Pregnancy and Childbirth Flashcards

Question 1

Q

Danger Signals! Placental Abruption (Abruptio Placentae) Overview

Answer

A

Pregnant woman in last few weeks of pregnancy
accounts for 5-8% of maternal deaths

RF:
- hx of HTN
- hx of preeclampsia/eclampsia
- smoking
- trauma
- cocaine use

Strongest risk: hx of placenta abruption

S/sx
- sudden onset of vaginal bleeding
- accompanied by contracted uterus, feels hard (hypertonic)
- very painful
- may have uterine contractions
- sudden onset of dark-red-colored vaginal bleeding

20% of women do not have vaginal bleeding (blood is trapped between placenta and uterine wall)

If mild → blood is reabsorbed and affected area reimplants

Severe cases causes:
- hemorrhages (e.g., DIC)

** Requires emergent treatment and C-section
* Fetus MUST be delivered to save mother’s life!

► CALL 911!

Question 2

Q

Danger Signals! Placenta Previa Overview

Answer

A

placenta implants too low either on top of the cervix or on the cervical isthmus/neck
Strong association b/t placenta previa and amniotic fluid embolism (sudden resp distress, hypoxia, and/or seizures followed by DIC during labor or after delivery)

multipara woman in late 2nd/3rd trimester w/ s/sx of:
- new onset of painless vaginal bleeding
- worsened w/ intercourse
- blood is bright red
- uterus is soft and nontender
* if cervix is not dilated, tx if strict bedrest

10-20% presents w/ both bleeding and uterine contractions

Lab/Dx:
- Transabdominal US to diagnose

Tx:
- IV magnesium sulfate if uterine cramping
- in mild, uterus will usually reimplant itself
- If cervix id dilated or if hemorrhaging → fetus delivered by C-section
- severe cases causes hemorrhage → fetus MUST be delivered to save mother’s life

Contraindications:
- vaginal or rectal insertion/stimulation (absolute contraindication!) → can precipitate severe hemorrhage

Question 3

Q

Danger Signals! Severe Preeclampsia Overview

Answer

A

Earliest time period preeclampsia/eclampsia can occur is 20 weeks gestation (and up to 4 weeks postpartum)
hemorrhagic stroke accounts for 36% of pregnancy-associated stroke
primigravida woman, late 3rd trimester of pregnancy (>34 weeks)

S/Sx:
- sudden onset of severe recurrent headaches
- visual abnormalities (e.g., blurred vision, scotomas)
- pitting edema (can easily seen on face/eyes and fingers)
- sudden rapid weight gain within 1-2 days (>2-4 lb/wk)
- new onset of RUQ abdominal pain
- BP >140/90
- Urine protein 1+ or higher
- sudden ↓ in UOP (oliguria)

Worrisome symptoms → encephalopathy
- Visual sx
- headache
- nausea/vomiting

If seizure, condition is reclassified as eclampsia

Tx:
- only known “cure” is delivery of fetus or baby
- magnesium sulfate is drug of choice to prevent eclampsia

Question 4

Q

Danger Signals! HELLP Syndrome Overview

Answer

A

Hemolysis
Elevated Liver Enzymes
Low Platelets

Serious but rare condition of preeclampsia/eclampsia (15%)

S/Sx: multipara woman 25 years in 3rd trimester
- s/sx preeclampsia
- RUQ (or midepigastric) abdominal pain w/ N/V
- malaise (may be mistaken for viral illness)

Sx can present suddenly
If severe, RUQ/epigastric pain may have hepatic bleed/swelling → impending hepatic rupture

Labs/Dx:
- ↑ AST, ALT
- ↑ total bilirubin (>1.2 mg/dL)
- ↑ lactate dehydrogenase
- ↓ platelet (<100,000 cells/mcL)
- DIC
- peripheral smear w/ schistocytes and burr cells
- ↓ Hgb & hct

Question 5

Q

Lab results during Pregnancy
1. Liver Function
2. Lipid Profile
3. Thyroid function
4. CBC
5. Renal function

Answer

A

Elevated:
- Alkaline phosphatase (2nd/3rd trimester)

Notes:
- AST, ALT, and GGT no changes

Elevated:
- Total cholesterol
- triglycerides
- HDL
- LDL

Notes:
- Wait 4-6 weeks after pregnancy to check lipids

Elevated:
- Total T3

Notes:
- Free T3, TSH

Elevated:
- WBC
- Platelet count
- Hemoglobin
- Sedimentation rate

Notes:
- Hemoglobin and hematocrit are ↓ in pregnancy

Elevated:
- GFR

Notes:
- Lower serum creatinine
- GFT and renal plasma flow ↑

Question 6

Q

Lab Testing: Urinalysis (Dipstick)
- How to obtain urine
- What indicates negative vs positive
- What happens if positive/negative?

Answer

A

Obtain midstream urine before gynecologic exam (minimizes contamination from vaginal discharge)

Check protein, leukocytes, nitrite, blood, glucose

Protein: Negative (trace 1+ to 4+)

If ≥ 20 weeks gestation, R/O preeclampsia if protein ≥1+

If proteinuria present, order 24-hour urine for protein and creatinine

Question 7

Q

Lab Testing: Liver Function Tests

Answer

A

ALT, AST, bilirubin, and gamma-glutamyl transpeptidase (GGT) remain the same except for alkaline phosphatase

Question 8

Q

Lab Testing: Alkaline Phosphatase

Answer

A

Expected to ↑ during pregnancy d/t growth of fetal bones
- values ↑ in multiple gestation pregnancies

Question 9

Q

Lab Testing: WBCs

Answer

A

WBC in nonpregnant adults: 4,500-10,500 cells/mm3

WBC is ↑ throughout pregnancy esp during 3rd trimester
may climb as high as 16,000 cells/mm3 in 3rd trimester
Leukocytosis w/ neutrophilia is “normal” during pregnancy (if not accompanied by signs of infection)

Question 10

Q

Lab Testing: Hemoglobin & Hematocrit

Answer

A

Both goes ↓ during pregnancy d/t hemodilution
Hgb value may be as low as 10.5 g/dL
hematocrit down ~30% (by 3rd trimester) → called physiologic or dilutional anemia of pregnancy
to R/O iron-deficiency anemia, check MCV (not affected by pregnancy)

Question 11

Q

Lab Testing: Erythrocyte Sedimentation Rate

Answer

A

↑ during pregnancy
By 3rd trimester, sedimentation rate ranges from 13-70 mm/hr

Normal ESR (nonpregnant): 0-20 mm/hr

Question 12

Q

Lab Testing: Thyroid Function Tests

Answer

A

Total triiodothyronine (T3) is ↑ during pregnancy d/t ↑ levels of thyroid-binding globulin (TBG)
Thyroid-stimulating hormone (TSH), free T3, and free th yroxine (T4) results remain unchanged

Question 13

Q

Lab Testing: Serum Alpha-Fetoprotein

Answer

A

manufactured by liver of fetus and mother
majority of maternal AFP comes from fetus (liver, fetal yok sac, GI tract)
Biochemical marker used to estimate pregnant woman’s risk of having a fetus/infant w/ Down syndrome (check b/w 15-18 weeks)
AFP levels are adjusted for weight and race; slightly higher levels are found in Black women and lower levels in Asian women (compared w/ Whites)

Indications:
- advanced maternal age
- previous births
- family hx of chromosomal or birth defects (e.g., neural tube defects)

Question 14

Q

Lab Testing: Low Alpha-Fetoprotein

Answer

A

Mature matneral age is most common risk factor for Down syndrome (≥35 yuears has a 1:350 at term)
women pregnant at ≥35 years have a “geriatric pregnancy”

If AFP is low → order triple screen test (AFP, HCG, and estriol) or the quadruple screen test (AFP, HCG, estriol, inhibin-A) to evaluate for Down syndrome (trisomy 21)

Question 15

Q

Lab Testing: High Alpha-Fetoprotein

Answer

A

R/O neural tube defects or multiple gestations

Most common reason for high AFP: pregnancy dating error

If AFP is high →
- neural tube defects
- omphalocele
- gastroschisis

► Order the triple screen or the quad screen test
► + sonogram to R/O neural tube abnormalities (higher sensitivity than AFP alone)

To prevent neural tube defects:
- ingest folic acid 400 mcg (0.4) daily (found in leafy green vegetables, fortified cereals)
- To ↓ risk, advise pts to take prenatal vitamins when planning to become pregnancy

Question 16

Q

Lab Testing: Triple Marker Screen Test

Answer

A

combines AFP, beta HCG, and estriol serum levels
hormone level results are used in a formula to figure out risk for a Down syndrome infant
Diagnostic test for genetic anomalies is chromosome testing

Question 17

Q

Lab Testing: Quadruple Marker Screen Test

Answer

A

Combo of triple screen hormones + inhibin-A (hormone released by placenta)
Tripole or quadruple screen tests are more sensitive than AFP alone (but have a higher rate of false positives)
GOLD STANDARD for genetic disorders is testing of fetal chromosomes/DNA

Question 18

Q

Lab Testing: Screening for Genetic Disorders
1. Jewish Descent
2. White
3. African Americans

Answer

A

- Tay-Sachs disease → fatal neurological ds w/ no known cure
  - More common among EAstern Europeans of Jewish descent (Ashkenazi Jews)
Cystic fibrosis
Sickle Cell Anemia

Question 19

Q

Lab Testing: Amniocentesis sand Chorionic Villus Sampling

Answer

A

can be done earlier (1012 weeks) than amniocentesis (15-18 weeks)
specimen contain fetal cells
Fetal chromosomes/DNA is tested for abnormalities

Question 20

Q

Lab Testing: Beta Human Chorionic Gonadotropin

Answer

A

manufactured by chorion (early placenta) by day 8-10
High-quality urine home pregnancy tests (e.g., First Response, EPT) can detect pregnancy as early as first missed period (2 weeks after conception)
Higher levels of HCG w/ twins/multipole fetuses

Question 21

Q

Lab Testing: Doubling Time

Answer

A

Important indicator of viability of a pregnancy
useful only in first trimester; therefore, loses its predictive value (DO NOT use after week 12)

Normal finding → HCG doubles Q48 hrs during first 12 weeks (1st trimester) in normal pregnancy

Ectopic pregnancy → HCG has lower values than normal; values ↑ slowly and do not double as expected

Inevitable abortion → values of HCG start ↓ rapidly; there is no doubling; cervix is dilated

Question 22

Q

Lab Testing: Vaginal Cultures

Answer

A

Group B Streptococcus (GBS) tested at 35-37 weeks
Swab vaginal introitus and rectum (insert up to anal sphincter) for C&S

If POSITIVE → give intrapartum antibiotic prophylaxis w/ Penicillin G 5 million units IF, followed by 2.5-3 million units IV Q4hrs until delivery

If PCN allergy → Use clindamycin or erythromycin

Question 23

Q

Lab Testing: Sexually Transmitted Disease
- What to screen for in pregnancy?

Answer

A

Hep B surface antigen (HBsAg)
HIV
gonorrhea
chlamydia
syphilis
herpesvirus type 1 & 2

Question 24

Q

Lab Testing: Titers

Answer

A

Rubella titer
varicella titers (if no proof of infection)

Question 25

Q

Drugs and Vaccine during Pregnancy

Answer

A

Most drugs in pregnancy are FDA category B drugs

FDA Pregnancy and Lactation Labeling Rule (PLLR) will eventually replace the pregnancy letter categories w/ new labeling

Question 26

Q

Drugs and Vaccine during Pregnancy: Category A Drugs

Answer

A

Animal and human data show no risk to pregnant woman

Prenatal vitamins (high-dose multivitamins are not used during pregnancy)
Insulin
Thyroid hormone (levothyroxine)
Folic acid (vitamin B9), pyridoxine (vitamin B6)

Question 27

Q

Drugs and Vaccine during Pregnancy: Category B Drugs

Answer

A

Animal studies show no risk, no human data available

Antacids (Tums, Maalox) are safe for pregnant women
Docusate sodium (Colace); a stool softener and is approved for pregnant women; it is NOT a laxative
Analgesics (acetaminophen preferred to NSAIDs) esp in 3rd trimester
Avoid laxatives (e.g., ex-lax, Bisacodyl), esp in 3rd trimester (may induce labor)

Question 28

Q

Drugs and Vaccine during Pregnancy: Antibiotics for Pregnant Women - Pencillins

Answer

A

Amoxicillin (Amoxil)
Penicillin
Dicloxacillin

Question 29

Q

Drugs and Vaccine during Pregnancy: Antibiotics for Pregnant Women - Cephalosporins

Answer

A

First Generation:
- Cephalexin (Keflex)
- cefadroxil (Duricef)

Second Gen
- Cefuroxine axetil (Ceftin)
- Cefaclor (Ceclor)
- Cefproxzil (Cefzil)

3rd Gen
- Ceftriaxone (Rocephin) injections
- Cefdinir (Omnicef)
- Cefixime (Suprax)

4th Gen
- Cefepime (Maxipime) injection/IV (used mainly in hospitals)

Question 30

Q

Drugs and Vaccine during Pregnancy: Antibiotics for Pregnant Women: Macrolides

Answer

A

Erythromycins
Erythromycin ethylsuccinate (E-mycin), erythromycin vase, erythromycin stearate, erythromycin estolate (EES)
Azithromycin (Zithromax)
Clarithromycin (Biaxin) is the only macrolide that is a category C; AVOID use during pregnancy; consult w/ physician before use and discuss risk vs benefits

Question 31

Q

Drugs and Vaccine during Pregnancy: Antibiotics for Pregnant Women: Macrobid

Answer

A

Nitrofurantoin (Furadantin, Macrobid)

Do NOT use w/ G6PD anemia → causes hemolysis (anemia, jaundice, dark urine)

Contraindication:
- during labor and delivery (or near term) d/t ↑ risk of hemolytic anemia (infant) d/t immature erythrocyte enzyme system (glutathione instability)

Question 32

Q

Drugs and Vaccine during Pregnancy: Antibiotics for Pregnant Women: Macrobid

Answer

A

Nitrofurantoin (Furadantin, Macrobid)

Do NOT use w/ G6PD anemia → causes hemolysis (anemia, jaundice, dark urine)

Contraindication:
- during labor and delivery (or near term) d/t ↑ risk of hemolytic anemia (infant) d/t- Nutrofuration (Furadantin, Macrobid) immature erythrocyte enzyme system (glutathione instability)

Question 33

Q

Drugs and Vaccine during Pregnancy: Antihypertensives for Pregnant Women

Answer

A

Used for women w/ preexisting HTN or for mod-severe preeclampsia or eclampsia
- Use of antihypertensive drugs to control mild HTN does NOT alter course of ds or ↓ perinatal morbidity or mortality of preeclampsia
→ Refer to obstetrician

Methyldopa (Aldomet)
CCB (Procardia)
Labetalol (Normodyne)

Question 34

Q

Drugs and Vaccine during Pregnancy: Category C Drugs

Answer

A

Adverse effects seen in animal studies
No human data available

Sulfa Drugs
- Considered category C in 3rd trimester d/t can cause hemolytic anemia in fetus/infant → hyperbilirubinemia
- displaces bilirubin from albumin
- high blood levels of unconjugated bilirubin can cross blood-brain barrier and cause brain damage (kernicterus)

Trimethoprim-Sulfamethoxazole (e.g., Bactrim DS, Septra)
- Clarithromycin (Biaxin) is the only category C macrolide abx
- Avoid use in pregnant women
- Consult w/ physician before using category C drugs during pregnancy

Pseudoephedrine (Sudafed)
- ↑ risk of gastroschisis
- Ideally, it should NOT be used in pregnancy and breast feeding (repeated doses may interfere w/ lactation, as it crosses breastmilk)

Question 35

Q

Kernicterus

Answer

A

When high blood levels of unconjugated bilirubin crosses blood-brain barrier and causes brain damage

Question 36

Q

Gastroschisis

Answer

A

Intestines protrude through abdominal wall defect

Question 37

Q

Drugs and Vaccine during Pregnancy: Category D Drugs

Answer

A

Evidence of fetal risk
- Benefits should outweigh risk of using drug

ACEi and ARBs
- causes fetal renal abnormalities, renal failure, and hypotension
- Captopril (Capoten) and losartan (Hyzaar)
- Category C in 1st trimester
- Category D in 2nd/3rd trimester

Fluoroquinolones
- Affect fetal cartilage development
- a rare side effect is Achilles tendon rupture in athlete; CONTRAINDICATED in pregnant or lactating women and children 18 years
- Ciprofloxacin (Cipro)
- Ofloxacin (Floxin)
- Gram+ activity → Levofloxacin (Levaquin), gemifloxacin (Factive), moxifloxacin (Avelox)

Tetracyclines
- Stain growing tooth enamel
- Tetracycline, minocycline (Minocin)
- Avoid in 3rd trimester

NSAIDs
- Block prostaglandins and may cause premature labor
- avoid using esp in last 2 weeks of pregnancy
- Category D in 3rd trimester, but category B during 1st/2nd trimester (ibuprofen, naproxen, other NSAIDs)

Sulfa drugs
- Risk of hyperbilirubinemia (neonatal jaundice or kernicterus)
- displace bilirubin from albumin → high levels of unconjugated bilirubin will cross blood-brain barrier and cause brain damage (mental retardation, seziures, deafness, etc)

Question 38

Q

Drugs and Vaccine during Pregnancy: Category X Drugs

Answer

A

Proven fetal risks outweigh the benefits

Accutane (isotretinoin - Vit A derivative)
- used for severe cystic and nodular scne recalcitrant to treatment; highly teratogenic
- Also avoid vita A derivative topicals such as retinol/retinoid, tretinoin (Retin A), adapalene

Methotrexate (antimetabolite) and anticancer drugs
- used for some types of autoimmune ds (psoriasis, RA) and certain cancers

Proscar (antiandrogen)
- Used for BPH and prostate CA

Misoprostol (prostaglandin analog)
- used as one of the drugs in medical abortions (a component of the “abortion pill”)

Evista and tamoxifen (selective estrogen receptor modulator [SERM])
- use reduces risk of reoccurrence of estrogen receptor-positive breast CA

All hormonal drugs (natural or synthetic) are category X in pregnancy–all forms of estrogens, testosterone, finasteride (Proscar), mifepristone (RU-86)
Any drug that blocks hormone synthesis or binding (Depo Lupron)
Depo Lupron is used for infertility, hormone-dependent CAs, and endometriosis

Question 39

Q

Drugs to avoid in 3rd Trimester of Pregnancy

Answer

A

NSAIDs (blocks prostaglandin)
Aspirin and salicylates (affect platelets)
Bismuth subsalicylate (Pepto-Bismol) contains salicylates
Sulfa-containing drugs (trimethoprim0sulfamethoxazole, nitrofurantoin) near term → higher risk of hyperbilirubinemia, jaundice, kernicterus, oligohydramnios, premature closure ductus arteriosis

Question 40

Q

Pregnancy: Live Vaccines

Answer

A

CONTRAINDICATED in Pregnancy:
- MMR; oral polio; varicella; and FluMist
- Live attenuated influenza virus (LAIV)

Influenza vaccine is an inactivated virus and is safe to use in pregnant women
- Recommended for pregnant women esp if pregnant during fall and winter seasons
- only use injectable inactivated flu vaccine

** After a live virus vaccine, advise reproductive-aged women not to get pregnant (and use reliable birth control) in the next 4 weeks (MMR) or 3 months (varicella and shingles vaccine)
- Inactivated flue vaccine and Tdap vaccines are recommended for pregnant women

Question 41

Q

Drugs and Vaccine during Pregnancy: Teratogens

Answer

A

Agents that can cause structural abnormalities during pregnancy

Paroxetine (Paxil) → increases risk of birth defects in 1st trimester; particularly heart defects (others are anencephaly, abdominal wall defects); FEDA category D drug
Fluoxetine (Prozac) → heart wall defects and craniosynostosis (premature closure of skill sutures)
Other SSRIs (citalopram, escitalopram, sertraline) → 1st trimester exposure may be associated w/ a low risk of teratogenicity
Alcohol → fetal alcohol syndrome
Cigarettes → Intrauterine growth retardation (IUGR), prematurity
Cocaine → CVAs, mental retardation, abruptio placentae
Isotretinoin (Accutane) → CNS/caraniofacial/ear/cardiovascular defects
Lithium → cardiac defects (Ebstein’s anomalies are malformations of tricuspid valve and R atrium that can cause HF, sudden death, TIA, stroke; presentation is middle teenager years)
Chronic hyperglycemia during pregnancy (poorly controlled diabetes or gestational DM (GDM) is a teratogenic state → increases risk of neural tube defects and craniofacial defects

Question 42

Q

Pregnancy: Health Education

Answer

A

Take prenatal vitamins w/ 400 mcg of folic acid daily (start 2-3 months before conception)
ALWAYS wear seatbelt (lap-style seatbelt below uterine fundus)
Avoid soft cheeses (blue cheese, brie), uncooked meats, raw milk (Listeria bacteria)
Sex is safe except during vaginal bleeding, incompetent cervix, placenta previa, or preterm labor
Catter litter or raw/undercooked meat can cause toxoplasmosis (congenital infection)
Do NOT eat raw shellfish or raw oysters (Vibrio vulnificus infection)
Be careful w/ cold cuts, uncooked hot dogs, and “deli” meat (Listeria bacteria)
Pregnant women 20x more likely to become infected and die from listeria monocytogenes
Smoking (vasoconstriction causes IUGR) and alcohol (fetal alcohol syndrome) are contraindicated
-Regular coffee (8 oz/d) is okay; do NOT consume an excessive amount of caffeine (premature labor)
Do not use hot tubs or saunas or expose oneself to excessive heat

Question 43

Q

Pregnancy: Zika Virus

Answer

A

can cause severe birth defects (eg, microcephaly) and neurodevelopmental abnormalities
the only way to completely prevent Zika infection during pregnancy is NOT travel to areas w/ Zika outbreak/risk & use condoms or avoid sex w/ someone who has recently traveled to a risk area
If travel is necessary, CDC recommends special precautions for pregnant women and women (and their partners) who are trying to become pregnant

Question 44

Q

Zika Virus: Pregnant Women - Patient Education

Answer

A

Use Environmental Protection Agency (EPA)-registered insect repellents and cover skin
Stay in places with AC, screens, and mosquito nets
Use condoms or abstain from sex during pregnancy
Be alert for sx after travel

Question 45

Q

Zika Virus: Women and Partners Trying to Become Pregnant

Answer

A

Use condoms or abstain from sex according to the following time frames:
- Both partners or only the male partner traveled to an outbreak/risk area → 3 months after return or from the start of symptoms or date of diagnosis

Only the female partner traveled to an outbreak/risk area → 2 months after return or from start of symptoms or date of diagnosis

Question 46

Q

Pregnancy: Weight Gain
1. When is the most weight gained?
2. Best weight gained?
3. Underweight patient’s expected healthy weight gain?
4. Obese patient “?
5. After delivery weight loss?
6. Twins?

Answer

A

In 3rd trimester (~1-2 lb [0.45-0.91 kg] per week)
Total gain of 25-35 lb (11.3-15.9 kg) if healthy weight before pregnancy (BMI 18.5-24.9) is ideal
BMI <18.5 → gain a total of 28-40 lb (12.7-18.1 kg)
BMI >30 → total of 11-20 lb (4.98-9.07 kg)
Loss of up to 15-20 lb (6.8-9.1 kg) in the first few weeks is appropriate
↑ weight gain 37-54 (16.8-24.5 kg) is appropriate, but weight gain should NOT be double that for a single fetus

Question 47

Q

Geriatric Pregnancy

Answer

A

Pregnancy age ≥35 years

At higher risk of:
- Chromosomal abnormalities (e.g., Down syndrome), birth defects
- Preeclampsia
- Low-birth-weight infants
- Miscarriage, premature birth
- Complications during delivery (e.g., stillbirth); more likely to have Cesarean delivery

Question 48

Q

Signs of Pregnancy: Positive Signs

Answer

A

Palpation of fetus by health provider
US and visualization of fetus
Fetal heart tones (FHTs) auscultated by health provider
10-12 weeks by Doppler/ Doptone
20 weeks by fetoscope/stethoscope

*** Memorize the 3 positive signs of pregnancy; this sit he shortest list to memorize; by the process of elimination, you can R/O (or in) the correct answer choice

Question 49

Q

Signs of Pregnancy: Probable Signs

Answer

A

Goodell’s sign (4 weeks): Cervical softening
Chadwick’s sign (6-8 weeks): Blue coloration of cervix and vagina
Hegar’s sign (6-8 weeks): Softening uterine isthmus
Enlarged uterus
Ballottement (seen in midpregnancy): when the fetus is pushed, it can be felt to bound back by tapping the palpating fingers inside vagina
Urine or blood pregnancy tests (beta HCG)

** The signs with surnames (Goodell, Chadwick, Hegar) are all probably signs

** Urine/serum pregnancy tests are considered probably sign s(do NOT confuse them as “positive signs); Beta HCG also presents in molar pregnancy and ovarian CA

*** Exam questions asking for one of the signs will mix them up (e.g., mix a positive sign w/ a probable sign); ensure the answer option contains the two signs from the same category

Question 50

Q

Goodell’s sign

Answer

A

4 weeks
Cervical softening

Question 51

Q

Chadwick’s sign

Answer

A

6-8 weeks
Blue coloration of cervix and vagina

Question 52

Q

Hegar’s sign

Answer

A

6-8 weeks
Softening uterine isthmus

Question 53

Q

Ballottement

Answer

A

seen in midpregnancy
when the fetus is pushed, it can be felt to bound back by tapping the palpating fingers inside vagina

Question 54

Q

Signs of Pregnancy: Presumptive Signs

Answer

A

The following are “softest” and least objective signs (from mother); can be caused by many other conditions besides pregnancy

Amenorrhea
N/V (most common in 1st trimester in AM, usually disappears by 2nd trimester)
Breast changes (Swollen and tender)
Fatigue
urinary frequency
slight ↑ in body temp
“Quickening” → mother feels baby’s movements for the first time; starts at 16 weeks

Question 55

Q

“Quickening”

Answer

A

Mother feels baby’s movements for the first time
- starts at 16 weeks

Question 56

Q

Signs of Pregnancy: Sign + Clinical Finding + Time from Conception
1. HCG
2. Goodell’s sign
3. Chadwick’s sign
4. Hegar’s sign

Answer

A

Clinical Finding → amenorrhea, no uncommon to have spotting in first missed menses

Time from conception → Approx 8-10 dyas after ovulation (earliest time that it can be detected w/ standard serum HCG test); serum HCG can detect it earlier

Clinical Finding: Cervical softening
Time from conception: 4 weeks
Clinical Finding:Bluish discoloration of cervix/vagina
Time from conception: 6-8 weeks
Clinical Finding: Softening of uterine isthmus
Time from conception: 6-8 weeks

Question 57

Q

Clinical Methods for Dating Pregnancy: Fundal Heights
1. 12 weeks (3rd month)
2. 16 weeks (4th month)
3. 20 weeks (5th month)
4. 20-35 weeks’ Gestation

Answer

A

- Uterine fundus first rises above the symphysis pubis
  - FHTs are heard by Doppler by 10-12 weeks
- uterine fundus b/w symphysis pubis and umbilicus
- uterine fundus at level of umbilicus
  - FHTs are heard w/ fetoscope or stethoscopy by 20 weeks
- Measure distance b/t upper edge of pubic symphysis and top of uterine fundus using a paper tape measure
  - Fundal height in cm = # of weeks of gestation (+/- 2 cm)
  Ex: a 32-week-gestation fetus should have a fundal high of b/ww 30-24 cm

Question 58

Q

Signs of Pregnancy: Positive Signs

Answer

A

Palpation of fetus by health provider
US and visualization of fetus
Fetal heart tones (FHTs) auscultated by health provider
10-12 weeks by Doppler/ Doptone
20 weeks by fetoscope/stethoscope

*** Memorize the 3 positive signs of pregnancy; this is the shortest list to memorize; by the process of elimination, you can R/O (or in) the correct answer choice

Question 59

Q

Clinical Methods for Dating Pregnancy: Size and Date Discrepancy

Answer

A

The size of uterus does NOT match gestation age

Defined: a difference of + or - 2 (or +/- 2) from # of weeks of gestation.

If uterine fundus is ≤2 cm (fetus smaller than expected), it can be caused by dating error, IUGR, or other problem
If fundus size ≥ 2 cm (fetus larger than expected), it may be d/t dating error, macrosomia, or other problem → Order an US
Screening US to check gestational age: At 10-14 weeks; gestation, will measure nuchal translucency, maternal serum beta HCG, and pregnancy-associated plasma protein0A (PAPP-A)

Question 60

Q

Physiologic Changes During Pregnancy: Cardiovascular System
1. Position of the Heart
2. Heart Rate
3. Heart Sounds
4. Murmurs
5. Cardiac Output

Answer

A

- Heart is shifted anteriorly toward left
  - Rotated toward a transverse position as uterus enlarges
- ↑ during pregnancy by 15-20 bpm
  - resting HR starts to rise during 1st trimester
- HS are louder in pregnancy
  - S3 heart sound is common (80%) but NOT S4
  - Wide splitting of S1
  - In 3rd trimester, splitting of S2 may be heard
  * S3 heart murmur is normal finding in pregnancy
- Systolic ejection murmur (grade II/Iv) over pulmonary and tricuspid area is common
  - A mammary souffle (systole or continuous) is heard over breasts later in pregnancy and during lactation (breastfeeding)
- ↑ by 30-50% and peaks at ~28-34 weeks’ gestation
  - Reduction of SVR and SBP

Question 61

Q

Physiologic Changes During Pregnancy: Cardiovascular System
6. Plasma Volume
7. Physiologic Anemia of Pregnancy
8. Preload and Afterload
9. BP

Answer

A

- ↑ almost 50% by end of 2nd trimester
  - Hemodilution → physiologic anemia or pregnancy (hematocrit ↓)
- most obvious from 6-9 months (2nd/3rd trimester)
  - Hgb & Hct ↓ d/t hemodilution from ↑ plasma volume; Hgb can ↓ to as low as 10.5 g/dL
- Preload ↑ d/t higher blood volume
  - Afterload ↓ d/t ↓ in PVR that occurs during pregnancy
- SBP and DBP starts ↓ in 1st trimester and continues in 2nd trimester; many m others who are hypertensive before pregnancy can be off prescription antihypertensives at this time

By 3rd trimester, BP gradually returns back to prepregnancy levels → antihypertensives used for pregnant women are methyldopa (Aldomet) and labetalol (Noirmodyne; beta-blocker)

Question 62

Q

Physiologic Changes During Pregnancy: Cardiovascular System
10. Vena Cava
11. Coagulation Factors
12. Varicose Veins
13. Edema

Answer

A

- Compression by enlarged uterus (20 weeks’ gestation til labor) of IVC ↓ blood return to the brain, → orthostatic hypotension (postural hypotensive syndrome)
  - advise women to lie on left side and change positions slowly
- Pregnancy is a hypercoagulable state (clotting factors go up) esp after labor (puerperium or postpartum period)
- varicose veins become more severe during pregnancy
- Peripheral edema is considered normal in pregnancy
  - mild edema of LE and feet is most noticeable in 3rd trimester

Question 63

Q

Physiologic Changes During Pregnancy: Respiratory System

Answer

A

Presence of basal rales that disappear w/ coughing or deep breathing
Feeling of breathlessness (innocent hyperpnea) and ↓ exercise tolerance
Physiologic dyspnea in pregnancy has slow onset; ** Sudden-onset dyspnea is abnormal → R/O PE (pleuritic chest pain, tachypnea, hemoptysis)
Gravid uterus pushes up diaphragm as it gets larger; diameter of thorax is ↑
No change in FEV1, but TLC ↓ slightly from 4.2 to 4 L

Question 64

Q

Physiologic Changes During Pregnancy: Endocrine System

Answer

A

diffusely enlarged (size up to 15% larger), w/ higher metabolic activity

Answer 65

A

↓ peristalsis from progesterone effects (constipation, heartburn)

Answer 66

A

- Pigmentary changes from ↑ in m elanocyte-stimulating hormone from higher levels of estrogen → causes linea nigra (dark pigmented “line” that extends from mons pubis to umbilicus located midline)
  - nipples and areola darken
Melasma
- blotchy hyperpigmentation on forehead, cheeks, noise,a nd upper lip seen in pregnant women and some birth control pill users
- usually gets lighter and regressed within 1 years; however, in some women, hyperpigmentation may be permanent
- Condition is more common in darker skins (olive skins and darker)

Cholasma/melasma is d/t high estrogen levels

Answer 67

A

dark pigmented “line” that extends from mons pubis to umbilicus located midline

Answer 68

A

Stretch Marks
- Most common locations are abdomen, breasts, and thighs
- Other less common areas: upper arms, lower back, and buttocks
Hair Loss
- During postpartum period, hair loss may accelerate, but it is temporary

Answer 69

A

Kidney size ↑
ureters and renal pelvis become dilated (physiologic hydronephrosis)
GFR is much ↑ in pregnancy d/t higher CO and renal blood flow

Answer 70

A

Kidney size ↑
ureters and renal pelvis become dilated (physiologic hydronephrosis)
GFR is much ↑ in pregnancy d/t higher CO and renal blood flow

Answer 71

A

Some women develop nasal congestion and/or epistaxis d/t ↑ blood flow to nasopharynx during pregnancy
R/O acute sinusitis if purulent mucus seen in posterior pharynx

Answer 72

A

Weight gain, enlarged uterus, and hormonal changes contribute to joint ligamentous laxity and exaggerated lordosis of lumbar spine
Up to 60% of pregnant women experience back pain (not r/t labor)
Gait change sot wider stance

Answer 73

A

Used to estimate date of delivery (EDD) during 1st trimester
Assumes regularly 28- to 30-day menstrual cycle; not as useful for irregular menstrual cycles
A full-term pregnancy is 40 weeks (280 days)

2 different ways to use Naegele’s rule. They are equivalent; pick the one w/ which you feel most comfortable
1 → LMP + 9 months + 7 days
2 → LMP - 3 months + 7 days

LMP = Last menstrual period

Answer 74

A

Method 1: LMP 2/20/2021
1. Add 9 months to Feb: 2+9=11 (November)
2. Add 7 days to date of LMP: 20+7=27
3. EDD = November 27, 2021

Method 2: LMP 2/20/2021
1. Subtract 2 months from Feb = November
2. Add 7 days to date of LMP: 20+7=27
3. EDD = November 27, 2021

Exam Tip: There is usually one question about the EDD (use Naegele’s rule).
- TheLMP month on exam will either by Jan, Feb, or March
If LMP is: LMP → EDD
Jan → Oct
Feb → Nov
Mar → Dec

Answer 75

A

Placenta previa: vaginal bleeding (bright red) without hypertonic tender uterus

Placenta abruptio: vaginal bleeding, intermittent w/ hypertonic, hard, and tender uterus

Answer 76

A

12 weeks → above symphysis pubis

16 weeks → between symphysis pubis and umbilicus

20 weeks → at the umbilicus

Answer 77

A

European Jews

Should be screened for Tay-Sachs disease

Answer 78

A

ACEi and ARBs to treat HRN → Category C/D

Answer 79

A

methyldopa (Aldomet)
labetalol (beta-blocker)
hydralazine
long-acting nifedipine

Answer 80

A

Check LEFTs at baseline and periodically

CONTRAINDICATED if active hepatic disease

Discontinue med if jaundice, abnormal LFTs, or unexplained fever

Answer 81

A

G: Gravida → # of pregnancies (twins or multiples counted as 1 pregnancy)

T: Term → # of deliveries after 37 weeks

P: Preterm → # of deliveries after 20 weeks (up to 38 weeks)

A: Abortion → # of deliveries before 20 weeks (induced or spontaneous)

L: Living → # of living children

Answer 82

A

G: 5 pregnancies total
T: 3 pregnancies full term
P: 1 One twin pregnancy preterm born at 34 weeks
A: 1 abortion
L: 5 living children

Answer 83

A

Occurs immediately after delivery and generally lasts ~6 weeks

Answer 84

A

Occurs immediately after delivery and generally lasts ~6 weeks

Answer 85

A

Normal for postpartum women to have uterine contractions (spontaneous or w/ breast feeding) during the first 2-3 days after giving birth
After delivery, uterus is size of a 20-week pregnancy (fundi at the umbilicus)
A soft boggy uterus accompanied by heavy vaginal bleeding is a sign of atony (inadequate contraction)
Uterine involution takes ~ 16 weeks

Answer 86

A

Amniotic fluid volume < than expected for gestational age
usually diagnosed by US and measured as amniotic fluid index (AFI <5 cm) or the deepest vertical pocket (DVP)

AFI - Normal rage: 5-25 cm

The uterus is smaller in size than expected

At higher risk of:
- fetal malformation
- pulmonary hypoplasia
- umbilical cord compression
- fetal or neonatal death

may occur in 1st, 2nd, or 3rd trimester

Multiple causes:
- idiopathic
- maternal, fetal, or placental causes

→ Refer to obstetrician for management

Answer 87

A

Excessive volume of amniotic fluid, more than expected for gestational age
occurs in ~1% of pregnancies
Fetal anomalies usually associated w/ genetic abnormality or syndrome are most common causes

→ Refer to obstetrician for management

Answer 88

A

In Rh-negative mothers w/ Rh-positive fetuses, maternal immune system develops antibodies against Rh-positive blood if not given RhoGAM (gamma globulin against Rh factor)
Give RhoGAM for all pregnancies of Rh-negative mothers–even if they terminate in miscarriages, abortions, or tubal or ectropic pregnancies

Answer 89

A

AKA anti-D immune globulin
made from pooled IgG antibodies against Rh (rhesus) factor
an immunoglobulin that helps prevent maternal isoimmunization (self-immunization) or alloimmunization (immunity against another individual of the same species)
If RhoGAM is not given to Rh-negative pregnant women, → fetal hemolysis and fetal anemia in her future pregnancies
Coombs test: Detects presence of Rh antibodies in the mother (indirect Coombs test) and the infant (direct Coombs test); test is done as part of labs performed early in pregnancy

RhoGAM 300 mcg IM first dose is at 28 weeks
- Give 2nd dose within 72 hrs (or sooner) after delivery

RhoGAM ↓ risk of isoimmunization of maternal immune system by destroying fetal Rh-positive RBCs that have crossed placenta

Answer 90

A

Detects presence of Rh antibodies in the mother (indirect Coombs test) and the infant (direct Coombs test)
- test is done as part of labs performed early in pregnancy

Answer 91

A

- diabetes occurring during pregnancy
  - GDM mothers are at high risk for DM2
  - high rates of reoccurrence (33-50%) in future pregnancies
  - concomitant higher rates of neural tube defects (anencephaly, microcephaly), congenital heart ds, birth trauma (shoulder dystocia), preeclampsia, and neonatal hypoglycemia

RF:
- Hx of GDM in previous pregnancy
- obesity
- ethnicity (Asian, American Indian, Pacific Islander, African American, Hispanic)
- Macrosomic infant (>9 lbs)
- age >35 years
- If hx of GDM, check for prediabetes or diabetes at 4-12 weeks postpartum and advise lifelong screening at least Q3 years

- Screen at the first visit of hx of GDM and/or presence of RF
  - If not high risk, screen at 24-28 weeks’ gestation
  - 2 mothers of testing for GDM (one-step or two-step strategy)

** Diagnosed in the 2nd/3rd trimester
- A woman w/ diabetes in the first trimester has DM2
- An A1C <6% (2nd/3rd trimester) has the lowest risk for large-for-gestational-age infants → lowest rates of adverse fetal outcomes (large-for-gestational age infant, preterm delivery, preeclampsia) occur with A1C <6% - 6.5%

Answer 92

A

Administer 75 g oral glucose tolerance test (OGTT)
check fasting, 1 hour, and 2 hours
Overnight fast of at least 8 hours
Perform test in the morning
Diagnostic Criteria
Fasting: ≥ 92 mg/dL
1 hour: ≥ 180 mg/dL
2 hours: ≥ 153 mg/dL
If one value is elevated in this test, it is diagnostic of GDM
The 75 g OGTT is the preferred test
Used for screening and diagnosis

Answer 93

A

Screening: 50 g glucose load (nonfasting), check plasma glucose at 1 hour
If ≥140 mg/dL → R/O GDM
Order 100 g OFTT (fasting, 1 hour, 2 hours, and 3 hours)

Diagnostic Criteria
* Fasting: ≥ 95 mg/dL
* 1 hour: ≥ 180 m g/dL
* 2 hours: ≥155 mg/dL
* 3 hours≥ 140 mg/dL

If 50 g OGTT is abnormal (postprandial >140 mg/dL or fasting > 95 g/dL), follow-up test is 100 g OGTT (must fast for at least 8 hours)

Answer 94

A

Glycemic targets in pregnancy:
Preprandial: ≤95 mg/dL
1-hour postmeal: ≤140 mg/dL
2-hour postmeal: ≤120- mg/dL
A1C goal: <6%

First-line treatment: lifestyle
- follow meal place and schedule physical activity
- Eat 3 meals/day + 2-3 snacks; Limit carbohydrates
- Exercise 30 mins/day at least 5 days/week ((total of 2 hrs/wk)

Low-impact exercises such as walking and swimming are preferred
- Perform frequent home glucose monitoring, 4-6 x/day
- If med needed, human insulin is preferred agent; insulin infections needed if unable to control blood glucose w/ diet and exercise
- May need to self-inject insulin from 3-6 x/day
- ADA and ACOG have endorsed use of oral antihyperglycemic drugs glyburide and metformin

Glucose monitoring: check BG at least QID (fasting, 1 or 2 hours after first bite of each meal)

Follow-up: Test of prediabetes or diabetes at 24-12 weeks postpartum and at least Q3 years afterward (future)

Answer 95

A

Acute cystitis can occur alone, or may be complicated by acute pyelonephritis
- Higher risk of preterm birth and low birth weight

Most common organism: E. coli (75-95%)

S/Sx:
- dysuria
- frequency
- urgency
- nocturia

Pregnant women w/ asymptomatic bacteriuria are ALWAYS tx because they are at high risk for acute pyelonephritis (25%)
- Diagnosis is based on midstream urine C&S results
- Obtain specimens before antibiotic tx and after (to check fo eradication of infection)
- UTIs ↑ risk of preterm birth, low birth weight, and piernatal mortality
- Urine dipstick
  ► WBCs (leukocyte esterase): Positive
  ► Nitrate: may be positive or negative
  - Send midstream urine for urinalysis (UA) and urine C&S
  - Document resolution of infection by ordering posttreatment urine C&S 1 week after completing antibiotic therapy
  - If suspect pyelonephritis → Refer to ED/physician

Answer 96

A

Acute cystitis can occur alone, or may be complicated by acute pyelonephritis
- Higher risk of preterm birth and low birth weight
** UTIs in pregnant women are classified as “complicated UTIs”

Most common organism: E. coli (75-95%)
- Lab: urine WBC ≥10^3 CFU/mL → considered UTI
- Normal nonpregnant health adult, UTI is defined as >100,000 CFU or 10^5 CFU, of one organism

S/Sx (same as those in nonpregnant state):
- dysuria
- frequency
- urgency
- nocturia

Pregnant women w/ asymptomatic bacteriuria are ALWAYS tx because they are at high risk for acute pyelonephritis (25%)
- Diagnosis is based on midstream urine C&S results
- Obtain specimens before antibiotic tx and after (to check for eradication of infection)
- UTIs ↑ risk of preterm birth, low birth weight, and perinatal mortality
** ALWAYS treat asymptomatic bacteriruia and UTIs in pregnant women
- Urine dipstick
  ► WBCs (leukocyte esterase): Positive
  ► Nitrate: may be positive or negative
  - Send midstreaPregnancy: Urinary Tract Infections urine for urinalysis (UA) and urine C&S
  - Document resolution of infection by ordering posttreatment urine C&S 1 week after completing antibiotic therapy
  - If suspect pyelonephritis → Refer to ED/physician

Answer 97

A

- Nitrofuratoin (Macrobid) BID x 5-7 days (avoid during last trimester)
  → Do NOT use sulfa drugs (e.g., Bactrim) or nitrofurantoin near term because of risk of hyperbilirubinemia; causes hemolysis if mother (or both mother and baby) has G6PD anemia
  - Amoxicillin-clavulanate (Augmentin) BID 3-7 days
  - Amoxicillin BID x 3-7 days
  - Cephalexin BID x 3-7 days
  - Fosfomycin 3g single dose
  ** Amoxicillin is NOT the first-line drug for empiric UTI treatment d/t high resistance rates
- Avoid near term (38-42 weeks), during labor, and during delivery
  - Also CONTRAINDICATED in neonates <4 weeks of age
  - These drugs ↑ risk of hyperbilirubinemia (bilirubin is toxic to nerves and CNS)
  - Complication of hyperbilirubinemia is called “kernicterus” (serious nerve/brain damage)
  - Do NOT use of G6PD anemia is suspected (causes hemolysis)
  - Nitrofurantoin causes serious adverse effects: pulmonary reactions (interstitial pneumonitis, pulmonary fibrosis), liver damage, neuropathy, others

Exam Tip: There are usually only a few questions that address pregnancy. Do NOT overstudy this subject area for the exam /dt ↓ # of questions over past few years

Answer 98

A

AKA miscarriage
- Spontaneous loss of the fetus before viable (<20 weeks)

Answer 99

A

Vaginal bleeding occurs, but cervical os remains closed
- Most of these cases will result in an ongoing pregnancy

Answer 100

A

Cercix is dilated and unable to stop process
- Fetus will be aborted

Answer 101

A

Vaginal bleeding w/ cramping occurs
- Placenta and fetus are expelled completely
- Cervical oss will close and bleeding stops

Answer 102

A

Vaginal bleeding w/ cramping occurs
- placental products remain in uterus
- cervical os remains dilated
- bleeding persists
-pieces of tissue may be seen at the cervical os
- vaginal discharge is fould smelling 9bacterial vaginosis)

TX: dilation and curettage (D&C) and antibiotics

Answer 103

A

Pregnancy loss that occurs at 20 weeks’ gestation or later or weight of ≥ 350 grams

Answer 104

A

Pregnancy-Induced HTN
- older name: “toxemia”
- Exact etiology: unknown
- If seizures develop → eclampsia

1 & 2. Most causes occur in late 3rd trimester (≥ 34 weeks)
- Can occur up to 4 weeks after childbirth (postpartum period)
- Mild cases of preeclampsia may not have symptoms (e.g., headaches, blurred vision, or RUQ abdominal pain)

RF:
- primigravida
- multipara
- >35 years
- obesity
- prior hx of preeclampsia
- HTN
- kidney ds

Will cause multiorgan damage:
- brain → stroke
- kidneys → acute renal failure
- lungs → pulmonary edema
- liver → hepatic rupture
- DIC
- fetal and/or maternal death

Classic triad: HTN, proteinuria, and edema occurring after 20 weeks’ gestation and up to 4 weeks postpartum
- Take at least 2 separate readings (at least 6 hours apart)
- SBP ≥140, DBP ≥ 90
- Proteinuria: >0.3 g protein in a 24-hr urine specimen
* Proteinuria ranges from trace to 1+ to 4+ (severe cases)
- Rapid weight gain of 2-5 lb/week
- Edema is most obvious in face, around eyes, and on hands
- Refer to obstetrician for management
  - Only definitive “cure” for preeclampsia and eclampsia is delivery of placenta/fetus

Answer 105

A

Defined as presence of an elevated BP (>140/90) before 20th week of gestation
Do NOT confuse this condition w/ preeclampsia
may be on a prescription
If on ACEi/ARB, discontinue ASAP and monitor BP closely
Most pregnant women w/ preexisting HTN can usually get off BP meds (temporarily) during 1st-2nd trimester d/t ↓ BP during pregnancy (less PVR)

Answer 106

A

Placental Abruption
1. premature partial to complete separation of a normally implanted placenta from uterine bed
- rupture of maternal blood vessels from decidua basalis
- bleeding ranges from mild to hemorrhage
- controllable RF: smoking, cocaine use, HTN, and encouraged seatbelt use

- sudden onset of vaginal bleeding (mild to hemorrhage)
  - abdominal and/or back pain
  - painful uterine contractions
  - Uterus is rigid (hypertonic) and very tender
→ Refer to ED
- Initial ED labs: CBC, PT/PTT, blood type, cross-match, Rh factor, etc
- Abdominal US and blood transfusion PRN
- If mild contractions, give magnesium sulfate IV; strict bed rest is needed
- Deliver fetus by C-section if mother’s life is threatened, give steroids if fetus is viable

Answer 107

A

abnormally implanted placenta
- placenta implants too low either on top of cervix or on cervical isthmus/neck
- most cases get better spontaneously (will reimplant)
some cases are asymptomatic
- high risk of if hx of placenta previa or C-section, multipara, older age, smoking, fibroids, or cocaine use
- late 2nd/3rd trimester or pregnancy
  - sudden onset of bright-red vaginal bleeding (light to heavy)
  - accompanied by mild contractions
  - uterus feels soft and is NOT tender
- Refer to ED
  - Avoid bimanual exam d/t palpation of uterus may cause severe hemorrhage
  - use abdominal US only; NO intravaginal US
  - NO rectal exams
  - avoid any vaginal/rectal sexual intercourse
  - bed rest required
  - close fetal and manteral monitoring
  - if contractions, give magnesium sulfate IV
  - If mild case, pregnancy can be salvaged, and placenta will reimplant
  - Perform C-section if mother’s life is in danger

Answer 108

A

First few days (days 1-2) → colostrum is produced (thick yellow color), which contains maternal antibodies (passive immunity)

By 3rd-4th day → mature breast milk is produced (contains fat, sugar/lactose, water, protein, and antibodies)

Full-term healthy infant can be exclusively breastfed for the first 6 months w/ no supplemental fluids unless ill or dehydrated

Answer 109

A

all breastfed infants need vit D supplementation started within first few days
formula-fed infants should only be given iron-fortified formula (has vit D)

Answer 110

A

All exclusively breastfed infants require iron (ferrous sulfate) supplementation at 4 months at dose of 1 mg/kg
Breast milk contains very little iron
Most full-term newborns have sufficient iron stores in their bodies for at least 4 months
At ~6 months, infants’ iron needs can be met through introduction of iron-rich foods, iron-fortified cereals, or iron supplement drops
If on iron-fortified formula, do not need additional iron supplementation

Answer 111

A

Breastfeed within 1st hr of birth → provides baby with colostrum and helps uterus contract
a new mother should be taught proper breastfeeding technique → Refer to lactation specialist if having problems, follow up at home
If noisy, assess for improper latch on (check positioning, sucking, clicking noises)
Swallowing noises are normal, but not clicking noises
For clicking, advise mother to us index finger to pull down baby’s chin so the baby’s lower lip will be outside → baby should have entire nipple and most of areola inside its mouth
Newborns will nurse about 8-12 times/24 hrs

Answer 112

A

Infants’ chest and stomach should rest against body; head is straight and not turned to side
Tickle infant’s lips w/ nipple and aim nipple just above infant’s top lip
Ensure nipple and areola are inside infant’s mouth (baby’s tongue will cup under breast w/ lip turns out)
May hear/see swallowing; infant’s ears may wiggle slightly
Breast soreness is normal the first few days; a proper latch will help make it more comfortable
If improper latch on, gently place a clean finger in corner of infant’s mouth to break seal (suction) and start again

** Swallowing noises may be heard in breastfeeding esp in younger babies → normal

** Clicking noises are abnormal → advise mother to use index finger to pull down baby’s chin so baby’s lower lip will latch better onto areola

Answer 113

A

advise mother not to stop breastfeeding → causes breast engorgement (painful)
If poor latch, infant may have to suck harder, which causes pain
This results from babies having difficulty “latching on” to an engorged breast
Nipple pain is worse during 1stweek and usually disappears by 2nd week
If nipple pain persists, assess nipples for fissures and infection
start nursing on less painful breast first
initiate “letdown reflex” of milk by massage/warm shower
Apply lanolin or breast milk to nipple after nursing to protect from skin breakdown
Avoid using plastic nipple shields, alcohol, and soap; wear nursing bras w/ good support
may need referral to lactation specialist (e.g., La Leche League)

Exam tip!
If a question describes a mother who complains of sore nipples, do NOT advise her to stop breastfeeding, to supplement w/ formula, or to use formula at nighttime feedings
- BEST answer is to advise mother that it is a common problem during the first 2 weeks and will resolve and to continue breastfeeding

Answer 114

A

stimulates uterine contractions (speeds up uterine involution after delivery)
↑ maternal bonding w/ infant (oxytocin effect)
Speeds up weight loss after pregnancy
↓ risk of breast/ovarian CA
can delay ovulation if mother breastfeeds exclusively

Answer 115

A

↓ risk of infections (necrotizing enterocolitis, acute otitis media)
↓ risk of bacterial/viral infections such as otitis media and diarrhea
↓ incidence of asthma and allergies in breastfed babies
Young infants who are exclusively breastfed get enough fluids and do not need extra water; juices should be avoided; ↑ risk of dental caries
↓ risk of sudden infant death syndrome and future obesity

Answer 116

A

- most common in first 2 months
  - skin fissures on nipple(s) allowing bacterial entry
  - most common organism: Staph aureus (Gram+)
  - Consider MRSA bacterial infection (becoming more common)
  - If severe or toxic → Refer to ED or admit to hospital
- frequent and complete emptying of breast and proper breastfeeding technique
  - Breast engorgement and poor technique ↑ risk of mastitis
- c/o sudden onset of red, firm, and tender area (induration) on one breast
  - may also have fever/chills
  - malaise (flu-like sx)
  - may have adenopathy on axilla be affected breast
  - most common in first 3 months of breast feeding

Answer 117

A

- usually not needed; clinical diagnosis
  - CBC shows leukocytosis; C&S of milk is usually not required, but can be useful to guide antibiotic esp if hospitalization or not responding to antibiotic tx
  - US may be useful if mastitis does not respond in 48-72 hrs
If low risk of MRSA
- Dicloxacillin 500 mg PO QID or cephalexin (Keflex) 500 mg PO QID for 10-14 days
- Do NOT use sulfas during newborn period d/t ↑ risk of kernicterus

If high risk of MRSA
- Trimethoprim-sulfamethoxazole (Bactrim) 1-2 tablets PO BID (can be used if healthy infant is 1 month or older, no jaundice) OR clindaymycin 300 mg PO QID for 10-14 days
- Continue to breastfeed on affected breast during antibiotic tx
- If unable to breastfeed, pump milk from infected breast and discard to prevent engorgement
- complete emptying of breast is important during infection
- If breast abscess is suspected, order US and refer for I&D
- NSAID for pain and fever PRN; apply cold compresses on indurated breast area
- Refer to lactation consultant if suspect poor breastfeeding technique

Answer 118

A

Cervicitis, urethritis
1. - Treating chlamydia trachomatis infection in mother will help prevent transmission (vertical transmission) of infection to NB through birth canal
- Ex: Trachoma ( or inclusion conjunctivitis of NB) and PNA

- obtain NAATs such as Gen-Probe, Amplicor, or ProbeTec
  - Gen-Probe can only be used on cervix and urethra → Do NOT collect specimens from eyes
  - Test of cure needed in 3 weeks after completing treatment
- FIRST-Line: Azithromycin 1 g PO (single dose)
  - Alternative: Amoxicillin 500 mg PO TID x 7 days (lower cure rate than azithromycin)
- FIRST-Line: Azithromycin 1 g PO (single dose)
  - Doxycycline 100 mg PO BID x 7 days (do NOT use if breastfeeding stains tooth enamel, category D)
  - Avoid sex activity for 7 days
  - Avoid unprotected intercourse until both partners are treated
  - test for other STDs (gonorrhea, syphilis, HIV)

Answer 119

A

Women who exclusively breastfeed (at least Q4hr daily) with amenorrhea and who are <6 months postpartum are much less likely to ovulate than woman who doe snot breastfeed exclusively (lactational amenorrhea method)
In women who do not breastfeed ovulation resumes (average) at 39 days postpartum
During postpartum period and w/ breastfeeding, BC pills or any contraceptive method containing estrogen (pregnancy category X) is contraindicated
Postpartum women or women who cannot take estrogens can use methods such as IUDs (copper or levonorgestrel) or progesterone-only contraception such as etonogestrel (Nexplanon), depot medroxyprogesterone (Depo-Provera), progestin-only pills, or barrier methods (condoms, diaphragm, cervical cap)
→ progestin-only contraceptive pill norethindrone (Micronor) contains 28 active pills that are taken daily (no pill-free week)
→ For max effectiveness, pill must be taken at the same time each day (very important)
→ If >3 hours late, take dose ASAP and use backup (condom) for the next 2 days; will probably have vaginal spotting for the next few days

Brainscape's Knowledge GenomeTM

Pregnancy and Childbirth Flashcards

Brainscape's Knowledge Genome^TM