Pregnancy and Antepartum Care Flashcards
what is the goal of preconception care?
reduce risk of adverse effects for mom and baby
what risks need to be addressed prior to conception?
smoking cessation EtOH cessation illicit drug cessation folic acid supplementation proper nutrition weight issues diabetes management stress reduction
why is folic acid supplementation vital to fetal health?
reduces risk of neural tube defects
- 4 mg/day without hx of NTD
- 0 mg/day with hx of NTD
Gravidity
number of times a woman has been pregnant
parity
number of pregnancies that result in a birth beyond 20 weeks
can be broken down into full-term, pre-term, abortions and living
abortions
include ectopic, spontaneous, and elective pregnancy loss prior to 20 weeks
woman has given birth to a set of twins at term and both are currently living. what is the GPA?
G1P1002
woman has given birth to one term infant, one set of preterm twins, 1 miscarriage and 1 ectopic pregnancy. she has 3 living children. GPA?
G4P1123
history obtained on first prenatal visit
medical (DM, HTN)
reproductive (GPA)
family (DM)
nutritional (folic acid, weight gain)
social (EtOH, drugs, smoking, employment)
psychosocial issues (depression, anxiety, domestic violence)
normal prenatal exam findings
systolic murmurs, exaggerative splitting and S3 palmar erythema spider angiomas linea nigra striae gravidarum chadwicks sign
labs obtained at first prenatal visit
CBC type and screen (Rh factor) rubella syphilis Hep B surface Ag HIV DM screen urine culture
what lab values tend to increase with pregnancy?
fibrinogen urine protein amylase leukocyte count clotting factors 7-10
fetal monitoring during first prenatal visit
confirm pregnancy and viability estimate gestational age and due date genetic counseling if necessary discuss teratogens advice on decreasing early pregnancy sx
when can hCG first be detected in serum?
6-8 days after ovulation
what hCG level is considered positive for pregnancy?
25 IU/L
hCG trend within first 30 days of pregnancy
doubles ever 2.2 days
*can determine early IUP vs ectopic
transvaginal US findings and hCG level at 5 weeks
gestational sac
hCG = 1500-2000
transvaginal US findings and hCG level at 6 weeks
fetal pole
hCG = 5200
transvaginal US findings and hCG level at 7 weeks
cardiac activity
hCG = 17,500
estimating due date based on last menstrual period
Naegels rule!
minus 3 months + 7 days
what US findings are best for estimating due date?
crown rump length (CRL)
femur length
biparietal diameter
abdominal circumference
who needs genetic counseling?
advanced maternal age (35+) previous hx of birth defects or genetic disorder previous child with MR previous neonatal death multiple fetal losses abnormal serum marker screening consanguinity maternal conditions teratogen exposure abnormal fetal US parent is a known carrier of a genetic disorder
what is the miscarriage rate of fetal chromosomal disorders?
50%
who is most at risk for chromosomal disorder development?
women who are 35+
what is the chance that a couple who previously had a child with Down syndrome would have another child with a chrom abnormality?
1%
when should a chromosomal study/karyotype be performed on couples?
3 or more spontaneous abortions
*may have balanced translocation
first trimester screening
maternal age
fetal nuchal translucency thickness (increased associated with abnormalities)
maternal serum b-hCG
pregnancy-associated plasma protein A (PAPP-A)
what could an elevated b-hCG and low PAPP-A indicate?
Down Syndrome
second trimester screening
Triple screen = b-hCG, estriol and maternal AFP
Quadruple screen = b-hCG, estriol, AFP and inhibin A
what is a noninvasive test to screen for fetal abnormalities?
cell-free fetal DNA detected in maternal blood
*can detect chrom abnormalities but not NTD
when would a cell-free fetal DNA be ordered?
advanced maternal age hx of prior pregnancy with trisomy fam hx of chrom abnormalities fetal US abnormalities \+ serum screening test
what is the next step if you have a positive cell-free fetal DNA?
invasive diagnostic test such as amniocentesis or CVS
when can you perform an amniocentesis?
16-20 weeks
0.3% miscarriage rate
when can you perform a chorionic villi sampling?
11 weeks
1% miscarriage rate
teratogen
any agent or factor that can cause abnormalities of form or function in an exposed fetus
describe the medication risk factor categories for pregnancy and breast feeding
A - its fine to take B - no human studies have shown fetal harm C - no studies have been conducted D - studies have shown risk X - dont fucking take it
fetal susceptibility to teratogenicity
dependent on genetic make-up of mother and fetus
dose dependence and teratogenicity
obviously small dose has lower risk vs high dose has greater risk
timing and teratogenicity
fetus is most vulnerable at 17-57 days post-conception (organogenesis)
what drugs are considered teratogens?
alcohol tobacco illicit drugs anti-anxiety anti-neoplastic anti-coagulants anti-convulsants Diethylstilbestrol (DES) retinoids (accutane)
fetal alcohol syndrome
growth restriction low set ears smooth philtrum thin upper lip short palpebral fissures flat midface microcephaly MR behavioral disorders
fetal hydantoin syndrome (FHS)
caused by Dilantin during pregnancy: craniofacial abnormalities limb reduction defects pre-natal onset growth restrictions MR CV anomalies
valproic acid and carbamazepine are associated with what specific fetal defect?
spina bifida
are OCPs teratogenic?
meh not really
may cause masculinization of fetal female external genitalia
what infectious agents are teratogens?
TORCH
toxoplasmosis other (syphilis, parvo B19, zoster) rubella CMV herpes
what is the rule of thumb for radiation exposure for pregnancy women?
less than 5 rads of exposure has no risk of teratogenicity
unpleasant sx of pregnancy
nausea/vomiting constipation heart burn hemorrhoids leg cramps backache
frequency of prenatal visits
every 4 weeks until 28 weeks
every 2 weeks from 28-36 weeks
weekly until delivery
normal pregnancy weight gain for BMI < 19
28-40 lbs
normal pregnancy weight gain for BMI 19-25
25-35 lbs
normal pregnancy weight gain for BMI > 25
15-25 lbs
what normally occurs during routine prenatal office visits?
BP weight urine protein measure uterine size fetal heart rate fetal movement/kick counts educate on complications discuss lifestyle
what is evaluated for near term office visits?
fetal lie (longitudinal, oblique or transverse) fetal position (vertex or breech)
what tools are used to assess fetal well-being?
kick count (10 movements in 2 hours)
nonstress test
contraction stress test (oxytocin)
what is a normal nonstress test result?
2 accelerations of at least 15 beats above baseline lasting at least 15 seconds during 20 mins of monitoring
what are the components of the reassuring biophysical profile?
- nonstress test
- fetal breathing movements
- fetal movement
- fetal tone
- amniotic fluid volume
*correlates to incidence of stillbirth
reassuring biophysical profile results
8-10 = good
6 = okay, deliver if patient is at term
4 or less = very concerning, consider delivery
