Module 6 Flashcards
What is the visit schedule for prenatal/postnatal care?
-Initial visit: between 6-8 weeks gestation (after 2 missed periods)
-Every 4 weeks until 28 weeks
-Every 2 weeks until 28-36 weeks
-Every week from 36-40 weeks
-Twice weekly if greater than 40 weeks
**closer supervision warranted for pts developing any of these problems: decreased fetal movement, GDM, PIH, PreE or placental problems
What are the initial labs?
CBC with differential
Blood type and Rh
Antibody screen
RPR and VDRL
HIV screening
HepB surface antigen (HBsAG)
Rubella and Varicella-zoster titers
Urinalysis/Urine C&S (clean catch or cath sample)
Pap smear if >21 yrs old (omit if normal Pap within past 3 years) –> include HPV co-testing if over age 30
DNA probe for Gonorrhea and Chlamydia
-screen for HSV in pts with past or current herpes lesions
-screening (wet prep) for trichomonas, candidiasis or bacterial vaginosis in those with sx
-Glucose challenge test if previous gestational diabetes or high risk for diabetes
-offer cystic fibrosis screening
-Zika testing if meets CDC criteria (exposure to Zika)
-Hb Electrophoresis to detect sickle cell or thalassemia based on racial/ethnic background and family hx
-PPD or Interferon Gold Test for those at high risk of TB
What are the choices for aneuploidy screening?
Neural tube defects: 13, 18, 21
2 options
1. stepwise integrated screening - two separate risk measures that are compared:
*first step between 11 0/7 and 13 6/7 weeks gestation: US measurement of fetal nuchal translucency. Serum test: pregnancy associated plasma protein A (PAPP-A) and BHCG. Used to screen for Trisomy 13, 18, 21
*second step between 15-18 weeks gestation: maternal AFP to detect open neural tube defect
2. Quadruple screening (15-20 weeks gestation, ideally 16-18 weeks):
*maternal serum a-fetoprotein (AFP)
*Serum B-human chorionic gonadotropin (BHCG)
*Unconjugated estriol
*Inhibin
What are the standard things that are checked at routine prenatal visits?
-weight
-urine dipstick for glucose, protein and nitrates
-BP
-Fundal height (after 18 weeks gestation)
-Fetal heart tones - audible with doppler usually after 10-12 weeks but really depends on patient habitus and fetal cooperation
-fetal movement - quickening by 18-20 weeks in a primiparous, 14-18 weeks in multigravida
-edema
-patient report of pressure/cramping/contractions
What are the danger signs of each trimester?
-Danger signs late pregnancy
*bleeding, leaking or change in vaginal discharge
*fever >100.6F (oral)
*pain-abdominal, uterine, or urinary
*decreased fetal movement (any concerns, patient should be assessed by BPP and NST)
What is the importance of antenatal Rhogam?
Rh Negative mothers (also called D negative)
-antibody screen
-if screen is negative, prophylactic Rhogam 300mg (anti-D immune globulin) is given to prevent isoimmunization
Can you name items for nutritional counseling?
-Nutritional counseling regarding carbohydrate intake
-blood glucose home monitoring
-Maternal/fetal SE of uncontrolled blood sugar levels
-Optimal glucose levels:
*fasting = 70-95
*1 hr postprandial < 130-140
*2 hr postprandial < 120
A firm, round, mobile, discrete, non-tender breast mass with well-defined borders is most likely consistent with:
fibroadenoma
Routine screening for group B strep (GBS) in pregnancy is recommended at:
36 weeks GA
A 29 year old female is seen in the clinic for an initial OB visit. As the NP, you will order all the following labs except:
TSH
Will want CBC and Rubella titer
You are examining a 10 year old female during a well child check. On physical exam, you notice she has developed breast buds. This is indicative of what stage of development?
Tanner 2
The development of axillary and public hair is known as:
pubarche
Which of the following statements is true regarding placenta previa?
diagnosed by US
Medications for initial antihypertensive therapy during pregnancy include all the following except:
enalapril
Methyldopa and labetalol okay
A patient is 32 weeks pregnant. She does not have a history of HTN and her BP up to now have been normotensive. Her BP today is 142/90. Her repeat BP was 144/92 four hours later. Urine dipstick is negative for protein. This is classified as:
gestational HTN
Your OB patient presents to the clinic at 26 weeks gestation for her routine 1-hour 50g oral glucose challenge test. Her result from the lab is 160. As the NP, what is your next plan of action?
order a 3-hour 100g OGTT
Montgomery glands
sebaceous
-responsible for lubrication of nipple, help prevent cracks and fissures during breastfeeding; hypertrophy during third trimester
mastodynia
breast tenderness; common in first trimester of pregnancy
Fibrocystic breast changes
-common or rare?
-related to what?
-differentiating factors of this disorder from others
-what test to dx?
-benign?
-tx
-common
-influx of hormones (estrogen and progesterone) and correlates often w/ the premenstrual phase of woman’s cycle
-painful, bilateral, mobile, masses; multiple; in the breast
*size rapidly fluctuates depending where person is in cycle (caffeine aggravates!)
-<35yrs = US; >35yrs = Mammogram
-fibrocystic breast changes are considered benign; do not inc risk of breast CA
-wear supportive bra, reduce caffeine intake, mild analgesics (tyl, ibup)
Fibroadenoma of the breast
-benign or metastatic?
-when do they increase in size?
-when will regress?
-typical findings
-gold standard for dx?
-benign, common; occurs frequently in women w/i 20 yrs after puberty
-during pregnancy or w/ estrogen replacement during menopause
-regress after menopause
-round, firm, moveable, nontender; 1-5cm in size
-biopsy
Nipple discharge
-when does this occur?
-how to eval discharge
-during pregnancy; d/t SE of medications; pituitary tumor
-consider the nature of discharge: serous, bloody, masses, unilateral/bilateral, spontaneously occur or must be manually expressed?
Nipple discharge
-clinical manifestations of physiologic nipple discharge
-physical exam (what is ordered; who to refer to)
occurs bilaterally, multiductal, milky nipple discharge in nonlactating breasts
-if physical exam is benign, imaging is negative, and discharge is multiductal and not bloody, order pregnancy test, prolactin levels, check renal and thyroid fx (refer to endocrinology as warranted depending on test findings)
Nipple discharge
-clinical manifestations of pathologic nipple discharge
-causes of nipple discharge?
-what does blood nipple discharge indicate? What should be ordered?
-unilateral, spontaneously occurs, serous or serosanguinous; comes from single duct
-commonly d/t intraductal papilloma (benign wart-like tumor that grows w/i the milk ducts of the breast)
-CA; US/mammogram depending on pt age (<35 US, >35 mammogram)
childbearing year
13 months
-2M preconception
-9M pregnancy
-2M PP
Preconception care
-screen for?
-folic acid supplementation
*dose
*purpose
*insulin dependent/valproic acid/carbamazepine
-health risks, H,W,BMI, BP, screenings for depression, domestic violence, substance abuse, provide smoking cessation counseling, medication reconciliation, start prenatal vitamins; immunizations up to date, screen for recent travel (zika)
-ALL women should be on folic acid (dec # of incidences of birth defects); dosing requirements depend on woman’s hx
-1MO prior to conception –> 0.4mg/day; if hx of birthing child w/ neural tube defect of have strong family hx of NTD’s = 4mg/day several MO before pregnancy
*women w/ insulin dependent DM and those taking valproic acid and carbamazepine for seizure disorder should take at least 1mg/day
Prenatal care
-when is initial visit?
-what is done at this visit?
-focus of pt education?
-possible testing that can be done
-other education
-6-8 wks GA
-perform hx and physical exam
-diet, PNV, exercise, teratogens, common discomforts of pregnancy (breast tenderness, pain in lower abd, finger and hand numbness, yeast infection ,HA, being tired and fatigued, inability to sleep, frequent urination, lower lumbar back pain, mood changes, sinusitis
-screening for NTD
-danger signs in first trimester, emergency contact info to get into touch w/ provider if pt has any issue
Initial lab testing for all pts (at initial OB visit)
-CBC w/ diff
-HIV screening
-Blood type
-Rh antibody screen
-RPR or VDRL
-Rubella and Varicella-zoster titers
-STD screening
-Hep B surface antigen
-UA w/ culture
-PAP smear if >21 yrs old (omit if normal pap smear w/i past 3 yrs)
-include HPV co-testing if over age 30
-DNA probe for gonorrhea and chlamydia
Screening for NTD (trisomy 13, 18, 21)
-stepwise integrated screening
2 steps (two separate risk measures are compared)
1. 11-13 6/7 weeks
*US - measures fetal nuchal translucency; coupled with serum blood test (PAPP-A (pregnancy associated plasma protein A) and BHCG ( used to screen for trisomy 13, 18, 21)
2. 15-18 weeks
*maternal AFP blood test (detect open neural tube defect)
-checks the level of AFP in pregnant woman’s blood. AFP made in liver of unborn fetus. AFP amount in maternal blood can indicate problems like spina bifida or anencephaly
Screening for NTD (trisomy 13, 18, 21)
-quadruple screening
15-20 weeks (16-18 best)
-maternal serum AFP and serum BHCG
-unconjugated estriol, inhibin
Invasive genetic testing
-when is this offered?
-Chorionic villus sampling
-Amniocentesis
-for pts >35yo or strong fHx of risk factors for genetic disorders
-performed b/w 10-13 weeks GA
*via transabdominal or transvaginal technique
-performed b/w 15-20 weeks GA
*only test w/ 100% detection rate however, a LOT of risks to performing this
schedule of prenatal visits (depends on clinic)
-first visit –> after 2 missed periods
-every 4 weeks until 28 weeks
-every 2 weeks until 36 weeks
-every week 36-40 wks
-If over 40 weeks, see physician 2x weekly
what happens if woman complains of dec. fetal movement, has GDM, pregnancy induced HTN?
closer supervision
what things are checked at each prenatal visit?
-what is normal?
-wt, BP, urine dipstick, fetal heart tones
-normal BMI: 18.5 - 24.9; can 25-35lbs
-normal BP: <equal 130-80 (HTN >140-90)
-normal UA dipstick: negative for glucose protein, and nitrates
-fetal heart tones: obtain w/ doppler –> audible after 10W, 120-160bpm
Fundal height
-begins when?
-@ 20 weeks, 1cm = ?
-where is fundal height at 8, 16, 20, 18-34, after 36 weeks?
-after 18 weeks gestation
*after 18 weeks gestation, fundal height is +/-1cm of GA
-after 20 weeks, 1cm = one week
-8: fundus is palpable; 16: midpoint (between pubic symphysis and umbilicus); 20: umbilicus; 18-34: fundal height should match GA in weeks; after 36 weeks, fundal height may not match weeks (d/t baby descending into pelvis)
*granmultips may not measure correctly d/t thinning of uterus and poor uterine support
when to assess if fundal height does not equate to GA?
if >2cm different than GA (between 20-36 wks), requires US to assess fetal growth and amniotic fluid status
When do primiparous women feel quickening?
When do multiparous women feel quickening?
-18-20 weeks
-14-18 weeks
Determining fetal presentation
-what position do we ideally want baby in for vaginal delivery?
normal/wanted presenting part of baby is fetal head
-head first facing backwards towards mothers back (occiput anterior)
Determining fetal presentation
-Leopold’s maneuver
- feel the fundus
- feel sides (the side that resists is the back)
- feel the presenting part
- listen for FHTs over baby’s lower back
GDM: ACOG guidelines
Step 1: (24-28 weeks)
-glucose challenge test: ingest 50g of glucola (no fasting)
-glucose draw in 1 hour (normal value depends on office policy)
*>130 (90% detection) or >140 (80% detection)
**>200 = dx with GDM w/o step 2
Step 2:
-fasting glucose drawn; ingestion of 100g of glucola; 3 glucose blood draws
*fasting: 95
*1 hr: 180
*2 hr: 155
*3 hr: 140
**dx with GDM if 2 or more measurements exceed normal values
GDM: ADA Guidelines
1 step
-75gm oral glucose tolerance test: done after 8 hour (overnight) fast at 24-28 weeks
*serum glucose drawn fasting, 1 hr, 2 hrs
*dx with GDM if any ONE value exceeds the cutpoints: fasting = 95, 1 hr = 180, 2 hr = 155
Rh Negative Mothers (D negative)
-what occurs if antibody screen is negative?
-what occurs if antibody screen is positive?
-300mugrams of anti-D immunoglobulin (RhIgG) is given
-manage patient as Rh-sensitized
When is Rhogam administered (how many weeks if Rh negative antibody screen)?
-when is it given at 40 weeks?
-when is it given PP?
-28 weeks
-if more than 12 weeks elapsed since anti-D immunoglobulin administration, consideration should be given to administering 300mugrams of anti-D immunoglobulin at 40 weeks gestation
-if infant is Rh(D)-positive, 300mugram of RhIgG is administered to mother (provided maternal antibody screening is negative)
*generally should be given w/i 72 hours after delivery; shown to be effective in preventing alloimmunization if given up to 28 days after delivery
*if antibody screen is positive, the patient is managed as if she will be Rh-sensitized during next pregnancy
how does maternal Rh alloimmunization occur?
- after incompatible blood transfusion
- after fetomaternal hemorrhage between mother and incompatible fetus (can occur during pregnancy or delivery via spontaneous or induced abortion, amniocentesis, chorionic villus sampling, abd trauma - MVA or external version, placenta previa, abruptio placentae, fetal death, multiple pregnancy, manual removal of placenta, and c-section
**within 6 weeks - 6MO, IgG antibodies become detectable –> IgG is capable of crossing placenta and destroying fetal Rh-positive cells
What tests are done between 24 and 28 weeks?
- glucose test
- antibody screen
- screen for anemia w/ CBC
quickening: how many movements in 2 hrs is considered okay?
10 movements in 2 hrs is reassuring
tests completed at 36 weeks GA
-check mom’s Hgb and Hct to screen for anemia
-GBS viz vaginal/rectal swab
-cervical ripening check at prenatal visits via manual check
common pregnancy complications: morning sickness
-when is it at its peak?
-education
-meds
-6-14/16 weeks
-avoid triggers (empty stomach, strong smells, eat frequent small meals)
-phenergan (can make you drowsy), vit B6 and unisom
common pregnancy complications: hyperemesis gravidarum
-def
-onset
-sx
-tx
-unremitting vomiting that causes dehydration and ketones in urine (may need hospitalization for IV fluid replacement)
-3-5 weeks, resolves by 20 wks (can continue throughout entire pregnancy)
-intractable N, retching, V –> leads to dehydration, ketonuria, and wt. loss of 5% prepregnancy wt (usually no effect on fetus)
-avoid triggers; if not helpful, try:
*B6 TID-QID
*B6 and Doxylamine (unisom) or another antihistamine (promethazine (phenergan), dimenhydrinate (dramamine))
*prochlorperazine (compazine), metoclopramide (reglan), or trimethobenzamide (tigan)
