Obstetrics Flashcards
29% of exam, ~ 51 questions 1. A&P of Pregnancy 2. Prenatal Care 3. Assessment of Fetal Well Being 4. Medical & Obstetric Complications of Pregnancy (Evaluation, Diagnosis, Treatment, Referral, Counseling/Education) 5. Postpartum Care & Complications
Define: gametogenesis
development of gametes: oogenesis or spermatogenesis
Define: oogenesis
development of mature human ovum - haploid # of chromosomes
Define: spermatogenesis
development of mature, functional spermatozoa - haploid # of chromosomes
Define: meiosis
two successive cell divisions that yield cells/egg/sperm that have 1/2 the number of chromosomes of somatic cells
Define: mitosis
somatic cell division in which the daughter cell contains the same number of chromosomes as the parent cell
Define: haploid
23 chromosomes, i.e. 1/2 the number of chromosomes in a typical somatic cell (46)
Define: fertilization
when the ovum and spermatazoa unite - occurs in fallopian tube usually within minutes or hours after ovulation. Typically occurs when intercourse occurs within 2 days of ovulation
What is a zygote?
a diploid cell with 46 chromosomes that results when ovum is fertilized by spermatozoan
What is a blastomere?
this is the product of mitotic cell division (cleavage) of the zygote wherein the daughter cells (blastomeres) have 46 chromosomes like the parent zygote.
What is a morula?
the solid ball of 16 or so blastomeres that enters the uterine cavity ~3 days after fertilization
What is a blastocyst?
this is when the morula has entered the uterus and fluid enters between blastomeres, converting the morula to a blastocyst. Inner cell mass @ one pole becomes embryo and the outer cell mass becomes the trophoblast.
Embryo
Between fertilized ovum and fetus, exists from weeks 2-8
Fetus
the developing conceptus after embryonic stage (i.e. after 8 weeks)
Conceptus
all tissue products of conception: fetus/embryo, fetal membranes, placenta
How does the blastocyst implant?
It adheres to the endometrial lining by eroding epithelial cells; trophoblasts burrow into endometrium; the blastocyst eventually becomes encased by the endometrium
When/where (typically) does implantation occur?
6-7 days after fertilization
upper, posterior wall of uterus
Implantation of the blastocyst provides…
maternal/embryonic physiological exchange until the placenta develops
What is the chorion?
the outer membrane that early on is the outer wall of the blastocyst. it eventually gives rise to the chorionic villi
What is the chorion frondosum?
outer chorion surface that has villi that contact the decidua basalis (the placental part of the chorion)
What is the chorion laeve?
the smooth, nonvillous portion of the chorion
What is the syncytiotrophoblast?
the outer layer of cells that cover the chorionic villi of the placenta and are in contact with the maternal blood or decidua
What is the cytotrophoblast?
the thin inner layer of the trophoblast composed of cuboidal cells
What is the decidua capsularias?
the part of the decidua that surrounds the chorionic sac.
What is the decidua basalis?
the part of the decidua that unites with the chorion to form the placenta
What is the decidua parientalis (vera)?
the endometrium during pregnancy, except the site of the implanted blastocyst
What is the amnion?
the innermost fetal membrane that holds the fetus in amniotic fluid; by end of 3rd month it fuses with the chorion forming the amniochorionic sac (bag of waters)
What function does the placenta serve? (3)
fetal lungs, liver, kidneys until birth
6 anatomical components of the placenta
trophoblasts, chorionic villi, intervillous spaces, chorion, amnion, decidual plate
5 steroid hormones produced by trophoblasts
estradiol, estriol, progesterone, aldosterone, cortisol
How is blood flow to the placenta regulated?
maternal blood transverses the placenta randomly by entering the intervillous spaces, propelled by maternal arterial pressure
How are oxygen and glucose transported across the placenta?
facilitated diffusion
What are the anatomical components of the umbilical cord?
2 arteries carry fetal deoxygenated blood to the placenta
1 vein carries oxygenated blood from the placenta to the fetus
Wharton’s jelly for protection
Typical umbilical cord measurements
0.8 - 2 cm in diameter
length ranges from 30 - 100 cm, average is 55 cm
What is an extremely short cord associated with?
abruptio placenta and uterine inversion (rare)
What is an abnormally long cord associated with?
vascular occlusion by clots and true knots
What produces amniotic fluid before the 2nd trimester?
the amniotic epithelium
What produces and regulates amniotic fluid starting in the 2nd trimester?
fetus: swallowing, urinating, inspiring
Define: polyhydramnios
AFI >/= 24 cm or maximum vertical pocket >/= 8 cm
excess of amniotic fluid
Incidence: polyhydramnios
1%
Etiology: polyhydramnios (7)
50-60% idiopathic fetal anomaly fetal infection twin-to-twin transfusion syndrome maternal diabetes isoimmunization multiple gestation
Risks: polyhydramnios (5)
fetal macrosomia preterm labor PPH cord prolapse erythroblastosis
Management: polyhydramnios
monitor w/ NST & BPP starting at 34 weeks
When is amniocentesis indicated for poly?
if AFI is >35 cm
Possible med tx for poly
indomethacin (thought to slow fluid production in utero…lungs/urine)
Define: oligohydramnios
AFI = 5 cm or max vert pocket < 2 cm
low amniotic fluid
Fetal conditions associated with oligo (6)
chromosomal abnormalities congenital abnormalities growth restriction demise post dates ruptured membranes or PROM
Placental conditions associated with oligo (2)
abruption
twin-twin transfusion syndrome
Maternal conditions associated with oligo (5)
Uteroplacental insufficiency hypertensive disorders diabetes drugs (ACE, prostaglandin synthesis inhibitors) idiopathic
What could you do to treat oligo that results in repeated variable decels?
Amnioinfusion
When does organogenesis in the embryonic development phase begin?
3rd week after fertilization
How early can a serum and urine assay detect hCG?
as early as 1 week after conception
How long does organogenesis last in the embryonic development phase?
8 weeks after fertilization
What happens 4 weeks after fertilization?
heart partitioning
arm/leg buds
amnion unsheathes body stalk that becomes the umbilical cord
What happens 6 weeks after fertilization?
head larger than body
heart completely formed
finger/toes present
What happens by 8 weeks after fertilization?
All major organ systems are formed, aside from the lungs
When does fetal development begin?
8 weeks after fertilization (10 after LMP)
What happens @ 12 weeks?
uterus palpable at pubic symphysis
fetus starts making spontaneous movements
What happens at 16 weeks?
sex determinable on US by experienced observers
What happens at 20 weeks?
fetus weighs 300 g
weight now begins to increase linearly
What happens at 24 weeks?
fetus weighs 630 g
fat deposition begins
terminal sacs in the lungs are still not completely formed
What happens at 28 weeks?
fetus weighs 1000 g
papillary membrane has disappeared from the eyes
90% chance of survival with no abnormalities
What happens at 32 - 36 weeks?
fetus continues to increase in weight as more subQ fat accumulates
Mass and volume of normal nonpregnant uterus
70 g
10mL
@ 6 weeks, the uterus is…
soft, globular, asymmetric (Piskacek’s sign)
@ 12 weeks, the uterus is..
8 - 10 cm
rising out of pelvis
@ 14 weeks, the uterus is…
1/4 the way to the umbilicus
@ 16 weeks, the uterus is…
1/2 the way to the umbilicus
@ 20 weeks, the uterus is…
at the umbilicus
After 20 weeks, the number of cm from the pubic symphysis to the fundus is…
of weeks gestation, within 2 cm
Term pregnancy uterus mass and volume
1100 g
5 L
2 anatomical changes to the cervix during pregnancy
increased vascularity
thick mucus plug forms
What is Hegar’s sign?
softening of the isthmus of the cervix
What is Chadwick’s sign?
bluish color of the cervix and vagina
What is Goodell’s sign?
softening of the cervix
Biggest anatomic change for ovaries?
anovulation
maybe produce relaxin
How long does the corpus luteum persist? What keeps it going?
until 12 weeks
maintained by hCG
What role does the corpus luteum play?
secretes progesterone and maintains endometrium and pregnancy until placenta takes over
4 anatomical changes to vagina in pregnancy
Chadwick’s sign
thickened mucosa
increased secretions
connective tissue loosening in preparation for birth
5 anatomical changes to breasts during pregnancy
increased size (mammary hyperplasia)
increased size and deepening pigmentation of areola
colostrum may be expressed after the first several months of pregnancy
Montgomery’s follicles
increase in vascularity
4 pelvic types
anthrpoid
android (male)
gynecoid (female)
platypelloid (rare)
Pregnancy changes to mouth and pharynx (3)
gingivitis and bleeding of gums
increased salivation
epulis (gum swelling)
Pregnancy changes to esophagus (2) and biggest thing it causes
decreased lower esophageal sphincter and tone
widening of hiatus w/ decrease in tone
heartburn!
Pregnancy changes to stomach (3)
decreased gastric emptying time
incompetence of pyloric sphincter
decreased gastric acidity and histamine output
Pregnancy changes to intestines (3)
decreased tone/motility
altered enzymatic transport across villi = increased absorption of vitamins
displacement of intestines, cecum and appendix by growing uterus
Pregnancy changes to gallbladder (1)
decreased tone/motility
Pregnancy changes to liver (1)
altered production of liver enzymes, plasma proteins, and serum lipids
Why are pregnant people more susceptible to UTI?
because of the dilation of renal calyces, pelvis and ureters
What happens to the bladder during pregnancy?
tone is decreased
What happens to renal blood flow during pregnancy?
increases 35 - 60%
What happens to the renal threshold for glucose, water-soluable vitamins, calcium, and hydrogen ions during pregnancy?
decreases
What happens to GFR during pregnancy?
increases 40 - 50%
What happens to the RAAS during pregnancy? What does this result in?
All components increase, causing retained sodium and water, resistance to pressor effect, and maintenance of normal BP
What role do relaxin and progesterone play on the MSK system during pregnancy?
they affect cartilage and connective tissue resulting in
- the loosening of sacroiliac joint and symphysis pubis
- the ‘characteristic gait’ of pregnancy
How else does pregnancy affect the MSK system?
lordosis
What happens to the diaphragm during pregnancy?
Rises 4 cm because of uterine size increase
What happens to thoracic circumference during pregnancy and residual volume during pregnancy?
circumference increases by 5-6 cm and volume decreases
What occurs because of decreased PCO2 during pregnancy?
mild respiratory alkalosis
Nasal changes during pregnancy?
congestion!
RR, TV, minute ventilatory and minute oxygen uptake changes during pregnancy?
RR remains the same, but all others increase
What do some pregnant people experience as a result of increased TV and lower PCO2?
dyspnea
How does blood volume change in pregnancy?
increases 30 - 50%
how does plasma volume change in pregnancy? what does this cause?
plasma volume expands leading to physiologic anemia
Average Hgb of pregnancy?
12.5
T/F some women require iron supplements during pregnancy
True
why is pregnancy considered a hypercoagulable state?
Fibrinogen (factor 1) and factors 7-10 increase
How is cardiac volume affected in pregnancy?
increases by 10%, peaks at 20 weeks
How does resting HR change during pregnancy?
increases by 10-15bpm and peaks at 28 weeks
Where is the slight cardiac shift?
up and to the left because of growing uterus
What percent of pregnant women develop this heart sound?
90%
systolic heart murmur
What other heart sounds are possible during pregnancy? (3)
exaggerated S1 split, audible S3, soft transient diastolic murmur
How does cardiac output change during pregnancy?
increased!
How does BP change during pregnancy? Why?
diastolic BP lower in first 2 trimesters
peripheral tone is relaxed by progesterone
new vascular beds are developed
both of these decrease resistance
Tell me 8 integumentary vascular changes that occur during pregnancy.
palmar erythema, spider angiomas, varicose veins/hemorrhoids, hyperpigmentation, chloasma/ freckles/nevi/recent scars darken, linea nigra, increased sweat/sebaceous activity, striae gravidarum
How does pregnancy affect hair growth?
estrogen can increase the length of growth phase of fair follicles
can also see some mild hirsutism early on
What are two pituitary endocrine changes during pregnancy?
prolactin 10x as high at term
pituitary gland doubles in size
Which thyroid hormone(s) cross(es) the placenta?
Thyroid-stimulating immunoglobulins and TRH
Which thyroid hormone does not cross the placenta?
TSH
What happens to thyroxin-binding globulin (TBG) during pregnancy?
increases because of estrogen
What happens to the size of the thyroid gland?
increases ~13%
What happens to the adrenal glands in pregnancy?
twofold increase in serum cortisol
size stays the same but the zona fasiculata increases
What 2 pancreatic changes do we see in pregnancy?
hypertrophy and hyperplasia of B cells
insulin resistance as a result of placental hormones
weight gain for BMI < 18.5 during pregnancy
28 - 40 pounds
weight gain for BMI 18.5 - 24.9 during pregnancy
25 - 35 pounds
weight gain for BMI 25 - 29.9 during pregnancy
15 - 25 pounds
weight gain for BMI > 30 during pregnancy
11 - 20 pounds
How is protein metabolism altered in pregnancy?
increases
How do fat deposit and storage change during pregnancy?
increased to prepare for breast feeding
How does carb metabolism change during pregnancy?
blood glucose levels are 10 - 20% lower
First trimester maternal psych alterations (1 -13 weeks)
focus is on physical changes and feelings
ambivalence
adjustment
Second trimester maternal psych alterations (14 - 26 weeks)
focus on fetus as a person
acceptance
period of radiant health
Third trimester maternal psych alterations (first part 27 - 36 weeks)
focus on baby’s needs
introversion
period of watchful waiting
9 subjective presumptive signs of pregnancy
amenorrhea, n/v, urinary frequency/nocturia, fatigue, breast tenderness/tingling/enlargement/color changes, vasomotor symptoms, skin changes, congestion of vaginal mucus, maternal belief of pregnancy
5 objective presumptive signs of pregnancy
continued elevated basal body temp, Chadwick’s sign, Montgomery’s tubercles or follicles, expression of colostrum, breast changes
10 probable signs of pregnancy
enlargement of abdomen, enlargement of uterus, palpation of the fettal outline, ballottment, changtes in uterine shape, Piskacek’s sign, Hegar’s sign, Goodell’s sign, palpation of Braxton Hicks contractions, + pregnancy test
3 positive signs of pregnancy
FHTs (fetoscope 18-20 weeks or doppler as early as 10 weeks), sonogram, palpation of fetal movement
4 differential diagnoses
pregnancy, leiomyoma, ovarian cyst, pseudocyesis
What is Naegele’s rule?
take the first day of the LMP, subtract 3 months, add 7 days and then add 1 year
When does quickening occur? what is it?
maternal perception of fetal movement
usually occurs 18 - 20 weeks for primaparas
14 -18 weeks for multigravidas
5 types of measurements that are helpful in determining GA
crown rump lenght, biparietal diameter, head circumference, abdominal circumference, femur length
how accurate is CRL in first trimester?
within 3 - 5 days
how accurate is BPD and FL in second trimester?
within 7 - 10 days
how accurate is BPD and FL in third trimester?
all measurements less accurate after 26 weeks
within 14 - 21 days
define: fertility rate
live births/1000 females ages 15 - 44 years
define: birth rate
births/total population in the given year(s)
define: live birth
the birth of an infant showing any signs of life (spontaneous breathing, beating heart, pulsation of the cord, movement of voluntary muscles) no matter gestational age
define: neonatal period
28 completed days after birth
define: perinatal period
from the end of 22 weeks to 7 days after birth
OR
births weighing 500 g or more and ending 28 completed days after birth
define: fetal death
spontaneous intrauterine death of a fetus at any time during the pregnancy
define stillbirth:
fetal death at 20 weeks or more
define: stillbirth rate
ratio of fetal deaths divided by the sum of births (including live births and fetal deaths in any given year)
define neonatal death
early neonatal death is death during first 7 days after birth
late neonatal death is during first 7 to 28 days after birth
define: neonatal mortality rate
the number of neonates dying before reaching 28 days of age per 1000 live births in a given year
define: perinatal mortality
number of stillbirths and deaths in the first week of life
define perinatal mortality rate
number of stillbirths and perinatal deaths (first week of life) per 1000 total births
define: infant mortality
death of an infant in the first 12 months
define infant mortality rate
number of infant deaths in the first 12 months per 1000 live births
define: maternal morbidity
illness or disease associated with childbearing
define: maternal mortality ratio
number of maternal deaths that result from the reproductive process per 100,000 live births
define:abortus
fetus or embryo removed or expelled from the uterus during the first half of gestation (20 weeks or less) weighing less than 500 g
define: late preterm infant
34 0/7 - 36 6/7
define early term infant
37 0/7 - 38 6/7
define term infant
infant born after 37 completed weeks gestation up until 42 completed weeks gestation
define: post-term infant
infant born anytime after completion of 42nd week gestation
define: direct maternal death
death of the mother resulting from obstetric complications of pregnancy, labor, or the puerperium and from interventions, omissions, incorrect treatment, or a chain of events resulting from any of these factors
define: gravida
of times a patient has been pregnant regardless of outcome
define: para
number of pregnancies carried to 20th week or beyond OR delivery of an infant weighing more than 500 g
define: nulligravida
never pregnant
define nullipara
never carried pregnancy to 20 weeks or 500 g
define primigravida
patient who is pregnant for the first time
define primipara
patient who has carried a pregnancy past the 20th week or who is currently pregnant for the firwstw time and is carrying past the 20th week
define multigravida
patient who has been pregnant 2 or more times
define multipara
patient who has carried 2 or more pregnancies past the 20th week of gestation or who has delivered an infant weighing more than 500 g more than once
define grand multipara
patient who has given birth 7 times or more
define TPAL
term >/= 37 weeks or 2500 g
premature 20 - 36 6/7; 500 - 2499 g
abortions < 20 weeks and 500 g
living children
how do we measure fundal height
in cm from pubic symphysis to fundus
what are Leopold’s maneuvers and what do they tell us?
4 abdominal palpation maneuvers that tell us the lie, presentation, position, attitude, variety (?) and estimated fetal weight
Components of lab testing at initial prenatal visit (18)
1 blood type 2 Rh factor 3 antibody screen 4 CBC 5 RPR or VDRL 6 rubella titer 7 hep B surface antigen (HBsAg) 8 urine culture/screen 9 HIV (option to decline) 10 GC 11 CT 12 wet mount 13 TSH 14 Hgb A1C 15 Pap 16 PPD skin test 17 Hgb electrophoresis 18 genetic screening
what are the two main types of prenatal genetic tests?
screening and diagnostic
screening tests tell us…
risk for certain genetic disorders
diagnostic tests tell us…
confirmatory information using cells from the fetus or placenta
what are the two types of prenatal screening tests?
carrier screening (mom or dad gets serologic or tissue testing to see if they are carriers) prenatal genetic screening (serologic testing combined with USG performed during pregnancy to screen for aneuploidy, spine and brain defects
when is first-trimester screening performed?
between 10 and 13 weeks
what is involved with 1st trimester screening?
serologic testing for PAPP-A (pregnancy-associated plasma protein) and hCG, US to measure nuchal translucency. mother’s age
used to calculate risk for trisomies 18 and 21
when is second trimester screening performed?
between 15 and 22 weeks
what is involved with 2nd trimester screening?
quad screening
serologic blood test to detect NTDs and trisomies 18 and 21
serologic testing looking at MSFAP, estriol, inhibin Am and hCG
can also do US 18 - 20 weeks to ID anatomic fetal defects
what is cell-free DNA testing?
can be performed as early as 10 weeks
serologic testing of mother’s blood for aneuploidu (trisomies 13, 18, 21)
what would follow a positive result from cell-free DNA testing?
possibly CVS or amniocentesis to diagnose
when should we screen for gestation DM?
24 - 28 weeks
if a patient is Rh-, what follows?
repeat antibody screen at 26 - 28 weeks
can repeat which labs in third trimester if indicated by history, exam findings, risk factors?
CBC/crit, RPR/VDRL, CT/GC, HIV, hep B
when do we screen for group B strep?
35 - 37 weeks
how frequently should prenatal visits occur?
Q4weeks up to 28 or 32 weeks
then until 36 weeks, Q2weeks
from 36 weeks to 41 weeks, weekly visit
genetic risk factors for pregnancy (4)
age >/=35
previous chromosomal abnormality
fam hx of birth defects or mental retardation
ethic/racial origins (african SS, Med/east asian B thalassemia, Jewish tay sachs)
other risks factors for pregnancy (4)
multiple pregnancy losses/previous stillbirth
psych/mental health disorders
history of IUGR
preterm birth(s)
11 risks factors for current pregnancy
abnormal multiple marker screening exposure to possible teratogens IUGR oligo/poly diabetes HTN multiple gestation PROM postdates decreased fetal movement Rh isoimmunization
4 types of possible teratogen exposure during preganncy
radiation
alcohol/meds/substances
occupational exposures
infections
7 risk increasing infections during pregnancy
toxo, rubella, CMV, herpes, HIV, syph, Zika
CDP (common discomforts of pregnancy): incidence of N/V
50% of pregnant women are affected, 25% affected by nausea only, 25% unaffected; 1st trimester
when should patients start taking a prenatal vitamin before trying to conceive?
3 months prior - can help reduce need for tx for N/V
what are some nutrition adjustments to manage N/V during pregnancy?
eat small, frequent meals Q1-2 hours
avoid spicy/fatty foods
eat protein
bland/dry foods before getting out of bed
other adjustments (non-food) for N/V?
avoid triggers (odors) stop prenatal and iron, but continue folic acid until resolution acupuncture/pressure (?)
3 comfort measures for breast tenderness during pregnancy
supportive bra
careful intercourse
reassurance that it will pass
possible differentials to consider when a pregnant patient presents with backache (5)
strain, sciatica, sacroiliac joint problem, preterm labor, UTI
interventions for backache related to pregnancy (9)
massage, ice/heat, hydrotherapy, pelvic rock, counseling on good body mechanics, pillow in lumbar area when sitting or between legs when laying on side, pregnancy support/girdle, supportive bra, supportive low-heeled shoes
what could you suggest for sacroiliac joint problems in a pregnant patient with backache?
appropriate exercises, nonelastic sacroiliac belt, trochanteric belt worn below abdomen at femoral heads to increase stability
interventions for fatigue related to pregnancy (6)
reassurance that it will pass (normal in 1st trimester)
mild exercise
good nutrition
planned rest periods
decrease activities
less fluid before bed to decrease nocturia
non-pharm/supplement interventions for heartburn during pregnancy? (3)
small, frequent meals
less fluid with meals - drink fluids in between meals
elevate head of bed 10 - 30 degrees
pharm/supplement interventions for heartburn during pregnancy (4)
papaya, slippery elm bark throat lozenges, antacids, PPIs and H2 blockers (preg cat B)
interventions for constipation during pregnancy (4)
increased fluids and fiber, prune juice or warm beverage in the morning, encourage exercise, stool softeners
interventions for hemorrhoids during pregnancy (7)
avoid constipation/BM straining, elevate hips with pillow or knee-chest position, sitz baths, witch hazel or epsom salt compress, reinsert hemorrhoid with lubed finger, Kegels, topical anesthetics (Preg cat C if combined with steroid)
interventions for varicosities related to pregnancy (4)
support stockings to be worn before getting out of bed
avoid restrictive clothing
perineal pad if vaginal varicosities
rest periods with elevated legs, avoid crossing legs
interventions for leg cramps related to pregnancy (7)
decrease phosphate (no more than 2 glasses of milk/day)
massage
no pointing toes - flex ankle to stretch calf
keep legs warm
walk, exercise
Ca tablets
Mg tablets
interventions for presyncopal episodes during pregnancy (3)
change positions slowly, push fluids and encourage regular caloric/glucose intake, avoid lying flat on back and avoid prolonged standing/sitting
important to do what when a pregnant patient presents with headache?
rule out migraine or other pathologic causes of headache
interventions for headaches in pregnancy (10)
massage, acupressure, hot/cold compress, rest, good sleep hygiene, warm baths, meditation/biofeedback, aromatherapy, smaller/more frequent meals, mild analgesic
important to do what when a pregnant patient presents with leukorrhea?
r/o vaginitis, STI
interventions for leukorrhea during pregnancy? (4)
good perineal hygiene, cotton undies and change frequently, unscented pantyliners, avoid douching and sprays
important to do what when a pregnant patient presents with urinary frequency?
r/o UTI
interventions for urinary frequency?
decrease fluids in evening to avoid nocturia
avoid caffeine
interventions for insomnia?
warm bath
hot drink - warm milk, chamomile tea
quiet/relaxing activities
avoid daytime naps
important to do what when a pregnant patient presents with round ligament pain?
r/o other abdominal pain causes like appendicitis, ovarian cyst, placental separation, inguinal hernia
interventions for round ligament pain (6)
warm/ice compress, hydrotherapy, avoid sudden or twisting movement, flex knees to abdomen/pelvic tilt, support uterus with pillow when lying down, maternity abdominal support/girdle
interventions for skin rash
ice, oatmeal bath, diphenhydramine 25 mg Q4 hrs PRN, derm referral PRN
interventions for carpal tunnel syndrome
good posture, lying down, rest/elevate affected hand(s), ice/wrist splints, mild analgesic
what is the recommended daily caloric intake during pregnancy?
2500
what is the recommended daily protein intake during pregnancy?
60 g
underweight BMI recommended weight gain during pregnancy?
28-40#
normal BMI recommended weight gain during pregnancy?
25-35#
overweight BMI recommended weight gain during pregnancy?
15-25#
obese BMI recommended weight gain during pregnancy?
11-20#
risk factors associated with low gestational weight gain (5)
low fam income, black race, young age, unmarried, low education
low gestational weight gain is associated with…
growth-restricted infants
fetal and infant mortality
high gestational weight gain is associated with…
large infant weight which can cause: fetopelvic disproportion operative delivery birth trauma asphyxia PPH mortality
what replaced the FDA risk factor category labelling on medications?
the PLLR which gives a more comprehensive narrative/description (pregnancy and lactation labeling final rule)
what were the previous FDA risk factor categories for meds during pregnancy?
A - safe (folic acid, levothyroxine) B - probably safe, Zofran, amoxacillin C - not great, sertraline, fluconazole D - risky, phenytoin, lithium X - contraindicated!!!! methotrexate, warfarin
are live vaccines considered safe during pregnancy?
nope
when can you give a live vaccine in relation to pregnancy?
4 weeks prior or during the PP period
which two specific vaccines are contraindicated during pregnancy?
Varicella and Rubella
Which vaccine is recommended every pregnancy?
Tdap
Which vaccine is recommended for high-risk patients who are antigen and antibody negative?
Hep B
Which vaccine is possibly indicated for maternal trauma?
Tetanus
Which vaccine is recommended during flu season?
TIV (the inactivated influenza vaccine)
When is amniocentesis typically performed, and why?
usually 14 -1 6 weeks for genetic evaluation or to assess NTDs
why might amniocentesis be used later in pregnancy?
assessing lung maturity, r/o amnionitis or fetal hemolytic disease
risks associated with amniocentesis (5)
infection, bleeding, preterm labor, PROM, fetal loss
what is a special precaution that needs to be taken with amniocentesis?
if the patient is Rh- and at risk for isoimmunization, you gotta give RhoGAM with the procedure
What is CVS and what is it used for?
sampling of the chorionic villi from the placenta (outer trophoblastic layer has the same genetic make up as the fetus) to look at genetic stuff
when is CVS typically performed?
between 10 and 13 weeks
risks with CVS (3)
infection, bleeding, miscarriage
can you do CVS in the case of maternal blood group sensitization?
nope, contraindicated
What is a nonstress test?
it’s when we can look at fetal well-being by watching the FHR response to fetal movement
Why might an NST be indicated?
decreased fetal movement post-term DM HTN IUGR
What is a reactive NST result?
2+ accels of 15 or more bpm lasting 15 or more seconds within a 15 -20 min period for > 32 weeks
2+ accels of 10 or more bpm lasting 10 or more seconds within a 15 - 20 min period for 28 - 32 weeks
What is a nonreactive NST result?
Criteria unmet within 40 minutes; need further eval (could be repeat, BPP, or CST)
What is an inconclusive/unsatisfactory NST result?
can’t tell, gotta repeat
what are 5 factors that can affect an NST result?
fetal sleep, smoking within 30 minutes before test, maternal intake of medications, fetal central nervous system anomalies, fetal hypoxia or acidosis
What is AFV?
amniotic fluid volume measurements
Expected range for single deepest pocket in an AFV measurement?
2 - 8 cm
What is AFI?
a way to measure AFV wherein you divide the uterus into 4 quads and and measure deepest verticle pocket in each and then sum them
normal is 5 - 24 cm
What are the five components of a BPP?
NST muscle tone breathing movements gross body movements AFV
how does BPP scoring work?
each variable gets a score from 0 (abnormal) to 2 (normal) total it 8 - 10 = normal 6 is equivocal (repeat) 4 or less is abnormal
what do you need to see in each category within what timeframe?
30 minutes (after NST) breathing = 1 or more episode(s) body movement = 3 or more discrete movements tone = 1 or more episodes of extension with return to flexion AFV = 1 or more pocket >2 cm NST = reactive
maternal effects related to consuming alcohol while pregnant (6)
preeclampsia placental abruption placenta previa spontaneous abortion ectopic pregnancy PROM
infant effects related to maternal consumption of alcohol while pregnant (4)
FASD (fetal alcohol spectrum disorders): physical, behavioral, intellectual disabilities that last a lifetime
also: low birth weight/growth
heart, kidney problems
brain damage
What are two screening tools we can use for alcohol misuse?
CAGE & TWEAK
What does the CAGE screening tool stand for?
ever felt the need to Cut down on drinking?
ever been Annoyed by people criticizing your drinking?
ever felt Guilty about drinking?
ever had drink first thing in the AM (eye opener?)
What does the TWEAK screening tool stand for?
Tolerance Worried Eye-openers Amnesia Cut down
Risks associated with nicotine use during pregnancy?
higher stillbirth risk
maternal: preeclampsia, placental abruption, placental previa, SA, ectopic, PROM
infant effects: IUGR, premature birth, small for GA
OB complications associated with drug use
NAS birth defects low birth weigh premature birth small head circumference SIDS
Symptoms of NAS
up to 14 days after birth
blotchy skin, diarrhea, CRYING, abnormal suckling reflex, fever, hyperactive reflexes, increased muscle tone, irritability, poor feeding, rapid breathing, seizures, sleep problem, slow weight gain, nasal congestion and sneezing, sweating, trembling, vomiting
What are the most common infections during pregnancy associated with congenital disease?
TORCH infx: Toxoplasmosis Other (syph, varicella-zoster, parvovirus B19) Rubella CMV Herpes
How to prevent Toxo
cook meat to 145 and poultry to 160 no unpasteurized milk or cheese avoid kitty litter avoid untreated water good handwashing or glove use when gardening
Preventing Varicella-Zoster (Herpes virus)
vaccinate 4 weeks prior to conception or PP
VZIG for exposure
Preventing fifth disease (parvovirus)
handwashing, avoid contact with sick people, avoid touching mouth/eyes/nose
Prevention of rubella
vaccinate preconception or PP
which is the most common congenital infection?
CMV
CMV infant mortality rate?
30%
Prevention of CMV
handwashing, avoid contact with sick people, avoid touching mouth/eyes/nose
what type of HIV screening occurs for pregnant patients?
opt-out screening
biggest predictor for vertical transmission of HIV?
viral load
when would a c be indicated for a patient with HIV?
if viral load is > 1000; C at 38 weeks
is breastfeeding okay for a patient with HIV?
not recommended
Prevention for Zika?
avoid travel to areas with Zika
condom use for anyone with Zika or possibly exposed
protect against mosquito bites
types of IUGR
symmetric and asymmetric
when does symmetric IUGR occur?
early in pregnancy
what can cause symmetric IUGR? (3)
congenital infection
chromosomal abnormality
maternal drug use
when does asymmetric IUGR occur?
later in pregnancy
what are the 2 main etiologic pathways of asymmetrical IUGR?
reduced nutrition to fetus
abnormal uteroplacental perfusion (head-sparing appearance)
maternal causes of asymmetric IUGR (4)
HTN, anemia, collagen disease, insulin-dependent DM
placental causes of asymmetric IUGR (4)
previa, abruption, malformations, infarctions
fetal causes of asymmetric IUGR (2)
multiple gestation, anomalies
definition of macrosomia
> 4000 g at birth or more than 90th percentile in weight for GA
dizygotic twins
2 separate ova fertilized by 2 separate sperm
monozygotic twins
splitting of a single fertilized egg
when do dichorionic diamniotic twins split?
days 0 - 3
when do monochorionic diamniotic twins split?
days 4 - 8
when do monochorionic monoamniotic twins split?
days 9 - 12
what happens after day 13 to MZ twins that haven’t split?
conjoined twins
what is the definition of a postdates pregnancy?
pregnancy that continues beyond 42 weeks gestation
complications associated with postdates pregnancy
shoulder dystocia (macrosomia) oligohydramnios uteroplacental insufficiency neonatal meconium aspiration stillbirth
what do we begin at 41 weeks for possible postdates management?
biweekly NST/AFI or BPP
expectant management and delivery for postdates
consider induction when cervix is ripe prostaglandins to promote cervical ripening inducing labor deliver if fetal compromise or oligo possible meconium staining of fluid
antepartum management of obesity in pregnancy (5)
US 18 - 24 weeks to detect anomalies and soft markers for aneuploidy US Q 4-6 weeks to monitor fetal growth weekly NSTs starting at 32 weeks prior OSA needs specialty evaluation early GDM screening with GTT
postpartum management of obesity in pregnancy
higher risk for VTE (meds a
nd non-pharm interventions)
define: hyperemesis graviadrum
persistent vomiting during pregnancy without another cause
incidence of HG
0.3 - 3% of pregnancies
theoretical considerations for etiology (3)
hCG correlation (peak of hCG often coinceds with severe symptoms estrogen correlation (lower levels of estrogen associated with lower incidence of n/v in pregnancy evolutionary adaptation to avoid certain foods that could be dangerous
risk factors for HG (4)
hx of HG in previous pregnancy, fam hx of HG, motion sickness, migraines
typical dx criteria for HG (4)
severe/intractable vomiting with unknown etiology
weight loss of at least 5% ofpre-pregnancy weight
ketonuria
electrolyte imbalance (thyroid/liver lab abnormalities)
what is the assessment tool we use for n/v during pregnancy? and what does it ask about? (3)
PUQE
length of nausea symptoms during a given day
# of times vomiting during a given day
# of times retching/dry heaving during a given day
what are the score break downs for the PUQE assessment tool
mild =6
moderate 7-12
severe >/=13
nonpharm options for HG (7)
multivitamins frequent small meals avoid spicy or fatty foods bland foods before getting out of bed avoiding triggering odors or other stimuli ginger 1 g per day divided doses acupressure/acupuncture
pharm options for HG (5)
Pyridoxine (B6) 10 - 25 mg QUID/TID PO Diclegis (pyridoxine + doxylamine 10mg/10mg PO) for moderate 2 tabs before bed, for severe 4 tabs (morning, afternoon, 2 before bed) metoclopramide 5 - 10 mg Q6-8h PO Promethazine 25 mg Q4h rectal supp Zofran (sketchy)
if HG unresponsive to medical therapy or weight unmaintainable, what could we do?
enteral tube feeds
if liquids intolerable and outpatient treatment not working for HG, what could we do?
hospitalize for IV rehydration, antiemetic therapy and nutritional support
define 1st trimester bleeding
bleeding that occurs within the first 12 weeks of pregnancy
differentials for 1st trimester bleeding (9)
implantation bleeding, threatened abortion, ectopic pregnancy, cervicitis, cervical polyps, vaginitis, trauma/intercourse, disappearing twin, autoantibody/autoimmune disorder
When is serum hCG positive after fertilization?
8 - 9 days
how does beta hCG increase with a normal pregnancy?
doubles every 2 days
according to the rule of 10, what is beta hCG at missed period? at 10 weeks? at term?
100, 100,000, 10,000
90% of ectopic pregnancies have less than ____ beta hCG?
6500
define spontaneous abortion
occurs without apparent cause
define threatened abortion
signs/symptoms of possible loss of fetus
define inevitable abortion
cervix is dilating and the uterus will be emptied
define incomplete abortion
part of the products of conception are retained in the uterus
define complete abortion
all products of conception have been expelled
define missed abortion
fetus died prior to 20 weeks, but contents were retained for 2 or more weeks
define recurrent pregnancy loss
3 or more consecutive abortions
etiology of abortion?
fetal chromosomal abnormalitiy (common)
maternal parity, short interpregnancy interval, maternal/paternal age
when should an IUP be visualized transabdominally? transvaginally?
hCG 6500, 2000
in general, how do we manage abortion?
blood type, baseline beta hCG and repeat in 48 hrs, US, RhoGAM for unsensitized Rh- patients
options for managing an inevitable or incomplete abortion?
D & C (surgical or chemical)
expectant management
emotional support/anticipatory guidance
options for managing a threatened abortion or disappearing twin?
pelvic rest
emotional support/anticipatory guidance
define ectopic pregnancy
implantation of the blastocyst anywhere other than the endometrium
risk factors for ectopic pregnancy (7)
STI, therapeutic abortion followed by infection, endometriosis, previous pelvic surgery, failed bilateral tubal, scarring of tubes, hormonal alteration of tubal motility/menstural reflux (functional)
symptoms of ectopic pregnancy (3)
amenorrhea with frequent vaginal spotting
lower pelvic/abdominal pain (unilateral)
unilateral tender adnexal mass
components of the clinical picture for an ectopic pregnancy (6)
severe abdominal pain CMT free fluid on US cul-de-sac fullness should pain s/t diaphragmatic irritation vertigo/fainting
how to manage an ectopic pregnancy?
transfer to medical management (goal is to preserve the tube)
methotrexate
RhoGAM for Rh- patients
how does hydatiform mole or trophoblastic disease manifest? (6)
AUB size/dates discrepancy lack of fetal activity HG gestation HTN passage of vesicular tissue
management of mole?
evacuate the uterus by suction curettage
close surveillance for persistent trophoblastic proliferation or malignant changes
rec avoid pregnancy for 1 year
serial beta hCG levels Q2 weeks until normal, then once a month for 6 mos, then Q2mos for 1 year
possible causes of mid-trimester SA (4)
autoimmune, cocaine, anatomic/physiologic factors, infection of cervix/vagina
symptoms of cervical insufficiency (4)
painless dilation, bloody show, spontaneous ROM, vaginal/pelvic pressure
risk factors for cervical insufficiency (3)
previous mid-trimester loss, cervical surgery, DES
treatment for cervical insufficiency
consultation
cerclage after 12 - 14 weeks
monitor cervical length with TV US
risks of cerclage
ROM and infection
incidence of low-lying placenta in 1st trimester
1/3
what are the three locations for placental abruption?
subchorionic (between placenta and membranes)
retroplacental (between placenta and myometrium, worse prognosis)
preplacental (between placenta and amniotic fluid)
what is predictive of fetal survival in association with abruption?
the size of the hemorrhage
when should you NEVER perform a digital vaginal exam on a pregnant patient?
3rd trimester bleeding UNLESS you know for sure there is no placenta previa
what is placenta previa?
when the placenta is located over or next to the internal oss
what are the degrees of previa?
partial, marginal, complete
risk factors for previa (3)
multiparity
previous C or uterine surgery
smoking
PRIMARY symptom of placenta previa?
PAINLESS vaginal bleeding
secondary symptom of previa?
unengaged fetal presentation and/or malpresentation
management of complete previa
medical management and C
management of partial, marginal previa?
observant until delivery
hospitalize if bleeding
possible tocolytic therapy
possible to deliver vaginally, will need immediate access to C
what is placental abruption?
the premature sepaation of the placenta from the uterus (can be partial or complete)
risk factors for abruption (6)
HTN, trauma, smoking, cocaine, multiparity, uterine anomalies or tumors
symptoms of abruption (4)
vaginal bleeding
uterine tenderness and rigidity
contractions or uterine irritability/tone
fetal tachy or brady
complications from abruption (3)
DIC
shock
fetal compromise/death
management of abruption (4)
COLLAB
monitor clotting studies and crit/hgb, platelets
stabilize mother
delivery as indicated by fetal or maternal condition
what is placenta accreta?
when the placenta invades the myometrium of the uterine wall
risk factors for accreta (6)
AMA previous C multiparity prior uterine surgery Asherman's previa
symptoms of accreta?
often none
sometimes vaginal bleeding
management of accreta
COLLAB
early dx
delivery where hemorrhage can be managed
possible risks/effects of epilepsy for a pregnant patient (8)
increase in seizure frequency and severity increase in maternal mortality preeclampsia preterm labor stillbirth increased risk of C increased risk of miscarriage PPH
possible risks to fetus of epilepsy during pregnancy (2)
growth restriction/LBW
birth defects because of medication
how do we manage epilepsy in pregnancy?
med therapy is key but not always effective (mono is best if possible)
adjust dose bc pharmokinetic metabolism changes in pregnancy
it’s helpful to know/monitor prior to pregnancy (9-12 mos w/o seizures is promising)
don’t use valproate
folic acid!!!
definition/range of thrombocytopenia?
low platelets, usually <150
managing thrombocytopenia?
draw platelets at each prenatal visit and 1-3 months PP
consider consult if warranted
managing idiopathic thrombocytopenic purpura (ITP)?
corticosteroids and IV immunoglobulins may be required
is GERD common in pregnancy?
you bet, 40 - 80% of pregnancies are affected
what is GERD?
the movement of gastric contents into the esophagus
what causes GERD in pregnancy?
estrogen and progesterone impact the lower esophageal sphincter
enlarging uterus too
all of this increases thoracic pressure
risk factors for GERD in pregnancy (4)
certain foods/beverages
medications
overeating or eating quickly
lying down after eating
2 important differentials for GERD in pregnancy?
HELLP and preeclampsia
symptoms of GERD (4)
burning/pain
sleep disturbance
n/v
cough/hoarseness
med management of GERD (3)
Mg hydroxide or trisilicate
Histamine-2 receptor agaonists (ranitidine)
avoid sodium carbonate antacids
important symptoms associated with GERD to report despite medication (5)
interrupted sleep difficulty swallowing weight loss blood in sputum/vomit black stools
what are the physical and anatomical changes associated with pregnancy that increase VTE risk? (5)
hypercoaguability increased venous stasis decreased venous outflow compression of the vena cava & pelvic veins from enlarging uterus decreased maternal mobility
types of VTE
DVT most common
PE (starts as DVT and moves to lungs)
risk factors for VTE (15)
pregnancy/PP hx/fam hx of VTE inheritied thrombophilia sickle cell autoimmune disorders DM HTN/preeclampsia heart disease BMI > 30 AMA varicose veins smoking multiple gestation C hospitalization
effects of VTE (5) both maternal and fetal
recurrent thrombosis ulceration post-thrombotic syndrom maternal death fetal compromise or death
how to medically manage VTE (tx or prophylaxis)
HEPARIN no warfarin
what are the two main types of fetal malpresentation?
breech and shoulder
what are the types and descriptions of breech position?
Breech - buttocks in the lower pole
Frank = legs extended up over abdomen and chest
Complete = legs are flexed at hips and knees
Footling = one or both feet or knees are lowermost
etiology for breech (5)
uterine septum fetal anomaly fetal attitude previa conditions that result in abnormal fetal movement or muscle tone
risks associated with breech (3)
labor dystocia, cord prolapse, fetal head entrapment
management options for breech (4)
external cephalic version
moxibustion
C?
webster maneuvers
criteria for external cephalic version
normal AFI
reactive NST
EFW 2500 - 4000 g
can a should presentation with transverse lie be a candidate for a vaginal birth?
No
etiology of shoulder presentation (4)
multiparity
previa
poly
uterine anomalies
management of shoulder presentation
similar to breech - ECV, moxi, C?, webster
define: chronic htn
bp over 140/90 diagnosed before pregnany, before 20 weeks, or after 12 weeks pp
define: GHTN
new-onset high BP after 20 weeks gestation without proteinuria
define: chronic HTN with superimposed preeclampsia
1) chronic htn with new onset proteinura at more than 300 mg in 24 hrs but no proteinuria before 20 weeks
OR
2) a sudden increase in proteinuria or BP or a platelet count of less than 100.000 in women with htn and proteinuria before 20 weeks
define: preeclampsia
pregnancy-specific htn disorder associated with headaches, visual disturbances, epigastric pain, rapid edema development
dx: 2 BP measurements that are >/= 140/90 on 2 separate occasions at least 4 hrs apart after 20 weeks gestation
OR
BP over 160/100 a previousl normotensive woman and proteinuria >/= 300 per 24 hr urine or protein/creatinie ratio >/= 0.3
OR
outside of other quantitiative measures, dipstick 2+
OR
without proteinuria, new onset HTN with new onset:
<100,000 platelets
serum creatinie >1.1 or doubled w/o renal disease
doubling of normal liver enzymes
pulmonary edema
cerebral or visual symptoms
what is HELLP syndrome?
hemolytic anemia
elevated liver enzymes
low platelet count
*can be ante or post partum
define: eclampsia
seizures that cannot be attributed to other causes in a woman with preeclampsia
maintenance goal for pregnant patient with preexisting htn on antihypertensive med(s)?
120/80-160/105
recommendation for pregnant patient with chronic hypertension and who is at great risk for adverse outcomes?
low-dose aspirin 60 - 80 mg, PO daily, starting in late first trimester
if a pt with chronic htn has no other maternal or fetal complications, when is delivery indicated?
not before 38 weeks
first choice antihypertensives for those who require them during pregnany?
labetolol, nifedipine, methyldopa
how to manage preeclampsia without severe features?
assessing maternal symptoms
daily fetal movement counts
2xweekly BP checks
weekly liver and platelet checks
additional rec for management of preeclampsia with severe features?
MgSO4 to prevent eclampsia is recommended in the intra/post partum period
8 risk factors for hypertensive disorders of pregnancy
nulliparity adolescent or AMA multiple gestation fam hx of pree or eclampsia obesity/insulin resistance chronic htn limited exposure to the father's sperm antiphospholipid antibody syndrome/thrombophilia
7 theories as to the cause of hypertensive disorders of pregnancy
abnormal trophoblast invasion coagulation abnormalities vascular endothelial damage cardiovascular maladaptation immunologic phenomena genetic predisposition dietary deficiencies or excesses
antepartum management of hypertensive disorders of pregnancy
diet assessment
adequate fluids
mayyyybe restrict activities
monitor: BP. proteinuria, edema, weight, intake/output, DTRs, subjective symptoms
6 lab tests associated with hypertensive disorders of pregnancy
creatinine Hgb/Hct platelets LFTs 24 hr urine creatinine clearance
assessing the fetus in a patient with a hypertensive disorder of pregnancy
daily movement counts
NST
AFI/BPP
US to monitor growth
main goal of intra and postpartum management of hypertensive disorders of pregnancy?
prevent seizures
main anticonvulsant used during intra/postpartum hyptersensive management?
IV mag
side effects of MgSO4?
flushing, somnolence
MgSO4 overdose signs
loss of patellar reflex
muscular paralysis
respiratory arrest
aggravated by decreased UO bc mag is excreted by kidneys
antidote to Mag?
calcium gluconate
when BP exceeds 160/100 intra or postpartum, how do we manage?
IV labetolol or hydralazine OR IR PO nifedipine (if no IV access)
what BP drug reserved for resistant HTN?
Na nitroprusside
what is not recommended for hypertensive disorders of pregnancy?
diuretics bc we are already volume depleted
incidence of HELLP syndrome
10% of patients with preeclampsia with severe features
5 diagnostics for HELLP
hemolysis abnormal peripheral blood smear increased bili >/= 1.2 elevated liver enzymes (ALT, AST, LDH) platelets less than 100,000
6 treatment/management pieces for HELLP
mag bed rest crystalloids albumin 5 - 25% delivery as indicated plasma volume expansion
eclampsia is basically…
preeclampsia with seizures
how to manage eclampsia? (4)
mag
O2
safety
stabilize and deliver
prevention of pregnancy-induced HTN? (2)
vit d and calcium if at risk and low dietary intake
low dose aspirin can be considered in high-risk pregnancy
define diabetes
endocrine disorder where you have abnormal carb metabolism resulting in inadequate production/utilization of insulin
incidence of diabetes in pregnancy?
7%…86% are GDM
what is the diabetogenic effect of pregnancy?
human placental lactogen acting like an insulin antagonist, and also maybe estrogen and progesterone acting the same way
what do we do w/ regards to DM in pregnancy at the FIRST prenatal visit?
risk assessment
12 high risk factors
overweight/obese physical inactivity hx of GDM prior babe over 9# (LGA) >25 years old fam hx of T2DM AA, hispanic, american indian, alaska native, native hawaiian or pacific islander HTN and/or hx of CVD high HDL and triglycerides PCOS/other insulin resistance conditions A1C > 5.7% being treated for HIV
6 low risk factors
<25 years normal weight prior to pregnancy ethnic group of low dm prevalence no DM in first degree relatives no hx of abnormal glucose tolerance no hx of poor obstetric outcome
when do we screen all pregnant women for DM, regardless of risk?
24-28 weeks
when should we screen for DM in high risk pregnant patients?
ASAP
describe the 2 step screening approach for DM
start with 1 hour 50 g glucose tolerance test
if 130 or more (or 140 or more..??), perform diagnostic 100 g 3 hr test on another day after 8 hours of fasting
need 2 or more abnormals on that test to dx
describe the 1 step screening approach for DM
75 g 2 hr test after 8 hrs fasting measure fasting, 1, 2 hrs you can dx if any one of these values is abnormal: fasting >/=95 1 hr >/=180 2 hr >/= 155
what 6 risk factors, if at least 3 of which are present, increased maternal mortality?
uncontrolled hyperglycemia ketonuria, n/v GHTN, edema, proteinuria pyelonephritis lack of care compliance AMA
main objective of managing diabetes?
strict glucose levels
how many cals/kilo of body weight/ideal body weight?
30
calorie breakdown percentages by meal for DM management
b-25
l-30
d-30
snack-15
sources of calories percentage breakdown
p-20
f-30-35
c-45-50
first line treatment of GMD and why?
insulin, doesn’t cross placenta
possible alternative to insulin?
metformin but crosses placenta
how do insulin requirements change during pregnancy? why?
decreased need during first trimester
increased need during second trimester
linked to HPL levels
what are fetal risks associated with non-gestational diabetes?
NTDs and cardiac anomolies
what do we monitor on US in diabetes?
IUGR, macrosomia, polyhdramnios
what do we begin at 28 weeks in diabetes management?
FMCs
if nutritional adjustments and glucose monitoring are effective, what antenatal testing is indicated?
none
if DM is poorly controlled or medically managed, when do we begin antenatal testing? and what?
32 weeks, BPP & NST
what happens pp to insulin requirements?
usually decrease 24 - 48 hrs after placenta is delivered
screening postpartum for dm?
75 g 2 hr test 6-12 weeks pp
what are the 4 most common thyroid diseases in pregnancy?
non-toxic goiter
hyper and hypo
thyroiditis
how signficant is the impact of pregnancy on maternal thyroid physiology?
GREAT!!
why does the thyroid enlarge during pregnancy?
hyperplasia
increased vascularity
are TSH and T4 affected during pregnancy?
no, no change
how do total serum thyroxine and triiodothyronine concnetrations change in pregnancy?
both increase
symptoms of throtoxicosis or hyperthyroidism in pregnancy?
tachy. thyromegaly, exophthalmos, failure to gain weight
how do we diagnose thyrotoxicosis or hyperthroidism in pregnancy?
elevated free T4, low TSH
risks for untreated thyroid problems during pregnancy? (5)
preeclampsia, stillbirth, IUGR, HF, preterm birth
treatment for thyroid probs during pregnancy?
thioamide drug: prophylthiouracil or methimazole
levels for Fe-deficiency anemia during pregnancy?
1st trim: Hgb < 11.0
2nd trim: Hgb < 10.5
3rd and PP: < 11.0
talk about the etioogy of iron deficiency anemia during pregnancy?
poor nutrition and a consequence of expanding blood volume without proper expansion of hgb
risks associated with iron-def anemia
LBW, premature delivery, perinatal mortality
how do we manage Fe-deficiency anemia?
correct hgb mass deficit and rebuild iron stores
iron replacement therapy with vit c and folic acid
3 mo iron therapy after anemia is corrected
what can cause anemia from acute blood loss during pregnancy? (7)
abortion ectopic pregnancy hydatiform mole placenta previa abruptio placenta placenta implantation abnormalities pp hemorrhage
etiology of megaloblastic anemia
usually folic acid deficiency
signs of megaloblastic anemia
n/v, anorexia
fetal risks of megaloblastic anemia
NTDs
prevention of megaloblastic anemia
folic acid 0.4mg daily normally
4 mg daily prior to and during pregnancy for women with a hx of previous infant with NTD
how to manage ss anemia in pregnancy?
fetal surveillance after 32-34 weeks
monitor and manage pain crises
definition of post partum period?
6 weeks initially after delivery
reviewing patient history pp: 7 pertinent diagnostic tests to know about
blood type/Rh rubella titer status hep b status HIV status RPR genetic testing group b strep
PP assessment (normal vs abnormal): tired but happy
normal
PP assessment (normal vs abnormal): unhappy, dissatisfied
abnormal
PP assessment (normal vs abnormal): 98.6-100.4 degrees
normal
PP assessment (normal vs abnormal): temp greater than 100.4
abnormal, consider infx, PE
PP assessment (normal vs abnormal): pulse 65-80
normal
PP assessment (normal vs abnormal): pulse >80 or < 65
abnormal, consider infx, blood loss, PE
PP assessment (normal vs abnormal): RR 12-16
normal
PP assessment (normal vs abnormal): RR < 12
abnormal, consider OD narcotics, atelactesis, pneumonia
PP assessment (normal vs abnormal): RR >16
abnormal, consider anxiety, pain
is it normal for there to be a transient increase in BP after delivery?
yes, by 5% for up to 4 days
PP assessment (normal vs abnormal): BP > 140/90
abnormal, evaluate for pp hypertensive disorder
PP assessment (normal vs abnormal): BP < 90/60
abnorma, consider blood loss, med reaction
PP assessment (normal vs abnormal): A&O x 3
normal
PP assessment (normal vs abnormal): disoriented, excessive sedation
abnormal
PP assessment (normal vs abnormal): no chest pain, regular HR and rhythm
normal
PP assessment (normal vs abnormal): chest pain, tachy, palpitations
abnormal
PP assessment (normal vs abnormal): no SOB, clear lung fields, breathe w/o difficulty
normal
PP assessment (normal vs abnormal): SOB, adventitious breath sounds
abnormal
PP assessment (normal vs abnormal): sore nipples
normal
PP assessment (normal vs abnormal): colostrum and breast fullness for 3-5 days
normal
PP assessment (normal vs abnormal): painful, cracked, bruised, bleedings nipples
abnormal
PP assessment (normal vs abnormal): no breast filling by day 5
abnormal
PP assessment (normal vs abnormal): BM 2-3 PP
normal
PP assessment (normal vs abnormal): decreased abdominal muscle tone
normal
PP assessment (normal vs abnormal): diastasis recti
normal
PP assessment (normal vs abnormal): fundus is midline and firm
normal
PP assessment (normal vs abnormal): n/v, diarrhea, constipation, abdominal pain
abnormal
PP assessment (normal vs abnormal): distended abdomen
abnormal
PP assessment (normal vs abnormal): unable to palpate uterus
abnormal
PP assessment (normal vs abnormal): non-midline fundal height, height is increasing out of line of PP day
abnormal
PP assessment (normal vs abnormal): signs of infection on surgical scar, not well approximated
abnormal
PP assessment (normal vs abnormal): diuresis
normal
PP assessment (normal vs abnormal): burning, retention, incontinence, lack of sensation or urge to void
normal (first 2 days)
PP assessment (normal vs abnormal): dysuria, persistent retention/incontinence, bladder distention, CVA tenderness
abnormal
PP assessment (normal vs abnormal): mild erythema, bruising, edema of the perineum
normal
PP assessment (normal vs abnormal): worsening perineal symptoms
abnormal
PP assessment (normal vs abnormal): perineal hematoma
abnormal
PP assessment (normal vs abnormal): episiotomy/lac repair showing signs of separation
abnormal
PP assessment (normal vs abnormal): malodorous lochia or excessive amounts of lochia with clots
abnormal
PP assessment (normal vs abnormal): pink hemorrhoids
normal
PP assessment (normal vs abnormal): deep blue or purple hemorrhoids
abnormal
PP assessment (normal vs abnormal): sore muscles in lower extremeties
normal
PP assessment (normal vs abnormal): bilateral, symmetric edema of lower extremeties
normal
PP assessment (normal vs abnormal): unilateral leg pain
abnormal
PP assessment (normal vs abnormal): unilateral calf tenderness
abnormal
PP assessment (normal vs abnormal): one leg more edematous than the other
abnormal
what. isinvolution
the process of the uterus returning to th epre-pregnant state
3 steps of involution?
1) contraction of uterus
2) autolysis of myometrial cells
3) regeneration of the epithelium
is involution the result of a reduction in cell number or cell size?
CELL SIZE
how much the fundus descends each day
1 cm
what might a fundus that is not midline indicate?
subinvolution, probably because of a full bladder
where is the uterus immediately after delivery? what size is it?
1/2 way between the umbilicus and symphysis pubis and it is the size of a grapefruit
where is the uterus 12 hours post delivery?
@ level of umbilicus
by what time after delivery should the uterus/fundus not be able to be palpated?
2 weeks
what happens by 6 weeks post delivery to the uterus?
returns to slightly larger than pre-pregnant size
what are the 3 components of lochia?
eschar, decidual cells, myometrial placental bed
what are the 3 stages of lochia?
rubra, serosa, alba
when do we see rubra?
first 3-7 days
when do we see serosa?
day 14-21
when do we see alba?
until cessation of flow 4-6 weeks post partrum
color of rubra, serosa, alba?
red/red-brown
pinkish-brown
yellow/white
content of rubra?
decidua, lanugo, meconium, necrotic placental remains, cellular remains from vernix
content of serosa?
blood, mucus, erythrocytes, leukocytes, decidual tissues
when is colostrum produced?
upon birth, sometimes even in 3rd trimester
when does engorgement occur?
approx. 72 hours after birth
where does human milk production begin and then where does it go from there?
upper-outer glands, then fills medially and inferiorly
when does let-down reflex develop (milk ejection)?
first 1-2 weeks
3 positive reactions to childbearing?
achievement, empowerment/strength, new baby thrill
4 negative reactions associated with childbearing?
frustration with breastfeeding if challenging
disappointment if l/d didn’t go as planned
body mistrust if birth was premature or birth process wasn’t completed as hoped
loss for individual self
what is bonding?
mother to infant connection, it is affective/behavior/chemical
how can we facilitate bonding?
skin to skin immediately after delivery and avoiding separation in the early/immediate pp period
what is attachment?
mother to infant interaction (face to face, skin to skin) how mother responds to infant’s needs
timeline for pp blues
within 3-5 days of birth up to 1-2 weeks pp
etiology of pp blues
profound shifts in hormones
pp depression timeline
occurs anytime within 4 weeks after childbirth or 3, 6, 8, 12 months after childbirth
symptoms of pp depression (5)
sleep disturbance, feeling overwhelmed, anxiety, irritability, unable to perform ADLs
one of the differences between pp blues and pp depression (progression)
blues usually improve
depression symptoms do not improve over time…likely to worsen
how do we screen for PP depression
EPDS
what are other (4) things we should rule out with pp depression symptoms
pp thyroiditis
anemia
infection
sleep deprivation
prevalence of blues, depression, psychosis
up to 80%
6.5-12%
1-2/1000 births
dx pp depression
DSM 5 criteria
tx pp depresssion, 1st line
SSRIs, usually oaky with breast feeding
4 symptoms of pp psychosis
hallucinations (auditory/visual disturbances), disorganized thinking, bizarre speech/behavior, delusions
when is it typical for ovulation to return for a patient who is non-breast feeding?
around 39 days pp
typical recommendation for return to sexual activity?
pelvic rest for 4-6 weeks, many return to intercourse earlier than that.
how long do pregnant patients continue to be ina hypercoagulable state after delivery? why?
3-4 weeks, physiologic adaptive mechanism to prevent hemorrhage
what should be avoided during this 3-4 weeks of hypercoaguability after birth?
estrogen
impact of hormonal contraception on lactation is _____
contraversial
can a patient be fitted/use a cap/diaphgrahm right away after birth?
no, must wait until involution is complete
what are the 3 criteria for the lactation amenorrhea method to be used?
no menses
infant is < 6 mos
breastfeeding Q4hrs during the day, Q6hrs at night, no solid food subs yet
old guidelines for pp folllow-up?
6 weeks after delivery, now ACOG suggests sooner
if the patient is high risk, when do we follow-up pp?
1-2 weeks after delivery
you have a patient who plans to breastfeed, wants long acting reversible contraception as soon as possible, and just delivered the placenta < 10 minutes ago. what BC option is best?
Cu-IUD
you have a patient who does not plan to breastfeed, wants long acting reversible contraception as soon as possible, and just delivered the placenta < 10 minutes ago. what BC option is best?
LNG-IUD
absolute contraindication to any IUD?
post partum sepsis
absolute contraindication to COCs?
<21 days PP and either breastfeeding or not
how do we diagnose urinary retention post-partum? (4)
can’t void spontaneous 6-8 hrs after birth or after removal of cath
residual > 150 ml
palpable bladder
fundus displaced/not midline
5 risk factors for PP urinary retention
epidural operative vaginal delivery episiotomy or lac LGA primiparity
how might we manage urinary retention?
cath, referral to urology
define pospartum fever/infection
> /= 100.4 x2 during pp days 2-10
3 differentials for pp fever (3 common, 3 less common)
endometritis wound infection UTI transfusion reaction drug raction septic pelvic thrombophlebitis
gold standard tx choice for uterine infection/endometritis
clindamycin and gentamycin
can add vanc if staph is suspected
what is the leading cause of maternal mortality worldwide?
PPH
PPH is defined as…(ACOG)
EBL 1000mL regardless of delivery route
blood loss accompanied by signs/symptoms of hypovolemia within 24 hrs of birth
traditional definition of PPH
EBL 500 vaginal
EBL 1000 c
8 risk factors for PPH
prolonged labor/prolonged use of oxytocin chorioamnionitis high parity twins. multiple gestation polyhydramnios macrosomia operative vaginal delivery precipitous delivery
7 primary etiologies for PPH
uterine atony obstetrical trauma lacs retained placenta placenta accreta coagulation defects inversion of the uterus
what part of the breast supports the shape?
cooper’s ligaments
how many milk ducts are in each breast? where do they converge?
4-18, at the nipple
describe a basic glandular unit
contains 4-18 lobules, each with alveoli responsible for milk ejection
which part of the breast is located in the areola and are sebaceous glands that provide protective secretion/lubrication to the nipple?
Montgomery tubercles
when does lactogenesis 1 occur?
early pregnancy to 3rd day postpartum
what occurs during lactogenesis 1?
small amounts of colostrum are secreted
100ml breastmilk produced on postpartum day 1
what is contained in the fluid produced during lactogenesis 1?
immunoglobulins, lactoferrin, oligosaccharides
when does lactogenesis. 2occur?
pp days 2-4
what is lactogenesis 2 initiated by? (3)
delivery of placenta
decrease in progestin
increase in prolactin
how much milk is produced during lactogenesis 2 on day 4
500 ml
which stage of milk production do patients typically refer to their milk coming in?
lactogenesis 2
when does lactogenesis 3 occur?
between days 7 and 14 pp
characterize lactogenesis 3 (4)
mature milk
maintenance of milk
supply-demand
discuss the supple-demand relationship with regards to lactation
suckling stimulates nipple/areola
hypothalamus receives message to secrete prolactin and oxytocin
prolactin stimulates milk production
oxytocin stimulates let-down (contraction of myoepithelial cells)
contraindications to breastfeeding (3)
maternal infection
illicit drug use
meds
maternal infections contraindicated for breast feeding (5)
HIV
herpes, active lesion on nipples and breasts
flu
untreated TB
varicella developed 5 days prior to birth to 2 days after delivery
medicaitons contraindicated for breastfeeding (6)
antiretrovirals anticonvulsants chemo radiation retinoids statins
interventions (5) for breast engorgement?
acupuncture hot/warm before feed, cold after cabbage leaves breast massage hand expression
2 possible meds for insufficient milk supply?
domperidone
metoclopramide
diagnostic criteria for mastitis (3)
erythematous/edematous wedge-shaped area in the breast, unilateral
fever >/= 101.3
flu-like symptoms
first line treatment for mastitis
dicloxacillin or flucloxacillin 500 mg PO QID x 10-14 days
cephalexin 500 mg QID X 10-14 days
clindamycin 300 mg QID or erthromycin 250 mg or 500 mg QID X 10-14 days if allergic to penicillin
what is abreast abcess?
a collection of pus in the breast, surrounded by inflammation
how do we diagnose and treat an abscess?
exam & US for dx
surgical drainage, needle aspiration
antibiotics
