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N825 > Pregnancy Screening and Management > Flashcards

Pregnancy Screening and Management Flashcards

1
Q

Initial Basic Lab Studies

A
  • Type and Rh, antibody screen
  • CBC (Hgb electrophoresis for genetic Dz), rubella titer, varicella
  • RPR, HB2Ag, urine C/S & Screen, HIV
  • GC/Chlamydia, wet prep, Pap
  • Thyroid (Hypo affects neuro dev., hyper can also affect fetus)
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2
Q

Lead Levels

A
  • Any elevation is dangerous to embryo/fetus (>5)
  • Any of the following criteria, check level:
  • recent immigration from high Pb contamination
  • Living near source of Pb
  • Pica
  • Occupational exposure
  • Environmental contamination
  • Cosmetics w/lead, lead-glazed pottery
  • Herbal alternative meds
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3
Q

Prenatal Screening/Diagnosis

A
  • Looking for birth abnormalities (Down syndrome, Spina bifida, etc.)
  • Opportunity to prepare, plan for, or elect for terminate
  • Options for fetal therapy
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4
Q

Prenatal SCREENING

A
  • Screening: determines risk for specific abnormality
  • Minimal risk (usually blood or serum & US)
  • Recommended for ALL women
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5
Q

Prenatal DIAGOSTICS

A
  • Diagnostic testing: Determines if fetus has abnormality
  • Invasive, small risk of loss of pregnancy
  • Amniocentesis, CVS
  • Recommended for SOME women
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6
Q

When/whom to screen

A
  • Carrier screening should be offered to all couple when at least 1 member is Caucasian for trisomy
  • Ethnic/racial Hx
  • Woman age >35yo or Hx of DM
  • Father >50yo
  • Previous pregnancy or First-relative or close blood relative w/ Hx of abnormality
  • Hx of 2+ miscarriages
  • Teratogen exposure
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7
Q

Types of Prenatal Screening

A
  • History
  • Carrier Testing
  • Multiple marker screening
  • Ultrasound
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8
Q

Ethnic/Racial Risks for Abnormalities

A
  • Tay Sachs: Ashkenazi Jewish, French Canadien
  • SCD: African, Mediterranean, Middle East, Carribean
  • Thalassemias: Mediterranean, Asian
  • Cystic Fibrosis: Northern European Caucasian, Ashkenazi Jewish
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9
Q

Neural Tube Defects (NTD)

A
  • Spina Bifida
  • Anencephaly
  • Cephalocele
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10
Q

NTD Risk Factors

A
  • Folate deficiency
  • Folate interfering meds (valproid acid)
  • Insulin dependent DM
  • UK decent
  • U.S. born hispanic women
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11
Q

NTD Initial Screening

A
  • Maternal AFP Level
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12
Q

AFP

A
  • Pattern:
  • Fetal AFP rises until 13wk
  • Maternal AFP rises after 12wk
  • Exposed fetal tissue let AFP leak into amniotic fluid
  • Maternal AFP is then abnormally high
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13
Q

Factors that influence AFP

A
  • Maternal weight
  • gestational age
  • Race/Ethinicity (AA have 10% higher AFP)
  • DM
  • Multiple gestation
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14
Q

When to draw AFP

A
  • Draw at 15-20wk
  • Adjust for: maternal age, wt, ethnicity, gestational age, & IDDM
  • If elevated: US to r/o twins, gestational age, etc.
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15
Q

** Causes of Elevated AFP **

A
  • Underestimated gestational age
  • Multiple gestation
  • Fetal death
  • NTD, Gastroschisis, omphacele
  • Low maternal wt.
  • Pilonidal or other fetal cyst
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16
Q

** Causes of low AFP **

A
  • Overestimated GA
  • Gestational trophoblastic Dz (Choriocarcinoma)
  • Fetal death
  • Trisomies
  • Obesity
  • DM
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17
Q

What to do if AFP is abnormal

A
  • Genetic counseling
  • Specialized sonography
  • Amniocentesis
  • Unexplained maternal AFP
  • MOST women with abnormal AFP have NL babies
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18
Q

Signs of Abnormalities

A
  • Banana spine: spina bifida

- Sandal toe: Down syndrome

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19
Q

Trisomy Facts

A
  • Risk increases at age 35 (higher risk %, more babies born w/DS <35yo)
  • AFP low in trisomy 21 (DS) pregnancy
  • All women seen before 20wk should be offered screening
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20
Q

Trisomy Incidence

A
  • DS is most common chromosomal abnormality
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21
Q

Ways to Screen

A
  • Most screening test have false positive rate of 5%
  • Addition of other serum marker tests in 2nd trimester increases accuracy up to 80% (for quad)
  • Serum markers + nuchal translucency (NT) can give good results at 11-14wk
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22
Q

Triple Screen Findings for DS

A
  • Low MSAFP + high HCG + low estriol
  • detection ~55-75%
  • > 35yo -> detection ~85%
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23
Q

Quad Screen Findings for DS

A
  • Triple screen + high inhibin-A

- Done b/n 15-22wk (best 16-18wk)

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24
Q

1st Trimester Screening (FTS)

A
  • NT + B-HCG + PAPP-A (pregnancy associated plam protein A)
  • Performed at 10.3-13.6wk
  • B-Hcg higher and PAPP-A lower in DS
  • Offered only if: sonogram tech who is qualified, lab can do testing, resources to provide counselling, access to CVS if test is positive
  • Advantages: high detection rates, reassuring, gives time for decision making, decreased rates of induction for post-term pregnancy
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25
Combined FTS and STS = Integrated screen
- Screening performed at different times with pt given single result only after all tests are done - 10-13wk: NT + PAPP-A - 15-18wk: MSAFP + Estriol + inhibin A - Advantage: Sn 94% - Disadvantage: Lack early Dx, physical/emotional results, increased costs
26
US markers for trisomy
- 1st Tri: Increased nuchal translucency (most reliable marker) - 2nd Tri: Nuchal fold - Other soft markers: absent nasal bone, echogenic bowel, shortened long bones
27
Options for high risk women
- FTS at 10-13wk: CVS earliest at 11wk, amnio 14wk, may choose termination 13-15wk - STS at 15-18wk: amnio, termination
28
Sequential Screening
- Integrated screening w/results provided after each test - Step-Wise Sequential: FTS, if (-) then STS - Contingent: FTS, if (-) no STS
29
Management of screening results
- Negative Test: Does not exclude possibility of DS, Actual risk report given to pt, no further DS testing recommended - Positive Test: Actual risk report given to pt; refer to genetic counseling; offer fetal karyotyping (CVS, Amnio)
30
Chorionic Villi Sampling
- Obtained from placenta - Transabdominal or transvaginal - done at 10-13wk - Contraindicated in Rh antibodies - Risk: Fetal loss, infection, bleeding
31
Amniocentesis
- Genetic wellbeing - Fetal lung maturity (later in pregnancy) - 14-16wk for NT or genetics - Risk: PROM, Infection, bleeding, PTL, Fetal loss
32
Dates of Prenatal Screening
- LMP and Date of Concepton (2wk) - 3-12wk: US to detect/confirm pregnancy - 10-13wk: CVS, FTS - 12-26wk: US to Dx abnormal - 12.5-15wk: Early amnio - 15+wk: amnio, fetal Dx, Assess - 15-20wk: STS (Mother's multiple markers) - 16+wk: cordocentesis (PUBS)
33
Changes in levels of HCG, PAPP-A
- mother smoker: low PAPP-A - Multiple Gest: high PAPP-A and HCG - Increased HCG and PAPP in trisomy defects
34
Ultrasound facts
- Abdominal or transvaginal - Discerns fluid, tissue, bone, fetal activity and vessels - ALARA Principle: As Low As Reasonably Achievable; Keepsake imaging not encouraged - Types of US: Standard, specialized, limited
35
1st Trimester US Sights
- Gestational/Yolk sac or embryo - C-R Length - Cardiac activity - Fetal number - Assess embryo/fetal anomaly - Evaluate uterus adnexa - Assess fetal neck - In 1st Tri, US is more reliable for EGA than LMP - Transvag: fetal heart, gestational age, r/o ectopic/molar pregnancy, measure cervical length, nuchal translucency
36
2nd Trimester US Sights
- Placements and grade of placenta - Fetal/uterine anomalies - Adjunct to procedures (amnio, fetoscopy) - Sex ID - Eval 2nd/3rd Tri bleeding - Amniotic fluid volume - Evaluate fetal growth - Presentation - R/O fetal demise
37
NOB Visit Screening (6-8wk)
- Risk profiles - Labs - BP - Ht/Wt/BMI - H&P - IPV, Depression Screens - Tx: Tdap, Nutritional supp, Flu Vacc, Varicella, VZIG, Pertussis
38
NOB Visit Counseling
- Preterm labor ED and Prevention - Prenatal and Lifestyle ED - Physical activity - Nutrition - F/U Modifiable risks - N/V - Warning signs - Course of care - physiology of preg - Prenatal Screening
39
Visit 2 Screening/Counseling (10-12wk)
- Weight, BP - Fetal aneuploidy - FHT - Counseling same as NOB Visit
40
Visit 3 Screening/Counseling (16-18wk)
- Weight, BP - Depression - Fetal aneuploidy screen - FHT - OB US - Fundal height - Counseling: Same + 2nd trimester growth & Quickening
41
Visit 4 Screening/Counseling (~22wk)
- Weight, BP - FHT - Fundal height - Counseling: Same + Classes, family issues, gestational DM, RhoGam
42
Visit 5 Screening/Counseling (~28wk)
- Preterm labor risks - weight, BP - Depression - FHT/Fundal height - GDM (Glucola test) - Rh Antibody status - HAVag, GC/Chlamydia - Conseling: Same + Preregistration, fetal growth, and fetal movement awareness
43
Visit 6 Screening/Counseling (~32wk)
- Start discussing travel, sexuality, contraception, pediatric care, L&D issues, birth plan, Warning signs PIH, VBAC
44
Visit 7 Screening/Counseling (36wk)
- Cervical exam - Confirm fetal position - Group B strep - When to call provider - PPD
45
Visit 8-11 Screening Counseling (38-41wk)
- Cervical exam - Postpartum vaccinations - Infant CPR - Post-term mgmt.
46
Nutritional Requirements in Pregnancy
- 300-340 kcal/d 2nd tri - 450 kcal/d 3rd tri - Protein: 75g/d - MV: Controversial - Fe: 30-60 mg/d - Folate: 400-800 mcg/d - Iodized salts - B12 supp if vegetarian
47
***Lowest Perimortal Mortality: Average wt gain
- Normal: 25-35 lbs (1lb/wk) - Underweight: 28-40 lbs (~1lb/wk) - Overweight: 15-25 lbs (~0.6lbs/wk) - Obese: 15-25lbs (0.5lbs/wk) - Morbidly obese: 0
48
***Pattern of Weight Gain During Pregnancy
- Usually 3-6 or 8lbs during 1st Tri - 1/2 - 1lb/wk (o.4kg) for rest of pregnancy - Higher gains (0.5kg/wk) - Underweight - Lower Gains (0.3kg/wk) - Overweight - If she has not gained 10lbs by midpregnancy, look into this - NO WEIGHT LOSS DURING PREGNANCY (Causes ketosis)
49
***Locations of pregnancy weight gain
- Fetus: 7.5lbs - Placenta and amniotic fluid: 3lbs - Blood volume: 3-4lbs - Breasts: 1-2lbs - Maternal fat: 4-6lbs - Uterus: 2lbs
50
Nutritional Advice During Pregnancy
- Eat what you want - Use salt to taste - Monitor weight gain - Periodically explore diet recall - Fe tabs with 27mg elemental Fe - Folate before and during early pregnancy - Check Hct at 28-32wk
51
GI Discomforts
- Progesterone: smooth muscle, decrease in GI motility, decreased acid production - Peptic ulcer rare - Mechanical displacement
52
N/V during pregnancy
- N/V (2/3rds have it again) * Interventions - Conservative: Avoid triggers; small, frequent meals; keep food in stomach at all times; get out of bed slowly; eat crackers before arising; small protein rich meals - If conservative fails: * 1st line: VB6 (pyridoxine) 25mg TID * 1st line: VB6 10-20mg + doxylamine 12.5mg qhs - Refractory: Might consider Zofran 4-8mg q8hr
53
Other GI discomforts
- Ptyalism: excessive salivation; associated with severe N/V | - Pica: Ingestion of substances that have no nutritional value
54
Dental changes during pregnancy
- Gum hypertrophy/bleeding - Interdental papillae may develop - NL procedures can be done at any time w/ local - Perform lengthy procedures after 1st Tri - Periodontal Dz associated w/preterm labor
55
Heartburn in pregnancy
- Relaxation of esophageal sphincter - Overeating contributes to discomfort - Eat smaller meals - Avoid eating before lying down - Antacids (liquid form better) (***NO phos) - H2 blockers in subset of patients
56
Constipation in pregnancy
- R/T decreased transit time; harder stools - Increase bulk w/fruits, veggies, and H2O - Stool softener if taking Fe - Metamucil or Colace
57
Hemorrhoids in Pregnancy
- Prevent constipation | - Sitz baths; ice or ointments
58
Itching in pregnancy
- Usually >32wks - If not due to liver Dz: ASA 600mg, but do not use after 32wks (bleeding, premature closure of ductus arteriosus, decrease in amniotic fluid) - Chlorpheniramine 4mg TID
59
Stretch Marks
- in 50% women - Massage with trofolastin cream q day - Verum oint. - No Tx once they occur
60
Sciatica in pregnancy
- True sciatica rare in pregnancy (<1%)
61
Low Back pain in pregnancy
- Increases with pregnancy - Body mechanics, squat when bending - Back support - Avoid high heels
62
Back pain Tx in Pregnancy
- water aerobics starting at 19wk - shaped pillows when lying on side - PT and acupuncture <32wk may be helpful - May try heat and back rub
63
***Round ligament pain
- Caused by stretching of round ligaments - NL changes - May awaken in night - Do not confuse w/contractions; appendicitis (RLQ pain); ovarian torsion - Belly support band helps
64
Leg Cramps in pregnancy
- Mg chewable tabs: 122mg in AM and 244mg in PM x 3wk | - Ca supplements do NOT help leg cramps
65
Restless leg syndrome in pregnancy
- usually in 2nd half - tingling in legs - May be associated IDA - Avoid caffeine later in day
66
Varicosities and leg edema in pregnancy
- No studies show efficacy of: leg elevation, compression hose, and swimming
67
Carpal tunnel syndrome in pregnancy
- Extra body fluid exacerbates - ~20-50% - Supportive Tx (nighttime splint) - Severe case: steroid injections
68
Other Common Complaints in Pregnancy
- Vaginitis - HA - Faintness/ light headedness - breast tenderness - N/V (Usually clears by 12wk) - Constipation - Varicose veins/hemorrhoids/leg edema - Lordosis - Leg cramps
69
Exercise in pregnancy
- Safe during uncomplicated pregnancy | - Sexual activity is associated w/better pregnancy outcomes
70
Things to avoid in pregnancy (No EBR)
- No sudden, exaggerated movements - Avoid exercise that stretches adductor muscles of the legs or exaggerate ML spinal curve - Avoid undue physical stress/exercise in hot/humid weather or when feeling bad - Activities w/high risk of ABD trauma (X-Country is OK)
71
Do NOT exercise and contact provider if:
- pain/bleeding - dizziness that doesn't resolve quickly - SOB, palpitations, faintness - Tachycardia - Back pain, pelvic pain or pressure, chest pain - Muscle weakness - Nausea
72
Immunizations prior to pregnancy
- All childhood immunizations - MMR: 3mo before or immediately postpartum - Tdap q 10yrs (boost after 2yr if puncture wound/bite) - Rubella titer: cannot immunize if negative
73
Immunizations in pregnancy
- Killed virus, toxoid, or recombinant OK - DT toxoid OK - HepB OK if at risk - Polio OK if at risk - Flu SHOT recommended - Give immune globulin if exposed to measles, HBV, HAV, chicken pox, or rabies
74
Workplace hazards
- Can affect women and fetus before, during, and after conception * Biologic agents * Primary HSV infection * Chemicals and other substances (Lead and mercury; 1st Tri)
75
Can work until delivery if:
- uncomplicated pregnancy | - Job has no hazards greater than those of normal community life
76
Pregnancy-related work modifications
- Do not work more than 8hr/day; 48hr/wk - 2 x10min breaks q 8hr shifts - Place to rest and use restroom - Short time to sit or walk q 2hr - If strenuous job, stop/reduce work 2-4wk prior to due date - Limit lifting to 10-15lbs and use proper technique
77
***Leopold's Maneuver
- 1st Maneuver: Determine which pole is in fundus - 2nd Maneuver: Palpate lateral aspects of utuerus to determine which side or small parts - 3rd Maneuver: Check engagement; presenting part moved side to side - 4th maneuver: With fetus vertex, cephalic prominence felt on side of small parts
78
Fetal NST
- Fetal monitor - 32-34wk - Daily or weekly - Reactive: 2+ of FHR accelerations of 15bpm for 15+sec in 20min period - Nonreactive: No such accelerations over 40min
79
Fetal Kick Counts
- Decrease in movement precedes fetal demise - Lie on side and count movements - 10 movements in up to 2hr: reassuring - <10 in 2hr: non-reassuring - No EBR
80
Vibroacoustic simulations
- Sound on abdomen to produce response
81
Oxytocin challenge test
- IV oxytocin until 3 contractions in 10min - Positive: late decelerations - Equivocal suspicious: intermittent late decelerations - Unsatisfactory: contractions fewer than 3 in 10min or tracing uninterpretable
82
Biophysical profile
- 2 points for: * Fetal movement * Fetal tone * Fetal breathing * Amniotic fluid volume * NST
83
Modified BPP
- NST | - Amniotic fluid index
84
Danger signs in pregnancy
- Preterm labor contractions >4x/hr - Change in vaginal secretions - Vaginal bleeding - Fluid from vagina - S/S Illness (Dysuria, urgency, frequency) - S/S Eclampsia ( HA unrelieved by APAP, visual disturbances, epigastric/RUQ pain, new or sudden swelling in extrmities, rapid weight gain
85
Assess for fetal maturity
- No elective delivery 2:1 at 35wk | * Phosphatidylglycerol (PG): appears at 35wk when lungs are mature
86
CV changes in pregnancy
- 30-50% increase in CO - HR increases 15-20bpm - Systolic ejection murmur and S3 gallop common - PVR decreases - BP decreases in 2nd Tri and returns to NL in 3rd Tri (~10/10-15mmHg)
87
Lung capacity in pregnancy
- Decreased functional residual capacity - Increased inspiratory capacity - Compensated respiratory alkalosis
88
Vaginal Birth After Caesarian (VBAC)
- Low transverse uterine incision - Risk: for baby is same as c-sect; for mother risk is lower - CI: High vertical scar; Hx of dehiscence; failure to progress; bordeline pelvi - Increased risk: short interval b/n pregnancies; induction; single layer repair; If 2 prior C-sects, need Hx of prior VagDeliv.

N825 (16 decks)

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