prenatal assessment Flashcards
division of trimesters
0-12 weeks
13-27 weeks
: 28-40 weeks
term and preterm
37-42 weeks
i. At term is 37 weeks
preterm is 37
post term
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
para
Number of viable (>20 wks) births
multiples count as 1 para
Total number of pregnancies
gravida
4 pregnancies (one of which was a miscarriage
how do you write this
G4P3 (SAB1)
at risk groups
teenagers and moms over 35
1 twin pregnancy:
G1P1002
diet for pregnancy
folic acid MVI; avoid EtOH, tobacco/drugs, caffeine (no more than 200mg of coffee per day), medications
folic acid recommendations
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),
HTN medications pregnancy
ACEi needs to be d/c’ed; any that are Category C should be carefully monitored or switched)
Vaccinations:
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
medical history
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
recommendation for overweight pregnant women
ii. If obese or morbidly obese when pregnant, then weight neutral pregnancy is recommended
when are urine pregnancy tests sensitive
what time is the most accurate
- Accurate 95%-98% of the time
- Sensitive within 7 days after implantation
- Use first morning void when possible b/c hCG concentration is the highest
gold standard for medical documentation
gold standard is QUANTITATIVE B-HCG (don’t get qualitative, it’s just like Upreg).
two types of serum ECG tests
Qualitative results are read as pos or neg
Quantitative B-HCG radioisotope test used for serial testing** this is the one you actually want
how to interpret hcg
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
when do we see a peak/decline in HCG (normally)
Level peaks at 60-70 days then levels
10 weeks
what should the levels be in a quantitative test
level should be 50 to 250 mIU/mL at the time of the first missed period
progesterone levels Remain constant through
Remain constant through first 9-10 weeks
when would you take a progesterone levels
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
what does of progesterone
(Prometrium 100-200 mg inserted vaginally)
Risks for ectopic pregnancy
PID
a. Prior tubal pregnancy
b. Tubal reversal surgery
c. Endometriosis
d. Intrauterine device
when do we normally do the prenatal demographic assessment
Initial prenatal social and demographic assessment
Usually, the assessment is done at 8-10 weeks of gestation
initial assessment
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?
frequent sxs associated with pregnancy
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
why do we typically see abdominal pain
(typically towards the end of pregnancy to get ready for labor round ligament growth spurt pain
if you have pain with bleeding NOT NORMAL
Increased vaginal d/c seen in pregnancy
when do you want to advise moms
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
headaches are due to
(d/t increase in blood volume; menstrual migraines typically go away during pregnancy but they come back after pregnancy)
nosebleeds are d/t
(d/t increased vascular congestion)
Heartburn
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
back pain in pregnancy associated with
RELAXIN soften hips but back pain is really common
lumbar lordosis gets significant; pubic symphysis pain is common and uncomfortable
quickening with pregnancy
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
Ptyalism
excessive salivation
fatigue is most common in the
(especially during 1st and 3rd trimester)
Chadwicks sign
bluish discoloration of the cervix from vascular congestion, after 6th week of pregnancy
Hegar’s sign
softening of the cervix, about 4-6 weeks after conception
ideal cervix in pregnancy
long and closed cervix which means the mucus plug is going to stay in
uterine sized should be assessed by
by bimanual exam
Adnexal tenderness or enlargement
may indicate an ectopic pregnancy
Fetal movement after
18-20 weeks
should feel movement everyday
fetal positionig
Fetal position after 28 weeks
doppler heart sounds can be heard
Doppler heart sounds 10-12 weeks
Fetoscope can be heard
Fetoscope auscultation 17-20 weeks (used by midwives)
cardiac activity can be heard
US 5-8 weeks for cardiac activity
Movement
Palpation of active fetal motion (quickening) at 18-20 weeks
Visualization of the fetus can be done at
US – fetal/embryonic pole seen 5-6 weeks
Naegele’s rule:
add 1 week, subtract 3 months from LMP for EDD
add a year
Average length of gestation
~ 280 days
Crown Rump Length (CRL)
up to ~14 weeks: ± 5-7 days accuracy
- One marker on top of head and other at the bottom of butt
> 16 weeks, less accurate
- Biparietal diameter (BPD)
- Head circumference (HC)
- Abdominal circumference (AC)
- Femur length (FL)
what do we use for dating a pregnancy
usually LMP and naegele’s rule
when should you see pts
usually around 10 to 12 weeks to get the most accurate gestational age
around 10-12 weeks the fundus should be
10-12 WK: fundus at symphysis pubis
around 20-22 weeks
the fundus will be at umbilicus
can measure how far along the patient is by
when is this most accurate
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
topics of discussion
a. Prenatal Vitamins
b. Lab tests
c. Exercise–> walking is great
d. Nutrition
e. Sex unless medical contraindication during the 3rd trimester
how should you educated pts about exercise
i. Avoid overheating/maintain adequate hydration
ii. Contraindications
normal weight gain
by trimester
i. Encourage appropriate weight gain 25-30 lbs
amniotic fluid
increased intravascular volume
the baby
- 3-5 in first trimester
- 10 in 2nd trimester
- And the rest in the 3rd trimester
ii. Pre-pregnant weight less than 90% or greater than 135%
most important calories for pregnancy weight come from
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
how much Ca needed
pancCalcium intake 1000-1500 mg/day 4 servings; vitamin D
how much folic acid
viii. Folic acid 800 mcg start preconception
- Prevention of neural tube defects
- Neural tube closes 18-26 days post conception
iron needed
Iron 15 mg/day over RDA 30 mg/day
vitamine A recommendation
Vitamin A > 10,000 IU/ day can be teratogenic
vitamin C recommendation
Vitamin C rich foods 3 servings
id deficient in vitamin levels then it is recommended that
If deficient in vitamins, then it is recommended to wait 2 years before you try to get pregnant again
schedule of prenatal visit
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
evaluate these
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
fundal height evaluated at
(20wk): evaluate fetal growth
Leopold’s Maneuver done at
Leopold’s Maneuver (28wk): determine fetal position
FHR evaluated at
(FHR) (10wk): evaluate fetal well being
edema should be evaluating for
screen for PIH (pregnancy induced htn)
braxton hicks
feels like a muscle spasm
painless and comes and goes
more noticeable after exercise
when would you do a prenatal pelvic exam
done at first prenatal visit and then don’t need to do another one until the 3rd trimester
questions for prenatal visits
• 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 soresVaginal bleeding -warning sign of
- Miscarriage/SAB, Ectopic
2. Placental abruption, early labor
ii. Fluid leaking from vagina
- PROM
premature rupture of membranes if <36wks
persistent headache, dizziness, edema, RUQ pain
PIH, HELLP syndrome, cholestasis
Decreased Fetal movement
Fetal compromise
Fever, chills
- Infection
Recurrent Vomiting – losing weight d/t vomiting
- Hyperemesis gravidum
a. Initial Prenatal Evaluation-i. Standard OB panel:
- Blood type, Rh and antibody screen
- Hgb & Hct
- Pap smear and Chlamydia screening
- Rubella immunity, Hep B sAg
- Urine culture
- RPR, HIV
- Thyroid function, vitamin D level
- Hgb A1c (goal <6.5%)
- Type A has antigen
, type B has antigen B, type AB has both, and type O has none
40-50% of ABO incompatibility occurs in
first pregnancies
Majority occurs in Type O mothers carrying type A or B fetus
Rh Negative Pregnant Women -what are we worried about
if RH positive fetus mom can produce antibodies this is detrimental for future pregnancies
- 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)
what do you do for Rh Negative
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
Hydrops Fetalis
get hemolytic anemia, brain fills with fluid and baby dies
at risk mothers should be screened for
- Gonorrhea
- TB
- Toxoplasmosis, Chagas disease
- Hep C Ab
- Varicella immunity
- BV, Trichomonas, HSV
- Lead level
when would you test for genetic disorders
- Advanced maternal age (35 years and over)
- Thalassemia (Asian, Mediterranean background)
- Hemoglobinopathies (African Americans)
- Tay-Sachs (Ashkenazi Jewish)
- Cystic fibrosis (carriers) all white women are recommended to get screening
when do we do prenatal screening for down syndrome
i. All women should be offered screening for Down syndrome and other genetic abnormalities
iii. Diagnostic tests if positive screening:
- CVS
- Amniocentesis
might do this first if mom has already had a baby with down’s syndrome
First trimester combined test
- NT (nuchal translucency) and CRL plus PAPP-A (pregnancy-associated plasma protein A), total β-hCG at 11-13 wks
- Screening for neural tube defects done in 2nd trimester with serum AFP
Integrated screening (full integrated test)
- 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
90% of fetuses with an NT of____ at _____weeks gestation are normal at birth
. 90% of fetuses with an NT of 3 mm at 12 weeks gestation are normal at birth
- 10% have major abnormalities
c. Nuchal Translucency
i. An ultrasonic examination to measure the amount of fluid accumulation behind the baby’s neck
vi. Cell-free free fetal DNA maternal serum markers
may not be as widely available
- Genomic sequencing to detect T21, T18, T13 after 10 wks gestation
- More $$$
Integrated Screen will detect up to____ of babies affected with Down Syndrome and up to ____ with Trisomy 18
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
i. Screen negative test
Risk of fetus having Down syndrome is less than chosen cut-off value (provided on report)
ii. Screen positive test
- US should be done if not already
- Genetic counseling
- Diagnostic fetal karyotyping
a. CVS (chorionic villus sampling) in 1st trimester
b. Amniocentesis in 2nd trimester
Chorionic Villus Sampling
can be done very early vs amnio which is usually done later on
when would you recommend CVS testing
- Advanced maternal age (>35 years)
- Previous infant with chromosome abnormality
- Mother carrier for x-linked disease
- Parents who are known carriers for autosomal recessively inherited disorders
inherited disorders where you would want to consider CVS
(Tay-Sachs, cystic fibrosis, inborn errors of metabolism)
contraindications to CVS
- IUD, Cervical Stenosis, Bleeding, PID, HSV, GC
when would you do a CVS
iii. Performed at 10-12 weeks gestation
risk of miscarriage with amniocentesis
iv. -Risk of miscarriage as a result of amniocentesis
1. 1 in 400 or less
genetic counseling occurs at what point with amniocentesis
v. Genetic Counseling 16 wks
indications for amniocentesis
- Assessment of presence of bilirubin
- Assessment of L/S ratio
- Assessment of genetic disorders
- Assessment of fetal sex chromosomes
- Advanced maternal age
- Positive AFP or 1st trimester screen
- X-linked disease (hemophilia)
- Carriers of autosomal recessive disorders
how does amniocentesis work
ii. -Under ultrasound guidance, small amount of amniotic fluid removed through the abdomen – cultured/karyotyped
advantages of CVS over amnio
- Performed earlier in pregnancy – 10 to 12 weeks rather than 15 to 20 weeks so can make decisions about termination earlier
- -Results are available by the end of the third month
disadvantage of CVS over amnio
Spinal cord defects cannot be detected
- -Ultrasound performed later in pregnancy to screen for spinal cord defects
- -Higher rates of pregnancy loss
i. Other Prenatal Testing
i. 24-28 weeks
- GDM (gestational diabetes mellitus) screening with GTT
2. Rhogam if Rh(-) at 28 wks
Rhogam
a. Anti-D immune globulin 300mcg at 28 weeks and within 72 hours postpartum
ii. 35-37 weeks – screen
for group B strep
1. Vaginal & rectal swab for GBS
milestones 6-12 wks
confirm pregnancy & GA, initial labs, complete H&P; possibly CVS
11-13 wks:
1st trimester/integrated screen
15-20 wks
Quad screen (if missed 1st trimester screening), Genetic Ultrasound done at 20 weeks, Amnio if high risk
iv. 24-28 wks
: GTT (glucose tolerance test) for GDM, Antibody screen if Rh(-) and get RhoGAM, Hgb/Hct especially if anemic in the first trimester
gender determined at
- Gender – @20 weeks
24-28 wks
GTT (glucose tolerance test) for GDM, Antibody screen if Rh(-) and get RhoGAM, Hgb/Hct especially if anemic in the first trimester
- Hgb has to be over 10 if want homebirth
35-37 wks:
GBS screen
Hgb has to be over ___ if want homebirth
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