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Obstetrics and Gynecology > Pregnancy and Prenatal Care > Flashcards

Pregnancy and Prenatal Care Flashcards

1
Q

define pregnancy

A

state of having products of conception implanted normally or abnormally in the uterus or occasionally elsewhere

terminated by spontaneous or elective abortion, or by delivery

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2
Q

how do you diagnose pregnancy

A

in a patient who has regular menstrual cycles and is sexually active, a period delayed more than a few days to a week is suggestive of pregnancy –> may already exhibit early signs and symptoms of pregnancy at this stage

can do urine or serum lab assay to test for pregnancy

can confirm a viable pregnancy by ultrasound which may show the gestational sac as early as 5 weeks on transvaginal US (or at bhcg of 1500-2000)

fetal heart motion can be seen on transvaginal US as soon as 6 weeks

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3
Q

what do urine and serum pregnancy tests measure

A

Bhcg (human chorionic gonadotropin)

this hormone is produced by the placenta and will rise to a peak of 100 000 mIU/mL by 10 weeks gestation, will decrease through second trimester and then level off at approc 20-30000 units in the third trimester

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4
Q

when can fetal heart motion be seen on transvaginal US

A

6 weeks

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5
Q

define an embryo

A

conceptus from conception to 8 weeks (10 weeks GA)

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6
Q

define a fetus

A

conceptus from 8 weeks (10 weeks GA) until birth

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7
Q

define infant

A

from delivery until 1 year

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8
Q

what are the timelines for the trimesters of pregnancy

A

1st–> up to 14 weeks GA (but is 12 weeks of pregnancy)

2nd–> 12-14 until 24-28 weeks GA

3rd–> 24-28 weeks until delivery

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9
Q

what is the GA limit of viability

A

born before 24 weeks

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10
Q

define preterm birth

A

between 24-37 weeks

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11
Q

define term birth

A

37-42 weeks l

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12
Q

define post term delivery

A

after 42 weeks

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13
Q

Define gravidity

A

number of times a woman has been pregnant

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14
Q

define parity

A

number of pregnancies that lead to a birth at or beyond 20 weeks GA or of an infant weighing more than 500 g

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15
Q

is a multiple gestation considered P1 or P2

A

P1–one pregnancy

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16
Q

what is gestational age

A

age in weeks and days measured from the LMP

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17
Q

what is developmental age

A

number of weeks and days since fertilization–usually about 14 days from LMP (therefore GA is usually 2 weeks before the DA)

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18
Q

what is the Nagele rule for calculating EDD

A

subtract 3 months from LMP, add 7 days, then add 1 year

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19
Q

how closely should US mirror EDD by dates

A

should not differ by more than 1 week in first trimester, by more than 2 weeks in second and by more than 3 in third

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20
Q

how accurate is crown-rump length dating in the first half of the first trimester?

A

within 3-5 days

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21
Q

when can you auscultate fetal heart sounds with doppler

A

10 weeks

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22
Q

when do fetal movements start

A

16-20 weeks

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23
Q

list signs of pregnancy

A

bluish discoloration of vagina and cervix–chadwick’s sign

softening and cyanosis of the cervix at or after 4 weeks–goodells sign

breast swelling and tenderness

development of the linea nigra (linea alba) from umbilicus to pubis

telangiectasias

palmar erythema

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24
Q

list symptoms of pregnancy

A

amenorrhea

nausea and vomiting

breast pain

quickening–fetal movements

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25
Q

by how much does cardiac output change in pregnancy

A

increases by 30-50%

most increases occur during the first trimester, with maximum being reached between 20-24 weeks gestation and maintained until delivery

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26
Q

what causes the increased cardiac output in pregnancy

A

first due to an increase in stroke volume and then is maintained by an increase in heart rate as stroke volume decreases to near pre-pregnancy levels at the end of the third trimester

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27
Q

how does SVR change during pregnancy

A

decreases

results in fall in arterial BP

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28
Q

why is there a fall is SVR during pregnancy

A

most likely due to elevated progesterone leading to smooth muscle relaxation

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29
Q

how does BP change in pregnancy

A

sBP decreases by about 5-10 mmHg and dBP decreases by about 10-15mmHg that nadirs at week 24

between 24 weeks GA and term, BP slowly returns to pre-pregnancy levels but should NEVER EXCEED them

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30
Q

how does tidal volume change in pregnancy? what are the implications of this for expiratory reserve volume?

A

increases by about 30-40% –> this is despite the fact that total lung capacity decreases by 5% due to elevation of the diaphragm

this increase in Vt decreases the expiratory reserve volume by about 20%

increase in Vt with constant respiratory rate leads to an increase in alveolar and arterial pO2 levels and a decrease in pCO2 levels

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31
Q

how does PaCO2 (arterial) change during pregnancy

A

decreases to approx 30 mmHg by 20 weeks (compared to normal 40mmHg)

leads to an increased CO2 gradient between mother and fetus and is likely caused by elevated progesterone that either increase the respiratory systems responsiveness to CO2 or act as a primary stimulant

this gradient facilitates oxygen delivery to the fetus and CO2 removal from the fetus

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32
Q

what % of women experience dyspnea of pregnancy

A

60-70%

possibly secondary to decreased PaCO2 levels, increased Vt or decreased TLC

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33
Q

what % of pregnant women experience nausea and vomiting

A

70%

“morning sickness” although can occur anytime throughout the day

caused by elevations in estrogen, progesterone and hCG

may also be due to hypoglycemia and can be treated with frequent snacking

typically resolves at 14-16 weeks gestation

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34
Q

define hyperemesis gravidarum

A

severe form of morning sickness associated with weight loss (more than or equal to 5% of pre pregnancy weight) and ketosis

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35
Q

why do you get reflux in pregnancy

A

delayed gastric emptying and decreased tone in gastroesophageal sphincter

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36
Q

why do you get decreased water absorption/diarrhea in pregnancy

A

decreased motility of large bowel

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37
Q

how do the kidneys change in pregnancy

A

increase in size and ureters dilate –> leads to increased rate of pyelonephritis

GFR increases by 50% early in pregnancy and is maintained until delivery –> BUN and Cr thus decrease by about 25% (above about 80 for Cr is abnormal)

increase in RAAS system leads to increased levels of aldosterone which results in increased sodium resorption –> BUT plasma levels of sodium do not increase as GFR also increases

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38
Q

how does plasma volume change in pregnancy

A

increases by 50%

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39
Q

how does RBC volume change in preganancy

A

increases by 20-30% –> thus, with the increase in plasma, you get a dilutional anemia

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40
Q

how does the WBC count change in pregnancy

A

increases to a mean of 10.5 with a range of 6-16 –> in labour this may increase to over 20

41
Q

how do platelet counts change in pregnancy

A

decreases slightly, probably due to increased plasma volume and an increase in peripheral destruction

in 7-8% of patients the platelets may decrease to between 100-150, a drop below 100 over a short time is not normal and should be investigated

42
Q

what hematologic event is more likely in pregnancy versus non pregnant women

A

thromboembolic events–> pregnancy is a hypercoagulable state

elevations in the levels of fibrinogen and factors VII-X–> however, actual bleeding and clotting times do not change

increased rates of thromboembolic events in pregnancy may also be secondary to the other elements of virchow’s triad (increase in venous stasis and vessel endothelial damage)

43
Q

how do estrogen levels change in pregnancy and what is the implication of this

A

pregnancy is a hyperestrogenic state

produced by placenta with ovaries contributing a small amount

estrogen produced from the placenta is derived from circulating plasma-borne precursors produced by the maternal adrenal glands

fetal wellbeing has been correlated to maternal serum estrogen levels, with low estrogen levels being associated with conditions like fetal death and anencephaly

44
Q

how do hCG levels change in pregnancy

A

double approximately every 48 hours in early pregnancy reaching a peak at about 10-12 weeks

then decline to reach steady state at about 15 weeks

45
Q

where is hCG produced

A

placenta

46
Q

what does hCG do

A

acts to preserve the corpus luteum during early pregnancy

47
Q

what does the corpus luteum do

A

produces progesterone which maintains the endometrium–> eventually the placenta takes over progesterone production and the corpus luteum degrades into the corpus albicans

48
Q

how do progesterone levels change in pregnancy

A

increase over course of pregnancy

49
Q

what does progesterone do

A

causes relaxation of smooth muscle which has multiple effects on the GI, CV and GU systems

50
Q

what is human placental lactogen

A

aka human chorionic somatomammotropin

hormone produced by the placenta which is important for ensuring a constant nutrient supply to the fetus

induces lipolysis with a concomitant increase in circulating FFAs

also acts as an insulin antagonist along with various other placental hormones which thus has a diabetogenic effect which leads to increased levels of insulin and protein synthesis

51
Q

how do prolactin levels change during pregnancy

A

markedly increased

decrease after delivery but later increase in response to suckling

52
Q

how do thyroid hormones change during pregnancy

A
  1. estrogen stimulates thyroid binding globulin (TBG) leading to elevation in total T3 and T4 –> but free T3 and T4 remain constant
  2. hCG has a weak stimulating effect on the thyroid likely because its alpha subgroup is similar to TSH –> slight increase in T3 and T4 and slight decrease in TSH during pregnancy

overall though-pregnancy considered a euthyroid state

53
Q

what are the skin changes during pregnancy

A

spider angiomas and palmar erythema secondary to high estrogen

hyperpigmentation of the nipples, umbilicus, linea alba/nigra, perineum, and face (melasma) secondary to increased levels of melanocyte simulating hormones and steroid hormones

54
Q

how does a womans daily caloric requirement change during pregnancy

A

increases by 300 kcal/day during pregnancy and 500 kcal/day during breastfeeding

most patients should gain between 20-30 pounds (overweight women should gain less, underweight women should gain more)

55
Q

what nutrient requirements do women require more of in pregnancy

A 
protein
iron
folate
calcium
other vitamins and minerals
56
Q

what should be done at the first prenatal visit

A

complete history and physical
initial lab tests
address diet, weight gain goals and exercise should be discussed

occurs in first trimester around 6-10 weeks GA

57
Q

what do ask on history at the first prenatal visit

A 
present pregnancy
LMP
symptoms of pregnancy
obstetric history--prior pregnancies, including date, outcome and mode of delivery, length of time in labour and second stage, birth weight, any complications 
complete medical and surgical history 
family history 
social history
58
Q

what should you pay attention to on physical exam in the first prenatal visit

A

pap smear (unless one done in last 6 months)

cultures for gonorrhea and chlamydia

size of uterus on bimanual exam

dating US

59
Q

what lab tests should be done in the first trimester

A

CBC
antibody screen, rapid plasma reagin or VDRL screening for syphilis, rubella antigen, hepatitis B surface antigen
UA and culture

titre for VZV if no history of chicken pox

PPD for TB

HIV testing

60
Q

what screening tests should be done in the first trimester

A

screening tests for aneuploidy with nuchal translucency by US and serum markers

61
Q

what should be done on routine prenatal follow up visits

A 
BP
weight
urine dipstick
measurement of SFH
auscultation of FH
62
Q

what do you worry about if you see protein on urine dipstick in pregnancy

A

pre-eclampsia

63
Q

what are symptoms of complications of pregnancy

A

vaginal bleeding–> possible miscarriage or ectopic pregnancy in first trimester, or placental abruption or previa later in pregnancy

vaginal discharge or leaking of fluid–> sign of infection or cervical changes (discharge) or ruptured fetal membranes (leaking fluid)

urinary symptoms

64
Q

what are braxton hicks contractions

A

irregular contractions, less than 5-6 per day, common in third trimester

(regular contractions more often than this may be sign of preterm labour and should be assessed)

65
Q

how and when do you screen for aneuploidy

A

ultrasound for nuchal translucency and correlation with serum levels of pregnancy-associated protein A (PAPP-A) and free B-hCG

between 11-13 weeks

66
Q

how and when do you screen for neural tube defects

A

maternal serum alpha fetoprotein (MSAFP) between 15-18 weeks (elevated means increased risk of NT defects)

use in conjunction with B-hCG and estriol for augmented screening (the triple screen)

addition of inhibin A further enhances it and it called the quad screen

67
Q

when do you do the screening ultrasound

A

between 18-20 weeks

68
Q

when do you usually feel the first fetal movement

A

between 16-20 weeks

69
Q

how often are prenatal visits in the first and second trimesters

A

monthly

70
Q

how often are prenatal visits in the third trimester

A

every 2-3 weeks between 28-36 weeks, and then weekly after 36 weeks

71
Q

when should Rh- mothers receive rho gam

A

28 weeks

72
Q

when do you order the third trimester lab tests

A

27-29 weeks

73
Q

what are the third trimester lab tests

A

hematocrit–> patients with hematocrit lower than 32% or are started on iron supplementation

RPR/VDRL

glucose loading test –> screening for gestational diabetes (glucose tolerance test is actually diagnostic)

74
Q

is active HSV an indication for cesarean delivery?

A

yes

75
Q

when do you do GBS screening

A

36 weeks

76
Q

how do you treat positive GBS screen

A

IV penicillin when they present in labour

77
Q

list routine problems of pregnancy

A 
back pain
constipation
contractions
dehydration
edema
GERD
hemorrhoids
PICA
round ligament pain
urinary frequency
varicose veins
78
Q

why are laxatives generally avoided in the third trimester

A

theoretical risk of preterm labour

79
Q

define braxton hicks contractions

A

occasional irregular contractions that do not lead to cervical change that can occur several times per day up to several times per hour

80
Q

why do pregnant women get edema

A

compression of the IVC and pelvic veins by the uterus can lead to increased hydrostatic pressure in the lower extremities and edema in feet and ankles

should sleep on sides to decrease compression

severe edema of face and hands may indicate pre-eclampsia and warrants investigation

81
Q

what genetic disorders may be screened for prior to conception

A

sickle cell
tay sachs
thalassemia
cystic fibrosis

82
Q

how are fetal karyotypes and genetic screens done

A

amniocentesis or chorionic villus sampling

83
Q

when is a dating US most accurate

A

first trimester

84
Q

what does the biophysical profile look at

A 
amniotic fluid volume
fetal tone
fetal activity
fetal breathing movements
non stress test

gives a score of either 0 or 2 for each
score of 8-10 is reassuring

85
Q

what is considered formal antenatal testing for fetal wellbeing

A

NST
BPP
oxytocin challenge

86
Q

when is an NST considered formally reactive (reassuring)

A

if there are two accelerations of the FHR in 20 min that are at least 15 beats above baseline HR and last for at least 15 sec

87
Q

what is a oxytocin challenge test/contraction stress test (CST)

A

obtained by getting at least 3 contractions in 10 min and analyzing the FHR tracing during that time

reactivity criteria are the same as for NST

late decelerations with at least half of the contractions is a positive test and is worrisome

88
Q

when do we start using NSTs

A

beginning 32-34 weeks in high risk and 40-41 in undelivered patients

89
Q

what do you do if the NST is nonreactive

A

assess fetus with US

if there are any worrisome tracings on the NST or if BPP not reassuring, OCT is usually performed

90
Q

what is percutaneous umbilical blood sampling, and why would you do it

A

“PUBS”

place a needle transabdominally into the uterus and phlebotimize the umbilical cord

may be used when fetal hematocrit needs to be obtained (i.e in case of Rh isoimmunization or other causes of fetal anemia, or hydrops)

also used for fetal transfusion, karyotype analysis and assessment of fetal platelet count in the setting of alloimmune thrombocytopenia

91
Q

how do you test for fetal lung maturity

A

amniotic fluid sample obtained through amniocentesis

classically–> lecithin to sphingomyelin (L/S) ratio has been used as marker for fetal lung maturity

type II pneumocytes secrete surfactant that uses phospholipids in its synthesis

lecithin increases as lungs mature whereas sphingomyelin decreases around 32 weeks

L/S ratio above 2 is associated with only rare cases of respiratory distress syndrome (RDS)

can also use phosphatidylglycerol (PG), saturated phosphatidylcholine (SPC), the presence of lamellar body count, or surfactant to albumin ratio

92
Q

how do you screen pregnant women with graves

A

TSH immunoglobins (can cause fetal disease)

93
Q

how do you follow PPD+ women who are pregnant

A

CXR afer 16 weeks

94
Q

what tests do you run in women with SLE who are pregnant

A

antiRho, antiLa antibodies –> can cause fetal complete heart block

95
Q

why do we care when a pregnant woman has SLE

A

antibodies can cause complete fetal heart block

96
Q

what groups are at high risk for sickle cell and should be screened

A

african americans
southeast asians
MCV less than 70

can do HgB electrophoresis or sickle cell prep for african americans

97
Q

list the routine tests ordered in the first trimester

A

hematocrit

blood type and screen

RPR/VDRL

rubella antibody

HBsAg

gonorrhea and chlamydia cultures

PPD

pap smear

UA and culture

VZV titre in patients with no hx of exposure

HIV

NT plus serum markers

98
Q

list the routine tests ordered in the second trimester

A

MSAFP/triple or quad screen

obstetric US

amniocentesis for women interested in prenatal dx

99
Q

list the routine tests ordered in the third trimester

A

hematocrit

RPR/VDRL

GLT

GBS screen

Obstetrics and Gynecology (21 decks)

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