Exam 3 Flashcards
Changes in cardio physiology
CARDIAC OUTPUT
- increased 40 percent in pregnancy, almost half is increased by 8 weeks, maximal at mid pregnancy. It is because of augmented stroke volume that results from decreased vascular resistance
PULSE AND STROKE VOUME
- increase more later in pregnancy because of increased end-diastolic ventricular volume, results from pregnancy hypervolemia
Increase SV Increase HR Increase CO increase preload decrease systemic vascular resistance decrease afterload
CO up 40%
HR up 17
vascular resistance- DECREASED
heart rate changes in pregnancy
HR rises in first trimester and slowly rises throughout pregnancy
by the middle of the third trimester, pulse is 15-20 beats above baseline
mild resting tachycardia is normal
systemic vascular resistance changes in pregnancy
fall in peripheral vascular resistance
decreased afterload
DROP in arterial BP (starting in 7th week)
normal cardiac exam findings in pregnant women
mammary souffle jugular venous distension venous hum S2P increased; S2 split S1M increased and widely split occasional s3 aortic or pulmonary flow murmurs
Symptoms heart disease in pregnancy
progressive dyspnea or orthopnea nocturnal cough hemoptysis syncope chest pain
Clinical Findings heart disease pregnancy
cyanosis clubbing of flingers persistent neck vein distension systolic murmur grade 3/6 or greater diastolic murmur cardiomegaly persistant arrhythmia persistant split second sound criteria for pulmonary hypertension
Heart changes in pregnancy
diaphram elevation benign pericardial effusion exagerated splitting of first sound no changes in aortic/pulm elements in second sound loud, easily heard third sound systolic murmur
EKG changes
-Mean QRS can shift leftward due to elevation of the diaphragm
-Can return to the right as the fetus descends at pregnancy end
-Minor ST-segment and T-wave changes may be observed
–Less often, T-wave inversions may appear transiently in the left precordial leads.
- These changes are seldom of sufficient magnitude to raise the question of ischemic heart disease
normal echocardiography changes
- Small, silent pericardial effusion = common
- Slightly but significantly increased tricuspid regurgitation
- Left atrial end-diastolic dimension
- Left ventricular mass
effects of fetus
worsening heart function
decreased oxygenation to tissues (including placenta)
decreased oxygen to fetus
IUGR, NRFHT
Palpitations in Pregnancy
occur frequently during pregnancy
common indication for cardiac eval
look for arrhythmia with EKG
if abnormal EKG, do echo to look for structural heart disease as underlying cause
physical exam for heart disease
HR
weight gain
SPO2
How many flights of stairs can you walk up with ease? Two? One? None?
Can you walk a level block?
Can you sleep flat in bed? How many pillows do you use?
Does your heart race?
Do you have chest pain?
• Does this occur with exercise?
• Do you have pain when your heart races?
Mitral Valve Prolapse (williams)
left atrium and left ventricle
blood backed up from left atrium into lungs
mitral insufficiency
mostly asymptomatic
sometimes experience anxiety, palpitations, atypical chest pain, dyspnea with exertion, and syncope
rare complications in pregnancy
hypervolemia may improve alignment of the mitral valve
NOT considered an indication for infective endocarditis prophylaxis
symptomatic women receive beta blockers to decrease sympathetic tone, relieve chest pain and palpitations and reduce the risk of life-threatening arrhythmias
headache etiology in pregnancy
hormonal changes, increase in blood volume, tension, postural changes, muscle strain, preeclampsia (3rd trimester)
common headache triggers
inadequate sleep, smoke, change in caffeine, stress, hormones, eyestrain, sensory overload, very cold food/drinks, MSG, chocolate, tyramine containing foods, alcohol
Migrane patho
without aura: unilateral, throbbing, N/V, photophobia
with aura: hallucinations, acrotoma, aphasia, numbness/weakness, can happen without a headache, reversible in 5-60minutes
chronic: 15 days/month for greater than 3 months
often decrease in pregnancy (2nd and 3rd)
increase risk of preeclampsia
Migraine pharm
- acetaminophen when symptoms start
- acetinophen + metoclopramide (reglan) or compazine
- aceta + codeine= watch for rebound headache with overuse NAS
- aceta + caffeine
- Fioricet = rebound headache with overuse
- compazine (antiemetic)
- triptans NOT first line
- opioids AVOID can worsen
- severe= IV hydration, IV antiemetics, IV mag, benadryl, compazine, botox
patient education migraine pharm
- tylenol 4g max per day
- NO NSAIDS, NO ergots
- tylenol with caffeine (how much extra caffeine)
- if they take fioricet- already HAS tylenol.. dont take more
- tylenol given at early onset
- NO ergots NO Ibuprofen
Tension headaches patho
- most in pregnancy infrequent episode - less than 1/month - last 30 minutes- 7 days - bilateral, non-pulsing, not worse with activity frequent episode - >10 per month - both N/V - photophobia or phonophobia Chronic - >15 days
tension pharm
aceta.
aceta + caffeine
aceta + codeine
Fioricet
non-pharm cluster treatments
relaxation, breathing, meditation, visual/guided imagery, progressive relaxation, cognitive behavioral therapy, physical therpay (massage, TENS, chiropractic, heat/cold) biofeedback, regular and adequate sleep patterns, dietary modifications; some cheese, salty foods
cluster headaches
pre-existing= neurology
presentation: Unilateral, severe, explosive, 15 minutes to 3 hours, watery eyes, stuffy nose, sweating
cluster headache treatment
100% 02
sumatriptan
topical lidocaine inside nostril
preventative: verapamil, glucocorticoids
postpartum headache
first week
differentials: preeclampsia, consider anesthesia complications, CVT, postpartum angiopathy
secondary headaches
idiopathic intracranial hypertension: loss of vision complication, no issue to pregnancy
central venous thrombosis:
subarachnoid hemorhage
reversible cerebral vasoconstriction syndrome
risks associated with migraine headaches
severe migraines <8 weeks: at risk for fetal-limb reduciton defects, MI, CV disease, venous thromboembolism, preeclampsia, gHTN
SNOOP
S: Systemic symptoms: illness or condition
(fever)
N: neurological symptoms or abnormal signs
(altered mental status, change in vision, seizures)
O: Onset is new or sudden or severe
(worst headache of my life, subarachnoid hemorrhage?_
O: other associated conditions or features
(trauma, illicit drug use, awakens from sleep)
P: previous HA history with changes in symptoms
lactogenesis II
“milk coming in”
32 to 96 hours after birth
rapid drop in maternal progesterone levels following the expulsion of the placenta combines with the secretion of prolactin and other permissive hormones such as cortisol and insulin to trigger lactogenesis II
Breastfeeding I/O
at least 3 poops per day after day 4
at least 6 wet/heavy diapers after day 4
breastfeeding triage
vomiting, lethargy, breathing problems, refusing to feed
press the forehead skin- is it yellow underneath?
how many times in 24 hours are you nursing? (less than 8 is bad)
how many poopy diapers in 24 hours (less than 3 or 4 by day 4)
are poops yellow by day 4?
how many wet of heavy diapers? (less than 4 is bad)
can you hear the baby swallowing?
is there red staining in the diaper? (less than day 3 is normal)
can you tell if milk is in?
feedback inhibitor of lactation
milk protein that inhibits milk secretion as milk accumulates in the alveoli. the longer milk remains in the breast, the higher concentrations of FIL, which downregulates milk production.
breastfeeding weight loss
5-7% of weight in hospital or by day 4 regain birthweight by 2 weeks 4-7oz a week during first month 1-2 lb/week for 1-6 months 1lb/month from 6-1year
nutrition for lactation
no dietary restrictions
can help with weight loss
breastfed fine if mom only eats 1800 calories a day
overweight women can restrict by 500 calories
can have moderate excersize
medications in lactation
less than 1% is transferred, some degree of transfer present
much less than in utero
more in colostrum
colostrum components
Water makes up majority of human milk (87.5%)
Colostrum is present from 12-16wks EGA onward
Thicker, yellowish (d/t beta carotene)
2-20ml/feeding, about 100ml avail during first 24h after birth
higher in protein and minerals, and fat soluble vitamins than mature milk
++ sodium, chloride, potassium, carotenoids
Note that the breast cannot synthesize water soluble vitamins (these must come from the mother’s diet - must supplement B12 if vegan)
lower in sugars, fat, and lactose than mature milk
Mild laxative effect
immunologic properties of milk
secretory IgA
interferon
fibronectin
pancreatic trypsin inhibitor
mastitis
risk factors: cracked or damaged nipples, plugged milk ducts, milk stasis by engorgement or ineffective milk removal, blocked nipple poore, nasal carrier of s. aureus, hyperlactation or high rate of milk synthesis, insulin dependent DM, nipple piercing
contraindications to TOLAC
more than 2 sections
classical incision
previous uterine rupture
other contraindications to vaginal delivery
twins are okay
not great candidates: uncontrolled diabetes, recurring issues (cephalo-pelvic disportion, failure to progress,)
higher rates of VBAcing if you go into spontaneous labor
contraindicated medications: miso and any cervical ripening (cervidil)
can use pitocin- increases risk of rupture 2-3 times
need to have a physician in the hospital (whole staff for c/section)
why PTL??
activation of HPA axis prematurely
pathologic uterine distention
inflamation (increased prostaglandin)
decidua issues (abruption, ect…
PTL triage
fetal fibronectin (greater than 20 weeks, marker of PTL, hormone released) when its negative it is pretty sure not PTL, but positive does not mean much
ferm, pool, dye
speculum until proven placental location
transvaginal US for cervical length
cervical change can only be deduced if cervix is more than 2cm and 80% effaced (people walk around at that)
stopping PTL
IV hydration mag sulfate bolus beta methazone terb (only for labor with tachysystole) niphedipine (calcium channel blockers NOT with mag) cerclage up to 24 weeks (put in 12-15) indomethicin (no more than 48) progesterone start 16-20 weeks (injeciton or vaginal)
shortened cervical length
less than 25mm 14-28 weeks
barker hypothesis
intrauterine environment is the first environment for a human. What happens there has an impact.
pregnancy/crisis
Jordan (p. 293): we could think of pregnancy as a crisis in that it is a “turning point or opportunity” that creates “disequilibrium” and prompts the pregnant person and the family to adapt to/make functional changes that are both physical and psychological.
The successful, healthy adaptation to this “crisis” depends upon the pregnant person’s perspective on the crisis, the person’s access to resources, and the “resiliency” of both the person and the family
anxiety/depression pharm
more likely to have relapse if pt. already on meds and we take them off
SSRI (c)
Venlafaxine (c) SNRI
zoloft most safe
prozac least most concentraion
buproprion (c)
paxil (D) ! (cardiac defects) NO PAROXITINE
no valproic acid! (no)
yes TCA (first line)
benzos.. maybe ok?
metabolize all meds faster the farther along in pregnancy you are
pp depression treatment
SSRI, CBT, first line
no antidepressants for biopolar folks
full trial of meds is 12 weeks at good dose, start feeling at 4-6 weeks
ideal antidepressant in breastfeeding
Highly protein bound, short-half life, a low M/P ratio, poor bioavailability ( poor oral absorption)
postpartum/breastfeeding anti-depressant recommendations
SSRI low risk with others monitor infant sedation/weight gain no pump and dump no routine milk or infant levels
diagnosis of preterm labor
gestational age 20-37 weeks
documented regular UCs >6/hour
ROM
cervical change, greater than 2cm and 80% effaced
term definitions
Late preterm: 34-36w
Moderate preterm: 32-33w
Very preterm: 28-31w
Extremely preterm: <28 w
clinical pathways to PTL
premature activation of HPA axis
pathological uterine distension
inflammation (increase prostaglandins)
increase decidual hemmorhage
steps for PTL triage
Fetal monitoring with Doppler and toco
STERILE SPECULUM EXAM BEFORE DIGITAL EXAM
Obtain fFN specimen with DACRON swab, THEN obtain cultures
Lightly rotate swab across posterior fornix of the vagina for 10 seconds to absorb cervicovaginal secretions
Transfer swab to buffer solution in transport tube and cap
Specimen is stable at room temperature for 24 hours
Obtain other cervicovaginal cultures and test for PROM as indicated
Direct assessment of cervix for dilation
Digital exam for effacement and dilation, if PROM has been ruled out
Consider ENDOVAGINAL Cervical Length if available.
stopping PTL meds
- Betamimetics - Ritodrine, Terbutaline
- MgSO4•NSAID’s - Indomethacin, Clinoril
- Calcium Channel Blockers - Nifedipine
- Atosiban
PTL Risks
POVERTY genetics weathering hypothesis prior PTB= highest predictor low weight, chronic stress, fertility treatment occupational physical activity peridontal disease BV UTI
Cervical insufficiency
singleton pregnnacy
cervical length less than 25
prior PTB
** TVU gold standard for detection
Rubella
can be asymptomatic, but still contagious
symptoms: lymphadatomphy and rash. Also: nasal congestion, conjunctivitis, fever, malaise,
person to person, airborne
serological testing
PCR
choronic villus PCR after 22 weeks to be performed
CRS unlikely after 20 weeks infection (worst in 1st trimester)
US characteristics: microcephaly, cardiac, early growth retardation
Congenital rubella syndrome: HEARING LOSS, cataracts, glaucoma, retinitis, patent ductus arteriosis, cardiac lesions
Varicella
positive serology for IgM and IgG
transmitted: respiratory droplets, close contacts, crosses placenta from infected mother to fetus, infection can ascend form lesions in birth canal
