Pregnancy Additional Info Flashcards
menstrual cycle
define these words:
* menarche
* menses
* perimenopause
* menopause
- Menarche: 1st mensturual period (starting on avg at 12 yrs)
- Menses: monthly cycles of menstruation
- Perimenopause: interval of menstural irregularities leading up to total cessation of cycles
- Menopause: cessation of menses for 12+ months (avg age = 51 yrs)
menstrual cycle
effects of progesterone on reproductive organs
- Stabilizes and causes maturation of endometrium for implantation
- increases Endometrial secretions/ thickness
- Lobular breast development
- elev Body temperature
Menstrual cycle
what is corpus luteum
forms from cells of the ovarian follicle wall after an ovum is released during ovulation; serves as a temporary endocrine gland during the latter half of the menstrual cycle and into early pregnancy
menstrual cycle
purpose of follicular phase
- Grow the endometrial layer of the uterus (increased number of stroma and glands, increasing depth of the spiral arteries that supply the endometrium)
- Create an environment that is friendly and helpful to possible incoming sperm (creation of channels within the cervix, allowing for sperm entry)
- develop a primordial follicle (a primordial follicle matures into the Graafian follicle that is ready for ovulation)
Menstural Cycle
- amenorrhea
- menorrhagia
- metrorrhagia
- menometrorrhagia
- dysmenorrhea
- oligomenorrhea
- polymenorrhea
- Amenorrhea: absence of menses due to hypothalamic, pituitary, ovarian, uterine, or vaginal cuases; can be primary (no menarche by age 15) or secondary (absence for 3+ mo w/ previously normal cycle)
- Menorrhagia: regular menstrual interval w/ excessive eflow (>80mL for 7+ d)
- Metorrhagia: irregular uterine bleeding between menstural periods or at irregular intervals
- Menometrorrhagia: menorrhagia (heavy menstrualflow(> 80 mL for > 7 days) with metrorrhagia (menses at irregular intervals)
- Dysmenorrhea: recurrent abdominalpainassociated with menstruation
- Oligomenorrhea: menstrual interval > 35 days
- Polymenorrhea: menstrual interval < 21 days
Pregnancy Diagnosis
pregnancy terminology (g/p/a system)
Gravidity (G)
* The number of times a woman has been pregnant
* Gravidity = Parity + Abortion
Parity (P)
* The total number of pregnancies reaching the age of viability regardless of the outcome (live birth, stillborn,cesarean delivery, etc.)
* Viability: ability to survive or live successfully; ≥ 24 weeks
Abortion (A)
* Number of lost pregnancies prior to the age of viability
* Includes both spontaneous abortions (miscarriages) and elective abortions (induced terminations of pregnancy)
Pregnancy Diagnosis
what does G3P2A1 mean
- G3: 3 pregnancies
- P2: 2 pregnancies carried after viability
- A1: one loss of pregnancy prior to viability
Pregnancy Diangosis
pregnancy terminology: LMP, gestational age, EDD
- Last menstrual period (LMP): 1st day of woman’s most recent period
- Gestational age (weeks, days): age of pregnancy calculated from LMP
- Estimated date of delivery (EDD): also known as the estimated date of confinement (EDC); Date when a pregnant woman is expected to give birth, Usually determined during the first prenatal visit, ~4–5% of women give birth on their EDD
pregnancy diagnosis
duration: classify terming + trimester
- Counted by completed weeks + completed days of the current week since the LMP
Duration of normal pregnancy:
* Full-term pregnancy: 37–42 weeks
* Preterm pregnancy: < 37 weeks
* Post-term pregnancy: > 42 weeks
Classified into trimesters:
* 1st trimester: first day of LMP to 13 weeks, 6 days
* 2nd trimester: 14 weeks, 0 days to 27 weeks, 6 days
* 3rd trimester: 28 weeks, 0 days to 40 weeks, 6 days
Pregnancy diagnosis
gestations vs embryonic age
- Gestational age: time that has passed since the onset of the last menstruation, which generally or as standard occurs 2 weeks before the actual fertilization
- Embryonic age: measures the actual age of the embryo or fetus from the time of fertilization
Pregnancy Diagnosis
US 1st trimester findings
Presence of a gestational sac:
* 1st visible finding of pregnancy is seen around 4.5–5 weeks
* Ahypoechoiccircle within the uterine cavity, surrounded byhyperechoicendometrium
* Should be visible in theuterusif quantitative serum β-hCG is >2,000 mIU/mL
Presence of a yolk sac:
* A thinhyperechoicring within the gestational sac
* 1st visible around 5–6weeks and disappears around 10 weeks
Presence of a fetal pole with a heartbeat:
* visible around 5.5–6weeks
Pregnancy Diagnosis
establishing the EDD
Calculating the EDD from the LMP:
* The date that falls exactly 40 weeks after the LMP
* Calculated by adding 9 months + 7 days to the LMP or subtracting 3 months from the LMP and adding 7 days
Dating by ultrasound:
* Measure the crown-rump length and compare to an established table
* Ultrasound dating is most accurate in the 1st trimester before genetic variation and the effects of intrauterine environment begin to have greater effects on fetal growth
- Calculating the EDD from the LMP is themost accuratemethod to date a pregnancyifthat EDD is consistent with the dates obtained from the ultrasound
- If the LMP is unknown, a 1st-trimester ultrasound is the next most accurate way to date a pregnancy
Pre-Natal Care
genital herpe management
- Receive antiviral prophylaxis with acyclovir 400 mg PO TID starting around 36 weeks gestational age
- Be evaluated specifically for any signs of active lesions (including on the cervix) at the onset of labor
- Active lesions at the time of labor are a relative contraindication to vaginal delivery
Pre-Natal Care
types of US screenings in pregnancy
- Viability US: Ultrasound at 8-12 weeks, first scan to determine the heart rate, placenta location, identify # of embryos
- Nuchal Translucency (NT): 11-14 weeks. Measures fluid behind the fetus neck. Can identify certain birth defects, including cardiac and risk for Down Syndrome.
- Anatomy US: 16-20 weeks. Check the entire anatomy of fetus, all organ development
Pre-Natal Care
US- cervical length, growth US
- Cervical Length: Measure length of cervix starting at 16 weeks, only indicated for those at risk of cervical shortening or cervical incompetence. (< 2.5 cm = short cervix)
- Growth US: Measure areas of the body to determine estimated fetal weight. Occurs at anatomy scan and every 4-8 weeks depending on maternal conditions
Pre-Natal Care
Fundal Height- location/measurement by age
- 12 weeks at pubic symphysis
- 16 weeks midway between pubic symphysis and umbilicus
- 20 weeks at umbilicus
- 20-36 weeks height in cm=gestational age
- After 36 weeks fetus descends into pelvis
Pre-Natal Care
Leopold’s Maneuver
- performed after 20 wks
- Determines fetal position, done near end of pregnancy
- What is at the fundus
- Where is fetal back and small parts
- What is the presenting part
- Where is the cephalic prominence
Pre-Natal Care
Folate + Folic Acid in Pregnancy
- Folate (Vitamin B9) naturally occurs in foods: beef, liver, leafy greens, peas, beans, eggs, milk
- Folic Acid: Synthetic form of folate
- Most important during the first trimester during organogenesis
Pregnancy Recommendations:
* Universal prophylaxis: 0.4mg (400mcg) once daily, Recommended to start at minimum 1 month before conception to help prevent neural tube defects
* High dose prophylaxis: 1-4mg, Recommended for individuals who are at higher risk of having fetal neural tube defects
Pre-Natal Care
recommended preg wt gain
- Twins: 15-20 kg
- BMI < 18.5: 12-17 kg
- BMI 18.5-24.9: 11-15 kg
- BMI 25-29.9: 6-11 kg
- BMI > 30: 6 kg
Pre-Natal Care
why to avoid smoking/EtOH in pregnancy
Smoking
* Increases risk of low birth weight and fetal growth restriction
* Increased risk of preterm labor and perinatal death
* Carbon monoxide > vasoconstriction of the fetal vessels in the placenta > decreased placental perfusion
Alcohol
* Fetal alcohol syndrome (FAS) birth defect syndrome
* Structural malformations (predominantly facial) (Microcephaly, short palpebral fissures, flat midface, underdeveloped philtrum, thin upper lip, low nasal bridge, epicanthal folds, minor ear anomalies, small teeth with faulty enamel, foreshortened nose, micrognathia)
* Growth restriction
* Neurologic abnormalities including mental retardation
* Alcohol consumption during pregnancy generally >3oz/day, no lower limit
Pre-Natal Care
genetic carrier screening
- Blood or saliva testing prior to pregnancy for pregnant patient and partner. Checks for any autosomal recessive inherited disorders
Single Gene Autosomal recessive disorders
* Able to test based on ethnicity that is most often affected, however these disorders are not restricted to these groups
* Common: Tay Sachs (Eastern/Central European Jewish, French Canadian, Cajun), Fragile X, Cystic Fibrosis, Sickle Cell Disease (African descent)
Benefits:
* Preconception identification of carriers of genetic disorders provides an opportunity for education regarding their risk of having an affected offspring, its prognosis, and their reproductive options.
* Patient can consult with genetic counselor
Pre-Natal Care
old pre-natal genetic testing
going out of use…
- sequential screen labs
- Triple screen (1st trimester): NT, bHCG, PAPP-A
- Quad screen (2nd trimester): AFP, bHCG, Estriol, Inhibin A
- Alpha fetoprotein: increased result suggests spina bifida, decreased result suggests trisomy 21 (Down Ayndrome)
- Down syndrome marker results: bHCG high, Inhibin A high, Estriol low, AFP low
- PAPPA-A: pregnancy associated plasma protein, key regulator of insulin-like growth factor essential for normal fetal development. Low PAPP-A indicative of placental insufficiency (increased risk of preterm delivery, fetal growth restriction, stillbirth and hypertensive disorders)
Pre-Natal Care
New Prenatal testing
Non-Invasive
* Non-Invasive Prenatal Testing (NIPT) (Screening Test)
* cfDNA: Small amount of cell-free DNA released from placenta into the pregnant woman’s bloodstream.
* test at 10-14 wks pregnancy for Trisomy 13, 18, 21, and sex chromosomes
* results return as “low risk” or “high risk”; detection rate > 98%
Invasive
* Chorionic Villi Sampling (CVS): Needle aspiration procedure, small amount of cells taken from the placenta; performed at 10-12 wks
* Amniocentesis: Needle aspiration procedure, cells taken from the amniotic sac; performed 16+ wks
Pre-Natal Care
things for providers to do at each visit 12-24 wks
- monthly visits
- maternal vital signs (BP, wt), feta heart rate, fundal height
- HPI: vaginal bleeding, fluid loss, contractions, fetal movement
Special Tests
* 12-16 wks: serum MSAFP
* 20+ wks: anatomy scan
Pre-Natal Care
common 2nd trimester issues/complaints
- Round ligament pain: Stretching, frequent position change, sleeping with a pillow between legs)
- UTI’s: Dilated urinary tract increases risk, asymptomatic bacteriuria is treated if >100,000 CFUs
- Yeast infections: immunosuppression, treat with Terconazole suppositories
- Constipation: Colace 100mg BID, educate on increased fruits/vegetables, water, fiber-rich foods; if necessary, consider Miralax)
- Iron-deficiency anemia: Ferrous sulfate with vitamin C supplementation
Pre-Natal Care
Non-Stress Test
- Test for fetal well-being (Assess response of FHR to periods of fetal movement)
- Most commonly performed antenatal testing
- Low risk pregnancy- performed weekly after 40 weeks
- High risk pregnancy: performed in the the late third trimester weekly/ biweekly
Describe
* An evaluation of the FHR pattern in the absence of regular uterine contractions to determine fetal oxygenation, neurologic, and cardiac function
* Based on premise that the normal fetus moves at various intervals; CNS and myocardium respond to FM with acceleration of FHR
* Acceleration is a sign of fetal well-being
Interpret Fetal Heart Monitoring
* NST reactive: two accelerations in FHR in a 20 minute period
Rh Alloimmunization
Rh Factor- what is it
- Inherited lipoprotein on the surface of RBCs
- Several Rh antigens, Rh (D)
- Presence of Rh (D) is Rh +; Absence of Rh is Rh-
Rh Alloimmunization
Rh (D) neg vs pos
- if mother & father are Rh (D) pos, baby will be pos. (no intervention required)
- if mother & father are Rh (D) neg, baby will be neg. (no intervention required)
- if mother is negative & father is positive, fetus could be negative or positive so RhoGam protocol should be initiated.
Rh Alloimmunization
first pregnancy vs second pregnancy
FIRST PREGNANCY
* if the mother is Rh neg and baby is Rh pos, there is Rh incompatibility and the mother will create anti-Rh antibodies
SECOND PREGNANCY
* mother’s IgG anti-Rh antibodies will travel through the placenta and attack the baby if the baby is Rh Pos
* this leads to fetal hemolytic anemia or hydrops fetalis
Rh Alloimmuniztion
Alloimmunization
- An immune response when exposed to foreign antigens which stimulates production of immunoglobulin G (IgG) antibodies
- Maternal Alloimmunization: reserved for Rh neg mother exposed to Rh pos fetal blood
- Antibody response develops slowly – not detectable serologically until 5-15 weeks after exposure. Primary immune response depends on several factors besides the volume of fetal blood the mother is exposed to frequency of Fetomaternal bleeding and abo compatibility
- exposure can occur due to miscarriage, therapeutic termination, ectopic pregnancy, antenatal bleeding, abd trauma; can do CVS, amniocentesis, ECV
Rh Alloimmunization
when to screen?
- first prenatal visit, all pregnant women should be screened for ABO blood group + Rh antigen
- common practice to just test the mother and give all Rh(D) negative mothers Rhogam prophylais
Rh Alloimmuniztion
Preventing Alloimmunization
Anti-D Immunoglobulin (RhoGam) Injection
* Administered to women exposed or at high risk of being exposed to Rh (D) + RBCs
* Suppresses immune response and antibody formation
* Protect against maternal alloimmunization from 15mL of fetal RBCs/ 30mL of fetal whole blood
* Dose: 300 µg IM injection
RhoGam Admin Protocol
* 28 weeks: Administer to all patients, if Rh negative
* 40 weeks: If more than 12 weeks have elapsed since Rhogam administration, administer again
* Postpartum: If infant Rh (D) +; Recommend 72 hours after delivery, however shown to be effective up to 28 days after delivery
* Fetomaternal bleeding: As little as 0.1 ml of Rh+ cells can cause sensitization !
Rh Alloimmuniztion
Evaluating Fetomaternal Hemorrhage
- Rosette Test: sensitive, qualitative test = can detect >2mL fetal whole blood in maternal circulation; if pos do KB
- Kleihauer-Betke (KB): measure amount of fetal hemoglobin txfr to maternal bloodstream & aid in determination of # of vials of RhoGam needed; 1 vial = 300mcg which protects against 30 mL of fetal blood
Fetal Monitoring
Antepartum Testing- screening vs diagnostic
- Screening: non-invasive tests, maternal blood work, imaging
- Diagnostic: invasive testing that involves obtaining sample of material from inside the uterus containing fetal DNA (CVS at 10-13 wks or amniocentesis 15-20 wks)
Fetal Monitoring
Antepartum Monitoring- describe
- monitoring when not in labor
- Cardiotocography = Electronic fetal monitoring
- Non-stress test (NST)
- Contraction stress test (CST)
- Biophysical Profile (BPP)
Fetal Monitoring
Antepartum Monitoring- describe
- monitoring when not in labor
- Cardiotocography = Electronic fetal monitoring
- Non-stress test (NST)
- Contraction stress test (CST)
- Biophysical Profile (BPP)
Fetal Monitoring
Indications for Antepartum Monitoring
Maternal vs Fetal
Maternal Indications
* Preterm labor, preterm prelabor rupture of membranes (PPROM)
* Prior fetal demise
* Pre-existing or gestational diabetes
* Chronic or pregnancy-induced hypertension (gestational HTN or preeclampsia)
* Rh Alloimmunization
* Other pre-existing medical conditions - SLE, cyanotic heart disease, sickle cell anemia
Fetal Indications
* Multiple gestations (twins, triplets, etc)
* Post-dates pregnancy (40+ weeks)
* Fetal growth restriction
* Oligohydramnios
* Decreased fetal movement (detected by mother)
Fetal Monitoring
Electronic Fetal Monitoring- describe
- Cardiotocography
- Monitors fetal heart rate on one graph, and contractions (toco) on second graph over time
- Provides data on how fetus is responding to intrauterine event
- External monitoring: Doppler ultrasound on the maternal abdomen; Picks up artifact, movement. Difficult in abdominally obese patients. Need physical transducer on abdomen at all times.
- Internal monitoring: Fetal scalp electrode; More invasive, need to feel fetal scalp transcervically in order to place.
Fetal Monitoring
why use EFM?
- For antenatal monitoring, EFM can give an idea of fetal well-being
- During labor uterine contractions cause interruptions in fetal oxygenation, so EFM helps providers decide when to intervene (offer resuscitation or c-section, etc)
- Identification of FHR changes potentially associated with inadequate fetal oxygenation may enable timely intervention to reduce the likelihood of hypoxic injury or death.
Fetal Monitoring
when to use EFM?
- Upon admission to L&D, monitor patient 20-30 minutes
- Monitor FHR at least every 30 minutes in first stage active labor
- Monitor FHR at least every 15 minutes in the second stage
- Either continuous or intermittent monitoring acceptable for uncomplicated pregnancies.
- Always continuously monitor high risk patients!
Fetal Monitoring
factors making it high risk
- pitocin for induction/augmentation
- HTN
- suspected chorio
- sepsis
- vag bleeding
- meconium
- febrile
- pre-eclampsia
Fetal Monitoring
EFM Definitions
* NST
* Labor
- NST: usually in outpatient/triage setting, at least 20 minute strip, classified as REACTIVE or NON-REACTIVE
- Labor: Continuous strip, interpret tracing as Category I, II, or III
Fetal Monitoring
EFM- Baseline
- mean FHR rounded to increments of 5 bpm during 10 min segment
- normal is 110-160
Fetal Monitoring
causes of brady and tachy cardia
Causes of bradycardia:
* beta-blocker therapy
* hypothermia
* hypoglycemia
* hypothyroidism
* fetal heart block or interruption of fetal oxygenation
Causes of tachycardia:
* maternal fever
* infection
* medications
* hyperthyroidism
* elevated catecholamines
* fetal anemia, arrhythmia
Fetal Monitoring
EFM Monitoring- Variability
- Fluctuations in the baseline that are irregular in amplitude and frequency.
- Resembles the variation from baseline, measured from highest to lowest FHR
Evaluating
* Absent: No variation in baseline, undetectable
* Minimal: < 5bpm
* Moderate: 6-25bpm
* Marked: >25bpm
Fetal Monitoring
EFM Monitoring- Accelerations
- A visually apparent abrupt increase (onset to peak less than 30 seconds) in the FHR
- Definition is based on gestational age
- reassuring, because usually based on fetal movement
Assessing
* < 32 weeks: Increase in 10bpm in at least 10 seconds
* >32 weeks: Increase in 15bpm in at least 15 seconds
- Total acceleration should last less than 2 minutes!
