Exam 3 Flashcards
How to diagnose pregnancy
Missed period Nausea/vomiting Fatigue Frequent Urination Breast Tenderness Positive urine or serum pregnancy test (HCG) Morning Sickness
Standard laboratory urine pregnancy tests become positive approximately _____ following the first day of the LMP (around the time of the missed period)
3.5–4 weeks
1st prenatal visit components
General Medical History OB history Calculate EDD/EDC Full physical exam Pelvic Exam, STD screen
CDC recommends all women should be tested for ___
ACOG recommends test high risk women (high risk entails __)
chlamydia
1+ sexual partner,
how to document GTPAL
most accurate way
G (gravida) = # of times pregnant
T (term) = # of full-term deliveries 37 weeks or after (36 weeks and 6 days is still preterm)
P (preterm) = # of preterm deliveries betwn 20-37 weeks
A (abortions) = # of ‘abortions’ prior to 20 weeks (SAB or TAB or ectopic)
L (living) = # of living children
how to document GP
G (gravida) P (parity)
Refers to # of pregnancies (G) and # of deliveries (P) of a fetus greater than 20 weeks gestation whether alive or stillborn
E.g. If just delivered: G2P1–>2 (2 pregnancies,1 delivery now 2)
TAB
SAB
terminated pregnancy/abortion
spontaneous abortion
What is the GTPAL of a woman with 2 pregnancies, 1 full term infant, 1 spontaneous abortion, and 1 living child?
G2T1P0A1L1
All prenatal care is based on the ____
EDD
how to determine EDD
- a pregnancy calculator wheel based on LMP
- use Naegele’s Rule: LMP + 7 days minus 3 months
- *Naegele’s Rules assumes a normal 28 day cycle
What is the EDD of a woman whose LMP was 8/8/13?
LMP + 7 days - 3 months
May 15, 2014
does pregnancy warrant an earlier PAP to be done?
no
PE for prenatal visit consists of
BP weight and height --> BMI Cardiac Thyroid Breast Exam Pelvic exam
Fetal heart tones at ____ with an acoustic fetoscope (dop-tone/Doppler)
Fetal heart tones at ____ (Doppler)
18-20 weeks
12 weeks
fetal movement at ___ weeks
16-20 weeks
uterine softening and enlargment at ___ weeks
6+ weeks
Chadwick’s sign? and when does it happen
vaginal pallor/bluish
*at 6-8 weeks
Hegar/Goodell sign? and when does it happen
Cervical softening
*at 6-8 weeks
at 20 weeks where should the uterus be at
umbilicus
what labs do you get done at the 1st prenatal vistis
Confirmation Lab: B-HCG
Labs: CBC (hemoglobin, hematocrit, MCV) Blood group Rh +/- Antibodies (to Rh) Serology for syphilis Gonorrhea/Chlamydia Rubella immunity (if mom is not immune could worry about TORCH infections) HIV Hepatitis B antigen testing Urinalysis, urine culture for bacteriuria
Rh + =
Rh - =
Rh + = has antigen
Rh - = lack antigen
Cramping on one side at ___ weeks worry about ectopic pregnancy
5 weeks
purpose of 1st trimester us
Confirm Diagnosis (cardiac activity)
Estimate Gestational Age (measure crown rump length)
Evaluate uterine anomalies
when do you do a transvaginal US and Abdominal US
Transvaginal at 7-9 weeks
Abdominal at 9+ weeks
*have to wait 7 weeks before you get an US
cardiac activity starts around
6.5 weeks
how many pregnancies are aborted in 1st trimester
1:5
schdule of visits for prenatal care
Assess every 4 weeks until 32 weeks
Assess every 2 weeks between 32-36 weeks
Assess weekly after 36 weeks
questions to ask at every visit
Vaginal bleeding, N/V, dysuria, vaginal discharge, overall feeling and fetal movements (after 20 weeks)
exam and labs done at ALL visits
BP
Weight
Edema
Urine glucose/protein
LE edema is common due to
inferior vena cava syndrome
how much weight should you gain in pregnancy
25-30 lbs
Normal BMI 20-26
Up to 40# if underweight
Up to 15# if overweight
what numbers suggest hypertension
Systolic change >30mm Hg (over baseline, not 1st trimester BP), diastolic change >15 mm
Leopold’s maneuvers
a common and systematic way to determine the position of a fetus inside the woman’s uterus
Between ______, the fundal height approximates the weeks of gestation
20-36 weeks
*measure with cm measuring tape
when/how do you test for nuchal translucency
10-13 weeks u/s with blood test (1st trimester screening)
- Measure crown rump lenght greater than 2.5mm worry about trisomy
- Rule out Trisomy 21, 13, and 18
Maternal blood draw detecting multiple fetal aneuploidies including
Trisomy 21, 13, 18 (some Turner Syndrome and all detect GENDER)-99% accurate
NIPT (noninvasive prenatal genetic testing) can be drawn as early as
10 weeks
(1st trimester screening)
*Trade Names: Maternity 21/Harmony/Verifi/Panorama
when is Quad screening done and what does it screen for
15-20 weeks (2nd trimester screening)
*older test- only if other this are not done (If they come in late
AFP, hCG, estriol, and inhibin-A
AFP (Alpha-FetoProtein) Test alone often done at ____ weeks for ___
15-20 weeks
Spina Bifida detection in conjunction with NT test (high= spina bifida)
hormone produced within the placenta
hCG
protein produced by fetus
AFP
produced by fetus and placenta
Estriol
protein produced by the placenta and ovaries
Inhibin-A
Low levels of AFP and abnormal levels of hCG and estriol may indicate that the developing baby has
Trisomy 21 (Down syndrome), Trisomy 18 (Edwards Syndrome) or another type of chromosome abnormality
____ if patient is at high risk/qualifies for insurance coverage
NIPT
Invasive Prenatal Tests
CVS (chorionic villus sampling)
Amniocentesis
when is CVS and amniocentesis done
CVS at 10-15 weeks
Amniocentesis at 15 -+ weeks
*both have ~1% risk of miscarriage
Sample of placental cells taken to perform genetic testing
>99% detection via karyotype
CVS-Chorionic Villus Sampling
Sample of amniotic fluid taken to perform genetic testing
>99% detection via karyotype
amniocentesis
what prenatal tests are done at 19-20 weeks
Routine ultrasound
Check EDD, fetal development
what prenatal tests are done at 24-28 weeks
Screen for Gestational Diabetes- Glucose tolerance test and 3 hour GTT (if GTT is high)
Rhogam for Rh- mothers
what prenatal tests are done at 32-36 weeks
Screen for Group B Strep
Recheck:
Hemoglobin and hematocrit levels
STIs if continued risk or new risk factor
of movements in 1 hour
Average movements in a time period
Several assessments/day
fetal kick count
Fetal heart rate to fetal movement
Mother notes fetal movement in a 20 minute period
Reactive (reassuring) if 2+ accelerations occur in 20 minutes
Nonreactive – no heart accelerations in 40 minutes
Non-stress test fetal assessment
Measurement of blood flow velocities in the umbilical artery, umbilical vein, uterine artery with U/S
Doppler velocimetry
Spontaneous or oxytocin-induced contractions compared to fetus heart rate
Measures the response of the fetal heart rate to the stress of a uterine contraction
contaction stress test
Five assessments –> NST, presence of fetal breathing, fetal movement of body or limbs, fetal tone (flexed extremities), adequate amniotic fluid volume
Biopysical profile
prenatal vitamins
extra iron
folic acid
exercise during pregnancy
Moderate exercise (HR less than 140) is okay daily Avoid risky exercise (no hot yoga)
travel guidelines for pregnancy
Avoid distant travel in 8th month
Most airlines won’t allow past 36 weeks
Cruise lines prohibit travel at 25th week
medications during pregnancy
Class A/B- generally safe
Class C/D benefits must outweigh risk
Class x- Contraindicated
what happens to cardiac output with pregnancy and why?
Initially due to _____
Later, due to _____
Increased cardiac output 30-50%
increased blood volume
increase heart rate (by 10-20 bpm)
Cardiac Ausculatory changes in pregnancy:
- Systolic ejection murmurs are common
- Accentuated split S2
*Diastolic murmurs are NOT normal in pregnancy!!
vascular changes in pregnancy
- Decreased peripheral vascular resistance-progesterone
- Decreased BP in the beginning of pregnancy (1st half)
*Don’t care 1st trimester BP to 3rd trimester BP
Ineffective shunting of blood through the paravertebral circulation due to the enlarging uterus compressing on the inferior vena cava
“Inferior Vena Cava Syndrome”
or
Supine hypotensive syndrome
sx:
Light-headed
Increased heart rate
Syncope
relieved by:
Supine hypotensive syndrome
Relieved by lying on the left side
lay on left side after 20 weeks!! (do not lay on their back)
hematologic changes associated with plasma volume and RBC mass
increase by 50%
RBC mass increases by 20-30% if taking iron supplements
15-20% if not taking iron supplements
Need increased blood volume for:
the loss of blood during delivery
- Dilution due to a greater increase in intravascular volume compared to RBC mass.
- Decrease in hemoglobin and hematocrit
- Better placental diffusion with lower cardiac output
- Iron preferentially goes to the fetus
“Physiologic Anemia” or “dilutional anemia”
Vascular Changes w/ pregnancy
- Hypercoagulable State (Helpful to prevent mother from hemorrhaging during delivery)
- edema (due to increased plasma volume)
- blurred vision (Fluid retention–> thickening of the cornea)
Respiratory Changes
- nasal congestion/secretions and epistaxis
- Diaphragm rises up by 4 cm
- Chest diameter increases 2+ cm –> “barrel chested”
- Increase in oxygen demand by 20%
- Maternal arterial PCO2 decreases/arterial PO2 increases**
why do you get nasal congestion/secretions and epistaxis
Increased blood flow/mucosal hyperemia- more flowy
Due to increased estrogen level
*unresponsive to meds
why does Maternal arterial PCO2 decreases/arterial PO2 increases
Facilitates carbon dioxide transfer from fetus to mother
*Hyperventilation is secondary to progesterone
Gastrointestinal Changes
- Major effect is on gastrointestinal motility (decreases)- due to progesterone
- Increase in gingivitis
- Nausea/vomiting
- Gastroesophageal reflux (heartburn)–> secondary to lower esophageal sphincter (LES) tone/pressure decreases
- Gallbladder dysfunction
- constipation/bloating
- hemorrhoids
why do you get morning sickness
Due to progesterone, HCG
*esp 1st trimester (4-8 weeks)
pica- cravings for ice, clay
think iron deficiency
cuase of gallbadder dysfunction
Decreased emptying
Secondary to progesterone and estrogen
*Increased risk of gallstones
cuases of constipation/bloating
Progesterone-mediated smooth muscle relaxation
Slower transit times
Intestinal water absorption from intestine
Increasing uterus size affects intestinal function
causes of hemorrhoids
Due to increase pelvic blood flow
Enlarging uterus impedes venous return
Constipation contributes treat with Metamucil and increased dietary fiber if drinking enough water
bladder and urinary changes
- Urinary stasis and predisposition for ureteral reflux
2. Decreased bladder capacity due to enlarging uterus
Urinary stasis and predisposition for ureteral reflux due to:
- Ureteral dilation (Secondary to progesterone)
- Decreased bladder tone–> retention of urine(Secondary to progesterone)
- To prevent pyelonephritis, even asymptomatic bacteruria is treated
- Glomerular filtration rate (GFR) increases right away! (Kidneys have to filtrate more blood volume)
kidney changes
- increase in renal blood flow
- Increased glomerular filtration rate (GFR) – 50%
- increase renal excretion of bicarbonate
Increased glomerular filtration rate (GFR) might present with:
increased Increased urinary glucose excretion
“Trace” glucose on dipstick is normal
why is there an increase in renal excretion of bicarbonate
- Compensation for respiratory changes (respiratory alkalosis)
- Keeps maternal arterial pH normal
endocrine changes
- glucose metabolism/Increased tissue insulin resistance
- increase in lipids (Provide maternal fuel so fetus can have glucose)
- increase in cortisol levels (via estrogen)
- increase in oxytocin
- increase in water retention of 3 L
- Euthyroid state
- Thyroid levels don’t fluctuate much
Triglycerides increase by ___%, cholesterol increase by __%
300%
50%
why is there an increase in water retention of 3 L
Secondary to the increase in the renin-angiotensin-aldoserone system due to decreased vascular resistance
breast changes
- Increase in size up to 50%
- Darker pigmentation of areola
- Enlargement of Montgomery Tubercles-sebaceous glands of areola
- breast tenderness (due to progesterone)
- increased blood flow
- colostrum
Brown papules/glands on the Areola –>hypertrophied sebaceous glands
montgomery tubercles
may be expressed at the end of pregnancy
-yellow thick fluid from nipples
colostrum
vaginal changes
Vaginal discharge
Increased shedding of vaginal epithelium
*Leukorrhea of pregnancy (WBC discharge)
cervix changes
Endocervix everts further
mucus plug formation (comes out over several days)
uterus changes
Uterine myometrium (muscular wall) hypertrophies
skin changes
- Hyperpigmentation (mask of pregnancy, Linea nigra, Darkening around the areola, axillae, genitalia, neck, anus)
- acne (sebum production)
- vascular spiders
- varicsoe veins
- stretch marks
- pruritus (scalp, anus, vulva, abdominal wall)
what causes hyperpigmentation
Due to estrogen, progesterone, HCG
- melasma/chloasma
Sometimes doesn’t go away (use sunscreen)
“mask of pregnancy”
Softening of the cervix
Goodell’s sign
Bluish/purple discoloration of the vagina –> increased blood flow –> sign of pregnancy on exam
(Chadwick sign)
growth phase, less in telogen phase so very little hair shedding
anagen phase
pathophysiology:
Dilation and proliferation of blood vessels secondary to increase in estrogen
Red lesions with branches extending out
vascular spiders
Increase blood volume and venous pressure on veins from uterus
Do not usually regress
varicose veins
striae gravidarum
stretch marks
*Fade postpartum but will not disappear
No true way to prevent them
Genetics play a huge role
hair and nail changes
- increased hair volume
- nails grow faster
*More follicles in anagen (growth) phase
Reverses 2-4 months post-partum =hair loss
___ is any condition in which the flow of bile from the liver is blocked
cholestasis
musculoskeletal changes
- ligament laxity
- lumbar lordosis
- hernias (umbilical and abdominal)
- increased bone turnover
cuase of ligament laxity
Progesterone and relaxin
Uterus tips forward
Bone turnover via _____ but no loss of bone density as calcitonin is high and kidneys compensate.
increase parathyroid hormone
____ is the most important substrate
Glucose
fetal physiology:
survive on low oxygen saturation due to
High cardiac output
High fetal hemoglobin
produced by fetal urine and from placenta
amniotic fluid
Passive immunity from mom to fetus
IgG
*crosses the placenta
