Normal Pregnancy from Fertilization--> Labor: OP

Question 1

Where does fertilization actually occur?

Answer 1

Ampulla of fallopian tube

Question 2

Which phase of the oocyte cell cycle is completed after fertilization?

Answer 2

Meiosis II

Question 3

The first cute little bundle of cells that forms after fertilization is called:
Describe the time frame, post conception.

Answer 3

a morula- a mullberry shaped embryo of a dozen or so cells

Roughly around day 4 post conception.

Question 4

The morula cavitates to form a:
Describe the two components of this structure and their differing fates.
Describe the time frame, post conception.

Answer 4

Blastocyst (imagine a ball with a tumor on the inside surface)
Inner cell mass becomes fetus
Outer cell mass becomes trophoblast
Roughly around day 5 post conception, around same time the blastocyst enters the uterine cavity.

Question 5

When does implantation occur (how many days after conception)?

Answer 5

Day 8-9 post conception

Question 6

The decidualization (glycogen and lipid rich buildup of endometrium) is promoted by this hormone. The hormone is produced where?

Answer 6

Progesterone. Produced by the corpus luteum.

Question 7

What component of the blastocyst invades the decidua?

Answer 7

Trophoblastic cells

Question 8

By week 5, the Beta subunit of this hormone, produced by the trophoblastic cells, can be detected in a urinary pregnancy test to confirm pregnancy.

Answer 8

human chorionic gonadotropin (hCG)

Question 9

How do you calculate the estimated due date?

Answer 9

Count back 3 months from the last menstrual period and add 7 days.

Question 10

A fetus is considered preterm when delivered before week ____.
Postterm when delivered after week ____.
Fetus is considered viable if delivered after week ___.

Answer 10

pre-term = before 37wk
post-term = 42wk or later
Viable after 23 weeks gestation.

Question 11

An abortion is the loss of a pregnancy before _____ weeks or when the fetus is less than ____ grams.

Answer 11

20wks

?g

Question 12

Organogenesis occurs between weeks ___ and ___ of gestation.

Answer 12

2-8

Question 13

The G’s and P’s. What are they all about?

Answer 13

Example: 
G3P1011
G3- has been pregnant 3 times (including this one)
P- pregnant now*
1- 1 full-term birth*
0- No preterm births
1- 1 abortion*
1- I child living

“GPfpal”
* count towards the ‘G’

Question 14

List some symptoms that a female may experience if they are pregnant but did not suspect so until now.

Answer 14

Missed menses
N/V
Breast tenderness
Perceived fetal movement (G0 @ 18 wks, G>0 @ 16 wks)

Question 15

To Dx a pregnancy purely based off of physical examination (no hCG testing) look for:

Answer 15

::Uterus soft @ 6-7 wks gestation
::Cervix is bluish from blood engorgement
::Uterus enlarged by 7-8 wks
::Hear fetal heart tones w/ doppler @ 10 wks

Question 16

Describe the physical landmarks for uterine growth based on weeks of gestation.

Answer 16

Uterus palpable at pelvic brim @ 12 wks
Palpable at umbilicus @ 20 wks
Beyond 20 wks, 1 cm from pubic bone for every wk.

Question 17

What is the most common type of antigen-antibody rxn in pregnancy?
Is it bad when the mother is + or - for this antigen?
Describe the problem.
Describe the solution.

Answer 17

RH factor (anti-D abs)
Found on chr. 1. Autosomal dominant inheritance
Problem arises when mom is RH negative.
In 1st RH+ preg., mom will develop abs to RH factor. If she has a 2nd RH+ fetus, her anti-D IgG abs will cross the placenta and raise hell in the fetus.
Antigen-ab complexes will form on fetal RBC, distorting RBC, which will then get lysed in fetal liver, bone and spleen. Fetus will be anemic.
Tx: intrauterine transfusion can be done or baby can be delivered early.

Question 18

Around what weeks of gestation would it be appropriate to perform ultrasound to look for anatomical defects such as a malformed heart or limbs?

Answer 18

weeks 18-20

Question 19

When do we administer Rhogam and screen for diabetes (in gestational weeks)?
Describe how Rhogam works.

Answer 19

Week 28
Rhogam is a synthetic anti-D ab. Administering it to mom will act as a surrogate for her immune system, binding up all the fetal D+ (RH) RBCs, causing them to be destroyed before mom mounts an immune response that would harm the fetus more.

Question 20

36 weeks is a benchmark to retest for these:

Answer 20

STIs. CDC recommends testing in high risk communities

Culture for Group B strep. Group B strep kills babies born healthy.

Question 21

Signs of labor?

Answer 21

Contractions
Ruptured membranes
Bleeding

Question 22

Describe the phases of labor.

Answer 22

Latent:
From not in labor to 4 cm dilation of cervix.
When contractions become regular, painful and cervical dilation picks up.
May be 18 hrs in a primigravada; may be very rapid in multigravada.

Active:
From this moment (4-5cm dilated), to delivery of infant.
Should progress 0.8cm/hr in primigravada; 1.3cm/hr in multigravada.

Question 23

Describe the 3 stages of the active phase of labor and delivery.

Answer 23

Stage 1: From 4cm to completely dilated
Stage 2: From completely dilated to delivery of baby
Stage 3: From delivery of baby to delivery of placenta

Question 24

Briefly describe the cardinal movements of delivery that a baby goes through.

Answer 24

1) head floating before engagement (nothing is happening)
2) engagement; flexion, descent (chin to chest, pushes down to efface and dilate cervix)
3) Further descent, internal rotation (baby’s chest faces laterally, head is rotating to face posteriorly)
4) Complete rotation, beginning extension (baby faces posteriorly with chest lateral, beginning to extend head as if to look up)
5) Complete extension
6) External rotation (baby faces same direction as chest, laterally) head has breached mother’s external vaginal opening
::Then one shoulder is delivered at a time

Question 25

Ms. L is concerned about excessive alcohol use over NYE. The first day of her LMP was Dec 6. When is her due date? What is your advice?

Answer 25

EDD is Sept 13th.
She should be reassured. The embryo was likely just at an implantations stage where a teratogen would have no affect on organdevelopment. Organogenesis occurs between weeks 2-8 (4-10 wks since LMP). The exception to the rule is Accutane, a fat soluble acne (Vit. A) drug that is stored in blood and is released slowly over time.

Question 26

Ms. F presents with vag. spotting. The first day of her LMP was 5 wks ago. hCG level is 938 mlu. Transvag. ultrasound shows no gestational sac.
Can you tell if she is pregnant?

Answer 26

She is too early. You may not see fetus even within TVU window (3-4wks). Go by your objective evidence (hCG 1000mlu-2000mlu).

Question 27

Ms. J is a 28 y/o G3P1011 at 16 wks for a new OB visit. Her blood type is O-. The ab screen is pos.; anti-D with a titer of 1:4 (low titer). Your next step?
She recalls receiving Rhogam with her previous baby.

Answer 27

This is a new partner. If he is RH-, there is nothing to be concerned about.

titer is of Anti-D in mom’s blood
Titer explained: The greater the ratio, the greater the immune response, because if you have diluted mom’s blood 1:256 and you’re still picking up anti-D in the titer, then she is REALLY mounting an immune response and the baby is fooked.
A 1:4 titer is not very strong. 1:32 is a cause for concern (8-fold increase).

Question 28

(prev. question continued) Ms. J’s new partner is RH+ on his blood donation card. The pt is now 17 weeks. What is the next step?

Answer 28

Repeat the titer in one month. If it is 1:32 or greater, the fetus may be at risk.

Question 29

(Prev. question continued) The titer is repeated at 20 weeks, but is stable. At 28 weeks, it is found to be 1:64. The next step?

Answer 29

The mom’s immune system is having an amnestic response and is recognizing the fetus as foreign. Ultrasound and fetal cord blood sampling is indicated.

titer needs to go up 8-fold for your to be concerned

Question 30

Ms. K is found to be Hep. B surface antigen pos. on third trimester labs. She was not tested earlier. What is the next step?

Answer 30

This will be an issue to discuss with the neonatal team. The baby will get immunoglobulin at birth. It will also be vaccinated early.

Question 31

Ms. O presents in early labor at term. She has bot been to the clinic for the past 6 months. Her initial labs, including HIV, were negative. What is the appropriate next step?

Answer 31

Rapid HIV is drawn and if pos., AZT is begun.

remember, we want to routinely screen for STIs at 36 weeks pt doesn’t always comply.

Question 32

(Prev. question) Pt. is HIV pos. The pt is informed; however, she does not believe it and refuses AZT intrapartum. Your next step?

Answer 32

If after discussion about benefit to the baby with the pt, she still refuses AZT, the pt’s wishes are respected.