ob Flashcards
HCG
when should it double?
what should it be at 5 and 6 weeks?
human chorionic gonatropic hormone
doubles every 2 days
at 5 weeks 1500
at 6 weeks 5200
when to check GDM test
with what tests?
24-28 weeks
GCT - glucose challange test 50g 1 hour glucose test
reservoir of GBS, where to swab?
GI tract, PV and anus
warning signs of preeclampsia
No 2nd trimester fall in BP Excessive weight gain (>1kg/week) Finger/Facial Edema Headaches not resolved with Acetominophen Scotoma (flashes of light) Blurred vision/visual disturbances Nausea, vomiting, abd pain
Mastitis
aka? 2
- inflammatory condition of the breast or breast tissue
- most common problems who are breastfeeding
- lactational mastitis
- puerperal mastitis
when mastitis usually occur?
ss?
- most common in first 2 to 6 weeks post-partum
- localized, painful inflammation, conjunction with ‘flu-like’ symptoms (e.g., fever, malaise).
- unilateral breast tenderness and erythema, accompanied by a fever of 101°F (38.5° C), malaise, fatigue, body aches, and headache
can mastitis increase the risk of transmission of HIV through breastfeeding?
complication of mastitis?
yes
- lead to a breast abscess
cause of mastitis? 2
pathogen?
rare causes? 4
prevention?
primary is milk stasis and infection
- Staphylococcus aureus
rare : Trauma A short frenulum (tongue-tie) Use of a pacifer or bottle Tight clothing
- BF, HE, efficient removal of milk
social economical status effect mastitis?
full-time work outside the home, associated with an increased incidence of mastitis
caused by long intervals between the breastfeeds and lack of time for adequate milk expression
flu in a lactating mother is ….
common site for mastitis ?
mastitis unless proven otherwise
- upper, outer quadrant of the breast is the most
tx for mastitis?
allergy to pen?
SE of these meds?
others?
Kflex - Cephalexin (500 mg po QID for 7-14 days (safe in pregnancy)
beta-lactam hypersensitivity, Clindamycin (300 to 450 mg PO TID)
SE - gastrointestinal disturbances (e.g., nausea and diarrhea).
NSAIDS - reduce inflam
when to f/u with mastitis
48 to 72 hours, evaluation with ultrasound imaging to determine if there is an underlying abscess should be pursued.
is it safe to continue to breastfeed from the affected side?
yes - important to empty the affected breast to prevent milk stasis and progression of the inflammation and infection and relapse.
PMS
PMDD
onset?
Premenstrual syndrome (pms) premenstrual dysphoric disorder (pmdd) - severe form of PMS with symptoms that interfere with some aspect of a woman’s life (family, social interactions and work).
Refers to a group of physical and behavioral symptoms that occur in a cyclic pattern.
Onset is during the second half of the menstrual cycle (luteal phase- day 14) and resolves within a few days of onset of menses.
cause of pms?
General agreement that symptoms are a result of cyclic changes in ovarian gonadal steroids (estrogen, progesterone) and central neurotransmitters.
can np manage PMDD?
PMDD is not listed under the CRNBC NP competencies. Anyone suspected of having PMDD would be referred to psychiatry!
tx of pmdd? prevent?
SSRI like fluoxetine (Prozac) & sertraline (Zoloft)
SNRI
oral contraception
prevent - exercise beneficial in general and should be recommended
To diagnose PMDD, the following must be established:
a) Symptoms must interfere with social, occupational, sexual, or school function.
b) Symptoms need to meet DSM V diagnostic criteria.
c) The symptoms must not be an exacerbation of an underlying depressive, anxiety, or personality disorder.
Which CRNBC codes?
Post partum depression Hyperemesis gravidarum Gestational hypertension Gestational diabetes Placenta Previa)
D - Post partum depression D - Hyperemesis gravidarum C - Gestational hypertension C - Gestational diabetes (C – Placenta Previa)
NP manage what types of pregnancies? 2
LOW RISK, singleton pregnancies
when to refer even if healthy?
or if not comfortable?
no CRNBC guidelines, but 28 wks
- If not comfortable with prenatal (PN) care refer to PN clinics around 8-12 wks
GTPAL
know criterial for P
G= the number of pregnancies (gravida) T= the number of term deliveries (after 37 weeks)
P= the number of premature deliveries (> 20 and < 37 wk)
(P can also mean para or how many children have been delivered after 20 weeks)
A= the number of abortions (either spontaneous or therapeutic) L= the number of living children
1st, 2nd 3rd trimester
First trimester: 0 - 13+6 weeks
Second trimester: 14 - 27+6 weeks
Third trimester: 28+0 – remainder of pregnancy (41+3)
at what weeks does stillborn doubles
so when to induce
when to induce at age 40
> 42
41+3
40
when for Dating Ultrasound?
first trimester between 7+0 - 13+6
Naegele’s Rule:
adding one year, subtracting three months, and adding seven days to the first day of a woman’s LMP
why use folic acid?
how much?
- to reduce incidence of Neural Tube Defects (NTD) by 70% (ie. Spina bifida)
- Folic Acid 1mg PO OD x 3 months prior
- increase 4mg OD if malabsorption issues, hx of NTDs, anti-seizure medications, poor diet (EtOHism), DM
What vaccinations needed to know in pregnancy?
which one are live vaccines and cant be given in pregnancy?
when given live vaccines, when is safe to get preggers?
MMR Varicella are live vaccines
Hep titre
- wait x 4 weeks after vaccination prior to conception
most teratogenic virus known to humans?
when is it most virulent?
Classic Triad:
Rubella
if contracted in 1st trimester
deafness, retinopathy/cataracts, congenital heart disease (PDA 50%)
Average cycle is?
Ovulation occurs around?
Follicular phase is variable; luteal phase is?
- 28 days (+/- 7 days)
- Day 14 based on 28 day cycle
- constant at 14 days length
Sperm can live?
Female egg (ovum) lives for how long after ovulation?
- 3-5 days
- 12-24hrs
positive pregnancy test.
Inform her she has 3 choices…
Continue pregnancy
Termination
Adoption
prenatal visits as per weeks?
1st and 2nd Trimester
Q 4 weeks from conception– 28 weeks
3rd Trimester
Q2 weeks from 28 – 35 weeks
Q1 week from 35 weeks - term
At first Prenatal visit order? 11
If high risk consider? 5
CBC, Fe, Urine culture, HbSAg, HIV, Rubella IgG, Varicella IgG, RPR, Blood Type and Screen, TSH, Dating US between 7-13+6 weeks ideally (or anytime if an ultrasound has not been performed)
high risk:
HCV, Vit B12, Random blood sugar
Toxoplasmosis titres (if has cat) - more serious in 3rd T
Consider Parovirus B19 (5th Disease) if around/works around many children, ie. Preschool teacher, etc.
Second Visit, do what?
CPX/PAP if due
PAP, GC/CT swab, +/- vaginal culture for BV/Trich/Yeast if symptomatic (or previous PTL)
If PAP UTD, can order urine GC/CT (NAAT testing)
what does dating U/S look at? 5
how many mm = 7 weeks?
- Crown Rump Length (CRL) = SIZE corresponding to weeks Ie., 10mm = 7+0
- Location (intrauterine)
- Number of gestations
- Heartbeat if seen
- Yolk sac/placenta
what does genetic screening estimates?
what conditions 3?
a woman’s RISK RATIO of having a baby with the following 3 conditions:
Down Syndrome (Trisomy 21)
Open spina bifida (NTD)
Trisomy 18
what happens if positive SIPS?
what confirms diagnosis of genetic problems? 2
POSITIVE… refer to Maternal Fetal Medicine where counseling regarding NIPT and amniocentesis is then offered for diagnosis
NIPT and amniocentesis
what can detailed US show? and when is it?
Detailed US at 19-21 weeks can also detect “soft markers”
what does soft markers means? common condition?
Choroid Plexus cysts (CPCs) : Small cyst(s) found in the choroid plexus (an area of the brain that produces fluid). When seen alone, there is a small increased risk for Trisomy 18. There is no association with abnormal brain development.
Echogenic intracardiac focus:
A bright spot in the fetal heart. When seen alone, it is associated with an increased risk for Down syndrome. It has not been associated with congenital heart disease
Pyelectasis:
A dilation of fetal renal pelvis measuring 5-10mm. When seen alone, it does not significantly increase the risk for Down syndrome. An ultrasound of the baby’s kidneys should be performed after birth. If the measurement is >10mm (hydronephrosis), referral to MFM/Medical Genetics is recommended.
Nuchal thickening:
Increased thickness of the skin at the back of the fetal neck. Associated with an increased risk for Down syndrome.
Short femur:
A short femur length (thigh bone) in relation to the size of the fetus. Increases the risk for Down syndrome.
Echogenic bowel:
A bright spot in the fetal bowel (intestine). Associated with an increase in the risk for aneuploidy. Also associated with an increased risk for fetal infection, cystic fibrosis and obstetrical complications. Further testing is recommended.
Single Umbilical Artery (2VC):
The absence of one of the arteries in the umbilical cord. The risk of aneuploidy (abnormal number of chromosomes) is not significantly increased. It has been associated with reduced fetal growth, and therefore a third-trimester ultrasound is recommended.
As with maternal serum screening, soft markers are NOT diagnostic. They are NOT structural abnormalities in the fetus.
Cord usually has 2 uterine arteries and 1 vein carrying
types of test for age rage
SIPS IPS Amnio NT NIPT
SIPS for all women <35 years, can just have quad screen as well.
IPS is for women >35 year, but <40 years with singleton pregnancy. (SIPS with NT)
Amnio for women over 40 years and for twins or known genetic anomalies in previous pregnancies. @ 15 weeks
Consider availability of NT when counselling.
NIPT - 9 weeks, fetal DNA - FREE with those with a +ve SIPS/IPS test
when is SIPS done? 2
1st SIPS: 9-13+6 weeks (ideal around 11 wks)
PAPPA –A (low levels associated with Down’s Syndrome)
2nd SIPS: 15-20+6 (ideal around 16wks)
Integrated Prenatal Screening (IPS)
NT?
SIPS+NT: >35 years
Nuchal Translucency – measuring skin fold thickness at the back of the fetus’ neck (<6mm, preferably 3mm is reassuring) and also initial views of heart structures
who is eligible for IPS? 5
a) Women ⩾ 35 years old at expected date of delivery (EDD);
b) Women with twin pregnancies;
c) Women who have a history of a previous child or fetus with Trisomy 21, 18 or 13
d) Women who are HIV positive; and
e) Women pregnant following in vitro fertilization with intracytoplasmic sperm injection (IVF with ICSI).
diff with IVF and ICSI - which has greater risk?
IVF - natural fertilization in outside of body
ICSI - artificially injecting sperm into egg outside of body
In IVF the zygote has less chances of carrying genetic disorder, while in ICSI chances of chromosome disorder are greater.
Weeks <12-16:
Review labs, discuss SIPS/IPS
Manage side effects
Dating US results for EDD (if done)
FHT doppler auscultated at 12 weeks
10 weeks if lean BMI
14 weeks if higher BMI
Weeks 16-20:
Review genetic screening results (if +ve, refer to MFM for NIPT/amnio consultation if pt so desires)
Detailed US at 19-21 weeks
order around 16 weeks since can take 4-6 weeks for US appt!
gender requests: it is now every pts right in BC to be told gender if detected
Weeks 24-28:
2hr GTT: Gestational Diabetes Screen, Hb/Fe (screen earlier for GDM if +ve history in previous pregnancy or if PCOS history or strong Fhx)
Rhogam if Rh negative at 28 weeks, earlier if bleeding occurs (Rhogam lasts 12 weeks)
Monitor for growth
after 28, refer to ob or physcian
Weeks 28-32:
Discuss intrapartum care provider (often a time to transfer care to delivering physician, if not sooner)
Monitor for growth and fetal movement
Discuss Prenatal classes; birthing plan
Weeks 35-37:
GBS swab
Prophylactic treatment of herpes if recurrent infections
Re-test for STI if infection during pregnancy or high risk
Urine culture if +ve UTI in previous trimesters
Monitor for growth, movement and position (breech vs cephalic?)
Weeks 36-40:
Monitor position/size of baby, U/S if needed, forward copy of prenatal records to intended hospital of birth weekly, cervical exam at 40 weeks
40+ weeks:
Book IOL and weekly NSTs (maximum gestation: 41+3)
1st T - 4 stages
what stimulates progesterone, and purpose?
From 0-13+6 weeks Zygote after conception occurs Blastocyst after 4 days/ implants to uterine wall day 5-7 Embryo until 10 weeks Fetus at 10 weeks until birth
Period of critical embryonic to fetal development, those most influenced by teratogens
hCG is now produced which in turn stimulates progesterone to maintain uterine lining and initiate the start of the placenta
Diclectin
safe SSRI for preggers?
Pyridoxine (Vit B6) 10mg and Doxylamine Succinate 10mg (antihistamine)
Fluoxetine (Prozac) also Celexa - citalopram
what else does progesterone do?
slows down gut - constipation, dyspepsia GERD
increased circulatory volume, hormones (progesterone is vasodilatory) - causes HA
why urine frequency in preggers?
relaxin hormone
max for tylenol in preggers?
what meds contraindicated?
Tylenol (max 3gms a day)
Ibuprofen contraindicated in 3rd trimester – preferred no use at all in pregnancy but if severe HA can use until 28 weeks with Tylenol - decrease prostaglandin, prostaglandin helps ductus arteriosis patent - crosses the placenta.
prostaglandin = vaso constriction - also produces cramps
ASA - cause premature brain bleeds, cardiac premature shunt closures
when to refer
REFER if concerned pathology present +ve neurological s/s
NPs don’t manage any pregnancy with neurological history
total weight gain, according to BMI?
Calorie requirements ?
Total: 25-35 lbs (10 to 14kg ),
less if higher BMI (>27), more if lower BMI (<20) or multiples, may be up to 50+ lbs
150 kcal per day in the first two trimesters
by 300 kcal per day in the third trimester
Pica? link to what?
craving and eating non-food substances
Can cause deficiencies/toxicities
May be linked to iron deficiency
Target to Fe levels
> 50- take separately of PNV, can take with OJ
Not Anemic: 30 mg elemental iron/day (usual dose given in prenatal vitamins)
Anemic: 90mg PO elemental iron given BID (150 mg Ferrous sulfate, 300 mg Ferrous gluconate, 100 mg Ferrous fumarate)
Vitamin A
how much needed?
what happens if high levels?
essential for the normal functioning of the retina and for growth and differentiation of epithelial tissue as well as necessary in embryonic development, reproduction and bone growth
Recommended Dose – limiting vitamin A in prenatal vitamins to 5000-8000 IU
*** High levels of Vit A or retinoids are TERATOGENIC
First fetal movements “quickening” when?
usually 18-22 weeks, earlier in multips
UTI - tested when?
tx with what
do what after?
12- 16 weeks -
E-coli gram –ve most common uropathogen (85%)
If +ve urine culture >100 CFUs treat with antibiotics
Nitrofurantoin 100mg PO BID x 7 days (<36wks)
Amoxicillin 500mg PO TID x 7 days
Test of cure x 1 week after completion of antibiotics
Culture urine q trimester t/o remainder of pregnancy
what to order for GERD
Trail TUMS © 500mg TID; Rx Ranitidine 150mg BID; Maxeran 10mg TID; may use PPI in severe cases but are Grade C (Rx Omeprazole most studied)
Edema
- Osmolarity receptors for Vasopressin are suppressed.
increased circulating fluid, increased capillary permeability, plasma osmolarity and the effects of the
Typical reports of mild edema that builds during the day and improves by morning.
Does not include neurological symptoms, sudden onset accompanied by facial edema, unilateral edema, headache, confusion, visual changes, N/V, dyspnea, upper abdominal pain, decreased fetal movement, rapid weight gain, decreased urine output
Thorough physical exam, check urine for protein (>trace, refer)
Check LOC, DTRs, presence of clonus, presence of pitting edema
Send for LFT’s (esp. AST, ALT, Alk. Phos, CBC if any warning signs and REFER!)
if HSV +, do what? when to treat?
36 weeks’ tx with acyclovir or valacyclovir
decrease the risk of clinical lesions and viral shedding at the time of delivery and therefore decrease the need for Caesarean section.
leading cause of serious neonatal infection?
when to screen
%?
GBS gram +
vaginal/rectal GBS colonization of all women between 35-37 weeks gestation
If +ve GBS bacteriauria at any time in pregnancy then considered +ve and no need to swab
30% of all pregnancy women will be +ve
dx HTN in pregnancy?
can NP dx and care for HTN?
- Diagnosed by two BP’s – 6 hours apart >140/90
- no
which is more common and benign form of HTN, which is worse
gestational HTN/PIH is common and benign - no protien over 20 wks (or HTN within 48-72 hours and resolves by 12 weeks pp
preeclampsia worse - has HTN and protein in urine over 20 weeks
BP tend to be lower and higher in what T?
lower in 1 &2, higher in 3
give ACE for HTN in preggers? which is better?
no
Nifedipine,labetalol, hydrazaline magnesium sulfate infusion and delivery.
If you see a change in LFT’s/platelets, think what? do what?
HELLP, REFER IMMEDIATELY TO OBS.
if have preeclampsia at risk for what later in life?
at a 50% greater risk of developing heart disease before the age of 50!!!
Ensure you ask obstetrical history
if bleeding and painless or less pain think what?
bleeding and pain
Placenta previa
- abruption
Gestational Trophoblastic Disease (GTD)
what do order to test for it?
of pregnancy related benign tumors that include:
Benign Hydatidiform Mole (Molar Pregnancy)
Invasive Mole
Choriocarcinoma (malignant)
usually benign but some can embolize into lungs
- Sensitive tumor marker= hCG secreted by these tumors allowing for accurate f/u and assessment
if preeclamptic early in prg 14-20 think what?
if have hx of this, do what
lab test? what it look on U/S
When arises early 14-20wks consider Trophoblastic Disease (CA)
- refer for subsequent pregnancies cuz greater risk for 2nd molar
Higher beta HCG/ snow storm, grape like vesicles
tx for molar prx
Evacuation with D+C (Dilatation and Curettage) asap
HPL?
high progesterone causes high HPL
breaks down fats from the mother to provide nutrition to the fetus and can increase resistance to insulin and carbohydrate intolerance in the mother
when to screen GDM
risk factors for gdm
24-28 weeks
Ethnic predisposition (Asian-American, Native Hawaiian, Pacific Islander, Hispanic, and African-American) Obesity (BMI >27) Accelerated weight gain >25 years Glycosuria Multiple gestation PCOS
Family history of Type 2 or gestational diabetes
- Previous history of GDM, macrosomia (>4000 gms or 8.8lbs)
- Unexplained stillbirth
GTT testing values
2 Hour (fasting) 75g OGTT – Done @ 24-28wks
FBS below or equal to 5.1 mmol/l
1 hour below or equal to 10.6 mmol/l
2 hour below or equal to 9 mmol/l
If higher risk factors, screen pt around 14 weeks (hx of GDM, PCOS) and if –ve then repeat screen again at 24 weeks
if pt is gdm, what to do post delivery?
NPs can usually co-manage GDM without insulin
GDM on insulin requires refer to OB
Ensure at 6wk PP check to repeat 2hr OGTT to assess risk for DM – GDM patients are 50% more likely to have T2DM later in life
when is fetus able to make own thyroid hormone
why thyroid important?
if hyperT? do what, at what level?
post 12 weeks, under 12, still using mom’s therefore low in preggers.
- fetal neurological development
- TSH 0.1 = HyperT = Refer
Low TSH <0.1, high T4 (>15 in pregnancy)
hCG can mimic thyroxine and often can have a result of
TSH <0.1 but NORMAL T4)
TSH for preggers
if high do what? 4
2.5-4.0 mIU/L (non pregnant cut off is typically 5-10mIU/L)
above 2.5 should do AntiTPO test, if positive tx with meds, usually 25mcg and refer to endo, RA in 4 weeks while titrate, then do growth US
> 4, definitely give meds, pos antiTPO test and refer to endo
if pre preggers, already HypoT, do what pre conception and during preggers
increase her levothyroxine (ie. Synthroid) dose by 25-50% preconception and/or as soon as pregnancy confirmed so in first trimester and monitor TSH q 4 weeks until 28 weeks and then once in 3rd trimester if stable
Cholestasis
what is it, does it have rash?
how to dx, and do what?
tx with what?
bile flow is stopped or slowed down, this causes build up of bile acids in liver which can spill into bloodstrea
Pruritis without liver dysfunction - hands, palms, soles, no rash
Benign course; no maternal sequelae; resolves within few days after delivery
** Increased rate of meconium stained amniotic fluid and fetal demise **
LFTs, bilirubin, fasting am bile salts
If elevated r/o other causes ie. Viral Hepatitis, gallstones, etc.
If elevated require immediate referral to OB
Need to monitor with US and NSTs (non-stress test) and may consider delivery at 37-38 wks
Ursidiol 300mg PO BID-TID daily until delivery
Reduces serum bile acids levels
most common rash in pregnancy?
cause?
DX?
tx?
PUPPPS: Pruritic Urticarial Papules and Plaques of Pregnancy
Does not usually affect subsequent pregnancies
unknown cause but : More common when pregnant with male fetus (70%)
Male fetal DNA acts as skin irritant?
DX - clinically DX
tx- Harmless to fetus: an annoyance for mother
Lasts average of 6 weeks; resolves spontaneously 1-2 weeks after delivery
which condition happens in subsequent preggers?
DM
Cholestasis
Baby Blues – Transient,
Normal during first 2 weeks, can turn into postpartum depression
Up to 80% of women experience
Post Partum Depression – after first two weeks of delivery, anytime within first year after delivery
NPs can manage but have low threshold for referral: RMH/supports
Post Partum Psychosis
Baby Blues – Transient, emotional changes related to hormone changes, sleeplessness
Feelings of being overwhelmed, questioning decision, crying spells
Normal during first 2 weeks, can turn into postpartum depression
Up to 80% of women experience
Post Partum Depression – after first two weeks of delivery, anytime within first year after delivery
Characterized by change in mood, irritability, fatigue, feelings of worthlessness, sleeping/eating changes, anxiety
10-30% of women experience
NPs can manage but have low threshold for referral: RMH/supports
Post Partum Psychosis – psychotic behaviour, hallucinations, delusions, very obvious, most common in first 24-72 hours
Is a safety concern to baby and mother, immediate referral to psychiatry!!
Approx. 1-2% of population affected
uterine arteries notched at risk for what?
HTN
