Normal And Abnormal Pregnancy - Dr. Moulton Flashcards
Folic Acid in pregnancy
- Should be over 0.4mg (give supp)
2. If mom has had previous NTD then make sure her level is at 4.0mg
G P
G = number times pregnant P = number of births (infant over 500g) = Florida P&L (F - full, P - pre, A - abortion, L - living)
G and P of a person with twins
G1 P1002 = 2 kids
G and P of pt with 1 term infant, 2 preterm twins, 1 miscarriage,1 ectopic , 3 living children
G 4 P1123
Signs physical that can tell you a women is pregnant 6
- Systolic murmurs, exaggerated splitting and S3
- Palmar erythema
- Spider angioma
- Lines nigra
- Striae gravidarum = stretch marks
- Chadwicks sign = blue color to cervix
Prenatal labs to do
- CBC, blood Rh type
- Rubella postpartum
- Syphilis
- HepB, HIV
- Pap : chlamydia, gonorrhea
- DM
- Urine culture
Plt and Factor 7-10, nd Hb hct levels during preg
- PLT : decrease
- Factor 7-10 increase
- Hb : decrease
- Hct: decrease
Gestational age
Last menstrual period date and delivery date
HCG can be seen when and how does it increase
7-8 days after ovulation
= increasing : doubling every 2 days for first 30 days** used for ectopic vs IUP when unsure
When can you do transvaginal US and see something **
At about 5 weeks, during Discriminatory phase when hCG is 1500-2000 (Gestational Sac seen)
When do you see fetal pole and when do you see cardiac activity
- Fetal pole = 6 weeks, hCG 5200
2. Cardiac activity = 7 weeks , hCG 17,500
Fetal pole measurement with cardiac activity
If fetal pole if over 5mm and no cardiac activity = fetal demise
Naegels rule
Estimate delivery date in women with 28 day cycle
= minus 3 months + 7 days
Gestational age can be predicted how
US
- 1st trimester (6-11 weeks): crown rump length (CRL) = off by 3-4 days
- 2nd trimester femur length, abd circumference : off by 10 days
- 3rd trimester : off by 3 weeks
Most common 1 chr and 3 chr causing abortion (SAB, spontaneous abortion)
- 46 XO = turner
- Trisomy 16
= most common is trisomy causing SAB
How to dx for any genetic condition of baby
Chorionic villus sampling, amniocentesis
AR disorders to screen for
- Tay-Sachs , high in Jewish, Eastern Europe)
2. CF (North America whites, 1:25, screen all pregnant women, parents with echogenic bowel, sperm donors)
Sex linked disorders primary effect and 2 most common ones
Males , Females only carry it + NO male to male transmission
- Fragile X : most common inherited mental retardation , trisomy 21 is second most common
- DMD
Multifactorial Disorders 3 types
- NTD (spins bifida)
- Cleft lip
- Congenital heart defects
First Trimester Screening
- For who
- What you do
- EXs
- Not in risk
- Amniocentesis has higher chance of termination of pregnancy then chance of genetic problem happening = do screening (if that is elevated then to amniocentesis)
- Fetal Nuchal Translucency = NT thickness (back of neck)
+ [low PAPP-A + elevated B-hCG = 80% trisomy21 detection]
Screening for possible Down syndrome in 1st trimester
Elevated b-hCG, and low PAPP-A
+ nasal bone assessment absent + NT measurement thickness
Second Trimester Screening
- Consists of what
- Sometimes consists of
- Triple screen : high b-hCG, lowestriol, high AFP markers (70% trisomy21 detection)
- Quadruple screen : b-hCG, estriol, AFP, Inhibin A markers (80% trisomy21 detection)
Cell-free fetal DNA is what 1. Done when 2 .what is it 3. How accurate 4. Does not test for
- During 1st or 2nd trimester, what people use now to detect trisomy 21
- Test cell-free fetal DNA (from apoptosis of trophoblastic cells entering maternal circulation)
- 99% of T21,T18, 92% T13
- NTD, need to evaluate AFT or US after 15 weeks
Positive cell-fetal dna test what to do
Make sure with invasive amniocentesis (16-20weeks, 0.3% miscarriage) or CVS(chorionic villi sampling = 11 weeks, 1% miscarriage)
Teratology is what and detected mostly when
Abnormal fetal development
= by age 5yo (usually you don’t know exact cause)
Teratogen
- Most common and what it causes
- When should pt avoid all drugs
- Thalidomide = phocomelia (flipper limbs, used to decrease N) (not taken any more)
- During organogenesis 1st trimester first 12 weeks
Pregnancy and Lactation Labeling Rule
- Is what
- 3 parts of it
- Risk of taking a drug vs not in a pregnant pt
2. Describes safety of pregnancy, lactation, Female and male reproductive potential
Factor that effect how safe a drug is when taken during pregnancy
- Dose and how many a day
- Other factors that cause fetus to be susceptible
- Timing : day 17-56 post conception , organogenesis
- If combined with other agent
Most common teratogen and 2 others
- Alcohol (microcephaly, low ears, flat midface)
- Antianxiety medication (meprobamate, chlordiazepoxide) = use FLUOXETINE
- Antineoplastic (aminopterinm methotrexate)
- Anticoagulants (Coumadin) use HEPARIN or lovnox
- Anticonvulsants (Diphenyldantoin = fetal hydantoin syndrome, cardio and growth restriction)
Anticonvulsants what cause problems in pregnancies
- Valproic Acid : spina bifida, cardiac, skeletal
- Carbamazepine (spina bifida, craniofacial)
- Phenobarbital with others drugs
2 Hormones that can cause fetal problems
- Estrogen/Progesterone OCP : masculinization of female external genitalia)
- DES : cervical cancer, vaginal Cancer, testicular abnormalities, T-heaped uterus
Retinoid and preg
Avoid
50% chance abortion, cardio and cranial and CNS problems
- Tobacco
- Drugs illicit
- Infections
Can do what
- Short weight and growth
- Fetal drug dependence
- Congenital problems, growth and mental problems (bulging eyes, depressed nose, triangle mouth = CMV at 1st trimester)
Radiation effect
- Problem
- No problem
- How much
- 2 -6 weeks : problems
- Before 2 weeks : nothing or miscarriage nothing inbetween ( so if no miscarriage then all is fine)
- 5 rads of exposure = no risk
When do you have the most preg sx
100,000 hCG at 10 weeks
N, V, avoid greasy foods, small meals, salt crackers, room temp soda, zofran, phenergan, VitB6
What causes this in pregnancy:
- Heartburn
- Constipation
- Hemorrhoids
- Leg cramps
- Backache
- High P, esophageal sphincter relaxes
- Low colonic activity
- Venous P in rectum increased (elevate legs, stool softeners)
- Last half of preg, at night, massage and stretch
- Weight is central front (belts, pillow, massage, heat)
How often do you meet with preg pt
- Every 4 weeks until 28weeks
- Every 2 weeks until 36 weeks
- every week until delivery
BMI recommend weight gain + urine Protein used for
- Under 19 = 28-40lb
- 19-25 = 25-35lb
- Over 25 = 15-25lb
= urine protein test for preeclampsia
Uterus size means
Amount of cm top of fundus to pubic bone = weeks pregnant
Fetal HR heard with
- After 12 weeks = Doppler device **
2. 18-20weeks = Fetoscope
- Fetal movement felt when
2. Near term what you looks for
- Quickening, around 20 weeks
2. Fetal lies how + position (vertex, breech)
What to do at :
- 20 weeks
- 28 weeks
- 36 weeks
- 20 weeks = fetal survey US (check all things)
- 28 weeks = gestational DM, Hb and hct recheck, RH = rhogam injection if RH-, Tdp injection
- 36 weeks = screen group B strep with vaginal culture (treat AB)
How much should baby move when healthy and when
At 28 weeks baby moves 10 times in 2 hours, 9:00pm-1:00am most active)
Nonstress Test
- Used for what
- And how to do it
- Not feeling baby move
- REACTIVE = 2 accelerations of 15 or more beats above baseline for 15sec or more (in 20min)
NONREACTIVE = not 2 accelerations in 20 min
Contraction Stress Test :
1. Done when
2 how
- When Nonstress test is nonreactive
- Give oxytocin to make 3 contractions (in 10min) = nipple stimulation OR pitocin
= assess Deceleration in fetal HR (if most are late then its bad sign, move to delivery)
On graph of nonstress test how much in dark line to dark line
1 min
LAte Deceleration (late decel)
Deceleration of fetal HR in contraction stress test happens late right after contraction peak
Biophysical profile
- Is done when
- How is it done
- After nonstress test and contraction stress test done
2. 8-10 points means good, 6 = deliver if pt is at term, 4 or less = nonreassuring
Biophysical profile points come from
2 points each
- Nonstress test
- Fetal breathing (1 breath per 30sec for 30min)
- Fetal movement = 3 in 30min
- Fetal tone = 1 extr extension with return to flexion in 30min
- Amniotic fluid volume = 2cm fluid in 2 planes, with US
Best antepartum test
Contraction stress test ,then biophysical profile, then nonstress test (however still all pretty good)
