OB Block 2 Flashcards
Define Embryo
Define Fetus
Define Fetal Viability
Fertilization to 8wks (10wks gestation)
> 8wks until birth (>10wks gestation)
20-24wks of gestation
Define Previable
Define Previable Birth
Why is gestational age two weeks older than fertilization age?
Infant delivered <24wks
Delivery from 20 +0/7-25+6/7 weeks of gestation
Gestational age calculated from date of LMP
Criteria for Preterm
Criteria for Term
Define Post-Term
Delivered 24-36w 6/7d,
Born <259 days
Delivered 37-41+7/7, 259-293
Delivery +42wks, 294 days
Define Placenta Previa
What are the 3 types and associated MC Sx
Placenta near/on cervical os
MC: 3rd trimester painless hemorrhage (8th mon):
Marginalis: at os margin
Partialis: covers part of os
Centralis: covers os
Define Abruptio Placentae
What are two RFs of Abruptio Placentae
What is the difference in presenting bleeds of an abruption?
Painful, premature detachment of placenta
Pre-Eclampsia
Chronic HTN
Marginal: external
Central: hemorrhage hidden
What layer is defected if a placenta Accreta/Increta/Percreta occurs?
Define Vasa Previa
A: placenta adheres to wall, deficient Nitabuch/decidua basalis
I: myometrium invasion
P: myometrium/structures penetrated
Umbilical vessels between head and cervical os; easily torn, fetal death d/t exsanguination
Common w/ multiple gestations
Define Velamentous Placenta
PTs presenting w/ Vasa Previa need to delivery baby via ?
Cord/vessels entering placenta separately
C-section at 35-37wks
Define Gravida
Define Parity
Number of pregnancy (regardless of multiples), including current (regardless of outcome)
Number of births after 20w gestation, twins= 1
Define Nulligravada
Define Primigravida
Define Multigravida
No prior pregnancy
Current first pregnancy
2 or more pregnancies including current
Define Nullipara
Define Primipara
Define Multipara
Define Grand Multipara
No births after 20wks
One birth after 20wks
+2 births after 20wks
Five+ births after 20wks
What’s the acronym for describing OB Hx
GTPAL Gravida- total number of pregnancy Term: 37-40+ wks Preterm: 20-36wks Abortions: before 20wks Living
How is Gestational Age calculated
Pregnancy trimesters are divided into equal ?
1st day LMP to birth
280 days, 40wks
Epochs: each 14wks
1: conception-14wks
2: 15-28wks
3: 29-42wks
When is a new OB appointment needed**
How long after are appointments needed?
10-12wks gestation
Every 4wks until 28wks
28-36wks: q2wks
+36wks: weekly
What screenings are checked during the first OB visit?
Which ones are done at the 15-20wk appointment
Cystic fibrosis
HIV
Aneuplody screen
Gonococcal
Cystic fibrosis
Aneuploidy
Neural tube defect
What screening is done at the 24-28wk appointment?
What screenings are done at the 29-41 wk appointments?
Ab screening
HepB HIV GBS culture Gonococcal/Chlamydia Syphilis
Clinical pelvimetry is not reliable to predict ? in labor
How is the obstetric conjugate measured
Cephalopelvic disproportion
Anteroposterior/Diagonal conjugate - 1.5-2cm= +10cm
Pelvimetry measures pelvic capacity w/ ? three measurements
What are the two pelvic shapes preferred for vaginal delivery
Diagonal conjugate
Interspinous diameter mid-pelvis
Intertuberous distance of pelvic outlet
Gynecoid*, Anthropoid
Where is the midpelvis measured at and what are they called during labor
The ? diameter is important when discussing obstructed/arrested labor
Ishial spine
Midpelvis + ischial= 0 station
Interspinous: 10cm
What is the name of the desired baby position during birth
Where is the sacrospinous ligament located
Occiput anterior
3 fingers between ischial spine and midline sacrum
The pelvic outlet is important if ? has occurred
What is the name of the device used figuring EDD and Gestational Age
Arrested labor
Naegles Rule:
1st day LMP - 3mon + 7 days
Early US is used in lieu of Naegles Rule if ?
What is the most accurate biometric predictor of gestational age
Uncertain LMP
Irregular periods
OCPs
Crown Rump length, greatest accuracy during 1st trimester
What adjustments are made if US and LMP don’t match up
Define Double Decidual Sign
What are the TORCH microbes
Correspond w/ US if:
<9wks GA: >5 day difference
9-<14wks GA: >1wk difference
D Parietalis outer layer
D Capsularis inner layer
Toxoplasmosis Other Rubella CMV HSV
When are HIV screening conducted during pregnancy
How is this RNA Retrovirus managed
New OB appointments
Repeat 3rd Tri if high risk
Load <1000- vaginal delivery
Load >1000= C-section
No breast feeding
What two TORCH microbes can cause blueberry muffin babies?
Which trimesters are Toxoplasmosis infections dangerous?
How are Toxo infections Dx?
Rubella
CMV
1st: low infection, high fatality
3rd: high infection, low fatality
IgM/Placenta culture
How are Toxo infections Tx
When is Syphilis screened for
Mother: Spiramycin
Mother and Baby: Pyrimethamine-sulfa w/ Folinic acid
RPR/VDRL for all
Repeat 3rd if high risk
How is congenital syphilis Tx
How is the following Jarisch Herxheimer reaction Tx
Pen G 2.4M unit x 1, rpt 1wk later
Fluid Antipyretic O2
When is Rubella infection dangerous
How is this infection avoided?
1st trimester
Avoid/Vaccine once post-partum, not c/i for breast feeding
What is the MC congenital viral infection
Why is this Dx difficult
When is acyclovir started for HSV positive mothers
CMV
IgM present x 2yrs
36wks
Can mothers get Varicella vaccine during pregnancy?
How is Varicella tx
When is Hep B screened for
DNA viruses
RNA viruses
No, wait 28 days
Infant: VZIG 96hrs and isolate
Exposed mom: VZIG <6days
HBsAg in all women
Rescreen high risk at 3rd trimester
DNA: CMV HSV Varicella HBV
RNA: HIV Rubella
How is Hep B Tx
How is Chlamydia or Gonorrhea Tx during pregnancy
Infant of +HBsAg PTs: HBIG + HBV vaccine <12hrs of birth
Mothers may breast feed
C: Amoxicillin 500mg TID x 7d or Azith 1000mg x 1d
G: Ceftriax 250mg IM or
Cefixime 400mg PO
What is the MC Cause of neonatal sepsis
If women tests + for this, how is it Tx
GBS- Strep Agalactiae
IV PCN G
PCN allergy= Clindamycin
What is the “Screening Strategy” for GBS
Results prior to labor
Screen at 35-37wks except**
Tx PTs w/ + cultures
Tx GBS bacteriuria this pregnancy**
Tx Pts w/ previously infected infants**
What is the Risk Factor strategy for GBS
Tx Pts w/ risk factors for colonization
Tx w/ GBS bacteriuria
Tx w/ previously infected infant
Intrapartum fevers +38*C
18+hrs ruptured membranes
When is intrapartum prophylaxis indicated
Previous infant w/ invasive GBS Dz
GBS bacteriuria during current pregnancy
+ GBS screening culture during current pregnancy
Unknown GBS status and delivery <37wks or membrane rupture +18hrs
When is intrapartum prophylaxis not indicated
Previous pregnancy w/ + GBS culture
Planned c-section w/out labor/membrane rupture
Neg vag/rectal culture in late gestation during current pregnancy
What is recommended for GBS Tx
What is the alternative
What is used for PCN allergies
Pen G 5M units IV
3M units IV q4hrs to delivery
Ampicillin 2g IV
1g IV q4hrs/2g q6hrs until delivery
Low anaphylaxis risk: Cefazolin 2g IV, 1g q8hrs
High risk anaphylaxis- Clindamycin 900mg IV q8hrs
High risk anaphylaxis and Clinda resistant- Vanc 1g IV q12hrs
How is bacteriuria Tx
What test is required for all PTs post-ABX
How are these PTs Tx if they develop pyelonephritis
Nitro Amox Ampicillin
Test of cure
Admit for IV therapy
Prophylaxis for remainder of therapy
When are pregnant PTs screened for TB
Conduct PPD and ? measurement is considered positive
High risk- HIV+
Lower socio-economics
Minorities
Immigrants from Africa Asia Cental/S America
5mm or bigger
What are the risks of TB to pregnant PTs and babies
How are latent infections Tx
How are active infections Tx
Preterm delivery
Low birth weight
IUGR
Perinatal mortality
INH 300mg PO daily w/ Pyridoxine x 9 mon
RIPE w/ B6 x 2mon
RI x 4mon
What are the Zika Sxs that may trigger need for testing
What is the risk babies can be born with
Fever Rash Arthralgia Conjunctivitis HA
Microcephaly
Lissencephaly- no brain grooves
What immunizations are in a Tdap vaccine
When can it be given
Tetanus Diphtheria Acellular Pertussis
27-36wks to maximize passive Abs to fetus
When can influenza vaccine be given?
When is MMR given and is breast feeding a c/i?
Any gestational age
Post-partum
Safe for breast feeding
Air travel is safe for pregnant PTs up to ? wk
Why is pregnancy itself a prothrombic/VTE risk phase
36wks
High estrogen
How much exercise should pregnant Pts get and what should be avoided
What recreation activity needs to be avoided
150min/wk
Falling/abdomen trauma
Extreme weather
Prolonged supine
No scuba: fetal decompression sickness
What supplement excess need to be avoided
What regular diet piece needs to be avoided
Iodine- congenital goiter
Raw eggs- Salmonella
What is a homeopathic remedy used to induce labor
What types of seafood need to be avoided
Raspberry leaf tea
Shark Tilefish Mackerel Swordfish
Pregnant PTs need to limit omega-3 fats/proteins to how much?
Ingestion of white/albacore tuna should be limited to /
8-12oz/wk
6oz/wk
Why do pregnant PTs need to avoided unpasteurized dairy/cheeses
What artificial sweetener needs to be avoided
Listeria
Toxoplasma
Saccharin (sweet n low)- crosses placenta
Avoidance of raw/under cooked seafood is exercised to prevent ? infection
PTs need to be careful and not exceed ? amount of prenatal vitamins
Parasites
Norovirus
Selenium Iron Zinc
Vit A B6 C D
What prenatal vitamin is best pre-conception
How much is recommended
Folic acid- neural tubes close by day 28
0.4-0.8mg PO daily 12wks prior 9400-800mcg)
When are PTs folic acid amounts increased to 4.0mg
What element is a form of Omega 3s key for brain/NS development
BMI >35
Anticonvulsants- Valproate Carbamazepine
T1DM
Hx/FamHx neural tube defects
DHA
What meds are c/i for pregnancy
Tetracyclines ACEIs Coumadin High ASA, 100mg or less ok Isotretinoin- including topicals Sulfonamides- not in late pregnancy
How much caffeine is considered a risk
How much is ok?
5 cups or 500mg
<300mg/day
Nicotine exposure leads to ? adverse fetal development
What is the leading cause of preventable developmental disabilities worldwide
Low birth weight
Alcohol intake
What are the discriminating features of FAS
What are the associated features
Flat midface Indistinct philtrum Short nose Thin upper lip Short palpebral fissure
Epicanthal fold
Low nasal bridge
Ear abnormalities
Micrognathia
When does sex need to be avoided during pregnancy
Since dental care is recommended, how much x-ray exposure is ok?
Hx/Risk of miscarriage
Placenta previa
Preterm labor
<5 rads not associated w/ fetal malformations
Why is iodinated contrast avoided in pregnancy
When are domestic violence screenings conducted
Neonatal hypothyroidism
1st prenatal visit
Once per trimester
Post-partum visit
When do depression/behavioral health screenings needs to be conducted
What are c/is to breast feeding?
Once during perinatal period
HIV
Chemical dependency
Lithium
Active TB
What are the emergent indications for pregnant PTs to return
All PTs should be given ?
Contractions q3-5min
Membrane rupture
Vaginal bleeding
24hr phone number
How many weeks of leave are authorized?
What are the neonatal interventions done during 2nd/3rd trimester education
12wks
Circumcision
Hep B Imm
Vit K
Conjunctival eye care
Why would an US be warranted during a placental abruption?
When is Bacteriuria screenings conducted
Differentiate from placenta previa but aburption is clinical Dx
All PTs new OB- UA and culture
What may be the first lab ordered during the first prenatal appointment?
What labs may also be ordered during this appointment?
hCG
HIV Hep Rubella
G/C
TSH Rh UA FT4
Why does prenatal care need to begin prior to pregnancy
First prenatal visit is often too late to address ? risks
Organogenesis/placental development start 7d post-conception
Low birth weight
Obesity
Birth defects- neural tube
What is the "Quick Run Down" for: 10w 18w 18-20wk 20wk 24-28wk 28w 36wk
10: FHTs by Doppler
18: quickening
18-20: anatomy scan
20: fundal height at umbilicus
24-28: glucose tolerance
28: Rhogam Rh- mom/Rh+ dad
36: GBS screen
How fast does hCG increase during the 1st mon of pregnancy
How is TVUS for viability determined
Doubles q2.2days
Gestational sac: 5w, 1500hCG
Fetal pole: 6w, 5200 hCG
Cardiac: 7w, 17500 hCG
All female PTs of reproductive age that present w/ abnormal vaginal bleeding need to have ? test?
What are TVUS indications of demise?
hCG
Gestational sac w/out yolk
Absent Fetal Cardiac Motion
Crown Rump Length >5mm
Define Threatened abortion
Define Inevitable abortion
Define Incomplete abortion
Th: bleeding <20wks, os closed, <50% loss
Inev: bleeding w/ dilated os, non-viable
Incom: bleeding w/ dilated os and passage of tissue
Define Complete abortion
Define Missed abortion
Define Recurrent abortion
Comp: passage of products, os closed, US to verify uterus
Miss: Fetal demise retained in uterus
Recurr: 3+ successive spot aborts
What is the MC cause of early pregnancy loss
Fetus are at risk to feel mothers stresses until ? wks
Genetic abnormalities
Cortisol- 22wks
How are threatened abortions managed?
How are incomplete abortions managed?
How are missed abortions managed?
Th: US and reassure
Incom: Type/Cross and evacuate immediately
Miss: US, reduce blood loss/pain (Misoprostol), possible D/C
Rhogam is given to ? PTs
Where is the uterus at by wks 12, 14-16, 20, 20-38 and 38-40
Rh- PT
12: palpable above pubic symphisis 14-16: midway pubic/umbilicus 20: at umbilicus 20-38: corresponds +/-2cm w/ wk of gestation 38-40: gravid uterus 3cm below xyphoid
Primigravida PTs may not feel fetal movement until ? while multigravida may feel at ?
What monitoring items are started and monitored during 3rd trimester
Primi: 18-20wks
Multi: 16-18wks
Fetal kick counts
Leopolds- fetal lie, weight, presentation at 28wks
What are the landmarks for measuring fundal height
Between weeks 20-36, how much growth is expected?
If there is a discrepancy of __ or more an US is needed
Top of symphysis pubis to top of fundus in cm
Weeks=height (cms)
1cm/wk
> 3cm
How much maternal weight gain is expected
If mother has excessive weight gain, what are the risks?
1st timester: 3-6lbs
20wks: 1lb/wk
25-35lbs total for women w/ normal BMI 18.5-24.9
Post-partum weight retention
C-section
Macrosomia: >4kg
How much of a calorie increase is needed for 2nd, 3rd trimester and breast feeding
How does maternal BP change during pregnancy and when would the lowest measurements be expected?
2/3: 300-400/day, 1lb/wk
500kcal/day while feeding
Dec 2nd trimester, returns during 3rd
Lowest at 26wks
What is the dangerous BP for pregnancy
What is normal range for fetal heart tones
140/90
Doptone at 110-160bpm
How is edema defined in pregnancy and how much of a weight gain is a concern
Why does edema occur so often in pregnancy
> +1 pitting after 12hrs bed rest
5lb gain <7days= concern
Uterine compression of IVC
What is the purpose of counting fetal kicks after 28wks?
How many is expected and what happens if it’s low?
Assess fetal well being
10 kicks/hr (>10 in 30min)
<10: drink sugar, re-eval
<10 after 2hrs- LnD for dec fetal movement
How long does fetal sleep cycle last
How is Rh alloimmunization screening done
20-75min, avg 23min
Blood type
Ab screen w/ Indirect Coombs
Why are Rh- pregnancies dangerous
What are the end results of this issue
Rh Ag exposure causes IgM/IgG reaction
IgG cross placenta, attack fetal RBCs
Fetal hemolysis
Anemia
Hydrops fetalis
What agglutination result is low enough for fetal survivability
When is Rhogam given?
Dilution titer below 1:16
28wks Rh-M/Rh+ or unknown Dad
72hrs post-partum Rh+ baby
What is the name of the quantitative test to assess if Rh- mother has had blood mixing/possible sensitization
Kleihauer Betke test- citric acid w/ pH of 3.2 dissolves maternal Hgb
Eosin stains remaining HgF creating maternal ghost cells
How much Rhogam is given
How much maternal blood does this cover
300mcg IM
30cc
When is prenatal genetic counseling done?
Screening for fetal aneuploidy is primarily aimed at ? since it’s the MC
Serum markers and 20wk US for all PTs
Downs
What are the RFs for each trimester for the occurrence of Down’s?
1: PAPP-A Age NT bhHCG
2: Triple screen (AFP, hCG, unconj estriol)
Quad screen (better for ID, lower false +: MSAFP, Total hCG Unconjugated estriol, Inhibin A**
What are examples of single gene d/os
Trisomy 21
Trisomy 18
Trisomy 13
CF Sickle Hgbopathies Tay-Sachs
Downs
Edwards
Patau
What single gene d/o screening is offered to ALL women in US?
How is Down’s screened for in 1st trimester w/ the earliest screening avail?
What finding indicates lower probability of Down’s risk?
CF
Serum marker added to US, look for nuchal translucency
Visualization of nasal bone
When is Triple Screen for Down’s conducted
2nd Trimester, optimal at 16-18wks:
Total Hcg
Unconjugated estriol
MSAFP: inc +90% of NT defects
What genetic screening test result is a better positive predictive value in older PTs
What are the results of the Quadruple Screening seen in 13, 18 and 21
MSAFP
13: depends x 4
18: all dec
21: dec MSAFP/Estriol, inc hCG, Inhibin
What are the indications to do cffDNA screening for chromosomal abnormalities
> 35y/o at delivery
US results of fetal aneuploidy
Prior pregnancy w/ 13/18/21
Robertsonian translocation carriers (inc risk for 13 or 21)
Abnormal 1st/2nd screening
When are amniocentesis or CVS genetic testing done?
All abnormal chromosome number
> 35y/o at delivery
32y/o w/ twins
Abnormal US
Previous affected pregnancy
Couples w/ known translocation/abnormalities
Women w/ + serum markers
What is the difference of procedure techniques and pro/cons between amniocentesis and CVS?
Amnio- 16-20wks; US guided through abdomen
2wk culture
Chrom specific trisomy probes
PCR for other genetic d/os
CVS- 10-12wks; through cervix Earlier/quicker Dx results Less precise than amnio No amniotic fluid AFPs Procedure <9wks- jaw/limg abnormalities
Define Antenatal Unit
When does antenatal testing start
Pregnancy eval for risks
ER for OB +20wks gestation
‘OB Triage’
32-34wks gestation q7 days
High risk PTs: 26-28wks
How is electronic fetal monitoring interpreted
What test is the first line tool for fetal surveillance
HR accelerations in response to fetal movement w/ NO deceleration
“Reactive HR=norm”
Non-Stress Test
Fetal HR monitoring is essentially ? monitoring
What is a reassuring test result
What is a moderate/reassuring result?
Fetal brain monitoring
Norm HR110-160
Two HR accelerations in 20min, reassuring if:
Inc 10bpmx10sec <32wks
Inc 15bpmx15sex>32wks
NST is most predictive when?
What can cause a non-reactive results
Normal
Fetal sleep cycle
Maternal sedative/opioids
Cardiac/neuro abnormality
Fetal hypoxemia
If fetus is suspected to be sleeping during NST, how are they awakened?
What is the benefit to conduct a contraction stress test, although rarely ever done
How is it done?
Acoustic stim NST
High negative predictive value
Nipple stim to release oxytocin
What does a + Contraction Stress test mean?
Amniotic fluid is similar to ? fluid
When does fetal urine production begin
High risk for fetal death, consider operative delivery
Extracellular fluids
8-11wks
Fetal kidneys become major contributor to amniotic fluid generation by ?
? assesses amniotic fluid volume
18wks
Amniotic Fluid Index- measured at deepest vertical pocket in each of 4 abdominal quadrants;
Norm 2-8cm/quad w/ norm of 5-24cm
Poly= >24cm
Oligo= <5cm
What is the desired result if Single Deepest Pocket” method is used for AFI
What are the 5 parts of a Biophysical Profile
2x2cm pocket
NST + US:
NST- HR inc
Breathing, movement, tone
AFI
What is a modified BPP that is adequately predictive
AFI + vibroacoustic NST, takes 10min (Norm BPP takes 60min)
What do BPP scores correlate to?
10: norm, repeat qWeek (DM, rpt twice/wk)
8 w/ normal AFI: repeat per protocol
8 w/ dec AFI: chronic asphyxia, deliver
6 w/ dec AFI- deliver
6 w/ norm AFI >36wks and favorable cervix- deliver
4, repeat same day, 6 or less= delivery
0-2: deliver, almost certain asphyxia
8-10: normal pH, reassuring unless + oligo
6: poor predictor
4 or less: not reassuring, consider delivery
When are Doppler US of umbilical artery done?
What is considered normal?
IUGRestrictions
Dec resistance as gestational age inc
What lab result is used as an indicator for giving steroids in preterm situations to prep for delivery?
What are the 1st Trimester precautions
Syst/Diastolic ratio from umbilical artery Doppler
Bleeding
Abdominal pain
UTI Sxs
Folic acid supplementation is how much?
When are neural tube defects screened for?
400-800ug/day
1st: nuchal translucent US
2nd: MSAFP during Triple/Quad screening
Where is MSAFP synthesized?
How is this protein linked to NT defects?
Yolk sac
Fetal GI tract/liver
Defected fetal integument allows AFP to leak into amnionic fluids
MSAFP can help detect what two issues occurring during development?
What is the Dx test of choice for NTDs?
Anencephaly
Spina bifida
MSAFP w/ Sonography/US
When are women screened for Trisomy 21
What type of genetic defect is Cystic Fibrosis
Prenatal care <20wks EGA
1st: Fetal NT
2nd: Triple/Quad screens
Auto Recessive on CFTR Chrom 7, defected Cl channel protein
What type of genetic defect is Tay-Scahs
How are high risk ethnicity tested?
How are low risk ethnicity tested?
Auto Recessive, progressive neurodegeneration/early death
High: molecular DNA base mutation
Low: Hexosaminidase A serum level
What happens if a baby w/ Tay-Sachs is given milk
What do babies present w/?
Unmetabolized sugars build up, damage liver, eyes, kidneys and brain
Brain/kidney damage
Cataracts
Jaundice
Large liver
Amniocentesis is used to detect fetal genetic d/os and ?
What test is done to analyze getal karyotype?
Fetal lung maturity assessment
CVS
Fetal blood sampling is AKA
What is the MC and other indications to do this test
Cordocentesis
Percutaneous UBS
MC: Fetal anemia assessment
Other: platelet alloimmunization, fetal karyotype
Amenorrhea is not a reliable S/Sx of pregnancy until ?
During 1st month of pregnancy, uterine bleeding can be from ?
+10 days after expected menses
Blastocyst implantation
Define Goodells
Define Hegars
Define Chadwicks
a
b
c
What is the ‘mask of pregnancy’?
What is a common early sign?
Chloasma
Fatigue
What is the purpose of the hcG during early pregnancy
When do these levels peak and plateau
Prevents involution of corpus luteum
60-70 days
What is the qualitative and quantitative method to test for pregnancy
What are 3 rare but possible causes of false-pos tests?
Qual: urine
Quant: blood
Exogenous/tumor making hCG
Renal failure
When will gestational sac, fetal pole and heart beat be detectable by TVUS?
What is the difference between a non and pregnant uterus
Sac: 21 days post-fertilization
Pole: 6wks
HR: 6-7wks
Non: 70gm
Preg: 1100gm, 1000x greater capacity by delivery
What is the total volume of contents in a pregnant uterus
By __wk, uterus is too big to fit in pelvis and as it ascends it rotates ?
Avg 5L
Can be +20L
13wks
Right
What supports a pregnant uterus when Pt is standing or laying
Define Braxton Hicks contractions
Up: Ant pressure on muscle wall, midline CT
Supine: vertebral columns, adjacent great vessels
Non-rhythmic, 5-25mmHg contraction w/out cervical changes
Uterine contractions do ? to uterine flow?
Maternal placental blood flow ? during gestation by means of ?
Dec
Inc, vasodilation due to estradiol
What is the difference between preg and non-preg cervix
What are the contents of the mucus plug and it’s function
Preg has inc water content
ImmGlobulins/Cytokines to prevent infections
Progesterone causes cervical mucus to ?
Define Theca-Lutein Cysts
Thicken, no ferning/poor crystalization
Inc hCG due to: Gestational trophoblastic dz Pre-eclampsia Hyperthryoid Placentomegaly- multi fetal pregnancy + DM
Where is relaxin released from
What changes does it cause in the body
Corpus luteum
Decidua
Placenta
CT remodeling, not peripheral joint laxity
Renal hemodynamics
Dec serum osmolality
Inc arterial compliance
Why are pregnant PTs more vulnerable to vaginal candidiasis
What do estrogen and progesterone stimulate on the breasts during pregnancy
Inc lactic acid= pH 3.5-6, inc glycogen stores
E: adipose deposition, duct growth
P: ampullary hypertrophy, secretory maturation
What part of the maternal endocrine system is not needed for pregnancy maintenance?
When does the part of the system reach peak size
Pituitary- serum Prl parallel pituitary size
First few days post-partum, possible chiasm compression
Normal by 6mon
? part of the thyroid correlates to expanding blood volume
What does progesterone do to the body during pregnancy
Thyroxine binding globulin
Dec smooth muscle tone
Relaxes uterus= inc tocolytic
Define Diastasis Recti
Define Striae gravidarum and the RFs for them
Seperated rectus muscles at midline
Stretch marks: weight gain, younger age, FamHx
Define Linea Nigra
Define Chloasma
Skin changes during pregnancy can be mimicked it PTs is on ?
Pigmented dark brown skin
Melasma gravidarum- irregular brown patches on face/neck
OCPs
Define Angiomas
What causes palmar erythema
Vascular spiders
Inc estrogen and cutaneous blood flow from heat released by inc metabolism
Basal metabolic rate inc by ?? by 3rd trimester
What is average weight gain for a pregnancy
20%
27.5lbs/12/5kgs
What is water retention normal during pregnancy
What can predispose PTs to late pregnancy edema
Dec plasma osmolality
Dec interstitial colloid osmotic pressure
Protein metabolism increases by ? during pregnancy
What are normal carbohydrate metabolism findings during pregnancy
1000g
Mild fasting hypoglycemia
Postprandial hyperglycemia
Hyperinsulinemia
Pregnant PTs who fast for prolonged periods will develop ? metabolic state
Leptin holds a key role in body fat/energy expenditure regulation so a deficiency can be associated w/?
Ketonemia
Anovulation
Infertility
During pregnancy, inc insulin resistance and estrogen stimulation causes maternal ?
When do leptin levels peak?
Hyperlipidemia
2nd trimester
What happens to thyroid hormones during pregnancy
What vitamin facilitates Ca absorption by the mother for fetal use?
Inc maternal T4 to maintain euthyroid
Fetal thyroid production in 2nd half req’s inc iodide
Vit D3
What happens to blood volume and Hgb/Hct during pregnancy
How much blood loss is expected during pregnancy?
Inc volume, dec Hgb/Hct
Vaginal; 500-600mL
C-Section: 1L
Metabolic increases during pregnancy
Early pregnancy is a ___inflammation state while mid pregnancy is a ___ inflammation state
Fe
WBC- d/t Estorgen/cortisol
Thromboembolism risk
IgA/IgG
Early: pro-inflammatory
Mid: anti-inflammatory, improvement of autoimmune dzs
? much Fe is needed during pregnancy
? WBC is elevated during pregnancy
Inflammatory markers are useless during pregnancy, what is used for indicators?
1000mg, 1mL RBC= 1.1mg Fe
Leukocyte
Procalcitonin
What are the cardiovascular changes during pregnancy by each week?
5w: inc CO= Dec SVR + Inc HR 6-7w: dec BPs, inc HR 10-20: inc pre-load LAD on EKG Exaggerated S1 split w/ inc loudness
What is the best position for pregnant PTs to lay down?
What is the change and significance of prostaglandins during pregnancy
LLR
Inc during, control vascular tone, BP and Na balance
What ratio has been considered an important pre-eclampsia pathogenesis
What other CV finding in high levels have a role in eclampsia?
PGI2:thromboxane ratio
Endothelin
When does morning sickness arise and disappear?
How can it be managed/Tx?
4-8wks, gone by 16wks
Small meals
Pyridoxine w/ Doxylamine or Phenothiazine
What meds are used w/ B6 or Ginger to help manage N/V during pregnancy
What Cat B or Cat C anti-emetics may be considered?
Doxlamine
Meclizine
Diphenhydramine
Metoclopramide
B: Ondansetron; long QT, serotonin syndrome
C: Promethazine, Prochlorperazine, Chlorpromazine
Define Pyogenic Granuloma
Stomach and intestines are displaced ? by enlarging uterus
Epulis gravidarum, highly vascular swelling of gums
Cephalad
Gastric emptying is not changed during pregnancy except for ?
Why do PTs need to urinate more during pregnancy?
Labor
Hypervolemia induced hemodilution: dec protein/oncotic pressure increases renal blood flow
What neuro decline is noted during the 3rd trimester?
Define Krukenberg spindles
Memory, dec verbal recall/processing speeds
Brown/red opacities on posterior cornea surgace due to hormone changes
What is the MC form of Pica and other forms seen in pregnant PTs
This condition is usually triggered by ?
*Amylophagia- starch
Pagophagia- ice
Geophagia- clay
Fe deficient
What is the first line medication for pregnancy GERD?
What can be used for constipation?
TUMS
Colace
What causes varicosities to develop?
How are vulvar varicosities Tx
Uterus inc LE venous pressure
Special hose/belt
Define Round Ligament pain and when/where is it seen
How is this Tx
Sharp groin pain early 2nd semester, R>L
Reassurance, modified activities
How is pregnancy induced back pain managed?
What is the best way to manage?
Acetaminophen
No NSAIDs
Cyclobenzaprine/Baclofen
Education Exercise PT/Chiropractor
Criteria for Low Birth Weight
Criteria for Very Low Birth Weight
Criteria for Extremely Low Birth Weight
1.5-2.5kg
1-1.49kg
0.5-0.99
What is the criteria for advanced maternal age?
Criteria for adolescent pregnancy
> 35y/o at delivery
<20y/o at delivery
What is the MC 1st trimester surgical procedure?
What monitoring is done for procedures?
Laparascopy for Dx/management
FHT before and after
What pregnancy change leads to inc insulin risks
What is the trifecta of metabolic syndrome during pregnancy
Adipokines
DM2 Dyslipidemia HTN
How much weight gain is recommended for PTs that are overweight?
How much gain is recommended for PTs that are obese?
BMI 25-29.9: 15-25lbs
BMI 30 or higher: 11-20lbs
How is asthma managed?
Steroid stress does is considered if PTs have been using steroids for longer than ?
SABAs and inhaled CCS
> 3wks
What is the leading cause of pregnancy related deaths?
What scoring method is not validated during pregnancy?
PEs
Wells, inc D-Dimer are not rliable
What anticoagulants are used in pregnant PTs
What is not used due to it’s ability to cross placenta
Lovenox, LMWH
Coumadin
What is the leading cause of septic shock during pregnancy
How are pregnancy related UTis Tx
Pyelonephritis
Empirically
What is the goal of diabetes control during pregnancy
When is screening conducted?
Euglycemia during organogenesis
24-28wks EGA
What are the two steps of screening for gestational diabetes
1: 50g glucose challenge-
Plasma glucose 1hr after
+ = 140mg or higher, order tolerance test
2: 100g glucose tolerance, overnight fast then drink 100g
Two or more levels at/above threshold= dx
Ranges for Gestational Diabetes D
When is f/u/repeat testing done
Fasting 92-126 at any gestational age
>126= overt diabetes
6-12wks post-partum
Q3yrs
How is GDM managed
What is the maternal risk for developing GDM
Insulin if fasting levels >95
PO sulfonylureas: Glyburide; Metformin= 1st line
50% chance of developing over DM in next 20yrs
Define Superfetation
Define Superfecundation
Two embryos at different ages in same uterus
Fertilization of two ova w/in same menstrual cycle, not same coitus/same male
Define TTT
Twin Twin Transfusion
Donor twin transfuses blood to recipient
Donor= polyhydra, anemic, restricted growth
Recipient: oligohydra, polycythemic, overloaded
Majority of early pregnancy losses occur w/in ?
Spontaneous abortions will have what possible 4 findings on sonogram
12wks
CRL +7mm, no HR
MSD >25mm, no embryo
11 days w/ gestational sac w/ yold, no embryo/heart beat
14 days w/ gestational sac w/out yolk, no embryo/heart beat
How are spontaneous abortions evaluated if VUS is unclear
MC site of ectopic pregnancy
Serial hCG:
Inc, no sac/embryo= ectopic
Dec, no sac/emryo= complete SAB
Ampulla d/t abnormal anatomy
What is the classic triad of ectopic pregnancy
How are ectopic pregnancies Dx when hCG is above threshold?
Amenorrhea
Abdominal pain
Vaginal bleeding
TVUS
As soon as an unruptured ectopic pregnancy is identified, what is the immediate/urgent next step
Define Heterotopic Pregnancy
Laparotomy removal
Coexisting intra-uterine and ectopic pregnancy
What drug is used to remove ectopic pregnancies in healthy PTs
Difference salpingostomy and salpinectomy
Methotrexate
Removal of unruptured tubal pregnancy
Excision of tube for un/ruptured pregnancy
What are the two types of Gestational Trophoblastic Dz
Define GTD complete molar pregnancy
What will be seen on lab work if this is present
Hydatidiform: + villi
Nonmolar malignant neoplasm; - villi
Empty ovum- all chromosomes are paternal
> 100K hCG, hyperemesis gravidum
Define GTD Partial Molar
Fertilized ovum w/ extra paternal haploid set: 69XXX or 69XXY
Non viable fetus developing w/ cluster of grapes
Define Grestational Trophoblastic Neoplasia types and risks
Invasive: MC GTN following hydatidiform moles
Choriocarcinoma: MC following SAB/pregnancy, most malignant
Placental site trophoblastic tumor: rare, chemo resistant
Epitheloid trophoblastic tumor: low hCG, chemo resistant, common metastatic Dz
What is the MC presentation of Gestational Trophoblastic Neoplasia
What clinical presentation is pathognemonic for molar pregnancy
Irregular bleeding w/ uterine subinvolution (failure to return to normal size)
Pre/eclampsia w/out chronic HTN/occurring prior to 20wks gestation
How are hydatidiform moles Tx
How are GTN Tx
D/C
Serial hCG q2wks until not detected (complete 9wks, partial 7wks)
qMon surveillance x 6mon
Chemo alone
Hysterectomy if Dz is chemo resistant
Complete hydatidiform mole fact
MC cause of fetal hematologic anemia
Snowstorm appearance on US w/ extremely high hCG, empty ovum
9 week serial hCG monitoring
RBC alloimmunization- maternal Abs cross placenta, destroy fetal RBCs
How is fetal anemia detected
Hydrops fetalis is defined as ?
Fetal blood sample
Doppler eval of middle cerebral artery during systole
Two or more effusion: pleural, pericardial, ascites or
One effusion and anasarca
Along w/ enlarged placenta
Nearly half of non-immune hydrops occurs in ? population
What is the most common infection cause
45XO
Parvovirus B19
How is Hydrops Fetalis evaluated for?
Indirect Coombs- alloimmunization
Sonograph: anatomy, MCA doppler, fetal echo
Amniocentesis- keryotype
Kleihauer Betke
A-thalassemia/inborn erros
AFI criteria for mild/mod/sev polyhydramnios
This can indicate an issue ? in the fetus
Mild: 25-29.9cm
Mod: 30-34.9cm
Sev: 35 or more
Tracheo/Esphageal fistula
Dx criteria for oligohydramnios
Presentation after midpregnancy can be associated with ?
AFI <5cm or
Deepest pocket <2cm
Growth restriction
Pre-eclampsia
Vascular dz
How are cases of oligohydramnios Tx
What are the 3 phases of fetal growth
Maternal hydration
Intrapartum amnioinfusion if FHR decelerations are present
1: 5g/day x 16wks
2: 15-20g/day (wk 17-32)
3: fetal fat/glyogen accumulation
Difference between Fetal Growth Restriction and Intrauterine Growth Restriction
If IUGR occurs early in pregnancy what will be seen?
What will be seen if it occurs later in pregnancy?
IUGR- pathological cause preventing growth
Symmetric- dec cell size and number from chemicals, viral or cellular agenesis
Asymmetric- placental insufficiency from maternal HTN; leads to brain sparing development
What affect does IUGR have on lung development
What is the criteria for macrosomia
Accelerated maturation
+4500g at birth
What is the most common sub-unit of hCG?
What is the MC form of pregnancy induced hyperthyroidism
How is it Dx
TSH
HyperThyroid: Graves
Dec TSH, Inc FT4 thyroxine
How is pregnancy induced hyperthyroid Tx
What is the MC form of pregnancy induced hypothyroidism
Propylthiouracil in 1st Trimester
Methimazole- 2nd trimester
Hashimotos
High TSH, Dec FT$
Tx w/ Levothyroxine
How are PTs w/ seizure d/os Tx
PTs w/ ? Sx signal a poor fetal outcome
Lowest dose of monotherapy
Folic Acid
Vit K
Hyperthermia
How is an acute seizure managed in a PTs w/ no seizure Hx?
MgSulfate
Stopped Vid 5
1 05 30
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