Pregnancy & prenatal care Flashcards
Beta-hCG levels in each trimester
Peak 100,000 at 10 weeks. Decreases during 2nd tri. Levels off at 20-30,000 in 3rd tri.
Gestational sac present when?
5 weeks
Morning sickness
N&v 12-16 weeks
Fetal heart when? At what bhCG?
6 weeks, bHCG of 5-6,000
Embryo
Up to 8 weeks
Fetus
8 weeks (10 weeks gestational age) or later
GA vs. DA
GA = days from LMP DA = days from conception. Usually 2 weeks less than GA.
Infant
Delivery to 1 year
Trimesters
1st = up to 12 -14weeksGA 2nd= from 12-14 weeks to 24-28 weeks 3rd = from 24-28 weeks to delivery
Term vs. preterm vs. post term
Term = 37-42
Preterm = 24-37
Post term = after 42
Previable
Before 24
G4P1123
Been pregnant 4 times, 1 term delivery, 1 preterm, 2 abortions, 3 living children (1 of the deliveries m/h/b twins)
Gravidity
times been pg
Parity
times having delivered beyond 20 weeks GA, or an infant > 500g
S&s of pg’y
Chadwick sign ( blue vag & cervix) Goodall sign (softening & cyanosis of cervix at or after 4 weeks) Ladin sign (softening of uterus after 6weeks) Breast swelling & tenderness Linea Nigra dvpt from umbilicus to pubis Telangiectasias Palmar erythema Amenorrhea N&v Breast pain Quickening (fetal mvt)
Nagele rule
For calculating EDC (estimated date of confinement) or EDD
LMP - 3 mos + 7 days
EDC (# days from…)
280 days after LMP, or 266 days after date of ovulation
U/s s/n differ from LMP by how much
1 week during 1st tri, 2 weeks during 2nd tri, 3 weeks during 3rd tri
When can fetal heart tones be heard?
10 weeks by Doppler
When does quickening occurr?
16-20 weeks
How much does CO INCREASE BY?
30-50%, most during 1st tri
BP changes during pg’y
SVR drops 2/2 PGs
DBP drops more than SBP
lowest at 24 weeks, then slowly returns to pre-pg’y levels till delivery but s/n exceed them
Plum changes during pg’y
VT increases by 30-40% => ERV drops by 20%
TLC decreases by 5% 2/2 diaphragm pushed up
RR is constant but VT increases => increased minute ventilation by 30-40%
PaO2 increases. PaCO2 decreases
GI changes during pg’y
N&v 2/2 ES, PG, hCG, or hyopG
Prolonged gastric emptying times, LES relaxes => reflux
Ptyalism (increased saliva)
Prolonged transit times in large bowel => increased water absn, constipation
Renal changes during pg’y
Increased rates of pyelo 2/2 increased kidney & ureter size
GFR increases by 50% => BUN & Cr drop
Increase RAAS actvn
Heme changes during pg’y
Plasma vol increases by 50%
RBC vol drops by 20%-30%
Hct drops
WBC increases (mean 10.5). Can be really high (>20) during labor
Plts drop but if < 100 or if sudden drop, further investig needed
Elevations in coag factor levels but clotting & bleeding times don’t change
Endo changes during pg’y
Increased:
ES (placenta) - low levels correlate with fetal death
hCG (same alpha subunit as TSH, FSH, LH) - placenta produces it to maintain progesterone prodn by CL
hPL (placenta) - maternal lipolysis, IN blocker, diabetogenic effect
Elevated T3/T4
Prl increases during pg’y, drop after delivery, increase w/suckling
How do hCG levels change?
Double q48h early on. Peak at 10-12 weeks. Decline to steady state by 15 weeks.
Effects of progesterone
SMC relaxation
Nutritional requirements
Increased by 300 kcal/day during pg’y, 500 kcal/day during breast feeding
Wt gain during pg’y
20-30 lbs. obese women s/gain 15-20. Thin women 25-35.
Recommended Ca++ intake
1.5 g/d
Folate needs
Increase from 0.4 to 0.8 mg/d
When will a urine pg’y test be positive?
At time of missed menses
Need to take ________ to meet nutrient reqts.
Prenatal vitamins
First prenatal visit is sched’d when?
6-10 wks
Hx to take at initial visit
LMP Sx's of pg'y Prior pg'ies (date, outcome) Abortions Ectopic pg'ies Term deliveries Preterm Mode of delivery Length of time in labor & second stage Birth weight Complications Complete medicl, surgical, fam hx
Physical Exam at initial visit
Complete
Pap unless one has been done in past 6 mos
G & C cx
Bimanual exam to dtm uterus size
1st tri labs
Hct Blood type & screen RPR Rubella Ig HBsAg G&C cx PPD UA & cx VZV if no hx of exposure HIV offered Urine pg'y test if pt unsure if pg b-hCG if bleeding or cramping Toxo titers Nuchal translucency testing for aneuploidy
Additional testing in AfAms
Sickle cell/Hgb electrophoresis
Additional testing in women age 35 or older at time of EDC
Prenatal genetics referral
Prior gestational DM, FHx of DM, Hispanic, NAm, SE Asian
Early G loading test
Additional testing in pt w/pre gestational DM, unsure dates, recurrent miscarriages
Dating sonogram.
Additional testing in HTN, renal dis, pre gestational DM, prior preeclampsia, renal tx, SLE
24-hr urine collection for proteinuria & cr clearance
Additional testing in pre gestational DM, prior cardiac dis, HTN
ECG
Additional testing in Pre gestational DM
HbA1c Ophtho exam Dating sonogram 24-hr urine for prot & cr CL ECG
Additional testing in graves dis
TSI
Additional testing in all thyroid dis
TSH
maybe T4
Additional testing in SLE
Anti-rho
Anti-La
Labs in 2nd tri
MSAFP/triple screen
U/s
Amniocentesis in AMA pts
Labs in 3rd tri
Hct RPR GLT repeat G&C Cxr if PPD + GBS cx
What is taken at each prenatal visit
BP
Wt
Urine dipstick for prot, G, leukocyte esterase
Meast of uterus
Doppler for fetal heart tones
Ask about vag bleeding, discharge, leaking fluid, uti sxs
If uterine fundal height is what then an u/s is ordered to eval
Progressively decreasing
3 cm diff from GA In Weeks
What is asked about after 20 weeks in addition to usual?
Quickening
Ctrns
Braxton-hicks vs. PTL
b-h = irregular, occur thru third tri Ptl = regular ctrns more than 5-6 per hr
What is MSAFP & when ordered
Maternal serum alpha fetoprotein
Increased levels = increased risk of neural tube defects
Decreased levels = risk of anuepldy
Ordered 15-18 weeks
What is triple screen
MSAFP + b-hCG + estriol
Quad screen
Triple screen + inhibin a
When is screening u/s offered?
18-20 weeks
When are childbirth classes offered & why
After 12 weeks b/c risk of SAB drops after 12 weeks
What if b-h become regular
Examine cervix to eval for ptl
How often are visits during 3rd tri
Q2-3 weeks from 28-36 weeks
Weekly after 36 weeks
Who & when to give RhoGam
Rh negative moms, at 28 weeks
When to do Leopold maneuvers
32-34 weeks to dtm fetal presentation
Cervix examined at every visit when?
After 37 weeks
Who gets iron supplements & when
Hct < 32-33%
Also give stool softener
What is GLT
50-g oral G given. Check serum G 1 hr later. If > 139, do GTT.
What is GTT
Fasting serum G, then give 100g oral G.
Measure serum G at 1, 2, 3 hrs.
GDM dx:
2 or more: Fasting G > 95 1-hr G > 180 2-hr G > 155 3-hr G > 140
what to do if GBS cx is + in third tri?
IV penicillin when in labor
routine problems of pg’y:
back pain constipation contractions dehydration edema GERD hemorrhoids PICA round lig pain urinary freq varicose veins
recommedations for back pain of pg’y
mild exercise/stretching Tylenol massage heat m. relaxants or narcotics if severe
why does constipation occur during pg’y
PG’s cause decreased bowel motility (SMC relaxation) => prolonged transit time in sm bowel => more water abs’n
recommendations for constipation in pg’y
increased PO fluids
stool softeners/bulking agents (docusate, miralax)
are laxatives used during pg’y
can be, but usually avoided during 3rd tri b/c of theoretical risk of PTL
how much water should a pg pt drink?
10-14 glasses per day to prevent dehy, which can => ctr’ns
when are ctr’ns considered a sign of PTL? What to do?
when they’re regular, as often as q10min. Need to do cervical exam. If there is no cervical change, then labor is not imminent.
why does dehydration occur?
expanded intravascular space, increased 3rd-spacing
why does dehydration promote ctr’ns
ADH is rel’d, which cross-reacts w/oxytocin R’s
why does edema occur
IVC & pelvic v.’s compressed by uterus => increased hydrostatic P in lower limbs
how to treat edema
elevate lower limbs, sleep on side
severe edema of face & hands may indicate…
preeclampsia
mgt of GERD:
first try antacids, eating multiple small meals, don’t lay down w/in 1 hr of eating.
then try H2 blockers or PPIs
why do hemorrhoids occur
increased venous stasis & IVC compression + increased ab’l P w/BM’s 2/2 constip => hemorrhoids.
tx of hemorrhoids
topical anesthetics & steroids. Increase fluids, fiber. Stool softeners.
tx of round lig pain:
usually self-limited. Try tylenol or heat.
when does round lig pain occur
late 2nd or early 3rd tri, 2/2 rapid expansion of uterus & stretch of ligs
what 3 factors contrib to urinary freq:
1) increased intravasc vol
2) increased GFR
3) compression of bladder
why do varicose veins of lower limbs or vulva develop?
increased venous hydrostatic P, relaxation of venous SMC
tx of varicose veins:
elevate legs, compression stockings.
Should resolve by 6 mos post-partum. If not, refer for surgery.
how to obtain fetal karyotype & genetic screen:
amniocentesis or CVS
what is looked for on routine screening u/s (18-20 weeks)
placental location
amniotic fluid volume
gestational age
fetal malformations
biophysical profile (BPP)
obtained in 3rd tri in high-risk pg’ies. Looks at 5 categories:
1) amniotic fluid volume
2) fetal tone
3) fetal activity
4) fetal breathing mvts
5) nonstress test
what is a nonstress test
test of fetal HR. Is + if there are 2 accelerations of fetal HR in 20 ins that are at least 15 bpm above baseline for at least 15 sec.
how is a BPP scored
each of 5 categories is given a score of 0 or 2. A score of 8 or more is reassuring.
How is umbilical a. bf assessed & what does it indicate?
eval’d on u/s. If bf is decreased, reversed, or absent, it suggests placental insufficiency
Antenatal tests of fetal well-being
NST (nonstress test)
OCT (oxytocin challenge test)
BPP
what is OCT?
induce at least 3 ctr’ns in 10 mins, monitor fetal HR. Is considered + if at least 2 accelerations of fetal HR in 20 mins that are at least 15 bpm above baseline for at least 15 sec. Also + if there are late decelerations in fetal HR with at least 1/2 of ctr’ns.
when is a NST ordered?
in high-risk pg’ies at 32-34 weeks, or at 40-41 weeks in undelivered pts
what if NST ordered but is negative?
eval fetus w/u/s
when is an OCT ordered?
if there are any worrisome decelerations in fetal HR, or if BPP is not reassuring
how is fetal blood sampling obtained?
phlebotomize the umbilical cord, through uterus.
why would you need to do fetal blood sampling?
Rh isoimmunization eval of fetal anemia hydrops fetalis fetal transfusion karyotype analysis eval of fetal plts in alloimmune thrombocytopenia
how to eval fetal lung maturity?
lecithin to sphingomyelin ratio. L/S should increase as pg’y progresses.
if L/S ratio < 1.5, increased risk of resp’y distress syndrome.
