Pregnancy Flashcards
1st trimester
1-13 weeks
2nd trimester
14-27 weeks
3rd trimester
28 weeks-birth
when to initiate folic acid supplementation … and how much
4 weeks before conception
400 mcg po qday
preterm
born between 20-37 weeks gestation
term infant
born between 37 and 41 weeks gestation
post-term infant
born after 42 weeks gestation
low birth-weight infant
live birth infant = 2500g
fetal growth restriction
at or below 10th percentile at any gestational age
neonatal period
birth through the 28th day of life
perinatal period
28 weeks gestation to first 7 days of life
how long should mom + dad wait to conceive after being exposed to zika
mom - 8 weeks to attempt pregnancy
dad - 6 weeks
when is nausea common in pregnancy
begins as early at 2 weeks gestation –> up until the 13-16th week
when does colostrum secretion begin
as early as 16 weeks gestation
hyperemesis gravidarum
extreme N/V –> dehydration, weight loss, ketonuria –> may require hospitalization, IVF, antiemetics, TPN
fetal movement in primiparous women can be felt when
weeks 18-20
fetal movement in multiparous women can be felt when
14 weeks gestation
why is basal body temp elevated during pregnancy
progesterone
how much is basal body temp elevated during pregnancy
0.5*
chloasma/melasma what and when
skin darkening of forehead, bridge of nose, cheek bones
usually occurs after 16 weeks
why linea nigra
melanocyte-stimulating hormone increases = darkening of the nipples and lower midline
why striae
due to collagen separation
why spider telangiectasia
elevated plasma estrogen
pruritic urticarial papules and plaques (PUPPS) what and tx
2nd/3rd trimester
tx: topical cortisone
chadwick’s sign
blueish tinge to the vagina/cervix
hegar’s sign what and when
softening/widening of the cervix
6-8 weeks gestation
when can you start to appreciate abdominal enlargement
when can the fetus be palpated
18 weeks
fetus palpated at 22 weeks
when do Braxton hick’s contractions begin
28 weeks gestation and increase in regularity
how early is B-hcg detected
8-11 days after fertilization (right before menstruation)
when do B-hcg levels peak
~10 weeks gestation
fetal heart tones can be detected with doppler ultrasound when
after 10 weeks gestation
fetal heart tones can be detected by fetoscope when
after 18-20 weeks gestation
normal fetal HR
110-160
Naegele’s rule to determine estimated date of delivery
(date of LNMP - 3 months) + 7
or 280 days from LNMP
typically just use online calculator
how to dx early pregnancy loss
US
bhcg if US equivocal
how to dx late pregnancy loss
typically identified by mother via lack of fetal movement
if fetal heart tones absent –> confirm with US
increase in plasma volume during pregnancy
50%
causes a drop in hematocrit
cardiac output and stroke volume increases
CO increases 40%
SV increases 25-30%
blood pressure changes during pregnancy
declines - lowest BP at 24-28 weeks (end of 2nd tri)
back to normal by 36 weeks
PVR during pregnancy
decreases most during 1st trimester = varicosity development
heart murmurs in pregnancy
systolic ejection murmurs
S3 heart sounds common
wide splitting of S1 and splitting of S2 in 3rd trimester
changes to pulmonary system during pregnancy (diaphragm, tidal volume, minute ventilation)
diaphragm elevation
increased tidal volume
increased resting minute ventilation and respiratory drive
renal system changes during pregnancy
length of kidneys increase, dilation of renal calyces, pelvices, ureters
increase in renal plasma flow, increase in GFR, decrease in Cr, mild proteinuria
bladder displaced
dysuria/hematuria is always abnormal - treat it!
Ptyalism
excessive salivation
“water thrush”
when is reflux the most common
1st > 2nd > 3rd
when are hemorrhoids the most common
3rd trimester
white blood cell count changes in pregnancy
leukocyte count increases (5,000-12,000)
clotting factors that increase in pregnancy
fibrinogen and factor VIII
causes an increased risk of VTE and hemorrhage
what type of analgesic is safe to use in pregnancy
APAP! (do not use ibuprofen)
uncomplicated pregnancy schedule
initial - 6-10 weeks gestation
Q4 weeks - 0-32 weeks gestation
Q2 weeks - 32-36 weeks gestation
Qweek - after 36 weeks
primigravida
first time pregnant
nulligravida
never been pregnant, not pregnant now
multigravida
2 or more pregnancies
nullipara
no pregnancy beyond 20 weeks
primipara
first delivery, first pregnancy > 20 weeks
multipara
delivered 2 or more pregnancies
when should you do a pelvic exam on a pregnant woman
first visit then after 36 weeks
unless she had a pelvic in the last year, the first one is not necessary
CBC during a pregnancy
anemia, leukocytosis, slight thrombocytopenia
if Rh(D) is negative and antibody screen is negative at initial visit…what should you do
recheck antibody screen at 28 weeks and again at time of delivery
treatment of Rh(-) mothers
RhoGam to prevent her from forming antibodies against Rh + blood
additional blood tests besides HCG, CBC, RH, blood group
varicella, rubella (if immunity is unknown) VDRL/RPR for syphilis HBsAg HIV test NAAT for chlamydia glucose challenge test - with hx of gestational DM selective - TSH? other infections genetic screening UA/culture
when should you consider screening for DM in pregnant women
risk factors or hx of gestational DM
fasting >/= 126
HbA1c >/= 6.5%
random plasma glucose >/= 200
when should patients be offered genetic screening
before 20 weeks gestation
what to assess at subsequent pregnancy office visits
maternal weight gain blood pressure uterine fundal height fetal heart tones edema fetal size/position labs pelvic exam (at 36 weeks)
ACOG recommendation for maternal weight gain
25-35 lbs - 2-4 lbs per visit
underweight should gain more, overweight should gain less
how often should fundal heights be measured
at every visit after 20 weeks
fundal height at 8 weeks
uterus palpated at pubic symphysis
fundal height at 16 weeks
uterus at midpoint between pubic symphysis and umbilicus
fundal height at 20 weeks
uterus is at umbilicus
fetal heart tones can be auscultated when with doppler
10-12 weeks
when should fetal size and position be manually assessed
after 26 weeks
how to screen for gestational diabetes (and when)
at 24-28 weeks - 1 hr glucose test after 50g glucose load
abnormal >130
if abnormal –> 3-hr glucose test (100g glucose after fasting glucose is checked, then checked at 1, 2, 3 hours)
when to test for GBS
35-37 weeks
if positive GBS culture … tx?
penicillin at time of labor
things to assess in cervical exam (after 36 weeks)
cervical consistency, effacement, diatation, station
1st trimester aneuploidy screening options
maternal cell-free fetal DNA test
combined test: US + biochemical markers
maternal cell-free fetal DNA test
assessment of cell-free DNA in maternal circulation for trisomy 21, 18, 13
done as early as 10 weeks gestation
combined genetic testing
US - increased fluid indicative of possible abnormality
biochemical markers - pregnancy-associated plasma protein A (PAPP-A) and B-hcg
performed at 11-14 weeks
2nd trimester genetic screening options
quad screen
when can you do quad screen
between 15-18 weeks
what does quad screen test for
neural tube defects and aneuploidy
what is included in quad screen
serum B-hcg
unconjugated estriol
AFP
inhibin A
high levels of AFP concerning for…?
neural tube defects
low levels of AFP concerning for…?
trisomy
chorionic villi sampling
more invasive than amniocentesis
10-13 weeks gestation
detection for chromosomal abnormalities
amniocentesis
usually used for confirmation of a positive screen in 1st/2nd trimesters
performed at 15-20 weeks
US-guided needle aspiration of amniotic fluid for direct assessment of AFP
mainstay of imaging in obstetrics
ultrasound
typically 2D
use of an MRI in pregnancy
abnormal neuroanatomy
delivery planning in 3rd tri
how to assess amniotic fluid volume
US typically in 2nd and 3rd trimesters
polyhydramnios (what, risks, when to suspect, most common etiology)
excessive volume of amniotic fluid
risks: preterm birth, placental abruption, fetal anomalies
suspected when fundal height is out of proportion
most common cause: fetal structural anomaly/anomalies
oligohydramnios (what, etiology, prognosis)
less than expected amniotic fluid
caused by a decrease in fetal urine production or increase in swallowing
many causes
poor prognosis if in 1st trimester
1st trimester US exam
viability US - confirmed with heart beat
Anatomy US
done after 18 weeks if doing single anatomy screen
if doing two: 1st at 14-16 weeks, 2nd after 20 weeks
growth US
identify fetal growth abnormalities (fundal height < expected, multiple gestations, complications associated with fetal growth restrictions)
evaluation of fetal well-being
during 3rd trimester when pregnancy at-risk or evidence of fetal distress
4 US parameters + nonstress test = points to assess risk of fetal hypoxia or intrauterine death
reactive nonstress test
> /= accelerations of 15 seconds in a 20 minute period
non-reactive nonstress test
reactive criteria not met within 30 minutes
placental location US
during the 2nd trimester anatomy US or 3rd trimester during growth US
Greatest effect of a drug on the fetus is during
weeks 2-10 after LNMP (organogenesis)
when to give live vaccines
3 months before pregnancy or post-partum
when should pregnant women receive Tdap vaccine
27-36 weeks
how many calories should they add during pregnancy
300kcal/day
how many calories should they add during breastfeeding?
500kcal/day
