Pregnant Flashcards
Hypertension in Pregnancy
Hypertensive Moms Love Nifedipine
Hydralazine
Methyldopa
Labetalol
Nifedipine
Pregnancy Trimesters
First Trimester: 1-12 weeks
Second Trimester: 13-28 weeks
Third Trimester: 29-40 weeks
Pregnancy Signs
presumptive
Probable
Positive
Presumptive: Subjective symptoms that patients report
Probable: Hegger’s, Chadwick, Goodall and Pregnancy Tests (HCG - probable because it can be atopic)
Positive: Objective or clinical signs that patient is pregnant
- PUF: Palpation of fetus (Leopold maneuvers), ultrasound of fetus, Fetal heart tones, ultrasound confirmation
Pregnancy and Folic Acid
Folic acid - 400 mcg daily to prevent neural tube defects
Human chorionic gonadotropin (hCG)
Human chorionic gonadotropin (hCG) = PREGNANCY HORMONE = Serial β-hCG levels
‣ Negative: < 5 mlU/ml
‣ Positive: > 25 mlU/ml
◦ Hormone for maternal recognition of pregnancy
‣ Produced by trophoblast cells of embryo
‣ Thickens uterine lining to support the embryo
‣ hCG levels rise with conception and continue to rise until about 10 weeks
‣ hCG is found in urine or blood about 10 to 11 days after conception
◦ Recommended to test for pregnancy using a strip test 1 week after a missed menses
Prenatal Visits Frequency
4 to 28 weeks - once a month
28 to 36 - every 2 weeks
36 to 41 weeks - once a week
Test Momma for Gestational Diabetes
Gestation Diabetes at 24 to 28 weeks, but not after birth
Test Momma for Group B Strep
Group B Strep at 36 and 38 weeks
* IV penicillin if mom has it during labor
What does Group B Strep cause?
- inflammation of the covering of the brain or spinal cord (meningitis) - both late and early onset
- infection of the lungs (pneumonia)
- infection in the blood (sepsis)
s/s
Lack of energy
Irritability
Poor feeding
High fever
Naegele’s Rule
Date of the last menstrual period
Subtract 3 months
Add 7 days
Fundal Height
12 weeks
20 weeks
Distance in centimeters from the pubic bone to the top of the fundus used to measure fetal growth & gestational age
◦ 12 weeks: level of pubic symphysis
◦ 20 weeks: level of umbilicus
‣ Measure is started at 20 weeks & should be close to fetus’s gestational age
First Prenatal Visit tests
Chlamydia
Gonorrhea
Syphilis
HIV
Hepatitis B & C
Monitoring Fetal Movement in the Third Trimester
“Kick counts”
Count the number of fetal movements in an hour with a goal of ten movements (kicks, flutters, or rolls) in an hour or less
Fetal Movement Stimulation
◦ If less than 10 kicks an hour, patient should
‣ Eat or drink something
‣ Take a brief walk
* If two hours pass without 10 movements, seek additional evaluation from their healthcare provide
Aneuploidy Condition with an Extra or Missing Chromosome
Primary risk is advanced maternal age
Trisomy: extra chromosome
Down Syndrome: Associated with an extra copy of chromosome 21 = most common type
Trisomy 16: Leads to fetal death in the first trimester
Trisomy 18 (Edwards Syndrome): genetic disorder caused by the presence of an extra copy of chromosome 18
- Most fetuses die before or soon after birth
Tay-Sachs Disease
Genetic disorder caused by the absence of the Hexosaminidase-A (Hex-A) enzyme due to a chromosomal defect in Chromosome 15. Lack of Hex-A leads to an abnormal accumulation of GM2 gangliosides
- Defects cause progressive deterioration of the neurologic system
- Symptoms
◦ Infants generally appear normal at birth
◦ Developmental regression usually occurs by 6 months of age
◦ Fatal, typically by the age of five
Genetic Screening Indications - offer screening to pregnant couples or those considering pregnancy if
◦ Either member is of Ashkenazi Jewish, French Canadian, or Canadian descent
◦ Family history of Tay-Sachs disease
Preggers Standard Screening - Genetics
Spinal muscular atrophy
Cystic fibrosis
Additional Screening Based on Risks
◦ Hemoglobinopathies: African, Middle Eastern, and Mediterranean descent
◦ Fragile X Syndrome: Family history
◦ Tay-Sachs Disease: Ashkenazi Jewish, French Canadian descent
Placental Abruption aka Abruptio Placenta
Occurs when the placenta separates from the lining of the uterus before the second stage of labor greater than 20 weeks gestation - a lot of bleeding
Increases neonates and mother’s morbidity and mortality
Placenta Previa
Placenta covers the internal cervical os
Symptoms is painless vaginal bleeding, occurring after 20 weeks of pregnancy (most common)
Diagnosis on routine ultrasound
Risk factors - History of Patient
◦ History of placenta previa with a prior pregnancy
◦ History of cesarean section
◦ History of multiple gestations
Management is routine monitoring with ultrasound to assess for changing placental positions
◦ Close monitoring for vaginal bleeding
◦ Possible pelvic rest (avoid sex and vigorous exercise)
◦ Possible cesarean section delivery
Placental Abruption
Medical Emergency
placenta separates from uterus after 20 weeks gestation (most common occurrence is 27-40 weeks)
Risk Factors:
- HTN
- physical uterine abnormalities
- genetics
- cocaine
- history smoking
- history of placental abruption with other pregnancies
S/S:
- abrupt vaginal bleeding
- abdominal pain
- hard stomach
- uterine contractions
- uterine tenderness
- non reassuring fetal heart rate
Tx (ED transfer)
- fetal heart rate monitoring
- maternal hemodynamics monitoring
- lab monitoring
- disseminated intravascular coagulation
- IV blood products
Chadwick Sign = early sign of pregnancy
presumptive
Bluish discoloration of the cervix
- Usually presents 6 to 8 weeks after conception
- Disappears after birth
Goodell Sign = sign of pregnancy
presumptive
Softening of the cervix from increased vascularization with hypertrophy and engorgement of vessels
- Occurs around 6 to 8 weeks after conception
Hegar Sign = sign of pregnancy
presumptive
Softening of the lower uterine segment
- Typically presents 4 to 6 weeks after conception
- Absence does not exclude pregnancy
Preeclampsia Diagnosis
Hypertension
- Elevated systolic blood pressure > 140 mmHg or diastolic > 90 mmHg on two occasions separated by 4 hours in patient without previous history of hypertension
- Elevated systolic blood pressure > 160 mmHg or diastolic > 110 mmHg
Proteinuria:
- > 300 mg in 24-hour collection
- Dipstick 2+
If proteinuria is absent, the presence of any additional features in addition to hypertension
- Thrombocytopenia
- Renal insufficiency without previous renal disease
- Pulmonary edema
- New onset headaches unresponsive to treatment
- Impaired liver function
- Liver transaminases > 2x upper limit of normal
Complication of untreated gestational diabetes and hyperglycemia
Preeclampsia
Preeclampsia
Tx
Only cure for preeclampsia-eclampsia is delivering the baby and placenta
- pelvic rest for patients over 20 weeks pregnant
- May schedule cesarean section after 37 weeks
- In addition to delivery, intrapartum management includes the management of hypertension and the prevention of seizures
Vaccines During Pregnancy
Seasonal flu vaccine
1. Inactivated vaccine administered intramuscularly during flu season, but bive attenuated intranasal vaccine is contraindicated
2. Tdap vaccine (Tetanus, Diphtheria, Pertussis) is recommended between 27 and 36 weeks of pregnancy, regardless of when she got it (otherwise it is every 10 years) because it protects the baby from pertussis or whooping cough
Safety and Benefits:
- Both vaccines contain inactivated forms of the virus
- Poses no risk of contracting the illness
- Maternal antibodies developed during pregnancy cross the placenta
- Provides immunity to the fetus for several months after delivery
Vaccines to Avoid in Pregnancy
◦ Live Attenuated Vaccines
‣ Contain a weakened version of the virus and carry the risk of infection
* MMR (measles, mumps, rubella)
* Varicella
* Intranasal flu vaccine
Mastitis
What is it?
Tx
Common complication with breastfeeding that occurs when skin tissues allow bacteria to enter breast tissue causing local infection
Tx
First Line: Dicloxacillin 500 mg PO for 7 days
Second Line: cephalexin 500 mg PO four times per day for 10-14 days
If allergic (angioedema, anaphylactic) to penicillin, clindamycin (Cleosin) or erythromycin (Erydem) are appropriate alternatives. Cephalosporin cannot be prescribed when it’s an anaphylactic reaction.
Continue to breastfeed or express milk every 2-3 hours or stasis can increase the risk of recurrence
RhoGAM
Who gets it
When administered
RhoGAM negative mom with RhoGAM positive baby
give shot to mom at 28 weeks gestation
give shot to mom at 72 hours post delivery
Threatened Spontaneous Abortion
vs.
Spontaneous Abortion
Threatened Spontaneous Abortion
vaginal bleeding where cervical os remains closed
- cramping may occur, but most can carry the baby to full term
Spontaneous Abortion
- pregnancy loss up to 20 weeks gestation
- placenta and fetus are spontaneously expelled
Folic Acid in Pregnancy - high risk
High dose supplementation of 4,000 mg is recommended for patients with prior children with neural tube defects (spina bifida) one to three months prior to conception
Folic acid of 400-800 mg is for all women of child bearing age
Preeclampsia
severe s/s
Clonus - involuntary muscle contraction of hands, ankle, jaw and proteinuria
Ectopic Pregnancy
pregnancy occurring anywhere outside of uterus - fallopian tubes, ovary, cervix, abdominal cavity
- risk of rupture is greatest in fallopian tubes
- Administer methotrexate that stops the embryo’s cells from growing and dividing that ends pregnancy
Live vaccinations - pregnancy planning
Avoid getting pregnant for one month after obtaining live vaccines: MMR, varicella
UTI in pregnancy
Tx
E. coli
- cephalexin (Keflex)
- nitrofurantoin (Macrobid) AVOID first and third trimester
- sulamethoxazole-trimethoprim (Bactrim) AVOID first and third trimester
Antibiotics in Pregnancy
- penicillins are safe during pregnancy and lactation
- amoxicillin is preferred - if allergy but not anaphylaxis, cephalosporins (-CEFs) can be prescribed: cefazolin and cephalexin; cefuroxime and cefoxitin; ceftriaxone and ceftazidime; cefepime
- macrolides are safe for pregnancy
Azithromycin, clarithromycin, and erythromycin
AVOID: Fluoroquinolones like ciprofloxacin
Gestational Diabetes
Tx
- lifestyle modification
- insulin
- metformin and glyuride (Diabeta) are second line treatments but not FDA approved
* no glipizide (Glucotrol) associated with neonatal hypoglycemia
Mammograms
Women between 40 and 44 have the option to start screening with a mammogram every year
Women 45 to 54 should get mammograms every year.
Women 55 and older can switch to a mammogram every other year, or they can choose to continue yearly mammograms.
Enoxaparin injections
stop them 18-24 hours prior to receiving spinal or epidural anesthesia to reduce spinal hematoma
Pregnant and Positive for group B streptococcus (GBS)
test for this between 36 and 37 weeks gestation
If positive:
IV penicillin G or ampicillin, if allergy to penicillin
IV clindamycin can be administered to safely deliver vaginally
HPV tests are more sensitive and specific, reliable than pap smears
American cancer society recommends HPV testing over Pap smear, although Pap smear are responsible for drastic decreases in cervical cancer rates
Exposure to Fifth Disease (erythema infectiosum)
How to test/monitor…
Test for parvovirus B19 antibodies to assess immunity status as soon as possible after exposure - B19 specific IgM and IgG is ordered
- repeat in 4 weeks if both are negative
- if IgM is positive, monitor fetus, even if Mom has IgG
