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ANCC - Fitzgerald Notecards > Pregnancy and Childbirth > Flashcards

Pregnancy and Childbirth Flashcards

1
Q

Danger Signals! Placental Abruption (Abruptio Placentae) Overview

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!

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2
Q

Danger Signals! Placenta Previa Overview

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

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3
Q

Danger Signals! Severe Preeclampsia Overview

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

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4
Q

Danger Signals! HELLP Syndrome Overview

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

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5
Q

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

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

Notes:
- AST, ALT, and GGT no changes

  1. Elevated:
    - Total cholesterol
    - triglycerides
    - HDL
    - LDL

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

  1. Elevated:
    - Total T3

Notes:
- Free T3, TSH

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

Notes:
- Hemoglobin and hematocrit are ↓ in pregnancy

  1. Elevated:
    - GFR

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

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6
Q

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

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

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7
Q

Lab Testing: Liver Function Tests

A

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

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8
Q

Lab Testing: Alkaline Phosphatase

A

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

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9
Q

Lab Testing: WBCs

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)
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10
Q

Lab Testing: Hemoglobin & Hematocrit

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)
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11
Q

Lab Testing: Erythrocyte Sedimentation Rate

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

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

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12
Q

Lab Testing: Thyroid Function Tests

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
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13
Q

Lab Testing: Serum Alpha-Fetoprotein

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)

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14
Q

Lab Testing: Low Alpha-Fetoprotein

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)

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15
Q

Lab Testing: High Alpha-Fetoprotein

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

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16
Q

Lab Testing: Triple Marker Screen Test

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
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17
Q

Lab Testing: Quadruple Marker Screen Test

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
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18
Q

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

A
    • Tay-Sachs disease → fatal neurological ds w/ no known cure
      - More common among EAstern Europeans of Jewish descent (Ashkenazi Jews)
  2. Cystic fibrosis
  3. Sickle Cell Anemia
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19
Q

Lab Testing: Amniocentesis sand Chorionic Villus Sampling

A
  • can be done earlier (1012 weeks) than amniocentesis (15-18 weeks)
  • specimen contain fetal cells
  • Fetal chromosomes/DNA is tested for abnormalities
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20
Q

Lab Testing: Beta Human Chorionic Gonadotropin

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
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21
Q

Lab Testing: Doubling Time

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

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22
Q

Lab Testing: Vaginal Cultures

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

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23
Q

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

A
  • Hep B surface antigen (HBsAg)
  • HIV
  • gonorrhea
  • chlamydia
  • syphilis
  • herpesvirus type 1 & 2
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24
Q

Lab Testing: Titers

A
  • Rubella titer
  • varicella titers (if no proof of infection)
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25
Q

Drugs and Vaccine during Pregnancy

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
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26
Q

Drugs and Vaccine during Pregnancy: Category A Drugs

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)
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27
Q

Drugs and Vaccine during Pregnancy: Category B Drugs

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)
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28
Q

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

A
  • Amoxicillin (Amoxil)
  • Penicillin
  • Dicloxacillin
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29
Q

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

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)

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30
Q

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

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
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31
Q

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

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)

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32
Q

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

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)

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33
Q

Drugs and Vaccine during Pregnancy: Antihypertensives for Pregnant Women

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)
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34
Q

Drugs and Vaccine during Pregnancy: Category C Drugs

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)

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35
Q

Kernicterus

A

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

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36
Q

Gastroschisis

A

Intestines protrude through abdominal wall defect

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37
Q

Drugs and Vaccine during Pregnancy: Category D Drugs

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)

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38
Q

Drugs and Vaccine during Pregnancy: Category X Drugs

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
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39
Q

Drugs to avoid in 3rd Trimester of Pregnancy

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
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40
Q

Pregnancy: Live Vaccines

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

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41
Q

Drugs and Vaccine during Pregnancy: Teratogens

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
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42
Q

Pregnancy: Health Education

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
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43
Q

Pregnancy: Zika Virus

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
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44
Q

Zika Virus: Pregnant Women - Patient Education

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
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45
Q

Zika Virus: Women and Partners Trying to Become Pregnant

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
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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?

A
  1. In 3rd trimester (~1-2 lb [0.45-0.91 kg] per week)
  2. Total gain of 25-35 lb (11.3-15.9 kg) if healthy weight before pregnancy (BMI 18.5-24.9) is ideal
  3. BMI <18.5 → gain a total of 28-40 lb (12.7-18.1 kg)
  4. BMI >30 → total of 11-20 lb (4.98-9.07 kg)
  5. Loss of up to 15-20 lb (6.8-9.1 kg) in the first few weeks is appropriate
  6. ↑ weight gain 37-54 (16.8-24.5 kg) is appropriate, but weight gain should NOT be double that for a single fetus
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47
Q

Geriatric Pregnancy

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

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48
Q

Signs of Pregnancy: Positive Signs

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

49
Q

Signs of Pregnancy: Probable Signs

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

50
Q

Goodell’s sign

A

4 weeks
Cervical softening

51
Q

Chadwick’s sign

A

6-8 weeks
Blue coloration of cervix and vagina

52
Q

Hegar’s sign

A

6-8 weeks
Softening uterine isthmus

53
Q

Ballottement

A
  • seen in midpregnancy
  • when the fetus is pushed, it can be felt to bound back by tapping the palpating fingers inside vagina
54
Q

Signs of Pregnancy: Presumptive Signs

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
55
Q

“Quickening”

A

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

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

A
  1. 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

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

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
58
Q

Signs of Pregnancy: Positive Signs

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

59
Q

Clinical Methods for Dating Pregnancy: Size and Date Discrepancy

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)
60
Q

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

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
61
Q

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

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)
62
Q

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

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
63
Q

Physiologic Changes During Pregnancy: Respiratory System

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
64
Q

Physiologic Changes During Pregnancy: Endocrine System

A
  • diffusely enlarged (size up to 15% larger), w/ higher metabolic activity
65
Q

Physiologic Changes During Pregnancy: Gastrointestinal System

A
  • ↓ peristalsis from progesterone effects (constipation, heartburn)
66
Q

Physiologic Changes During Pregnancy: Integumentary System (Skin and Hair)
1. Pigmentary Changes
2. Chloasma

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
  2. 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
67
Q

Linea Nigra

A

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

68
Q

Physiologic Changes During Pregnancy: Integumentary System (Skin and Hair)
3. Striae Gravidarum
4. Telogen Effluvium

A
  1. Stretch Marks
    - Most common locations are abdomen, breasts, and thighs
    - Other less common areas: upper arms, lower back, and buttocks
  2. Hair Loss
    - During postpartum period, hair loss may accelerate, but it is temporary
69
Q

Physiologic Changes During Pregnancy: Renal System

A
  • Kidney size ↑
  • ureters and renal pelvis become dilated (physiologic hydronephrosis)
  • GFR is much ↑ in pregnancy d/t higher CO and renal blood flow
70
Q

Physiologic Changes During Pregnancy: Renal System

A
  • Kidney size ↑
  • ureters and renal pelvis become dilated (physiologic hydronephrosis)
  • GFR is much ↑ in pregnancy d/t higher CO and renal blood flow
71
Q

Physiologic Changes During Pregnancy: Ear, Nose, and Throat

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
72
Q

Physiologic Changes During Pregnancy: Musculoskeletal System

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
73
Q

Naegele’s Rule: 2 methods

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

74
Q

Naegele’s Rule Example:
A 28-year-old woman who is at 8 weeks’ gestation reports that her LMP was February 20, 2021. Using Naegele’s rule, which of the following dates is correct for her expected EDD?
A. November 10, 2021
B. November 27, 2021
C. December 10, 2021
D. December 27, 2021

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

75
Q

Difference between placenta previa vs placenta abruptio

A

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

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

76
Q

Fundus height at 12 weeks, 16 weeks, and 20 weeks

A

12 weeks → above symphysis pubis

16 weeks → between symphysis pubis and umbilicus

20 weeks → at the umbilicus

77
Q

What should Ashkenazi Jews should be screened for?

A

European Jews

Should be screened for Tay-Sachs disease

78
Q

What medications should sexually active females w/ HTN who do not use birth control avoid?

A

ACEi and ARBs to treat HRN → Category C/D

79
Q

What are the preferred antihypertensives for pregnancy?

A
  • methyldopa (Aldomet)
  • labetalol (beta-blocker)
  • hydralazine
  • long-acting nifedipine
80
Q

For methyldopa, what baseline labs should be obtained?

A

Check LEFTs at baseline and periodically

CONTRAINDICATED if active hepatic disease

Discontinue med if jaundice, abnormal LFTs, or unexplained fever

81
Q

Obstetric History: GTPAL

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

82
Q

Obstetric History Example: 28-year-old G5T3P1A1L5

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

83
Q

Postpartum or puerperium

A

Occurs immediately after delivery and generally lasts ~6 weeks

84
Q

Postpartum or puerperium

A

Occurs immediately after delivery and generally lasts ~6 weeks

85
Q

Uterine Involution

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
86
Q

Oligohydramnios

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

87
Q

Polyhydramnios

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

88
Q

Rh- Incompatibility Disease

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
89
Q

RhoGAM

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
90
Q

Coombs test

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

91
Q

Gestational Diabetes Mellitus
1. Definition/Etiology
2. Evaluation

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%

92
Q

GDM: One-Step Method

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
93
Q

GDM: Two-Step Method

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)
94
Q

GDM: Treatment Plan and Follow-up

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)

95
Q

Pregnancy: Urinary Tract Infections
1. Definition/Etiology/S&Sx
2. Asymptomatic Bacteriuria
3. Treatment Plan

A
  1. 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

  1. 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
96
Q

Pregnancy: Urinary Tract Infections
1. Definition/Etiology/S&Sx
2. Asymptomatic Bacteriuria
3. Treatment Plan

A
  1. 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

  1. 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
97
Q

Pregnancy: Urinary Tract Infections
4. Medications
6. Sulfa Drugs, yes or no?

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

98
Q

Spontaneous abortion

A

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

99
Q

Threatened Abortion

A

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

100
Q

Inevitable abortion

A

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

101
Q

Complete Abortion

A

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

102
Q

Incomplete Abortion (abortion w/ retained products of conception)

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

103
Q

Still Birth or Fetal Death

A

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

104
Q

Obstetric Complications: Preeclampsia
1. Definition/Etiology
2. Clinical Presentation
3. Diagnostic Criteria
4. Treatment Plan

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

  1. 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
105
Q

Preexisting/Chronic HTN

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)
106
Q

Placenta Abruptio
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan

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
  2. → 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
107
Q

Placenta Previa
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan

A
  1. 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
108
Q

Breastfeeding: Colostrum and Breast Milk

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

109
Q

Breastfeeding: Vitamin D

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)
110
Q

Breastfeeding: Iron

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
111
Q

Breastfeeding Technique

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
112
Q

Steps to a Good Latch

A
  1. Infants’ chest and stomach should rest against body; head is straight and not turned to side
  2. Tickle infant’s lips w/ nipple and aim nipple just above infant’s top lip
  3. Ensure nipple and areola are inside infant’s mouth (baby’s tongue will cup under breast w/ lip turns out)
  4. May hear/see swallowing; infant’s ears may wiggle slightly
  5. Breast soreness is normal the first few days; a proper latch will help make it more comfortable
  6. 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

113
Q

Breastfeeding: Sore Nipples

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

114
Q

Breastfeeding: Maternal Benefits

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
115
Q

Breastfeeding: Fetal Health Benefits

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
116
Q

Lactational Mastitis
1. Definition/Etiology
2. Prevention
3. Clinical Presentation

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
117
Q

Lactational Mastitis
4. Lab/Diagnostics
5. Treatment Plan

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
  2. 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

118
Q

Uncomplicated Chlamydia Infection
1. Definition/Etiology
2. Labs/Diagnostics
3. Treatment Plan
4. Sexual Partners Consideration

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)
119
Q

Postpartum Contraception

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

ANCC - Fitzgerald Notecards (27 decks)

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