Pregnancy Flashcards
Calculate EDD from LMP w/ Nagele’s rule
Subtract 3 months, add 7 days
Changes during pregnancy:
- CO
- SVR
- HR
- TV
- TLC
- PaCO2
Changes during pregnancy:
- CO: increases 30-50%
- SVR: decreases bc progesterone relaxes smooth muscles (resulting in decreased arterial BP)
- HR: increases
- TV: increases 30-40%
- TLC: decreases 5% (bc diaphragm elevated)
- PaCO2: decreases to facilitate gradient where O2 is delivered to fetus and CO2 goes back to mom
GI changes in pregnancy:
- Gastric emptying
- GE sphincter tone
- large bowel motility
GI changes in pregnancy:
- Gastric emptying: prolonged
- GE sphincter tone: decreased (leads to reflux)
- large bowel motility: decreased (leads to increased water reabsorption and constipation)
GRF increases, which leads to (increase/decrease) in BUN and Creatinine
GRF increases, which leads to (decrease) in BUN and Creatinine
Increased rate of thrombotic events is due to…?
elements of Virchow triad (increased venous stasis, vessel endothelial damage)
What is the purpose of hCG?
maintains corpus luteum in early pregnancy (corpus luteum produces progesterone, which maintains the endometrium)
What is the purpose of hPL?
ensures constant nutrient supply to the fetus (causes lipolysis –> increase in free fatty acids)
Elevated AFP suggests ____________ and decreased AFP suggests ___________
- elevated AFP: NT defects
- decreased AFP: Down syndrome
(Lecithin/Sphingomyelin) increases as the lung matures, while (Lecithin/Sphingomyelin) decreases beyond 32 weeks
(Lecithin) increases as the lung matures, while (Sphingomyelin) decreases beyond 32 weeks
What are the 5 components of the biophysical profile?
- amniotic fluid volume
- fetal tone
- fetal activity
- fetal breathing movement
- NST
Presentation of patient w/ ectopic pregnancy
- sxs: unilateral pelvic pain, vaginal bleeding
- signs: tender adnexal mass, bleeding from cervix, hypotensive, peritoneal abdomen
Risk factors for cervical incompetence
- hx cervical surgery (ie: cone bx, dilation of cervix)
- hx cervical lacerations w/ vaginal delivery
- uterine anomalies
- DES exposure
Difference in presentation between cervical incompetence and PTL
- incompetent cervix: presents w/ painless dilation
- PTL: painful contractions
Antiphospholipid antibody syndrome
- autoimmune disorder where body makes antibodies that attack phospholipids (a type of fat found in blood vessels)
- antibodies attack phospholipids –> damages blood vessels –> blood clots
2 common causes of recurrent pregnancy loss and treatments
- antiphospholipid antibody syndrome (ASA)
- luteal phase defect (progesterone)
Sickle cell disease is an (AD/AR) disease caused by a _______ mutation in the gene for _____________
- AR
- point mutation
- beta chain in Hgb
Symptoms of Tay Sachs Disease
- loss of alertness
- excessive reaction to noise (hyperacusis)
- developmental delay
- cherry red spot
Tay Sachs is due to a deficiency in what enzyme?
-Hexosaminidase A (enzyme responsible for degradation of Gm2 ganglioside)
CBC and Hgb electrophoresis findings for pt w/ beta thalassemia
CBC:
- mild hemolytic anemia
- low MVC
Hgb electrophoresis: increased alpha:beta ratio (Hgb A2)
Quad screen components
AFP, estriol, bhCG, inhibin
Edward syndrome
- Trisomy 18
- sxs: clenched fists, overlapping digits, rocker bottom feet, VSD, tetralogy of Fallot, omphalocele, congenital diaphragmatic hernia, NT defects, choroid plexus cysts
Patau syndrome
- Trisomy 13
- sxs: holoprosencephaly, cleft lip and palate, cystic hygroma, omphalocele, hypoplastic left heart, clubfoot, polydactyly, overlapping fingers
Progression of ova through fertilization
egg –> combines w/ sperm –> morula –> blastocyst (inner cell mass and outer cell layer ) –> embryo and trophoblast –> trophoblast differentiates into cytotrophoblast and syncytiotrophoblast (placenta) and embryo differentiates into epiblast –> ectoderm, endoderm, mesoderm
What serum factor is elevated in spina bifida?
AFP (open tube leads to AFP crossing into maternal serum)
The bulbus cordis (caudal section of heart tube) forms:
- proximal third –>
- midportion (cous cordis) –>
- distal segment (truncus arteriosus) –>
- proximal third –> trabeculated part of R. ventricle
- midportion (cous cordis) –> outflow tracts of ventricles
- distal segment (truncus arteriosus) –> proximal portion of aorta and pulmonary artery
Eisenmenger physiology
-VSD that doesn’t get repaired –> RVH, pulmonary HTN, R–>L shunt
Tetralogy of Fallot
- VSD w/ overriding aorta
- pulmonary stenosis
- RVH
The kidneys are formed from the…
intermediate mesoderm
The mesonephros create the…
mesonephric duct (wolffian duct) -in the presence of testosterone, also creates the vas deferens, epididymis, ejaculatory duct, seminal vesicles
The ureteric bud creates the…
collecting tubules, calyces, renal pelvis, ureter
The metanephros creates the…
kidney
Levels of AFP, Estriol, and B-hCG in…
- Trisomy 21
- Trisomy 18
- Trisomy 13
- Trisomy 21: decreased, decreased, increased
- Trisomy 18: decreased, decreased, decreased
- Trisomy 13: depends
When might PUBS be useful?
- to obtain fetal Hct (in setting of Rh alloimmunization, fetal anemia, etc.)
- rapid karyotype analysis
- transfuse fetus in cases of fetal anemia
Fetal diagnosis in the first trimester is by _________, which obtains ____________ cells. Fetal diagnosis in the second trimester is by ___________, which obtains ___________ cells.
-1st trimester: CVS, trophoblastic cells (from placenta)
2nd trimester: amniocentesis, fetal cells in amniotic fluid
Causes of baby being small for gestational age
- decreased growth potential: congenital abnormalities, intrauterine infxns (CMV, rubella), teratogens (alcohol, cigarettes)
- IUGR (maternal risk factors: HTN, anemia, renal disease, APLA syndrome, SLE, malnutrition; placental factors: previa, marginal cord insertion, placental thrombosis; multiple gestations)
Risk factors for macrosomic infants
- DM
- maternal obesity
- post-term pregnancy
- previous LGA or macrosomic infant
- multiparity
Fetal hydrops
- Rh+ moms have IgG Abs that cross placenta –> hemolysis –> anemia –> extramedullary fetal RBC production
- hyperdynamic state, HF, diffuse edema, ascites, pericardial effusion
What is a Kleihauer-Betke test?
tests for amount of fetal RBCs in maternal circulation (for Rh incompatibility)
What is the risk of a retained IUFD?
DIC (fetus releases thromboplastic substances –> hypofibrinogenemia)
What twin type is most likely to develop twin-to-twin transfusion syndrome?
monochorionic (one placenta) diamniotic (two amniotic sacs)
Pathogenesis of different types of twins
- Di-Di (days 1-3): separation before differentiation of trophoblasts
- Mo-Di (days 3-8): separation after trophoblast differentiation and before amnion formation
- Mo-Mo (days 8-13): division after amnion formation
- Conjoined twins (days 13-15)
What is the pathophysiology of preeclampsia?
involves generalized arteriolar constriction (vasospasm) and intravascular depletion secondary to a generalized transudative edema
How is uteroplacental insufficiency caused in pre-eclampsia?
vasoconstriction –> decreased blood flow to placenta
What labs are associated with acute fatty liver of pregnancy?
- elevated ammonia
- BG <50
- reduced fibrinogen and anti-thrombin III
How do you stabilize a pt w/ severe pre-eclampsia?
- magnesium sulfate (seizure ppx)
- hydralazine (direct arteriolar dilator) or labetalol (beta and alpha blockade) for BP control
What treatment can help pts w/ HELLP syndrome to avoid post-partum thrombocytopenia?
corticosteroids
What do you give in the context of Mg overdose for pre-eclampsia?
calcium chloride (for cardiac protection)
labetalol
BB w/ concomitant alpha blockade
nifedipine
peripheral CCB
Why do pregnant women experience GMD?
placenta produces hPL –> hPL acts as anti-insulin agent –> increased insulin resistance and carb intolerance
Common BV organisms
- Gardnerella vaginosis
- Bacteroides
- Mycoplasma hominis
Group B strep is responsible for…
- UTIs
- chorioamnionitis
- endomyometritis
Who is treated w/ penicillin for GBS?
- people who swab positive
- women w/ unknown GBS status who labor before 37 weeks
- women w/ >18hr ROM
What is chorioamnionitis?
- infxn of membranes and amniotic fluid surrounding the fetus
- can cause neonatal sepsis and maternal endomyometritis and septic shock
What is the most sensitive screening test for chorioamnionitis?
IL-6 levels in amniotic fluid that rise prior to changes in other screening tests
What type of virus is VZV?
-DNA herpes virus
What is parvovirus B19 associated with at different stages of pregnancy?
- 1st trimester: miscarriage
- mid-trimester and later: fetal hydrops (attacks fetal erythrocytes –> hemolytic anemia, hydrops, death)
Infant sxs of CMV
hepatomegaly, splenomegaly, thrombocytopenia, jaundice, cerebral calcifications, chorioretinitis, interstitial pneumonitis
Maternal sxs of rubella
maculopapular rash, arthritis, arthralgias, diffuse LAD
Infant sxs of rubella
deafness, cardiac abnormalities, cataracts, mental retardation
Virchow’s triad
- increased coagulation factors
- endothelial damage
- venous stasis
In pregnancy, the production of clotting factors is (increased/decreased), turnover time for fibrinogen is (increased/decreased), and there are (increased/decreased) levels of circulating fibrin.
In pregnancy, the production of clotting factors is (increased), turnover time for fibrinogen is (decreased), and there are (increased) levels of circulating fibrin.
How do you treat prophylactically for DVT in pregnancy?
IV heparin –> subQ heparin or LMWH (Lovenox)
-Lovenox –> unfractionated heparin at 36wks bc Lovenox has long half-life and increased risk of epidural hematoma
What are the infants of moms w/ Graves disease at risk of?
fetal goiter (Graves is result of thyroid-stimulating immunoglobulin)
What causes high rates of early pregnancy loss in the first and second trimesters for women with SLE or APLA?
placental thrombosis
How do you tell the difference between a lupus flare and pre-E?
- pts w/ lupus have reduced C3 & C4, pre-E have nml levels
- lupus flares are accompanied by an active urine sediment whereas pre-E is not
What are sxs of fetal alcohol syndrome?
- growth retardation
- CNS effects
- abnml facies
- cardiac defects
Cocaine use in pregnancy is associated with increased risk of…
abruption placentae, IUGR, preterm labor and delivery
Common causes of PPH
- uterine atony
- retained POCs
- placenta accrete (superficial invasion into myometrium)
- cervical lacerations
- vaginal lacerations
How do you distinguish a lupus flare from preeclampsia?
Obtain complement levels (decreased C3, C4 signal lupus flare)
What is the classic triad of pre-eclampsia?
- HTN
- proteinuria
- nondependent edema in the face and hand
During pregnancy, what happens to…?
- MAP
- CO
- SVR
- MAP: decreases
- CO: increases (bc HR increases)
- SVR: decreases
Why does Hgb decrease in pregnancy?
because Hgb = RBC/plasma and RBCs increase but plasma increases a lot
How do you treat endometritis/chorioamnionitis?
Amp, gent, clinda
What is the biggest cause of placenta abruption?
maternal HTN (followed by prior hx of abruption, AMA, multiparity, cocaine abuse, vascular disease)
How does ITP affect the fetus?
IgG antibodies cross placenta –> destroy fetal platelets
What increases susceptibility to pulmonary edema in pregnancy?
decreased plasma osmolality
What are common causes of acute pulmonary edema in pregnancy?
tocolytics, cardiac disease, fluid overload, pre-E
In pregnancy, TBG (increases/decreases) because of circulating ____________ and an increase in ________________
increases, estrogen, total thyroxine
After a molar pregnancy has been identified, what is the appropriate next step/test?
CXR (most likely to metastasize to lungs)
In people who are Black, what preconception screening is recommended?
Hgb electrophoresis and CBC
What are some examples of diseases that occur with an increased incidence in Ashkenazi Jews?
- Fanconi anemia
- Tay-Sachs disease
- Cystic Fibrosis
- Niemann-Pick
Chorionic villous sampling can be used to detect…
- fetal chromosomal abnormalities
- biochemical or DNA-based mutations
What is the difference between placenta previa and vasa previa?
Both present with painless vaginal bleeding >20 weeks gestation but vasa previa leads to rapid deterioration in FHR
Why does pre-E cause fetal growth restriction/low birth weight?
chronic uteroplacental insufficiency
What are first line drugs for treating HTN in pts w/ pre-E?
IV hydralazine (vasodilator) IV labetalol (alpha-blocking BB) oral nifedipine (CCB)
Difficulty ambulating, radiating suprapubic pain, pubic symphysis tenderness, and an intact neuro exam suggest…
pubic symphysis diastasis
What are risk factors for pubic symphysis diastasis?
fetal macrosomia, multiparity, precipitous labor, operative vaginal delivery
In neonatal thyrotoxicosis, there is transplacental passage of maternal ___________, which bind to the infant’s ____ receptors and cause excessive thyroid hormones
- TSH receptor antibodies
- TSH receptors
How does oxytocin toxicity present?
hyponatreia, hypotension, tachysystole, seizure
What is the most common inherited form of intellectual disability?
Fragile X
How should placenta previa be managed?
no sex, no digital cervical exam, inpatient admission for bleeding
Pregnancy results in a (acute/chronic) (respiratory/metabolic) (acidosis/alkalosis) (with/without) compensation
chronic respiratory alkalosis with metabolic compensatin
___________ stimulates the respiratory centers to (increase/decrease) TV and MV
progesterone, increase
The prothrombotic state in pregnancy is created because of a hormone-mediated (increase/decrease) in ________ and (increase/decrease) in fibrinogen and coagulation factors
decrease in protein S, increase in fibrinogen and coagulation factors
Mild hyponatremia occurs because…
hormones reset threshold to increase ADH release from pituitary
Lactation failure, amenorrhea, fatigue, bradycardia, weight loss, hypotension, and decreased lean body mass can be sxs of…
Sheehan syndrome
- decreased prolactin (lactation failure)
- decreased FSH, LH (amenorrhea, hot flashes, vaginal dryness)
- decreased TSH (fatigue, bradycardia)
- decreased ACTH (anorexia, weight loss)
- decreased growth hormone (decreased lean body mass)
Patients with dehydration present with …
maternal tachycardia, ketonuria
How do you treat a woman with hx of neonate with early onset GBS?
intrapartum antibiotic prophylaxis (no need for cultures)
What bacteria cause endometritis?
polymicrobial (anaerobes and aerobes; staph and strep)
What is the most common abnormal karyotype seen in SABs?
autosomal trisomy
When should women with risk factors for DM be screened during pregnancy?
at their first visit
What is someone with a history of depression or psychiatric illness at greatest risk for post-partum?
postpartum depressio
What effects can maternal use of SSRIs have on neonates?
- abnormal muscle mvmts (EPS)
- withdrawal sxs (agitation, change in muscle tone, tremor, sleepiness, difficulty breathing and feeding)
Proper follow-up after surgical abortion includes…
IV antibiotics (doxycycline)
ABO incompatibility typically occurs between a mom with _____ blood type and an infant with ____ blood type
mom: O
baby: AB
Obesity in pregnancy increases the risk of…
- chronic HTN
- GDM
- pre-E
- fetal macrosomia
- C/S
- postpartum complications
What SSRI should not be used in pregnancy and why?
paroxetine: increased risk of fetal cardiac malformations and persistent pulmonary HTN
What is the best test for noninvasive diagnosis of fetal anemia?
middle cerebral artery peak systolic velocity
What are Lewis antibodies?
IgM antibodies that do not cross placenta (so not associated with isosensitization)
Recurrent pregnancy loss and transient ischemic attacks suggest…
APLA syndrome
At what gestational age is the fetus most at risk for microcephaly and brain damage?
8-15 weeks
___________ mutation is associated with obstetric complications, including stillbirth, pre-E, placental abruption, and IUGR
factor V leiden
_____________ during pregnancy is associated with NT defects and polyhydramnios
uncontrolled DM
What happens to the liver in HELLP syndrome?
process can cause liver swelling and distension of hepatic capsule –> RUQ or epigastric pain
How does HELLP syndrome differ from fatty infiltration of the liver?
- Acute fatty liver of pregnancy: n/v, abdominal pain, elevated liver markers, leukocytosis, hypoglycemia, AKI
- HELLP: severe HTN
A nonreactive NST requires further testing with a…
biophysical profile
Wernicke encephalopathy is a complication of ____________ due to __________ deficiency
- hyperemesis gravidarum
- thiamine
What is the most common explanation for an increased AFP?
underestimation of gestational age
How do you treat asymptomatic bacteria in the first trimester?
amoxicillin-clavulonate
Increasing lower abdominal pain, nausea, scant bleeding, fever, tender uterus, 8mm endometrial stripe two days post-op from D&C suggest…
uterine perforation
Insulin-dependent diabetes increases the risk of…
spontaneous abortion & major congenital malformations
When can amniocentesis be done and when can CVS be done?
- amniocentesis: 10-13 weeks
- CVS: 15-20 weeks
Is syphilis tested for in pregnancy and, if so, when?
yes - universally in 1st trimester
How is postpartum endometritis treated?
clindamycin & gentamycin
How should symptomatic mitral valve prolapse be treated in pregnancy?
beta-blocker
How do you treat cholestasis of pregnancy?
- antihistamines, topical emollients
2. urosdeoxycholic acid
How do you distinguish between normal nausea & vomiting of pregnancy and hyperemesis gravidarum?
hyperemesis gravidarum has ketones on UA
How do you further work up a non-reactive NST?
biophysical profile
How can OCPs affect breastfeeding women?
delayed uterine involution
