Mod 7. Prenatal Flashcards
true or false?
domestic violence often worsens during pregnancy?
true
discuss safty plan
During preconception what ethnicity based screening would you consider for Ashkenazi Jewish Ancestry?
they will need Hematopoietic stem cell screening
For genetics purposes, an individual with one biological grandparent of Ashkenazi Jewish heritage
is considered a candidate for carrier screening.
Certain ethnicities are at a higher risk of developing Hemoglobinopathies (thalassemia and sickle cell disease)
During preconception screening, which ethnicities would you offer screening for hemoglobinopathies, and how do you do this screening?
The following are at risk:
- Mediterranean
- Caribbean
- South American (Hispanic)
-Western Pacific
- Asian & South east asian
- Middle eastern
-African
To conduct screening, begin with female and obtain CBC or electrophoresis, and if the MCV is less than 80 or electrophoresis reveals an abnormal hemoglobin type then screen male partner
refer couple to genetic counselor if both members are carriers of thalaseemia
What family history would require preconception genetic testing?
For all patients you must obtain a 3 generation family history, and if there is any family history of:
-congenital malformatino
- developmental/learning disabilities
- ethnicity
- genetic disorders
- consanguinity (first cousin or closer)
- Children who died at young age
- Sudden death
- history of infertility/ multiple miscarriages
What infectious diseases do you need to screen for during preconception?
- TB
- HIV
- Hep B/C
- Parovirus
- syphilis
- toxoplasmosis
- Cytomeglovirus
if a patient tests positive on an at home pregnancy test do you need to do anymore investigations?
yes you should follow up with serum or urine hCG
which test can confirm pregnancy the earliest?
- blood serum HCG can detect positive pregnancy the earliest
- Urine HCG can detect 9-15 days after ovulation and as early as 3-5 days after implantation
during prenatal care what blood work would you order?
CBC
Rubella & Varicella titre
HIV (w client consent)
Syphilis (rapid plasma reagin)
Chlamydia + Gonorrhea (urine or cervical)
HBsAG
ABO group and RH factor
Antibody screen
TB testing
urine culture and sensitivity
Bacterial vaginosis screening
when are the routine prenatal visits?
Your patient should see you every 4 weeks until 28 weeks gestation, then every 2 weeks till 36 weeks gestation, then weekly till delivery
how often should a pregnant women be exercising?
aim for 150 minutes per week
at what gestational age is the gestational sac identified by abdominal ultrasound?
5-6 weeks
When can you confirm intrauterine pregnancy by transvaginal ultrasound
At 6 weeks you can see a secondary yolk sac which confirms intrauterine pregnancy
in most healthy pregnancies, beta HCG levels increase by what?
Between 4-8 weeks gestation the beta HCG will double every 2-3 days
It will peak at 8-10 weeks gestation (100,000 IU) then start to decline down to 20 000 IU/L
if a pregnant patient has a vaginal bleed at 11 weeks, what test would you order to confirm viability of pregnancy?
You would order transvaginal or abdominal ultrasound, DO NOT ORDER BETA HCG after 10 weeks of pregnancy as the beta HCG levels will start to declien
why would you order a transvaginal ultrasound in the first trimester?
- Assessment of vaginal bleeding in early pregnancy
- identifying retained products of conception in an incomplete miscarriage (you terminate pregnancy and need to check for extra tissue growth)
- Confirming diagnosis of complete miscarriage
- confirming diagnosis of delayed miscarriage
- investigating possible ectopic pregnancy or pelvic masses
under what circumstances would you order serial beta hcg? (every 2-3 days getting bloodwork)
Uncertain location or viability of a pregnancy i.e., βhCG has not reached the discriminatory threshold & the site of pregnancy not identified by TVUS
Monitor the progress of expectant or medical management of a miscarriage or ectopic pregnancy.
what characteristics of betaHCG would you expect to see in ectopic pregnancy?
BHCG levels that rise at a significantly slower rate than normal intrauterine pregnancies although the normal doubling is seen in up 21% of ectopic pregnancies.
A plateau early in the pregnancy
Note: “Falling levels confirm nonviability but do not rule out ectopic pregnancy.”
if a mother is hep B positive, what percentage of likihood will the baby develop chronic hepatitis?
If the newborn is not immunized at birth there is a 90% chance of the newborn developing chronic hepatitis
what investigations would you order at the 2nd and 3rd trimester?
Hb
Platelets
Abo/rh(D)
Repeat antibodies
1 hr gct
2hr gtt
during the 2nd and 3rd trimester what investigations can be ordered ONLY IF INDICATED?
the following Additional investigations would be performed only if indicated:
TSH, Diabetes Screen
Hb Electrophoresis/ HPLC, Ferritin, B12,
ID (e.g. Hep C, Parvo B19, Varicella, Toxo, CMV)
Drug Screen, repeat STI screen
when is the enhanced first trimester screening done? (EFTS)
eFTS (between 11-13+6wks) - enhanced first trimester screening; this has replaced the ips screening
who should NOT have enhanced first trimester screening?
You should not have eFTS if you:
already have a “low risk” result from Non-Invasive Prenatal Testing (NIPT), or you are waiting for your NIPT results.
had a “vanishing” twin / co-twin demise. This is a pregnancy that started as twins, but one of the twins was lost.
are expecting more than one baby (twins, triplets, quadruplets etc).
when is the NIPTI screening covered by ohip?
a positive prenatal screening result from multiple marker screening (MMS) for this pregnancy
the maternal age will be 40 years or older at the expected date of delivery
in the context of in vitro fertilization, the maternal age is guided by the age at egg retrieval (whether own egg or donor egg)
the nuchal translucency (NT) measurement is ≥3.5mm
there is a personal history of a previous pregnancy or child with Trisomy 21, 18 or 13
there is an ongoing twin pregnancy
if a pt tests positive on eFTS what are the next steps?
If positive, eligible for amniocentesis (risk of 1/100 to 1/175 for pregnancy loss) or by chorionic villus sampling, (risk of 1/100 for pregnancy loss).
Positive eFTS does not mean genetic abnormality
when do you screen for gestational diabetes?
All pregnant PEOPLE should be screened for GDM at 24-28 weeks of gestation
If there is a high risk of GDM based on multiple clinical factors, screening should be offered at any stage in the pregnancy (Grade D, Consensus).
If the initial screening is performed before 24 weeks of gestation and is negative, rescreen between 24-28 weeks of gestation
At how many weeks is the Obestric ultrasonography? (detailed ultrasound)
18-20 weeks gestation
At how many weeks is Group B strep swab obtained for pregnant women?
35-37 weeks gestation
At how many weeks would you repeat RH antibody for RH negative pregnant women?
24-26 weeks
Under what circumstances would you screen a pregnant women for hypothyroidism?
- previous miscarriage/preterm labor
- Goiter
-Family Hx - Obesity
- Lives in area with iodine insufficiency
If you order a TSH for a pregnant women to screen for hypothyroidism, what values would prompt a reflex t4 to be ordered?
If the inital TSH comes back between 2.5-10 then you will get a t4 ordered
this is because TSH will be natrually lower during pregnancy
If the Free T4 is LOW (below 5th percentile) you would start treatment
what are risk factors for gestational diabetes?
- precious GDM
- Macrosomic infant
- ethnicity (hispanic, indigenous)
- BMI above 30
- PCOS
- Steroid use
- older than 35
How can you calculate the gestational age of a fetus in a pregnant women? What is the math trick you can do?
You will be expected to do this
The estimated Date of Confinement (EDC) using nagels rule:
First, determine the first day of your last menstrual period. Next, count back 3 calendar months from that date. Lastly, add 1 year and 7 days to that date
What are contraindications to exercise during pregnancy?
- multiple gestation (triplets or more)
- persistent bleeding 2/3rd trimester
- uncontrolled type 1 diabetes
- thyroid disease
- rupture membrane, preterm labor, placenta previa after 28 weeks
when is air travel not a good idea during pregnancy?
Do not fly after 36 weeks
it can cause preterm labor
In terms of genetic screening during pregnant can a pregnant person have both eFTS screening and Second trimester screening?
No,
EFTS is screening that occurs in the first trimester, if a pregnant person misses that window then their second option is a second trimester screening which occurs from 14 weeks- 20 weeks
What are the next steps if you screen positive for eFTS or Second trimester screening?
next steps are NIPTI screening which would be covered by OHIP
what happens if you screen positive for NIPTI screening?
you have the option of doing diagnostic tests including:
- Amniocentesis
-chorionic villus sampling
Which can be associated with miscarriage
When do you start measuring the fundal height?
Fundal height is the distance between the top of your uterus and your pubic bone. Healthcare providers use it to measure if fetal growth is on track. Your fundal height is measured beginning at about 20 weeks in pregnancy.
After about 20 weeks of pregnancy, your fundal height in centimeters should be close to the fetus’s gestational age. For example, if you are 24 weeks pregnant, your fundal height should be around 24 centimeters.
When is your patient referred to the OBGYN?
after the anatomy scan of 18-22 week
When would you be seeing your pregnant patient in the third trimester?
See them for episodic care, UTI, Vaginitis, tdap immunizations 28-34 w
otherwise they see the OBGYN
Explain what is involved in the test for Gestational diabetes?
Its called the oral glucose challenge
A patient will consume 50g of glucose then you will re-check their plasma glucose level at the 1 hour mark
What is a normal plasma glucose level @ the one hour mark post 50g of glucose?
Anything less than/equal to 7.8 is considered normal
you would only repeat this test if the patient did this test prior to 24-28 weeks
In what senario would you need your pregnant patient to perform a two hour 75g glucose challenge test?
During the inital non fasting 50g glucose challenge test, if a patients plasma glucose is 7.8-11.0 they will need to return on another day to complete the 2 hour fasting 75g glucose challege test
please explain what is involved in the 2 hour 75g glucose challenge test?
you must fast 8 hours before the test, and you have bloodwork drawn before the test and @ 1 hour mark, @ 2hr mark
these are positive results for gestational diabetes
Fasting plasma glucose above/equal 5.3
PG @1 hour = 10.6 or greater
PG @ 2 hour = 9.0 or greater
What BP is considered hypertension in pregnancy?
140/80
this is a red flag
Explain what decresed fetal movements means?
less than 6 kicks in 2 hours
red flag
What is normal weight gain during pregnancy?
first trimester 1-3.5 kg
then 0.45kg/week
What are the risk factors to Rh incompatability during pregnancy
The risk of Rh incompatibility is higher in an Rh-negative pregnant woman who:
Had a prior pregnancy with a baby that was Rh positive
Had a prior blood transfusion or amniocentesis
Did not get an Rh immunization during a prior pregnancy with an Rh-positive baby
