NCB II Midterm material Flashcards
average weight gain in PG? fetus lbs? EC fluid lbs? placenta lbs? blood lbs? breast lbs? fat lbs? uterine muscle lbs?
average wt gain: 25-35 lbs fetus: 7-8 lbs EC fluid: 6.6 lbs placenta: 4 lbs blood: 3.3 lbs breast: 3 lbs fat: 3 lbs uterine muscle: 2 lbs
how much does CO increase by? blood volume?
CO increases by 30-40%
blood volume by 35%
how much does O2 consumption increase by? what breathing sx can one experience in PG?
20% increase in O2
may experience SOB
what 3 things increase in relations to the UT?
increased urine production, increased frequency of urination
increased risk of UTIs
what changes with digestion? dt what? (decreased)
decreased HCl, pepsin, gastric emptying and intestinal motility
all are decreased dt progesterone b/c it is a SM relaxor
what hormones increase in PG? what decrease? what body process increases?
increase in: thyroid fxn (decreased TSH, increased T4, same T3), prolactin, cortisol, aldosterone
increased resistance to maternal glucose
hyperlipidemia
decreased GH, FSH, LH
increased metabolism
how much does estrogen increase by? produced by? purpose of it?
estrogen increases by 1000x’s in PG
produced by ovaries and adrenal cortex
E + relaxin increases relaxation of SI jts
influences growth and function of uterus, breasts, labia
stimulates prostaglandin production in 3rd TM
how much does progesterone increase by? produced by? purpose?
increases 10x's in PG produced by corpus luteum and placenta increases blood supply to uterus suppresses maternal immunological response to fetus decreases contractility of uterus
how much does PL increase in PG? produced by? purpose?
increases to 200 mg/mL at term
produced by maternal and fetal pituitary glands and uterus
milk production, increases bonding
prostaglandins are produced by who? purpose?
prostaglandins produced by mother, fetus and placenta
softens cervix and primes maternal body for labor
oxytocin is produced by? purpose?
produced by hypothalamus, released by pituitary
stimulates uterine contractions
milk let-down and ejection
increases bonding
b-hCG is produced by what? purpose?
secreted by early trophoblasts starting at 6th-8th d
provides message to corpus luteum that PG has occurred and prevents degeneration
purpose of HPL?
responsible for insulin resistance and lipolysis
normal placenta anatomy? purpose?
2 arteries, 1 vein
transfers blood from mother to fetus, secretes hormones which maintain PG
how much amniotic fluid is present during PG? flow? functions?
1-1.5 L
flow: fluid replaced every 3hours, metabolizes every 15 hrs
functions: protection, temperature maintenance, allows fetal movement
definition of an embryo? what is going on at this stage?
8 weeks after conception (10 wks PG)
major organ systems are being formed at this time
definition of a fetus?
8 weeks after conception to term
average wt at term? average length at term? during what mos of gestation does most growth occur?
7.0 lbs for females
7.5 lbs for males
20 in average
most growth is b/w 6-8 mos
definition of GD?
glucose intolerance (diabetes) developed during 2nd half of PG, greater than 20 wks gestation
comes on during PG and disappears w/in 6 d of delivery
if develops less than 20 wks gestation considered pre-existing diabetes
GD has no association with increased congenital malformations
average fasting glucose? cut-off for normal? average 1 hr post-prandial glucose? cut-off for normal?
average fasting: 69-75; cut off is less than 95
average 1 hr pc: 105-108; cut-off is less than 120
risk factors for developing GD?
age greater than 30 previous baby greater than 9 lbs maternal HTN maternal obesity FHx of DM excessive maternal wt gain
screening for GD? is HbA1c a good screening test for PG moms?
test random blood glucose at 1st PN if pt is at increased risk: morbid obesity, strong FHx, previous GD, prior macrosomic baby
screen ALL pts at 24-28 wks w/GST
HbA1c is INSENSITIVE at detecting GD
describe the procedure for a GST
when would you recommend a OGTT? when would you recommend checking fasting glucose?
- eat a normal meal
- 2 hours later drink 50 gm glucose drink
- plasma glucose drawn 1 hr later (nothing by mouth except water 1 hr later)
- if GST greater or equal to 130 do OGTT
- if GST greater or equal to 190 do fasting glucose
describe the procedure for an OGTT
at what levels (fasting, 1 hr, 2 hrs, 3 hrs) would you be able to dx GD?
fast overnight (at least 8 hrs)
draw blood
drink 100 gm glucose drink
draw blood again at 1 hr, 2hrs and 3 hrs post drink
at least 2 of the 4 values must be abn to dx GD: fasting greater than 95, 1 hr greater than 180, 2 hrs greater than 155, 3 hrs greater than 140
is a dipstick glucosuria test a good way to monitor or dx GD?
NO
but can be a good screening if not doing a blood draw at that PN
done at every PN
when would you do a random blood glucose test?
to f/u if you have 2 episodes of glucosuria
f/u with a GST if greater than 110 w/in 2 hrs pc or if greater than 101 greater than 2 hrs pc
what can you have a pt w/GD do at home?
home glucometer monitoring so as to monitor their levels
have them measure their blood glucose at 1 or 2 hrs pc (start w/4x/d and decrease)
fasting should be less than 90
1 hr pc should be less than 130
2 hr pc should be less than 120
when do you do biophysical profiles w/a mom w/GD? what other things should the mom be noticing towards the end of PG?
wks 34-36, 38, 40, 41
mom: daily fetal movement counts, close observation for signs of fetal distress
* we need to monitor closely when post-dates or large baby
* standard of care is to deliver at 38 wks
what classification of GD mom’s are eligible for OOH birth? which are not?
Class A1 GD pts w/well controlled blood glucose are safe for OOH births (normal fasting, abn pc glucose)
Class A2 GD are NOT good candidates for OOH birth (abn fasting and pc glucose)
diet recommendations for a mom w/GD? herbs? supplements? lifestyle?
no refined carbs increase fiber increase fruits and veggies herbs: wise woman herbals DM tincture, devil's club root, jambul seed, blueberry lead, dandelion root, bitter melon, gymnema supplements: chromium picolinate lifestyle: exercise 30-60/d
when would you need to check sugar levels during labor?
if mom is on oral meds or insulin need to monitor blood sugar hourly
7 maternal sequelae of GD?
preeclampsia infections pelvic injury (macrosomic baby) C-section dt fetal distress and dystocia cardio-respiratory sxs dt polyhydramnios increased risk of PPH development of T2 DM after PG
4 fetal sequelae of mom w/Class A1 GD?
birth injuries b/c macrosomic
hypoglycemia in neonatal period
hypoxemia in-utero
hyperbilirubinemia
9 fetal sequelae of mom w/Class A2 GD?
birth injuries b/c macrosomic hypoglycemia in neonatal period hypoxemia in-utero hyperbilirubinemia increased perinatal and intra-uterine mortality acidosis dt maternal acidosis hypocalcemia respiratory distress syndrome congenital anomalies
when do you test for MSAFP? what does it stand for? high levels can indicate what? low levels can indicate what?
test for MSAFP at wks 16-18 gestation (must have accurate due dates!)
maternal serum alpha-fetal protein
high levels in: NTDs, underestimation of fetal age, multiple gestation, threatened abortion, fetal demise
low levels in: Down syndrome, overestimation of fetal age, fetal demise, hydatidiform mole
if MSAFP is high or low, what is your f/u?
f/u with U/S and possibly amniocentesis
3 abn lab findings in Down’s?
low MSAFP, low uE3, high hCG
3 abn lab findings in Trisomy 18?
low MSAFP, low uE3, low hCG
when can early amnio be performed? mid-TM amnio? when is it indicated to do an amnio?
early: 11-15 wks
mid-TM: 15-17 or 14-16 wks
indications: abn MSAFP, detection of chromosomal abn, surfactant activity, bilirubin levels abn
when would you do chorionic villi sampling? indications?
11-13 wks
indications: abn MSAFP, detection of chromosomal abn, surfactant activity, bilirubin levels abn
* high risk of loss of PG than amnio*
what is the triple test? the quadruple test? when do you do quadruple test?
triple: MSAFP, hCG, estriol
quadruple: MSAFP, uE3, free b-hCG, inhibin-A
quadruple performed b/w 14-22 wks (16-18 wks best for open NTDs)
what is the U/S marker for Down syndrome? done when? what are the 2 causes of the tell-tale sign?
nuchal fold scan shows nuchal translucency
done at 10-14 wks
nuchal translucency: caused by cystic hygroma or by nuchal edema
11 initial lab tests?
ABO Rh and Ab screen HCT/Hgb/MCV cervical cytology (if due for PAP) rubella immunity syphilis testing HBVSAg screening GC/CT screening thyroid function testing HIV urine culture Down syndrome screening
10 tests for at-risk women?
GC TB toxoplasmosis HCV Abs Varicella BV Trichomonas vaginalis HSV Chagas dz lead level screening (not testing in US)
4 tests for heritable d/os?
RBC indicies
CF
serum phenylalanine levels
fragile X
what test do you need to do to make sure you have an accurate EDD?
U/S!!!
six 2nd and 3rd TM tests?
NTD screening and Down’s screening
GD
STDs (repeat if have prior PN hx of dx of STD or those at risk)
CBC and Ab screening (anemia screen and Rh)
GBS screening (35-37 wks)
U/S
during the 2nd/3rd TM U/S what 4 things are you assessing for?
fetal presentation amniotic fluid volume placental appearance and location fetal biometry *during 3rd TM specifically looking for IUGRs
what does the biophysical profile assess (3 standard, 1 extra)?
fetal movement/fetal tone
fetal breathing
amniotic fluid volume
placental grade- have to ask for
what is the normal measurement for measuring amniotic fluid? oligo? poly?
normal is 5-20 cm
olihydramnios is less than 5
polyhydramnios is greater than 20
fetal swallowing and urination account for 50% of fluid volume; maternal hydration also
when would order a biophysical profile?
weeks 34-36 for OOH birth (also for placental position and fetus)
post-dates
any complications
question of fetal well-being after 31 wks or when feel something is wrong
what is ‘reactive’ on a non-stress test? what is ‘non-reactive’?
with doppler, record an acceleration of 15 bpm with at least 2 fetal movements for 15 seconds
non-reactive: lack of beat to beat variability and/or no increase or decrease of FHT and no movement after 40 mins
what other 3 tests can you do to assess fetal well being?
fetal vibroacoustic stimulation test
fetal movement counts
umbilical artery doppler velocimetry
what is HELLP syndrome? labs show what? ssxs? tests to run?
Hemolysis of RBCs, Elevated Liver enzymes, Low Platelets
liver is severely compromised
labs: increased BUN, decreased WBCs, low HCT and Hgb may also be present
ssxs: malaise, epigastric pain, N/V, HA, RUQ tenderness, HTN, proteinuria (maybe present or mild)
tests: Hgb, HCT, platelet count, AST/ALT (PT/PTT and fibrinogen should be normal)
what is intrahepatic cholestasis of PG? sxs? when does it present? lab tests? dx? tx?
stasis of liver, no movement of bile
sxs: body itching of trunk, extremities, scalp, worse at night and early morning, jaundice, no rash!
presents in 3rd TM
labs: fasting serum bile acids
dx: fasting serum bile acids 3x’s normal + itching
tx: homeopathy, botanicals like milk thistle, yellow dock and dandelion or ursodeoxycholic acid
what is preeclampsia? ssxs?
immunologically mediated inflammatory condition of PG that leads to systemic vasoconstriction and end organ damage
ssxs: HTN and proteinuria
4 classifications of HTN in PG?
chronic HTN (before 20 wks and no proteinuria)
chronic HTN w/superimposed preeclampsia (new or increased proteinuria before 20 wks)
gestational HTN (after 20 wks, no proteinuria)
preeclampsia/eclampsia (after 20 wks, proteinuria)
diagnostic criteria of mild, severe preeclampsia and eclampia. ssxs?
mild: BP 140/90 or greater in a woman who was previously normotensive, protein 300 mg or greater on 24 hr urine collection
severe: BP 160/100 or greater, protein 500 mg or greater
eclampsia: convulsions or coma assoc w/preeclampsia
ssxs: HA, edema, RUQ pn, decreased urinary output, N/V, malaise, altered mentation
maternal risk factors for developing preeclampsia?
DM, chronic HTN, vascular and CT dzs, obesity, chronic renal dz, hydatidiform mole, chromosomal abn, erythroblastosis fetalis, thrombophilias, less than 25 or greater than 35 yo, previous PHx of, FHx of, stress
paternal risk factors for mother developing preeclampsia?
first time dad, previously fathered a preeclamptic PG in another woman, limited sperm exposure w/current father
one theory of etiology for preeclampsia?
abn maternal immunological response to trophoblasts preventing normal trophoblastic invasion
normally placental cytotrophoblasts invade spiral arteries and remodel so that the maternal arteries become large, dilated and low P
what two inflammatory markers will be elevated in preeclampsia?
CRP and homocysteine
lab tests for women at high risk for preeclampsia?
Hgb/HCT platelet count 12 or 24 hr urine collection serum creatinine serum uric acid
lab tests for women who develop HTN after 20 wks?
Hgb/HCT platelet count 12 or 24 hr urine collection serum creatinine serum uric acid AST/ALT serum albumin LDH coagulation profile
how does GFR change in normal PG? in a preeclamptic PG? 24 hr urine protein, what amount of protein to dx preeclampsia?
normal: GFR should increase
preeclampsia: GFR decreases
more than 300 mg is preeclampsia on 24 hr urine collection
what hematological tests are the best indicator of preeclampsia dz severity?
thrombocytopenia (low platelet count)
increasing Hgb/HCT
when will preeclampsia resolve?
should resolve upon delivery of the baby
what are 8 maternal complications of preeclampsia?
renal, hepatic, cerebrovascular, opthalmic, CV, pulmonary, hematologic, HELLP
what are 3 fetal complications of preeclampsia?
IUGR, prematurity, intra-uterine fetal death
what nutrition advice can you give to help manage preeclampsia?
eat lots of veggies adequate Ca2+ adequate folate antioxidants vitamin D L-arginine (to help produce NO)
5 ddxs of 3rd TM bleeding?
placental abruption, rupture of marginal sinus placenta previa, vasa previa cervical/vaginal bleeding bloody show uterine rupture
etiology of placental abruption?
chronic HTN trauma short umbilical cord sudden decompression of uterus increased stretch of uterus
ssxs of placental abruption?
vaginal bleeding uterine tenderness fetal distress hypertonic uterus severe back pain ssxs of shock idiopathic premature labor
labs for suspected placental abruption?
U/S
non-stress test
CBC, coagulation panel, CMP, platelets
Ab screen on Rh- moms
management of mild and moderate/severe bleeding with placental abruption?
mild: U/S, FHT, vaginal rest, fetal movement counts, biophysical profile or non-stress test
moderate/severe: U/S, FHT, vaginal rest, fetal movement counts, biophysical profile or non-stress test plus REFER b/c may need to induce or perform C-section
complications of placental abruption?
DIC, fetal death, maternal hemorrhage, maternal shock, preterm labor
ssxs of marginal sinus rupture?
mild vaginal bleeding, painless
not assoc w/uterine rigidity or FHT changes
management of suspected marginal sinus rupture?
U/S FHT uterine exam vitals vaginal rest fetal movement counts consider biophysical profile or non-stress test
tx of marginal sinus rupture?
vit E, vit C, bioflavinoids, hamamelis virginiana, viburnum prunifolium, homeopathy
what is placenta previa? different levels?
placenta previa: placenta implanted over or near internal os
total: internal os completely covered
partial: internal os partially covered
marginal: edge of placenta on marginal edge of internal os
low-lying: placenta edge does not touch os but close to it
risk factors for placenta previa?
greater than 3 births, greater than 30 yo, prior C-section or other uterine surgery, poor quality of uterine lining, endometriosis following prior PG
problems that come with placenta previa?
greater incidence of PPH
assoc w/placenta accrete (implanting down into muscular layer of uterus)
assoc w/congenital anomalies
ssxs of placenta previa?
painless vaginal bleeding usu at 28-30 wks, usu just a small amount but can vary
w/u for suspected placenta previa?
U/S
NEVER do a vaginal exam in the 3rd TM bleed before doing an U/S (could disrupt if have placenta previa)
management of placenta previa?
delay delivery if blood loss is non-threatening, labor hasn’t begun, baby is not in distress, fetus is premature
bed rest until delivery, delivery via C-section when time
what is vasa previa? what is it associated with?
fetal blood vessels lying across os
associated with velamentous insertion of cord (no Wharton’s jelly wrapping vessels tightly together) and low lying placenta
how do you dx vasa previa?
vaginal exam
wright stain of vaginal blood shows nucleated RBCs
complications associated with vasa previa? management?
compressed vessel can lead to decreased FHT and fetal distress
risk of fetal hemorrhage
TRANSPORT IMMEDIATELY- keep mom in knee to chest position, monitor FHT, delivery via C-section
prognosis of vasa previa if vessel has rupture?
VERY POOR
reasons for cervical/vaginal bleeding?
cervicitis, cervical erosion, polyps, CA, lacerations, foreign bodies, varicosities
ask if bleeding occurs after intercourse or vaginal exam and about exercise, hiking or anything else that could have led to cervical trauma
what labs to do with cervical/vaginal bleeding in 3rd TM? PE?
labs: pap, GC/CT, wet prep, cervical culture
PE: visualize cervix (after U/S to look for polyps, masses, etc.)
tx options for varicosities?
decrease standing
collinsonia, hamamelis
pycnogenols
how can you tell it’s the bloody show vs other causes of bleeding in the 3rd TM?
cervical blood will be mixed with mucous, will usually have other signs of being in labor
