Normal pregnancy and labor Flashcards
What is the definition of pregnancy?
The state of having products of conception implanted normally or abnormally in the uterus or occasionally elsewhere
how to dx pregnancy?
- otc pregnancy test, test the beta subunit of hCG
- viable pregnancy can be confirmed w US. May show gestational sac at 5w og hCG 1500-2000. Fetal heart motion may be seen on TVS at 6w or at hCG of 5000-6000
definition of embryo
pregnancy until 8w
definition of fetus
> 8w until birth
infant
From delivery to 1y
define the trimesters
1st is up to 12w (14 GA)
2nd 12- 24 (28 GA)
3rd is 24/28 until birth
Viable infant
> 24, before is previable
preterm
24-37w
term
37-42
post term
> 42
gravidy (G)
Refers to number of times a woman has been pregnant
parity (P)
number of pregnancies that led to birth at or beyond 20w GA or >500g BW
what is the G/TPAL
- Gravida= total nr of known prgenancies regardless of outcome
- Term= nr of pregnancies that resulted in term delivery (>37w)
- Preterm= nr of pregnancies that resulted in a preterm delivery
- Abortus= nr of pregnancies that resulted in spontaneous or induced abortion
- Living= the nr of live infants born
how is the GA measured
Is the age in weeks and days measured from the last menstrual period (LMP)
what is the developmental age of the fetus (DA)
Is the conceptional age or embryonic age. The number of weeks and days since fertilization. Usually 2 weeks less than GA
what is the Nagele rule for calculating the estimated date of confinement?
Subtract 3 months from LMP and add 7 days. A pat w lmp 16/1/19 would have the EDC 23/10/19
How to calculate if known ovulation date (as in ART) ?
Add 266 days
How to determine EDC in ultrasound
Should not differ from LMP more than 1w in 1st TM ,2w in 2nd TM and 3w in 3rd TM. It is done with crown-rump length (CRL).
What clinical measures can be used to estimate EDC
- Auscultation on fetal heart rate (FH) at 20w by nonelectronic fetoscopy or at 10w by Doppler
- Maternal awareness of fetal movement “quickening” occuring at 16-20w
what are the sx of pregnancy
- Amennorhea
- N/V
- Breast tenderness/swelling
- Fetal quickening
what are the clinical signs of pregnancy
- Linea nigra at 22w
- Bluish color of vagina and cervix (Chadvix sign)
- Softening and cyanosis of cervix at 4w (Goodell sign)
- Telangiectasia
- Palmar erythema
- Softening of uterus at 6w (Ladin sign)
What are the cardiovascular changes is pregnancy?
- CO decrease increase by 30-50%. It is due to both increased stroke volume and HR
- Systemic vascular resistance decrease, resulting in fall in BP w 5-10 in systolic and 10-15 diastolic. Nadir at 24w, then slowly return to normal
- Is a high output, low resistanc state!
What are the pulmonary changes in pregnancy?
- Tidal volume increase 30-40%
- Minute ventilation increases 40%
- Residual volum decreases 20%
- PaO2 increase and PaCO2 decrease
- Oxygen consumption goes up
- Dyspnea of pregnancy occurs in 60-70% of pat
- A state of resp. alkalosis compensated by increased renal bicarbonate excretion
What are the GI changes in pregnancy?
- N/V in 70% “morning sickness”, attributed to elevation in estrogen, progesterone and hCG. May also be due to hypoglycemia
- Prolonged gastric emptying time, GES has decreased tone
- Large bowel has decreased motility, which leads to increased water absorption and constipation
What is hyperemesis gravidarum ?
Severe form of morning sickness ass w WL more than or 5% of pregnancy weight and ketosis
What is the renal changes in pregnancy?
- Kidney size increase w 100%
- Ureters dilate + urine glucose = more susceptible for UTI and pyelonephritis
- Increase in GFR by 50%
- BUN, Cr, uric acid decrease by 20%
- RAAS is activated = total body sodium increase
- Lightening makes it easier to breathe but increase urinary urgency and frequency
What are the hematologic changes in pregnancy?
- Plasma volume increase with 50%
- RBC volume increase w 20-30%
- Hematocrit decrease (dilution)
- WBC increase slightly
- plt a bit decreased (dilution)
- Pregnancy is a hypercoagulable state, elevation of fibrinogen and factors 7-10
What are the pregnant pat w hypercoagulability predisposed for?
- Placental vascular thrombosis incresing risk for:
- Incresed risk for preeclampsia
- gestational HT
- fetal complications
- 5-fold incresed risk for DVT
How is the hCG in pregnancy fluctuating?
- Peak at 10-12w
- Declining to reach a stedy state after 15w
- Acts to maintain corpus luteum to produce progesterone
What kind of hormonal state is pregnancy?
Hyperestrogenic! It is produced by placenta, derived from circulating precursors produced by maternal adrenal glands. Fetal well being is correlated w estrogen levels.
What fetal conditions are ass w low levels of estrogen
Anencephaly and fetal death
what are the alpha subunit of hCG similar to?
LH, FSH and TSH
progesterone during pregnancy
First produced by corpus luteum, then taken over by placenta. Corpus luteum progress to corpus albicans. Levels of progesterone increase over the corse of pregnancy. Cause relaxation of smooth muscle that affects GI, CV and Gu systems
What is hPL
Human placental lectogen, also called human chorionic somatomammotropin. It is important for ensuring a constant nutrient supply to the fetus. Induce lipolysis which increase circulating free fatty acids. Act as insulin antagonist having a diabetogenic effect. Leads to increased level of insulin and protein synthesis.
How is prolactin during pregnancy?
Increased markedly. Decrease after delivery, but again increase in response to suckling.
How are the thyroid hormones during pregnancy?
- Estrogen stimulate TBG, lead to elevated total T3 and T4. Free T3 and T4 remain constant
- hCG have a weak stimulating effect on thyroid (alpha = TSH). Leads to slight increase in T3 and T4 and decrease in TSH
- Pregnancy is a euthyroid state
how to tx hyperemesis gravidarum ?
frequent snacking ant antiemetics
what are the skin changes in pregnancy?
Spider angioma, hyperpigmentation of nipples, umbilicus, abd. midline, perineum and face (melasma /chloasma). Striae gravidarum. Palmar erythema.
What are the musculoskeletal changes in pregnancy?
Shift in posture, lower back strain. Ass. w carpal tunnel sd
what is the nutritional intake requirements in pregnancy
About 300kcal increased. It is 500kcal per day when breastfeeding. Increased requirement for protein, iron, folate(double) , calcium and other vitamins and minerals.
what is the recommended schedule fore prenatal visits
Every 4 w from dx until 28w. Every 2w until 36w. Every week after this.
what are the goals of prenatal care
- dx of pregnancy and estimation of GA
- identification of any potential complication
- ongoing estimation of health status of mother and baby
- anticipation of prblems and intervention
- pat education and communication
what should be included in history during first initial prenatal visit?
- LMP and sx during the pregnancy
- prior pregnancies, date, outcome, SAB, TAB, ectopic pregnancy, term delivery, mode of delivery, length of time in labor
- BW, any complications
- medical, surgical, family and social history
PE in initial prenatal visit
Pelivc exam w pap (unless one was done in past 6m), culture for gonorhea and chlamydia. On bimanual, size of uterus (if consistent w GA and LMP). If size and LMP not consistent, should be done US.
what are the diagnostic evaluation done at initial prenatal visit
CBC, blood type, antibody screen, rapid plasma reagin (RPR) or VDRL (syphillis), Rubella antibodies, hep B surface antigen, urinalysis, urinculture. If no hx of chickenpx VZV titer should be taken. PPD for TB in high risk pat. Urine hCG if not sure. Often toxoplasma. Conseling of HIV.
what is done on all routing prenatal visits
BP, weight, urine dipstick, measurement of the uterus, auscultation of FH.
At what fundal heigh should there be done an US?
If fundal height is decreasing or is 3 cm less than GA.
What sx should the pregnant women be asked about at every visit?
Vaginal bleed, vaginal discharge, leaking fluid, urinary sx. After 20w ask about fetal movements and contractions.
What may vaginal bleed be a sign of in pregnancy?
Possible miscariage, ectopic pregnancy in 1st TM. Placental abruption or placenta previa as pregnancy advances.
What may vaginal discharge be a sign of in pregnancy?
Sign of infection or cervical change. Leaking fluid can indicate ruptured fetal membranes.
What may cantractions be during third tm?
- Irregular (Braxton Hicks) are common throughout 3rd tm
- Regular contractions more than 5 or 6 per hr may be a sign of preterm labor, and should be assessed.
How should changes in fetal movement be evaluated?
Changes or ansence of fetal movement should be evaluated by auscultation of FH in the previable fetus, and further testing as a nonstress test or biophysical profile in viable fetus
What can be done at end of 1st tm (1st tm screen)
- US
- Maternal serum hCG
- AFP
- PAPP-A
What vaccines is not safte in pregnancy?
- MMR!
- Polio
- Varicella
- Yellow fever
Any live vaccine
screen in African American, Southeast Asian, MCV<70
Sickle cell prep, Hgb electrophoresis
screen in fhx of genetic disorder (e.g. hemophilia, fragile X, maternal age >35)
Prenatal genetics referral
Screen in Prior GDM, fhx of DM, Hispanic, Native American, Southeast Asian
Early GLT
Screen in Pregestational DM, unsure dates, recurrent miscarriage
Dating sonogram at first visit
Screen in HT, renal disease, pregestDM, prior preeclampsia, renal transplant, SLE
BUN, Cr, uric acid, 24hr urine collection for protein and creatinine clearance
Screen in PregestDM, prior cardiac disease, HT
ECG
Screen in pregestDM
HbA1c, ophthalmology
Screen in Graves disease
Thyroid-stimulating immunoglobulin (can cause fetal disease)
Screen in All thyroid disease
TSH, free T4
Screen in PPD+
CXR after 16wga
Screen in SLE
AntiRo, antiLa antibodies, can cause fetal complete heart block