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Obstetrics > Prenatal Assessment > Flashcards

Prenatal Assessment Flashcards

1
Q

gestation, term pregnancy, preterm, post-dates

A
  • Gestation: # of weeks from last menstrual period
    • 1st trimester: 0-12 weeks
    • 2nd trimester: 13-27 weeks
    • 3rd trimester: 28-40 weeks
  • Term Pregnancy: 37-42 weeks
    • At term = 37 weeks
  • Preterm: before 37 weeks
  • Post-Dates: after 42 weeks
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2
Q

gravida, para

A
  • Gravida: Total number of pregnancies
    • Regardless of whether they were carried to term
  • Para: Number of viable (>20 wks) births
    • Multiples count as 1 birth
  • Examples:
    • 2 pregnancies (both of which resulted in live births): G2P2
    • 4 pregnancies (one of which was a miscarriage): G4P3 (SAB1)
    • 1 twin pregnancy: G1P1002
    • 4 pregnancies, with 3 live births, 1 preterm birth, 1 therapeutic abortion, and 3 living children: G4P3113 (TAB1)
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3
Q

nulligravida, nullipara, primigravida, multigravida, multipara

A
  • Nulligravida: never pregnant
  • Nullipara: never delivered
  • Primigravida: pregnant for the first time or has been pregnant one time
  • Multigravida: pregnant more than one time
  • Multipara: given birth two or more times
  • Gravidity & Parity refer to number of pregnancies/deliveries, not number of children born
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4
Q

preconception counseling

A
  • Identify patients at increased risk of complications before pregnancy
  • Age: >35 at increased risk; teenagers at risk
    • Mostly genetic risks
    • A lot of times teens don’t have great social support
  • Diet: folic acid, MVI; avoid EtOH, tobacco/drugs, caffeine, medications
  • Vaccinations: Varicella, Rubella, Hep B
  • Medical history: DM, mental health, STD, etc
  • Weight: under or overweight discussed
    • For women that are severely overweight, sometimes you recommend a weight neutral pregnancy
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5
Q

documentation of pregnancy

A
  • Urine Pregnancy Tests
    • Accurate 95%-98% of the time
    • Sensitive within 7 days after implantation
    • Pregnancy detected before first missed period
    • Inexpensive
    • Use first morning void when possible
  • Serum HCG levels are the gold standard
    • Qualitative results are read as pos or neg
    • Quantitative B-HCG radioisotope test used for serial testing – this gives you a NUMBER – helps so that if youre going to follow a pt over time, you need a number
      • Level doubles every 48 hrs the first 3-4 wks
      • Level peaks at 60-70 days then levels off
      • Level should be 50 to 250 mIU/mL at the time of the first missed period
  • Progesterone Levels
    • Remain constant through first 9-10 weeks
    • Non viable pregnancies have lower levels
    • Highly predictive of pregnancy outcomes
    • Serum level checked if frequent SAB
    • If level < 20, Progesterone vaginal suppository
      • (Prometrium 100-200 mg inserted vaginally)
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6
Q

assess risk factor for ectopic pregnancy

A
  • Prior tubal pregnancy
  • Tubal reversal surgery
  • Endometriosis
  • Intrauterine device
    • decreases overall risk of pregnancy; if pregnant with IUD, more likely ectopic
  • Once IUP seen on sono, patient can be reassured
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7
Q

symptoms of pregnancy

A
  • You WANT women to have signs like breast tenderness and vomiting. That’s a GOOD sign
  • Nausea and Vomiting
  • Breast Tenderness
  • Abdominal pain or cramping – not typically first trimester – usually pain in the first trimester is a problem (like ectopic pregnancy, etc.)
  • Vaginal discharge or bleeding
    • If it is itchy, stinky, uncomfortable, associated with bleeding, etc. is not normal
    • BLEEDING may be normal but ALWAYS needs to be evaluated
  • Urinary frequency
  • Headache
  • Nosebleeds, gums bleed
  • Heartburn
  • Back Pain
  • Quickening – baby moving around – feels like a little goldfish
  • Skin changes
  • Ptyalism = excessive secretion of saliva
  • Absence of menses
  • Constipation
  • Fatigue
  • Frequent, consistent vomiting: dehydration, weight loss, electrolyte imbalance, poor appetite or food intake, ketonuria may indicate hyperemesis gravidum.
  • Most common problem assoc. With pregnancy.
  • Abd. Pain and cramping - associated with round ligament pain. Check for signs of SAB or ectopic pregnancy.
  • Bleeding can be normal. May indicate infection.
  • Heavy bleeding is abnormal. Get HcG. Spotting can be implantation of blastocyte resulting from invasive chorionic villi activity in the uterine lining. Usually occurs at time of expected menses if not pregnant.
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8
Q

initial physical examination

A
  • Complete physical examination
  • Explanation of what to expect
  • Baseline vital signs: BP, weight
  • Breast exam
  • Abdominal exam
    • Note surgical scars
    • Fundal height in cm if 20 wks or more
    • Fetal Heart Rate by Doppler if 10+wks
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9
Q

initial physical examination: cervical and vaginal tests

A
  • Pap Smear
  • Chlamydia
  • Gonorrhea
  • As needed:
    • BV
    • HSV
    • Trichomonas
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10
Q

physical examination: pelvic exam

A
  • Hegar’s sign - softening of the cervix, about 4-6 weeks after conception
  • Chadwicks sign - bluish discoloration of the cervix from vascular congestion, after 6th week of pregnancy
  • Cervical position and length – particularly if the women have had miscarriages in the past
  • Uterine size by bimanual exam
  • Adnexal tenderness or enlargement – particularly if worried about ectopic pregnancy
  • Fetal heart tones (FHT)
    • 120-160 beats per minute
    • Heard at 10-12 weeks with Doppler
  • Fetal movement after 18-20 weeks
  • Fetal position after 28 weeks
  • Once mom starts feeling the baby move, she should be able to feel the baby move every day
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11
Q

determination of gestational age

A
  • Positive signs
    • Fetal heart
      • US 5-8 weeks for cardiac activity
      • Doppler heart sounds 10-12 weeks
      • Fetoscope auscultation 17-20 weeks
    • Visualization of the fetus
      • US – fetal/embryonic pole seen 5-6 weeks
    • Movement
      • Palpation of active fetal motion (quickening) at 18-20 weeks
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12
Q

diagnosis of pregnancy

A
  • Gestational sac appears at about
  • 4-5 weeks gestational age
  • Grows at 1 mm/day through the
  • 9th week of pregnancy
  • Serum hCG levels 1000-1500 mIU
  • Yolk sac visible 5 weeks to 10-12 weeks provides confirmation of IUP
  • Visible embryo with measurable CRL (fetal/embryonic pole) about 6 weeks
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13
Q

dating the pregnancy

A
  • Last menstrual period – if known and if mom is confident for LMP
    • Exact date?
    • Regular cycles?
  • Naegele’s rule: add 1 week, subtract 3 months, add one year from LMP for EDD
  • Average length of gestation ~ 280 days
  • Confirm with ultrasound, best in 1st trimester
  • Plenty of apps that act as pregnancy wheel to date pregnancy easily/quickly/accurately
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14
Q

determination of gestation age by ultrasound

A
  • Crown Rump Length (CRL) up to ~14 weeks: ± 5-7 days accuracy
    • If LMP and CRL match within 5 days, then you use CRL as dating. If not, you use US as dating
  • >16 weeks, less accurate
    • Biparietal diameter (BPD)
    • Head circumference (HC)
    • Abdominal circumference (AC)
    • Femur length (FL)
  • Crown-rump length (CRL) measured in the first trimester, if available, is the most accurate sonographic method of determining the EDD.
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15
Q

assessing fetal growth

A
  • 10-12 WK: fundus at symphysis pubis
  • 20-22 WK: fundus at umbilicus
  • Measure from symphysis pubis to top of fundus
  • Measurement in cm: weeks gestation +/- 3cm, most accurate btw 22-34 weeks
  • Its important to have the same practitioner measure each week because different practitioners have different ways of doing it
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16
Q

topics of discussion: first visit

A
  • Prenatal Vitamins
  • Lab tests
  • Exercise
  • Nutrition
  • Sex
  • Outline of care
  • Handouts, books
  • Grooming, dental hygiene, travel
    • A lot of things can happen to your gums and mouth during pregnancy and if you have an infection it is worse during pregnancy
17
Q

general health and nutrition

A
  • Drink plenty of water/fluids
  • Get plenty of rest
  • Exercise
    • Avoid overheating/maintain adequate hydration
    • Contraindications
  • Exercise should not be fatiguing.
  • Consult with provider about current or new exercise program
  • Avoid high risk sports and activities
  • decrease intensity as pregnancy progresses
  • exercise 3-5 times a week for 15-30 min intervals with pulse 140-150
  • Wear supportive bra and shoes
  • drink liquids before and after
  • avoid hyperthermia in hot weather
  • stretch and warm up and cool down
  • stop if palpitation SOB dizziness, abd. pain bleeding numbness, tingling
  • avoid standing or sitting for long periods.
  • Nutrition: Assess Risk Factors
    • Encourage appropriate weight gain 25-30 lbs
    • Pre-pregnant weight less than 90% or greater than 135%
    • Adolescent less than 15 yo
    • Two or more pregnancies during 2 years
    • Breast feeding
    • Multiple gestation
    • Food faddism, smoking, drugs, or alcoholism
    • Therapeutic diet for chronic systemic disease
  • Diet
    • 2000-3000 calories per day*
    • Vegetarian may be deficient in essential amino acids, iron, complex lipids
    • Food allergies
    • Calcium intake 1000-1500 mg/day 4 servings; vitamin D
    • Protein 5-6 grams protein/day above non-pregnant 8 servings per day
    • Breads and Cereals 6 servings
    • Fruits and vegetables 3 servings
    • Need about 300 Cal/d from baseline in healthy mom
  • Diet
    • Folic acid 800 mcg start preconception
      • Prevention of neural tube defects
      • Neural tube closes 18-26 days post conception
    • Iron 15 mg/day over RDA 30 mg/day
    • Vitamin A > 10,000 IU/ day Teratogenic
    • Vitamin C rich foods 3 servings
    • Herbal supplements no randomized clinical trials to evaluate safety in pregnancy
18
Q

common discomforts of pregnancy

A
  • N&V
  • Changes in libido
  • Diarrhea
  • Angry or irritable
  • Hemorrhoids
  • Constipation
  • Heartburn
  • Loss of appetite
  • Varicose veins
  • Insomnia
  • Fatigue
  • Numbness of hands, Carpal Tunnel
  • Sciatica
  • Leg cramps
  • Irregular heart beat
  • Abdominal pain and cramping
19
Q

schedule of future visits

A
  • Once a month for 28-30 weeks
  • Every 2 weeks until 36 weeks
  • Weekly until delivery
  • More frequent visits as indicated
20
Q

evaluate at each visit

A
  • Weight gain
    • Evaluate fetal growth
    • Nutritional intake
  • BP: screen for pregnancy induced hypertension (PIH)
  • Fundal Height (20wk): evaluate fetal growth
  • Leopold’s Maneuver (28wk): determine fetal position
  • Fetal heart tones (FHR) (10wk): evaluate fetal well being
  • Edema: screen for PIH
  • Urinalysis: glucose and protein
  • Symptoms: identify problems, discomforts
21
Q

prenatal revisit questions

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
  • Recent illness or fever
  • Vaginal Lesions or sores
22
Q

warning signs during pregnancy

A
  • Vaginal bleeding
    • Miscarriage/SAB, Ectopic
  • Fluid leaking from vagina
    • PROM
  • Persistent headache, dizziness, edema, RUQ pain
    • PIH, HELLP syndrome, cholestasis
  • Decreased Fetal movement
    • Fetal compromise
  • Fever, chills
    • Infection
  • Recurrent Vomiting
    • Hyperemis gravidum
23
Q

initial prenatal evaluation

A
  • 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%)
24
Q

ABO incompatibility

A
  • 4 major blood groups: A, B, AB, O
    • Type A has antigen A, 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
  • Causes less severe hemolytic anemia, jaundice in newborns
25
Q

rhesus (Rh) factor

A
  • In addition to ABO blood types, humans have Rh factors (type A+ or B-, for example)
  • Rh factor is an inherited antigen on RBC surface
    • Dd, Cc, Ee are antigens
    • Rh-D presence is Rh+
    • Rh-D absence is Rh-
26
Q

Rh negative pregnant women

A
  • Pt produces IgG antibodies in response to Rh+ fetal RBC in maternal circulation
    • Sensitization through previous pregnancy, transfusion, trauma causing maternal/fetal blood to mix
  • IgG crosses placenta; coated erythrocytes are destroyed in reticuloendothelial system causing fetal hemolytic anemia, hydrops and fetal death
  • Mom given IM RhoGam to prevent sensitization
  • RhoGAM (anti-D immune globulin) given at 28 wks, within 72 hrs of delivery, and any time there is a potential cross of blood from baby to mom (amnio, injury/accident such as MVA, SAB, ectopic pg, etc)
27
Q

fetal hydrops

A
  • Transverse ultrasonographic sections of the head (left) and chest (right) of a fetus with hydrops fetalis
28
Q

initial prenatal evaluation

A
  • At risk mothers should also be screened for:
    • Gonorrhea
    • TB
    • Toxoplasmosis, Chagas disease
      • Chagas disease = trypanosomiasis; parasite that causes African sleeping sickness, can cause chronic disease and affect fetus
    • Hep C Ab
    • Varicella immunity
    • BV, Trichomonas, HSV
    • Lead level
  • Testing for genetic disorders:
    • Advanced maternal age (35 years and over)
    • Thalassemia (Asian, Mediterranean background)
    • Hemoglobinopathies (African Americans)
    • Tay-Sachs (Ashkenazi Jewish)
    • Cystic fibrosis (carriers)
29
Q

prenatal screening

A
  • All women should be offered screening for Down syndrome and other genetic abnormalities
  • Noninvasive screening tests:
    • First trimester combined test
    • Integrated Screening
  • Diagnostic tests if positive screening:
    • CVS
    • Amniocentesis
  • Choosing the appropriate test can be very confusing! Individual counseling for each patient is recommended.
  • First trimester combined test
    • NT and CRL plus PAPP-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
  • Cell-free free fetal DNA maternal serum markers
    • Genomic sequencing to detect T21, T18, T13 after 10 wks gestation
  • PAPP-A = pregnancy-associated plasma protein-A (maternal serum marker)
  • uE3 = unconjugated estriol (maternal serum marker)
  • NT= nuchal translucency (by US)
  • CRL = crown rump length (measurement of GA by US)
  • Quadruple screen is serum AFP, uE3, hCG, inhibin A done at 15-18 wks (up to 22 wks) for women who missed the first trimester screening option – no US for CRL or NT associated with screening, which makes it different from integrated screen
  • Integrated screening 85-95% predictive detection rate, lowest false positive rate
  • Harmony test 98% predictive detection rate, low false positives
  • Cell-free free fetal DNA maternal serum markers recommended by ACOG for women with singleton gestations at increased risk of fetal aneuploidy, including:
    • Maternal age ≥35 years at delivery
    • Presence of sonographic findings associated with fetal aneuploidy
    • History of previous pregnancy with fetal trisomy
    • Parental balanced robertsonian translocation with increased risk of trisomy 21 or 13
    • Screen-positive result for aneuploidy on screening tests such as the first trimester combined test, integrated test, sequential test, or quadruple test
30
Q

nuchal translucency

A
  • An ultrasonic examination to measure the amount of fluid accumulation behind the baby’s neck
  • Non-invasive test
  • Identify increased risk for Down syndrome
  • Offered to women of all ages 11-14 weeks
  • 90% of fetuses with an NT of 3 mm at 12 weeks gestation are normal at birth
    • 10% have major abnormalities
  • Normal
  • Trisomy 21
31
Q

integrated screen: summary

A
  • Integrated Screen will detect up to 92% of babies affected with Down Syndrome and up to 90% with Trisomy 18
  • It will also detect up to 80% of babies that have open neural tube defects such as Spina Bifida
  • The first and second trimester results are combined, so risk assessment available when second trimester blood work is completed
32
Q

prenatal screening management

A
  • Screen negative test
    • Risk of fetus having Down syndrome is less than chosen cut-off value (provided on report)
  • Screen positive test
    • US should be done if not already
    • Genetic counseling
    • Diagnostic fetal karyotyping
      • CVS in 1st trimester
      • Amniocentesis in 2nd trimester
  • Harmony test can be used as a secondary screening test in women who screen positive for T21 with integrated or quad screen; if positive, still needs to be confirmed by karyotype, but if negative can provide reassurance and avoid invasive testing.
33
Q

chorionic villus sampling

A
  • looks for genetic defects in baby
    • Indications
      • 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 (Tay-Sachs, cystic fibrosis, inborn errors of metabolism)
    • Contraindications
      • IUD
      • Cervical Stenosis
      • Bleeding
      • PID, HSV, GC
  • Performed at 10-12 weeks gestation
  • Provides earlier detection
    • Identify chromosomal problems early: Down Syndrome, Cystic Fibrosis, Tay-Sachs Disease, Sickle Cell Disease
  • Procedure: removal of tiny piece of tissue from the placenta
    • Needle inserted through the abdomen or catheter through cervix with ultrasonic visualization
    • Cultured for karyotype analysis
  • Genetic Counseling at 10-12 wks
  • Transabdominal or transcervical
  • Karyotype result in 2-3 weeks
  • 0.8% risk pregnancy loss
    • (1:100 – 1:150)
34
Q

amniocentesis

A
  • significantly lower risk than CVS
    • Indications:
      • 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
    • lecithin/sphingomyelin (L/S) ratio for fetal lung maturity
  • Under ultrasound guidance, small amount of amniotic fluid removed through the abdomen – cultured/karyotyped
  • Detects most chromosomal disorders with high degree of accuracy: Down syndrome, Tay-Sachs disease, Neural tube defects, spina bifida, and more
  • Risk of miscarriage as a result of amniocentesis
    • 1 in 400 or less
  • Genetic Counseling 16 wks
  • Ultrasonic visualization
  • 20 cc amniotic fluid
  • Culture fetal fibroblasts
  • Karyotype for genetics
  • Result 2-3 weeks
  • Pregnancy loss <1:400
35
Q

advantage/disadvantages of CVS over amniocentesis

A
  • Advantage
    • Performed earlier in pregnancy – 10 to 12 weeks rather than 15 to 20 weeks
    • Results are available by the end of the third month
  • Disadvantage
    • Spinal cord defects cannot be detected
    • Ultrasound performed later in pregnancy to screen for spinal cord defects
    • Higher rates of pregnancy loss
36
Q

other prenatal testing

A
  • 24-28 weeks
    • GDM screening with GTT
    • Rhogam if Rh(-) at 28 wks
      • RhoGAM = anti-D immune globulin 300mcg at 28 wks and within 72 hrs postpartum
  • 35-37 weeks
    • Vaginal & rectal swab for GBS – most common for babies to have meningitis = GBS
37
Q

milestone visits

A
  • 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, Amnio if high risk
  • 24-28 wks: GTT for GDM, Antibody screen if Rh(-) and RhoGAM, Hgb/Hct
  • 35-37 wks: GBS screen

Obstetrics (14 decks)

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