NORMAL PREGNANCY Flashcards
PRECONCEPTION HISTORY
⦁ chronic diseases ⦁ meds known to be teratogens ⦁ reproductive hx ⦁ genetic conditions in the family ⦁ substance use ⦁ infectious diseases & vaccinations ⦁ folic acid intake & nutrition ⦁ environmental hazards & toxins ⦁ mental health & social health concerns
goals of prenatal care
- ensure birth of healthy baby with minimal risk to mom
- early, accurate estimation of gestational age
- identify if patient at risk for complications - continue risk assessment
- ongoing evaluation of health status of both mother & fetus
- patient education & communication
PRECONCEPTION INTERVENTIONS
⦁ folic acid supplements ⦁ glycemic control in women with DM ⦁ no alcohol, illicit or rx drugs ⦁ stop smoking ⦁ vaccinations up to date (live vaccines should be given 1 month or more prior to pregnancy ⦁ weight management (18 < BMI < 30) ⦁ no depression ⦁ avoid teratogens ⦁ no STIs ⦁ planned pregnancy with an early prenatal visit
antepartum care (before birth) includes
- diagnosing pregnancy & determining gestational age
- monitor pregnancy with periodic exams & appropriate screening tests
- provide patient education that addresses all aspects of pregnancy
- prepare pt & family for her management during labor, delivery & postpartum
- detect medical & psychosocial complications and institute indicated interventions
first trimester = _________ weeks
weeks 1-12
Naegele’s rule
add 7 days to LMP, then subtract 3 months = Naegele’s rule - to find out due date
ex: LMP was june 9th. 9 + 7 = june 16th - 3 months = march 16th is the due date
remember LMP = first day of last period
Usual methods to determining gestational age =
⦁ hx - use date of last menstrual period
⦁ uterine size - physical exam
⦁ ultrasound - measure “crown rump length” or biparietal diameter
what is used on ultrasound to determine gestational age
crown rump length
femur length
biparietal diameter
FIRST PRENATAL VISIT
- LOTS of info to collect/assess/review ⦁ medical hx ⦁ reproductive hx ⦁ family hx ⦁ genetic hx ⦁ nutritional hx ⦁ psychosocial hx - critical to screen for domestic violence (20% of women are physically abused when pregnant)
FACTORS THAT INCREASE THE LIKELIHOOD OF HAVING TWINS
- Factors that increase the likelihood of having twins
⦁ advancing age
⦁ increased parity (# of births)
⦁ fam hx from either parent
⦁ obese & tall women = greater chance of twins
⦁ use of fertility drugs
**Increased calories are needed for pregnant mother with multiple babies
RISKS OF MULTIPLE GESTATIONS (twins+)
- preterm birth - can lead to bed rest early in the pregnancy
- intrauterine growth retardation or unequal growth
PHYSICAL EXAM - 1ST PRENATAL VISIT
⦁ Baseline BP ⦁ Height & weight - calculate baseline BMI ⦁ general PE ⦁ pay attention to oral hygiene* ⦁ cardiac exam ⦁ DTRs** ⦁ breast exam ⦁ pelvic exam
after ______ weeks = can no longer use femur length & biparietal diameter to estimate gestational age
25
after 25 weeks, the baby’s growth is determined by genetics
what labs are done for first visit
- urine specimen for pregnancy test
- urine is checked EACH VISIT for glucose & protein
- 1st visit = both UA & urine culture are done
- CBC - to detect anemia & screen for thalassemia (iron overload)
- Rubella immunity & varicella immunity
- syphilis test
- HepBsAg - tests for chronic Hep B
other labs needed
- HIV
- Rhogam test
- lipids if indicated
- PPD if indicated
- Hbg A1C if indicated
- thyroid testing if indicated
- testing for other infections if indicated: Hep C, Zika
- 1st visit = both UA & urine________are done
culture
why is a urine culture obtained along with the UA in the 1st visit
o because asymptomatic bacteria occurs in 2-7% of pregnant women
⦁ will lead to a UTI in 30-40% if left untreated
⦁ is associated with increased risk of preterm birth, low birth weight & perinatal mortality
⦁ 2 consecutive specimens with same bacterial strain or 1 cath specimen with 1 isolated bacterial species = considered “positive” and requires treatment
⦁ need to repeat culture to know it is sterile after treatment; some repeat urine culture in each month of pregnancy
⦁ some providers choose to give suppressive therapy without pregnancy
TREATMENT OF ASYMPTOMATIC BACTERIURIA IN PREGNANT WOMEN
WHICH ABX CLASS CAN YOU NOT GIVE?
TREATMENT OF ASYMPTOMATIC BACTERIURIA IN PREGNANT WOMAN ⦁ sulfisoxazole ⦁ amoxicillin ⦁ augmentin ⦁ nitrofurantoin ⦁ cefpodoxime proxetil
which abx classes are NOT here? = FLUOROQUINOLONES - teratogenic
ACUTE CYSTITIS IN PREGNANCY
- complication in pregnancy; can lead to cystitis or pyelonephritis
- to diagnose = need UA & midstream urine culture to diagnose
- TX = Augmentin, nitrofurantoin, cephalexin.
NO FLUOROQUINOLONES! = teratogenic - can cause cartilage deformities
Rhogam given at
28 weeks
- important to know blood type if transfusions are needed
- Rh status - if mother is Rh negative = give Rhogam - whenever there is a risk of fetomaternal hemorrhage to prevent allimmunization
- if mother is Rh negative, another antibody screen is drawn at 28 weeks; if still negative, then mother is given Rhogam at 28 weeks
- if Rh negative woman is exposed to Rh positive blood from her baby, she will produce antibodies against Rh positive blood in subsequent pregnancies, causing fetal hemolytic disease (fetalis hydrops)
instances in which rhogam is given
- 28 weeks gestation
- abortion
- ectopic pregnancy
- invasive procedures
- hydatidiform mole
- fetal death in 2nd or 3rd trimester
- blunt trauma to abdomen
- antepartum hemorrhage in 2nd or 3rd trimester (placenta previa or abruption)
- external cephalic version
markers that can detect for down syndrome
⦁ hCG level
⦁ PAPP-A = pregnancy associated plasma protein
⦁ nuchal transparency (NT)
- Women found to have increased risk of aneuploidy with these tests should be offered chorionic villous sampling
chorionic villous sampling should NOT be done before _______ weeks
10
increased risk of pregnancy loss
what is chorionic villous sampling
procedurer to get fetal DNA to test for down syndrome and other abnormalities; done under ultrasound guidance through vagina or by abdominal US
- do NOT do before 10 weeks - increased risk of pregnancy loss
screening options for down syndrome
1) nuchal translucency - width of translucent space at back of fetal neck - ultrasound
2) combined test = 1st trimester; sonographic measurements, maternal serum mmts, hcg, PAPP-A, along with maternal age
3) Triple test = 2nd trimester = AFP, estriol, hcg with maternal age
4) Quadruple test = 2nd trimester = AFP, estriol, hcg and inhibin A with maternal age
5) Integrated test = combination of tests from 1st & 2nd trimester into single test
which condition is MSAFP low
down syndrome
MATERNAL SERUM ALPHA FETAL PROTEIN (MSAFP)
- can be used to detect abnormalities in fetus
⦁ neural tube defects = MSAFP is high
⦁ ***DOWN SYNDROME = MSAFP IS LOW
⦁ Anencephaly = MSAFP is high
⦁ multiple gestation = MSAFP is high
INDICATIONS FOR AMNIOCENTESIS
- prenatal genetic studies = Most common **
- assessment of fetal lung maturity
- evaluation of fetus for infection
- degree of hemolytic anemia
- evaluation of diagnosed neural tube defects
- therapeutic - to remove excess amniotic fluid
MOST COMMON INDICATION FOR AMNIOCENTESIS
PRENATAL GENETIC STUDIES
risks of amniocentesis
⦁ leakage of amniotic fluid
⦁ fetal injury (rare)
⦁ fetal loss - 1/300 - 1/500
prenatal visit schedule
every 4 weeks until 28 weeks
every 2 weeks from 28 weeks - 34/36 weeks
then weekly until delivery
what is checked at each prenatal visit
maternal weight, BP, uterine growth, urine dipstick, fetal activity & fetal HR
warning signs to educate patient about
vaginal bleeding cramping fever passing clots or tissue dizziness fainting abdominal pain
Avoid hot tubs and saunas—maternal heat exposure during the first trimester has been associated w/
neural tube defects
EDUCATION FOR 1ST TRIMESTER
- need prenatal visits every 4 weeks until 28 weeks, then every 2 weeks until 34-36 weeks, then weekly
- at each visit = maternal weight, BP, uterine growth, urine dipstick, fetal activity & fetal HR
- educate pt on how to reach provider after business hours
- WARNING SIGNS = vaginal bleeding, cramping, fever, passing clots or tissue, dizziness, fainting, or abdominal pain
- Avoid hot tubs and saunas—maternal heat exposure during the first trimester has been associated w/ neural tube defects
- avoid substance abuse - alcohol, smoking, illicit drugs, excessive caffeine
- wear seatbelt at all times
- infection precautions: influenza & toxoplasmosis (cat feces)
- exercise = moderate (30 min/day) - avoid strenuous exercise. avoid supine positions after 1st trimester
- work is ok unless lifting or prolonged standing
- sex is ok unless risk of STI or vaginal bleeding
- travel = increased risk of DVT; can fly up to 36 weeks if not high risk
- meds: acetaminophen is ok, check everything else, including herbals
- weight gain counseling = 20-25 lbs, sometimes much more
- breastfeeding
- childbirth classes / hospital facilities
- Diet = fully cook all meats/eggs. no unpasteurized dairy products or juice. can get listeria from processed deli meats. risk of methylmercury exposure from fish. Avoid high iron, vitamin A and selenium - teratogenic
- increase daily calories by 340 calories in 2nd trimester, and 450 calories in 3rd
- breastfeeding = increase calories by another 300-500 and add 1000mg Calcium
COMMON SYMPTOMS OF PREGNANCY
⦁ Headaches: common in early pregnancy**
⦁ N/V: hyperemisis gravidum <2%
⦁ Heartburn: general maneuvers, may use tums
⦁ Constipation: can try stool softeners, add bulk, drink fluids
⦁ Fatigue
⦁ Back pain: later in pregnancy
⦁ Round ligament pain: as uterus grows; sharp groin pain–reassurance
⦁ edema
⦁ hemorrhoids
⦁ increased vaginal discharge (check for infxn if changes or malodorous)
⦁ Pica = cravings for clay or dirt = associated with anemia
