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prenatal assessment Flashcards

1
Q

division of trimesters

A

0-12 weeks
13-27 weeks
: 28-40 weeks

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2
Q

term and preterm

A

37-42 weeks
i. At term is 37 weeks

preterm is 37

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3
Q

post term

A

i. Almost nobody goes to 42 weeks anymore b/c mom and baby gets testing every 3 days; risks are too great so induction is done by 40-41 weeks

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4
Q

para

A

Number of viable (>20 wks) births

multiples count as 1 para

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5
Q

Total number of pregnancies

A

gravida

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6
Q

4 pregnancies (one of which was a miscarriage

how do you write this

A

G4P3 (SAB1)

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7
Q

at risk groups

A

teenagers and moms over 35

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8
Q

1 twin pregnancy:

A

G1P1002

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9
Q

diet for pregnancy

A 
folic acid 
MVI; 
avoid EtOH,
 tobacco/drugs, 
caffeine (no more than 200mg of coffee per day),
 medications
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10
Q

folic acid recommendations

A

folic acid (especially important in the first trimester; now recommended all women of child bearing age regardless of whether they are trying to get pregnant should be taking prenatal vitamins),

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11
Q

HTN medications pregnancy

A

ACEi needs to be d/c’ed; any that are Category C should be carefully monitored or switched)

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12
Q

Vaccinations:

A

Varicella, Rubella, Hep B

i. Live virus vaccines cannot be given to pregnant women
ii. If mom gets varicella infection, it is potentially devastating for the fetus
iii. Get the vaccines minimum 1 month before they get pregnant, but getting it 3 months before is better

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13
Q

medical history

A

DM, mental health, STD, etc

PID makes it difficult to get pregnant
salpingo gram can be helpful for looking at the patency of the tubes

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14
Q

recommendation for overweight pregnant women

A

ii. If obese or morbidly obese when pregnant, then weight neutral pregnancy is recommended

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15
Q

when are urine pregnancy tests sensitive

what time is the most accurate

A
  1. Accurate 95%-98% of the time
  2. Sensitive within 7 days after implantation
  3. Use first morning void when possible b/c hCG concentration is the highest
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16
Q

gold standard for medical documentation

A

gold standard is QUANTITATIVE B-HCG (don’t get qualitative, it’s just like Upreg).

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17
Q

two types of serum ECG tests

A

Qualitative results are read as pos or neg

Quantitative B-HCG radioisotope test used for serial testing** this is the one you actually want

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18
Q

how to interpret hcg

A

Level doubles every 48 hrs the first 3-4 wks

If having an ectopic pregnancy, the levels will not

Level should be 50 to 250 mIU/mL at the time of the first missed period

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19
Q

when do we see a peak/decline in HCG (normally)

A

Level peaks at 60-70 days then levels

10 weeks

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20
Q

what should the levels be in a quantitative test

A

level should be 50 to 250 mIU/mL at the time of the first missed period

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21
Q

progesterone levels Remain constant through

A

Remain constant through first 9-10 weeks

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22
Q

when would you take a progesterone levels

A

get them early for women that have had two or more miscarriages

early in the pregnancy might check hcg and progesterone
-Serum level checked if frequent SAB

If level < 20, Progesterone vaginal suppository

  • Non viable pregnancies have lower levels
  • Highly predictive of pregnancy outcomes
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23
Q

what does of progesterone

A

(Prometrium 100-200 mg inserted vaginally)

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24
Q

Risks for ectopic pregnancy

A

PID

a. Prior tubal pregnancy
b. Tubal reversal surgery
c. Endometriosis
d. Intrauterine device

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25
Q

when do we normally do the prenatal demographic assessment

A

Initial prenatal social and demographic assessment

Usually, the assessment is done at 8-10 weeks of gestation

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26
Q

initial assessment

A

names of patient, partner, emergency contact, marital status, age, home address, telephone numbers for day, night, emergency, education, occupation, partner’s name and occupation, pediatrician, PCP, hospital for delivery, religion, past obstetrical history, genetic disorders in mom or dad’s side, LMP

have you ever been pregnant before?

paternal family history of genetic disorders or medical disorders
CF
hemophilia

first day of LMP
normal or not?
really light –> implantation bleeding

MEDs? OTC? ETOH? SMOKING?

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27
Q

frequent sxs associated with pregnancy

A

you want these because they indicate that hormones are rising and pregnancy is doing what they are supposed to be doing

  • Nausea and Vomiting
  • Breast Tenderness
  • Abdominal pain or cramping
  • Vaginal discharge or bleeding
  • Urinary frequency
  • Headache
  • Nosebleeds, gums bleed
  • Heartburn
  • Back Pain (
  • Quickening
  • Skin change
  • Ptyalism
  • Absence of menses
  • Constipation
  • Fatigue
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28
Q

why do we typically see abdominal pain

A

(typically towards the end of pregnancy to get ready for labor round ligament growth spurt pain

if you have pain with bleeding NOT NORMAL

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29
Q

Increased vaginal d/c seen in pregnancy

when do you want to advise moms

A

d/c increases during pregnancy d/t increase in estrogen. If smelly, associated with pain or bleeding – not normal.

Rates of bac vag and yeast infxn go up during pregnancy)\

need to prevent PROM

BLEEDING ALWAYS EVALUATE

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30
Q

headaches are due to

A

(d/t increase in blood volume; menstrual migraines typically go away during pregnancy but they come back after pregnancy)

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31
Q

nosebleeds are d/t

A

(d/t increased vascular congestion)

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32
Q

Heartburn

A

especially towards the end of pregnancy; relaxin relaxes the LES which causes an increase in heartburn during pregnancy

slow gastric emptying and gut motility (constipation) and relaxed esophageal sphincter

–> 100% of women by the third trimester for GERD

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33
Q

back pain in pregnancy associated with

A

RELAXIN soften hips but back pain is really common

lumbar lordosis gets significant; pubic symphysis pain is common and uncomfortable

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34
Q

quickening with pregnancy

A

flushy flittery

baby starts to move, happens around 18-20 weeks in first time moms

16 weeks for 2nd time moms

evening is more common

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35
Q

Ptyalism

A

excessive salivation

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36
Q

fatigue is most common in the

A

(especially during 1st and 3rd trimester)

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37
Q

Chadwicks sign

A

bluish discoloration of the cervix from vascular congestion, after 6th week of pregnancy

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38
Q

Hegar’s sign

A

softening of the cervix, about 4-6 weeks after conception

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39
Q

ideal cervix in pregnancy

A

long and closed cervix which means the mucus plug is going to stay in

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40
Q

uterine sized should be assessed by

A

by bimanual exam

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41
Q

Adnexal tenderness or enlargement

A

may indicate an ectopic pregnancy

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42
Q

Fetal movement after

A

18-20 weeks

should feel movement everyday

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43
Q

fetal positionig

A

Fetal position after 28 weeks

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44
Q

doppler heart sounds can be heard

A

Doppler heart sounds 10-12 weeks

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45
Q

Fetoscope can be heard

A

Fetoscope auscultation 17-20 weeks (used by midwives)

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46
Q

cardiac activity can be heard

A

US 5-8 weeks for cardiac activity

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47
Q

Movement

A

Palpation of active fetal motion (quickening) at 18-20 weeks

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48
Q

Visualization of the fetus can be done at

A

US – fetal/embryonic pole seen 5-6 weeks

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49
Q

Naegele’s rule:

A

add 1 week, subtract 3 months from LMP for EDD

add a year

50
Q

Average length of gestation

A

~ 280 days

51
Q

Crown Rump Length (CRL)

A

up to ~14 weeks: ± 5-7 days accuracy

  1. One marker on top of head and other at the bottom of butt
52
Q

> 16 weeks, less accurate

A
  1. Biparietal diameter (BPD)
  2. Head circumference (HC)
  3. Abdominal circumference (AC)
  4. Femur length (FL)
53
Q

what do we use for dating a pregnancy

A

usually LMP and naegele’s rule

54
Q

when should you see pts

A

usually around 10 to 12 weeks to get the most accurate gestational age

55
Q

around 10-12 weeks the fundus should be

A

10-12 WK: fundus at symphysis pubis

56
Q

around 20-22 weeks

A

the fundus will be at umbilicus

57
Q

can measure how far along the patient is by

when is this most accurate

A

Measure from symphysis pubis to top of fundus

most accurate

Measurement in cm: weeks gestation +/- 3cm, most accurate btw 22-34 weeks

as long as patients continue to have growth they are ok

58
Q

topics of discussion

A

a. Prenatal Vitamins
b. Lab tests
c. Exercise–> walking is great
d. Nutrition
e. Sex  unless medical contraindication during the 3rd trimester

59
Q

how should you educated pts about exercise

A

i. Avoid overheating/maintain adequate hydration

ii. Contraindications

60
Q

normal weight gain

by trimester

A

i. Encourage appropriate weight gain 25-30 lbs

amniotic fluid
increased intravascular volume
the baby

  1. 3-5 in first trimester
  2. 10 in 2nd trimester
  3. And the rest in the 3rd trimester

ii. Pre-pregnant weight less than 90% or greater than 135%

61
Q

most important calories for pregnancy weight come from

A

protein

Protein 5-6 grams protein/day above non-pregnant, 8 servings per day

vi. Breads and Cereals 6 servings
vii. Fruits and vegetables 3 servings

62
Q

how much Ca needed

A

pancCalcium intake 1000-1500 mg/day 4 servings; vitamin D

63
Q

how much folic acid

A

viii. Folic acid 800 mcg start preconception

  1. Prevention of neural tube defects
  2. Neural tube closes 18-26 days post conception
64
Q

iron needed

A

Iron 15 mg/day over RDA 30 mg/day

65
Q

vitamine A recommendation

A

Vitamin A > 10,000 IU/ day can be teratogenic

66
Q

vitamin C recommendation

A

Vitamin C rich foods 3 servings

67
Q

id deficient in vitamin levels then it is recommended that

A

If deficient in vitamins, then it is recommended to wait 2 years before you try to get pregnant again

68
Q

schedule of prenatal visit

A

10-12 weeks

if you are going to use the LMP of ULS for the gestational date moving forward

Once a month for 28-30 weeks
Every 2 weeks until 36 weeks
69
Q

evaluate these

A

i. Weight gain
ii. BP: screen for pregnancy induced hypertension (PIH)
iii. Fundal Height (20wk): evaluate fetal growth
iv. Leopold’s Maneuver (28wk): determine fetal position
v. Fetal heart tones (FHR) (10wk): evaluate fetal well being
vi. Edema: screen for PIH (pregnancy induced htn)
vii. Urinalysis: glucose and protein
viii. Symptoms: identify problems, discomforts
ix. Pelvic exam

70
Q

fundal height evaluated at

A

(20wk): evaluate fetal growth

71
Q

Leopold’s Maneuver done at

A

Leopold’s Maneuver (28wk): determine fetal position

72
Q

FHR evaluated at

A

(FHR) (10wk): evaluate fetal well being

73
Q

edema should be evaluating for

A

screen for PIH (pregnancy induced htn)

74
Q

braxton hicks

A

feels like a muscle spasm
painless and comes and goes

more noticeable after exercise

75
Q

when would you do a prenatal pelvic exam

A

done at first prenatal visit and then don’t need to do another one until the 3rd trimester

76
Q

questions for prenatal visits

A 
•	Headaches
•	Visual Changes
•	Swelling
•	Pain in chest, legs, abd, back
•	Problems with Urination
•	Vaginal bleeding or abnl discharge	•	
         Exposure to disease
•	Skin rashes or itching
•	Signs of labor
•	Accidents or falls
•	Changes in fetal motion (should feel the 
        baby move everyday by 20 weeks)
•	Recent illness or fever
•	Vaginal Lesions or sores
77
Q

Vaginal bleeding -warning sign of

A
  1. Miscarriage/SAB, Ectopic

2. Placental abruption, early labor

78
Q

ii. Fluid leaking from vagina

A
  1. PROM

premature rupture of membranes if <36wks

79
Q

persistent headache, dizziness, edema, RUQ pain

A

PIH, HELLP syndrome, cholestasis

80
Q

Decreased Fetal movement

A

Fetal compromise

81
Q

Fever, chills

A
  1. Infection
82
Q

Recurrent Vomiting – losing weight d/t vomiting

A
  1. Hyperemesis gravidum
83
Q

a. Initial Prenatal Evaluation-i. Standard OB panel:

A
  1. Blood type, Rh and antibody screen
  2. Hgb & Hct
  3. Pap smear and Chlamydia screening
  4. Rubella immunity, Hep B sAg
  5. Urine culture
  6. RPR, HIV
  7. Thyroid function, vitamin D level
  8. Hgb A1c (goal <6.5%)
84
Q
  1. Type A has antigen
A

, type B has antigen B, type AB has both, and type O has none

85
Q

40-50% of ABO incompatibility occurs in

A

first pregnancies

Majority occurs in Type O mothers carrying type A or B fetus

86
Q

Rh Negative Pregnant Women -what are we worried about

A

if RH positive fetus mom can produce antibodies this is detrimental for future pregnancies

  1. Pt produces IgG antibodies in response to Rh+ fetal RBC in maternal circulation
    a. Sensitization through previous pregnancy, transfusion, trauma causing maternal/fetal blood to mix

iii. Rh Negative Pregnant Women (get rhogam at 28 weeks; and again at 72 hours of delivery)

87
Q

what do you do for Rh Negative

A

Rh Negative Pregnant Women (get IM rhogam at 28 weeks; and again at 72 hours of delivery)

rhogam is an antibody given at these two times and anytime there is potential for interaction

amniocentesis or car accident

88
Q

Hydrops Fetalis

A

get hemolytic anemia, brain fills with fluid and baby dies

89
Q

at risk mothers should be screened for

A
  1. Gonorrhea
  2. TB
  3. Toxoplasmosis, Chagas disease
  4. Hep C Ab
  5. Varicella immunity
  6. BV, Trichomonas, HSV
  7. Lead level
90
Q

when would you test for genetic disorders

A
  1. Advanced maternal age (35 years and over)
  2. Thalassemia (Asian, Mediterranean background)
  3. Hemoglobinopathies (African Americans)
  4. Tay-Sachs (Ashkenazi Jewish)
  5. Cystic fibrosis (carriers)  all white women are recommended to get screening
91
Q

when do we do prenatal screening for down syndrome

A

i. All women should be offered screening for Down syndrome and other genetic abnormalities

92
Q

iii. Diagnostic tests if positive screening:

A
  1. CVS
  2. Amniocentesis

might do this first if mom has already had a baby with down’s syndrome

93
Q

First trimester combined test

A
  1. NT (nuchal translucency) and CRL plus PAPP-A (pregnancy-associated plasma protein A), total β-hCG at 11-13 wks
  2. Screening for neural tube defects done in 2nd trimester with serum AFP
94
Q

Integrated screening (full integrated test)

A
  1. NT and PAPP-A at 11-13 wks plus serum AFP, uE3, hCG, inhibin A at 15-18 wks

still do ULS but there is additional blood testing too

95
Q

90% of fetuses with an NT of____ at _____weeks gestation are normal at birth

A

. 90% of fetuses with an NT of 3 mm at 12 weeks gestation are normal at birth

  1. 10% have major abnormalities
96
Q

c. Nuchal Translucency

A

i. An ultrasonic examination to measure the amount of fluid accumulation behind the baby’s neck

97
Q

vi. Cell-free free fetal DNA maternal serum markers

A

may not be as widely available

  1. Genomic sequencing to detect T21, T18, T13 after 10 wks gestation
  2. More $$$
98
Q

Integrated Screen will detect up to____ of babies affected with Down Syndrome and up to ____ with Trisomy 18

A

Integrated Screen will detect up to 92% of babies affected with Down Syndrome and up to 90% with Trisomy 18

ii. It will also detect up to 80% of babies that have open neural tube defects such as Spina Bifida
iii. The first and second trimester results are combined, so risk assessment available when second trimester blood work is completed

99
Q

i. Screen negative test

A

Risk of fetus having Down syndrome is less than chosen cut-off value (provided on report)

100
Q

ii. Screen positive test

A
  1. US should be done if not already
  2. Genetic counseling
  3. Diagnostic fetal karyotyping
    a. CVS (chorionic villus sampling) in 1st trimester
    b. Amniocentesis in 2nd trimester
101
Q

Chorionic Villus Sampling

A

can be done very early vs amnio which is usually done later on

102
Q

when would you recommend CVS testing

A
  1. Advanced maternal age (>35 years)
  2. Previous infant with chromosome abnormality
  3. Mother carrier for x-linked disease
  4. Parents who are known carriers for autosomal recessively inherited disorders
103
Q

inherited disorders where you would want to consider CVS

A

(Tay-Sachs, cystic fibrosis, inborn errors of metabolism)

104
Q

contraindications to CVS

A
  1. IUD, Cervical Stenosis, Bleeding, PID, HSV, GC
105
Q

when would you do a CVS

A

iii. Performed at 10-12 weeks gestation

106
Q

risk of miscarriage with amniocentesis

A

iv. -Risk of miscarriage as a result of amniocentesis

1. 1 in 400 or less

107
Q

genetic counseling occurs at what point with amniocentesis

A

v. Genetic Counseling 16 wks

108
Q

indications for amniocentesis

A
  1. Assessment of presence of bilirubin
  2. Assessment of L/S ratio
  3. Assessment of genetic disorders
  4. Assessment of fetal sex chromosomes
  5. Advanced maternal age
  6. Positive AFP or 1st trimester screen
  7. X-linked disease (hemophilia)
  8. Carriers of autosomal recessive disorders
109
Q

how does amniocentesis work

A

ii. -Under ultrasound guidance, small amount of amniotic fluid removed through the abdomen – cultured/karyotyped

110
Q

advantages of CVS over amnio

A
  1. Performed earlier in pregnancy – 10 to 12 weeks rather than 15 to 20 weeks so can make decisions about termination earlier
  2. -Results are available by the end of the third month
111
Q

disadvantage of CVS over amnio

A

Spinal cord defects cannot be detected

  1. -Ultrasound performed later in pregnancy to screen for spinal cord defects
  2. -Higher rates of pregnancy loss
112
Q

i. Other Prenatal Testing

i. 24-28 weeks

A
  1. GDM (gestational diabetes mellitus) screening with GTT

2. Rhogam if Rh(-) at 28 wks

113
Q

Rhogam

A

a. Anti-D immune globulin 300mcg at 28 weeks and within 72 hours postpartum

114
Q

ii. 35-37 weeks – screen

A

for group B strep

1. Vaginal & rectal swab for GBS

115
Q

milestones 6-12 wks

A

confirm pregnancy & GA, initial labs, complete H&P; possibly CVS

116
Q

11-13 wks:

A

1st trimester/integrated screen

117
Q

15-20 wks

A

Quad screen (if missed 1st trimester screening), Genetic Ultrasound done at 20 weeks, Amnio if high risk

118
Q

iv. 24-28 wks

A

: GTT (glucose tolerance test) for GDM, Antibody screen if Rh(-) and get RhoGAM, Hgb/Hct especially if anemic in the first trimester

119
Q

gender determined at

A
  1. Gender – @20 weeks
120
Q

24-28 wks

A

GTT (glucose tolerance test) for GDM, Antibody screen if Rh(-) and get RhoGAM, Hgb/Hct especially if anemic in the first trimester

  1. Hgb has to be over 10 if want homebirth
121
Q

35-37 wks:

A

GBS screen

122
Q

Hgb has to be over ___ if want homebirth

A

10

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