Pregnancy - Prenatal Care Flashcards
1
Q
Name Physiological changes associated with pregnancy in this organ system: CV (4)
A
- Hyperdynamic circulation → ↑ CO, ↑ HR, ↑ SV
- ↓ Mean arterial BP (lowest at 24 wk)
- ↓ PVR due to vasodilation
- ↓ Venous return and ↑ venous pressure due to compression of inferior vena cava + pelvic veins by uterus (e.g. supine hypotensive syndrome)
2
Q
Name Physiological changes associated with pregnancy in this organ system: Hematologic (4)
A
- Hemodilution (↑↑ plasma volume relative to ↑ RBCs) → apparent ↓ Hgb and Hct
- ↑ WBC but ↓ function leads to improvement of AI disease
- ↓ # Platelets → gestational thrombocytopenia
- Hypercoagulable state → ↑ risk DVT, PE
3
Q
Name Physiological changes associated with pregnancy in this organ system: Respiratory (5)
A
- Level of diaphragm rises and ↑ subcostal angle
- ↑ O2 requirements
- ↓ TLC, FRC, RV
- Increase minute ventilation
- RR stays the same
4
Q
Name Physiological changes associated with pregnancy in this organ system: Breasts (7)
A
- Breast tenderness, tingling (Progesterone induced)
- ↑ Breast size, enlargement of nipples
- ↑ Vascularity/blood flow to breast
- ↑ Cuboidal alveolar cell and ductal (Estrogen induced)
- ↑ Synthesis of milk components—casein, lactalbumin, fatty acids (R/PRLinduced)
- Initiation of secretory activity due to PRL and human placental lactogen (expression of colostrum [thick glossy, protein-rich uid]) from 2nd trimester onward + rst 30 h after delivery
- Inhibition of full lactation high E/P levels
5
Q
Name Physiological changes associated with pregnancy in this organ system: Skin (2)
A
- ↑ Pigmentation (areola; cholasma - under eyes; linea nigra - anterior abdo wall) → due to ↑ secretion of melanocyte-stimulating hormone
- Stretch marks—striae gravidarum (abdo wall, lateral thighs, breasts) → due to ↑ glucocorticoids
6
Q
Name Physiological changes associated with pregnancy in this organ system: GI (5)
A
- Tone and motility of stomach, small/large intestines → constipation
- ↑ GERD Sx due to ↑ intra-abdo pressure and ↓ lower esophageal sphincter tone
- ↑ Gallstones
- Hemorrhoids
- N/V - morning sickness in up to 70% ; cause unclear
7
Q
Name Physiological changes associated with pregnancy in this organ system: Renal (4)
A
- GFR, (↑ renal blood ow)
- Urinary frequency
- UTI risk due to ↑ urine stasis + ↑ glucose content of urine
- Bladder tone, ↑ ureter and renal pelvis dilation (P induced smooth muscle relaxation)
8
Q
Name Physiological changes associated with pregnancy in this organ system: Endocrine (3)
A
- Size and vascularity of pituitary, thyroid glands
- ↑ PRL, oxytocin, ↑ ACTH, ↑ GC secretion vs. normal TSH, ↑ thyroid hormones, ↑ BMR
- Suppressed GH but replaced by hPL
9
Q
Name Physiological changes associated with pregnancy in this organ system: Uterine (3)
A
- ↑ Size uterine fundus through hypertrophy of stroma
- from pear shape to globular, eventually becoming spherical by the end of 1st trimester; begins to assume an ovoid shape starting in 2nd trimester; 2nd and 3rd trimester → expansion of uterine cavity from 4 mL in nonpregnant state to up to 5L at full term
- Hypertrophy of blood vessels supplying uterus → dilation of arteries, ↑ blood flow
10
Q
Describe: Preconception counseling (4)
A
- Review and optimize medical illnesses (ie., HTN, DM, seizure etc.)
- Review and optimize meds
- Risk assessment and modifications:
* (a) Lifestyle—diet, exercise
* (b) Social—alcohol, smoking, illicit drugs, domestic violence, marital dysfunction, Hx depression
* (c) Genetic testing—if FHx of genetic disease
* (d) Infectious disease testing
* (e) Update immunizations for Hepatitis B, rubella, varicella, Tdap (tetanus, diptheria, pertussis), HPV and influenza
- Risk assessment and modifications:
- Nutrition supplementation
11
Q
Name which infectious disease to test in pregnancy (6)
A
- HIV
- Rubella IgG
- Varicella
- Syphilis
- Hepatitis B
- Gonorrhoea/chlamydia
12
Q
In pregnancy, we should update immunizations for what? (6)
A
- Hepatitis B
- Rubella
- Varicella
- Tdap (tetanus, diptheria, pertussis)
- HPV
- Influenza
13
Q
Describe Nutrition supplementation for pregnant women (3)
A
- Folic acid
- Fe
- Prenatal multivitamins
14
Q
Describe doses for Folic acid supplementation in pregnancy (2)
A
- 0.4–1 mg OD starting at least 2–3 mo preconception until end of T1
- or 5 mg OD if have FHx of neural tube defects, current Hx Insulin-dependent diabetes mellitus , obesity, epilepsy, or Hx poor compliance
15
Q
Describe doses for Fe supplementation in pregnancy (2)
A
- recommended 27 mg/d for maintenance
- 150–200 mg /d to treat anemia
16
Q
Describe hx, physical exam, investigations and counselling in initial prenatal visit
A
17
Q
Describe timing of subsequent prenatal visits (3)
A
- q4 wk until GA 28 wk
- q2 wk at 28–36 wk
- q1 wk at >36 wk to delivery
18
Q
Name signs and sx of pregnancy (12)
A
Sx
- Amenorrhea
- Nausea/vomiting
- ↑ Urinaryfrequency
- ↑ Fatigue/lassitude
- Breast tenderness/ heaviness
- Constipation
- Lower abdo cramps
- Backaches/headaches
Signs
- Uterine enlargement
- Chadwick sign—blue cervix/vagina at 6 wk
- Goodell sign—soft cervix at 4 to 6 wk
- Hegarsign—softuterine isthmus at 6 to 8 wk
19
Q
Describe Routine antenatal assessments according to GA: 8-12 weeks (1)
A
Dating U/S → measure of crown-rump length; margin of error± 5d
20
Q
Describe Routine antenatal assessments according to GA: 10-12 weeks (1)
A
CVS
21
Q
Describe Routine antenatal assessments according to GA: 11-14 weeks (2)
A
- First Trimester Screening → measures (a) Nuchal Translucency Ultrasound, (b) b-hCG, + (c) Pregnancy-associated plasma protein A (PAPP-A); provides risk estimate for trisomy 21. If + = CVS or amniocentesis should be offered
- Integrated Prenatal Screening IPS part 1 (NTUS + PAPP-A)
22
Q
Describe Routine antenatal assessments according to GA: 11-13 + 6 weeks (3)
A
- NTUS → measures AFV behind neck of fetus; early screen for congenital anomalies, i.e., trisomy 21 measures “thickness of neck”
- Should only be used alone for twin pregnancy estimation of T21 risk
- Singleton pregnancy should have FTS, IPS, or QUAD screen
23
Q
Describe Routine antenatal assessments according to GA: 15-18 weeks (1)
A
Integrated Prenatal Screening IPS part 2 MSS markers (e.g. QUAD screen))
24
Q
Describe Routine antenatal assessments according to GA: 15-20 weeks (2)
A
- QUAD screen (screen for trisomy 21, 18, and open NTDs) → measures
- (a) Maternal serum alpha-fetoprotein (MSAFP)
- (b) b-hCG
- (c) unconjugated E (E3/estriol)
- (d) inhibin-A
- Amniocentesis if indicated
25
Describe Routine antenatal assessments according to GA: 18-22 weeks to term (1)
Fetal movements FMs (quickening)
26
Describe Routine antenatal assessments according to GA: 18-22 weeks (3)
U/S for
* (a) anatomy and growth of fetus; margin of error ± 7 d;
* (b) placental position;
* (c) Amniotic fluid volume (Note: In obese women, U/S should be delayed until 21–22 wk GA)
27
Describe Routine antenatal assessments according to GA: 24-28 weeks (2)
* Screen for gestational diabetes (GDM)—50 g oral glucose tolerance test (OGTT)
* Plasma glucose \< 7.8 mmol/L → normal
* Plasma glucose \> 7.8 to \< 10.3 mmol/L (50g OGTT) → do 2h 75g OGTT
* Plasma glucose \> 10.3 (50 g OGTT) → GDM
* Dx of impaired glucose tolerance and/or GDM (Note: Both of these should be treated as GDM with increased surveillance, glucose monitoring, and referral.)
* 1–2h 75g OGTT: 1 AbN = IGT and 2 + AbN= GDM
* Fasting plasma glucose \> 5.3 mmol/L
* 1 h plasma glucose (75 g OGTT) \> 10.6 mmol/L
* 2 h plasma glucose (75 g OGTT) \> 8.9 mmol/L
28
Describe Routine antenatal assessments according to GA: 28 weeks (3)
* Repeat CBC (Hg, Hct)
* Check Rh—antibody titers
* RhoGAM (RhIgG) for all Rh− women
29
Describe Routine antenatal assessments according to GA: 35-37 weeks (1)
Vaginal and anorectal culture for GBS
30
Describe Routine antenatal assessments : Every visit (9)
* Hx: estimate GA, Hx of present pregnancy, vaginal bleeding/ leaking, abdo cramping
* Weight of mother—expect steady increase (target weight gain depends on prepregnancy BMI)
* Maternal BP (normal \< 140/90 mm Hg)
* FHR using Doppler U/S (normal = 110–160 bpm)
* FMs—noticed by 18–20 wk in primigravida vs. potentially earlier in multigravida
* Leopold maneuvers for lie, position, and presentation of the fetus (especially important toward the end of 3rd trimester for delivery)
* Size of uterus symphysial fundal height: at 12 wk—symphysis, 20 wk—umbilicus, 36 wk—xiphoid process
* Urine glucose and protein (diabetes, kidney disease)
* Additional U/S done if medically indicated
31
Describe: GTPAL
* GTPAL
* Gravida (G)
* G= total # pregnancies (current, abortions, miscarriages, ectopic)
* Parity (TPAL)
* T= #term births delivered (37–40 + wk)
* P= #premature births delivered (20–36 wk)
* A= #abortions (induced or spontaneous loss of intrauterine pregnancy before fetus viability—\< 20 wk+ \<500g)
* L= # living children
32
33
Describe: Estimating Date of Confinement (EDC) (7)
* Firstday of LMP
* Remember to determine length of cycle (28d vs. 32d)
* Naegele’srule= (LMP + 7d) − 3 mo (for 28-d menstrualcycle)
* Date of conception
* Date of positive pregnancy test
* U/S findings
* Size of uterus (SFH)—12wk at symphysis, 20 wk at umbilicus
34
Name factors that influence Estimating Date of Confinement (3)
* Hx of irregular menstrual cycle
* Unknown LMP
* Use of OCP at time of conception
35
Describe: Leopold Maneuvers (4)
A series of four abdo palpitations of the gravid uterus used to determine fetal lie, presentation, and position:
* First maneuver determines what part of the fetus occupies thefundus.
* Head= round, hard, and ballotable versus buttocks= irregular
* Second maneuver determines which side the fetal back lies on.
* Spine = long, linear, and rm versus extremities = multiple mobile small parts
* Third maneuver determines the presenting part of the fetus.
* Vertex (head) = round, rm ballotable versus breech (sacrum) = irregular and nodular
* Fourth maneuver determines the position of the fetal head (if the infant is in vertex position) by palpating the cephalic prominence.
* Flexed= brow is most prominent on the opposite side from the fetal back
* Extended= occiput is most prominent and felt on same side as spine
36
Confirmation of pregnancy can be performed by what? (2)
urine or serum b-hCG
37
Location of pregnancy can be confirmed by what? (2)
by transvaginal or transabdominal U/S.
38
39
Describe: b - h CG (2)
* Peptide hormone produced by trophoblast cells
* maintains the CL during pregnancy
* Detected in serum 10 d and urine 10 to 14 d postconception
* Serum b-hCG concentration is approximately 10 IU at time of missed menses, 100,000 IU at 10 wk, and 10,000 IUat term
40
How to conform pregnancy with Transvaginal U/S? (3)
* Visible gestational sac at 5 wk (b-hCG \> 1,500–3,000 IU)
* fetal pole at 6 wk
* and fetal heart beat by 6 to 7 wk
41
How to conform pregnancy with Transabdominal U/S? (1)
Intrauterine pregnancy visible by 6 to 8 wk (hCG \> 6,500 IU)
42
Name: Indications for Prenatal Dx (4)
* AbnormalU/S
* Abnormal prenatal screen
* PMHx or FHx genetic disease, chromosomal anomalies, recurrent pregnancy loss, consanguinity
Every pt should be offered, regardless of age or Hx, the option for prenatal Dx.
43
Name types of prenatal Dx (2)
* CVS= biopsy of placental tissue
* Amniocentesis = U/S-guided transabdominal extraction of amniotic fluid
44
Name: Types of Prenatal Screening Tests (3)
* First Trimester Screening (FTS)
* QUAD
* Integrated Prenatal Screening (IPS)
45
Describe: First Trimester Screening (FTS) (2)
* measures Nuchal translucency US (NTUS) + pregnancy-associated plasma protein A (PAPP-A)+ b-hCG
* Estimates the risk for trisomy 21; approximately 85% sensitivity when combined with age
46
Describe: QUAD screen (2)
* measures Maternal serum alpha-fetoprotein (MSAFP) + b-hCG+ unconjugated E+ inhibin A
* Estimates the risk for NTD, trisomy 21 and 18
* NTD → ↑ MSAFP approximately 80% to 90% sensitivity
* Trisomy 21 → ↓ MSAFP, ↑ b-hCG, ↓ unconjugated E3, ↑ inhibin Approximately 77% detection rate
* Trisomy 18 → ↓ MSAFP, ↓ b-hCG, ↓ unconjugated E3, ↓ inhibin Approximately 75% detection rate
47
Describe: Integrated Prenatal Screening (IPS) (2)
* combines QUAD screen markers + NTUS+ PAPP-A
* Estimates the risk for trisomy 21, 18, and NTD
48
Describe: Management of Positive Genetic Screen in Pregnancy (4)
* All women should be notified and have the result explained to them in clear language.
* All women should be referred to the regional tertiary center for genetic counseling, a detailed U/S, and review of management options.
* Women should be notified of the referral and that they may be offered further testing in the form of either a CVS or amniocentesis. They should be reassured that they are under no obligation to undergo further invasive testing simply by attending this appointment. However, many women/couples find it helpful to go to the appointment to obtain further information.
* All referrals and review of results should be done on an urgent basis as management options are time sensitive.
49
Describe: Immunizations in Pregnancy (4)
* Provide all women who wish to become pregnant with clinically indicated immunizations, **at least 3 mo before conception**
* If at high risk for hepatitis A or pneumococcal infection, should be immunized
* Inactivated virus vaccines, toxoids, and immune globulin = safe in pregnancy → delay administration until T2
* Influenzavaccinesarerecommended for all pregnant women and are safe during pregnancy
50
Vaccines may begiven during pregnancy when? (3)
* Have ↑ risk exposure to infection
* Infection is hazardous tomother or fetus
* Immunizing agent not likely to cause harm
51
In Counseling the pregnant patient, describe: Nutrition (7)
* (A) Require ↑ kcal/d:
* 1. 100 kcal/d ↑ in T1
* 2. 300 kcal/d ↑ in T2 or T3
* 3. 450–500 kcal/d during lactation
* (B) Important nutrients:
* Ca2+: 1000 mg/d
* Vit D: 600 IU/d
* Folate: 0.4–1.0 g/d
* Fe2+: 13–18 mg/d in T1; 27 mg/d
52
In Counseling the pregnant patient, describe: Physical Activity (1)
Recommend non–weight bearing exercises (cycling, swimming)
53
Name absolute CI for physical activity (8)
* Premature rupture of membranes PROM
* Preterm labor PTL
* Intrauterine growth restriction IUGR
* Pregnancy-induced hypertension PIH
* incompetent cervix
* placenta previa
* persistent T2/T3 bleeding
* uncontrolled systemic disease
54
Name relative CI for physical activity (5)
* previous SA/preterm birth
* anemia
* twin pregnancy after 28th week
* malnutrition/eating disorder
* mild to moderate systemic disease
55
Describe: Optimal weight (4)
* gain depends on pre pregnancy weight
* 1. BMI \<20 → 12.5–18 kg
* 2. BMI 20–27 → 11.5–16 kg
* 3. BMI \>27 → 7–11.5 kg
56
In Counseling the pregnant patient, describe: Breast-feeding (6)
* Easier to digest
* Provides passive immunity
* May help prevent allergies
* Cheaper, always ready/right temperature
* Lactation support available
* If choose not to breast-feed, Fe2+ fortified
57
In Counseling the pregnant patient, describe: Travel and vaccines (3)
* Avoid prolonged sitting, wear supportive stockings if must occur
* Air travel discouraged at \>36 wk
* Live vaccines carry risk to fetus
58
In Counseling the pregnant patient, describe: Sexual activity (2)
* Pregnancy may cause change in comfort and sexual desire
* Can continue unless at risk for PTL, placenta previa, or abortion
59
In Counseling the pregnant patient, describe: Complications of Smoking (7)
* ↓Amount of O2 and nutrients transferred to baby
* Associated with ↑ risk of:
* 1. Spontaneous abortion (1.2–1.8×)
* 2. Abruptio placentae
* 3. Placenta previa
* 4. Preterm birth
* 5. Low birth weight infant
* 6. Sudden infant death syndrome SIDS
60
In Counseling the pregnant patient, describe: Complications of EtoH (4)
* Ethanol is a teratogen → freely crosses the placenta and fetal blood brain barrier.
* Associated with FAS— characterized by:
* 1. Growth retardation
* 2. Facial abnormalities
* 3. CNS dysfunction
61
Name Unsafe meds (teratogenic) during pregnancy (9)
* ACE-I—IUGR, oligohydramnios
* Anticonvulsants—increased risk NTD 3
* Lithium—Ebstein anomaly, goiter
* Coumadin—warfarin embryopathy
* Retinoids—CNS, CVS, craniofacial anomalies
* Anti-sulfa drugs: NTD (T1), kernicterus (ifusedat\>36wks)
* Tetracycline—stains teeth
* Chloramphenicol—grey baby syndrome
* Fluoroquinolones—possible cartilage damage
62
Describe Management of common Sx: Nausea/vomiting (5)
* Non pharmacologic:
* avoid spicy/greasy foods.
* Eat dry crackers, small frequent meals
* Pharmacologic: if causing dehydration, weight loss, and metabolic abnormalities (hyperemesis gravidarum)
* IV/P.O. hydration
* antiemetic therapy (i.e., diclectin)
* ± nutrient supplementation
63
Describe Management of common Sx: UTIs (3)
* Treat asymptomatic bacturia and uncomplicated UTI based on culture results
* Common antibiotics include: **amoxicillin**, **Nitrofurantoin**.
* **Avoid TMP-SMX**, especially in T1, due to antifolate effect.
64
Describe Management of common Sx: Complicated UTIs or pyelonephritis (2)
* hospitalization and IV antibiotics
* \*\* Follow with post treatment urine culture and monthly cultures for remainder of pregnancy
65
Describe Management of common Sx: Constipation (3)
* Drink ≥6–8 glasses fluid/d
* ↑ High fiber foods intake
* Exercise
66
Name Indications for specialty care referral in prenatal women: Maternal Factors (8)
* Diabetes
* Chronic HTN
* Obesity(BMI\> 35)
* Severe psychosocial issues
* FHx of genetic disease or congenital anomalies
* Other signicant FHx: Deep vein thrombosis DVT/PE, recurrent pregnancy loss
* Signicant tobacco, EtOH, drug use
* Signicant medical illness (heart failure, renal disease, HIV)
67
Name Indications for speciality care referral in prenatal women: Current Pregnancy Complications (11)
* Gestational HTN
* Placenta previa (± bleeding)
* Ongoing antepartum hemorrhage
* Multiple gestation
* PPROM
* PTL
* Rh or atypical blood group sensitization (i.e., C, E)
* Hydramnios (poly or oligo)
* Fetal malposition (breech, transverse at 36 wk)
* Anemia not responding to Fe2+ + Hgb\<100g/L
* Fetal congenital anomaly
68
Name Indications for speciality care referral in prenatal women: Current Pregnancy Hx (5)
* PTL\< 36 wk
* Stillbirth or neonatal death
* Intrauterine growth restriction IUGR, \< 10th % , reverse ow Doppler
* Cervical incompetence
* Prev. uterine surgery
69
Name the strongest work-related risk factor for preterm labor. (1)
High cumulative work fatigue scores
* The physical demands of mother’s employment should be considered and risks thereof disclosed to the pt, especially to women at high risk for preterm delivery.
70
Describe Initial Management of: **Discrepancy** in **symphysis-fundal height** — smaller than expected (\> 3 cm below expected) (5)
* Review current pregnancy:
* R/O incorrect dates
* possible etiologies for Small-for-Gestational-Age fetus (GDM, placental abnormalities, congenital anomalies on U/S, meds/toxins, smoking)
* Review maternal Hx: DM, Systemic Lupus Erythematosus, HTN; inadequate wt gain, Hx of IUGR in prev. pregnancy
* Maternal investigations: BP, urine dip for protein, GDS if not done yet
* Fetal investigation: U/S assessment of fetal growth, fluid volume
* Based on U/S results
71
Describe Initial Management of Discrepancy in symphysis-fundal height — smaller than expected (\> 3 cm below expected) if: Normal growth and fluid on U/S results (2)
* Continue with daily kick counts and routine surveillance for SFH growth
* Repeat U/S for growth/BPP if continued SFH lag and/or other risk factors for poor fetal growth exist (e.g., maternal disease, GDM, inadequate wt gain)
72
Describe Initial Management of Discrepancy in symphysis-fundal height — smaller than expected (\> 3 cm below expected) if: Small for gestational age /possible IUGR fetus on U/S results (5)
* Obtain obstetrics consult
* Fetal surveillance:
* repeat U/S for growth in 2 wk
* BPP in 1 wk
* add umbilical Dopplers
* consider uterine Dopplers if ~24 wk GA
* Investigations: increase surveillance for Gestational hypertension, TORCH screen, consider amniocentesis if other AbN on U/S
* Modify controllable factors: smoking and drug use cessation; adequate nutrition; optimize treatment of maternal disease
* Timing of delivery/site of delivery depends on the clinical situation.
73
Describe Initial Management: Discrepancy in symphysis-fundal height — larger than expected (5)
* Review current pregnancy: R/O incorrect dates, excessive wt gain, GDM, multiple gestation
* Review maternal Hx: Hx of Large for gestational age infants, Insulin-dependent diabetes mellitus , maternal obesity
* Maternal investigations: GDS if not done
* Fetal investigation: U/S assessment for growth, fluid volume
* Based on U/S results
74
Describe Initial Management Discrepancy in symphysis-fundal height — larger than expected if on U/S: Normal growth and fluid (2)
* Continue with daily kick counts and routine surveillance for SFH growth
* Repeat U/S for growth/BPP if continued SFH discrepancy and/or other risk factors for exces- sive fetal growth exist (GDM, IDDM)
75
Describe Initial Management Discrepancy in symphysis-fundal height — larger than expected if on U/S: LGA (5)
* Consider obstetrics consult
* Fetal surveillance: repeat U/S for growth in 3 wk, daily kick counts
* Investigations: GDS if not already done; if normal, consider 2-h oral glucose tolerance test
* Modify controllable factors: optimize treatment of maternal disease (DM); nutrition and exercise counseling if excessive wt gain
* Timing of delivery/site of delivery depends on the clinical situation
76
Describe management: Postdates (7)
* Review current pregnancy: confirm stimated due date, confirm low-risk pregnancy (no GDM, GHTN, fetal anomalies), no CI to vaginal delivery
* Review maternal Hx: confirm no maternal disease
* Management
* Offer membrane stripping from 38 to 41 wk
* Expectant management until 41 + 0
* Daily fetal kick counts from 40 + 0
* Increase surveillance (Min NST, fluid assessment 2× /wk) at 41 wk
* Induction of labor between 41 and 42 GA
77
Describe management: ↓ Fetal movements (3)
* Review current pregnancy: medications, drug use, S/S abruption
* Review maternal Hx: diseases that increase risk of fetal compromise (HTN, DM, etc.)
* Fetal investigation: educate re: kick counts, NST ± BPP
78
Describe: Assessing Amniotic fluid volume (2)
* AFI—measurement and summation of deepest pocket in four quadrants
* Verication of 2 × 2 cm pocket—U/S survey to verify presence of \> 1 to 2 × 2 cm pocket
79
Amniotic fluid is composed of what? (4)
* proteins
* carbohydrates
* electrolytes
* fetal skin cells
80
• Amniotic fluid is essential for proper fetal development as it functions for what? (4)
* Cushion the fetus from external injury
* Ensure proper MSK development
* Develop the fetal lungs and GI system
* Maintain a constant temperature
81
Describe volume of Amniotic fluid at:
* 1 wk GA
* 34-36 wk Ga
* ~250 mL at 1 wk GA
* ~800 mL at 34–36 wk GA
82
Describe Physiology of amniotic fluid regulation. (Figure)
83
Describe: Postdates Pregnancy (1)
* Pregnancy \> 42 wk GA
84
Name etiologies: Postdates Pregnancy (3)
* Idiopathic (majority)
* Anencephaly (rare)
* serious birth defect in which a baby is born without parts of the brain and skull. It is a type of neural tube defect (NTD)
* Placental sulfatase deficiency (rare)
85
Postdates Pregnancy are at risk of what? (9)
At ↑ Risk for
* Macrosomia
* Postmaturity syndrome
* Oligohydramnios
* Meconium aspiration
* Asphyxia
* Intrauterine infection
* Placental insufciency
* Fetal distress
* Dystocia
86
What's it called when amniotic fluid is too low? (1)
oligohydramnios
87
What's it called when amniotic fluid is too high? (1)
polyhydramnios
88
Describe: Oligohydraminos (3)
* AFI \<5th percentile for GA or \<5 cm at term
* R/O PROM
* AF usually decreases after 35 wks
89
Describe: Pathophysiology of amniotic fluid regulation—oligohydramnios (Figure)
90
How to dx oligohydramnios (4)
1. Quantify AFV through U/S
2. Sterile speculum exam to R/O PROM
3. Fetal surveillance to identify IUGR or congenital anomalies (esp. renal/GU)
4. Idiopathic most common
91
Describe management oligohydramnios (4)
* Consult Obstetrics
* Stop medications such as NSAID, Angiotensin-converting enzyme (ACE) inhibitors
* Transient: maternal hydration
* Frequent fetal surveillance
92
Name Indications for induction of labor for oligohydramnios (3)
\*\*Depends on clinicalsituation:
* 1. PPROM and \>34 wks GA
* 2. Idiopathic and \>37–38 wks GA
* 3. Non reassuring fetal testing
93
Describe: Polyhydraminos (3)
* \> 2,000 mL AF at any GA
* \> 95th percentile for GA
* AFI \>25 cm at term
94
Describe Pathophysiology of amniotic fluid regulation—polyhydramnios. (Figure)
95
Name most common etiologies: Polyhydramnios (2)
* Maternal DM—Preexisting and gestational
* Idiopathic
96
Describe DX: Polyhydramnios (6)
* Quantify AFV through U/S
* U/S to identify multiple fetuses, fetal abnormality, fetal anemia
* GDM screening – 50 g
* GDS if not done, or 2h OGT (75g) if normal 50 g test
* ± therapeutic amniocentesis
* Idiopathic most common
97
Name Indications for Increased Fetal Surveillance in Pregnancy: Fetal Kick Counting (4)
* Women with low-risk pregnancies: reinforce the importance of fetal movement in the late 2nd and 3rd trimester of pregnancy. In the event of decreased fetal movement, women should be instructed to do fetal kick counts.
* Women with high-risk pregnancies: encourage daily kick counts and also PRN when they note decreased fetal movements.
* Any women **noting less than 6 movements in 2h** should be instructed to contact their care giver or hospital immediately for further testing.
* Women presenting with concerns of decreased fetal movements should have a maternal and fetal assessment including a NST ± BPP.
98
Name Indications for Increased Fetal Surveillance in Pregnancy: NST (6)
* Should be classified as normal, atypical or abnormal
* **Indication: decreased fetal movement**
* Normal NST and no risk factors for oligo/IUGR= continue with kick counting
* Normal NST and risk factors or suspected oligo/IUGR = BPP within 24h
* Atypical or abnormal NST = urgent assessment with U/S
* **Indication: pregnancies at high risk of adverse perinatal outcome**
* If maternal and fetal status is stable, anormal NST generally indicates favorable outcome for 1 wk.
* In Insulin-dependent diabetes mellitus or GDM, or postdates pregnancy, **frequency of NST is recommended 2×/wk**.
99
Name Indications for Increased Fetal Surveillance in Pregnancy: Biophysical Profile (BPP) Test (5)
Indication : pregnancy at risk of adverse perinatal outcome
* To be done where expertise is available
* Abnormal results should be communicated to the responsible physician immediately.
* 8/10 to 10/10 with normal fluid, 8/8 with no NST= intervention for obstetric/maternal factors
* 6/10 or 8/10 with low fluid = consult obstetrician
* 0/10 to 4/10 = immediate delivery required—consult obstetrician
100
Name components and criteria of BPP (4)
* Movement: ≥ 3 limb or body movements
* Tone: ≥ 1 flex/ext of limb or opening/closing hand
* Breathign: ≥ 30 sec
* Amniotic Fluid: Minof2× 2cmpocketofcord/limb-freefluid
101
Name RiskFactorsfor Development of Gestational HTN (9)
* Nulliparity
* First pregnancy with new partner
* Personal or FHx of HTN
* Extremes of age
* Multiple gestation
* Obesity
* Prev.Hx of GHTN/preeclampsia
* Medical disease (renal,DM,SLE, thrombophilia)
* Abnormal pregnancy (molar/partial mole)
102
Differentiate chronic and gestational Elevated Blood Pressure (2)
* chronic (Dx preceding pregnancy or diagnosed at GA \< 20 wk)
* gestational (Dx at GA ≥ 20 wk)
103
Define: Elevated Blood Pressure in Pregnancy (4)
* **HTN**: systolic pressure **\> 140** mmHg or diastolic pressure **\> 90 mmHg** on two occasions
* **Severe HTN**: systolic pressure **≥ 160 mm Hg ± diastolic pressure ≥ 110 mm Hg**
* **Proteinuria—\> 300 mg/d protein on 24-h urine collection or \> 30 mg/mmol random spot urinary protein/creatinine ratio**
* Severe preeclampsia—preeclampsia associated with any severe complication (warrants delivery at any GA)
104
Describe: Diagnosis of elevated blood pressure in pregnancy (Figure)
105
Name Adverse conditions Adverse Conditions (Increased risk of Severe Complications) of HTA (11)
* Headache/visual sx
* N/V
* RUQ/epigastric pain
* ↑ liver enzymes
* chest pain
* hypoxia
* increased WBC/INR/PTT/SCr
* abnormal FHR
* IUGR
* oligohydramnios
* absent or reversed end diastolic dopplers, etc
106
Name Severe Complications (Necessitates Immediate Delivery) of HTA (10)
* Eclampsia
* stroke/TIA
* MI
* cardiorespiratory compromise
* inotrope requirement
* platelets \<50x10^9
* need for transfusion
* AKI
* new indication for dialysis
* hepatic dysfunctions, abruption, stillbirth etc
107
Name investigations
for HTN in Pregnancy: MATERNAL (4)
* Hematologic—CBC,blood film, PT/PTT, fibrinogen (if suspecting abruption)
* Liver function—ALT/AST/LDH,serum albumin
* Renal function—uric acid, CR, urinalysis, 24-h urine for protein, or spot urine/creatinine
* Imaging—consider CXR, liver U/S
108
Name investigations
for HTN in Pregnancy: FETAL (2)
* NST
* U/S for fetal growth, fluid, BPP, umbilical artery Dopplers
109
Describe target BP in pregnancy (1)
130/80 to 155/105 mm Hg if no comorbidities
110
Describe the management of HTA (4)
* **Methyldopa**—250 to 500 mg PO b.i.d. to q.i.d (2 g/d max)
* **b-Blockers**—**labetalol** first line: 100 to 400 mg b.i.d./t.i.d. (1,200 mg/d max)
Note: can also be given IV for emergencies (20 mg IV q30min to max 300 mg IV)
* **Nifedipine XL**—20 to 60 mg daily (120 mg/d max)
* **Hydralazine**—for emergencies only—give 5 mg IV rpt q30min (max 20 mg IV
111
Describe indication of hospitalization of HTA (2)
* For BP \> 160/110 mm Hg, or any adverse features
* Requires obstetrical consult
112
Describe Outpatient management of HTA (2)
* Increased surveillance required (weekly clinic visits, daily BP, weekly investiga- tions including blood work and U/S for fluid, fetal well-being)
* Consider OB consult
113
Describe Timing of delivery in HTA (3)
* **induction of labour at ≥ 37 wk** for pts with preeclampsia or GHTN
* Requires OB consult
* Pts with severe preeclampsia may require earlier delivery—requires OB consult
114
Poorly controlled blood glucose levels during pregnancy are associated with an ↑ risk of what? (6)
* polyhydramnios
* fetal macrosomia
* preeclampsia
* operative delivery
* birth trauma
* neonatal hypoglycemia.
115
Describe Classification of Diabetes in Pregnancy (2)
* Preexisting diabetes (type 1 or 2)
* GDM (onset of DM during pregnancy)
* GDM is usually diagnosed in the late gestation (i.e., T2 pregnancy).
* f diagnosed before 24 wk, GA is likely undiagnosed type 2 DM. (Consider ordering an HbA1c; if elevated, more likely undiagnosed type 2 DM.)
116
Describe DX and management: Diabetes in Pregnancy (4)
* Dx relies on plasma glucose levels following an oral glucose tolerance test.
* Complications of GDM can be separated into maternal and fetal categories,
* Note that some provinces may use different screening and Dx parameters.
* Be familiar with the local method of GDM screening and Dx.
117
Describe use of Angiotensin-converting enzyme inhibitors (ACEIs) in pregnancy (1)
All ACEI should be stopped immediately in pregnancy or preconception and replaced with antihypertensive known to be safe in pregnancy. Failing to do so can result in complications.
118
Failing to stop Angiotensin-converting enzyme inhibitors (ACEIs) use in pregnancy can result in what? (7)
* Craniummalformation
* Renal failure
* Renal agenesis
* Oligohydramnios
* Fetal contractures
* Intrauterine growth restriction
* Intrauterine fetal demise (IUFD)
119
Name risk factors of GDM (10)
* Prev. Hx of GDM or glucose intolerance
* FHx of diabetes
* Prev. macrosomia (\>4,000g)
* Prev. unexplained still birth
* Prev.neonatal hypoglycemia, hypocalcemia, or hyperbilirubinemia
* Advanced maternal age
* Obesity
* Repeated glycosuria in pregnancy
* Polyhydramnios
* Suspected macrosomia
120
Describe screening of GDM
121
Describe the management of GDM (4)
* Strict glycemic control
* Diet control, exercise → maintenance of healthy, consistent activity level as long as no contraindications
* Insulin therapy → initiate if blood glucose not well controlled on lifestyle modification alone
* Fetal surveillance:
* FM counts (6 movements in 2 hours)
* U/S to asses fetal growth/size at 36–39 wk
* If on insulin → twice weekly NST and BPP from 32 wk until delivery
* Delivery:
* Recommend delivery by 41 weeks to all GDM, and by 39 weeks to IDGDM
* If EFW \>4.5 kg → C/S recommended
* Postpartum (R/O persistent DM):
* Follow up fasting plasma glucose + 2 h 75 g oral glucose tolerance test at 6–12 wk postpartum (for mothers with postdelivery fasting glucose \> 7 mmol)
122
Name MATERNAL Complications due to DM in pregnancy (14)
* Obstetric:
* Preeclampsia
* ↑ Risk of C/S
* ↑ Risk of birth trauma
* ↑ Risk of operative delivery
* ↑ Risk of spontaneous abortion (in preexisting DM only)
* Polyhydramnios
* ↑ Risk of PTL (associated with polyhydramnios)
* ↑ Risk of infection (asymptomatic bacteria, pyelonephritis, vulvovaginitis, respiratory infections)
* Metabolic
* Diabetic ketoacidosis (DKA) (only in preexisting DM)
* Severe hemorrhage
* Worsening microvascular disease: (only in preexisting DM)
* Coronary Artery Disease, Retinopathy, HTN, Nephropathy, Neuropathy, Retinopathy
* Postpartum
* ↑ Risk infection
* Long-term maternal risks
* Recurrence of GDM in future pregnancies
* Development of T2DM in women with GDM in pregnancy
123
Name FETAL Complications due to DM in pregnancy (13)
* Growth:
* Macrosomia
* IUGR (preexisting DM only)
* Intrauterine Fetal Demise (IUFD)
* Risk of structural malformations (only for preexisting DM with elevated HbA1c at conception):
* Congenital heart defects
* NTD
* Skeletal defects
* Neonatal sequelae:
* Respiratory Distress Syndrome (RDS)
* Hypoglycemia
* Hyperbilirubinemia/jaundice
* Hypocalcemia
* Polycythemia
* Long-term infant risks:
* Risk of obesity
* ↑ Risk of T2DM
124
Describe: PROM (3)
* PROM is the spontaneous rupture of the amnion and chorion before the onset of labor.
* ROM before labor at any GA
* PROM occurs in approximately 10% of all pregnancies and is responsible for ap- proximately 30% of all preterm deliveries.
125
Describe: Latency period (1)
time between ROM and onset of labor.
126
# Define:
* Prolonged PROM
* Preterm ROM
* Preterm PROM (PPROM)
* Prolonged PROM: \> 24 h between ROM and labor onset
* Preterm ROM: ROM before 37 wk GA
* Preterm PROM (PPROM): ROM before 37 wk GA and before onset of labor
127
Name MATERNAL PROM (6)
* Infection (UTI, STI, cervicitis, vaginitis, intrauterine)
* Prev. Hx of PTL or PPROM
* Cervical insufficiency or Hx of cervical surgery
* Trauma
* Smoking
* Low socioeconomic status, poor nutrition
128
Name FETAL PROM (2)
* Multiple gestations
* Polyhydramnios
129
Name PREGNANCY PROM (3)
* Amniocentesis
* Chronic abruption, Antepartum Hemorrhage (APH)
* Cerclage in current pregnancy
130
Confirmation of rupture of membranes should be performed with what? (1)
with a sterile speculum exam.
131
Describe PROM Prognosis (2)
Spontaneous Labor within 1 wk
* Approximately 50% of women \< 26 wk GA
* Approximately 85% of women 28 to 34 wk GA
132
Name PROM complications (4)
* Chorioamnionitis
* Cord prolapse
* Premature delivery
* Limb contracture
