hello Flashcards
What is Mastodynia/mastalgia?
breast tenderness or pain
What does cyclic Mastodynia suggest?
luteal phase tenderness
Is Mastodynia increased or decreased in OCP and HRT users?
increased
What is the MOA of bromocriptine?
dopaminergic agonist that inhibits the release of prolactin from the anterior pituitary
What is the MOA of danazol?
synthetic testosterone that binds to progesterone and androgen receptor sites
What is the most common benign breast condition?
fibrocystic breast disease
What ages is fibrocystic breast disease common in?
30 to 50 yo
What is the etiology behind fibrocystic breast disease?
due to an exaggerated stromal response to hormones - assoc with a long follicular or luteal phase
What all does fibrocystic breast disease include?
cysts, papillomatosis, fibrosis, adenosis, and ductal epithelial hyperplasia
What are the most common pathologic causes of nipple d/c?
Intraductal papillomas, carcinoma and fibrocystic chgs with ectasia of the ducts (less frequently)
What are common causes of nipple d/c?
CNS lesions, hypothalamic pituitary d/o, systemic dz, medications and herbs, chest wall lesions
What is the mean age of breast cancer diagnosis?
60-61 yo
What is Rubin Maneuver?
insert index and middle fingers into vagina against the fetal posterior and anterior shoulder and push/rotate towards the fetal chest –> this helps rotate the shoulders into the oblique position
What is Woods (Screw) maneuver?
fingers are used to apply pressure posterior shoulder and push/rotate towards the fetal back –> this will rotate the fetal trunk inward about 180 degrees in a winding motion
What is Barnum (or Jacquemier) maneuver?
delivery of the posterior arm - hand is placed into the maternal sacral hollow - the fetal posterior arm is identified and pressure is placed on the antecubital fossa - this should cause forearm flexion across the chest where the forearm can be gripped extending the arm above the head and delivering the fetus arm first
What is the Zavanelli maneuver?
the infants head is replaced into the vaginal canal and uterus if possible and there is a subsequent C section –> however high infant mortality if possible
What is the treatment for Mastodynia?
acetaminophen/NSAIDs, Vit B6, Danazol, Bromocriptine Danazol is preferred over bromocriptine
What is the work up for fibrocystic breast disease?
biopsy to r/out carcinoma –> FNA is both diagnostic and therapeutic
What is the tx for fibrocystic breast disease?
may only need supportive bra, dec intake of nicotine and caffeine, there is a possible response to low salt diet and vit E supplements, HCTZ can be given premenstrually, if symptoms are severe enough Danazol can be used
What are the clinical characteristics of fibrocystic breast disease?
round, soft to firm or tense, mobile, usually TENDER, multiple and well demarcated
What is the most common causative organism of mastitis?
staph aureus
What are the clinical manifestations of mastitis?
flu like symptoms with unilateral breast tenderness that is red and warm to the touch –> diagnosis is mostly made by PE findings
What is the treatment for mastitis?
penicillinase-resistant antibiotic such as dicloxacillin or Nafcillin OR a cephalosporin
Should a lactating women continue to breastfeed after being diagnosed with mastitis?
YES, prevents the accumulation of infected material in the breast
What are two different types of abscesses?
lactational and subareolar
What is the causative organism of a lactational abscess?
staph aureus
What is the causative organism of a subareolar abscess?
mixed infection w/ anaerobes, staphylococci and streptococci
How can you treat a lactational abscess?
w/ Nafcillin, cefazolin, or vancomycin
How do you treat a subareolar abscess?
broad spectrum ABX
How can the involved duct in galactorrhea be identified?
by pressure at different sites around the nipple at the margin of the areola
What are the clinical manifestations of pathologic galactorrhea?
unilateral discharge coming from a single duct that can be serous, bloody or serosanguineous… +/- mass
What tests should be ordered in a women presenting with multiductal non-bloody discharge from the breast with a normal physical exam and negative imaging?
pregnancy tests, prolactin levels, renal and thyroid function tests, w/ endocrinology follow up
What tests should be ordered when a women presents with discharge from the breast that is suggestive of a pathologic cause (unilateral, single duct, bloody or serous)?
mammogram and US - can reveal underlying abnormalities of the duct ductography - can delineate an Intraductal filling defect
When may purulent discharge from the breast be present?
when there is a subareolar abscess –> tx may require excision of the abscess and related lactiferous sinus
What is a Fibroadenoma?
a benign tumor composed of stromal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit
What is the age range from Fibroadenoma?
15 to 55… however most common in those younger than 40
What are the clinical characteristics of a fibroadenoma?
round or discoid, smooth, firm, rubbery, well circumscribed, mobile, and NON TENDER
What is the most common size of a fibroadenoma?
1 to 5 cm
How do you diagnosis a fibroadenoma?
physical exam and biopsy results
What is the treatment for a fibroadenoma?
if no family hx of breast cancer and the pt is stable she can be followed up clinically… if the fibroadenoma is large it can be removed by excisional biopsy
When should a fibroadenoma be biopsied?
in women younger than 25 years of age, and if the mass is suspicious for cancer
What cancer does breast cancer increase the risk of developing?
endometrial cancer
What are some preventative measures for breast cancer?
early pregnancy, prolonged lactation, chemical or surgical sterilization, exercise, and low fat diet
What are the risk factors of breast cancer?
increasing age, known BRCA 1 or 2 gene, fam hx of gynecologic malignancy, first degree relative with BC, personal hx of BC, exposure to ionizing radiation especially if prior to the age of 30
What amount of invasive breast cancers are estrogen receptor positive?
all invasive lobular cancers and 2/3 of invasive ductal cancers
What are the clinical characteristics of inflammatory breast carcinoma?
diffuse, brawny edema with an erysipeloid border –> usually w/out an underlying palpable mass
What type of carcinoma does Paget’s disease typically lead to?
ductal carcinoma
What are the clinical manifestations of Paget’s disease?
eczematous lesion - red, scaling, and crusty patch on the nipple, areola, or surrounding skin
What is the significance of finding a palpable mass in a woman with paget’s disease?
95% of masses are found to be invasive… mostly infiltrating ductal carcinoma
What is the definition of pregnancy associated breast cancer?
breast cancer that is diagnosed during pregnancy, in the first post partum year, or anytime during lactation
What is the minimal tx of choice for breast cancer during pregnancy?
modified radical mastectomy
What are the mammogram results for ductal carcinoma in situ?
clustered microcalcification –> diagnosed then by needle or excision bx and treatment is surgical excision
What are the mammogram results for lobular carcinoma in situ?
nothing is seen on mammogram –> dx incidentally when a bx is done for another condition –> tx is a local excision
Where are ER positive tumors most likely to metastasize?
the bone, soft tissue, and genital organs
Where are ER negative tumors mostly likely to metastasize to?
liver, lung, and brain
Where are most breast cancers found?
45% are found in the upper outer quadrant and 25% are under the nipple and areolar area
Is breast pain a typical symptom of breast cancer?
NO, breast cancer rarely presents with breast pain
What are the later symptoms of breast cancer?
skin or nipple retraction, axillary lymphadenopathy, breast enlargement, redness, edema, brawny induration, peau d’orange, pain, fixation of mass to chin or chest wall
What are the late symptoms of breast cancer?
ulceration, supraclavicular lymphadenopathy, edema of arm, distant mets
When are monthly self breast exams recommended?
5 days after menses for pts older than age 20
What is the only screening method that has been consistently found to decrease the mortality of breast cancer?
mammogram
What are the screening recommendations for clinical breast exams for a pt younger than 40 yo?
every 3 yrs if greater than 40 exams should be done annually
When is an MRI indicated for screening for BC?
should be given in addition to a mammogram every year for women at high risk: known BRCA gene or first degree relative with BRCA gene, greater than 20% lifetime risk based primarily on family history, and prior mantle radiation
What are biopsy findings suggestive of carcinoma?
spiculated mass, asymmetric local fibrosis, and microcalcifications with a linear branched pattern
Oncotype dx is used for?
used to help determine the need for chemo for women with stage I or hormone receptor positive cancer –> looks at 21 genes and determines the likelihood of the cancer recurring or spreading
What stages of BC are curative treatments most commonly used for?
stage I, IIA, IIB, or locally advanced IIIB
At what stage of BC is palliative treatment considered?
stage IV disease, and for previously tx pts who develop distant mets or unresectable local recurrence
When is adjuvant therapy such as medical tx options considered?
based on lymph node status, age of patient, size of primary tumor, and ER/PR status
When is chemotherapy indicated in BC?
lymph node positive pts or high risk lymph node negative pts… those with adverse prognostic factors such as tumor size > 1 cm, positive lymph nodes, and high grade disease
What is the duration for chemotherapy during BC?
duration for 3-6 mo or 4-6 cycles offer the optimal benefit
What is the difference in aromatase inhibitors and tamoxifen in developing adverse complications?
AIs have less risk of endometrial cancer, venous thromboembolic events and hot flashes than tamoxifen however AIs have a higher risk of musculoskeletal d/o, osteoporosis, and cardiac events
Can aromatase inhibitors be used in premenopausal women?
NO, b/c of the paradoxical estrogen feedback on the hypothalamus
How often is a physical exam recommended for follow up post breast cancer treatment?
every 4 mo for the first 2 years then every 6 mo until year 5 (so for the next 2 years) then annually after that
When is a mammogram recommended for follow up post breast cancer treatment?
annually for all patients and no less than 6 mo after the completion of RDX
When is a CXR recommended for follow up post BC tx?
annually for those that received irradiation
True or False: pts with ER/PR positive tumors have a more favorable prognosis
TRUE
True or False: modified and simple or partial mastectomies have equivalent survival rates when followed by XRT
TRUE
When is surgery indicated for palliative treatment?
pts with good performance status, minimal organ involvement, prolonged disease free interval, or slow disease growth –> if complete resection of the tumor or metastasis is reasonable
What is considered local palliative therapy?
radiation or surgery –> these are reserved for pts in order to control their symptoms and minimize the risk for complications
When is palliative radiation treatment indicated?
good for certain bone or soft tissue mets to control pain or avoid fracture - can be especially useful in the tx of the isolated bony mets and chest wall recurrences
True or False: hormone manipulation for BC tx is less successful in postmenopausal women
false! it is usually more successful
When should cytotoxic drugs be considered in the treatment of metastatic breast cancer?
if visceral mets are present (especially brain or pulm lymph node spread), if hormonal tx is unsuccessful and the dz has progressed after an initial response to hormone manipulation, and if the tumor is ER and PR negative
What are the most common cytotoxic drugs being used for hormone refractory metastatic breast cancer?
taxanes
What is the most common site of breast cancer metastasis?
the BONE
How is bisphosphonate therapy dosed in palliative tx for breast cancer?
typically given IV every 3-4 wks and continued indefinitely
What labs and exams are recommended with the use of bisphosphonate therapy?
dental exams, creatinine and renal fxn, calcium and vit D levels are recommended b/c of the risk of osteonecrosis of the jaw, renal insufficiency, and hypocalcemia with prolonged therapy
Mauriceau maneuver
used during the 3rd step of partial extraction/assisted delivery of breech presentation – used to deliver the head of the fetus
When is a total breech extraction used in a vaginal delivery?
when there is fetal distress or when the 2nd twin is in non-vertex position after the 1st is successfully delivered
What are complications of vaginal delivery of a fetus that is in breech presentation?
umbilical cord prolapse, spinal injury to infant, and head entrapment at the cervix
When is a transverse incision used in a caesarean section for a breeched presentation baby?
term labor w/ a well developed lower uterine segment
When is a low vertical incision used in a C-section for the delivery of a fetus with a breech presentation?
premature gestation, unlabored uterus, malpresentations
What are specific indications for a C-section for a breech presentation fetus?
EFW greater than or equal to 3500 gms or less than 1500 gms contracted or borderline maternal pelvic measurements nonflexed or hyperextended head footling presentation variable fetal HR decelerations unengaged presenting fetal part dysfunctional or prolonged labor prolonged ROM premature fetus (25-35 wks) mother that: elderly primigravida, infertility problems, or poor obstetric hx
What is the definition of premature rupture of membranes?
rupture of the amniotic membranes occurring at least 1 hour before the onset of active labor at or after 37 wks gestation
What is the definition or preterm premature rupture of membranes?
rupture of the amniotic membranes that occurs before 37 wks gestation
What is the definition of prolonged premature rupture of membranes?
rupture that occurs more than 18 hours before the onset of labor
What are some potential causes of PROM?
apoptosis and catabolic enzyme activity, inflammatory process or maternal uterine infection, multiple prior pregnancies, hx of PROM, nutritional deficits, dec tensile strength of membranes
What should you do if there is no obvious leakage but PROM is suspected?
place pad under the perineum and monitor for leakage, cough of Valsalva can detect loss of fluid through the cervix on exam
What will be seen on an US in PROM?
low placental fluid index, oligohydraminos
When do most patient go into spontaneous labor when PROM is at or near term?
within 24 hours
What is the most common causative organism of Chorioamnionitis?
B streptococcus
What is the management when Chorioamnionitis is present?
IMMEDIATE deliver regardless of gestational age… induce labor PRN
When is external cephalic version best indicated?
with a single pregnancy greater than or equal to 36 weeks or a non vertex 2nd twin
How is external cephalic version performed?
for breech delivery –> move fetus into cephalic position with external pressure and manipulation of the maternal abdomen
If external cephalic version is unsuccessful what should you do?
wait for spontaneous labor and monitor for spontaneous conversion to cephalic position –> can induce labor or C-section as indicated
When is external cephalic version contraindicated?
multiple pregnancies, placental abnormalities, fetal distress, and abnormal uterine structure
What are complications of a breech vaginal delivery?
umbilical cord prolapse, spinal injury to the infant, head entrapment at the cervix
What are favorable indicators when considering a vaginal delivery of a breech fetus?
frank breech, gestation >/= 34 weeks, EFW 2000-3500 gms, flexed head, adequate maternal pelvis of approx 10 x 11.5 cm)
When do Braxton hicks contractions occur?
final 1-2 wks of pregnancy
What are examples of fetal lie?
transverse of longitudinal
What are examples of fetal presentation?
breech or vertex
What is the definition of dilation?
determines how open the cervix is at the internal os
What is the rate of dilation for a nulliparous women?
1-1.2 cm/hr
What is the rate of dilation for a multiparous women?
1.5 cm/hr (dilate faster than nulliparous women)
True or false: in a nulliparous woman effacement usually precedes dilation where as in a multiparous woman dilation precedes effacement
TRUE
What is 100% effacement?
when the mother is ready to deliver and the cervix is paper thin or ripened
What is the bloody show?
loss of the mucous plug and often proceeds true labor
What is station?
the relationship of the fetal head to the ischial spines
What is a bishop score that indicates a cervix that is favorable for spontaneous deliver?
a score of greater than 8
What is induction?
the attempt to begin labor in a non laboring patient
What is augmentation?
the process of increasing already present labor
What is related to the success of induction?
the bishop score
What bishop score leads to an increased number of failed inductions?
a score of less than 5
What medication can you use to prepare a woman for induction?
prostaglandins to ripen the cervix
When are prostaglandins contraindicated?
maternal asthma, glaucoma, more than one prior C-section, or an unstable fetus
What is stage 1 of labor?
begins with onset of true labor to complete cervical dilation and effacement
What is the avg duration of stage 1 of labor in a nulliparous vs multiparous woman?
nulli - 6 to 18 hrs multi - 2 to 10 hours
What is the latent phase of stage 1 of labor?
onset of labor until 3-4 cm of dilation
What is the active phase of stage 1 of labor?
ranges until greater than 9 cm dilation
What is the transmit time during stage 1 on labor affected by?
power - the strength and frequency of contractions passenger - size and position of the fetus pelvis - size and shape of pelvis
What is stage 2 of labor?
expulsion - from the time of full dilation to the delivery of the infant
What is the average time for stage 2 of labor?
usually 30 min; may be up to 3 hrs in a nulliparous woman
How often should you assess the apgar score after delivery?
at 1 and 5 min post delivery
What are the degrees of lacerations during labor?
First degree - through the skin and mucous Second degree- extends into the perineal body Third Degree- extends into our through the anal sphincter Fourth degree - into the mucous of the anus
What is stage 3 of labor?
from delivery to the separation and expulsion of the placenta
What are the 4 signs of placental separation?
cord lengthening outside the vagina, a fresh rush of blood, uterine fundus rising up, uterus becoming more firm and globular
When is a retained placenta diagnosed?
when it has not been delivered after 30 minutes
What is considered the 4th stage of labor?
the hour after delivery when tears, lacerations, and hemorrhage are evaluated and treated
In a pt in labor how often should you check the status of membranes and perform cervical exams?
usually every 2 hrs; can be more frequent as labor progresses
During stage 1 of labor how is the patient positioned?
she can sit in a chair or ambulate
What is the diet of a woman in stage 1 of labor?
clear liquids and ice chips - avoid food
How often is intermittent fetal monitoring performed?
every 15 minutes
When is continuous monitoring of fetal heart done?
after determining baseline to monitor for fetal distress
What is the typical baseline fetal HR?
between 120-160 bpm
What are normal accelerations in fetal HR?
an increase of 15 bpm for 15 sec above the normal baseline HR are reassuring and actually are a sign of fetal well being
What can a fetal HR of above 160 indicate?
infection, hypoxia, or anemia
What can cause early decelerations?
increased vagal tone due to compression of the fetal head during contractions… these occur when approaching the 2nd stage of labor and are usually benign
How are early decelerations related to contractions?
they begin and end at the same time
What are variable declarations?
occur at any time and drop more than early or late decels; rapid drops in fetal HR with a return to baseline with variable shape and no pattern; usually a result of umbilical cord compression but if mild and infrequent then they are benign
What are late decelerations?
fetal HR drops during the 2nd half of the contraction - begins at the peak of contraction and then returns to baseline after the contraction is complete; associated with uteroplacental compromise and always are worrisome
What test gives the most accurate fetal HR pattern?
an electrode attached to the fetus head
When is an electrode attached to the fetal head used?
when there are repetitive decelerations and it is difficult to monitor externally
What are contraindication to electrode monitoring the fetus?
fetal thrombocytopenia, maternal hepatitis or HIV
What is the management when a non-reassuring fetal HR is present?
stop oxytocin if able change maternal position administer O2 per mask measure fetal scalp pH - can eval for hypoxia and acidosis pH > 7.25 is normal pH
How soon can US confirm or detect pregnancy?
as early as 5 wks by detecting the gestation sac or the fetal heart at 6 wks
What is Nagel’s rule?
EDC is first day of LMP minus 3 mo plus 7 days
What is EDC?
estimated date of confinement
Is EDC measured from menstrual weeks or conception weeks?
menstrual weeks 40 wks = really 38 wks + 2 weeks of ovulation
What does US use to determine gestational age?
uses the fetal crown to rump length at 5-12 wks can also use femur length
TRUE or FALSE: the further along a pregnancy the more reliable an US is in determining age
FALSE: it is less reliable
When does fetal quickening occur?
18-20 wks primigravida 14-18 wks multigravida
When can a fetal US detect fetal heart tones?
by 5-6 weeks
When can a handheld doppler US detect fetal heart tones?
9-10 weeks
When can a non-electrical fetoscope detect fetal heart tones?
18-20 weeks
What is gravida?
every pregnancy is a gravid event
What is considered term?
37-42 weeks
What is considered preterm?
20-36 weeks
What is Chadwick’s sign?
bluish discoloration of the vagina and cervix
What is Goodell’s sign?
softening and cyanosis of the cervix after 4 weeks
What is Hegar sign?
softening between the fundus and the cervix
What is the time frame for the first trimester?
lasts until 14 wks gestation
What is the time frame for the second trimester?
14 weeks - 28 weeks
What is the time frame for the third trimester?
lasts from 28 weeks gestation to delivery
What are the most common causes of direct obstetrical deaths?
hypertensive diseases of pregnancy hemorrhage infection/sepsis thromboembolism in developing countries obstructed labor and complications from illegal abortion, ectopic pregnancy, complications from anesthesia, and amniotic fluid embolism
What are the most common causes of indirect obstetrical deaths?
asthma heart disease Type 1 Diabetes SLE and other conditions that are aggravated by pregnancy to the point of death
What is the estimated % of preventable pregnancy related deaths?
80%
What is the definition of pregnancy related mortality?
direct or indirect causes of maternal death counted from conception to 1 year postpartum
What immunizations should you educate a pt on before conception that are not recommended during pregnancy?
MMR, varicella, polio, and yellow fever
Ideally when should the first visit occur after the LMP?
6-8 weeks
At what week is a brush no longer allowed to be used during a pap smear exam?
no brush after 10 weeks, spatula only
What cultures are required at the initial visit?
cultures for G/C
What are the labs included during the initial visit?
CBC, blood type and Rh antibody screen, RPR/syphilis, rubella titer, varicella, Hep B surface antigen, herpes simplex virus, urinalysis, random glucose, HIV testing, screening for CF, SC, and thalassemia, and Coombs test ir irregular antibody screen
What medical history is required to obtain on an initial visit?
GYN hx: pap smears, ovarian cysts, fibroids, and STIs cardiovascular asthma, autoimmune d/o, bleeding d/o, and seizure d/o
After the initial visit how often are follow up visits recommended?
every 4 weeks until the 32nd week every 2 weeks up until the 36th week then weekly thereafter
When can fetal movement typically be detected?
approx 20 weeks
When is a vaginal exam to check to cervix usually added into the visits?
added after 36 weeks
What should be included in each return visit after the initial visit?
focused history and physical, maternal vitals, BP, and weight checked, measurement of fundal height, evaluation of heart sounds starting at 10 weeks, and labs such as urinalysis which may show glucosuria, ketonuria, and proteinuria
When is the fundal height just above the pubic symphysis?
12 weeks
When is the fundal height between the pubic symphysis and the umbilicus?
14-16 weeks
When is the fundal height at the level of the umbilicus?
20-22 weeks
When does the fundal height start correlating to the gestational age?
22-38 weeks
At 22-38 weeks how much should the fundal height be growing?
1 cm every week
When is the fundal height found 2-3 cm below the xiphoid process?
38-40 weeks
When does genetic and congenital screening typically occur?
during the second trimester
What is included in the Ultrascreen?
US to look at nuchal translucency, PAPP-a and hCG, screening for trisomy 21 and 18
When is can the Ultrascreen be performed?
during the 1st trimester however better when combined with the 2nd trimester testing for combined risk
During the second trimester special testing when is it appropriate to only get an AFP?
if the first trimester Ultrascreen was performed
What is the Quadruple Screen?
hCG, estriol, inhibin-A, and AFP
When is the Quadruple screen typically performed?
during the 2nd trimester 15-19 6/7 weeks - longer if specialty labs
What does an elevated AFP correlate with an increased risk of?
risk of neural tube defects
What does a decreased AFP correlate with?
down syndrome
What does a decreased estriol indicate?
increased risk of trisomy 21 and 18
What is an increased hCG correlated with?
trisomy 21
What is a decreased hCG correlated with?
trisomy 18
When is an anatomy US usually performed?
usually around 20 weeks; there is a lower sensitivity when performed prior to 18 weeks
What can be seen on the anatomy US?
head, heart, abdomen, long bones, genitalia, fluid, uterine architecture
What is included in the 24-28 week prenatal care visit?
a GDM screen 1 hour after non-fasting 50g load standard to screen everyone
What is a normal blood sugar level when screening for GDM?
less than 130-140
What happens if you fail the initial GDM screening?
you will fast over night and then drink a glucose solution and blood levels will be measured every hour for 3 hours… if two are higher than normal then GDM is diagnosed
What is included in the 27-36 prenatal care visits?
TDAP new recommendations violence screening plans for feeding, circumcision, and pain control (no need to educate patients of breast feeding yet)
What is included in the 36 wks prenatal care visits?
group B hemolytic strep testing - GBS results expire after 5 wks G/C testing –> chlamydia can lead to blindness Leopold maneuvers to estimate fetal size begin more routine checking of cervix
What should you begin checking at prenatal visits at >37 weeks?
cervical checks dilation effacement station
What is the increase in body water during pregnancy?
6.5 to 8.5 L
How many liters is the amniotic fluid?
3.5 L
How soon can cardiovascular changes be seen in a pregnant woman?
as early as 5 weeks gestation
When taking an EKG on a pregnant pt how should the leads be adjusted?
move the leads out to the left
How much does the HR increase in a pregnant woman?
15-20 above nongravid
When does the CO increase peak?
30-50% increase peaks at 30 wks
What is increased cardiac output dependent upon?
maternal position supine is lower than lateral recumbent or knee-chest
How can supine hypotension manifest?
N/V, dizziness, and syncope
Is vascular resistance decreased or increased during pregnancy?
decreased
What murmur can be heard in a pregnant patient?
splitting 1st heart sound - systolic murmur diastolic murmurs can be heard and should still be worked up
When can BP changes start being seen?
as early as 8 weeks typically nadir midpregnancy and then return to normal at term - although sometimes they can be higher
What are normal pregnancy complaints?
dyspnea, decreased exercise tolerance, fatigue, orthopnea, and chest discomfort
What pregnancy complaints should you not ignore?
hemoptysis, worsening dyspnea, syncope or CP with exertion
When a pregnant pt has cold symptoms what should you tell them to avoid?
nasal decongestants –> can lead to HTN and rebound congestion
What acid/base disturbance occurs during pregnancy?
chronic respiratory alkalosis - decreased PaCO2, and increased PaO2
What makes a pregnant patient more susceptible to apnea?
decreased O2 reserves
Is total lung capacity decreased of increased during pregnancy?
dec 5% secondary to elevation of the diaphragm
Is the tidal volume decreased or increased during pregnancy?
increased 30-40% the tidal volume is the amount of air that is displaced when normal inhalation and exhalation occurs
How many calories should a pregnant woman be consuming in a day?
300kCal/day
What is the pathology behind GERD in a pregnancy woman?
progesterone relaxes the sphincter
What are GI labs that may present during pregnancy?
decreased albumin increased alk phos other liver enzymes should not be changed - changes can indicate a pregnancy complication such as pre-eclampsia or cholestasis or pregnancy
What is the treatment for N/V during pregnancy?
supportive care B6 and Unisom are 1st line treatment
What is Zofran associated with when used early in pregnancy?
heart defects and cleft palate
When can Zofran be used to tx N/V during pregnancy?
used as a last resort when everything else has been tried and they still cannot keep anything down and they are losing weight and have electrolyte imbalances
Is hydronephrosis uncommon during pregnancy?
No, this may be visualized on US because of position of the uterus pressing more on the right the ureter are dilated and can make radiographs more difficult to interpret - Right > left
Should hematuria in a pregnant pt be worked up?
it is common but still should be worked up
What kidney laboratory test results may be seen during pregnancy?
BUN/Cr decrease (b/c of hyperfiltration) proteinuria 300 mg glycosuria (1-10mg of glucose per day)
Is A1c useful for diagnosing GDM during pregnancy?
NO, look at the postprandial glucose levels
When should proteinuria during pregnancy be cause for concern?
when there is associated HTN
What cholesterol levels can be seen during pregnancy?
increased triglycerides (200-300 is normal) increased total cholesterol and increased LDL
When does total triglycerides return to normal?
around 8 weeks postpartum
Does cholesterol return to normal faster or slower than triglycerides?
cholesterol takes longer to return to normal; especially is the mother is nursing
Does TSH increase or decreased during first trimester?
slightly decreases then it returns to normal pre-pregnant levels
For how long is the fetus dependent on maternal thyroid hormone?
until 12 weeks
What adrenal levels can be seen during pregnancy?
increased aldosterone, cortisol, and ACTH
What pituitary hormones increase during pregnancy?
the pituitary increases in size making it susceptible to bleeding prolactin from anterior and oxytocin from posterior increase
What can rash of hands and feet of a pregnant women indicate?
cholestasis disease and in these cases early delivery is needed
What musculoskeletal chgs are seen during pregnancy?
inc maternal calcium absorption reversible trabecular bone loss lumbar lordosis widening of the pubic symphysis loosening of the sacroiliac and pubic joints relaxin
What is severe gum disease linked to during pregnancy?
poor outcomes such as preterm labor and low birthweight unfortunately treatment does not decrease the risk
What are the 5 components of electronic fetal monitoring?
baseline heartrate beat to beat variability accelerations decelerations maternal contractions
What is the teratogenic period?
day 31 to day 71
When have all major organ systems of the fetus been established?
by 10 weeks
What is drug category A?
tested safe on a human fetus?
What is drug category B?
tested safe on animals or tested safe on pregnancy despite abnormal animal
What is drug category C?
some risks noted in animals; Phenergan
What is drug category D?
risks likely outweigh the benefits ACEIs, Warfarin, NSAIDs
What is drug category X?
no; incompatible with life, requires surgery producing major dysfunction
What are examples of category B drugs?
Tylenol (acetaminophen), Benadryl (diphenhydramine), Pepcid (famotidine), Claritin (loratadine)
What pregnancy complications can occur from smoking?
abruption, placenta previa, growth restriction, prematurity, prolonged rupture of membranes, SAB, SIDs, cleft palate
What pregnancy complications can occur from alcohol?
growth retardation, facial anomalies, CNS defects
What pregnancy complications can occur from cocaine use?
cardiac, CNS, and abruption
What are medications to avoid during pregnancy?
decongestants, HMG CoA reductase inhibitors, ACEIs and ARBs, Warfarin, Retinoic Acid, NSAIDs, Methotrexate, Cytotec (misoprostol), sulfonamide antibiotics, valproic acid and carbamazepine, lithium, tetracyclines, aminoglycosides
What are the side effects of aminoglycosides?
ototoxicity and nephrotoxicity
What are some side effects of tetracyclines?
cartilage and bone; bone earlier in pregnancy and cartilage later in pregnancy
What are some effects of valproic acid and carbamazepine?
neural tube defects and cleft lip
What are the effects of NSAIDs during pregnancy?
increase PG and premature closure of PDA
What effect do statins have during pregnancy?
fetal skeleton
What effect do ACEIs and ARBs have during pregnancy?
fetal kidneys
What effects does Warfarin have during pregnancy?
skeletal defects
When is the initial postpartum visit usually scheduled?
4-6 wks after delivery C-section mothers may be seen sooner
What labs are usually ran during the postpartum visit?
2h 75g glucose challenge for GDM CBC, TSH
What are the B’s of postpartum visits?
bleeding/lochia - gone by 6 wks postpartum breastfeeding bowels - constipation can continue bladder - dysuria normal for a few weeks, not after 6 wks Blues - postpartum depression Birth control - wait until postpartum visit for intercourse; try to wait 6 wks to heal
What do abnormally low PAPP-A and abnormally high beta-hCG levels indicate an increased risk for?
trisomy 21 … and other genetic d/os
What is the nuchal translucency screening test?
US measurement of the nuchal space - screens for trisomy’s 13, 18, and 21 as well as for turner syndrome
When is the nuchal translucency screening test performed?
10-13 weeks
What happens if an abnormally wide measurement for gestation age is detected on the nuchal fold scan?
chorionic villus sampling or amniocentesis is offered
How is CVS performed?
a catheter or needle is used to biopsy placental cells
What is a disadvantage of CVS?
CVS specimens cannot be used in AFP testing for neural tube defects amniocentesis specimens however can
Is the risk of spontaneous abortion after CVS and amniocentesis the same?
yes, once adjusted for the fact that CVS is performed at an earlier gestational age
What levels are screened for during second trimester screening?
unconjugated estriol, AFP, and inhibin A
What levels of estriol, AFP, and inhibin A indicate an increased risk for trisomy 21?
low estriol low AFP high inhibin A
Abnormally high levels of what are associated with an increased risk for neural tube defects?
abnormally high AFP AFP can detect 75-85% of defects such as spina bifida and anencephaly
What strategy gives the best chance of detecting trisomy 21 disorders?
combining first trimester screening and second trimester screening can detect 94% to 96% of trisomy 21 d/o
In second trimester screening what are you checking by US?
fetal viability, growth in relation to gestational age, placental status and location, amniotic fluid levels, looking for lethal malformations
What is amniocentesis?
involves the withdrawal of amniotic fluid via needle under US guidance for prenatal diagnosis
When is amniocentesis usually performed?
during 15-18 weeks
What are the indications for amniocentesis and CVS?
maternal age of 35 yrs or older previous child with chromosomal abnormality patient or father of baby with chromosomal anomaly neural tube defect risk (amniocentesis only) abnormal first-trimester or second-trimester maternal serum screening tests two previous pregnancy losses abnormal ultrasound
When are results for amniocentesis available?
they are not available for a minimum of 7 days
When are CVS results available?
preliminary test results are available 48 hours after the procedure
What is the goal of third trimester screening?
screening for fetal well being
What is used to monitor fetal well being during the 3rd trimester?
external doppler monitor along with an external stress test gauge for uterine contraction (together these are called the non-stress test (NST)) –> these tests can also assess risks for those with preexisting maternal complications and pregnancies with complications US can also be used late in pregnancy
What does a normal (reactive) NST require?
two accelerations of fetal HR in 20 minutes of up to 15 bpm from the baseline HR for a duration of 15 seconds… and the absence of deceleration
What are a negative side effect of contractions?
they decrease the flow of blood to the placenta –> this is poorly tolerated by a stressed fetus and can lead to hypoxia and concomitant relative bradycardia
What are decelerations defined as?
a decline in fetal HR of 15 bpm or lasting more than 15 sec or a slow return to baseline… persistent late decelerations which begin after the peak of the contraction warrant intervention
What is the biophysical profile (BPP)?
the BPP examines five parameters, including NST, amniotic fluid level, gross fetal movements, fetal tone, and fetal breathing. each parameter has a maximum of 2 points; a total of 10 points is possible
How is the BPP evaluated?
with ultrasound later in pregnancy to monitor fetal well being
What are maternal complications associated with GDM?
infection, miscarriage, neuropathy, postpartum hemorrhage, pre-eclampsia, vascular or end organ involvement (kidneys)
What are fetal complications of GDM?
should dystocia, traumatic delivery, prematurity, IUGR, delayed lung maturity, macrosomia, congenital abnormalities
When is the first glucose tested recommended for pregnant women?
a random glucose should be obtained at the first prenatal visit to check for pre-existing DM –> then follow up with repeat screening around 24-28 wks
What are the high risk factors that mandate early GDM screening?
age greater than 35-40 yo obesity (non pregnant BMI > 30) prior hx of GDM heavy glucosuria (> +2 on dipstick) hx or unexplained stillbirth PCOS strong family history of DM
What is the normal fasting glucose?
less than 105
In the 1 hr glucose test after a glucose load of 50 gm what is the normal glucose level?
What is done if the glucose test 1hr after a 50 gm glucose load is abnormal (positive) what should be done?
an OGTT
What is an OGTT?
the pt fasts overnight then receives 100 gm of glucose in the am - the glucose is then checked at hour 1,2, and 3 post glucose load
In the OGTT what is the normal 1 hr glucose level?
less than 180
In the OGTT what is the normal 2 hr glucose level?
less than 155
In the OGTT what is the normal 3 hr glucose level?
less than 140
When is GDM diagnosed?
when 2 or more of the levels in the OGTT are elevated
Are oral hypoglycemic agents such as metformin indicated in GDM?
not as of now because they can cross the placenta - they are used in other countries and the US is debating them
When does more aggressive non-stress test monitoring begin for a pt with GDM?
at 24 weeks
What should be given to a GDM pt in labor?
IB glucose as 5% dextrose in LR –> want to avoid hyperglycemia in the mother in order to minimize the risk of neonatal hypoglycemia after delivery if the mother is on insulin during the pregnancy it is reasonable to have continuous infusion during labor
How often are you monitoring BG during labor in a pt with GDM?
every 2-4 hours in early labor and every 1-2 hours in active labor
What is the at home management for a pt with GDM?
a glucometer should be used at home in order to check their blood glucose levels fasting, 1-2 hr postprandial at each meal, and again at bedtime
When does induction occur in a pt with GDM?
when the glucose is poorly controlled or there are signs of macrosomia induction occurs at 38 weeks
When should pts who had GDM receive screening postpartum?
screened again at 6 weeks and then yearly
