Final Exam

Question 1

How are Gs and Ps calculate? Twins?

Answer 1

Gravida-the # of times a woman has been pregnant regardless of the result of the pregnancy
Para-the # of pregnancies carried to the 20th week of gestation or the delivery of an infant weighing more than 500 g, regardless of the outcome
TPAL-numerical description of parity-four-digit system that counts all fetuses/babies born rather than pregnancies carried to viability
For example, a woman who has been pregnant once and given birth to twins at 35 weeks would be described as G1 P1. This is because multiples, such as twins or triplets, are counted as a single successful birth.

Question 2

What education should be given for pregnant women who are traveling?

Answer 2

• Use seatbelt; wear low on hip bones between protuberant abdomen and pelvis
• abruptio placentae leading cause of fetal loss in MVA
• Avoid long periods of inactivity such as sitting-walk every 1-2 hrs even for short periods
• Most airlines allow pregnant women to fly up to 36 wks; some airlines may restrict pregnant women from flying early in gestation for international flights or other complications
• Air travel not recommended for women with medical or obstetric complications (poorly controlled HTN/DM, or sickle cell disease)
• Carry copy of obstetric record
• Consider preventive antiemetics for increase nausea

Question 3

What increases a pregnant woman’s risk of a venous thromboembolism?

Answer 3

Question 4

What is the cause of the different blood pressure changes during pregnancy?

Answer 4

• Serial blood pressure recordings during pregnancy are influenced by maternal position; highest when seated, somewhat lower when supine, and lowest while lying on side
• In the first trimester blood pressure decreases, with systolic and diastolic pressures often being lower than pre-pregnancy levels due to the relaxation of the vascular smooth tissue
• In the second trimester blood pressures may begin to slightly increase but usually remains lower than pre-pregnancy levels.
• In the third trimester blood pressure often increases slightly towards the end of pregnancy. It should remain within normal limits but can indicate hypertensive disorders such as gestation hypertension, preeclampsia or HELLP.

Question 5

How do you educate women on quickening and when would it be appropriate to feel it?

Answer 5

• Quickening is when pregnant women start to feel their baby move. It usually occurs arounf 16-20 weeks but can be felt sooner
• It can usually be felt low in the belly, near the pubic bone
• Quickening has been described as fluttering like a butterfly, tapping or tiny pulses, bubbles popping, tiny muscle spasms, light rolls or tumbles or flickering

Question 6

What is periodontal disease and why does it occur?

Answer 6

• common and can lead to poor pregnancy outcomes
• chronic inflammation of the gums than can destroy underlying tissue and bone
• Pathogens from the oral cavity and inflammatory mediators are believed to enter the systemic circulation and reduce fertility and increase rates of preterm birth, low birth weight, and pre-eclampsia.
• link between severe gum disease in pregnant women and premature birth with low birth weight
• Recommend regular dental checkups to all women especially those wanting to get pregnant in the next year

Question 7

What is epistaxis in pregnancy and why does it occur?

Answer 7

Epistaxis (nose bleeds) occurs when a blood vessel bursts. Blood vessels in the nose vasodilate resulting in the capillaries’ engorgement, resulting in nosebleeds

Question 8

Recommended weight gain in pregnancy

Answer 8

• Under wt. (BMI lower 18.5) 28-40 lbs which is 1 lb per week
• Normal wt. (BMI 18.5-24.9) 25-35 lbs which is 1 lb per week
• Over wt. (BMI 25-29.9) 15-25 lbs which is 0.6 lb per week
• Obese wt. (BMI 30 and greater) 11-20 lbs ) 0.5 lb per week

Question 9

How to educate patients about exercise in pregnancy?

Answer 9

• Uncomplicated pregnant women should be encouraged to engage in aerobic and strength conditioning before, during, and after pregnancy. Healthy pregnancy guidelines recommend at least 150 minutes per week of moderate-intensity aerobic exercise.
• Do not let your heart rate exceed 140 beats per minute

Question 10

What early signs of pregnancy can be seen in the vagina?

Answer 10

• Chadwick’s sign (blue/ purple color b/c increased vascularization.
• Thickening of the vaginal mucosa
• Increase of vaginal secretions

Question 11

What is round ligament pain? Why does it occur?

Answer 11

• Round ligament pain is caused when ligaments are stretched as the uterus grows. Round ligaments are found on each side of the uterus. They are bands of tissue that hold the uterus in place. It happens most often in the 2nd trimester; it is normal and usually resolves by the 3rd trimester.
• S/S: Pain on one side of the lower ABD or groin that may move into the hip, spasms in muscles in ABD pain. Last a few seconds. Pain with exercising, sneezing, changing position or standing quickly.

Question 12

Discuss dating in pregnancy-most accurate indicator for determining gestational age

Answer 12

The crown rump length in the 1st trimester (before 13 6/7 wks) is accurate to 3-5 days

Question 13

Discuss thyroid changes in pregnancy

Answer 13

• increased demand for thyroid hormone, increased vascularity and hyperplasia-goiters require evaluation
• placental transfer of maternal hormones to fetus; fetus fully dependent on maternal thyroids for first 12 wks
• increased iodine requirement

Question 14

What are contraindications to breastfeeding?

Answer 14

• infant diagnosed with galactosemia
• HIV
• T-cell lymphotropic virus type I or type II
• maternal drug use (PCP, cocaine, opioids)-narcotic dependent mothers in supervised methadone program can breastfeed
• mother has Ebola
• They are undergoing diagnostic imaging with radiopharmaceuticals
• active TB or varicella or mpox virus
• HSV with open lesion*

Question 15

How to educate on kick counts?

Answer 15

• Perform kick counts after meals d/t increased glucose can stimulate movement
• Time how long it takes you to feel 10 kicks, flutters, swishes or rolls-ideally, you want to feel 10 movements within two hours.
• Can stimulate movement by: Taking a walk or moving your body, drinking juice or another sweet beverage, eating a meal, lying down on your left side (this maximizes blood flow), playing loud music
• Call OB-GYN if no movement after 2hrs and/or after all efforts exhausted

Question 16

What is Physiologic Anemia?

Answer 16

Question 17

Management of breast engorgement and how to differentiate from mastitis

Answer 17

• Breast engorgement-painful swollen breasts between 2-4 days after birth or later
  Management-increase frequency of feedings, nurse on-demand, shower, bath or breast water bath to relieve compression and aid milk flow, mild analgesics. If not breastfeeding cold compress, supportive bra, mild analgesics
• Mastitis-sudden illness with flu-like symptoms (fever) and a painful, hard, reddened area on one breast

Question 18

Respiratory changes during pregnancy

Answer 18

• diaphragm rises approximately 4 centimeters during pregnancy, but subcostal angle widens appreciably as the transverse diameter of the thoracic caves lengthens approximately 2cm.
• thoracic circumference increases about 6 centimeters, but not sufficiently to prevent reduce residual lung volumes created by the elevated diaphragm. Even so, diaphragmatic excursion is greater in pregnancy.
• Dyspnea is common
• Physiological lung changes -functional residual capacity decreases by approximately 20 to 30% during pregnancy.

Question 19

Cardiac output and changes in pregnancy

Answer 19

• Earliest and most dramatic changes in maternal physiology-improve fetal oxygenation and nutrition
• Cardiomegaly-d/t increase in fluid volume
• Dextroversion-displacement of heart up and to the left
• Increased cardiac ouput 30-50%-Cardiac output increases in first half of pregnancy due to increased stroke volume and in second half of pregnancy d/t increased maternal heart rate
• increase of circulating blood volume 45%
• Blood pressure changes-Drop in blood pressure mid pregnancy d/t progesterone causing relaxation in the vessels
• increased heart rate (not tachycardia) d/t increased blood volume- HR increases by 15-20 beats/min by week 32.

Question 20

Discuss vaginal discharge during pregnancy/Leukorrhea of pregnancy

Answer 20

• An increase in vaginal transudation as well as stimulation of the vaginal epithelium results in a heavier vaginal discharge, called leukorrhea of pregnancy that some women may mistake as infection or ruptured membranes
• Normal vaginal discharge-clear/white, limited amt, odorless
• Abnormal-red/yellow, excessive amt, foul odor, itchiness

Question 21

Cardiovascular changes during pregnancy-specifically hypervolemia

Answer 21

Hypervolemia, or fluid volume excess, is a common physiological state during pregnancy when the body retains more water and sodium due to hormonal changes (elevated levels of estrogen and progesterone increase plasma aldosterone levels and renin activity)

mild swelling, bloating, and discomfort, especially in the legs and ankles

hypervolemia can also provide survival benefits for pregnant women by increasing blood volume and improving tolerance to hemorrhage during delivery

Question 22

Describe different renal changes during pregnancy-specifically creatinine

Answer 22

decrease in serum creatinine-during a normal pregnancy, increased blood volume and kidney function cause an increase in the amount of creatinine filtered out of the blood and passed into the urine-creatinine clearance is accurate assessment of the renal function in pregnancy

kidneys enlarge (estrogen), uterers dilate (progesterone)-causes increased risk for UTI;

bladder tone decreases (urinary retention, UTI)

Question 23

What vaccines are safe during pregnancy? When are they done?

Answer 23

TDAP-given optimally between 27-36 weeks (3rd trimester) to protect mom and baby from pertussis

certain circumstances in which it is appropriate to administer the Tdap vaccine outside of the 27–36-weeks-of-gestation window-wound management, a pertussis outbreak, or other extenuating circumstances, the need for protection from infection supercedes the benefit of administering the vaccine during the 27–36-weeks-of-gestation window.

Question 24

Hematological changes during pregnancy

Answer 24

1. 50% increase in plasma volume-peaks at 30-34 wks
2. hypercoagulable-clotting factors increase d/t blood loss associated with labor and delivery
3. red blood cell size increase to maximize oxygen-carrying capacity of the mother to enhance oxygen delivery to fetus-adequate iron availability important
4. increased leukocyte production during pregnancy/labor; platelet counts may decline

Question 25

Coagulation changes during pregnancy

Answer 25

Increase in Factors 1, 2, 3, 8, 9, 12 and activity decrease in protein S & C which prevent clots and decrease bleeding complications associated with delivery but increases the risk for thromboembolism

Question 26

Metabolic changes during pregnancy

Answer 26

• Insulin resistance-diabetogenic effect on maternal carbohydrate metabolism, may cause postprandial hyperglycemia
• Maternal hypoglycemia during periods of fasting-glucose is primary fuel for placenta and fetus
• Increase in circulating concentrations of all lipids, lipoproteins, and apolipoproteins
• Intake and utilization of 1kg of protein above prepregnant state; 50% of additional protein used at term

Question 27

Pulmonary changes in pregnancy

Answer 27

• diaphragm moves upward toward chest and chest diameter increases in size
• Increase in the amount of air movement and decrease in amount of air the lungs capacity

Question 28

What are the different hormones in pregnancy, specifically in labor?

Answer 28

Oxytocin rise at the beginning of labor, causing the womb and abdominal muscles to contract regularly. Oxytocin is often administered to induce labor, or to “kick-start” the process. Oxytocin continues to be released as long as the baby is in the birth canal.
Progesterone-maintains pregnancy by relaxing uterine muscles to prevent contractions and levels drop at end to allow labor to begin
Estrogen: Increases the sensitivity of the uterus to oxytocin, helps in the maturation of the fetal lungs and mainly produced by the placenta
Prostaglandins: help ripen cervix and stimulate contractions

Question 29

Explain Rhogam

Answer 29

Indication for use is prevention of Rh (anti-D) isoimmunization in mothers who are Rh negative
* Screen mother during pregnancy-if Rh factor negative receives Rhogam IM at 28 weeks AND within 72 hours after delivery if baby Rh positive
* Rhogam stops immune system from creating antibodies
* Rhogam is given with each pregnancy to prevent mother from becoming sensitized

Question 30

When are the different ultrasounds performed during pregnancy and how to educate on when they are performed

Answer 30

• Sonogram between 6-8 wks to confirm pregnancy, due date, and checks that embryo is developing in womb
• Anatomy Scan can be done between 18 and 22 weeks but is usually performed at 20 weeks. This is a detailed exam of the fetal anatomy including the brain, heart, spine, limbs and other organs. It also assesses the placenta, amniotic fluid levels and fetal position.
• Growth scan-(if indicated) 3rd trimester-growth Scan-24-36 weeks if concerns about fetal growth and development; assesses fetal growth, weight, movements, position, placenta and amniotic fluid levels
• nuchal translucency ultrasound (optional) is performed between 11 and 13 weeks and assesses the risk for chromosomal abnormalities like down syndrome.
• Biophysical Profile (BPP)-(if indicated) perform at any point if delivery is an option if increased risk of fetal demise present
• BPP assesses: fetal breathing (2), amniotic fluid volume (2), fetal movement (2), and fetal muscle tone (2); 8 is a perfect score; can be combined with a non-stress test

Question 31

What is Group B strep and how is it treated? When is culture collected?

Answer 31

• Usually obtained between 36-37 weeks gestation-can be collected earlier if signs of PTL or other risk factors.
• The proper technique to collect a GBS swab is to collecting sample from both the vagina and the rectum.
• Insert a sterile swab about 2-3 cm into the vagina and gently rotate it to collect cells from the vaginal wall. Insert a sterile swab into the rectum about 1-2 cm and gently rotate it to collect cells from the rectal mucosa.
• Penicillin is the drug of choice for + GBS IV at least 4 hours before delivery. If patient is allergic to PCN, can administer Vancomycin, clindamycin or cefazolin.

Question 32

Discuss uterine involution in the postpartum period

Answer 32

• return of uterus to prepregnancy state that begins after delivery of placenta
• takes about 6 weeks to complete
• uterine muscles contract, uterus shrinks in size, tone, and position
• decidua shed and replaced by new endometrium

Question 33

Discuss afterpains from uterine contractions in postpartum patients

Answer 33

• sharp, menstrual-like cramps that occur in first few days after birth
• caused by uterus contracting and relaxting as it returns to pre-pregnancy size
• can help reduce uterine bleeding and swelling
• more common in multiparas and breastfeeding d/t release of oxytocin

Question 34

Discuss postpartum endometrial changes. When is regeneration of the endometrium complete?

Answer 34

• endometrium regenerates rapidly following childbirth; endometrium is restored throughout the uterus by 16 days postpartum
• superficial layer of decidua around placenta site becomes necrotic and sheds during day 5-6
• post delivery-lochia is a mixture of blood and necrotic decidua

Question 35

Discuss different lab tests during prenatal testing, which tests are recommended?

Answer 35

• CBC, thyroid
• blood type and Rh status, antibodies (indirect Coombs test)
• urinalysis, urine culture
• HIV, Hep B/C
• syphillis, chlamydia, gonorrhea, RPR/VDRL, HSV
• rubella, varicella, PPD
• Hgb electrophoresis, diabetes screen
• PAP
• drug screen

Question 36

Discuss edema in pregnancy, what would constitute further testing and what is normal?

Answer 36

• presence of significant edema in the lower extremities (dependent edema) and or in the hands is very common in pregnancy and by itself is not abnormal
• Fluid retention can be associated with hypertension, however, so the blood pressure as well as weight gain and edema must be evaluated