PPt. 1-3 Flashcards
1
Q
Generally takes __ days for conceptus to migrate from fallopian tube into uterus
A
8
2
Q
when is the fertilized egg independent of environment but not of genetics
A
pre-embyronic phase
8 days from fertilization to implant
3
Q
when is the embryonic phase
A
weeks 3-8
4
Q
the time when all of the tissues are specializing and organs are forming
A
Period of Organogenesis
5
Q
when is the Period of Organogenesis
A
embryonic phase
weeks 3-8
6
Q
-Time when malformations occur and greatest vulnerability to teratogens
A
Period of Organogenesis during the embryonic phase (weeks 3-8)
7
Q
Embryonic development into what 3 germ layers
A
- Ectoderm will become skin and nervous system
- Mesoderm will become muscle and bone
- Endoderrm will become GI tract (alimentary canal), endocrine and respiratory systems
8
Q
When can you start to see the heart beat
A
on 6 week ultrasound
9
Q
When is the fetal phase
A
9 weeks until delivery
10
Q
What happens during the fetal phase
A
Further growth, differentiation and maturation of organs
11
Q
when do Pulmonary alveoli begin to develop
A
24 weeks
12
Q
When does surfactant present in lungs
A
at 34 weeks
13
Q
What is the importance of surfactant
A
it reduces the surface tension of lungs to keep the alveoli open so baby can breath
14
Q
What happens if the baby is born before 24 weeks
A
pulmonary alveoli won’t be develooped and the fetus won’t be viable outside the womb
15
Q
Fetal membranes and what do they do
A
Amnion is inner layer
Chorion is outer layer
Function: act to protect fetus from injury and infection
16
Q
What happens when a mother’s water breaks
A
the fused chorion/aminion membrane ruptures and amniotic fluid poors out
17
Q
PROM
A
prolonged rupture of membranes > 18 hr
*prior to delivery- makes you prone for infection
18
Q
PPROM
A
premature, prolonged ROM
*breaks prior to 35 weeks of gestation
19
Q
SROM
A
spontenous ROM
20
Q
AROM
A
artificial ROM
*can have AROM that becomes PROM
21
Q
What are the functions of amniotic fluid
A
- Acts as a cushion for fetus as mother moves
- Prevents membranes from sticking to baby
- Allows for fetal movement
- Necessary for lung development
22
Q
How does the fetus contribute to the placenta
A
Chorionic villi
23
Q
Finger-like projections of chorion which penetrate into the endometrium, the lining of the uterus
A
Chorionic villi
24
Q
what does a chorionic villi contain
A
- fetal arteriole, venule, and capillary
25
What is the placenta made up of
1. Chorionic villi- fetal contribution
| 2. Decidua Basalis- maternal contribution
26
What happens when c.villus invades the endometrium
it causes the maternal capillary beds to break down into sinusoids
27
blood flow in placenta
arteriole --> open space --> venule
28
Where is the fetal capillary
sits within the sinusoid and is bathed by maternal blood
| *drug transfer occurs this way
29
Mother to fetus exchange across the placenta
oxygen, aminio acids, fats, glucose, some hormones, antibodies, most drugs, viruses
30
Fetus to mother exchange across the fetus
carbon dioxide, bilirubin, ammonia and other waste products
31
"crossing the placenta" refers to
the diffusion of molecules in either direction
32
What happens if mom has DM1 and has high blood sugars high throughout the pregnancy. Therefore baby see lots of maternal glucose in utero but what happens with insulin?
- insulin does not cross placenta because too big of a molecule, therefore baby's pancreas produces its own insulin to take care of mother's glucose
- baby continues to produce insulin after birth and becomes hypoglycemic--> may require force feeding
33
What produces hCG
the chorion (or more generally the placenta)
34
What hormones maintain the lush endometrium necessary to sustain pregnancy
hCG and progesterone
35
When is there enough hormones for a pregnancy test to detect pregnancy
2 weeks post conception
| maternal blood and urine
36
What hormone does a pregnancy test detect
hCG
37
when does ovulation occur
14 days before menstruation (regardless of cycle length)
38
How do you date pregnancy?
date pregnancy counting 40 weeks from first day of last menstrual period
39
When does pregnancy actually start occuring, when dating pregnancy
2 weeks before ovulation and fertilization
40
Whats the purpose of ultrasounds
1. Dating pregnancy
2. Evaluating anatomy
3. Checking position of placenta (important for C-sectino and wanting a chorionic villi sample)
4. Checking volume of amniotic fluid
41
Useful early on in pregnancy because can get closer to fetus and give more accurate images in first weeks
transvaginal u/s
42
Disadvantage of transvaginal u/s
uncomfortable for mother (its tucked under the cervix)
43
More standard u/s
transabdominal u/s
44
what do you measure with U/S dating in 1st trimester and what is its accuracy
Measure crown-rump length
| Accurate +/- 3 days
45
what do you measure with U/S dating in 2nd trimester and what is its accuracy
Measure biparietal diameter
| Accurate +/- 1 week
46
what do you measure with U/S dating in 3rd trimester and what is its accuracy
measure biparietal diameter
| Accurate +/- 2 weeks
47
Why is it important to accurately date your pregnancy
- Surfactant develops around 35 weeks
| - know the development of other systems
48
Why is dating less accurate later on in the pregnancy?
genetics, environmental factors, difficult to visualize teh baby due to its position and limbs
49
What is considered the 1st trimester
weeks 1- 12
50
What is considered the 2nd trimester
weeks 13- 28
51
What is considered the 3rd trimester
weeks 29- delivery
52
what is considered the ideal term?
40 weeks, or 38-42 weeks
| no later than 42 weeks bc placenta starts to die off and baby gets too big
53
Can maternal antibodies cross the placenta
yes
54
Rh incompatibilty
mismatch between maternal and fetal blood types that results in mother making anitbodies to fetus blood cells and results in hemolysis of fetus RBC
55
What can Rh incompatibilty cause
```
jaundice
hydrops fetalis (total body edema)
```
56
Prenatal screening consists of:
1. Rh compatibility
2. u/s for anatomy
3. Glucose tolerance test (16 weeks)
4. option gentic screening
5. Hep B*
6. HIV*
7. Syphilis, Gonorrhea, Chlamydia*
* at first prenatal visit
8. Immunity to Rubella (conferred by vaccine)
9. GBS at 36- 37 weeks
10. Alpha fetoprotein
11. other disease specific to population
57
when is the best time to do an u/s for anatomic survey
18-20 weeks when all the organs have formed
| later than that then baby is too large to see details bc of superimpsed body parts
58
what type of u/s do you do for an anatomic survey
transabdominal
59
Optional screening offered to patients deemed to be at increased risk of having baby with genetic problems:
- Advanced maternal age (35 or older)
- Abnormal findings on prenatal ultrasound
- Family history of genetic disorder
- Previous miscarriages
60
what are the 2 forms of genetic testing
1. amniocentesis (go through abdomin)
| 2. chorionic villus sampling (go through abdomin or up vaginal canal)
61
pros and cons of amniocentesis
P: can do whenever during pregancny
C: 1. mom can have cramping
2. can introduce bacteria to baby
3. can nick the baby or the cord
62
pros and cons of chorionic villus sampling
P: less risk
C: can only perform in a certain time frame (11-14 weeks)
63
Fasting blood sugar provides a baseline for comparing other glucose values
glucose tolerance test, testing for maternal diabetes
64
Pregnant women drink ___ grams of glucose.
| Blood samples will be collected at timed intervals of __ and ___ hours after patient drinks the glucose.
drink 75grams of glucose
| collect at intervals of 1 and 3 hrs
65
when is the glucose tolerance test performed
16 weeks
66
when do you screen for GBS
36- 37 weeks
67
What does alpha fetoprotien screen for
- high in neural tube defects
| - low in down syndrome
68
“Ashchkinasi screen”
for diseases found in people of European Jewish descent
69
The process by which products of conception (baby, placenta, cord and membranes) are expelled from the uterus
labor
70
Requires progressive effacement (thinning) and dilation of the cervix, resulting from rhythmic contractions of the uterine muscles
labor
71
Dilatation in absence of contractions
cervical insufficiency
72
ways to decrase cesarean deliveries
1. allow prolonged latent (early phase labor
2. changing the definition of active labor to start at 6 cm (instead of 4cm)
3. Allowing more time for labor to progress in the active phase
4. Allowing women to push for at least two hours if they have delivered before, three hours if it’s their first delivery, and even longer in some situations, for example, with an epidural.
5. Using techniques to assist with vaginal delivery, which is the preferred method when possible. This may include the use of forceps, for example
6. Encouraging patients to avoid excessive weight gain during pregnancy.
73
Process whereby baby’s heart rate and its response to uterine contractions is monitored
fetal monitoring
74
what is a normal fetal heart rate
120-160 bpm and should show variability
75
Fetal heart rate usually _____ with contractions
increases
76
_______ after contraction or _________ are abnormal
decelerations
| slow recovery to baseline
77
Decelerations after contraction can indicate
1. stress
| 2. need for operative intervention
78
This type of monitoring uses a doppler to pick up the babies heart rate and tocodynamometer to measure the intensity of contractions
external monitor
79
cons on external fetal monitoring
sussceptible to artifact and requires that mom and baby remain relatively still
80
An electrode screwed to the babys scalp can accurately measure fetal heart rate including subtle variations
internal fetal monitoring
81
Cons of internal fetal monitoring
requires rupture of membranes leaving potential site of infection
82
Late decelerations are associated with
uteroplacental insufficiency or decreased uterine blood flow
83
The pain of labor and delivery is a result of
muscular contractions and pelvic pressure from organ distention
84
In what stage of labor does autonomic innervation of the visceral uterus senses pain from contractions and cervical dilation.
1st stage
85
In what stage of labor does somatic innervation of the vagina, vulva, and perineum sense pressure pain from the newborn passing through the birth canal
2nd stage
86
do narcotics cross the placenta
Yes, but only some cross the fetal blood-brain barrier
87
Fentanyl (an opiate) used for pain managment in pregnancy
- drug of choice bc of short half-life
- risks include include hypotension, nausea, vomiting, respiratory depression, depressed mental status, and decreased GI motility
- make sure resuscitation medication and equipment for the newborn should be readily available
88
Epidurals provide ___ not _____
provide analgesia NOT anethesia
89
risks of epidurals
1. short-term backache
2. puncture headache,
3. hypotension,
4. maternal fever,
5. prolonged labor, and
6. increased rate of instrumental delivery
90
Do epidurals increase a mother's risk of delivering by cesarean?
no
91
when can you do an epidural?
any time
| placement of epidural at maternal request regardless of cervical dilatation
92
amniorrhexis
rupture of membranes
93
birth starts with
amniorrhexis
94
Membrane ruptures when in relation to labor
before or during labor
| Not related to specific stage
95
What is the purpose of amniotic sac
cushions the fetus
| guards it from infection
96
- Facilitates monitoring
- Increases force of contractions
- Risk of cord prolapse if head is not “engaged”
AROM
97
- Defined as rupture greater than 18 hours
| - Increases the risk of ascending infection
PROM
98
Rupture prior to 37 weeks
PPROM
99
Baby delivered with membranes intact is said to be
delivered “en caul”
(Irish legend has it that the baby will be protected from drowning and It’s considered lucky and some believe increases psychic ability)
100
forms of operative deliveries
1. forceps
2. vacuum
3. cesarean section
101
risks of using forceps
1. skull fractures
2. facial nerve palsy
(affected side will not have creases and eye may remain open--> consider using artifical tears)
102
risks of using a vaccum
1. shearing forces on the scalp can cause subgaleal hemorrhage
2. cephalohematoma
3. damage to skin.
103
risks of c-sections
1. retained lung fluid
2. lacteration of the fetus
3. surgical complicaitons
4. prolonged recovery for mom
104
The most common presenting birth position
occiput anterior (OA): head first, face down
105
occiput posterior (OA)
head first, face up
106
transverse lie
baby is positioned horizontally, incompatible with vaginal delivery
107
Breeching position
when the buttocks are delivered before the head
108
Recommendations of breeched babyies
1. attempt external cephalic version (an attempt to turn the baby by manipulated the fetus from the outside of the maternal abdomen)
2. depends of physicians preferance/ experience
109
when doe the transitional period for a newbord occur
first few hours after birth
110
periodic breathing
bursts of rapid breaths, slowing, then rests for
111
what is the cause of a newborns periodic breathing
immature CNS
| *Not respiratory in origin
112
normal axillary temperature for a new born in transition
36.5-37.5°C
113
normal heart rate for a new born in transition
80-160 beats/min
114
normal respirtory rate for a new born in transition
30-60 breaths/min
115
normal BP for a newborn in transition
60/40
116
Skin to Skin Care is associated with
1. increased body temp (compared to those who used warmers)
2. longer duration of breast feeding
3. longer sleep periods
4. better organization
117
If baby is at ambient warmer, turn heat to ___ and then do what
100%
- dry quickly to avoid evaporative loss
- dress with a hat ASAP
118
When should you bathe a newborn
- after their temperature is stable and infant is acting well
- adequate skin to skin and bonding with mom (6 hrs)
119
Risks of hypothermia
1. Breakdown of proteins and fats as fuel to create heat
2. fatigue
3. weight loss
120
goal of temperature management of a newborn
prevent heat loss
121
3 preventative interventions given within 2 hrs of delivery
1. Eye prophylaxis with 0.5% erythromycin ophthalmic ointment
2. HepB vaccine
3. Vitamin K, 1mg IM
122
why is 0.5% Eyrthromycin opthamlmic ointment is placed in both eyes
preventing gonorrhea and chlamydia infections of the eye
123
Why is HepB given at birth
risk of chronic disease with congenital infection is high
124
Approximately ____ of infants infected by HepB are infected from their mothers at birth, and between __ and __% of those infected before age ____, become chronic HBV carriers
90%
30-50%
5
125
Why is Vit. K given at birth
Prophylaxis against early and late Vitamin K Deficiency Bleeding (Endogenous Vitamin K levels low until eighth day of life)
126
how is Vit. K administered orally
generally 2-3 doses but less studied in US
127
how does vit. K prophylaxis prevent VKDB
Promotes hepatic synthesis of vitamin K-dependent clotting factors
128
facial nerve damage from forceps usually resolves when
within first 48 hrs
- completely by 2 months
* *there is risk though of long term paralysis
129
collection of blood that does not cross suture lines and is taught (not fluidy), often occurs with caput
cephalhematoma
130
large potential space where baby can bleed out.
subgaleal hemorrhage
131
How do you treat GBS + moms
use penicillin (5 million units) 4.5 hrs prior to delivery and second bag (2.5 million units) just prior to delivery
132
Normal respiration duirng transition
RR= 40-60
periodic breathing
pO2>85%
133
a baby can be apnea for how long before it is considered abnormal
10 seconds
134
tachypnea and retractions reflect what
increased work of breathing "WOB"
135
what is considered tachypnea
RR >60 breaths/min
136
Tachypnea is the most sensitive indicator of
Lower airway disease
137
what an infant is found to be in any sort of respiratory distress, what is your first course of action
complete a cardiac and respiratory exam
138
grunting or singing on exam reflects what
baby's attempt to keep air in lungs to prevent collapse
139
grunting or singing are on inspiration or expiration?
expiration
140
is stridor inspiratory or expiratory?
inspiratory
141
what does stridor indicate
obstruction of middle airway
142
crackles or rales indicate
fluid in the air-spaces
143
are crackles and rales inspiratory or expiratory
inspiratory
144
are wheezing or rhonchi inspiratory or expiratory
expiration (inspiration when severe)
145
wheezing or rhonchi indicate
air trying to escape past obstruction in middle airways
146
auscultory noises
1. crackles or rales
| 2. wheezing or rhonic
147
audible noises
1. grunting or singing
| 2. stridor
148
what is the primary muscle of breathing
diaphragm
149
look for "pulling" of these areas to look for respiratory distress
1. suprasternal
2. intercostal
3. paradoxical movement of abdomen
150
pallor indicates
early sign of hypoxia
151
blue color of skin and muccous membranes, occurs O2 sat.
central cyanosis
152
acral cyanosis reflects ___ rather than ____
reflects perfusion
| rather than oxygenation
153
is perioral cyanosis worrisome
usually not--> sign of acral cyanosis
| -check mucous membrane color
154
simple non-invasive technique to measure oxygen saturation of blood
Pulse oximetry
155
90 on pulse ox means
90% of RBCs are carrying O2
156
how does pulse work
by measuring the amount of light in an appropriate spectrum
157
```
acceptable O2 sats at birth
2 min-
3 min-
4 min-
5 min-
10 min-
```
```
2 min- 60%
3 min- 70%
4 min- 80%
5 min- 85%
10 min-90%
```
158
can tolerate O2 sats of ___-___% for the first few hours of life, if baby is otherwise asymtomatic
85-87%
159
why might the % sats be different depending upon which hand you place the probe?
Left will be higher when the DA is still open (postductal)
160
what hand is the preferred hand to take the SpO2 of a newborn
```
right hand (preductal)
-more representative for brain oxygenation)
```
161
Causes of increased WOB
1. pulmonary disorder (upper airway obstruction, lower airway)
2. cardiac disorders
3. Infection
4. Hematological disorders
5. Metabolic disorders
162
what is the most common cause of respiratory distress in newborns
Pulmonary disorder
| -Lower airway is more common than upper airway
163
causes of lower airway diseases
1. aspiration, including mesconium
2. Hyaline membrane disease/RDS
3. pneumothorax
4. TTN (transient tachypnea of newborn)
5. pneumonia
164
causes of upper airway obstruction
1. nasal stuffiness
2. choanal atresia
3. masses
4. micrognathia (gnath=jaw)
5. laryngeal or tracheal obstruction (middle airway)
165
complications associated nasal obstruction
1. noisy breathing
2. increased WOB
3. feeding can be a challenge
166
how to examine for nasal obstruction
1. check nasal patency
| 2. try passing a small soft feeding tube through each nostril
167
what is the most common cause nasal stuffiness
vernix, mucus or old blood blocking the airway
168
causes of nasal stuffiness
1. vernix
2. mucus or blood blocking airway
3. swelling of mucosal lining from enthusiastic suctioning (especially with DeLee catheter)
4. Dry air (colorado)
169
when the thin tissue separating the nose and mouth area during fetal development remains after birth
choanal atresia
170
cause of choanal atresia
unknown
171
Presents with a baby who is cyanotic at rest and pink with crying
choanal atresia
172
how to treat choanal atresia
surgical intervention
173
the middle airway is comprised of
larynx and trachea
174
Causes of middle airway obstruction
1. blockage within: voal cord paralysis
2. compression from without: tumor
4. floppy airway
175
what is the most common middle airway obstruction
floppy airway
176
how does floppy airway present
presents with stridor with each breath and deep retractions
| -better when baby is placed on stomach (gravity opens airway)
177
RFLL stands for
Respiratory fliud liquid in lungs
178
RLL is the same as ___
TTN
| transient tachypnea of newborn
179
why are fetal lungs filled with fluid
1. acts as a barrier to the passage of O2 from alveolous to bloodstream
2. lungs are stiffer when filled (increase pulmonary pressure)
180
How do fetal lungs clear fluid
- hormonal changes associated with labor and 2-3 days prior to labor (40% fluid is cleared before NSVD)
- neg. pressure in lungs with first breaths
181
Why do c-section babys have risk of RFLLS
don't experince the hormonal changes associated with labor that help clear fluid
182
if you suspect Lower airway disease what test would be useful
chest xray
183
how to read a chest xray
R-rotation (compare clavicles)
I-inspiration (count at least 9 ribs)
P-penetration (check intervertebral discs)
A-airway (trachea should be midline and see bronchi splitting)
B-bones (look for fractures/abnormalities)
C-cardiac silhouette (
184
if blunted costophrenic angles on chest xray, think ___
pulmonary effusion
185
pulmonary vasculature should fill ____ if it extends beyond this think ______
medial 1/3
| if extends think heart failure
186
when does RFLL resolve
symptoms resolve 1-5 days w/ minimal intervention
187
tachypnea and hypoxia which resolve in 1-5 days
RFLL or TNN
188
diagnosis is exclusion
RFLL or TNN
189
CXR shows: ill-defined peri-hilar fluid*, hyperinflation, pleural effusions
RFLL
190
"well silhouette" on CXR
RFLL
191
causes of aspiration
1. meconium
2. amniotic fluid
3. maternal blood
192
how often is meconium present in amniotic fluid duirng deleiveries
12%
193
what percent of deliverys are complicated by meconium aspiration
4-6%
194
how the percentage of deliveries complicated by meconium aspiration, how many require mechanical ventilation
50%
195
meconium aspiration is most common is who
term or near term infants
196
passage of meconium is rare before ___
34 weeks
197
why does MAS occur
1. if fetus is stressed in utero and gasps in meconium from amniotic fluid
2. thick, viscous meconium in the oropharynx at birth can contribute to postnatal aspiration
198
3 serious outcomes of MAS
1. persistent pulmonary hypertension of newborn (PPHN)
2. blockage of small airways, over inflation and pneumothorax
3. Pneumonia (inflammatory rather than infection)
199
cause of PPHN
MAS
200
how does meconium cause PPHN
- Mec can inactivate surfactant
- cause inflammation and a thick coating obstructing the airway
- results in increased PVR
201
what occurs when pulmonary vascular resistance remains elevated, resulting in right to left shunting of blood through fetal circulatory pathways
PPH
202
Echo results: normal structural anatomy with flattened ventricular septum, right to left shunting through thte DA and/or FO
PPHN
203
Gold standard diagnostic test for PPHN
echo
204
treatment of PPHN
1. supplemental oxygen
2. surfactant infusion
3. inhaled nictric oxide
4. ventilation support
205
Hyaline membrane disease/RDS occurs almost exclusively in
premature infants
206
RDS is a result of
surfactant deficiency
207
RDS can be seen in near term babys (34-37 weeks) if:
1. mother is diabetic (hyperglycemia/hyperinsulinemia can delay lung maturation and surfactant production)
2. Septic infant (inflammatory response causes "washout")
208
RDS is indishinguishable from ___
pneumonia
| *therefore history is critical
209
CXR: ground glass appearance or white out of lungs
RDS
210
caused by microatelectasis of alveoli
RDS
211
how is RDS treated
recombinant surfactant and ventilator support
212
air leak outside of lung, within chest wall
pneumothorax
213
progressive accumulation of air leakage outside of lung leads to
collapse of lung
214
risk factors for what disease include:
1. positive pressure ventilation
2. stiff lungs
3. aspiration
pneumothorax
215
when does pneumothorax typically occur
at delivery (bc the first breath a baby takes is enormous)
216
___% of all newborns have pneumothorax
1%
217
T/F: all pneumothorax are symptomatic
F: some small pneumothoraces may be asymptomatic
218
these signs indicate what disease:
1. sudden cyanosis
2. respiratory distress
3. asymmetric breath sounds
4. muffled heart tones
5. poor perfusion/mottling/pallor
pneumothorax
219
CXR: dark film on edges of lungs
pneumothorax
220
```
what do these pathogens typically cause:
GBS
E. coli
other gram neg. rods
Staph species
Listeria
```
pneumonia
221
```
what do these pathogens cause less commonly:
ureaplasma
chlamydia
herpes simplex
CMV
```
pneumonia
222
pneumonia caused transplacental
bactermia
223
pneumonia caused ascending
chorioamnionitis, PROM + GBS
224
inflammatory exudates in the lungs interfere with surfactant function in what disease
pneumonia
225
pleural effusin are common and PPHN can develop with
pneumonia
226
CXR: fluffiness
pleural effusion/ pnuemonia
