Midterm Flashcards
1
Q
Between what weeks gestation do we want babies born?
A
36-42 weeks
2
Q
By what week does terminating a pregnancy need to done by?
A
week 24
3
Q
What is a miscarriage?
A
Pregnancy that ends before the fetus has reached 20 weeks gestation.
After 20 weeks it is called an intrauterine fetal death, or stillbirth.
4
Q
How might a miscarriage present clinically?
A
Amenorrhea
Vaginal bleeding
Pelvic pain
5
Q
How would you Dx a miscarriage?
A
with Ultrasound - see an “empty sac” (no yolk sac, no embryo) or blood around the sac
6
Q
How might an inevitable miscarriage present clinically?
A
Increasing uterine bleeding
Cramping
Dilated cervix
most occur early in gestation and are due to chromosomal abnormalities - “blighted ovum”
7
Q
How would you manage an inevitable miscarriage?
A
Labs: ABOrh, hCG, CBC
Surgically / medically / expectantly
8
Q
How long should you monitor hCG following miscarriage?
A
until it returns to zero - risk of tumor growth if retained tissue
9
Q
What’s a D&C?
A
Dilation and curettage - early abortion
10
Q
What’s a D&E?
A
Dilation and evacuation - late abortion, after 12-13 weeks
11
Q
What inexpensive tablets are used p.o. or p.v. to induce contractions (start labor, induce abortion)?
A
Misoprostol
12
Q
What are the 5 subcategories of miscarriage?
A
- threatened miscarriage - viable pg with bleeding
- inevitable miscarriage - non-viable pg
- complete miscarriage - all tissue passed
- incomplete miscarriage - some tissue passed
- missed abortion - fetal demise, no tissue passed
13
Q
How long would you expect to manage an inevitable miscarriage?
A
Typically passed in 2 weeks
Reasonable to manage expectantly for 1 month
14
Q
How much cervical dilation is needed to miscarry?
A
2-3 cm
blood with become bright, cramping will increase, then tissue will pass, and all sx should decrease
15
Q
What is the MC cause of bleeding in pregnancy?
A
maternal source (but can't always be determined) 20-40% of women bleed in early pregnancy
16
Q
How does a threatened miscarriage present?
A
Viable intrauterine pregnancy
Uterine bleeding - often small quantity
Often painless
17
Q
What are the MC causes of threatened miscarriage?
A
** placental abruption: disruption of decidual vessels**
subchorionic hematoma (blood clot) marginal sinus rupture
18
Q
How would you manage a threatened miscarriage?
A
- bed rest
- pelvic rest
- labs: hCG, ABOrh, CBC
- consider progesterone - oral micronized 100-200mg BID through 1st trimester
- botanicals: viburnum, dioscorea, valerian, hammamelis
- supplements: vit E, vit C, citrus bioflavinoids
19
Q
What is the most concerning risk in missed abortion?
A
DIC
20
Q
What is the most concerning risk in bleeding of early pregnancy?
A
ectopic pregnancy
Ddx: spontaneous abortion placental abruption/hematoma trophoblastic dz vaginitis/cervicitis/trauma/cancer/warts/fibroids/etc cervical ectropion physiologic/implantation bleeding
21
Q
What are the MC sx of early pregnancy?
A
- Amenorrhea
- N/V
- Breast enlargement & tenderness
- Urinary frequency
- Fatigue
22
Q
How likely is a miscarriage if a woman has bleeding btw 7-11 weeks gestation?
A
low risk - 90-96% of pregnancies with a viable intrauterine fetus and bleeding will not miscarry
23
Q
What is hCG?
When do we usually test for it?
A
Human chorionic gonadotropin
secreted by placental cell line into maternal circulation after implantation (which is 5-7 days after fertilization)
test at 9 days after implantation
24
Q
How often should hCG double?
For how long?
A
every 2-3 days
for about one month (useful to 7 weeks of pregnancy)
25
What might a falling hCG indicate?
| Plateau or slow rising?
falling - nonviable pregnancy, miscarriage
| slow - ectopic
26
Is hCG useful to determine gestational age or EDD?
NO!!
27
What are 2 ways to test hCG?
Serum - qualitative or quantitative; most sensitive, positive around 9 days after implantation/conception
Urine - positive around missed menses; first morning void
28
Why do we draw serial hCGs?
to determine viability of pregnancy
29
How is viability of pregnancy diagnosed & when?
TVUS - typically order at 7 weeks
gestational sac - 4.5-5 weeks
yolk sac - 5 weeks
*cardiac activity - 5.5-6 weeks* - viable
fetal pole (crown to rump length) - 6 weeks
30
What is the name of the halo seen on US in early pg?
double decidual sign
31
What's an EDD?
| How would you determine an EDD?
Estimated date of delivery, "due date"
use Naegle's rule: LMP -3 months +7 days
1st wk starts 1st day of LMP. Implantation occurs ~wk 3, hCG will increase from then until wk 7.
32
How else might you calculate EDD?
Ultrasound (TVUS)
| In first half of pregnancy - Cochrane database systemic review found US dating superior.
33
When is the best time for estimating EDD via US?
7-10 weeks - accuracy is +/- 3 days!
at 14-20 weeks accuracy is within 7 days.
34
Why is an accurate EDD important?
* to determine pre/post-maturity
* eligibility for out-of-hospital birth
* timing of tests / procedures
* determine intrauterine growth restrictions (IUGR)
35
What are the MC risk factors for spontaneous abortion?
```
advanced maternal age
previous spontaneous abortion
smoking - 10+ cigs/day
cocaine
NSAIDs (excluding acetaminophen)
low or high maternal BMI
celiac dz
```
36
What is a spontaneous abortion usually due to?
error in early cell division - chromosomal abnormality
37
What dx would you be concerned about if she has RLQ or LLQ pain?
ectopic
Ddx:
ovarian cyst
appendicitis
38
What is an ectopic pregnancy?
| Where are MC sites?
Implantation of developing blastocyst in a site other than the endometrium.
Fallopian tube - MC
ovary
abdomen
cervix
39
MC clinical manifestations of ectopic pg?
* typically present at 6-8 wks gestation (rupture 6-12)
* normal pg sx
* abdominal pain
* vaginal bleeding
40
What are PE findings of ectopic pg?
low grade fever
adnexal, cervical motion, and/or abd tenderness
adnexal mass
** PE may be unremarkable**
41
What are some risk factors for ectopic pg?
Hx of PID
previous ectopic
adnexal / abdominal surgery
42
How can you rule out ectopic pg?
must stay on Ddx until you visualize a viable intrauterine pregnancy!!
43
Can you use hCG to dx ectopic pg?
No - but helpful guide
If hCG is below 1500, difficult to dx pg
If hCG is 2500 w/empty uterus --> highly suspect ectopic
44
Why do we worry so much about ectopic pg?
risk of rupture -> hemorrhage -> maternal death
| leading cause of pregnancy-related mortality in 1st trimester
45
What are treatment options for ectopic pg?
* medical - methotrexate, 1st line, stops blastocyst development, folic-acid antagonist
* surgical - usu laparoscopic salpingostomy or salpingectomy
46
When is 1st trimester?
2nd?
3rd?
1st - 0-13 weeks gestation
2nd - 14-26 weeks
3rd - 27-40 weeks
47
What week should a woman establish prenatal care?
By 10 weeks to get the most accurate EDD
| allopaths say end of 1st trimester
48
How often should she get prenatal visits during pg?
Monthly until 32 weeks
Biweekly 32-36 weeks
Weekly 36 weeks - delivery
49
What pregnancy-related issues are important to catch early on?
```
pre-eclampsia (HTN, proteinuria)
gestational diabetes (24-28 weeks)
```
50
What nutritional advice would you give a pg woman?
* varied diet
* Inc calories: 340 2nd trimester, 452 in 3rd
* protein: 1.1 gm/kg/day
* carbs: 175 gm/day
* only fully cooked fish/meat/poultry
* avoid unpasteurized dairy, juices
* heat deli meats - listeria
* avoid raw sprouts
* thoroughly rinse fruits / veg
51
What vitamin recommendations would you give a pg woman?
* prenatal vitamin: may make more nauseaus
* Iron 30 mg/day
* folic acid 800 mcg/day
* calcium 1000 mg/day
* vit D 400 IU/day
* vit A no more than 10K IU/day
52
What advice would you give a pg woman regarding wt gain?
depends on BMI - the lower the BMI, the more weight gain is needed for a healthy pregnancy.
range is from 11-40 lbs total wt gain.
53
What are the MC risks of smoking in pregnancy?
low birth weight
premature rupture of membranes
placental abruption
pre-term delivery
54
What are the alcohol recommendations in pregnancy?
undetermined -
| risk of FAS
55
What are the caffeine recommendations in pregnancy?
200-300 mg/day (16 oz house = 330mg)
56
What are the exercise recommendations in pregnancy?
150 minutes/week
30 mins/day most days
moderate intensity - low weight, high reps
57
What is the ddx for bleeding in the 2nd/3rd trimester?
```
miscarriage/stillbirth
cervical, vaginal, or uterine pathology
cervical insufficiency
placenta previa
placental abruption
vasa previa
uterine rupture
```
58
Why is digital cervical exam contraindicated with 2nd/3rd trimester bleeding?
in case of placenta previa - may increase bleeding or disrupt placenta further
59
What should you do at a first prenatal visit?
* establish EDD
* physical exam
- baseline wt, ht, BP
- complete physical
- GYN exam - PAP, STI screen mb
- auscultation of fetal heart tones (if over 10 wks)
* labs
60
What labs are done as part of an obstetric panel?
* ABO-rh typing and anti-rh antibody screen
* CBC
* rubella IgG
* Syphilis RPR
* HIV
* Hepatitis B sAg
* Varicella IgG
also do:
urine culture
cervical cytology if indicated
GC/CT screen
61
What additional labs might be done for at-risk women?
* Thyroid panel
* DM II
if symptomatic, you might test for:
* gonorrhea
* TB
* toxoplasmosis
* Hep C
* BV
* Trich
* HSV
62
How do Rh factor problems arise?
if mom is rh-neg & dad is rh-pos, baby might inherit Rh from dad -> reaction btw maternal & fetal blood
Rhogam (Rh-D immune globulin) tx needed to prevent sensitization of mom (rhesus dz)
63
Name some teratogens and their effects.
* pesticides - stillbirth, birth defects, cancer
* PCB's & DDT - preterm labor
* tobacco - learning d/o's, vasoconstriction (dec blood to placenta), CO in fetal blood, risk of SAB, plancetal abruption, low birth weight.
* Alcohol - vit deficiency, bleeding more common, infx, SAB, placental abruption, FAS
* aspartame - phenylalanine concentrates in fetus -> mental retardation
* radiation - leukemia, asthma, pneumonia, rheumatic fever, dysentary, etc
* ibuprofen - bleeding, taxes kidneys
* aspirin - prolonged gestation, long labor, maternal bleeding with birth, stillbirth, jaundice, intracranial hemorrhage, reduced attention span
* decongestants - birth defects
* accutane (retinoic acid) - neuro injuries, small or absent ears, cardiac defects, facial malformations
* antidepressants - pulmonary HTN, SAB, heart defects, preterm birth, IUGR, withdrawal sx
64
What is oxytocin and what does it do?
"love" hormone, released by pituitary, plays a role in bonding
65
Common causes of fatigue in pg?
* Anemia
* blood sugar imbalance
* insomnia
* drowsiness (dt progesterone)
66
Describe how pg hormones can induce N/V.
hCG - slows peristalsis
| progesterone - slows peristalsis, diminishes HCl
67
What recommendations might you give for nausea d/t pg?
* dry crackers upon waking
* B vitamins in diet (kale, molasses, wh germ, nutch)
* protein snack at bedtime
* small, frequent meals
* easily digested foods
* fluids - cold, carbonated, clear, or sour
* avoid food sensitivities
* almonds
* yogurt/kefir with cinnamon
* beiller's broth
* hard candies
* ACV w/meals, and upon waking
68
What botanical remedies might you recommend for N/V?
* zingiber - 15 gtts q 2 hrs
* dioscorea - 30-60 gtts TID
* raspberry, peppermint, or catnip tea
* cardamom boiled in milk (chai)
69
What homeopathic N/V remedies for pg?
* sepia
* taraxacum
* nat mur
* phosphorus
70
What nutritional (supplemental) N/V remedies for pg?
B6
vit K
vit C
71
What is the ddx to rule out hyperemesis graviderum?
```
pancreatitis
hepatitis
appendicitis
cholecystitis
gastroenteritis
pyelonephritis
gastritis
```
72
What herbs might you give for anemia of pg?
* rumex crispus
* urtica dioica
* taraxacum
73
What herbs might you give for blood sugar regulation in pg?
* oplopanax
* gymnema
* syzygium
* taraxacum
74
What herbs might you give for insomnia in pg?
* matricaria chamomila
* scutellaria
* valeriana
** NO PASSIFLORA**
75
What risks are we worried about related to anemia in pg?
* preterm birth
* IUGR
* pre-eclampsia or primips
* high ratio of placenta to fetus weight (predicts HTN)
* post-partum hemorrhage
76
What stages of life are particular teratogen risks?
* early fetus - cell division
* infancy
* adolescence
* luteal cycle of menses
77
What are physical signs of fetal alcohol syndrome?
* no central groove in upper lip
* flattened face/lip
* low ears
* slant eyes
* short, upturned nose
* abn testes
