Exam 2 Flashcards
Risk Factors for post term pregnancy
Nulliparity, history of post term pregnancy, maternal obesity, carrying a male fetus, having a family history of post-term pregnnacy
Maternal risk for post term pregnancy
dysfunctional labor, operative birth, operative vaginal birth, perineal trauma, postpartum hemorrhage (associated with risk of macrosomia)
fetal risk in post term pregnancy
mec stainted fluid
areas of infarction and calcium on placenta
amniotic fluid normally begins to decrease at 38 weeks.. oligo incidence higher in post term pregnancy= cord compression and fetal distress during labor
risk of still birth after 42 weeks is twice as high
risk of death during first year of life is higher
labor stimulating activities
stripping of membranes
60mg castor oil PO (diarrhea and cramping)
unprotected intercourse
Induction for post dates/bishops scoring
42+ for sure a candidate >6 is a good bishops score 0= closed, 0-30, -3. firm, posterior 1= 1-3 cm, 40-50, -2, medium, midline ... 3 = >5 cm ect..
Post dates fetal surveillance
fetal movement count (daily) NST (twice weekly) BPP (twice weekly) modified Bpp (twice weekly) AFI (twice weekly) CST? weekly
Placenta Previa risk factors
AMA >35 multiparity prior c section infertility treatments smoking unexplained AFP multiple gestation short inter pregnancy interval prior uterine cutterage
Placenta previa Presentation
painless vaginal bleeding in late second or early third trimester
Placenta previa management
no digital exam!
asymptomatic previa- delivery 36-37 weeks, complicated deliver immediately
Risks for Placental Abruption
HTN!! short interpregnancy interval C sections PPROM smoking cocaine black or caucasian polyhydramnios multiple gestation uterine decompression thrombophelias uterine leiomyoma maternal trauma unexplained elevated AFP
Maternal Issues Placental Abruption
risk for shock, coagulopathy, renal failure, death
high recurrence rate
couvelaire uterus- blood seeping into uterine musculature
Placental Abruption Presentation
could be no s/s, especially with a concealed abruption
visible bleeding in a marginal placental separation
** hallmarks are visible bleeding and abdominal pain (uterine hypertonicity and tenderness)
Management- bleeding in second half of pregnancy
blood type, rh risk factors: Rhogam within first 48-72 hours (before 12 weeks dose if 50, after dose is 300) of bleeding onset
CBC, coags
ultrasound to see location of placenta (no digital exam!)
hospitalization for bleeding with previa
serial growth US for women with history of abruption
Complete pregnancy loss
history of heavy bleeding, cramping, passage of clots/tissue, followed by an abrupt decrease in pain and bleeding
complete passage of products of conception
cervix closed
uterus small
may see blood in vaginal vault
Incomplete pregnancy loss `
cramping intense, bleeding heavy
partial passage of products of conception
cervix open or closed
Delayed pregnancy loss (missed abortion or blighted ovum)
cervix closed
uterus small or appropriate for gestational age
amenorrhea may be only symptoms, FHT not heard
Early pregnancy loss medical management
oral or vaginal misoprostol for uterus less than 12 weeks.
4-16 hours to evacuate uterus
early pregnancy loss follow-up
1-2 weeks of pelvic rest
ovulation can return in 21 days, menses typically resumes in 6 weeks
no reason to wait to get pregnant again
follow up visit in 2 weeks- check for involution
fetal effects IUGR
** second highest cause of perinatal mortality, after prematurity not ALWAYS SGA still birth neonatal mortality delayed effects of CP and adult disease
Symmetric IUGR
smaller number and size of cells
happens early pregnancy
commonly caused by genetic, infectious, teratogenic insults
CMV, rubella, or drugs like phenytoin or valproate
occurred during period of hyperplasia
less likely to respond to antenatal interventions
Asymmetric IUGR
uteroplacental insufficiency
chronic fetal hypoxemia and malnutrition in utero
fetal cell size is small but normal in number
associated with HTN, preeclampsia, diabetes, renal disease, and abnormal placentation
IUGR diagnosis
fundal height measurement off by more than 3cm
consecutive US measurements made 2 weeks apart
targeted US for anatomy scan and AFV ( aneuploidy?)
IUGR causes
Aneuploidy
non-aneuploidy syndrome
viral infections
placental insufficiency
IUGR management
serial growth US 3-4 weeks apart
AC provides best measurements
serial doppler flow studies weekly or bi-weekly
NST weekly or bi-weekly
BPP
AFI- declining is sign of worsening placental function
Recommended fluid intake in pregnancy
3L/day or 8-12 8oz glasses a day
Caloric intake in pregnancy
No extra calories first trimester
2nd- 340/day
3rd- 450/day
Fats in pregnancy diet
20-35%
DHA (omega 3) is super important for brain and eye development
may prevent preterm birth
pregnancy fish recommendations
consume 2 servings (12 oz) of fish per week
supplement with fish oil if fish is not eaten
NO shark, swordfish, king mackerel, tilefish
canned chunk light tuna has less mercury and can eat 2x/week, limit albacore to 6oz per week
remove skin and surface fat from fish before cooking
Carbs in pregnancy
175g/day
complex carbs
Protein in pregnancy
71g/day
high-protein diets should be avoided
meat, fish, poultry eggs, dairy products, tofu, soy, legumes, nuts, seeds
Iron in pregnancy
first trimester- requirements reduced needed in second, peaks in end of third 27mg/day (found in PNV) heme iron- found in meat is better non-heme in plants and ferrous sulfate take with vitamin c tannins decrease absorption
Calcium in pregnancy
1000mg/day 19-5- years old 1300mg/day 14-18 milk, yogurt, cheese more fat, less calcium fortified like orange juice and calcium
Vitamin D
600-4000IU
achieve circulating level of 40-60ng/ml
Weight gain recommendations
Underweight 28-40 or 1-2lbs per week
normal 25-35 or 1-2 lbs per week
overweight 15-25 1/2-2/3 per week
obese BMI >30 11-20 1/2 lb per week
Off limits cheeses in pregnancy
Raw milk cheeses
goats milk, chevre, queso fresco, brie, camembert, danish blue, gorgonzola, roquefort
449 rule
1gm fat= 9 calories
1gm carb= 4 calories
1gm protein= 4 calories
obesity is linked with….
increased risks for pregnancy complications such as GDM, preeclampsia, NTDs, oomphalocele, and cardiac anomalies; obesity doubles the risk of stillbirth, and neonatal death
Endometrium post partum
day 1: decidual necrosis is sloughed off as lochia
day 7: necrotic and viable tissue at placental site, non-necrotic helps reconstruct endometrium
day 16: endometrium fully restored
Uterus sizes post partum
immediately: 1000g
1 week: 500g
2 weeks: 300g
6 weeks: 100g
Uterine involution post partum
immediately: uterus at the level of the umbilicus
1-2 hours: uterus between umbilicus and sympthesis
12 hours: 1 cm above umbillicus
24 hours: 1 cm below umbillicus
3 days: 3 cm below
7 days: at symphesis
14 days: in pelvis (non palpable)
Lochia postpartum
Rubra: 1-3 days pp bright red
Serosa: 4-10
alba: 10 days.. last 24 to 36 days pp
Cervix postpartum
2-3 days cervix regains shape (maybe still 2-3 cm)
7 days: uterus 1cm
3rd week- vagina gets rugae back
6 weeks- pelvic floor strength
Urinary tract postpartum
returns to normal dilation between 2nd and 8th week postpartum
Weight loss postpartum
immediate 10-13lbs infant, placenta, amniotic fluid, blood loss
may not have weight loss until 1-2 weeks because of fluid retention
labor may increase anti-dieuretic homrone after labor- leading to fluid retention
EBB phase- fluid retention
Flow phase- dieuresis at 4-7 days pp
Hair loss pregnancy
hair in anegen phase (growth) due to estrogen in postpartum it goes through the catagen phase
definition of PPH
1000ml blood loss
or blood loss with s/s of hypovolemia
within first 24 hours
secondary PPH
24h- 12 weeks postpartum
PP depression
can be diagnosed at any time during pregnancy
ACOG recommends we screen all women at least once
1 in 7 women affected by perinatal depression
Pelvic floor
supports the pelvic organs
facilitates movement of the fetus towards the pelvic girdle
maintain optimal intra-abdominal pressure
helps baby be born head-first
Levator ani muscles/pelvic diaphram
Pelvic diaphram: levantor ani: puborectalis pubococcygeous iliococcygeous
other:
coccygeous
Puborectalis
part of levator ani! encircles anal rectal junction interwoven with external anal sphincter Innervated by: S3 S4, levator ani nerve function: inhibit defication
pubococcygeus
floor of pelvic cavity, pelvic floor
part of levator ani!
innervated by S3 S4,
functions: control urine flow, contract during orgasm
Illiococcygeus
part of levator ani!
innervated by Pudendal nerve!
function: lift/closes anus
coccygeus
posterior to levator ani arieses from spine of ischium also sacro-spinus ligament innervated by: S4, S5, s3-s4 funciton: ppulling coccyx after defication, closes in back outlet of pelvis
Urogenital diaphragam
deep transverse perineum
sphincter urethrae
deep transverse perineum
innervated by pudendal nerve
function: fixate the central tendon of the perinum, suppport to pelvic floor, last drops of urine.
external urethral sphincter
innervated by deep branch of perineal nerve
functions: constricts urethra
External anal sphincter
innervated by fourth sacral and pudendal nerve (rectal branch)
functions: keep anal canal closed, fix central point of perineum
Bulbospongiosis
innervated by deep branch of perineal nerve (branch of pudendal nerve)
functions:clitoral errection and orgasm
Ischiocaverneosis
innervated by perineal nerve
compresses the crus of clitoris
superficial transverse perineum
goes across perineal space anterior to anus attach to tuberosity of ischium insert at central tendon of perineum innervated by perineal nerve fixation of central tendon of perineum support of pelvic floor
Obturator Internus
attach to torcanter
nerve to obturator internis, L5, S1, S2
laterally rotates the femur
Piriformis
gluteal region
lateral rotator group
originates from sacrum
Round Ligament
lateral cornu of the uterus, through broad ligament, into inguinal canal, ends in connective tissue of labia majus in the perineum
Chronic HTN definiton
greater than 140/90 before 20 weeks gestation, or persisting after 12 weeks postpartum
severe= 180/110
CHTN management
24 hour urine protein, creatinine EKG opthamalogy exam growth scan 28, 32, 36 weeks twice weekly nst beginning at 32 weeks delivery by EDC
CHTN med guidelines
Do not treat BP if under 160/105 and no evidence of end organ damage
if using anti HTN agent- maintain BPs 120/160 - 80/105
safe HTN meds
- labetolol
- nifedipine, norvasc
- methyldopa
Do NOT USE ACE
GHTN and mild PEC without severe features
management
fetal kick counts
Bp measurement and BPP 2x per week
weekly office visit and lab assessment (LFT, CBC, platelets)
growth scans every 3-4 weeks (20, 28, 32, 36)
pregnancy related HTN
BP decrease with nadir in mid second trimester
increases in third trimester
PEC without severe features criteria
BP greater than 140/90 after 20 weeks gestation
with PROTEINURIA
greater than 300mg in 24 hours
1+ protein on dipstick
protein creatinine ratio of greater than 0.3
preeclampsia with severe features
Bp greater than 160/110
with proteinuria
if no proteinuria.. signs of END ORGAN DAMAGE
- thrombocytopenia platelets less than 100
- impaired liver function (ALT (7-56), AST (10-40))
- creatinine 1:1, or oligouria <500 in 24 hours
- pulmonary edema
- new onset headache
Eclampsia
- not related to degree of proteinuria
- most occur first 48 hours
- greater than 48-72 hrs post partum, think of other causes
HELLP syndrome
Hemolytic anemia ( s. on peripheral blood smear, elevated liver enzymes low platelets)
Vasa previa management
c section at 34 36 weeks
management 3x week NST 28 weeks
problems with circumvallate nutrients
abruption, IUGR, preterm birth
decreased supply of nutrients
Risk factors for accreta
placental previa pervious c/s (scarring) s/s: similar to previa, bleeding? hematuria with placenta percreta AFP elevated US/MRI
risks for previa
short interval prior D&C prior c/s smoking ama infertility AFP elevated
complications from previa
hemorrhage preterm birth stillbirth perinatal mortality and morbidity low birth weight/IUGR neonatal respiratory distress
GDM blood sugars
before breakfast 60-90 before 60-105 1 hr post parandial <130 2 hour post parandial <120 night >60
post partum 2 hour
less than 140
more than 200.. diabetes
pregnant 2 hour
fasting less than 92
1 hour less than 180
2 hour less than 153
Rubins 4 tasks
Safe passage: finds way to ensure safe passage and birth
Acceptance: relationships, behaviors, siblings
Binding into the child: stop seeing them as separate
giving of oneself: most complex and demanding
lederman 7 dimensions of maternal development
acceptance of pregnancy identification of a mother role relationship with her mother relationship with partner preparation for labor fear of loss of control in labor fear of loss of self esteem in labor
