Obstetrics - Exam 1 Flashcards
Define the obstetrical terms: Gravity, parity and the TPAL system
Gravity: number of times a woman has been pregnant
Parity: number of pregnancies that led to a birth at or beyond 20 weeks
Define the following terms: nulligravida, primigravida, multigravida
Nulligravida – a woman who currently is not pregnant and never has ever been pregnant
Primigravida – a woman who currently is pregnant and has never been pregnant before
Multigravida – a woman who currently is pregnant and who has been pregnant before
Define primipara and multipara
Primipara – a woman who has been delivered only once of a fetus or fetuses born alive or dead with an estimate length of gestation of >20weeks
Multipara – a woman who has completed 2 or more pregnancies to 20 weeks gestation or more
What are the trimester breakdowns by week?
1st Trimester until 14 weeks gestation
2nd Trimester from 15 weeks until 28weeks
3rd Trimester from 29 weeks until 42 weeks
______ is one a s/s of pregnancy. When does it become a reliable indicator?
Amenorrhea
10 days or more after expected menses
some women have _______ from blastocyst implantation and can mistake this as their ______
implantation bleeding
menses
What is the Chadwick sign? What does it possibly indicate? What are 2 additional lower reproductive tract changes that occur with pregnancy?
Vaginal mucosa appears dark-bluish/red and congested
pregnancy but NOT a conclusive sign
cervical softening and mucus
What is the Hegar sign? What does it possibly indicate?
isthmus softening of the uterus
pregnancy
What are some breast changes that occur during pregnancy?
breast tenderness, increased size of breast and nipple
areola becomes more deeply pigmented
When can mom start to feel fetal movement? give primigravida and mutligravida timelines
Primigravida may not feel till 20 weeks gestation
Multigravida may feel around 16-18 weeks gestation
B-hCG has a similar _____ to what 3 hormones? What is it produced by?
similar alpha unit to LH, FSH and TSH
Produced by syncytiotrophoblasts following implantation
How can B-hCG be detected? What is it’s role?
in both blood and urine
B-hCG prevent involution of the corpus luteum
What are some causes that could make a pregnancy test be a FALSE positive? Which one is the most common?
**heterophilic antibodies: urine test would be negative- MC
Exogenous hCG injection for weight loss
Renal failure with impaired hCG clearance
Physiological pituitary hCG
hCG producing tumors usually in the GI tract, ovary, bladder or lung
If monitoring hCG levels, values should DOUBLE every ________. In order for home pregnancy tests to be the most accurate, when should pt’s take them? Why? What is the minimum level to be detected?
1.4 - 2.0 days
Should use with first urination of the day because urine is the most concentrated at that time
Require β-hCG of 12.3 mIU/mL to detect 95% of pregnancies
______ is the FIRST sonographic evidence of pregnancy. What is it made of? When is it first seen?
Gestational sac
small anechoic fluid collection within endometrial cavity
4-5 weeks of gestation
_______ confirms with certainty an intrauterine location. What does it look like? When can you see it?
Yolk sac
brightly echogenic ring with an anechoic center
Seen around 5-6 weeks gestation
When can a fetal pole/embryo be seen?
seen after 6 weeks
______ is the measure from head to butt at ______ is when it shows up best. Can be used up to ___ weeks to predict estimate due date
crown rump length
6-12 weeks
12 weeks and accurate within 4 days
What is Naegele’s Rule with estimating date of delivery? **What is the most accurate tool for gestational age assignment?
LMP + 7 days - 3 months = EDD
**US in the first trimester crown rump length
What is important to ask a pt regarding their obstetrical hx? menstrual hx?
Prior pregnancies – vaginal or C-section
Prior complications
Infertility components
Interval between menses
Contraceptive use
During the first bimanual exam, what size will the uterus be in the mom is 6 weeks, 8 weeks, 12 weeks? Also need to screen for _____ and ______
Small orange 6 week size
Large orange 8 week size
Grapefruit 12 week size
Chlamydia and Gonorrhea testing
Why is it important to test blood type during the first visit? What do you do if it comes back negative?
need to screen for Rh factor
is mom is negative she needs RhoGam
What is the recommended RhoGam schedule for Rh negative moms?
RhoGAM at 28 weeks
RhoGAM should be given if vaginal bleeding or trauma prior to this time
RhoGAM should be given postpartum if infant is Rh positive
What is the dosing recommendations for RhoGam? What is the test called?
0.3mg of Rh IgG will eradicate 15mL of fetal red blood cells. Equivalent to 30mL of fetal blood
Kleihauer-Betke
What does the Kleihauer-Betke test for?
Tests the amount of fetal red blood cells in the maternal circulation
In cases of trauma or abruption, can perform test and administer additional RhoGAM if necessary
______ is a common infectious cause of fetal growth restriction and is worse in the _____ trimester
rubella
FIRST
What is the tx for rubella? When should pts get vaccined?
no specific tx
at least 1 month BEFORE getting pregnant, preg women CANNOT get MMR while pregnant because it is a LIVE vaccine
What causes syphilis? What is the tx?
Treponema pallidum
Penicillin G
What is the tx for syphilis is the pt is allergic to PCN?
Women with Penicillin G allergy should have either a oral stepwise penicillin dose challenge or skin testing performed
If allergy confirmed, penicillin desensitization is recommended
What is the recommended dose of folic acid for a preg pt? What is hx of neural tube defects?
400 μg of folic acid
at least 4mg per day!!
Maternal _____ is correlated with infant birth weight. What is the recommended additional calorie requirements?
weight gain
100-300 calories per day
What is the guideline regarding seafood in pregnancy? Should get a blood ____ test if certain risk factors are identified
Most fish and shellfish contain mercury which should be avoided in pregnant and lactating women
blood lead if at high risk
How should a pregnant women wear her seat belt?
Recommend wearing three point restraints throughout pregnancy while riding in automobiles
Place lap belt under abdomen and across upper thighs
When is it safe for a preg women to fly? Dental tx?
Pregnant women can safely fly up to 35 weeks gestation
normal dental tx is fine for preg women
What is the max caffeine intake for preg pt?
less than 200mg
any higher and have increased risk of abortion
T/F: Preg women can safely scuba dive until 32 weeks
FALSE preg women should not scuba dive due to decompression sickness
What is the breastfeeding recommendation? How often?
Exclusive breast feeding is preferred until 6 months
feed 8-12 times daily for approximately 15mins at a time
What are the 8 CI to breastfeeding?
Use of street drugs or uncontrolled alcohol intake
Infant with galactosemia
HIV
Hepatitis C with cracked nipples or broken skin
Active tuberculosis
Certain medications
Women undergoing breast cancer treatment
Active herpes lesions on the breast
What are the genetic disorders that the following ethnic groups are at the highest risk for?
African Americans
Mediterranean
Asian
Jewish
North European Caucasians
Native Americans
African Americans Sickle Cell
Mediterranean Beta thalassemia
Asian Alpha Thalassemia
Jewish Tay Sachs, Canavan Disease, Cystic Fibrosis
North European Caucasians Cystic Fibrosis
Native Americans Cystic Fibrosis
______ should be provided to every preg women. If positive, what is the next step? What does it NOT replace?
carrier screening
pt’s partner should be offered testing
Prenatal carrier screening does not replace newborn screening, nor does newborn screening replace the potential value of prenatal carrier screening
What is the FDA pregnancy classification system?
**What are the normal prenatal visit schedule for routine care?
Every 4 weeks until 28 weeks
Every 2 weeks until 36 weeks
Every week until delivery
What is monitored at every pre-natal visit moving forward?
fetal heart rate
fetal growth
What is a normal fetal heart rate? When is it detected?
110-160bpm
detectable at 10 weeks via doppler
Describe the normal trend for a healthy pregnancy in terms of fetal growth
Fundal height used to monitor fetal growth and amniotic fluid volume
At 12 weeks, the fundus is emerging from the bony pelvis
At 16 weeks, fundus is between the pubic symphysis and the umbilicus
At 20 weeks, fundus is at the umbilicus
Between 20-34 weeks, the height of the uterine fundus measured in centimeters correlates closely with gestational age
–> Ex: At 25 weeks, the fundal height will be 25 centimeters
How is the fundal height measured?
When is the anatomy scan typically done?
Anatomy ultrasound (around 18 weeks)-basic scan for all the organ systems to make sure they are healthy
What symptoms do you need to ask mom at every prenatal visit?
Leakage of fluid
Contractions
Nausea and vomiting
Pelvic pain
Bleeding
When do you screen for gestational diabetes? When do you get a repeat CBC?
week 24-28
repeat around 28 weeks to monitor for anemia
_____ and _____ tests are repeats around 28 weeks and at delivery
syphilis and HIV
_______ is obtain via vaginal/anal culture obtained between 35-37 weeks. If positive, what do you do?
Group B Streptococcal
Intrapartum antibiotic prophylaxis given in labor if culture is positive
What vaccines are recommended for preg pts?
Hep A and B: if risk of exposure
flu vaccine
Tetanus, Diptheria and Pertussis
RSV
COVID
When should a preg pt received the flu and COVID vaccine?
at any point in their pregnancy
When should Tetanus, Diptheria and Pertussis
be administered?
Given in 3rd trimester so mom can pass immunity to the baby
When should RSV be administered?
preg pt between 32 0/7 and 36 6/7 weeks of gestation this respiratory season who have a planned delivery within 2 weeks
and did NOT receive maternal RSV vaccine the previous year
When is N/V common in pregnancy? How long does it last? What is the tx?
first trimester until about 16 weeks
lasts about 35 days
Vitamin B6 with or without Doxylamine
Prochlorperazine, Metoclopramide, Ondansetron
What is Hyperemesis gravidarum? Why is it dangerous?
Vomiting so severe that dehydration, electrolyte and acid-base disturbances and starvation ketosis occur
Severe enough to cause weight loss
What is the tx for hemorrhoids in a preg pt?
Topical applied anesthetics
Warm soaks
Stool softeners
What is pica? What does it indicate?
craving of pregnant women for strange food ice, starch, dirt
severe iron deficiency
Why does a preg pt always want to sleep? What is Leukorrhea?
Likely due to progesterone and associated discomforts
increase vaginal discharge due to increased mucus secretion by cervical glands in response to increase in estrogen
Major congenital abnormalities are identified in_____ of pregnancies. All women before _____ should be offered screening
2-3%
20 weeks gestation
What is the MC class of birth defects? 2nd MC?
cardiac anomalies
neural tube defects
elevated _____ is associated with neural tube defects. Where is it synthesized?
alpha-fetoprotein (AFP) in maternal and fetal serum and amniotic fluid
AFP synthesized by fetal yolk sac and later by fetal GI tract and liver
What are the 6 risk factors for having a fetus with neural tube defects?
Family history
MTHFR mutation
Aneuploidy
Diabetes
Hyperthermia
Medications specifically seizure medications
When do you screen for neural tube defects? What level indicates a NTD?
Screen by measuring maternal serum AFP between 15-18 weeks gestation
> 2.0 - 2.5 MoM is indicative of a neural tube defect with a false positive rate of 5%
AFP can be elevated for 7 other reasons besides NTD, what are they?
Multifetal gestation
Pilonidal cyst
Chorioangioma of the placenta
Placental abruption
Oligohydramnios
Preeclampsia
Fetal growth restriction
_______ is more important for detecting NTDs than AFP
Second-trimester fetal US has a higher rate of detection for NTDs than using AFP
Risk of fetal trisomy increases with maternal age, particularly after ____. Who should get screened for genetic syndromes?
35yo
EVERYONE should be offered a screening regardless of maternal age or risk of chromosomal abnormalities
What is the goal of prenatal screenings?
to provide a RISK assessment they are NOT diagnostic
When do you perform the first trimester screening? What are you looking for?
11-14 weeks -> Combined First screen
Evaluates nuchal translucency and serum analytes (PAPP-A, hCG) to detect Down syndrome
What is nuchal translucency?
maximum thickness of the subcutaneous translucent area between the skin and soft tissue overlying the fetal spine at the back of the neck
On first trimester screening, if If nuchal translucency is _____ patient should be offered targeted sonography with or without fetal echocardiography and fetal karyotyping. How is the risk assessed?
> 3.0mm
Risk of fetal aneuploidy and structural malformations is proportional to degree of NT enlargement
**When looking at a first trimester screening, if the hCG is elevated and the PAPP-A is decreased, what does it indicate?
Down Syndrome
**When looking at a first trimester screening, if the hCG is decreased and the PAPP-A is decreased, what does it indicate?
trisomy 18 and 13
What does the triple test test for? When is it used?
triple test: hCG, AFP and unconjugated estriol
when pt presents for prenatal care later in the pregnancy
Using the triple test, what will a down syndrome result look like? trisomy 18?
lower AFP, lower estriol, higher hCG
all 3 markers decreased
What does the quad screen test for? When is it used?
hCG, AFP, unconjugated estriol and inhibin
2nd trimester screening
What will a pt with down syndrome’s quad test result look like?
lower AFP, lower estriol, higher hCG, higher inhibin
What should you do if a pt’s fetus tests positive for down syndrome on the first trimester screen?
offer invasive testing and screen again in the second trimester
offer genetic counseling and definitive fetal chromosome analysis: CVS vs amniocentesis
What does an US of a fetus that indicates a high risk of fetal aneuploidy show?
A structural abnormality involving a major organ or the presence of two or more minor structural abnormalities or dysmorphisms in the same fetus can indicate high risk of fetal aneuploidy
If any major anomalies are found on US, what should you do? What is considered a minor abnormalities? What is a minor one is found?
major: invasive testing
minor includes:
Nuchal fold >6mm
Pylectasis (dilation of kidney)
Hyperechogenic bowel
Choroid plexus cyst
minor: genetic testing
**______ is the best screening approach to detect fetal abnormalities. When can it be done? What if the test is inconclusive?
Cell-free DNA
9-10 weeks to term
inconclusive result: associated with increased risk of having chromosomal abnormalities
Fetal component of cell-free DNA is derived from ______ that are released into the maternal circulation from cells undergoing programmed _____
placental trophoblasts
cell death
______ is the most SENSITIVE and SPECIFIC screening test for the common fetal aneuploidies. Is it equivalent to diagnostic testing?
Cell free DNA
NOT equivalent and can be wrong
What if you have a Positive Screen?
Offer patient confirmatory testing/diagnostic testing= Invasive Testing
CVS
Amniocentesis
What is amniocentesis? When is it performed? What is the purpose?
Transabdominal withdrawal of amnionic fluid
Performed typically between 15-20 weeks gestation
**Most common procedure for DIAGNOSIS of fetal aneuploidy
What are the indications for amniocentesis?
assess fetal karyotype
polyhydramnios
assess fetal anemia
assess fetal lung maturity
What is polyhydramnios? What does it cause? What is the tx?
more than 25 ml of fluid in the mom can cause contractions
amniocentesis
_____ is done to assess fetal anemia and ______ is measured in the fluid which has an indirect measure of ______
amniocentesis
ΔOD 450 measurement
fetal hemolysis (to assess fetal anemia)
amniocentesis can assess fetal lung maturity by elevating _______. _____ begins to elevate after 32 weeks while ______ does not. When ratio is _____ risk of respiratory distress is low
Lecithin/Sphingomyelin ratio (L/S ratio)
Lecitihin
Sphingomyelin
> 2.0, risk is LOW
What are the complications of amniocentesis?
Pregnancy loss rate 1 per 300-500
Amniotic fluid leakage
Chorioamnionitis
Needle injuries to fetus
What is Chorionic Villus Sampling (CVS)? When can it be performed? What is the indication? What is the advantage of amniocentesis?
Biopsy of the chorionic villi in the placental tissue
Performed between 10-13 weeks gestation
Assess fetal karyotype
Primary advantage over amniocentesis is that it can be done earlier allowing for earlier pregnancy termination if desired
What are the relative CI for CVS?
Vaginal bleeding
Active genital tract infection
Extreme uterine ante- or retroflexion
Body habitus precluding visualization
What are the complications associated with CVS?
pregnancy loss
limb reduction defects: especially if done at 7 weeks gestation, LESS risk if done at greater than 10 weeks
vaginal spotting
infection
What is Cordocentesis? When is it used? What are the indications?
fetal blood sampling or percutaneous umbilical blood sampling
Initially used for fetal transfusion of red blood cells
-Fetal anemia – Most common
-Assessment and treatment of platelet alloimmunization
-Fetal karyotype assessment
What are the complications of fetal blood sampling?
Fetal loss rate is about 1.4%
Cord vessel bleeding
Fetal-maternal bleeding
Fetal bradycardia
What are 3 invasive testings options?
amniocentesis
CVS
fetal blood sampling
What is antepartum fetal assessment used for? What is it based on?
To identify fetuses at risk of intrauterine death or other complications of intrauterine asphyxia and intervene to prevent adverse outcomes if possible
Based on idea that fetus responds to hypoxemia in a predictable manner
When is it recommended to start Antepartum Fetal Surveillance? What about those at high risk?
Begin testing around 32-34 weeks with repeat testing every 7 days
high risk: start at 26-28 weeks
What are 3 factors that can affect fetal movement?
Amniotic fluid: Less fluid = less fetal activity
fetal sleep-wake cycles
gestational age: advanced gestational age they have LESS space and activity may diminish
When should you start counting fetal movements? On average, what should you feel? How often should mom count fetal movement?
around 28 weeks
Patient should perceive 10 movements in up to 2 hours
count fetal movement for 1 hour a day
Non-stress tests evaluate the ______. What are the normal accelerations seen for a fetus less than 32 weeks? Older than 32 weeks?
fetal HR for 20 minutes: 2 or more accelerations is normal
In fetuses < 32 weeks, an acceleration is a 10bpm change in baseline that lasts 10 seconds or longer
In fetuses > 32 weeks, an acceleration is a 15bpm change in baseline that lasts 15 seconds or longer
What should you do if you think the fetus is sleeping during a non-stress test?
acoustic stimulator on mom’s belly for 1-2 seconds and it can be repeated up to 3 times
should wake baby up and should start to see HR accelerations in a normal baby
If non-stress test is abnormal, what should you do next? What are the 5 components?
Biophysical Profile (BPP) aka you get an ultrasound
- Non-stress test (NST)
- Fetal breathing
- fetal movement
- fetal tone
- amniotic fluid volume
What is the scoring system for BPP? What is the intrepration?
0-10 at 2 intervals (10,8,6,4,2,0)
In the BPP, how does the fetus get 2 points per category?
points are good! score of 10 is perfect, normal, healthy baby
8/10 is also a normal score
What are the 2 components of the modified BPP?
AFI (amniotic fluid index) and non-stress test
What 3 fetal vascular circuits are evaluated during a doppler velocimetry?
Umbilical artery
Middle cerebral artery
Ductus venosus
When is an umbilical artery velocimetry considered abnormal? What does it indicate?
aka measures the velocity of the blood flow through the umbilical artery
if the systolic/diastolic ratio is >95th percentile for gestational age
something is impeding the umbilical artery blood flow, leads to fetal growth restriction
When would you want to assess a fetus’s middle cerebral artery velocity via doppler US?
is considered about:
-Intrauterine growth restriction
-Isoimmunization
-Fetal anemia
