LATE PREGNANCY (C6) Flashcards
Common between first and second missed menstrual pd and continue until 14-16 wks
Nausea & vomiting
Tx for mild symptoms of nausea and vomiting
Vit B6 along w doxylamine
Some will need phenothiazine or H1 receptor blocking anti-emetics
Severe vomiting that results to dehydration, electrolyte and acid-base disturbances and starvation ketosis
Hyperemesis gravidarum
May be dt steroid-induced suppression of bowel activity, compression of bowels by enlarging uterus
Constipation
In constipation, what should be avoided?
Enemas & strong cathartics
Muscular spasm and tenderness –> acute strain or fibrositis
Respond to analgesics, heat and rest
Backache
Cause: congenital predisposition abd accrue with advancing age dt increased lower extremity venous pressures
Varicosities
Venous femoral pressure in the supine pregnant is
8 mmHg early
to
24 mmHg at term
Symptoms of varicosities
Mild cosmetic blemishes –> severe discomfort
Management of varicosities
Periodic rest w leg elevation
Elastic stockings
Coexist with leg varicosities
Vulvar varicosities
Rectal vein varicosities and may first appear during pregnancy as pelvic venous pressures increase
Hemorrhoids
Relieved by topical anesthetics, warm soaks, stool softening agents
SMS: pain and swelling
caused by gastric content reflux into lower esophagus due to upward displacement and compression of stomach by uterus, combined w relaxation of lower esophageal sphincter
Heartburn
how to relieve heartburn
frequent feedings
avoid of bending over or lying flat
antacids
antacids
aluminum or magnesium trisilicate
pagophagia
craving ice
amylophagia
starch cravings
geophagia
craving for clay
triggered by severe iron def
pica
profuse salivation wc appears to follow saliv gland stimulation by starch ingestion
ptyalism
dt soporific effect of progesterone but may be compounded in the first trimester by nausea and vomiting and in the latter stages of pregnancy by general discomforts, urinary frequency and dyspnea
fatigue/sleeping (sis same)
as pregnancy advances, what happens to sleep efficiency?
progressively diminish
3rd trimester sleep situation
sleep disturbance and restless leg syndrome
more frequent early pregnancy
may be ass w hypertension in late preg
headache
increased in vaginal discharge, mostly dt mucus secretion by cervical glands in response to hyperestrogenemia in pregnancy
Leukorrhea
Abnormal: bacterial vaginosis, candidiasis and trichomoniasis
study of birth defects and their etiology
teratology
any agent (drugs, chemical, physical, envi, maternal metabolite, genetic abn and infxn – that acts during embryonic or fetal dev to produce a permanent alternation of form or fxn
basically causes STRUCTURAL ABNORMALITIES
Teratogen
after Hades - god who possessed a helmet conferring invisibility — an agent that interferes w normal maturation and fxn of an organ
Hadegen
an agent that alters growth
Hadegens and trophogens typically affect dev in fetal pd and after birth
Trophogen
these act by disturbing sp physio processes, leading to abn cellular differentiation, altered tissue growth or cell death
Teratogens
it has been linked to susceptibility to teratogenic effects ofspecific meds
genetic composition or fetal genome
more likely to develop anomalies if homozygous for a gene mutation that results in abn low lvls of epoxide hydrolase
hydantoin exposure
metabolized by microsomes to oxidative intermediates that accumulate in fetal tissues
hydantoin
carbamazepine
phenobarbital
these have carcinogenic, mutagenic and other toxic effects that are dose related and increase w multidrug therapy
free oxide radicals
fetal neural tube defects, cardiac defects and oral clefts can be a result of
folic acid metabolic path disturbances
essential for methionine prod
wc is required for methylation —> prod CHON, lipids and myelin
Folates
It can either impair folic acid absorption or acts as folic acid antagonists
anticonvulsant drugs (phenytoin, carbamazepine, valproic acid and phenobarbital)
low periconceptional folic acid lvls in women w epilepsy may cause
fetal malformations
may increase the risk of adverse fetal outcomes dt
paternal exposure to drugs or environmental influences
proposed mechanisms:
- induction of a gene mutation or chromosomal abnormality in sperm
- during coitus, dev embryo is exposed to teratogenic agent in seminal fluid
- occupational - inc risk for men w anomalous offspring include janitors, woodworkers, firemen, printers and painters
induction of a gene mutation or chromosomal abnormality in sperm
- it takes 64 days for male germ cells mature into spermatogonia - drug exposure may cause gene mutation during the 2 mos before conception
- epigenetic pathways may suppress germ-cell apoptosis or interfere w imprinting
exposure to these are linked to early pregnancy loss
mercury, lead, solvents, pesticides, anesthetic gases or hydrocarbons
moat freq nongenetic cause of mental retardation
alcohol
potent and prevalent teratogen
ethyl alcohol
dysmorphic facial features, pre- or postnatal growth impairment, CNS abn that may be structural, neurological or fxnal, cardiac and renal anomalies, orthpedic probs and eye and ear abn
fetal alcohol syndrome
there is an association w periconceptional alcohol use and
omphalocele and gastroschisis
valproic acid can cause
low IQ
fetotoxic and result in ACE-inhibitor fetopathy
disruption of RAS (essential for normal renal development)
ACE inhi
causes fetal hypotension and renal hypoperfusion, w subsequent ischemia and anuria
ACE inhi
reduced perf may cause fetal growth restriction rand calvarium maldevelopment, whereas oligohydramnios may result in
pulmonary hypoplasia and limb contractures
Associated w a pattern of congenital malformations resembling the autosomal recessive Antley-Bixler syndrome (at doses of 400-800mg daily) and Tetralogy of Fallot
Fluconazole (antifungal)
Abn: oral clefts, abn faces and cardiac, skull, lung, long bone and joint abnormalities
Antifungals
Single 150mg dose to treat vulvovaginal candidiasis doesn’t appear teratogenic
Inhibits prostaglandin synthesis
Anti-inflammatory agents
Not teratogenic but cab have adverse fetal effects when used in 3rd trimester
NSAIDs
Cause constriction of fetal ductus arteriosus resulting in pulmonary hypertension
Also decrease fetal urine production thereby reducing amniotic volume
Indomethacin
Pyrimidine synthesis inhibitor for treatment of RA
Leflunomide
Animal studies showed hydrocephalus, eye anomalies, skeletal abnormalities and embryo death
Leflunomide
Detectable in plasma for 2 years following discontinuation so women w childbearing potential should consider cholestyramine tx or washout
Leflunomide
Nephrotoxicity and ototoxicity in preterm newborns
Aminoglycosides
GBS gray
preterm infants are unable to conjugate and excrete the drug and manifested abn distention, respiratory abnormalities
Chloramphenicol
Associated w four-fold increased risk for hypoplastic left heart syndrome and microphthalmia/anophthalmia
2-fold increase for clefts and atrial septal defects
Nitrofurantoin
ACOG: first trimester use is appropriate if no sustainable alternatives are available
Nitrofurantoin
3-fold risk inc risk anencephaly and left ventricular outflow tract obstruction
8-fold inc risk of choanal atresia and 2-fold inc risk of diaphragmatic hernia
Sulfonamides
Yellowish brown discoloration of deciduous teeth when used after 25 weeks
Tetracycline
Antineoplastic
Cyclophosphamide
Methotrexate/Aminopterin
Tamoxifen
Trastuzumab
Alkylating agent wc inflicts a chemical insult on developing fetal tissues and leads to cell death and heritable DNA alterations in surviving cells
Cyclophosphamide
Inc preg loss (HWs) and malformations include skeletal abn, limb defects, cleft palate and eye abnormalities
Cyclophosphamide
Folic acid antagonist, potent teratogen and abortifacient
Methotrexate/Aminopterin
Craniosynostosis w “clover-leaf” skull, wide nasal bridge, low-set ears, micrognathia and limb abnormalities
Fetal Methotrexate-Aminopterin syndrome
A nonsteroidal selective estrogen-receptor modulator (SERM) used as an adjunct to treat breast cancer that causes malformations similar to those cb DES (diethylstilbestrol) exposure
Tamoxifen
A recombinant monoclonal Ab directed to the human epidermal growth factor receptor-2 (HER-2) protein
Used to treat breast cancer that over express HER2 CHON
Transtuzumab
Causes oligohydramnios, anhydramnios and fetal renal failure —> fetal pulmonary hypoplasia, skeletal abn and neonatal death
Trastuzumab
Antiviral
Ribavirin
Efavirenz
Is a nucleoside analogue and a component of therapy for hepa C infxn
Malformations: skull, palate, eye, skeleton and gastrointestinal abn
Ribavirin
Is a nonnucleoside reverse transcriptase inhibitor used to treat HIV that causes CNS and ocular abn
Efavirenz
An endothelin-receptor antagonist
Used to treat pulmonary arterial hypertension: no human studies and teratogenic concerns arise from mice deficient in endo receptor develop abn of head, face and large BV
Bosentan and Ambrisentan
Sex hormones
Testosterone and Anabolic steroids
Danazol
Diethylstilbestrol
Causes virilization and may result in ambiguous genitalia similar to congenital adrenal hyperplasia: labioscrotal fusion w first trimester exposure and phallic enlargement
Testosterone and Anabolic steroids
An ethinyl testosterone derivative has weak androgenic activity that causes virilization
Clitoromegaly, fused labia and urogenital sinus malformation
Danazol
This exposure in utero resulted to vaginal clear cell adenocarcinoma and 2-fold increase in vaginal and cervical intraepithelial neoplasia
Diethylstilbestrol
Genital tract abn in women: hypoplastic, T shaped uterine cavity, cervical collars, hood, septa and coxcombs and withered fallopian tubes, early menopause and testicular hypoplasia
Diethylstilbestrol
Genital tract in men: abn
Epididymal cysts, microphallus, hypospadias, cryptorchidism and testicular hypoplasia
Diethylstilbestrol
Immunosuppressant meds
Corticosteroids Mycophenolate Mofetil Radioiodine Lead Methyl mercury
Includes glucocorticoids and mineralocorticoids wc have antiinflammatory and immunosuppressive actions (used to treat asthma and autoimmune dse
3-fold increase in clefts (3 per 1000 exposed fetus)
Corticosteroids
An inosine monophosphate dehydrogenase inhibitor that is a potent immunosuppressant used to prevent rejection in organ-transplant recipients, and lupus nephritis
Half of exposed preg resulted in spontaneous abortion and 1/5 of surviving infants had malformations- ear abnormalities
Mycophenolate Mofetil
Tx thyroid cancer and thyrotoxicosis; nonhodgkins lymphoma
Radioactive iodine-131
Radioiodine
Contraindicated during preg bcs cross placenta and conc in fetal thyroid at 12 wks
Irreversible fetal hypothyroidism and increased risk for childhood thyroid cancer
Radioiodine
Prenatal exposure is associated w fetal-growth abnormalities and w childhood developmental delay and behavioral abnormalities
Lead
Causes disturbances in neuronal cell division and migration and leads to a range of defects from developmental delay to microcephaly and severe brain damage
Methyl mercury
3% risk of Ebstein anomaly
Lithium
Neonatal lithium toxicity from exposure near delivery:
Hypothyroidism DI Cardiomegaly Bradycardia ECG abnormalities Cyanosis Hypotonia
Associated w increased risk of ASD/VSD
Late preg exp is associated w persistent pulmonary hypertension of the newborn
Selective serotonin and Norepinephrine re-uptake inhibitors
Jitteriness, irritability, hyper- or hypo- tonia, feeding abn, vomit, hypoglycemia thermoregulatory instability and respi abn
Neonatal behavioral syndrome
Antipsychotic meds - abn extrapyramidal muscle movements and withdrawal symptoms
Haloperidol Chlorpromazine Aripiprazole Olanzapine Quetiapine Risperidone
Vit A -retinol is associated w cranial neural crest defects
-beta carotene no detects
RDA?
3,000 IU/day
Most potent human teratogen: isotretinoin, acitretin and bexarotene
Inhi neural crest cell migration during embryogenesis—> retinoic acid embryopathy (CNS, face, heart, thymus)
Vit A derivatives
Causes venticulomegaly
Maldevelopment of facial bones or cranium, microtia or anotia, micrognathia, cleft palate, conotruncal heart defects and thymic aplasia or hypoplasia
Vit A derivatives
13-cis-retinoic acid
Cell differentiation and used for cystic nodular acne
First trim exposure – high rate of pregnancy loss and malformations in 1/3 of fetus loss
Isotretinoin
Severe psoriasis tx
Metabolized to Etretinate
Should delay conception for at least 3 yrs following therapy discontinuation
Acitretin
Used to treat cutaneous T-cell lymphoma–> cause eye and ear abn, cleft palate and incomplete ossification
Bexarotene
Tretinoin and Tazarotene –> possible neural crest defects
Topical retinoids
Most notorious human teratogen
Used to treat leprosy and multiple myeloma
34-50 days mens age -> phocomelia
Causes cardiac malf, GI abn, limb redxn defects
Thalidomide
An absence of one or more long bones which results in hands and feet being attached to the trunk by a smol rudimentary bone
Phocomelia
Analogue of thalidomide used to treat types of myelodysplastic syndrome and multiple myeloma
Lenalidomide
Exposure of warfarin between 6-9th wks
Stippling of the vertebrae and femoral epiphysis and by nasal hypoplasia w depression of nasal bridge; some may have choanal atresia resulting in respiratory distress
Warfarin used in first trimester
Agenesis of corpus callosum, cerebellar vermian agenesis – Dandy Walker malformation, microphthalmia and optic atrophy
Warfarin used in first trimester
Agenesis of corpus callosum, cerebellar vermian agenesis – Dandy Walker malformation, microphthalmia and optic atrophy
Poland sequence (interruption in vascular supply to one side of fetal chest and ipsilateral arm), cardiac anomalies, hydrocephaly, microcephaly, omphalocele, gastroschisis, cleft lip and palate and hand abn
Tobacco
Fetal growth restriction and behavioral abn in infancy and early childhood
Amphetamines
Vasoconstrictive and hypertensive effects: cerebrovascular hemorrhage, myocardial damage and placental abruption and preterm delivery
Coke jk cocaine
Preterm birth
Placental abruption
Fetal growth restriction or death
Opioids-Narcotics Heroin
Not associated w fetal anomalies hmmmm
MJ 🍃
Theoretically premature closure of ductus arteriosus
Aspirin
Not associated w increased risk of anomalies
Acetaminophen
Not known teratogen but possibility of fetal bradycardia
Local anesthesia
Not teratogen anticoagulant
Heparin
Can cause embryopathy
Coumarin derivatives
Anti-emetics
Phenothiazine - no known terato
Ondansetron HCl - no human studies
Antihypertensive
No known teratogenic effects w methyldopa, hydralazine, diuretics
Beta-adrenergic agonists - possible fetal growth restriction, neonatal hypoglycemia
Calcium channel blockers - possible limb defects
Antimicrobials
Penicillin - safest
Erythromycin
Nitrofurantoin
Quinolones - fluoroquinolones - arthropathy and cartilage erosion in animals
Antifungals: nystatin, clotrimazole, miconazole - no anomalies
Herbal remedies
Black cohosh - abortifacient
Garlic/Ginger/Gingko biloba/Ginseng - risk of bleeding
Yohimbe/Ephedra - hypertension, arrhythmias
Fluid secretion that contains essentially the same conc of proteins and lactose as milk but almost no fat
Colostrum
What allows lactogenic effect of prolactin to assume its milk promoting role, and over 1-7 days, breasts begin to secrete copious amounts of milk instead of colostrum
Estrogen and progesterone loss
Hormones that contribute to milk prod
GH
Cortisol
Parathyroid hormone
Insulin
Hormones are necessary to provide what that is required for milk formation
AA
FA
Glucose
Ca
Stimulates release of oxytocin from Neurohypophysis, which stimulates milk ejection from the milk ducts (let-down reflex) by causing contract of myoepithelial cells –> expressing milk from alveoli into ducts
Sucking
It usually can be expressed from the nipples by the 2nd postpartum day
Colostrum
Secretion of colostrum persists for about how many dayz?
5 daze w gradual conversion to mature milk in the ensuing 4 wks
Suspension of fat and protein in a carbohydrate-mineral soln
Vol prod by nursing mom: 600mL/day
Isotonic w plasma
Most milk proteins are unique and aren’t found elsewhere
Human meellkkk
IL what are in large amt in colostrum and human milk
IL 2
May be absorbed orally and promote growth and maturation of intestinal mucosa
EGF epidermal growth factor
All vitamins are found in human melk EXCEPT???????
K
Vit K ok okay kkk
10 steps to successful breastfeeding (WHO/UNICEF)
- BF policy
- Train all HC staff necessary to implement policy
- Inform preggy on benefits and mgmt of BF
- Initiate BF within first 30 mins after birth whoawhoa
- How to BF and maintain lactation even in separation
- NB infants no milk feeds or water other than Breast MELK
- Practice rooming in
- Encourage BF on demand
- No to artificial treats or dummies to beeastfed infacts
- Foster est of BF support grps and refer moms to them on discharge from hospi or clinic
Strong evidences shows that human milk feeding decreases the incidence and severity of
Diarrhea Lower respiratory infxn Otitis media Bacteremia Bacterial meningitis Botulism UTI Necrotizing enterocolitis
