normal pregnancy: antepartum care Flashcards
what is preconception care
care to reduce the risk of adverse effects for the woman, fetus, neonate, and optimizing health
everyone considering pregnancy should get an appointment to go over risk assessment, health promotion, medical intervention, and stress reduction
however 50 % of pregnancies are unplanned
starting folic acid supplementaiton at leadt 1 month before concception reduces incidence of?
neural tube defects like spina bifida and anecephaly
if there is no history of neurl tube defects how much folic acid should be give 1 month before conception
0.4 mg
if someone has a history of a birth with a neural tube defect how much folic acid should we give them?
4.0mg of folic acid
adequate _ control in a pt before conception and throughout pregnancy can decrease maternal morbitiy, SABs, fetal malformations, fetal macrosomia and intrauterine fetal demiase
glucose
gravidity
number of times a women has been pregnant
parity
number of pregnancies that led to a birth at or beyond 20 weeks or an infant weighing more than 500 grams
parity can be broken down into ?
FPAL
full term (37-42)
perterm (20-36)
abortions (includes pregnancy loses before 20 weeks, ectopic, spontaeous, elective)
Living
the first prenatal visit should consist of?
thorough history
medical history, reproductive history, family history, nutritional status, social history (drinking, smoking), and psychosocial issues (depression/anxiety)
physical exam
Labs
what physcial exam findings are normally associated with pregnancy
systolic murmurs, exaggerated splitting and s3
palmar erythema
spider angiomas
linea nigra- belly button line
striae gravidarum- stretch marks
chadwicks sign (bluish hue to the cervix)
what labs should be done at the 1st prenantal visit
CBC, Type and screen (RH), rubella, syphyllis, hepatitis B, HIV, cervical cytology and STD (chlamydia and gonorrhea), screen for obesity, urine culutre
Rh negative patients recieve _ at 28 weeks and anytime sensitization may occur (threatned abortion, amniocentesis, abdominal trauma)
rhogam
if a pregnant patient isnt immune to rubella when should you give the vaccine?
postpartum
how would you screen diabetes based on risk factors in a pregnant patient
obesity, previous history of gestational diabetes, previous macrosomia (over 4,500 grams)
what is a lab that increases in pregnancy
fibrinogen (it is a hypercoaulable state), protein, amylase, leukocyte count, factor 7-10
typically everything else decreases or stays the same
how do platelets, hematocrit, and hemoglobin change in pregnancy
they decrease: physiological anemia
during a first prenantal visit you must also confirm _ and _ of the baby
pregnancy and viability
gestational age and due date is taken at the first prenantal visit what is gestational age?
the number of weeks that have elapsed between the first day of the last menstural period and the date of delivery
what are some additional things you should be doing at a virst prenatal visit?
provide genetic counseling
discuss teratology medications
advice onmanaging early pregnancy symptoms like nausea
how do you confirm pregnancy and viability
pregnancy test to detect hCG in the blood of urine
hCG can be first detected in the serum when?
6-8 days after ovulation
hcg less than _ is negative
5
hcg level above _ is considered posititve
25
a level of HCG about _ is reached by the time of expected menses
100
most urine tests can detect hCG at about _
25
in the first 30 days of a normal pregnancy HCG _ every _ days (this is used to evaluate for eary intrauterine pregnancy vs ectopic)
doubles
every 2.2 days
a transvaginal ultrasound can also be used to confirm pregnancy and viability:
the gestational sac is seen around _
the fetal pole is seen at _
cardiac activity is seen at _
give corresponding HCG levels
gestational sac at 5 weeks : hcg around 1500
fetal pole at 6 weeks: hcg at 5200
cardiac activity at 7 weeks: hcg at 17,500
how can you determine the due date based on naegels rule
the last menstrual period minus 3 months + 7 days = expected date of delivery
only helpul if patient has regular 28 day cycles
how can you use physcial examination to determine the gestational age
size of uterus : halway uterus is at the umbilicus (22 weeks)
how can you use ultrasound to determine the gestational age/ due date
crown rump length between 6-11 weeks and can determine due date within 7 days
femus length/biparietal diameter/abdominal circumference at 12-20 weeks and can determine due date within 10 days
third trimester due date can be off by 3 weeks
what is used for gestational age in first trimester
2nd trimester?
crown rump length-1st
snd- bipariteal diameter, femur lenght, abdominal circumference
who needs genetic counseling during pregnancy?
a lot of reasons
- advanced maternal age
- previous child/history of birth defects or genetic disorders
- previous child with undiagnosed mental retardation
- previous baby who dies in neonatal period
- multiple fetal losses
- abnormal serum marker screening
- consanguitity (sex with family)
- maternal conditions
- exposure to teratogens
- abnormal ultrasound findings
- partent who is a known carrier of a genetic disorder
chromosomal disorders occur in .5 live births what is the most common sex chromosomal abnormality, what is the most common trisomy?
turners syndrome: chromsome anueploidy
downs syndrome: trisomy
chromosomal disorders have a 50% rate for sponatneous aboritons: women that are _ years of older are at an increased risk for _ or _
35 years or older
trisomies (13,18,21) or sec chromsome abnormalities
the single most common reason for spontaneous miscarriages is
chromosomal abnormalities- turner syndrome
what class is the most responsible for sponatneous micsarriages
trisomy 16
as _ increases there is a higher risk for spontaneous miscarriages
age
what is down syndrome? what is it caused by?
extra copy of chromsome 21 (long arm) - most is from meiotic nondisjunction leading to 47 chromsomes
4% are unbalanced translocations
characterisitcs: flattned nose and face, single palmar crease, wide space between first toe
what are the chances that a couple who previously has a child with downs dynsrome will have another child with down syndrome
about 1% chance
about 1 in 500 people carry a balanced structural chromosomal rearrangement like a translocation or inversion, chromosomal studies (karyotype) should be done on couples after _ or more spontaneous abortions
3 or more spontaenous abortions
baalanced translocations couples should recieve _ regarding possibility of having a child with an _ translocation and therefore be offered a prenatal diagnosis ( diagnosis through chorionic villous sampling or amniocentesis)
counseling
unbalanced
autosomal dominant disorders is when there is _ abnormal gene to manifest disease and the affected indivudal has _ percent chance of passing on the disorder to their offspring.
is this influence by gender?
one abnormal gene
50%
no not influenced by gender
examples of autosomal dominante disorders
tuberous sclerosis, musclar dystrophy
in autosomal recessive disorders _ genes must be present for manifestations of diease, there is usually no _ _, and consanguineous couples are at increased risk for homozygous recessive gene.
examples:
2
family history
tay-sachs, sickle cell disorders, thalasemias, cystic fibrosis
genetic screening for autosomal receissive disorders have a carrier screening program that focuses on _ _ populations
this is because the frequency of heretozygotes is greater than that of the general population
high risk populations
*tay sachs- higher in eastern european jewish population
_ _ is the most common gene carried in north american whites
cystic fibrosis
genetic counseling for _ screening is important becuase 15 % of carriers are undetected
CF
who should be offerend CF screening
all pregnant women, people with a family history of CF, partners of known CF carriers, ultrasound findings of echogenic bowel, any patient requesting screening
sex linked disorders are caused by _ genes located on the X chromsome, they primarily affect _ , and unaffected females carry the _. There is not _ to _ transmission of X linked recessive disorders.
recessive
males
gene
male to male transmission
what are some examples of recessive x linked disorders
duchenne muscular dystrophy and fragile X syndrome
what is the most common form of inherited mental retardation
fragile X syndrome
many sex linked disorders can be diagnosed prenatally via _ or _
chronionic villus sampling or amniocentesis
features of fragile X syndrome
-male
-broad forehead
-elongated face
-large prominent ears
-strabismus
-MVP
-flat feet
-mental retardation
many birth defects are inherited _
multifactorally
genetic + environment
multifactorial birth defects examples
cleft lip, congenital heart defects, Neural tube defects
mutlifactorial disorders have a _ percent recurrence rate
3%
NTD examples
spina bifida, anencephaly
what are the first semester screening tools for fetal aneuploidy
maternal age (not at an increased risk so younger than 35)
fetal nuchal translucency (NT) which measures the echo area at the back of the fetal neck)
maternal HCG- bhCG
pregnancy associated plasma protein A (PAPP-A)
what are the second trimester screening for fetal aneuploidy
triple screen-b-hCG, maternal serum alpha fetoprotein (AFP) , estriol
quadruple screen- bhCG, estriol, AFP , inhibin A-
what does maternal AFP test for?
neural tube defects
what is cell -free fetal DNA
this is a way to check for fetal anueploidy, chromsomal abnormalities but NOT Neural tube defects (used by AFP in the second trimester)
tests cells free fetal DNA from apoptosis of trobphoblastic cells that are int the maternal circulation
replacing amniocentesis
cell free fetal DNA is ordered in who?
high risk patients (like older age, prior history of trisomy, family chromosomal abnormalities, fetal ultrasound abnormaliites-nuchal translucency) abnormal serum testing in first trimester or triple/quad screen)
if a cell free fetal DNA is positive you can proceed with what for diagnosis
this is just a screening tool
amniocentesis (2nd trimester)
chorionic villi sampling (11 weeks)
amniocentesis can be done at _ weeks and has a _ % miscarriage rate
16-20 weeks
.03% miscarriage rate
chorionic villi sampling can be preformed at _ weeks and has a _ % miscarriage rate
11 weeks
1%
what is a teratogen, what can it cause?
what is the most important histoical teratogen and what does it specifically cause
a teratogen is any agent or factor that can cause abnormalities of form or function in a fetus (fetal loss, growth restriction, malformations, abnomral CNS)
thalidomide can cause phocomelia (flipper like limbs)
thalidomide was used for nausea
40% of women take medication during the first timester when _ occurs
organogenesis
what is the pregnancy lactaction labeling rule (PLLR)
changed from the letter categories , changed the content and format for information presented in prescription drug labeling to assist health care providers in figuring out the risk vs. benefit of medications in pregnant women and nursing mothers
what are the subsections of the pregnancy and lactation labeling rule
pregnancy
lactation
females and males of reproductive potential
what are the princples of teratology (4)
fetal susceptibility- efficacy of the teratogen is dependent on the genetic makeup of mother and fetus and maternal-fetal environment (multifactorial)
dose- drug can be dose dependent (low dose- no effect, intermediate dose- organ malformation, high dose-spontaneous abortion
timing- most vulnerable during 17-56 days which is organogensis , which organ systems are affected
nature of teratogenic agent- can cause malformations by itself or with another agent. (how potent the agent is)
from the fourth month to the end of gestations teratogens can affect _ size (not malformation)
organ
what is the most common teratogen
alcohol- causes fetal alcohol syndrome
dose dependent
what are the outcomes of fetal alcohol syndrome
growth restriction
facial abnormalities (low set ears, thin upper lip, underdeveloped jaw, short nose)
CNS dysfunction (microcephaly, mental retardation)
what two antineoplastic durgs are teratogens and inhibit folate.
exposure to these before 40 days is _ to the embryo
later exposure causes IUGR, craniofacial abnormalities, and mental retardation
aminopterin and methotrexate
lethal to the embryo
_ is the drug of choice in pregnancy for anxiety and depression
fluoxetine
what anticoagulant do we use in pregnancy? why?
heparin
it does not cross the placenta
anticonvulsants in pregnancy can cause what in pregnancy
example: diphenyhydantoid (dilantin)
considered a teratogen
fetal hydantoin syndrome
what is fetal hydantoin syndrome ?
craniofacial abnormalities, limb reduction defects, pre-natal growth restrictions, mental deficinecy, cardiovascular anomalies
caused by dilantin (diphenylhydantoin)
anticonvulsants like _ and _ can cause open spina bifida
valproic acids and carbemazepine
what is the most common major congenital anomaly (birth defect)
2nd?
cardiac abnormalities
neural tube defects/spina bifida
what is the possible abnormality associated with using higly androgenic progestin (combination birth control) during pregnancy
masculinization of female external genitalia
diethylstilbesterol used to be used to treat _ but it causes what?
threatned abortions
can cause cervical abnormalities, uterine malformations, female offspring at greater risk for vaginal cell cancers, male offspring more at risk for testicular abnormalities
t shaped uterus
are retinoids a teratogen?
yes they can cause central nervous sytem malformations, cardiovascular issues, and craniofacial defects
the risk of spontaneous abortion or congential malformations is 50% in women who take retinoids in their first trimester
is tobacco smoke a teratogen?
yes it interferes with fetal growt and increased risk for spontenaous abotion, fetla death, and prematurity
opiate exposed fetus may experience ?
withdrawl symptoms
(fetal drug exposure to illicit drugs is often unrecognized because there are no overt symptoms of strutrual abnormalities following birth)
what infectious agents are teratogenic
some viruses, bacteria, parasites which can cause congenital malformations
CMV
how does a baby exposed to CMV present
proptosis of the eye, depressed nasal bridge, and triagnular mouth
radiation can cause teratogenicity/malformations in the fetus but it is usually dose dependent. what is the rule of thumb for radiation and risk to the baby
less than 5 rads of exposure is equal to no risk for teratogenicity
how to treat Nausea and vomiting in pregnancy
related the HCG levels which peak in the first trimester
east small but frequent meals
avoid greasy foods
room temperature soda
accupunture
medications- antihistamines, vitamin b6, antiemetics (zofran, phenegren)
heart burn in pregnancy is due to?
relaxation of the esophageal spinchter by progesterone
lower eshopageal sphincter cant collapse
how to treat heartburn in pregnancy
do not lie doen after eating
elevate head of bead
eat smaller but frequent neaks
antacids
cimetidine or famotidine
constipation in pregnancy is due to ?
decreased colonic activity
how to treat constipation in pregnancy
increase water, increase fiber, fruits, veggies
stool softener
hemorroids in pregnancy are caused by ? how do you treat
increase in venous pressure in the rectum
rest, stool softeners, sitz baths, elevate lgs, avoid constipation
leg cramps in pregnancy are most frequent in _ (body part) how do you treat
calves
massage/stretching
_ is common expecially in late pregnancy so we try to acoid excess weight gain, give comfortable shoes, use pregnancy pillows, and use stretching to help
backaches
frequency of prenantal offcie visits after first pregnancy visit (pap smear, dating, CBC, history physical etc. )
every 4 weeks until 28 weeks
ebery 2 weeks from 28 to 36 weeks
weekly after 36 weeks until delivery
what occurs at routine office visits?
- blood pressure (checking for gestational HTN)
- weight
- urine protein (looking for pre-eclampsia)
- uterine size measurement
- fetal heart rate
- fetal kick count
- educate on preterm/term labors
- discuss lifestyle situations
20 weeks the uterine size is at the _
umbilicus
20cm=20 weeks pregnant
fetal heart rate is determied by ?
@ 12 weeks
@18-20 weeks
12 weeks: doppler
18 weeks: fetoscope
average weight of a baby
7.6 oz
the first sensation of movement is known as quickening and occurs on average _ weeks
feeling baby kick
20 weeks
near term you want to evaluate what two things?
fetal lie (longitudinal, oblique, transverse)
fetal position (vertex, breech)
20 weeks you should obtain a fetal _ _
survey ultrasound
easiest time to see all little structures
at 28 weeks you screen everyone for _ and repeat _ and _ , give rhogram injection to Rh _ patients and give them the _ shot
gestational diabets
hematocrit and hemoglobin
negative
TDAP
at 36 weeks you screen for?
group B strep carrier with vaginal and rectal culute
tdap is given in pregnancy between what weeks
27-36
how do we assess fetal well being
with kick count, nonstress test, contraction test, biophysical profile
what is a positive kick count
10 movements in 2 hours
what is a positive nonstress test?
reactive: 2 accelerations of at least 15 beats per baseline lasting at least 15 seconds during 20 minutes of monitoring
if the nonstress test (NST) is nonreactive you must do further evaluation with either a _ test or a _ profile
contraction stress test
biophyscial profile
what is a contraction stress test
giving oxytocin or nipple stimulation to establish 3 contractions in a 10 minute period
in a contraction stress test if late decelerations are noted with the majority of contractions then the test is _ and delivery is warranted
positive
concering
what are the components of a biophysical profile (5 things)
nonstress test
fetal breathing
fetal movement
fetal tone
amniotic fluid volume
30 minute test with ultrasound !!! ( nonstess is 20 mins, contraction stress is 10 mins)
what is a reassuring score in a biophysical profile
-equivocal
- no reassuring
8-10 is reassuring
6- equivocal (may deliver if at term)
4 or less- nonreassuring (consider delivery)
what is fetal breathing movements on biophyscial profile looking for
one or more episodes of rhythmic breathing movements for 30 seconds
what is fetal movement in a biophysical profile looking for
three or more body movments or limb movement in 30 mins
what is fetal tone looking for in a biophysical profile
one or morefetal extremity extension with return to flexion or opening and closing of hand in 30 minutes
what is amniotic fluid volume looking for in biophysical profile
a pocket of amniotic fluid that measures at least 2 cm in two planes perpendicular to each other
what are the rates of still births with good antepartum testing
reactive stress test- 1.9/1000
negative contraction stress test- .3/1000
reassuring biophysical profile - .8/1000
