Module 3 First Trimester Unit A-D Flashcards
What symptoms might make a person suspect they are pregnant?
Presumptive elements=Subjective
Examples: Amenorrhea, Breast tenderness, enlargement, tingling, changes in shape/color, Fatigue, Nausea/vomiting, Urinary frequency/nocturia, Perception of fetal movement, Pigmentation changes, Sustained basal body temperature
What signs might make a clinician suspect a patient is pregnant?
Probable elements=Objective
Examples: Enlargement of abdomen or uterus, Pelvic exam changes: Chadwick’s, Goodell’s, Hegar’s, or Piskacek’s signs, Ballottment, Palpation of fetal outline, fetal movements, or uterine contractions, Positive pregnancy test
How does a clinician definitively diagnose pregnancy?
Pregnancy can be confirmed through positive elements (cannot be from anything else) such as:
-Audible fetal heart tones
-Sonographic evidence of pregnancy
When should a clinician use urine pregnancy testing vs. serum pregnancy testing? Serum quantitative vs. qualitative?
Qualitative urine pregnancy tests are used most often in the office, and serum pregnancy tests are used for special circumstances.
-Serum qualitative tests are done with urine is unavailable, and blood is already being sent.
-Serum quantitative is used when there is doubt about the health of the pregnancy.
Why is a false negative urine pregnancy test more likely than a false positive urine pregnancy test?
The test could be taken too early to detect hcg.
How can quantitative beta hCG patterns assist in clinical decision-making?
-HCG levels should double every 48-72 hours. If they don’t, this can indicate an embryo that is not developing properly or an ectopic.
-If higher than expected, could indicate multiples or molar pregnancy.
-Cannot be used to date pregnancy, and needs to be serial.
How do you calculate an estimated date of birth using menstrual dates/Naegele’s Rule?
If 28 day cycle, take LMP + 7 days - 3 months + one year=due date.
Must have 28 day cycle that is regular. (If greater than 28 days, add days. If less than, subtract days)
Not on birth control or breastfeeding.
In which clinical situations is ultrasound-based pregnancy dating clinically preferable?
-Cannot remember the first day of LMP
-LMP was unusual in some way (shorter, longer, lighter, heavier than expected or came at a time different than it was expected)
-Conceived while using hormonal contraception
-Breastfeeding at the time of conception
-There is a question about the health or development of the pregnancy because of spotting, the uterus is smaller than expected, or pregnancy symptoms have stopped unexpectedly. An ultrasound would then be for dating and for assessing the health of the pregnancy. Vaginal if <12 weeks suspected, abdominal if >12 weeks by clincal assessment.
When should you change an estimated date of birth based on a subsequent ultrasound?
If <9 weeks gestation, change if greater than 5 days difference.
If 9-13.6 weeks gestation, change if greater than 7 days difference.
How will you incorporate shared decision-making in the decision about menstrual vs. ultrasound dating?
Pros of ultrasound: Less chance for a unncessary post-dates induction, maternal bonding, low risk.
Cons: Midwifery hallmark is low intervention unless necessary, they are vaginal which can be uncomfortable/traumatic, some insurance only covers a limited number of ultrasounds so it might be costly.
How will you use bimanual exam results to assess gestational age in the first trimester?
6 weeks: small orange or pear.
8 weeks: naval orange
10-12 weeks = grapefruit
16 weeks= 3cm above pubic bone
What are the elements of an initial obstetric history and physical exam that clinicians should assess? Why is each of them important? (In other words, don’t just memorize the list; think about why they matter.)
Height, weight, BMI, blood pressure, head-to-toe (if not done recently), assessment of uterus size.
Clinical pelivimetry is controversal and not routinely done.
What are the principles of prescribing for pregnant people?
Choose the lowest dose, for the shortest time, with the most evidence.
When possible, use a single medication as opposed to combination products.
Weigh the risks vs. benefits and include the patient in the decision-making process.
If possible, do not prescribe drugs during the first trimester.
When appropriate, prescribe topical instead of systemic drugs.
If the pregnant person is already taking a medication, discontinue only if the medication is harmful to the pregnancy and only if safe to do so. Some maternal conditions can be more dangerous if they are untreated (e.g. asthma, depression), compared with the risks of medication exposure during pregnancy.
How will you determine if a medication is safe for a person to continue during pregnancy?
Briggs on Lexicomp!
Compatible = The human pregnancy experience, either for the drug itself or drugs in the same class or with similar mechanisms of action, is adequate to demonstrate that the embryo–fetal risk is very low or nonexistent. Animal reproduction data are not relevant.
What labs do clinicians order as part of the initial obstetric panel?
Urine culture, CBC, RPR, MMR, blood type (RH factor), Hepatitis C/B, HIV
How do clinicians record obstetric history using the GTPALM system?
G= How many pregnancies.
T: Term (37+ weeks)
P: Preterm (20-27 weeks)
A: Abortion (elective and spontaneous)
L: Living
M: Muliples (1= one set of twins)
How do clinicians assess maternal well-being at subsequent/routine interval prenatal visits during the first trimester?
Blood pressure, weight, urine by dipstick (if indicated), evaluation of discomforts.
How do clinicians manage common discomforts in the first trimester, including subjective and objective data collection, development of assessment/differential diagnoses, determination of normalcy, development of a plan, and patient education? (You should be able to navigate that process for each of the common discomforts listed below.) ADD SLIDES ABOUT EACH DISCOMFORT. ANOTHER DECK MAYBE?
Shortness of breath
Urinary frequency
Nausea and vomiting
Heartburn
Breast tenderness/enlargement
Fatigue
Bleeding gums
What subjective and objective findings would reassure you that a pregnancy is intrauterine and developing as it should be, even though a patient is experiencing first trimester bleeding?
Normal rising HcG, gestational sac and yolk in uterus.
Painless bleeding.
What are the subjective and objective data that you must assess to investigate the possibility of serious causes of first trimester bleeding such as ectopic pregnancy, molar pregnancy, and incomplete/inevitable early pregnancy loss?
Subjective: Ectopic and loss (painful), increased n/v (molar)
Objective: No yolk sac/pole/etc in uterus, abnormal hcg levels (higher for molar or lower than expected for loss and ectopic).. Bright red bleeding for ectopic or loss, dark brown for molar.
What is the role of serial quantitative beta hCG testing in the setting of first trimester bleeding?
If betas are not rising normally, could indicate a embryo that is not growing in conjunction with the bleeding.
What are the less serious causes of first trimester bleeding and how will you assess for those?
-Subchorionic hemorrhage: Painless bleeding typically week 8-10, beta rises normally, seen on u/s.
Implantation bleeding: Roughly 2 weeks after ovulation, small amount for short amount of time, too early to see anything on ultrasound, betas would rise normally.
-Cervical irritation from infection or intercourse: Small amounts, irritation seen on cervix, no u/s findings, STI testing may be indicated.
-Fibroids/polyps: Uterus may be enlarged, will see on u/s, no conern if small, beta would rise.
