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OBGYN Clerkship- Amboss Study Plan > Pregnancy and Prenatal Care > Flashcards

Pregnancy and Prenatal Care Flashcards

1
Q

Duration of Pregnancy

A
  • Normal duration of pregnancy: 40 weeks (280 days)
  • Preterm birth: live birth before the completion of 37 weeks
  • Post-term birth: live birth after 42 weeks
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2
Q

Gravidity

A

the number of times a woman has been pregnant

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3
Q

parity

A

the number of times a woman has given birth

P1001

1 delivery

0

0 abortions

1 live birth

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4
Q

Trimester breakdown

A
  1. First trimester (week 1–13)
  2. Second trimester (week 14–26)
  3. Third trimester (week 27–40)
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5
Q

Day of implantation

A

Day 6

Implantation (embryology) of the blastocyst (most commonly into the anterior or posterior wall of the uterus); The trophoblast penetrates the endometrium.

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6
Q

When is embryogenesis?

A

weeks 3-8

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7
Q

When is fetogenesis?

A

from week 9 onward

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8
Q

Prenatal Counseling aim

A
  • Identifying and addressing any modifiable risk factors for the woman, future pregnancy, and the fetus
  • Educating a woman about the risk factors and options for their reduction or elimination
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9
Q

Prenatal Evaluation general medical conditions

A

General chronic diseases: review history and identify chronic medical conditions which may affect the pregnancy (e.g., hypothyroidism, diabetes mellitus, chronic hypertension, etc.)

  • Hypothyroidism
    • Treat women with elevated TSH
  • Diabetes mellitus
    • Aim for an HbA1c < 6.5%
  • Hypertension
    • Avoid using ACE inhibitors and angiotensin receptor blockers, as they are teratogenic.
  • Family history of heritable conditions: assess family history
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10
Q

Prenatal evaluation communicable diseases (HIV)

A
  • Screen all women for HIV.
  • Initiate antiretroviral therapy in all women with HIV.
  • Counsel women with HIV regarding the risk of vertical transmission.
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11
Q

Pregnancy and Immunizations

A

Measles, mumps, rubella and varicella

  • Screen all women for immunity with antibody titer.
  • Vaccinate all nonimmune women
  • Counsel to avoid conceiving 28 days after the last vaccine dose.

Influenza:

  • Administer annual influenza vaccination to all women.

Tdap

  • single dose between the 27th and 36th week of pregnancy
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12
Q

Lifestyle modifications for pregnancy

A
  • maintaining a normal body weight
  • moderate-intensity exercise

Nutrition

  • sufficient intake of macronutrients and micronutrients
  • 0.4 mg of folic acid daily, ideally 4 weeks prior to pregnancy and continue for at least the first 2–3 months of pregnancy

Substance use

  • smoking cessation and alcohol and drug use discontinuation
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13
Q

Clinical signs of early pregnancy

A
  • Hyperpigmentation of the areola and formation of linea nigra
  • Increased urinary frequency
  • Fatigue

abdominal cramps, fatigue, polyuria, amenorrhea, and a lower abdominal mass

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14
Q

Measurment of hCG

A
  1. Peaks at 10 weeks of gestation (peak value: ∼100,000 mlU/mL)
  2. Decreases During 2nd trimester
  3. Stabilizes During 3rd trimester
  • Urine beta-hCG test
    • Qualitative test; less sensitive
    • 14 days after fertilization
  • Serum beta-hCG test
    • (quantitative, high sensitivity)
    • 6–9 days (on average) after fertilization
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15
Q

Ultrasound findings in correlation to hCG

A

At 1,500–2,000 mlU/mL pregnancy is visible with transvaginal ultrasound

(if beta-hCG< 1000 mlU/mL, then do transvaginal ultrasound in 2-4 days, allowing enough time for hCG toreach 1500)

1500-2000

  • week 5
  • gestational sac

2500

  • week 5
  • yolk sac

5000

  • week 7
  • fetal pole

17000

  • week 10
  • fetal heartbeat
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16
Q

Gestational Age

A

the age (in weeks and days) of the fetus calculated from the first day of the last menstrual period

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17
Q

Conceptional Age

A

the age (in weeks and days) of the fetus calculated from the day of conception (fertilization)

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18
Q

Naegele’s Rule

A

First day of the last menstrual period + 7 days + 1 year - 3 months

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19
Q

Ultrasound calculation of due date

A
  • more accurate than Naegele’s rule
  • Measurement of the crown-rump length (CRL) in the first trimester
  • Approx. 5 cm at 12 weeks
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20
Q

Physiological changes during preganancy

Cardiovascular

A
  • ↑ Progesterone → ↓ vascular tone → ↓ peripheral vascular resistance (↓ afterload)
    • ↑ Cardiac output by up to 40% (↑ preload)
    • ↑ Stroke volume (by ∼ 10–30%)
    • ↑ Heart rate (by ∼ 12–18 bpm) → ↑ uterine perfusion
    • ↓ Mean arterial pressure
  • Innocent systolic murmur (due to increaded CO and plasma volume)
  • The apex beat is displaced upward.
  • Varicosity and edema of lower limbs
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21
Q

physiological changes during pregnancy

Respiratory

A
  • increased Oxygen consumption (by ∼ 20%)
  • decreased total lung capacity, residual volume, functional residual capacity, and expiratory reserve volume
  • increased Intra-abdominal pressure through uterine growth → dyspnea
  • Progesterone stimulates the respiratory centers in the brain → hyperventilation (aimed to eliminate fetal CO2 more efficiently) → physiological, chronic compensated respiratory alkalosis (high normal pH, low CO2, high bicarb)
    • ↑ Tidal volume (by ∼ 40%) → ↑ minute ventilation
    • ↓ PCO2 (∼ 30 mm Hg)
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22
Q

physiological changes during pregnancy

RENAL

A
  • ↑ GFR (↑CO=↑ renal perfusion) → ↓ BUN and creatinine
  • ↑ Aldosterone (activation of ↓RAAS by resistance) → ↑ plasma volume + hypernatremia
  • ↑ Glucose levels in urine
    • (increased glomerular filtration results in overload of the glucose carrier responsible for its resorption)
  • ↑ Urinary frequency
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23
Q

physiologic changes in pregnancy

endocrine

A
  • Human placental lactogen increases insulin levels and insulin resistance
  • ↑ Triglycerides and cholesterol (due to increased lipolysis and fat utilization)
  • Hyperplasia of lactotroph cells in the anterior pituitary → physiological enlargement of the pituitary gland
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24
Q

physiological changes in pregnancy

Hematologic

A
  1. ↑ Plasma volume → ↓ hematocrit particularly towards the end of pregnancy (30–34th week of gestation); dilutional anemia ; (minimal hemoglobin value is 11 g/dL)
  2. ↑ RBC count
  3. ↓ Platelet count
  4. ↑ WBC count
  5. ↓ Albumin
  6. ↑ Fibrinogen and factor VII, VIII, ↓ protein S → hypercoagulability(to reduce the risk of intrapartum blood loss)
  7. ↑ Alkaline phosphatase
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25
Q

physiological changes in preganancy

gastrointestinal

A
  • ↑ Salivation
  • ↓ Motility (due to progesterone) → constipation
  • Hemorrhoids (uterus presses against the pelvic veinsand vena cava, impairing venous return)
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26
Q

physiologic changes in pregnancy

MSK

A

Increased lumbar lordosis and relaxation of the ligaments supporting the joints of the pelvic girdle can cause lower back pain

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27
Q

physoilogical changes in preganancy

skin

A
  • Spider angioma
  • Palmar erythema
  • Striae gravidarum
  • Hyperpigmentation: chloasma, linea nigra, hyperpigmentation of the nipples
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28
Q

physiological changes in pregnancy

vulva and vigaina

A

Progesterone and estrogen increase vaginal blood supply, thereby increasing Bartholin gland secretions= increased vaginal discharge

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29
Q

Recomened Weight Gain during pregnancy

A

The recommendations are determined by the BMI prior to the pregnancy:

  • BMI < 18.5 (underweight): 28–40 lb (12–18 kg)
  • BMI 18.5–24.9 (normal weight): 25–35 lb (11–16 kg)
  • BMI 25–29.9 (overweight): 15–25 lb (7–11 kg)
  • BMI ≥ 30 (obese): 11–20 lb (5–9 kg)’

Approx. 2 lb in the first trimester and up to 1 lb per week in the second and third trimesters

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30
Q

Benefits of physical activity during pregnancy

A
  1. weight control,
  2. improved or maintained physical fitness,
  3. ↓ risk of gestational diabetes,
  4. ↓ risk of operative delivery,
  5. ↓ risk of eclampsia,
  6. improved psychological wellbeing
  7. ↓ postpartum recovery time
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31
Q

Safe physical activities in pregnancy

A
  1. Walking
  2. Running or jogging***
  3. Swimming
  4. Stationary cycling
  5. Pilates
  6. Yoga**
  7. Racquet sports***
  8. Strength training***

* Avoid positions associated with ↓ venous return

*** May be considered safe in women who took part in these exercises before

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32
Q

Unsafe physical activities in pregnancy

A
  1. Contact sports (e.g., soccer, basketball)
  2. Activities associated with a high risk of falling (e.g., snow skiing, water skiing, gymnastics, surfing)
  3. Hot yoga
  4. Hot Pilates
  5. Skydiving
  6. Scuba diving
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33
Q

Amntiotic fluid index

A

8-18 = normal, AFI ≤5 cm = oligohydramnios, AFI ≥24 cm = polyhydramnios.

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34
Q

Oligohydramnios

A

amount of amniotic fluid < 500 mL in the third trimester

Complications

  • Intrauterine growth restriction
  • Intrauterine compression and decreased amniotic fluid ingestion → Potter sequence: pulmonary hypoplasia (cause of death due to severe neonatal respiratory insufficiency), craniofacial abnormalities, limb anomalies
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35
Q

Polyhydramnios

A

excessive amniotic fluid volume (> 2000 mL in the third trimester)

Complications

  • Fetal malposition
  • Umbilical cord prolapse
  • Premature rupture of membranes
  • Premature uterine contractions
  • Premature birth
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36
Q

Oligohydramnios

Fetal Etiologies

A
  1. Urethral obstruction (e.g., posterior urethral valves)
  2. Bilateral renal agenesis
  3. Autosomal recessive polycystic kidney disease (ARPKD)
  4. Chromosomal aberrations (e.g., trisomy 18)
  5. Intrauterine infections (e.g., congenital TORCH infections)
  6. In multiple pregnancies: twin-to-twin transfusion syndrome
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37
Q

oligohydramnios

maternal etiologies

A
  1. Late or post-term pregnancies (> 42 weeks of gestation)
  2. Placental insufficiency
  3. Preeclampsia
  4. Premature rupture of membranes
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38
Q

polyhydramnios

fetal etiologies

A
  1. Gastrointestinal anomalies (e.g., esophageal atresia, duodenal atresia and stenosis)
  2. CNS anomalies (e.g., anencephaly , meningomyelocele )
  3. Chromosomal aberrations
  4. Intrauterine infections (e.g., congenital TORCH infections)
  5. Multiple pregnancy: twin-to-twin transfusion syndrome
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39
Q

polyhydramnios

maternal etiologies

A
  1. Diabetes mellitus (increased fetal glucose levels, resulting in polyuria)
  2. Rhesus incompatibility: hemolytic disease of the newborn
40
Q

Predisposing factors for multiple pregnancy

A
  • Advanced maternal age (> 35 years)
  • Previous multiple pregnancy
  • Use of fertility enhancing treatments
  • Maternal family history of dizygotic twins
41
Q

Monozygotic twins

A
  • 1/3 twin pregnancies
  • division of fertilized oocyte
  • genetically identical
42
Q

Dizygotic twins

A
  • 2/3 of twin pregnancies
  • two oocyted with two spermatozoa
  • genetically different
  • Dichorionic- diamniotic
43
Q

Dichorionic- diamniotic

A

Each twin has an individual amniotic sac and placenta.

44
Q

Monochorionic- diamniotic

A

The twins share a placenta and have individual amniotic sacs.

(twin-to-twin transfusion syndrome)

45
Q

monochotionic- monoamniotic

A

The twins share both the placenta and amniotic sac.

46
Q

Exam findings multiple pragnancy

A
  • Fundal height and abdominal girth are unusually large for the gestational age
  • Two or more fetal heart rates can be heard on auscultation
47
Q

Ultrasound multiple pregnancy

A
  • Dichorionic twins: lambda sign
    • Separation of the chorionic and amniotic sacs resembles the Greek symbol “λ = lambda”
  • Monochorionic twins: T-sign
    • Separation of the amniotic sacs resembles a “T” on ultrasound.
48
Q

Maternal complications of a multiple preganancy

A
  1. Hyperemesis gravidarum and gestational diabetes
  2. preeclampsia
  3. Cervical incompetence, premature birth, preterm labor, premature rupture of membranes
  4. Placental insufficiency
  5. Uterine atony
49
Q

Fetal complications of a multiple preganancy:

Twin-to-twin transfusion syndrome

A
  • Blood is continuously shunted from one twin to the other through vascular anastomoses on the shared placenta
  • Recipient twin: polycythemia; polyhydramnios in diamniotic pregnancies
  • Donor twin: anemia, dehydration, growth retardation; oligohydramnios in diamniotic pregnancies
50
Q

Ectopic pregnancy

A

a pregnancy in which the fertilized egg attaches in a location other than the endometrium

  • Tubal pregnancy: occurs within the fallopian tube- most common
  • Complicated ectopic pregnancy: associated with severe bleeding, rupture, or hemodynamic compromise.
  • Interstitial pregnancy: within the interstitial portion of the fallopian tube (connects the tube to the endometrial cavity)
51
Q

Location of ectiopic cases

A
  1. Fallopian tube (96% of cases): ampulla >> other
  2. Ovary (3% of cases)
  3. Abdomen (1% of cases)
  4. Cervix (very rare)
52
Q

Risk factors for ectopic preganancy

A

Anatomic alteration of the fallopian tubes:

  • A history of PID
  • Previous ectopic pregnancy
  • Past surgeries involving the fallopian tubes
  • Endometriosis

Non‑anatomical risk factors

  • History of infertility
  • IUD (implantations outside uterus)
53
Q

Clinical features of ectopic preganancy

A
  • 4–6 weeks after their last menstrual period
  • Lower abdominal pain and guarding
  • Vaginal bleeding (mistaken for menstrations)
  • Signs of pregnancy: amenorrhea, nausea, breast tenderness, frequent urination
  • Tenderness in the area of the ectopic pregnancy
  • Cervical motion tenderness, closed cervix
  • Enlarged uterus
  • Interstitial pregnancies tend to present late, at 7–12 weeks of gestation, because of myometrial distensibility
54
Q

clincal features of tubal rupture

A
  • Acute course with sudden and severe lower abdominal pain (acute abdomen)
  • Signs of hemorrhagic shock: e.g., tachycardia, hypotension, syncope
  • More common in interstitial pregnancy
55
Q

hCG in ectopic preganancy

A

Serial β-hCG measurements(48 hours)

  • Intrauterine pregnancies: β-hCG increases by ≥ 50% in 99% of patients.
  • Ectopic pregnancies: Approx. 70% of patients show an insufficient increase or decrease of β-hCG.
56
Q

Ectopic Pregnancy diagnostics

A

Transvaginal ultrasound (TVUS)

  • best initial imaging test
  • Empty uterine cavity in combination with a thickened endometrial lining
  • Possible free fluid within the pouch of Douglas
  • Tubal ring sign
  • Interstitial line sign
  • A thin myometrial layer (< 5 mm) surrounding the gestational sac
57
Q

tubal ring sign

A

an echogenic ring that surrounds an unruptured ectopic pregnancy

58
Q

interstitial line sign

A

an echogenic line that extends from the gestational sac into the upper uterus

59
Q

treatment ectopic pregnancy

A
  • uncomplicated: methotrexate
  • hemodynamically unstable or signs or rupture
    1. fluid resuscitation normal saline or lactated Ringer’s solution
      • Hgb >10 no blood even if in shock
    2. salpingostomy
60
Q

Differential Painful Vaginal Bleeding

A
  1. Ectopic pregnancy
    • Lower unilateral abdominal pain and guarding
    • Positive pregnancy test
    • Ultrasound shows echogenic mass.
  2. Benign neoplasms
    • chronic pelvic or back pain/discomfort
    • irregularly enlarged uterus, infertility
  3. Ovarian cyst rupture
    • Sudden onset of unilateral abdominal pain
    • Onset usually during physical activity
  4. Infection/Inflammation (PID, cervicitis)
    • lower bilateral abdominal pain/ lower abdominal or pelvic pain
    • fever, dyspareunia, purulent cervical discharge
  5. Endometriosis
    • Chronic pelvic pain that worsens before the onset of menses
    • Dysmenorrhea Dyspareunia
  6. Trauma
    • Pelvic pain
61
Q

Differential Painless Vaginal Bleeding

A
  1. PCOS
    • Amenorrhea, oligomenorrhea
    • Hirsutism, obesity, acne vulgaris, infertility
    • Ultrasound shows enlarged ovaries with numerous anechoic cysts.
  2. Endometrial hyperplasia
    • Constant bleeding
    • Ultrasonography- endometrial thickening.
  3. Endometrial polyp
    • Irregular menstrual bleeding
  4. Malignant neoplasms
    • Cervical cancer: menometrorrhagia, postcoital spotting, abnormal vaginal discharge
    • Endometrial cancer: metrorrhagia, menometrorrhagia
62
Q

Frequency of Prental check up

A
  1. Until the 28th week of pregnancy: monthly
  2. From the 28th week until the 36th week: every two weeks
  3. From the 36th week until birth: every week
63
Q

Initial Pregnency encounter

A
  1. Personal and family history, previous pregnancies
  2. Gynecological examination
  3. Laboratory analysis
  4. Ultrasound assessment
64
Q

STD test in pregnancy

A
  • HIV (using 3rd or 4th generation ELISA),
  • syphilis(using nontreponemal tests such as VDRL or RPR),
  • hepatitis B infection (using HBsAg).
  • < 25 years, have risk factor: Chlamydia and N. gonorrhea infection by PCR of vaginal swabs
65
Q

Initial lab analysis for preganancy

A
  1. CBC
  2. Anemia
  3. Blood typing (ABO and rhesus)
  4. Proteinuria
  5. Asymptomatic bacteriuria
  6. Screening for STIs
    • HIV testing
    • Syphilis screening
    • Hepatitis B surface antigen testing
    • Chlamydia testing:
    • < 25 years of age and ≥ 25 years with high risk of infection
  7. Rubella and varicella antibody testing
66
Q

Follow Up Preganancy encounters

A
  1. Blood pressure monitoring: early detection of pregnancy-induced hypertension
  2. First-trimester screening: screening of chromosomopathies
  3. Physical examination
    • Leopold’s maneuver
    • Fetal heart monitoring
  4. Laboratory
67
Q

Follow up encounter

Labs for preganancy

A
  1. Group B streptococcus screening performed between 36 0/7 and 37 6/7 weeks of gestation
  2. Repeat Hb from the 24th week
  3. 50-g, one-hour oral glucose challenge test (initial screening) at 24–28 weeks gestation
    • 100-g, three-hour oral glucose tolerance test to confirm diagnosis
  4. Repeat rhesus screening
68
Q

Group B Screening

A
  • vaginal and rectal swab for culture and gram staining
  • colonization by this bacteria may cause chorioamnionitisand neonatal infection.
69
Q

Leopold Maneuver

A
  1. First: bimanual examination of the fetal position (longitudinal/oblique/transverse) and fundal height
  2. Second: bimanual examination of the location of the fetal back (i.e., either on the mother’s left or right side)
  3. Third: One hand grasps above the symphysis in an attempt to determine if the presenting part of the fetus is engaged.
  4. Fourth: Bimanual determination of the location of the fetal brow and the degree of flexion of the fetus’s head. when the fetus has entered the pelvic inlet.
70
Q

Fundal Height

A

increases ∼ 1 cm/week in the second and third trimester.

  • Week 12 = Just above the symphysis
  • week 20 = Between the symphysis and navel
  • week 24 = Navel
  • week 32 = Between the navel and xiphoid
  • week 36 = Peak: at the costal arch
  • week 40 = Two finger widths below the costal arch
71
Q

Prenatal diagnostics

A

All pregnant women (regardless of age) should be offered noninvasive aneuploidy screening tests (before 20 weeks gestation)

  • Possible tests:
    • Testing maternal serum; specific biomarkers and ultrasound
    • Cell-free fetal DNA testing
  • invasive genetic testing; amniocentesis or CVS
72
Q

Noninvasive screening tests:

First trimenster combinded screaning (11-13wks)

A
  • Sonographic nuchal translucency (NT)
  • β-HCG in maternal serum
  • PAPP-A in maternal serum

Detects:

  1. Down syndrome/Trisomy 21: ↑ HCG, ↓ PAPP-A, ↑NT
  2. Trisomy 18 & 13: ↓ HCG, ↓↓ PAPP-A, ↑ NT
  3. Molar pregnancy: ↑↑ HCG
  4. Ectopic pregnancy: ↓ HCG
  5. Neural tube defects: ↑ HCG
73
Q

Noninvasive screening tests:

Triple Screen (15-20wks)

A
  • based on maternal age and ultrasound
  • HCG
  • Alpha-fetoprotein(AFP)
  • Estriol

Diagnoses:

  1. Trisomy 21: ↑ β-HCG, ↓ AFP, ↓ free estriol, ↑ Inh A
  2. Trisomy 18: ↓↓ β-HCG, ↓ AFP, ↓↓ free estriol,↔︎ or ↓ Inh A
  3. Molar pregnancy: ↑↑ HCG
  4. Ectopic pregnancy: ↓ HCG, ↓ AFP, ↓ free estriol
  5. Neural tube defects: ↔︎ HCG, ↑ AFP, ↔︎ free estriol, ↔︎ inh A
  6. Abdominal wall defects: ↔︎ HCG, ↑ AFP, ↔︎ free estriol, ↔︎ inh A
74
Q

Noninvasive screening tests:

Quad Screen (15-20wks)

A
  • based on maternal age and ultrasound
  • HCG
  • Alpha-fetoprotein(AFP)
  • Estriol
  • Inhibin A (Inh A)

Diagnoses:

  1. Trisomy 21: ↑ β-HCG, ↓ AFP, ↓ free estriol, ↑ Inh A
  2. Trisomy 18: ↓↓ β-HCG, ↓ AFP, ↓↓ free estriol,↔︎ or ↓ Inh A
  3. Molar pregnancy: ↑↑ HCG
  4. Ectopic pregnancy: ↓ HCG, ↓ AFP, ↓ free estriol
  5. Neural tube defects: ↔︎ HCG, ↑ AFP, ↔︎ free estriol, ↔︎ inh A
  6. Abdominal wall defects: ↔︎ HCG, ↑ AFP, ↔︎ free estriol, ↔︎ inh A
75
Q

Noninvasive screening twsts:

Sequential integrated tests

A
  1. Frist trimerster combined (10-13 wks)
  2. Quad screen test (15-20 wks)
76
Q

Noninvasive screen tests:

cell free fetal DNA testing (cffDNA)- 10wks +

A
  • Fetal DNA is isolated from a maternal blood specimen for genetic testing’

Detects:

  1. Identifies chromosomal aberrations
    • (high specificity and sensitivity for trisomy 21 > trisomy 18 >trisomy 13)
  2. Determine the sex of the fetus
  3. high sensitivity (> 99%) and specificity (> 99%) for Down syndrome
77
Q

Invasive diagnostic tests:

Chorionic Villus Sampling (10-13 wks)

A
  • removal of chorionic tissue under sonographic guidance
  • Analysis of DNA for genetic diagnosis in early pregnancy
  • preferred testing method before 15wks for prenatal genetic diagnosis (conformatory)
  • perform after 1st trimester screening

Complications:

  1. Miscarriage(approximate risk: 2–3%)
  2. Limb defects
78
Q

invasive diagnostic tests:

amniocentesis (15 wks +)

A
  • AF is extracted under sonographicguidance via transabdominal puncture

Comlications

  1. Miscarriage(approximate risk: 0.5–1%)
  2. Premature rupture of the membranes
  3. Infection
79
Q

Invasive diagnostic testing:

cordocentesis (17wks +)

A
  • Fetal blood sampling via ultrasound-guided transabdominal needle insertion into the umbilical cord
  • dentify the type of fetal hemoglobinand to assess the severity of fetal anemia

Complications

  1. miscarriage
  2. infection
80
Q

Doppler Ultrasound

indications

A
  • Suspected intrauterine growth restriction
  • Suspected fetal deformities
  • Growth discordance in multiple pregnancies
81
Q

doppler ultrasound

findings

A
  1. Uterine artery
    • Early diastolic notch
    • risk of preeclampsiaand/or fetal growth restriction
  2. Umbilical artery
    • Decline or loss of end diastolic flow velocity or negative flow
    • increased resistance to the placentalvascular bed
  3. Fetal middle cerebral artery
    • Increased diastolic flow velocity
    • centralization (“brain sparing effect”) in fetal hypoxia
82
Q

Antepartum fetal surveillance

A
  1. Nonstress Test (NST)
  2. Contraction stress test (CST)
  3. Biophysical Profile (BPP)
83
Q

Nonstress Test

A
  • a noninvasive test cardiotography (CTG) that measures FHR reactivity to fetal movements
  • Indications:
    • maternal medical conditions (e.g., gestational diabetes, preeclampsia)
    • fetal conditions (e.g., fetal heart defects, fetal growth restriction)
  • performed in the third trimester
84
Q

Nonstress Test Findings

A
  1. A normal NST would show ≥ 2 FHR accelerations.
  2. Reactive nonstress test: normal
  3. Non-reactive nonstress test: <2 FHR accelerations
    1. Perform vibroacoustic stimulation
    2. If the NST is still non-reactive: check the biophysical profile (BPP) or perform contraction stress test
85
Q

Contraction Stress test (CST)

A
  • measures FHR reactivity in response to uterine contractions
  • contractions are stimulated with oxytocin administration.
86
Q

Biophysical Profile (BPP)

A

evaluates the risk of antenatal fetal death. Ultrasound exam.

Measured parameters: 0 (abnormal) or 2 (normal)

  1. Fetal movement
  2. Fetal tone
  3. Fetal breathing
  4. Amniotic fluid volume

≥ 8 points: no signs of fetal compromise at the time of testing

≤ 4 points: potential fetal compromise → delivery is indicated

87
Q

BPP Parameters

A
  1. Fetal movement
    • ≥ 3 body or limb movements within a 30-minute period
  2. Fetal tone
    • ≥ 1 episodes of a fetal extremity or fetal spine extension with return to flexion
  3. Fetal breathing
    • ≥ 1 rhythmic breathing episode(s) ≥ 30 seconds within a 30-minute period
  4. Amniotic fluid volume
    • A single deepest vertical pocket ≥ 2 cm
  5. Nonstress test
    • ≥ 2 episodes of FHR accelerations
88
Q

HIV in pregnancy

transmission

A
  • Highest risk during birth (perinatal vertical transmission)
  • Prenatal transmission is possible
  • Risk depends on maternal viral load
89
Q

HIV in preganancy:

reducing risk of transmition

A
  1. Combined antiretroviral therapy (cART) is recommended throughout pregnancy
  2. Delivery method Viral load > 1,000 copies/mL: increased risk of HIV transmission
    • Cesarean delivery should be scheduled at 38 weeks
    • post-exposure prophylaxis with zidovudine, lamivudine and nevirapine OR zidovudine and nevirapine
  3. Viral load ≤ 1,000 copies/mL and mother has received cART
    • HIV post-exposure prophylaxis with zidovudine for the newborn
    • vaginal delivery considered
  4. Breastfeeding should generally be avoided , because risk of transmission is 5–20%
90
Q

HIV in preganancy:

Diagnosis in infants

A

if < 18 months, diagnosis is confirmed via PCR, not ELISA

91
Q

Anti-D immunoglobulin (RhoGAM)

A
  • An antibody against the rhesus D antigen that is used as prophylaxis against hemolytic disease of the fetus and newborn in Rh(D) negative mothers.
  • Anti-D prophylaxis protects newborns in subsequent pregnancies.
  • Only indicated in unsensitized mothers
92
Q

Anti-D immunoglobulin indication and implementation

A

Anti-D prophylaxis should be administered during the 28th week of gestation and within 72 hours following the birth of an Rh-positive baby.

Further indicaitons:

  1. Following a miscarriage, ectopic pregnancy, or termination of pregnancy
  2. Bleeding during pregnancy
  3. Following invasive procedures (e.g., amniocentesis, chorionic villus sampling
93
Q

RH negative mothers

A
  1. No anti-D antibodies (unsensitized mothers): antibody screening repeated at 28 weeks’ gestation and at delivery.
  2. Anti-D antibodies manifest with an anti-D antibody titer > 1:8, which indicates maternal sensitization to fetal Rh antigens (sensitized mothers).
    • Further monitoring with amniocentesis and imaging is required for evidence of hemolysis.
94
Q

Fetomaternal Hemorrahe in Rh- negative mother

A
  1. Conduct a rosette test (initial test of choice). This is a qualitative test that assesses whether fetomaternal hemorrhage has occurred.
  2. If the rosette test is positive, conduct a Kleihauer-Betke test.
    • The amount of fetal hemoglobin determines the amount of Anti-D immunoglobulin necessary.
95
Q

Rosette Test

A

Maternal Rh-negative blood is incubated with Rho(D) immunoglobulin, which binds to fetal Rh-positive erythrocytes. The addition of an indicator causes these erythrocytes to form a rosette pattern

96
Q

Kleihauer Betke Test

A

maternal blood smear is exposed to acid and then stained. Adult hemoglobin is removed by the acid whereas fetal hemoglobin (HbF) is not, thus, cells appear pink on a positive test for fetal hemoglobin

97
Q

Birth weight

A
  • very low 1000-1499
  • low: <2500g
  • Normal: 2500-4000g
  • Macrosomic: 4500g

OBGYN Clerkship- Amboss Study Plan (9 decks)

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