Midterm Flashcards
Between what weeks gestation do we want babies born?
36-42 weeks
By what week does terminating a pregnancy need to done by?
week 24
What is a miscarriage?
Pregnancy that ends before the fetus has reached 20 weeks gestation.
After 20 weeks it is called an intrauterine fetal death, or stillbirth.
How might a miscarriage present clinically?
Amenorrhea
Vaginal bleeding
Pelvic pain
How would you Dx a miscarriage?
with Ultrasound - see an “empty sac” (no yolk sac, no embryo) or blood around the sac
How might an inevitable miscarriage present clinically?
Increasing uterine bleeding
Cramping
Dilated cervix
most occur early in gestation and are due to chromosomal abnormalities - “blighted ovum”
How would you manage an inevitable miscarriage?
Labs: ABOrh, hCG, CBC
Surgically / medically / expectantly
How long should you monitor hCG following miscarriage?
until it returns to zero - risk of tumor growth if retained tissue
What’s a D&C?
Dilation and curettage - early abortion
What’s a D&E?
Dilation and evacuation - late abortion, after 12-13 weeks
What inexpensive tablets are used p.o. or p.v. to induce contractions (start labor, induce abortion)?
Misoprostol
What are the 5 subcategories of miscarriage?
- 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
How long would you expect to manage an inevitable miscarriage?
Typically passed in 2 weeks
Reasonable to manage expectantly for 1 month
How much cervical dilation is needed to miscarry?
2-3 cm
blood with become bright, cramping will increase, then tissue will pass, and all sx should decrease
What is the MC cause of bleeding in pregnancy?
maternal source (but can't always be determined) 20-40% of women bleed in early pregnancy
How does a threatened miscarriage present?
Viable intrauterine pregnancy
Uterine bleeding - often small quantity
Often painless
What are the MC causes of threatened miscarriage?
** placental abruption: disruption of decidual vessels**
subchorionic hematoma (blood clot) marginal sinus rupture
How would you manage a threatened miscarriage?
- 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
What is the most concerning risk in missed abortion?
DIC
What is the most concerning risk in bleeding of early pregnancy?
ectopic pregnancy
Ddx: spontaneous abortion placental abruption/hematoma trophoblastic dz vaginitis/cervicitis/trauma/cancer/warts/fibroids/etc cervical ectropion physiologic/implantation bleeding
What are the MC sx of early pregnancy?
- Amenorrhea
- N/V
- Breast enlargement & tenderness
- Urinary frequency
- Fatigue
How likely is a miscarriage if a woman has bleeding btw 7-11 weeks gestation?
low risk - 90-96% of pregnancies with a viable intrauterine fetus and bleeding will not miscarry
What is hCG?
When do we usually test for it?
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
How often should hCG double?
For how long?
every 2-3 days
for about one month (useful to 7 weeks of pregnancy)
What might a falling hCG indicate?
Plateau or slow rising?
falling - nonviable pregnancy, miscarriage
slow - ectopic
Is hCG useful to determine gestational age or EDD?
NO!!
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
Why do we draw serial hCGs?
to determine viability of pregnancy
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
What is the name of the halo seen on US in early pg?
double decidual sign
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.
How else might you calculate EDD?
Ultrasound (TVUS)
In first half of pregnancy - Cochrane database systemic review found US dating superior.
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.
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)
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
What is a spontaneous abortion usually due to?
error in early cell division - chromosomal abnormality
What dx would you be concerned about if she has RLQ or LLQ pain?
ectopic
Ddx:
ovarian cyst
appendicitis
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
MC clinical manifestations of ectopic pg?
- typically present at 6-8 wks gestation (rupture 6-12)
- normal pg sx
- abdominal pain
- vaginal bleeding
What are PE findings of ectopic pg?
low grade fever
adnexal, cervical motion, and/or abd tenderness
adnexal mass
** PE may be unremarkable**
What are some risk factors for ectopic pg?
Hx of PID
previous ectopic
adnexal / abdominal surgery
How can you rule out ectopic pg?
must stay on Ddx until you visualize a viable intrauterine pregnancy!!
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
Why do we worry so much about ectopic pg?
risk of rupture -> hemorrhage -> maternal death
leading cause of pregnancy-related mortality in 1st trimester
What are treatment options for ectopic pg?
- medical - methotrexate, 1st line, stops blastocyst development, folic-acid antagonist
- surgical - usu laparoscopic salpingostomy or salpingectomy
When is 1st trimester?
2nd?
3rd?
1st - 0-13 weeks gestation
2nd - 14-26 weeks
3rd - 27-40 weeks
What week should a woman establish prenatal care?
By 10 weeks to get the most accurate EDD
allopaths say end of 1st trimester
How often should she get prenatal visits during pg?
Monthly until 32 weeks
Biweekly 32-36 weeks
Weekly 36 weeks - delivery
What pregnancy-related issues are important to catch early on?
pre-eclampsia (HTN, proteinuria) gestational diabetes (24-28 weeks)
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
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
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.
What are the MC risks of smoking in pregnancy?
low birth weight
premature rupture of membranes
placental abruption
pre-term delivery
What are the alcohol recommendations in pregnancy?
undetermined -
risk of FAS
What are the caffeine recommendations in pregnancy?
200-300 mg/day (16 oz house = 330mg)
What are the exercise recommendations in pregnancy?
150 minutes/week
30 mins/day most days
moderate intensity - low weight, high reps
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
Why is digital cervical exam contraindicated with 2nd/3rd trimester bleeding?
in case of placenta previa - may increase bleeding or disrupt placenta further
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
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
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
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)
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
What is oxytocin and what does it do?
“love” hormone, released by pituitary, plays a role in bonding
Common causes of fatigue in pg?
- Anemia
- blood sugar imbalance
- insomnia
- drowsiness (dt progesterone)
Describe how pg hormones can induce N/V.
hCG - slows peristalsis
progesterone - slows peristalsis, diminishes HCl
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
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)
What homeopathic N/V remedies for pg?
- sepia
- taraxacum
- nat mur
- phosphorus
What nutritional (supplemental) N/V remedies for pg?
B6
vit K
vit C
What is the ddx to rule out hyperemesis graviderum?
pancreatitis hepatitis appendicitis cholecystitis gastroenteritis pyelonephritis gastritis
What herbs might you give for anemia of pg?
- rumex crispus
- urtica dioica
- taraxacum
What herbs might you give for blood sugar regulation in pg?
- oplopanax
- gymnema
- syzygium
- taraxacum
What herbs might you give for insomnia in pg?
- matricaria chamomila
- scutellaria
- valeriana
** NO PASSIFLORA**
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
What stages of life are particular teratogen risks?
- early fetus - cell division
- infancy
- adolescence
- luteal cycle of menses
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
