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Natural Childbirth > Midterm > Flashcards

Midterm Flashcards

1
Q

Between what weeks gestation do we want babies born?

A

36-42 weeks

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2
Q

By what week does terminating a pregnancy need to done by?

A

week 24

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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.

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4
Q

How might a miscarriage present clinically?

A

Amenorrhea
Vaginal bleeding
Pelvic pain

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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

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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”

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7
Q

How would you manage an inevitable miscarriage?

A

Labs: ABOrh, hCG, CBC

Surgically / medically / expectantly

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8
Q

How long should you monitor hCG following miscarriage?

A

until it returns to zero - risk of tumor growth if retained tissue

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9
Q

What’s a D&C?

A

Dilation and curettage - early abortion

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10
Q

What’s a D&E?

A

Dilation and evacuation - late abortion, after 12-13 weeks

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11
Q

What inexpensive tablets are used p.o. or p.v. to induce contractions (start labor, induce abortion)?

A

Misoprostol

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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
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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

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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

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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
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16
Q

How does a threatened miscarriage present?

A

Viable intrauterine pregnancy
Uterine bleeding - often small quantity
Often painless

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17
Q

What are the MC causes of threatened miscarriage?

A

** placental abruption: disruption of decidual vessels**

subchorionic hematoma (blood clot)
marginal sinus rupture
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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
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19
Q

What is the most concerning risk in missed abortion?

A

DIC

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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
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21
Q

What are the MC sx of early pregnancy?

A
  • Amenorrhea
  • N/V
  • Breast enlargement & tenderness
  • Urinary frequency
  • Fatigue
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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

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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

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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)

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25
Q

What might a falling hCG indicate?

Plateau or slow rising?

A

falling - nonviable pregnancy, miscarriage

slow - ectopic

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26
Q

Is hCG useful to determine gestational age or EDD?

A

NO!!

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27
Q

What are 2 ways to test hCG?

A

Serum - qualitative or quantitative; most sensitive, positive around 9 days after implantation/conception

Urine - positive around missed menses; first morning void

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28
Q

Why do we draw serial hCGs?

A

to determine viability of pregnancy

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29
Q

How is viability of pregnancy diagnosed & when?

A

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

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30
Q

What is the name of the halo seen on US in early pg?

A

double decidual sign

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31
Q

What’s an EDD?

How would you determine an EDD?

A

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
Q

How else might you calculate EDD?

A

Ultrasound (TVUS)

In first half of pregnancy - Cochrane database systemic review found US dating superior.

33
Q

When is the best time for estimating EDD via US?

A

7-10 weeks - accuracy is +/- 3 days!

at 14-20 weeks accuracy is within 7 days.

34
Q

Why is an accurate EDD important?

A
  • to determine pre/post-maturity
  • eligibility for out-of-hospital birth
  • timing of tests / procedures
  • determine intrauterine growth restrictions (IUGR)
35
Q

What are the MC risk factors for spontaneous abortion?

A 
advanced maternal age
previous spontaneous abortion
smoking - 10+ cigs/day
cocaine
NSAIDs (excluding acetaminophen)
low or high maternal BMI
celiac dz
36
Q

What is a spontaneous abortion usually due to?

A

error in early cell division - chromosomal abnormality

37
Q

What dx would you be concerned about if she has RLQ or LLQ pain?

A

ectopic

Ddx:
ovarian cyst
appendicitis

38
Q

What is an ectopic pregnancy?

Where are MC sites?

A

Implantation of developing blastocyst in a site other than the endometrium.

Fallopian tube - MC
ovary
abdomen
cervix

39
Q

MC clinical manifestations of ectopic pg?

A
  • typically present at 6-8 wks gestation (rupture 6-12)
  • normal pg sx
  • abdominal pain
  • vaginal bleeding
40
Q

What are PE findings of ectopic pg?

A

low grade fever
adnexal, cervical motion, and/or abd tenderness
adnexal mass
** PE may be unremarkable**

41
Q

What are some risk factors for ectopic pg?

A

Hx of PID
previous ectopic
adnexal / abdominal surgery

42
Q

How can you rule out ectopic pg?

A

must stay on Ddx until you visualize a viable intrauterine pregnancy!!

43
Q

Can you use hCG to dx ectopic pg?

A

No - but helpful guide
If hCG is below 1500, difficult to dx pg
If hCG is 2500 w/empty uterus –> highly suspect ectopic

44
Q

Why do we worry so much about ectopic pg?

A

risk of rupture -> hemorrhage -> maternal death

leading cause of pregnancy-related mortality in 1st trimester

45
Q

What are treatment options for ectopic pg?

A
  • medical - methotrexate, 1st line, stops blastocyst development, folic-acid antagonist
  • surgical - usu laparoscopic salpingostomy or salpingectomy
46
Q

When is 1st trimester?
2nd?
3rd?

A

1st - 0-13 weeks gestation
2nd - 14-26 weeks
3rd - 27-40 weeks

47
Q

What week should a woman establish prenatal care?

A

By 10 weeks to get the most accurate EDD

allopaths say end of 1st trimester

48
Q

How often should she get prenatal visits during pg?

A

Monthly until 32 weeks
Biweekly 32-36 weeks
Weekly 36 weeks - delivery

49
Q

What pregnancy-related issues are important to catch early on?

A 
pre-eclampsia (HTN, proteinuria)
gestational diabetes (24-28 weeks)
50
Q

What nutritional advice would you give a pg woman?

A
  • 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
Q

What vitamin recommendations would you give a pg woman?

A
  • 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
Q

What advice would you give a pg woman regarding wt gain?

A

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
Q

What are the MC risks of smoking in pregnancy?

A

low birth weight
premature rupture of membranes
placental abruption
pre-term delivery

54
Q

What are the alcohol recommendations in pregnancy?

A

undetermined -

risk of FAS

55
Q

What are the caffeine recommendations in pregnancy?

A

200-300 mg/day (16 oz house = 330mg)

56
Q

What are the exercise recommendations in pregnancy?

A

150 minutes/week
30 mins/day most days
moderate intensity - low weight, high reps

57
Q

What is the ddx for bleeding in the 2nd/3rd trimester?

A 
miscarriage/stillbirth
cervical, vaginal, or uterine pathology
cervical insufficiency
placenta previa
placental abruption
vasa previa
uterine rupture
58
Q

Why is digital cervical exam contraindicated with 2nd/3rd trimester bleeding?

A

in case of placenta previa - may increase bleeding or disrupt placenta further

59
Q

What should you do at a first prenatal visit?

A
  • 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
Q

What labs are done as part of an obstetric panel?

A
  • 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
Q

What additional labs might be done for at-risk women?

A
  • Thyroid panel
  • DM II

if symptomatic, you might test for:

  • gonorrhea
  • TB
  • toxoplasmosis
  • Hep C
  • BV
  • Trich
  • HSV
62
Q

How do Rh factor problems arise?

A

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
Q

Name some teratogens and their effects.

A
  • 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
Q

What is oxytocin and what does it do?

A

“love” hormone, released by pituitary, plays a role in bonding

65
Q

Common causes of fatigue in pg?

A
  • Anemia
  • blood sugar imbalance
  • insomnia
  • drowsiness (dt progesterone)
66
Q

Describe how pg hormones can induce N/V.

A

hCG - slows peristalsis

progesterone - slows peristalsis, diminishes HCl

67
Q

What recommendations might you give for nausea d/t pg?

A
  • 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
Q

What botanical remedies might you recommend for N/V?

A
  • zingiber - 15 gtts q 2 hrs
  • dioscorea - 30-60 gtts TID
  • raspberry, peppermint, or catnip tea
  • cardamom boiled in milk (chai)
69
Q

What homeopathic N/V remedies for pg?

A
  • sepia
  • taraxacum
  • nat mur
  • phosphorus
70
Q

What nutritional (supplemental) N/V remedies for pg?

A

B6
vit K
vit C

71
Q

What is the ddx to rule out hyperemesis graviderum?

A 
pancreatitis
hepatitis
appendicitis
cholecystitis
gastroenteritis
pyelonephritis
gastritis
72
Q

What herbs might you give for anemia of pg?

A
  • rumex crispus
  • urtica dioica
  • taraxacum
73
Q

What herbs might you give for blood sugar regulation in pg?

A
  • oplopanax
  • gymnema
  • syzygium
  • taraxacum
74
Q

What herbs might you give for insomnia in pg?

A
  • matricaria chamomila
  • scutellaria
  • valeriana

** NO PASSIFLORA**

75
Q

What risks are we worried about related to anemia in pg?

A
  • preterm birth
  • IUGR
  • pre-eclampsia or primips
  • high ratio of placenta to fetus weight (predicts HTN)
  • post-partum hemorrhage
76
Q

What stages of life are particular teratogen risks?

A
  • early fetus - cell division
  • infancy
  • adolescence
  • luteal cycle of menses
77
Q

What are physical signs of fetal alcohol syndrome?

A
  • no central groove in upper lip
  • flattened face/lip
  • low ears
  • slant eyes
  • short, upturned nose
  • abn testes

Natural Childbirth (2 decks)

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