Obstetric Patient Flashcards
What are different signs and symptoms considered in manifestations of pregnancy?
Presumptive, probable, and positive
Presumptive definition
Affording reasonable ground for belief
Things may resemble pregnancy signs and symptoms, but may in fact be caused by something else
Presumptive signs of pregnancy
Linea nigra- which is a deep pigmentation at the midline of the lower abdomen. Some women have this naturally
Chloasma- deep pigmentation over bridge of nose, and under eyes. Could also result from BC
Definition of probable
Signs that indicate pregnancy the majority of the time however, there is some chance it could be caused by something else
What are probable signs of pregnancy?
Discoloration and cyanosis of the vulva, vagina and cervix
**Chadwick’s sign dark discoloration of vulva and vaginal walls
Leukorrhea- increased white, noninfectious vaginal discharge
Abdominal or uterine enlargement
relaxation of bones and ligaments of pelvis
Hegar’s sign- uterine isthmus and cervix becomes softer
What is a positive sign
Signs that cannot under any circumstances, be mistaken for other conditions, and are evidence that pregnancy occurred
What are positive signs of pregnancy?
Detection of fetal heartbeat at 10 weeks by Doppler and 18 weeks by fetoscope
Palpation of fetal outline at 22 weeks
Visualizing the fetus by ultrasound
What is increased hCG categorized as a sign?
Probable
Pituitary tumor can increase hCG as well
What produces progesterone until the placenta takes over?
Ovaries until 8-10 weeks
What is hCG secreted by?
Trophoblast(blastocyst) cells; later chorion
What does hCG act on?
Prompts corpus luteum to continue secretion of progesterone and estrogen
Promotes placental development. Yeah, it’s autocrine growth factor activity
How should hCG levels rise?
Should double every day for the first two months, then decline as placenta takes over and begins to secrete progesterone and estrogen
Low values at four months and the rest of the pregnancy
What subunit of hCG is measured in pregnancy and it’s a bacis for Serum pregnancy tests?
Beta hCG
When does hCG begin to rise?
eight days after fertilization
If pregnancy continues values peek at 10 to 12 weeks and then decline after 34
What level can serum assays detect for beta hCG
> 3 mlU/ml
What level can urine tests detect hCG?
> 25-50 mIU/ml
Is the hCG level definitive for where the patient is at in pregnancy?
No, because the levels overlap
What does serum beta hCG > 1000-1500 signify?
The discriminatory zone: ultrasound is expected to show a viable pregnancy
What can cause some high or low hCG levels
Falsely Very high- molar pregnancy and twin gestation, Down syndrome, choriocarcinoma
Low - ectopic pregnancy and impending spontaneous abortions
What is the most accurate type of pregnancy test?
Serum pregnancy test beta hCG
What can provide information on the stage of pregnancy?
Quantitative serum pregnancy tests
Can urine give quantitative levels of hCG
No
When is the corpus luteum the primary source of progesterone?
<7 weeks
When does the placenta take over for progesterone production?
> 10 weeks
Between seven and 10 weeks the placenta begins to take over
What happens to the red cell mass during pregnancy?
Expands by ~33%
Body has to supply fetus and mom
Why does hemoglobin and hematocrit drop in pregnancy
Due to great increase in plasma with slightly smaller increase in red blood cells
This is called physiologic anemia of pregnancy
How much does the blood volume increase by in pregnancy?
30 to 50%
How much does cardiac output increase in pregnancy and why?
Increases by 40% early in pregnancy to deliver more oxygen and nutrients to the fetus
How much does the resting pulse rate of the mother increase in pregnancy?
By 15 bpm
What happens to blood pressure in pregnancy? Why?
Blood pressure decreases in mid pregnancy and rises later
because progesterone causes vasculature to relax so BP initially drops but the opposite happens later
What is the prevalence of systolic murmur in pregnant women and why?
90%
From increase cardiac output
Why does total body water increase in pregnancy?
Due to sodium and water retention (edema/swelling in feet)
What can happen to a pregnant patient lying supine
Gravid uterus compresses vessels(IVC/aorta) with supine position, resulting in fall of BP (nausea, dizziness, syncope)
lateral position relieves symptom
Why are pregnant women more at risk for hemorrhoids and thrombosis?
Venus compression of gravid uterus, compresses scenes of LE’s resulting in hemorrhoids and thrombosis
Increased intra-abdominal pressure can cause hemorrhoids because they’re being squeezed especially because of constipation from straining
What does the uterus due to the diaphragm?
Elevates diaphragm about 4 cm and may increase chest circumference but decreases lung volume
What is a result of decreased lung volume and increased work of a pregnant patient
Shortness of breath, tachypnea
What happens to tidal volume during pregnancy?
Increases due to progesterone
What happens to total lung capacity in pregnancy
Decreases because no space for the lung to expand
What can hyperventilation result in?
Respiratory alkalosis- rapid, deep breathing leads to decrease in co2 and increase in pH
This is very severe case
What happens to G.I. in pregnancy
Enlarging uterus displaces stomach and bowel
Gallbladder function slows in pregnancy- can cause cholestasis
Increased acidity of gastric secretions and reduced function of lower esophageal sphincter because of progesterone increasing reflux symptoms
What are some renal affects of pregnancy?
Urinary collecting system dilates so the ureters relax, very little REabsorption due to progesterone relaxing smooth muscle and increase volume it has to filter
Due to enlarging uterus, bladder capacity decreases resulting in urinary frequency
What happens to the GFR in pregnant women?
Increases due to increase blood volume and Renal blood flow
Why does glycosuria occur and what can it lead to?
Due to impaired tubular reabsorption of glucose
Patient could become insulin resistant and passes glucose in urine
May lead to UTI
What happens to glucose levels early in pregnancy
Insulin response to glucose stimulation is augmented early in pregnancy.
Fasting insulin levels are increased, resulting in decreased levels of glucose available in the blood
Could become hypoglycemic
What happens to glucose levels later in pregnancy
Insulin resistance emerges resulting in elevated postprandial glucose levels
What can happen if lipolysis occurs in pregnant women
Lipolysis can increase and plasma free fatty acids increase, which may result in ketosis after fasting, which increases the risk of spontaneous abortion
What is the recommended weight gain in pregnant women by the ACOG
25 to 35 pounds and women of normal weight before pregnancy
What changes in the breasts can you see in pregnancy?
They in large in pregnancy due to hormonal stimulation and increased vascularity
Breast may be tender and tingling and more sensitive to examination
By the third month of pregnancy breasts become more nodular, nipples become larger and more erectile
What specifically can happen to the nipple during pregnancy?
Areola darken and Montgomery’s glands become more prominent
Venous patterns become more prominent
What can happen to the vulva in pregnancy?
Due to increased to vascularity, vulvar variscosities are common
Or darkening/purple appearance - Chadwick sign
What abdominal changes can occur in pregnancy
Muscle tone diminishes as pregnancy advances
Decreased gastric motility results in constipation
What is the linea nigra caused by?
The dark pigmented line down the center of the abdomen is a result of progesterone that stimulates melanocytes
What are striae
As skin stretches purpleish/red striae appear
Collagen fibers break
Genetic
What is diastasis recti
Separation of rectus muscles at the midline of the abdomen, occurs later in trimesters
Most women it goes back to normal after birth
What happens to the vaginal pH during pregnancy?
More acidic due to acting on glycogen in vaginal epithelium
Protective measure
What is Hegars sign? Is it an early or late sign?
Softening of the isthmus of the uterus
Early sign of pregnancy
What happens to the uterus during pregnancy?
Weight of the uterus increases during the course of pregnancy
Early on, it’s a pelvic organ then it transitions to an abdominal organ
Up to what week is the uterus considered a pelvic organ
Up to the 12th week
What are Braxton Hicks contractions?
False labor
Painless contractions, starting in the first trimester
Sporadic and unpredictable , no timing
Increase in frequency at the end of pregnancy
Occurs in the myometrium
When does the mucous plug form and what is it called when its expelled?
Soon after conception, mucous plug forms in the cervical canal to prevent infection
At the onset of labor, it’s expelled called the bloody show
What is the first sign of labor?
Mucousy discharge
What does cervical mucus look like under the microscope?
Cervical mucus displays beading or ferning** pattern
In obstetric history, what’s important to ask for prior pregnancies
Any complications with pregnancy or Labor?
Premature or growth retarded infant?
How long is pregnancy usually last?
280 days (40 weeks) from last menstrual period
What is Naegle’s Rule?
Way to calculate the expected due date
Take the first day of the last menstrual period and add 9 months and 7 days (if 28 day cycle)
Compare info from physical exam an ultrasound findings to confirm
What is considered term?
37 to 40 weeks
What is considered preterm
Before 37 weeks
What are common complaints in pregnancy?
Leg cramps and numbness
Varicose veins
Joint or back pain
What are leg cramps and numbness caused by and what’s the treatment?
Common, etiology unknown (maybe electrolyte imbalance)
Treatment- heat, massage, calcium and magnesium replacement
What are varicose thing is caused by what’s the treatment?
Due to enlargement of uterus and progesterone
Treatment - leg elevation, compression stockings
What is joint or back Pain caused by in pregnancy? what is the treatment?
Separation of symphysis pubis and SI joint. Compensation of lordosis to balance center of gravity.
Treatment - maternity girdle, low heeled shoes
How would you position a pregnant patient for a physical exam?
Semi reclining with pillow under knees
Allows for evaluation of uterus and fetal heart evaluation and results in less compression of organs by the uterus in advanced pregnancy
What do you use to inspect the cervix and obtain specimens in pregnancy?
A vaginal speculum
Wooden spatula or cotton tipped applicator instead of a cervical brush (less bleeding), tape measure, fetoscope or portable ultrasound
What does hypertension prior to 24 weeks gestation indicate?
Chronic hypertension
What is hypertension after 24 weeks considered?
Pregnancy induced hypertension(PIH)
Have to manage because it can progress into pre-clampsia
First trimester weight loss from nausea and vomiting should not exceed
5 lbs
What can Periorbital edema indicate in a pregnant patient?
PIH
What common things can occur to the nose in pregnancy
Nose bleeds
URIs
Nasal congestion (vasodilation from progesterone)
If there is a solitary mass in the breasts, what should you do?
Send to be evaluated
What can no feeling of fetal movement by 24 weeks indicate
Maybe incorrect estimate of gestation, fetal demise
When can a mother or examiner feel fetal movement
18 to 20 weeks by mother
At 24 weeks for examiner
When should the fundus of the uterus be at the umbilicus?
20 weeks
When does the fetus drop?
40 weeks
When do use a doptone versus fetoscope?
Doptone- FHR after 12 weeks
Fetoscope- after 18 weeks
What is a standard fetal heart rate
160s in early pregnancy
120s-140s near term
Where is the location of fetal heartbeat at 12 to 14 weeks
Midline of lower abdomen
After 28 weeks location of FHR depends on fetal position
At 24 weeks, auscultation of more than one heart rate suggests more than one fetus
What can occur due to muscle relaxation in pregnancy?
Cystocele- anterior bulge
Rectocele- posterior bulge
How to perform bimanual examination
Insert to lubricated fingers into introitus (Palmar side down) with downward pressure on perineum
Slide fingers into posterior vaginal vault, then turn fingers palmar side up
Tissues are soft and vaginal walls close in on examining fingers - cervix difficult to feel due to softening
Palpate os and surface of cervix
How do you estimate the length of the cervix?
Palpating lateral surface from cervical tip to lateral fornix
Prior to 34 to 36 weeks, should be normal length of 2 to 3 cm
What is the uterus shaped like until eight weeks
An inverted pear
When does the uterus become globular by?
10 to 12 weeks
When is anteflexion and retroflexion lost by
12 weeks
What is cervical motion tenderness a sign of
Infection
Why do you palpate right and left adnexa
To rule out ectopic pregnancy
What type of edema can be associated with PIH?
Pathologic edema associated with the pretibial area, hands, and face
What is common for the patellar reflex in pregnancy?
Knee and ankle reflexes increase
What are Leopold maneuver is used for and when do you start it?
Begin at 28 weeks gestation to determine fetal position in uterus, and how far presenting part has descended into uterus
What is the first Leopold maneuver?
Stand at woman’s side, facing her head, keep fingers of both examining hands together and palpate what part of the fetus is in the **upper pole of the uterine fundus
What is the second Leopold maneuver?
Place one hand on each side of the abdomen, trying to capture the body of the fetus between them.
** fetal back feels smooth, arms and legs feel irregular
What is the third Leopold maneuver?
Face women’s feet using fingers palpate area above pubic symphysis
If hands diverge ** presenting part has descended into pelvic inlet
If hand stay together ** presenting part has not descended into pelvis
What is the fourth Leopold maneuver?
To confirm, presenting part,
Grasp part of fetus in lower pole in one hand, and part of fetus in upper pole with other hand
** You may be able to distinguish head from buttocks
