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Internal medicine > Gynecology - Fundamentals of pregnancy > Flashcards

Gynecology - Fundamentals of pregnancy Flashcards

1
Q

At what week can the gestational sac be located?

A

As early as 5 weeks LMP

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2
Q

At what age can the fetal heart motion be visualized?

A

As early as 6 weeks LMP

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3
Q

How do you calculate pregnancy-dates?

A

Pregnancy is dated as beginning at the first day of the cycle during which the woman becomes pregnant or the date of her last menstrual period (LMP).

  • Conception occurs around 2 weeks LMP
  • Implantation occurs around 3 weeks LMP
  • The pregnant women often discovers her pregnancy around 4-5 weeks LMP(she misses her normal period)
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4
Q

Calculating the due date, which rule can you use and what does it say?

A

“Naegle’s Rule: to determine the due date, subtract 3 months from the LMP and add 7 days.
- Assymes a 28-day cycle

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5
Q

Which fase of the menstrual cycle can vary? And by how much?

A

Follicular phase vary by +/- 7 days. Lutheal phase is usually always 14 days.

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6
Q

Which weeks counts as “preterm”?

A

20-37 weeks.

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7
Q

Which weeks counts as “term”?

A

37-42 weeks.

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8
Q

Which weeks counts as “postterm”?

A

After 42 weeks LMP

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9
Q

G/TPAL system

A

G (Gravida) is the total number of known pregnancies the woman has had, including the current one, regardless of outcome.
-Multiple gestation counts only as one pregnancy

T (term) - the number of pregnancies that resulted in a term delivery. Term is considered a delivery after 37 weeks LMP.

P (preterm) is the number of pregnancies that resulted in a preterm delivery.

A (abortus) is the number of pregnancies that resulted in spontaneous or induced abortion.

  • Delivery of a dead fetus before 20 weeks LMP = abortus
  • Delivery of a ded featus after 20 weeks LMP = stillbirth.

L (living) is the number of infants born.

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10
Q

GPA system

A

G (gravida) is the number of known pregnancies the women has had, regardless of outcome.

P (para, not preterm) is the total number of pregnancies the woman has had that led to a birth of an infant after 20 weeks LMP o greaterthan 500g
- Multiple gestation is considered one pregnancy

A - Abortions

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11
Q

In what physiologic “state” is a pregnancy?

A

Pregnancy is a high flow, low resistance state.

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12
Q

How does the cardiovascular system change in pregnancy?

A 
Cardiac output - incr. 30-50%
Stroke volume - incr. 30%
Plasma volume - incr. 50% 
Heart rate - incr. 15-25%
Systemic vascular resistence - DECR. 20%
- Systolic BP - slight decr. 
- Diastolic BP - DECR. 20%
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13
Q

Which murmur can you hear in pregnancy?

A

Systolic ejection murmur along the L sternal border is normal during pregnancy. A diastolic murmur however, requires investigation.

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14
Q

How does the pulmonary system change in pregnancy?

A 
Tidal volume increases 40%
Minute ventilation increases 40%
Residual volume decreases 20%
PaCO2 Decreases 25%
Oxygen comsumption increases 20-30%
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15
Q

Pulmonary changes in pregnancy

A
  • Pregnancy induces a state of respiratory alkalosis, compensated by increased renal bicarbonate excretion.

Progesterone dilates smooth muscle in the airway, but estrogen causes tissue edema and hyperplasia of mucus glands.

Respiratory drive increases due to various factors and leads to a degree of dyspnea in the majority of patients.
- Avoiding the supine position is advisable

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16
Q

Hematologic changes during pregnancy

A 
Plasma volume INCR 50%
RBC volume INCR 20-30%
Hematocrit DECR 
WBC count Incr slightly
ESR incr. 
Coag factors INCR.
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17
Q

Hematologic changes during pregnancy

A

Pregnancy is a hypercoagulable state, likely owing to venous stasis and endothelial damage.

  • Women with inherited hypercoagulability are predisposed to placental vascular thrombosis, raising the risk of pre-eclampsia, gestational hypertension and fetal complication.
  • Five-fold increased risk of DVT
  • Increased RBC count underscores the need for iron and folate supplementation during pregnancy.
  • Borth iron and folate requirements approx. double during pregnancy!
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18
Q

What is the most common cause of anemia in pregnancy?

A

Iron-deficiency anemia

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19
Q

Renal changes in pregnancy

A

Kidney size - INCR 100%
GFR - INCR 50%
Urine glucose - INCR

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20
Q

Renal changes in pregnancy

A

Increased uteral size, increased urine glucose, and mechanical factors predispose the patient to pyelonephritis and UTI

  • Proteinuria
  • RAAS activated (total body sodiumincreases though serum concentration remains relatively constant)
  • Lightening makes it easier to breathe, but increases urinary urgency and frequency
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21
Q

Endocrine changes in pregnancy

A 
Estrogen - INCR
Progesterone - INCR
Pituitary size - INCR 
Thyroid size - INCR 
Total thyroid hormone - INCR
Thyroid binding globulin - INCR
Human placental lactogen - INCR
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22
Q

Endocrine changes in pregnancy

A

Pregnancy is a hyperestrogenic state, mediated by the placenta and fetal DHEAS production
- Estriol is the major estrogen that is produced in pregnancy

Pituitary size increases
- Postpartum hypotension leaves the pituitary extremely vulnerable to ischemic damage (Sheehan’s syndrome)

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23
Q

Gastrointestinal changes in pregnancy

A 
Gastric motility - DECR
GES tone - DECR
Colonic motility - DECR
Gastric emptying time - INCR
Colonic transit time - INCR
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24
Q

Gastrointestinal changes in pregnancy

A

Relaxed GES tone, incr. emptying time, decr. gastric motility, incr gastric pressure all contribute to a higher risk of gastric reflux during pregnancy.

  • hCG concentration assoc. with nausea
  • Hyperemesis gravidarum - severe nausea during pregnancy assoc. with decrease in pre-pregnancy body weight of at least 5%.
    Tx: frequent snacking and antiemetics (doxylamine/B6)
  • Hemorrhoids are a problem for 30-40% of women.
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25
Q

Dermatologic changes during pregnancy

A
  • Striae gravidarum: stretch marks along the abdomen/buttochs.
  • Linea nigra - incr. pigmentation of the abdominal midline due to incr. MSH levels
  • Cholasma - Blotchy pigmentation of the nose and face
  • Spider angiomata and palmar erythema - stigmata resulting from increased vascularity
  • Chadwick sign - Bluish/purpulish discoloration of the vagina and cervix.
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26
Q

How do you interpret Electronic Fetal monitoring?

A

“Reassuring” vs “non-reassuring”

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27
Q

What do you “check” on electronic fetal monitoring?

A
  1. Baseline fetal heart rate
    - Bradycardia
    - Tachycardia
  2. Variability
    - Low variability
    - Moderate variability
    - High variability
    - Marked variability
  3. Accelerations
  4. Decelerations
    - Early decelerations
    - Variable decelerations
    - Late decelerations
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28
Q

Normal fetal heart rate?

A

110-160 bpm

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29
Q

Causes of fetal bradycardia?

A

Can be normal if fetus is sleeping.

  1. Maternal factors:
    Supine positioning
    Hypotension
    Hypoglycemia
  2. Maternal - fetal interface :
    - Poor uterine perfusion
    - Umbilical cord prolapse
  3. Fetal factors:
    - Arrhytmia
    - Vagal stimulation
  4. Medications:
    - Opioids
    - Anesthesia
    - Magnesium sulfate
    - B-blockers
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30
Q

Causes of fetal tachycardia?

A

Fetal movement/stimulation can be a normal cause.

  1. Maternal factors:
    - Stress/anxiety
    - Fever/infection
    - Thyrotoxicosis
    - Anemia
    - Hypoxia
  2. Maternal-fetal interface
    - Chorioamnionitis
    - Abruptio placentae
  3. Fetal factors:
    - Arrhytmia
    - Anemia/acute blood loss
  4. Medications:
    - Anticholinergics
    - Sympathomimetics
    - Illicit drugs (e.g cocaine)
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31
Q

What is assuring if there is an abnormality of the baseline FHR?

A

If there is good variability, then the abnormality is usually benign.

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32
Q

What is variability?

A

Variability is a fluctuation of the baseline in amplitude and frequency of > 2 cycles/min.

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33
Q

What is Non-reassuring?

A

Absent variability (= undetectable variability)

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34
Q

What is Low variability?

A

Delta of < 5 bpm

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35
Q

What is Reassuring?

A

Moderate variability (delta of 6-25 bpm)

36
Q

What is marked variability?

A

delta of > 25 bpm

37
Q

What can be associated with fetal hypoxia?

A

Marked variability

38
Q

What is accelerations?

A

Periodic increase in FHR of 15 bpm, sustained for at least 15 sec.
- Always reassuring!!

39
Q

What is decelerations?

A

A drop in FHR of > 15 bpm with onset to nadir of > 30 secs duration

40
Q

Early vs. Variable vs. Late decelerations?

A

Early decelerations = Inconsequential

  • Decelerations coincide with contractions
  • Early decelerations are associated with head compression.

Variable decelerations = Non-reassuring when severe.

  • Decelerations variable in relation to contractions
  • Variable decelerations are associated with cord compression (mild or moderate decels) or acidosis (severe decels).

Late decelerations = Always non-reassuring!

  • Decelerations beginning after contractions; more gradual
  • Late decelerations are associated with uteroplacental insufficiency.
41
Q

Mild vs moderate vs severe variable decelerations in bpm?

A

Mild variable: Drop of 15-40 bpm.
Moderate variable: Drop of 40-60 bpm.
Severe variable deceleration: Drop of > 60 bpm or drop below 70 bpm.

42
Q

What is typical for cord-compression?

A

Mild or moderate variable decelerations

43
Q

What is typical for fetal acidosis?

A

Severe variable decelerations.

44
Q

What do we want in an electronic fetal monitor?

A
  1. Normal baseline FHR (110-160)
  2. Accelerations (15x 15)
  3. Moderate variability
  4. No decelerations or early decelerations
45
Q

What do we fear in an electronic fetal monitor?

A
  1. Severe, persistent tachycardia or bradycardia
  2. Absent variability
  3. Severe variable or late decelerations
46
Q

How do you manage non-reassuring fetal heart pattern?

A
  1. Consider non-hypoxic causes: Particularly anesthesia/medications
  2. Intrauterine resuscitation procedures: D/C oxytocin, high-flow oxygen facemask, change position from supine, vaginal exam, scalp stimulation.
  3. Re-assess EFM strip
  4. Consider fetal scalp pH assessment
  5. Prepare for prompt delivery if normalization does not occur.
47
Q

How often is the prenatal care/visits?

A
  • Every four weeks from diagnosis until 28 weeks.
  • Every two weeks from 28 weeks until 36 weeks
  • Every week from 36 weeks to birth
48
Q

What lab-test do you perform at the first trimester visit?

A
  • CBC
  • Type, Rh, and AAT screen
  • Rubella and Varicella IgG
  • HBV screen
  • STD screen (syphilis, hiv, clamydia etc)
  • Urinalysis and culture
  • Pap smear
49
Q

What time-period is the first trimester?

A

Conception up to 12th week.

50
Q

When is the first trimester screen?

A

Towards the end of the first trimester (11-13 weeks), then the patient may be offered an ultrasound along with maternal serum hCG, AFP and PAPP-A levels. It should not be confused with the triple screen or the quad screen, performed in the second trimester.

51
Q

In first trimester, what should you be aware of in the labs?

A

CBC -> anemia, obtain iron studies

Blood type, rh factor, AAT -> Rh negative? risk for maternal/fetal anti-D isoimmunization, should be worked up for the presence of anti-D antibodies via the atypical antibody test (AAT)
The presence of AAT indicates that the fetus is at risk of isoimmunization.

Rubella and Varicella IgG - a positive is indivative of immunity and is what we want to see. The MMR and varicella vaccine are NOT safe during pregnancy!!

HBV screen:
- All women should be screened.
+ HBsAG -> LFTs and HBIg for baby after birth

STD Screen:
All women should be screened for HIV, chlamydia and gonorrhea

Urinalysis and culture:
To rule out asymptomatic bacteriuria and assess renal function. asymptomatic bacteruria should immediately be treated with abx.

52
Q

Normal events in the first trimester visit

A

Nausea/vomiting, fatigue, breast tenderness, urinary frequency, spotting/bleeding in 20%, average weight gain of 5-6lbs, spontaneous abortion.

53
Q

What Folate and Iron supplementation is reccomended per day?

A

Folate 600ug/day

Iron 27mg/day

54
Q

When is the second trimester of pregnancy?

A

From the beginning of the 13th week after conception to the end of the 27th week.

55
Q

What two routine tests are performed in the second trimester?

A

The triple/quad screen and the fetal anatomy ultrasound.

56
Q

What is the quad screen?

A

It is a maternal blood test that looks for four biomarkers. It is performed between 16 and 18 weeks and replaces the triple screen. Includes:

  1. Alpha-fetoprotein (AFP)
  2. Estriol
  3. hCG
  4. Inhibin A (not included in the triple screen)

! The most important biomarker is AFP !

57
Q

Which vaccines are safe, and which are not, in pregnancy?

A

SAFE:

  • Influenza
  • HBV
  • HAV
  • Pneumococcus
  • Meningococcus
  • Typhoid

UNSAFE:

  • MMR
  • Polio
  • Varicella
  • Yellow fever
58
Q

What is the most common cause of abnormal AFP-levels, and when should it peak?

A

Inaccurate dating is the most common cause of abnormal levels. In maternal serum, peaks at about 30 weeks.

59
Q

What can a LOW AFP mean?

A
  • Inaccurate gestational age
  • Down’s syndrome
  • Turner’s syndrome
    (If a sonogram confirms the gestational age -> amniocentesis)
60
Q

What can a HIGH AFP mean?

A
  • Inaccurate gestational age
  • Multiple gestation
  • Neural tube defect
  • Ventral wall defect
  • Patau’s syndrome
  • Fetal renal disease

=> sonography to confirm gest. age and look for anomalies.

61
Q

How would the result of the quad-screen be in Down’s syndrome?

A

AFP: Low
Estriol: Low
hCG: High
Inhibin A: High

62
Q

How would the result of the quad-screen be in Edward’s syndrome?

A

AFP: –
Estriol: Low
hCG: Low
Inhibin: –

63
Q

How would the result of the quad-screen be in Patau’s syndrome?

A

AFP: High
Estriol: –
hCG: –
Inhibin A: —

64
Q

How would the result of the quad-screen be in Turners?

A

AFP: Low
Estriol: Low
hCG: Very high
Inhibin A: Very high

Mnemonic:

Downs: HIgh
Edwards: HEdward’s is low
Patau: AFPatau’s is high
Turners: HIgh

65
Q

Fetal weight can be estimated by measuring?

A
  1. Head circumference
  2. Biparietal diameter
  3. Abdominal circumference
  4. Femur length
66
Q

What is normal in second trimester visit?

A
  • Improved sense of well-being
  • mild pelvic pain
  • Quickening/fetal movement (about 18-20w for primigravidas, and 16-20 w for multigravidas)
  • “Contractions”
  • Average weight gain is about 1lb/week.
67
Q

What is common complaints in the second trimester?

A
  • Mid pelvic pain
  • Back pain
  • Ongoing breast pain
  • Unwanted hair growth
  • Skin changes
  • Hemorrhoids
  • Cervical insufficiency
  • Preterm premature rupture of membranes
  • Preterm labor
68
Q

Which labs and tests should be done in 3rd trimester?

A

Labs:

  • UA
  • CBC
  • AAT
  • OGTT
  • GBS screen
  • Gestational diabetes mellitus (GDM) testing; 1-hr 50g OCTT, 3-hr 100g OGTT
69
Q

When is the third trimester?

A

Extends from the beginning of 28th week until the end of pregnancy.

70
Q

What is especially important to pay attention to in 3rd trimester?

A

The patient’s blood pressure (should not exceed 120/80)
Also, screen for gest. diabetes, which is a common complication in the third trimester.
Re-test for gestational anemia

71
Q

Which BP in third trimester is suggestive of pre-eclampsia?

A

SBP > 140 or DBP > 90 x 2

72
Q

What could be needed to do in third trimester checkup?

A

Urinalysis - check for glycosuria and proteinura

CBC - check iron-def-anemia

OGTT (24-28w)

AAT (28 weeks) - Pts who are Rh negative and AAT negative should be given RhoGAM at 28 weeks.

GBS (36 week) - if positive, give IV penicillin G during labor

Gest. DM-testing:
Screening to all pregnant women between 24-28w gestation.

73
Q

When is the 1hr-50g OGTT positive in a pregnant woman?

A

Normal < 140mg/dL, positive screen >140mg/dl.

74
Q

What can you detect via Leopold maneuvers?

A

During the final several weeks of pregnancy, the fetus moves into its presenting position, which you can detect via this maneuver.

75
Q

What is lightening?

A

Around 36-40 weeks, the fetal head descends in the pelvis causing lightening. This may be accompanied by a sensation of easier breathing for the mother, but is also associated with increased urinary frequency and pelvic discomfort.

76
Q

When are you officially in labor?

A

Regular contractions (every 5 min lasting - 30 secs - ACCOMPANIED BY CERVICAL CHANGE.

77
Q

When are you in stage 1 of labor?

A

Closed to full dilation (10 cm)
- Latent stage one: closed to 3-4cm dilated (should last <20h in primipara, <14h in multipara)

  • Active stage one: 3-4cm to full dilation(dilation accelerates) (should last <5-6h in primipara and < 4-5h in multipara)

!Cervical dilation should be 1-1,2 cm/hr for primipara and 1,2-1,5 cm/hr in multipara!

78
Q

When are you in stage 2 of labor?

A

Full dilation to delivery of fetus (Should last <2h in primipara, and <1h in multipara)

79
Q

When are you in stage 3 of labor?

A

Delivery of fetus to delivery of placenta (should last 30min)

80
Q

When are you in stage 4 of labor?

A

The two hours following delivery.

81
Q

What happens in prolonged latent phase, what are causes, and what should you do?

A

Pt in labor and remains < 3 cm dilated for > 20h (primip) or > 14 hrs (multip)

Causes:

  • Anesthesia too early
  • Irregular contractions (Hypotonic - infrequent, weak. Hypertonic - strong, short)

Mx:
Rest and IV morphine sedation
If false labor - contractions stop after administration. If true labor - cervical change will have occured by the time sedative wears off.

82
Q

What happens in prolonged active phase, what are causes, and what should you do?

A

Pt in labor and has cervical change of < 1,2cm/hr (primi) or < 1,5 cm/hr (multi)

Causes:

  1. Passenger- increased fetal size, abnormal orientation in utero
  2. Pelvis - Inadequate bony pelvis anatomy
  3. Power - dysfunctional or inadequate contractions

Mx: depends on the tonicity of contractions

  • Hypotonic: IV oxytoci
  • Hypertonic: Morphine
  • Eutonic: EmergentC-section
83
Q

What is an arrested active phase, and what is management?

A

Pt in labor and has no cervical change for 2-3h.

Mx: same as prolonged active phase.

84
Q

What happens in prolonged second stage, what are causes and how do you treat?

A

Pt is 10cm dilated and fails to deliver infants in < 2hr (primi) or < 1 hr (multip). Add one hour if pt has recieved anesthesia

Causes: 3P’s

Mx: Assess contractions
- Inadequate: IV oxytocin
- Adequate: assess engagement of fetal head
(If engaged - consider forceps or vacuum delivery attempt. if not engaged: emergent c-section).

85
Q

What happens in prolonged third stage, what are causes and how do you treat?

A

Failure to deliver placenta in <30mins.

Causes:

  • Inadequate contractions
  • Abnormal placentation (accreta, increta, percreta)

Mx: Assess contractions
(Inadequate - IV oxytocin,
Adequate - Manual removal, rarely hysterectomy)

86
Q

What is a prolapsed umbilical cord?

A

Protrusion of the umbilical cord ahead of or alongside the presenting part of the fetus

Internal medicine (16 decks)

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