Types (3)

A
  • offered to high risk OR positive screening

Types
- Chorionic Villi Sampling (CVS) at 11-13 weeks
- Amniocentesis at 14-16 weeks (results in 2 weeks)
- Percutaneous Umbilical Cord Sampling (PUBS)- assess for fetal anemia, isoimmunization; diagnosis genetic disorders

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27
Q

Pre-embryonic: Germ layers

Mesoderm (5)

A

Mesoderm
- bones (4th week)
- muscles (4th week)
- kidneys (5th week)
- hematologic system (bone marrow, blood, lymphatic tissue)
- Heart (4th week beats; forms in 3rd week

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28
Q

Pre-embryonic: Germ layers

Ectoderm (4)

A

Ectoderm
- CNS
- Integumentary (skin, hair, nails, sweat, oral mucosa)
- optic
- otic

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29
Q

Pre-embryonic: Germ layers

Endoderm (3)

A

Endoderm
- GI (liver, pancreas, esophagus, stomach)
- Respiratory
- Thyroid

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30
Q

Membranes: Amniotic fluid

Function (6)

A

Function
- maintain body temp
- barrier for infection
- musculoskeletal development (freedom for movement and symmetrical growth via prevention of membrane tangling)
- fetal lung development (swallow fluid)
- electrolyte balance (urinates around 11 wks)
- cushion

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31
Q

Membranes: Amniotic fluid

Structure (4)

A

Structure
- Volume is important to fetal well-being (700-1000 mL)
- contains mostly water plus urine (urea), lanugo hair, epithelial cells
- usually clear (brown/yellow if meconium)
- maintained by amniotic membrane then fetal kidneys

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32
Q

Membranes: Amniotic fluid

Problems (2)

A

Problems
- Oligohydramnios (< 500 ml) cause reduced fetal lung development, renal problems
- Polyhydramnios (>1500-2000 ml) cause chromosomal, GI, cardiac, and NTDs

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33
Q

Fetal Period (3)

A
  • 9 weeks to end of pregnancy
  • refinement of structure and function
  • viability (ability to live outside uterus, 22-25 weeks based on CNS and lung maturity)
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34
Q

Membranes: Umbilical cord

Function
Composition (2)
Problems (3)

A

Function: Supplies the embryo with maternal nutrients and oxygen

Composition
- Wharton’s jelly (CT cushions vessels from compression)
-2 arteries (carry deoxygenated blood from embryo to placenta), 1 vein (carry oxygenated blood from placenta to embryo- larger than 2 arteries)

Problems
- thin cord
- short cord
- cord w/ one artery and one vein (risk for cardiac or vascular anomaly)

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35
Q

Membranes: Placenta

Composition (3)
Problems (2)

A

Composition
- Chorionic villus (contains fetal blood vessels and imbeds in decidua basalis)
- intervillous space (contains maternal blood)
- Cell layer (prevents mixing of maternal and fetal blood)

Problems
- small placenta (poorly nourished and oxygenated child)
- teratogens can cross placenta (C, D, X drugs, live vaccines, viruses (rubella, cytomegalovirus)

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36
Q

Membranes: Placenta

Function (2)
Expected appearance

A

Function
- metabolic (exchange of gases, nutrients, wastes, and antibodies b/w fetus and maternal)
- endocrine gland (hCG, hCS, progesterone, estrogen, hPL, Growth hormone, Cortiotropin-releasing hormone)– insulin antagonists starting at week 6 or 7

Expected appearance
- maternal side dull, fetal side shiny

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37
Q

Membranes

Yolk Sac
Endometrium (2)

A

Yolk sac
- Becomes primitive digestive system

Endometrium
- Decidua parietalis (lines uterine cavity)
- Decidua basalis (maternal part of placenta; divided in cotyledons/lobes; hemorrhage here usually for miscarriage)

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38
Q

Hormones in Pregnancy: Follicle Stimulating Hormone (FSH)

Functions (5)

A

Secreted from the anterior pituitary
Stimulates growth of the ovarian follicles
stimulates the follicles to secrete estrogen.
Stimulates sperm production
Decreases in pregnancy (Amenorrhea)

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39
Q

Hormones in Pregnancy: Estrogen

Functions (6)

A
  • Secreted from the follicle cells,
  • promotes the maturation of the ovum
  • Stimulates enlargement of breasts and uterus.
  • Decreases maternal use of insulin.
  • Increases vascularity
  • responsible for hyperpigmentation
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40
Q

Hormones in Pregnancy: Luteinizing Hormone (LH)

Functions (2)

A

Secreted from the pituitary gland
Stimulates testosterone production

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41
Q

Hormones in Pregnancy: Progesterone

Functions (2)

A
  • Facilitates implantation by thickening and making endometrium more vascular
  • decreases uterine contractility to maintain pregnancy by relaxing smooth muscles
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42
Q

Hormones in Pregnancy: Human Chorionic Gonadotropin (hCG)

Functions (3)

A
  • produced by fertilized ovum and chorionic villi
  • Stimulates corpus luteum so it will secrete estrogen and progesterone until placenta takes over
  • Pregnancy tests detect this hormone in 1st trimester
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43
Q

Hormones in Pregnancy: Prolactin

Function

A

Prepares breast for lactation

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44
Q

Hormones in Pregnancy: Oxytocin

Functions (2)

A
  • Stimulates uterine contractions
  • stimulates milk ejection from breasts (milk let-down or ejection reflex)
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45
Q

Hormones in Pregnancy: Human placental lactogen (hPL) and human chorionic somatomammotropin (hCS)

Functions (2)

A
  • insulin antagonist (promotes fetal growth by regulating glucose)
  • stimulates breast development in preparation for lactation.
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46
Q

Fetal Developmental Milestones: 9 weeks (2)

A
  • urine in amniotic fluid
  • male/female anatomy (9-12 weeks)
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47
Q

Fetal Developmental Milestones: 12 weeks (5)

A
  • Placenta complete
  • organ systems complete
  • thumb sucking
  • somersaults
  • heart tone heard on doppler
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48
Q

Fetal Developmental Milestones: 16 weeks (3)

A
  • meconium in bowel
  • sucking motions
  • skin transparent
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49
Q

Fetal Developmental Milestones: 20 weeks (6)

A
  • hearing develops
  • quickening
  • vernix caseosa and lanugo covers body
  • sleep/wake cycles
  • insulin produced
  • brown fat develops
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50
Q

Fetal Developmental Milestones: 24 weeks (4)

A
  • rapid brain growth
  • hiccups
  • vernix caseosa = thick
  • Lecithin (L) present (lungs begin producing surfactant)
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51
Q

Fetal Developmental Milestones: 28 weeks (5)

A
  • Lungs allow gas exchange)
  • hair on head
  • eyes open and close
  • senses develop (taste buds, process sounds)
  • subQ fat develops
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52
Q

Fetal Developmental Milestones: 32 weeks (3)

A
  • bones fully developed
  • increased subQ fat
  • Lecithin/sphingomyelin (L/S) ratio (1.2:1) - enough surfactant to increase survival
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53
Q

Fetal Developmental Milestones: 36 weeks (3)

A
  • decreased amniotic fluid
  • Lanugo disappears
  • Lecithin/sphingomyelin (L/S) ratio > 2:1 (lungs mature)
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54
Q

Fetal Developmental Milestones: 40+ weeks (2)

A
  • considered full term at 38 weeks
  • Hepatic (enough iron for 5 months post birth)
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55
Q

Fetal Circulatory System

Functions
- ductus venosus (2)
- foramen ovale (2)
- ductus arteriosus (3)

A

Ductus venosus
- Connects umbilical vein to inferior vena cava
- Allows most of oxygenated blood to enter right atrium

Foramen ovale
- may not fully close till 3 months of age
- Opening b/w right and left atria which shunts oxygenated blood right-to-left

Ductus arteriosus
-lungs do not function for gas exchange; ductus arteriosus (b/w aorta and pulmonary artery) used to bypass lungs
- Majority of oxygenated blood shunted from left atria to aorta; small amount to lungs
- Constricts after delivery due to higher blood oxygen levels and prostaglandins

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56
Q

What do the following mean:

Mono-di
mono-mono
di-di

A

Mono-di: share placenta but own amniotic sac for monozygotic twins

Mono-mono: share placenta and amniotic sac for monozygotic twins

di-di: own placenta and own amniotic sac for fraternal twins twins

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57
Q

Presumptive Signs of Pregnancy (7)

A
  • any subjective symptoms reported by patient
  • Amenorrhea
  • Nausea/vomiting (weeks 2-12)
  • Breast changes (sore, enlarged) - wks 2-3
  • Fatigue (1st trimester)
  • Increased Urinary frequency (pressure of enlarged uterus)
  • Quickening (sensation of fetal movement around 18-20 wks)
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58
Q

Probable signs of Pregnancy (7)

A
  • Chadwick’s sign (bluish-purple cervix) - 6-8 wks
  • Goodell’s sign (cervix softens w/ leukorrhea) - 8 weeks
  • Hegar’s sign (softened lower uterine segment) - 6 weeks
  • Uterine growth
  • Skin hyperpigmentation (chloasma, linea nigra)
  • Ballottement (tap of examiner finger causes fetus to bounce in amniotic fluid) - 16-18 wks
  • Positive pregnancy test (hCG blood, urine or home test) - detects anywhere from 1 week before missed period to 4 weeks gestation
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59
Q

Positive signs of Pregnancy (3)

A
  • Auscultation of fetal heart (normal: 110-160 bpm) - 10-12 wks
  • Observation and palpation of fetal movement by provider - 20 wks
  • Sonographic visualization (cardiac movement or gestational sac) - 4-8 wks
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60
Q

Determining Pregnancy Due Date

Naegele’s rule (2)

A
  • 1st day of LMP + 7 days - 3 months = EDD
  • inaccurate if irregular cycles or cycles > 28 days
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61
Q

Determining Pregnancy Due Date

Ultrasound (2)

A
  • measure crown-rump length (< 14 weeks)
  • measure Biparietal diameter, Head circumference, Femur length, Abdominal circumference (> 14 weeks)
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62
Q

Determining Pregnancy Due Date

Fundal height (4)

A
  • in cm = gestational age starting at 10-12 weeks
  • zero tape on symphysis pubis and top on fundus
  • empty bladder prior to measurement
  • unreliable in obese, IUGR, multi-gestation
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63
Q

Ultrasound: When indicated? (7)

A
  • used when unclear hx of LMP or irregular cycles
  • Pelvic pain or vaginal bleeding in first trimester
  • Hx of repeated pregnancy loss or ectopic pregnancy
  • Discrepancy b/w actual size and expected size of pregnancy based on history
  • screen for aneuploidy (enlarged nuchal translucency i.e fluid filled space on dorsal of neck))
  • Fetal biometric measurements (gestational age measurements, growth, activity, amnionicity, number)
  • identify placental placement
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64
Q

Ultrasound: Transabdominal

Notes (3)

A
  • Pt in supine position
  • Full bladder necessary in first half of pregnancy
  • Transmission gel and transducer placed on abdomen to create image
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65
Q

Ultrasound: Transvaginal

Notes (5)

A
  • done in 1st trimester or if abdominal inconclusive b-c more accurate
  • Pt in lithotomy position
  • HCP uses sterile probe or transducer in vagina
  • Assess for latex allergies
  • Inform pt. they will feel pressure but not pain
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66
Q

Adaptations in Pregnancy: Endocrine (4)

A
  • Thyroid (hyperplasia and increased vascularity) - causes heat intolerance and fatigue
  • Decreased Glucose due to high BMR from fetal activity
  • Increased insulin and pancreatic activity due to fetal depletion of glucose
  • Increased cortisol (which increases risk of hyperglycemia if maternal resistance to insulin)
67
Q

GTPAL

A

Gravida: total # of times woman has been pregnant (INCLUDES CURRENT PREGNANCY and no regard to # of fetus)

Term: # of births after 20 weeks’ gestation whether live or stillbirths ( twins= 1 delivery)

Preterm: number of Preterm deliveries (b/w 20 weeks & 1 day to 36 weeks & 6 days)

Abortion: number of Abortions (either spontaneous/miscarriage or induced) before 20 weeks’ gestation

Living: number of children currently Living (not including adopted or step children)

68
Q

Adaptations in Pregnancy: Skin (7)

A
  • striae (thighs, breast, buttocks, abdomen–usually darkish gray)
  • chloasma (mask of pregnancy, brownish pigmentation on face)
  • linea nigra (dark line on abdomen)
  • acne (due to increased estrogen, progesterone, sebaceous glands secretions)
  • Angiomas (spider nevi)
  • Palmar erythema (pinkish-red mottling over palms of hands; red fingers)
  • Vasomotor instability (hot flashes, flushing, alt hot and cold, increased perspiration)
69
Q

Adaptations in Pregnancy: Breast (3)

A
  • tenderness
  • enlarged and darkened areola
  • colostrum @ 16 weeks
70
Q

Benefits of left lateral recumbent position (4)

A
  • Maximize cardiac output, renal plasma volume, and urine output.
  • Stabilize fluid and electrolyte balance.
  • Minimize dependent edema.
  • Maintain optimal blood pressure.
71
Q

Adaptations in Pregnancy: Cardiac (10)

A
  • heart shifts up and to the left
  • systolic murmur and S3
  • 45% increase in blood volume
  • anemia (physiologic b-c hemodilution of high volume more than polycythemia AND iron-deficiency from fetal demand)
  • high WBC (no infection)
  • decreased systemic vascular resistance
  • increased circulation (10-20 bpm increase)
  • supine hypotension ( enlarged uterus compresses inferior vena cava so reduced blood flow to right atrium; decreased CO, BP, GFR, and urine output
  • varicose veins and venous stasis (incl. hemorrhoids
  • hypercoagulability (increased fibrin and decreased inhibition of coagulation)- low platelets
72
Q

Adaptations in Pregnancy: Respiratory (4)

A
  • increased nasal congestion and epistaxis
  • upward displacement of diaphragm (dyspnea, decreased capacity)
  • increased oxygen needs ( high RR, increased inspiratory capacity and decreased expiratory volume)
  • slight hyperventilation (light respiratory alkalosis)
73
Q

Adaptations in Pregnancy: Renal (4)

A
  • increased UTI risk due to dripping
  • delayed emptying times (urinary stasis b-c poor tone)
  • Hyperemia (increased renal blood flow b-c increased CO and blood volume)– decreased in 3rd trimester
  • glycosuria and proteinuria (b-c exceeds tubal reabsorption threshold)
74
Q

Adaptations in Pregnancy: Gastrointestinal (8)

A
  • NV due to HcG (better by 16 weeks)
  • lost of esophageal tone (heartburn)
  • delayed emptying (normal may be BM q3days)
  • displaced intestines (bloating, flatulence, cramping, pelvic heaviness, constipation)
  • gingivitis/bleeding gums r/t vascular congestion
  • change in taste and smell ( Pica, aversions)
  • gallstones and cholestasis (b-c bile stasis and elevated LDL, Pruritis is sign)
  • profuse salivation (ptyalism)
75
Q

Adaptations in Pregnancy: Musculoskeletal (5)

A
  • round ligament spasm
  • waddle gait (softens ligaments; increases joint mobility)
  • lordosis (lumbar curvature to compensate for change in center of gravity)
  • widening and increased mobility of pubis
  • diastasis recti (separation of rectus abdominis muscles in midline; benign in 3rd trimester)—weakened muscles
76
Q

Adaptations in Pregnancy: Uterus (3)

A
  • Cervical mucus plug (protective barrier b/w uterus and vagina via hypertrophy of cervical glands) – opens during labor
  • Braxton-Hick’s contractions (2nd trimester; intermittent and painless; irregular pattern)
  • changes from elastic and muscular to thin in pregnancy
77
Q

Adaptations in Pregnancy: Vagina (3)

A
  • Increased acidity to prevent bacteria (allows Candida albicans)
  • Relaxation and softening of wall and perineal body to stretch
  • Leukorrhea: increased discharge in response to estrogen-induced hypertrophy of glands and increased vascularity
78
Q

Discomforts in Pregnancy: Nausea and Vomiting

Tips (3)

A
  • level blood sugar before getting out of bed (eat crackers)
  • scopolamine patch
  • biggest concern = dehydration (hyperemesis gravidarum)
79
Q

Discomforts in Pregnancy: Headaches

Tips (4)

A
  • Tylenol
  • hydration
  • tap of caffeine
  • normal discomfort in 1st trimester; concern in 3rd trimester due to possible hypertension and preeclampsia)
80
Q

Discomforts in Pregnancy: Indigestion/heartburn

Tips (3)

A
  • antacids (tums)
  • stay upright postprandial
  • eat smaller meals
81
Q

Discomforts in Pregnancy: Frequent urination

Tips (5)

A
  • urinate as soon as the urge comes (b-c UTI from stasis possible and can lead to preterm pregnancy or pylonephritis)
  • encourage wearing pads for dripples
  • do kegel exercises (prevent prolapse as well)
  • do not limit fluids
  • Prevent UTI (wipe front to back, cotton underwear, voiding after intercourse, and not douching)
82
Q

Discomforts in Pregnancy: Backache

Tips (4)

A
  • wear good supportive bra b-c heavy breast can impair posture
  • maternity belt and clothes to support uterus esp in multigravida or multi-gestation
  • use pillow b/w legs
  • Tylenol
83
Q

Discomforts in Pregnancy: Constipation

Tips (6)

A
  • hydration
  • increased fiber
  • avoid straining
  • understand BM q3day (may be impaction if > 5 days)
  • never use enema during pregnancy
  • stool softeners are okay but risk for rebound constipation
84
Q

Prenatal Care: Frequency of visits (4)

A
  • monthly until 28 weeks
  • Biweekly until 36 weeks
  • Weekly until delivery/ 40 weeks
  • twice a week over 40 weeks
85
Q

Initial Prenatal Visit: Assessment (6)

A
  • 1st day of LMP and degree of certainty about the date (Regularity, frequency, and length of menstrual cycles
  • hx of current pregnancy (knowledge of conception date, Recent use or cessation of contraception, Signs and symptoms of pregnancy)
  • psychosocial concerns (intended or unintended?, woman’s response to being pregnant, familial and partner support)
  • Obstetrical history (GTPAL, Type of birth experiences, complications and neonatal outcomes)
  • Physical and pelvic exams (bimanual)
  • Fetal Heart rate w/ ultrasound doppler around 10-12 wks.
86
Q

Initial Prenatal Visit: Labs (7)

A
  • ABO and Rh (RhoGAM @26-28 wks if Rh-)
  • Hct/Hgb (detect anemia, give iron if low)
  • serological (varicella, rubella, syphilis, gonorrhea, chlamydia, HIV)
  • Urine culture and protein ( UTI)
  • HepB (Hep B vaccine at birth)
  • HPV (pap q3 yrs even if pregnant till 30 then q5 yrs)
  • TB skin test (if high risk)
87
Q

First Trimester: Warning Signs (6)

A
  • Vaginal bleeding (postcoital spotting is normal)
  • Urinary symptoms (dysuria, frequency, urgency)- (UTIs need antibiotic)
  • Abdominal cramping or pain( threatened abortion, UTI, or appendicitis)
  • Absence of fetal heart tone (missed abortion)
  • Fever or chills (infection)
  • Prolonged NV (hyperemesis gravidarum, risk of dehydration)
88
Q

2nd and 3rd Trimester: Assessments (8)

A
  • BP decreases slightly at end of 2nd trimester
  • Urine dipstick for glucose, albumin, ketone (mild proteinuria and glucosuria normal)
  • Fetal- quickening (confirms EDD), FHR, kick count
  • Leopold’s maneuvers (palpation of abdomen) to identify fetus in utero
  • Ultrasound (to confirm EDD
  • Fundal height measurement (equal weeks of gestation)
  • Edema (slight in lower body is normal, abnormal if upper body esp. face)
  • discuss psychosocial (fetal attachment, sexual activity, familial support, body image)
89
Q

Second Trimester: Labs (3)

A
  • Glucola (1-hr @ 24-28 weeks, earlier if obese; not done if pregestational diabetic)
  • ABO and Rh (RhoGAM @26-28 wks if Rh-)
  • Hct/Hgb (detect anemia, give iron if low) @ 29-32 weeks
90
Q

2nd and 3rd Trimester: Warning Signs (5)

A
  • Absence of fetal movements once felt ((fetal hypoxia or death))
  • s/s of preeclampsia (swelling in face; new onset heartburn (liver involvement), severe headache, visual changes)
  • Rhythmic intermittent Abdominal or pelvic pain ( PTL, UTI, pyelonephritis, or appendicitis)
  • Vaginal bleeding (possible infection, friable cervix due to pregnancy changes, placenta previa, abruptio ­placenta, or PTL)
  • Leaking of amniotic fluid (PROM)
91
Q

Assessments: Fetal Kick Count

Procedure
Reassuring (2)

A

Procedure: pt. palpates abdomen and tracks fetal movement (kicks, flutters, swishes, rolls) daily for 1-2 hrs while at home

Reassuring:
- at least 10 movements in 2 hrs
- at least 4 movements in 1 hr.

92
Q

Third Trimester: Labs (3)

A
  • GBS vaginal and rectal swab at 35-37 wks (intrapartal antibiotics if positive)
  • repeat STI (gonorrhea, chlamydia, syphilis, HIV, Hep B)
  • do glucola, H&H if not done in 2nd
93
Q

Pregnancy Education: Safety (6)

A
  • avoid chemicals (hair dyes) in first trimester
  • avoid piercings and tattoos
  • avoid contact w/ cat feces (no cleaning or changing litter box- toxoplasmosis risk)
  • cook all EGGS, MEATS,FISH thoroughly
  • do not eat food left out for > 2hrs
  • rinse all rare fruits and veggies
94
Q

Pregnancy: Foods to avoid (7)

A
  • sushi or smoked seafood)
  • cold deli meats and hot dogs (must be heated) (listeriosis risk)
  • unpasteurized products (brie, camembert, feta cheeses; juices, dairy)
  • limit caffeine to 200 mg (includes coffee, tea, soft drinks, cocoa butter)
  • rare beef or lamb (toxoplasmosis risk)
  • Certain fish (king mackerel, orange roughie, marlin, shark, swordfish, tilefish) due to high mercury
  • Raw sprouts of any kind
95
Q

Pregnancy Education: Travel (3)

A
  • okay up until 36 weeks if low-risk
  • travel w/ prenatal records for safety
  • extended travel puts you at risk for blood clots (stay hydrated, take baby aspirin, wear antiembolism stockings)
96
Q

Pregnancy Education: Dentition (3)

A
  • good oral care (increased gingivitis risk)
  • x-rays are okay
  • get two dental screenings
97
Q

Pregnancy Education: Exercise (3)

A
  • recommended 30 minutes each day
  • swimming and brisk walking are good
  • Not recommended (things that can fall or easy loss of hydration): horse riding, hot yoga, sauna, hot tubs
98
Q

Psychosocial Adaptation in Pregnancy

Changes in Trimesters (2)

A

Changes with trimester
- Ambivalence in 1st trimester (Concern if ambivalence in 3rd trimester)
- nesting behavior in 3rd trimester

99
Q

Psychosocial Adaptation in Pregnancy

Factors that influence maternal adaptation (9)

A
  • parity (multiparity have more info but may grieve special bond w/ first child)
  • maternal age (adolescence and older have difficult time)
  • sexual orientation (social stigma, heteronormativity of care, legal implications for gender miniorites)
  • single parenting (legal and financial concerns)
  • hx of abuse (pregnancy can trigger or worsen IPV)
  • multigestational
  • military deployment (higher mental health disorders)
  • cultural and SES factors
  • planned vs unplanned
100
Q

Maternal Adaptation in Pregnancy

Significant tasks (4)

A
  • Ensure safe passage of child and self (knowledge and care-seeking)
  • Ensure social acceptance of child by significant others
  • Attaching or binding in to the child (maternal-fetal attachment)
  • Giving oneself to demands of motherhood (willingness and efforts to make personal sacrifices for child)
101
Q

Maternal Adaptation in Pregnancy

Dimensions of Maternal Role Development (6)

A
  • Acceptance of pregnancy
  • Identification with motherhood role
  • Relationship to her mother (Ideal is positive and relates to daughter as adult vs child)
  • Reordering partner relationships ( sexual activity, impact of pregnancy on relationship, partner support) - open communication is key
  • Preparation for labor (via classes, reading, fantasizing, dreaming)
  • fears about labor (self-esteem, helplessness, loss of control over body and emotions))
102
Q

Paternal Adaptation in Pregnancy

Effects of Pregnancy on Partner (2)

A
  • Partners have fears, questions, concerns esp anxiety and worry
  • Couvade syndrome/sympathetic pregnancy: pregnancy-like symptoms similar to pregnant pt such as minor weight gain, altered hormone levels, morning nausea, disturbed
103
Q

Paternal Adaptation in Pregnancy

Announcement phase (3)

A

Announcement Phase (as news of pregnancy is revealed)
- Lasts from hours to weeks
- Internal conflict if partner feels different from societal expectations (Often men feel ambivalence in early pregnancy and postpartum)
- Main task: accept biological fact of pregnancy and accept expectant father role

104
Q

Paternal Adaptation in Pregnancy

Moratorium Phase (3)

A

Moratorium Phase
- Often put conscious thought of pregnancy aside
- Problems: Conflict when woman communicates about pregnancy to partner, Fear of hurting fetus during intercourse, Feeling of rivalry with fetus
- Main task: accept pregnancy including pt’s emotional state, reality of fetus usually in 2nd trimester when changes in pt body, fetal movements

105
Q

Paternal Adaptation in Pregnancy

Focusing phase (3)

A

Focusing Phase (last trimester)
- Actively involved in pregnancy and relationship with child
- See self as father
- Main task: negotiate w/ patient the role they will play in labor and prepare for parenthood

106
Q

Sibling Adaptation to Pregnancy

Under 2
2-4 yrs
4-5 yrs
school-age
adolescence

A
  • Under 2, usually unaware and do not understand explanations about new arrival
  • 2-4 yrs, sensitive to environmental disruptions esp parental behavior and changes in home (may regress or show jealousy) – prep 2 months in advance
  • 4-5 yrs, interested in fetal development unless interferes w/ maternal ability to lift and play w/ them
  • School age (6-12), usually enthusiastic and interested in details of pregnancy and birth
  • Adolescent, May be uncomfortable w/ evidence of parent’s sexuality OR indifferent OR offer support and help like an adult
107
Q

Nutritional Needs for Pregnancy

Calories
Needs (2)
Cravings

A

Caloric requirements
- 300 extra calories

Needs
- Vitamins (folic acid)
- Hydration (8 to 10 glasses)

Cravings
- Pica: nonnutritive cravings (clay, dirt, starch)—can be toxic or lead to malnutrition

108
Q

Suggested Weight Gain during Pregnancy based on Pre-pregnancy BMI

Underweight (<18.5)
Normal (18.5-24.9)
Overweight (25-25.9)
Obese (>30)

A

Underweight: 28-40 lb
Normal: 25-35 (37-54 for twins)
Overweight: 15-25 (31-50 for twins)
Obese (>30): 11-20 (25-42 for twins)

109
Q

Difference b/w the following

Miscarriage
Spontaneous abortion
Early Pregnancy loss

A

Miscarriage: loss of intrauterine pregnancy before 20 weeks/viability

Spontaneous abortion: Nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus w/o fetal heart activity within the first 12 6⁄7 weeks of gestation

Early Pregnancy loss: Spontaneous pregnancy demise before 10 weeks of gestational age

110
Q

Miscarriage: Assessment Findings

S/s (2)
Confirmation (2)

A

S/s
- Uterine bleeding and cramping
- infection (fever, uterine tenderness, foul smell)

Confirmation: Ultrasound (if had previous ultrasound, now is bleeding and has an empty uterus) or serial HCG

111
Q

Miscarriage: Medical Management (3)

A
  • surgical evacuation
  • mistoprostol (prostaglandin) - 800 microgram to remove products
  • Rhogam (50 micrograms) if Rh- and unsensitized (given 72 hrs after diagnosis)
112
Q

Miscarriage: Patient Education (5)

A
  • report heavy bleeding (if soak 2 pads in 1 hr for 2 hrs) esp if mistoprostol used
  • prevent miscarriage w/ vaginal micronized progesterone in women w/ hx of early pregnancy bleeding and miscarriage
  • diet high in iron and protein to replace blood loss
  • Pelvic rest (Nothing per vagina i.e. no tampons, douching, sexual intercourse
  • Pericare (hygiene, prevent hemorrhage and infection)
113
Q

Risks of recurrent miscarriages (2)

A
  • obstetric complications in future pregnancies
  • predictor of CVD and VTE
114
Q

Swanson’s Theory of Caring (r/t miscarriages)

5 concepts

A
  • Knowing (assess needs, what did the loss mean to them)
  • Being with (listen, be present, accepting their emotions/feelings)
  • Doing for (performing interventions the patient and/or partner can’t do for themselves)
  • Enabling (gives options for care,guides, educates,empowers the couple; encourage to name baby and use baby name)
  • Maintaining hope (instills believe in their ability to cope and move through)
115
Q

Miscarriage: Psychosocial Education (5)

A
  • Educate parents about what to expect (What the baby might look like)
  • Encourage them to hold the baby.
  • Ask them what they want (Funeral, burial, chaplain, pastor, priest)
  • Encourage memory making with the family (Take photos, footprints, use a special gown for the baby, provide blankets and bereavement boxes as the hospital provides)
  • Allow as much time with the baby as they want.
116
Q

Maternal risks of Hypertension/Preeclampsia (6)

A
  • Renal Failure
  • Coagulopathy (DIC, thrombocytopenia)
  • Cardiac (higher risk for heart disease, CHF, Pulmonary edema)
  • hepatic Failure (HELLP)
  • Placental abruption
  • CNS (Stroke, cerebral edema, hemorrhage)
117
Q

Fetal risks of Hypertension/Preeclampsia (6)

A
  • Uteroplacental Insufficiency (placenta abruption, hypoxia, asphyxia)
  • intolerance of labor (Premature Birth)
  • IUGR
  • metabolic and Cardiovascular diseases (DM, obesity, metabolic syndrome)
  • oligohydramnios
  • stillbirth
118
Q

Define the following:

Gestational Hypertension
Preeclampsia
Eclampsia (2)

A

Gestational hypertension
- Onset of hypertension without proteinuria after week 20 of pregnancy and returns to normal 12 weeks postpartum

Preeclampsia (Pregnancy-specific syndrome)
- new onset hypertension and proteinuria develop after 20 weeks of gestation in a previously normotensive woman

Eclampsia
- Onset of seizure activity or coma in a woman with preeclampsia
- can occur during pregnancy or postpartum

119
Q

Define the following:

Chronic hypertension (2)
Chronic hypertension w/ superimposed preeclampsia (2)

A

Chronic hypertension
- Hypertension present before pregnancy or diagnosed before week 20 of gestation
- Persist longer than 12 weeks postpartum

Chronic hypertension with superimposed preeclampsia
- Chronic hypertension with new onset proteinuria
- Significant worsening of hypertension or proteinuria

120
Q

Chronic Hypertension: Patient Education (4)

A

-severity of HTN and organ damage assessed at initial visit to determine risk for complications
- limit sodium to 2.4 g per day
- use methyldopa (Aldomet) OR labetalol, hydralazine, nifedipine– safe for breastfeeding
- increase # of prenatal visits

121
Q

4 Causes of Preeclampsia

A
  • Abnormal Placental implantation with abnormal trophoblasts invasion of uterine vessels at 8-10 wks gestation (higher systemic resistance) - (early onset before 34 wks gestation)
  • Immunological maladaptive tolerance between maternal, paternal (placental), and fetal tissues ((late onset after 34 wks gestation)
  • Maternal maladaptation to cardiovascular changes or inflammatory changes of pregnancy
  • Genetic factors incl. inherited predisposing genes and epigenetic influences
122
Q

6 Signs and Symptoms of Preeclampsia

A
  • HTN > 140/90 on 2 occasions (4-6 hrs apart)
  • Proteinuria = 2+ or 3+ dip on 2 occasions (6hrs apart) OR > 300 mg in 24 hrs
  • Dependent or pitting edema (esp on face, hands, feet)
  • CNS (Blurred vision, Scotoma (blindspot), headache, irritability)
  • Hepatic signs (RUQ pain, jaundice, elevated enzymes)
  • muscle changes (Hyperreflexia (DTR 3+ or 4+, clonus), seizures, coma)
123
Q

Risk factors for preeclampsia (8)

A
  • Nulliparity
  • Age >35 years
  • Pregnancy with assisted reproductive technology
  • Family hx or personal hx of preeclampsia; poor outcome in pregnancy
  • Interpregnancy interval >7 years
  • Woman herself born small for gestational age
  • obesity (> 30 prepregnancy)
  • multifetal gestation
124
Q

7 Medical Conditions which increase risk for Preeclampsia

A
  • Renal disease
  • Type 1 DM or GDM
  • Antiphospholipid antibody syndrome
  • Factor V Leiden mutation
  • Autoimmune (SLE)
  • chronic HTN
  • thrombophilia
125
Q

General Patho of Preeclampsia

A
  • poor perfusion to placenta secondary to vasospasm, increased peripheral resistance, and increased endothelial cell permeability leading to poor tissue perfusion
126
Q

Preeclampsia: Consequences of Vasospasm (7)

A
  • hypertension
  • uteroplacental spasm (IUGR)
  • glomerular damage (oliguria, increased plasma, uric acid, creatinine, calcium; decreased GFR)
  • cortical brain spasm ( headaches, hyperreflexia, seizures)
  • retinal arteriolar spasm (blurred vision, scotoma, double vision, photophobia)
  • hyperlipidemia
  • liver ischemia (elevated liver enzymes, NV, epigastric pain (microvascular fat deposits), RUQ pain (hemorrhage necrosis))
127
Q

Preeclampsia: Consequences of Intravascular coagulation (3)

A
  • hemolysis of RBCs
  • platelet adhesion (thrombocytopenia, Disseminated intravascular coagulation)
  • increased factor VIII antigen
128
Q

Preeclampsia: Consequences of Increased permeability/capillary leakage (4)

A
  • proteinuria
  • generalized edema
  • pulmonary edema (dyspnea; left ventricular failure b-c high vascular resistance)
  • hemoconcentration (high hct)
129
Q

9 Signs of Severe Preeclampsia

A
  • oliguria
  • platelets < 100,000 (thombocytopenia)
  • BP > 160/110 (4-6 hrs apart x 2)
  • Proteinuria (> 3+ dip or > 500 mg 24 hr)
  • Creatinine > 1.1 or doubled in absence of renal disease
  • Elevated liver enzymes (2x normal)
  • New onset cerebral or visual disturbances (headaches, blurred vision, scotoma (blind spot), hyperreflexia), photophobia
  • Persistent epigastric pain (RUQ pain) due to subcapsular hematoma in liver from hemorrhagic necrosis
  • Pulmonary edema (r/t volume overload from high vascular resistance)—s/s: SOB, chest tightness, cough O2 < 95%, increased RR or HR, apprehension, anxiety, restlessness
130
Q

Severe Preeclampsia: medical management

Goal
Notes (5)

A

Goal: control BP and prevent seizures

  • corticosteroids (fetal lung maturity) if preterm
  • magnesium sulfate
  • benzos (if magnesium sulfate contraindicated)
  • antihypertensives
  • Induced birth indicated at >34 weeks if unstable or with severe features to prevent poor outcomes (hospitalization if < 34 weeks)
131
Q

Preeclampsia: Antihypertensives

Tips (4)

A
  • Given within 30-60 minutes for severe hypertension
  • No need for cardiac monitoring if IV or immediate release
  • Monitor BP q5-15 mins
  • Give q20 min PRN
132
Q

Severe Preeclampsia: Nursing management (6)

A
  • Continuous EFM ( intrauterine resuscitation of fetus (IV fluid, O2, lateral position))
  • Seizure precautions (side-lying)
  • Limit stimulation (Quiet environment, dim lighting, relaxation techniques)
  • Strict I & O and daily weights (fluid < 2 L/24 hr)
  • check DTRs (brachial if regional anesthesia used)
  • check BP at level of heart (not left lateral b-c gives false low)
133
Q

Biophysical Profile

5 components
Normal value
Abnormal Value

A

Components: nonstress test (NST), fetal movement, fetal breathing, fetal tone, and amniotic fluid index (AFI))

Normal: 8 (w/ NST) to 10 (w/ reactive NST)

Abnormal: <4 = fetal compromise

134
Q

Umbilical artery Doppler velocimetry

Purpose (2)
Normal value
Abnormal Values (2)

A

Purpose:
- Shows fetal compromise (IUGR) or placental dysfunction prior to clinical signs
- measure hemodynamic changes in fetal and placental circulation

Normal: Systolic/Diastolic ratio declines w/ pregnancy due to decreased placental resistance

Abnormal
- increased S/D ratio in IUGR due to arthrosis of placenta vessels increasing resistance in preeclampsia
- absent or reversed-end diastolic flow through arteries (deoxygenated blood should be in arteries and carry to placenta, veins carry oxygenated blood)

135
Q

Preeclampsia: medical management

Mild (5)

A
  • low dose prophylaxis aspirin
  • Activity restriction
  • Frequent office visits (weekly)
  • BP monitoring
  • Antenatal testing (BPP, NST, kick counts, serial ultrasounds)
136
Q

Magnesium sulfate

Use
Action
Loading dose
Continuous dose
Therapeutic level
Antidote

A

Use: CNS depressant/muscle relaxant to prevent seizures

Action: Promotes cerebral vasodilation and reduce ischemia caused by vasospasm

Loading dose: 4-6 grams in 100 ml over 15-20 minutes

Continuous piggyback infusion: 1-2 g/hr in 100 ml

Therapeutic level: 4.8-9.6 mg/dl (4-7 mEq/L)

Antidote: calcium gluconate

137
Q

Magnesium sulfate

Maternal Side effects (8)

A
  • Hot flashes and sweating
  • burning at IV site
  • N&V
  • dry mouth
  • drowsiness, lethargy
  • blurred vision
  • SOB
  • transient hypotension
138
Q

Magnesium sulfate

Fetal Side effects (4)

A
  • decreased variability
  • respiratory depression
  • hypotonia
  • decreased suck reflex
139
Q

Magnesium sulfate

Nursing Care (5)

A
  • monitor CNS (DTRS, clonus) q 1 hr
  • may need oxytocin stimulation for contractions
  • give 24 hr after delivery (discontinue within 48 hrs)
  • Verify dose / second nurse
  • Labs: Serum magnesium levels q 4-6 hours
140
Q

Magnesium sulfate

Signs of Magnesium Toxicity (7)

A
  • hypocalcemia (muscle weakness)
  • RR < 12/min
  • absent DTRs
  • Mg level > 8mEq/dl
  • Urine output < 30/hr
  • slurred speech
  • dysrhythmias and circulatory collapse
141
Q

Magnesium sulfate

Contraindications (3)

A
  • renal failure
  • myasthenia gravis
  • pulmonary edema
142
Q

HELLP Syndrome

3 parts

A

Hemolysis (RBC destruction via constricted vessels)- total bilirubin > 0.2, abnormal peripheral smear

Elevated Liver Enzymes (Decreased blood flow and Damage to the liver)- AST > 70, RUQ pain, NV, malaise

Low platelets (<100,000)- Platelets aggregate at the site of damaged endothelial vessels (platelet consumption and thrombocytopenia)– easy bleeding, bruising

143
Q

HELLP Syndrome

Onset
Risks (3)
Treatment (2)

A

Onset: any time including postpartum

Risks: placental abruption (PTL, death), renal failure, liver hematoma

Treatment
- Delivery but may worsen in first 48 hrs postpartum
- platelet replacement

144
Q

Hydralazine (Apresoline)

Side Effect
Contraindication

A
  • Side effect: maternal hypotension
  • Contraindication: mitral valve disease
145
Q

Labetalol Hydrochloride (Normodyne)

Side Effect
Contraindications (3)

A

Side Effect: neonatal bradycardia
Contraindication: HF, heart disease, asthma

146
Q

Nifedipine (Procardia)

Side Effects (2)

A

maternal tachycardia and overshoot hypotension

147
Q

Corticosteroids (betamethasone, dexamethasone)

Use
Action
Dosage (2)
Maternal Side Effects (2)
Fetal Side effect

A

Action: Stimulates fetal lung maturity

Indication: Prevent/reduce the severity of neonatal respiratory distress syndrome b/w 24-34 weeks gestation

Dosage and Route:
Betamethasone – 12mg IM, 2 doses 24 hrs apart
Dexamethasone – 6mg IM, 4 doses 12 hours apart

Side effects:
Maternal – increase in WBCs, hyperglycemia (lasts 72 hrs)
Fetal – decrease in fetal breathing and body movements (lasts 72 hrs)

148
Q

Eclampsia: care during seizure(4)

A
  • Stay with patient
  • Call for help and notify HCP
  • Safety (lower bed, turn on side, suction PRN to prevent aspiration; keep side rails up and padded)
  • Record time, length, and type of seizure activity
149
Q

Eclampsia: care after seizure (4)

A
  • Delivery after maternal hemodynamic stabilization
  • Monitor maternal and fetal vitals
  • Give meds (magnesium, antihypertensive)
  • Give oxygen 10L/min via mask
150
Q

Eclampsia

Fetal Risks (3)
Maternal risks (4)

A

Fetal
- Recurrent and prolonged FHR decelerations
- Fetal tachycardia (bradycardia during seizure r/t hypoxia)
- reduced variability

Maternal
- hypoxia
- trauma
- aspiration pneumonia
- neurologic damage (impaired memory and cognition)

151
Q

Diabetes in Pregnancy: Contributors to Insulin Resistance (6)

A
  • Increased maternal adiposity
  • Insulin desensitizing hormones from placenta ((Progesterone, growth hormone, Corticotropin releasing hormone, human placental lactogen, insulinase secretion, human chorionic somatomammotropin (HCS)) shift energy source to ketones and fatty acids
  • increased calories
  • decreased exercise
  • Glucose is the primary fuel for the fetus
  • Insulin needs increase during the first trimester
152
Q

Define the following:

Pregestational Diabetes
Gestational Diabetes

A

Pregestational diabetes: glucose levels above normal but below cutoff for overt diabetes in nonpregnant women

Gestational Diabetes: glucose intolerance not present before pregnancy due to insulin resistance in pregnancy

153
Q

Preconception care: women w/ pre-existing diabetes (3)

A
  • Establish glycemic control before conception (Poor glycemic control at conception and in the early weeks increases risk for miscarriage and fetal anomalies)
  • Diagnose any vascular complications (kidney, heart, thyroid function, ophthalmic tests)
  • May need 3-4x prepregnancy level of insulin
154
Q

Gestational Diabetes Mellitus: Maternal Risks (9)

A
  • polyhydramnios ( >2000ml = risks for abruption, PROM and preterm labor, anomalies)
  • infection, inflammation, leukocyte function (UTI, monilial vaginitis)
  • placental abruption
  • Postpartum hemorrhage and anemia
  • C-section, assisted delivery
  • type 2 DM, GDM in future
  • Metabolic disturbances (hyperemesis, NV)
  • Exacerbation of chronic conditions (DKA (2nd semester), HTN, preeclampsia)
  • Oligohydramnios (decreased placental perfusion)
155
Q

Diabetes Mellitus: Fetal risk (5)

A
  • macrosomia (> 4-4.5 kg b-c high glucose= high insulin = high growth)
  • congenital defects (during organogenesis mainly for pregestational)
  • IUFD (intrauterine fetal death) ( r/t hyperglycemia, infection)– stillbirth
  • IUGR (due to vascular issues)
  • asphyxiation
156
Q

Diabetes Mellitus: Neonatal risks (7)

A
  • hypoglycemia (few hrs)
  • hypocalcemia/ hypomagnesemia
  • hyperbilirubinemia (r/t polycythemia and increased erythropoietin; RBC breakdown)
  • Respiratory Distress Syndrome (RDS) and transient tachypnea of newborn (TTN)
  • cardiomyopathy
  • shoulder dystocia, birth trauma
  • chronic conditions later in life (Type 2 DM, obesity)
157
Q

Gestational Diabetes

Risk Factors (5)

A
  • Metabolic syndrome (central obesity, dyslipidemia, hyperglycemia, hypertension)
  • Hx of fetal macrosomia, GDM
  • Physical inactivity
  • PCOS
  • Family hx of diabetes
158
Q

GDM: Blood sugar goals

Fasting
1-hr postprandial
2-hr postprandial
HgbA1C

A

Fasting <95mg/dl
1 hr PP < 140
2 hr PP < 120mg/dl
HgbA1C < 6%

159
Q

GDM: Management (6)

A
  • diet preferred (2000-2500 cals/day; minimum 1800)
  • Nutritional breakdown (40% carbs, 20% protein, 30-40% fat)
  • moderate exercise (3/ week for 20 min)
  • Self-monitoring (SMBG 4-8 times a day before and after meals
  • Medication Therapy: Insulin (if necessary) or Oral agents (Glyburide, metformin)
  • Fetal surveillance (detect compromise early to prevent IUFD– NST around 28-32 weeks)
160
Q

GDM: When to call provider (4)

A
  • Glucose > 200 mg/dL
  • Moderate ketones in urine
  • Decreased fetal movement
  • Persistent nausea and vomiting
161
Q

GDM: Intrapartal care (4)

A
  • Evaluate fetal lung maturity via checking amniotic fluid for phosphatidylglycerol (averts RDS in < 38 wks gestation)
  • glucose-maintained b/w 70-110 in labor (IV insulin given; glucose checked q1-2 hrs and ketones q4h)
  • If corticosteroid given to prevent preterm delivery, increase insulin
  • cesarean needed if fetus > 4.5 kg
162
Q

GDM Screening

Who? (2)
Two-steps

A
  • all pregnant at 24-28 weeks (high risk also at first prenatal visit)

Steps
- Initial: 50-g oral glucose load (positive if > 135-140 mg/dl (fasting not necessary))
- If positive, do 3-hour oral glucose tolerance test (OGTT) with a 100gm oral glucose load: (fasting required)

163
Q

GDM: 3 hr Glucose tolerance test

Procedure
Criteria for Positive (4)

A

Procedure
- 3-hr glucose tolerance test after 8-12 hrs of fasting w/ 100 g glucose
- Plasma glucose drawn at fasting, 1, 2, 3 hrs

Criteria
If 2 or more levels high
GDM diagnosis made
* Fasting > 95
* 1 hr > 180
* 2 hr > 155
* 3 hr > 140

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