Exam 2 OB Flashcards
what do you need to know to determine estimated date of birth?
need to know LMP
if mom doesn’t know first day of LMP, how is EDB estimated?
- uterine size
- auscultating fetal HR ~ 12-14 weeks
- US is most accurate
nagele’s rule
begin with first day of LMP, subtract 3 months, add 7 days
1st trimester typical emotional responses
- disbelief
- ambbivalence
- baby doesn’t seem real
- focus is on herself and her symptoms and may feel hostility toward pregnancy and unborn child
2nd semester emotional responses
- quickening occurs and mom starts to think of baby as a separate person
- feel more excited
- feel best physically
3rd trimester emotional responses
- pride
- anxious about labor and birth
- eager for pregnancy to end
- concerned about health and safety of herself and baby
- begins “nest-building”
Couvade syndrome
some men experience pregnancy-like symptoms (N/V, backaches) and this is a healthy response and signifies acceptance
how often are prenatal visits done?
once a month until week 28 then every 2 weeks, then weekley
2 categories of pregnancy at risk
- pre-existing conditions
- gestational onset
what can pregnancy at risk lead to?
- complication for fetus
- uteroplacental insufficiency (UPI)
- decreased oxygenation and nutrients to fetus
what happens with BP during pregnancy?
should NOT increase ~ BP over 140/90 needs further investigation
daily fetal movement counts
- called “kick counts”
- count for 1 hour
- fetal movement is reassuring sign of fetal health
what are some results with the kick count test?
- need to further investigate if only 2 kicks felt in 1 hours
- no movement for 12 hours is called “fetal alarm sign”
what should we educate a mom about kick counts?
- they decrease when fetus is sleeping
- can be affected by diet/nutrition (good to do after eating)
- will decrease if mom is taking antidepressant medication or other CNS depressants
- will decrease with alcohol intake and smoking
- obese women have a decreased ability to sense movement
how can an ultrasound be conducted?
abdominally or transvaginally
why would a transvaginal ultrasound be good?
allows pelvic anatomic features to be evaluated in greater detail and pregnancy can be detected earlier
what trimester is transvaginal US done in and why?
- 1st trimester
- detects ectopic pregnancy
- identify abnormalities
- gestational age by measuring crown to rump length
when is abdominal US conducted and why?
after 1st trimester when uterus is in the abdominal cavity
what would you want to tell a pregnant mom who is getting an abdominal US?
they need a full bladder to displace uterus upward
oligohydramnios
decreased amniotic fluid ~ congenital anomalies (kidney problem), growth restriction)
polyhydramnios
increased amniotic fluid ~ neural tube disorders, obstructed fetal GI tract, fetal hydrops, multiple fetuses
Biophysical profile (BPP)
- comprehensive test to evaluate health of fetus
- combined test using US and NST
what does BPP score on?
- amniotic fluid volume (AFV)
- fetal breathing movements (FBM)
- fetal movements
- fetal tone
- reactive NST
what do scores mean on BPP?
- each variable receives maximum of 2
- 8-10 = normal
- 6 = equivocal (suspicious)
- <4 = abnormal
how early can a cell free fetal DNA test be performed?
as early as 10 weeks
amniocentesis
- obtains a sample of amniotic fluid that contains fetal cells
- needle inserted trans-abdominally into uterus with guidance from US
- possible after 14 weeks of pregnancy so the uterus is big enough
why would an amniocentesis be done?
- genetic testing
- fetal lung disease
- diagnosis of fetal infections
- treatment
- paternity testing
risks of amniocentesis
- very rare (<1%)
- maternal risks: hemorrhage, infection, miscarriage or preterm labor, abruptio placenta, amniotic fluid embolism, leaking amniotic fluid
- fetal risks: hemorrhage, infection, direct injury from needle, leakage of amniotic fluid, death
three maternal serum markers
- maternal serum alpha-fetoprotein
- unconjugated estriol
- hCG
what does maternal serum alpha-fetoprotein test for?
neural tube disorders
when is glucose tolerance tested in pregnant women?
24-28 weeks
why are electronic fetal monitoring (EFM) assessments done?
to determine fetal wellbeing
examples of EFM
- nonstress test (NST)
- contraction stress test or oxytocin challenge test (CST)
nonstress test (NST)
- most widely used fetal assessment test
- non-invasive and inexpensive
- looks at HR in relation to fetal movement
top vs. bottom of NST strips
- top = uterus
- bottom = fetal HR
test results of NST and are they good or bad?
- tests are either reactive or nonreactive
- reactive is good
- nonreactive is bad
what would a reactive NST look like?
at least 2 accelerations in 20-minute period
accelerations
at least 15 seconds long and peaking at least 15 BPM above baseline
what would a NST look like with someone before 32 weeks gestation?
increase of at least 10 BPM and lasting at least 10 seconds
variability
able to see accelerations
nonreactive stress test
a test that does not produce 2 or more qualifying accelerations in a 20 minute period
what would need to happen if NST is nonreactive?
further intervention or evaluation: vibroacoustic stimulation, hydrate mom, BPP
contraction stress test
- identifies fetal wellbeing in response to stress
- IV infusion of oxytocin
- administer until 3 uterine contractions, of good quality, lasting 40-60 seconds, in a 10 minutes period occur
how are the results in a CST?
either positive or negative
test results of CST and are they good or bad?
- positive or negative
- negative is good
- positive is bad
negative CST
- at least 3 uterine contractions occur in 10 minute period, with no late or significant variable decelerations
- implies that fetus can handle stress of contractions
positive CST
- implies that fetus cannot handle stress of uterine contractions
- late decelerations occur with 50% or more of contractions
why is folic acid recommended in pregnant women?
it can prevent neural tube defects
folic acid recommendation
all women capable of becoming pregnant need 400 mcg daily
those underweight prior to conception risks
- preterm labor
- LBW infants
- IUGR infants
those overweight prior to conception risks
- macrosomic infants
- fetopelvic disproportion
- emergency c-sections
- postpartum hemorrhages
- birth trauma
- late fetal deaths
- gestational diabetes
- gestational HTN
- cephalopelvic disproportion
recommended weight gain for normal weight before pregnancy
25-35 lbs
recommended weight gain for overweight before pregnancy
15-25 lbs
recommended weight gain for underweight before pregnancy
should reach their ideal weight, then gain 25-35 lbs
energy needs are met by eating what types of foods during pregnancy?
- carbs
- fat
- proteins
protein
the nutritional element basic to growth
daily recommendation of protein
- 3 or more serving of milk, yogurt, or cheese
- 6 oz of meat, poultry, or fish
fluids are essential for…
the exchange of nutrients and waste products
recommended daily intake of fluids
8-10 glasses or 1500-2000 mL
what might inadequate fluid increase the risk of?
cramping, contractions, preterm labor
can caffeine be consumed during pregnancy?
- in small amounts, has not been proven to cause adverse effects
- greater than 3 cups of coffee may increase risk of miscarriage and IUGR infants
- recommendation is to avoid caffeine or consume in limited quantities
why is iron good during pregnancy?
necessary to allow transfer of iron to the fetus and to support expansion of the maternal RBC mass
recommended intake of iron
30 mg daily starting by 12 weeks gestation
what could iron cause that you would want to educate the patient on?
can cause constipation, so educate them about increasing fiber and fluids
pica
practice of consuming nonfood substances such as clay, dirt, laundry, starch, baking powder, corn starch, baking soda, ice ~ influenced by cultural background
risks associated with pica
- lower Hgb (pregnancy already causes lower H&H)
- malnutrition
- electrolyte imbalances
- acid base imbalances
- rhabdomyolysis
what might those who eat vegetarian diets lack?
vitamin B12 - must supplement
how might nutrient needs during lactation change from pregnancy?
- it is similar but iron and folic acid needs are lower
- needs for energy calories (protein) are higher
- fluid intake must be adequate
- calcium intake needs to be adequate and may have to supplement with 600 mg Ca
dangers during pregnancy
- limit caffeine
- quit smoking/tobacco
- alcohol
- toxoplasmosis (from raw/undercooked meats or litter of infected cats)
- lunch meats (rish of listeria); fish (mercury risk)
what does use of tobacco affect with pregnancy?
- causes vasoconstriction
- higher incidence of low birth weight babies
- higher incidence of preterm birth, PROM, placenta previa, abruptio placenta, SIDS, lower IQ learning problems
hyperemesis gravidarum
- extreme N/V
- severed enough to cause weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria
- may occur in any trimester
- may cause maternal hepatic and renal damage
what effects does diabetes have during pregnancy?
- inc. risk of pre-eclampsia, HTN
- inc. risk infections, i.e. pyelonephritis, monilial vaginitis
- inc. polyhydramnios and malpresentation
- inc. macrosomia, LGA, shoulder dystocia, C/S
- neonatal complications
- IUGR and stillbirth
- congenital anomalies
concerns for the pregnant diabetic mother
- maintain mom’s BG - insulin control!!!!
- protect fetus in utero from the fluctuation in BG levels
- protect NB the first 24 hours until insulin-glucose regulatory mechanism is stable
what hypoglycemic agents have teratogenic effects?
sulfonylureas (glyburide)
how is glycemic control in first trimester?
- it is improved
- risk for hypoglycemia
- reduction in insulin dose
how is glycemic control in second and third trimester?
- insulin requirements slowly increase
- doses must be adjusted daily
- insulin may double or quadruple by the end of pregnancy
- requirements will level off at 36 weeks
what occurs with insulin requirements post partum?
expulsion of the placenta dec. the levels of placental hormones and maternal insulin requirements dec.
how many days postpartum with insulin requirements return to pre-pregnancy requirements?
7-10 days
how does breastfeeding affect insulin requirements?
will be lower than pre-pregnancy requirements because breastfeeding utilizes glucose more effectively
does a fetus make its own insulin?
yes, by 10-14 weeks; fetus just depends on mother for glucose
fetus glucose levels in relation to mom’s glucose levels
they are proportional
macrosomia
LGA infants (>90th percentile); high glucose levels lead to this (glucose acts as GH)
complications of macrosomia
- cephalopelvic disproportion or should dystocia (fractured clavicle, liver or spleen laceration, brachial plexus injury, facial palsy, subdural hemorrhage)
- increased rate of c-section
ketoacidosis in pregnancy
- most common during 2nd and 3rd trimester
- more prevalent if the pregnancy is stressed by an illness or infection
what does terbutaline do in terms of DKA?
increases risk of DKA; used to stop contractions
when does ketoacidosis occur in pregnant women?
with blood sugars @ 200 mg/dL
what increases the risk of sudden and unexplained stillbirth?
women with vascular disease and poor glycemic control. may be associate with DKA, preeclampsia, polyhydramnios, macrosomia
who are IUGR seen in?
with women who have vascular disease due to their diabetes; related to compromised uteroplacental circulation
treatment goal for pregestational diabetic pregnant women
- maintain glucose level between 65-95 preprandially and 130-140 postprandially
- diet
- exercise
- frequent BG monitoring
- insulin/glucose medication
- consistency of activities
- close fetal monitoring
how would we assess a patient with diabetes before delivery?
- DFM counts
- frequent US
- NST
- 1-2 times/week BPP, amino for lung maturity
how would we assess a patient with diabetes during and after delivery?
- C/S for macrosomia
- glucose levels every 1-2 hours
- insulin drip to keep BG 70-120
- frequent monitoring; usually stabilizes in 2-3 days
what can maternal hyperglycemia lead to?
fetal hyperglycemia, hyperinsulinemia, macrosomia, RDS, hypoglycemia, hypocalcemia, stillbirth, polycythemia, hyperbilirubinemia
neonatal hypoglycemia
term: <40 mg/dL
preterm: <25 mg/dL
signs: hypothermia, tremors, jitteriness, weak cry, floppy, lethargic, convulsions
treatment of neonatal hypoglycemia
primary: feed or glucose IV
CV changes during pregnancy
- vast increase in BV
- heart murmurs
- heart palpitations
how do you treat CV disease?
- reduce stress of heart by eliminating anemia, stress, hypertension, constipation, hyperthyroidism, obesity
class I heart disease
- cardiac with no limitations
- absence of symptoms, generally few problems
- encourage plenty of rest
*won’t do too much
class II heart disease
- slight limitation
- comfortable at rest
- experience fatigue, palpitations, dyspnea, or angina with ordinary activity
- may need O2 in labor and delivery
class III heart disease
- moderate to marked limitation of physical activity
- comfortable at rest
- symptomatic with less than normal activity
- often advised against pregnancy
- often bedrest much of pregnancy
- breastfeeding contraindicated
class IV heart disease
- unable to perform normal ADL without discomfort
- angina
- maternal mortality high
- postpartum period is hazardous
- delivery is very risk
signs of cardiac decompensation
- increase in fatigue
- inc. in difficulty breathing
- tachypnea
- frequent, moist cough
- palpitations
- generalized edema
- irregular, weak rapid pulse
- crackles
- orthopnea
treatment of asthma with pregnancy
terbutaline and albuterol: they will reduce/stop uterine contractions due to their beta 2 action ~ goal is to maintain adequate O2 for the fetus
can epilepsy be treated during pregnancy?
most meds are contraindicated so risk vs. benefit: especially carbamazepine (tegretol) and valproate (depakote)
how much does maternal insulin demand increase during the 2nd half of pregnancy?
3x
how do we screen for gestational diabetes?
glucola: 50 g of PO glucose, then a BG test 1 hour later
when are diabetes tests done?
24-28 weeks gestation
what is a positive score in diabetes and what does it mean?
130-140 is considered positive: double check with 3 hr OGTT and try to maintain normal levels
levels of hypertension in pregnancy
- gestational HTN
- preeclampsia
- eclampsia
- HELLP syndrome
diagnosis of gestational HTN
- without proteinuria
- after 20 weeks pregnancy
- BP greater than 140/90 in someone who is normotensive
what is preeclampsia caused by?
vasospasm
is preeclampsia a problem with BP?
no, all symptoms stem from arterial vasospasms (pinching off arteries)
characteristics of mild preeclampsia
- HTN after 20 weeks gestation
- proteinuria
- edema
characteristics of severe preeclampsia
- HTN (greater than 160/110)
- proteinuria
- oliguria
- cerebral or visual disturbances
- hepatic involvement
- reflexes (hyperreflexia)
- thrombocytopenia
HELLP syndrome diagnosis
*based on a group of lab findings
- H = hemolysis (wiping our RBC leading to inc. bilirubin or burr cells)
- EL = elevated liver enzymes
- LP = low platelets (less than 100,000
eclampsia
preeclampsia symptoms with onset of seizure or coma; can develop during pregnancy, labor, or postpartum
if pregnancy is past 37 weeks in someone with HTN, what usually happens?
induction
magnesium sulfate
- commonly prescribed to prevent seizures
- since it relaxes smooth muscle, may not be able to do a vaginal delivery
goal of using magnesium sulfate
to maintain a therapeutic serum Mg level of 4-7 mg/dL
*make sure to draw levels frequently
symptoms of mag toxicity
- nausea
- feeling of warmth
- flushing of skin
- dec. reflexes
- slurred speech
- muscle weakness
- hyporeflexia and absent reflexes
- RR less than 12/min.
- significant drop in maternal pulse and BP
- urine output less than 30 mL/hr
- levels greater than 9.6
- fetal tachycardia or bradycardia
interventions for mag toxicity
- stop magnesium infusion
- call provider
- administer antidote: calcium gluconate
- monitor patient status
- monitor mag levels and sulfate levels
early pregnancy bleeding possiblities
- miscarriage
- premature dilation of the cervix
- ectopic pregnancy
- hydatidiform mole
late pregnancy bleeding possibilities
- placenta previa
- placenta abruption
- variations in the insertion of the cord
threatened miscarriage s/s
- spotting
- no or mild cramping
- closed cervix
*has not happened: a threat for one
inevitable miscarriage s/s
- moderate/heavy bleeding
- open cervical os
- mild/severe cramping
- may have ruptured membranes
*already happening
incomplete miscarriage s/s
- expulsion of the fetus with retention of the placenta
- moderate/heavy amount of bleeding and cramping
*not everything expells out
complete miscarriage s/s
- all tissue and fetus is passed
- milk bleeding and cramping
missed miscarriage s/s
fetus has died, but expulsion does not occur
how do Hcg levels change with a miscarriage?
they might stay the same or dec.
cervical cerclage
sutures to close cervix to maintain pregnancy
ectopic pregnancy
- fertilized ovum is implanted outside the uterus
- maternal mortality
- leading cause of infertility
3 classic symptoms of ectopic pregnancy
- abdominal pain
- amenorrhea
- abnormal vaginal bleeding
how do we treat tubal ectopic pregnancy?
- methotrexate before rupture if possible
- salpingostomy before rupture if possible: remove the pregnancy and use methotrexate for the remaining tissue
- laparotomy for ruptured ectopic pregnancy to remove conceptus
what would you do if the placenta is attached to a vital organ during an ectopic pregnancy?
it is left in place and usually absorbed by the body without complication ~ methotrexate may be given
symptoms of ruptured fallopian tube
- sharp stabbing pain
- referred shoulder pain
- signs of shock
- cullen sign: blueness around umbilicus
if a ruptured fallopian tube is in the interstitial portions of the tube, where the tube is connected to the uterus, how much bleeding will there be?
profuse blood loss due to the great blood supply
if a ruptured fallopian tube is in the distal third, how much bleeding will there be?
less bleeding due to decrease blood supply there; this is where most ectopics are
two types of hydatidiform
- complete or classic mole
- partial mole
complete molar pregnancy
- fertilization of an ovum that is “empty”
- embryoblast becomes fluid filled and embryo does not form
- no fetal blood is present
- all of the trophoblast villi become like a “cluster of grapes”
complete molar pregnancy
- fertilization of an ovum that is “empty”
- embryoblast becomes fluid filled and embryo does not form
- no fetal blood is present
- all of the trophoblast villi become like a “cluster of grapes”
how does HCG change in a complete molar pregnancy?
they will be extremely high
clinical manifestations of complete molar pregnancy
- uterus expands faster than in normal pregnancy
- no fetal HR
- blood/urine test for HCG is strongly positive
- N/V are present and are worse than with a normal pregnancy
when do symptoms of HTN, edema, and proteinuria occur in a molar pregnancy?
before the 20th week, usually between 9-12 weeks
what might bleeding look like with a molar pregnancy?
prune juice
what kind of cancer might moms get as a result of a molar pregnancy?
choriocarcinoma
what precautions do we take to assess for choriocarcinoma?
- serum HCG levels are monitored monthly for six months, then every 2 months for the next 6 months (1 year total)
- avoid pregnancy for 1 year to avoid confusing pregnancy with it
placenta previa
low implantation of the placenta in the uterus
three degrees of placenta previa
- complete
- marginal
- low-lying
manifestations of placenta previa
- painless vaginal bleeding
- placenta doesn’t stretch
- initial bleeding is usually a small amount of bright red blood
- bleeding will recur at various times
- soft, relaxed, non-tender uterus
- baby might be in transverse position
what should be avoided in moms with placenta previa?
- never perform sterile/vaginal exams until after 34 weeks
- avoid intercourse
how will delivery be done in placenta previa?
c-section because you can’t deliver the placenta first
placenta abruptio
detachment of part of all of the placenta from its implantation site
when does placenta abruptio occur?
usually after 20 weeks, if it occurs before it will be considered SAB
risk factors for placenta abruptio
- maternal HTN
- direct abdominal trauma
- smoking/cocaine
- previous abruptions
- preterm rupture of membranes
manifestations of placenta abruptio
- vaginal bleeding (mild or severe)
- abdominal pain (located high in the uterine fundus)
- uterine tenderness upon palpation
- hypertonicity of uterus
what should we always suspect in a woman who has sudden onset of localized fundal pain with or without bleeding?
abruption
how would be position mom who has an abruption?
laterally
in a patient brought in with a trauma, what do we want to do first?
stabilize mom first as if she were not pregnant
