Prenatal Care Flashcards
When are prenatal care visits scheduled for a low-risk pregnancy?
Pre-conceptual counseling Prenatal visit every 4 wks for 24-28 wks every 2 weeks 28-35 wks every week from 36, 40-41 wks 2x/wk if 40+
In a perfect world, when should women start the prenatal process?
before pregnancy happens!
What occurs at preconception counseling?
- Folic acid-4mg per day
- Calcium and iron
- Prenatal vitamins
- Dietary concerns
- Exposures (workplace, environmental, medicinal)
- Manage chronic dz
- Switch meds if necessary to meds that are safe in pregnancy
Pregnancy is generally considered to be ___ calendar months or ___ weeks.
10 mo
40 wks
**This includes the 2 “free weeks” prior to the fertilized ovulation.
If a patient had any assisted reproduction, IUI, IVF (embryo transfer) or ovulation induction, then dates should be based on _____
ovulation date
If LMP is uncertain or unreliable, what can be used to estimate how many weeks the pregnancy is?
U/S
How do you use U/S to estimate how far along the pregnancy is?
measure fetal C-R (crown-rump)
Fetal C-R (crown rump) length between 6-11 weeks can define gestational age to ____ days
+/- 7 days
Fetal C-R (crown rump) length between 12-20 weeks: U/S should define gestational age to __days
+/- 10
After 20 weeks: U/S estimate is ____ days of accuracy
+/- 14-20
What Information about prior pregnancies can alert you to possible problems in the present pregnancy?
- Gravity and Parity
- wt and length of previous children at birth
- previous labor experience
- maternal/infant complications
How do you write out a patient’s Gravidity and Parity?
G \_\_(how many times the woman has been pregnant P _1_, \_\_2_, _3_, _4\_\_
- full term delivery
- pre-term delivery
- mis-carriages
- live births
What 6 dzs can affect the outcome of the pregnancy and must be investigated?
DM HTN Cardiac Pulmonary Autoimmune Renal dz
Other than dz, what other PMHx do you need to know in a pregnant woman?
Prior surgeries (esp obstetric surgeries)
allergies
meds
Previous trauma (esp to bony pelvis)
What FHx chronic dzs do you need to know about?
DM HTN Heart disease CA Anemia Bleeding disorders
Why is the PE important at the initial prenatal visit?
- detect undx illness that can affect pregnancy
- est baseline levels (this helps guide tx later)
- eval pelvic inlet/outlet
____ is used to determine blood type
Blood group
___ is used to detect anemia
Hgb
Hct
___ is used to screen for syphilis
Rapid plasma reagin (RPR)
venereal dz test (VDRL)
What other infectious dz do you need to screen for?
rubella
chlamydia
Hep B/C (surface antigne)
HIV
___ is used to detect infection or renal dz (protein, glucose, ketones)
UA
___is used to scree for cervical neoplasia
papanicolaou (pap) test
___ is used to screen for DM
glucose
What other testing may you order for at risk pts?
- genetic testing (sickle cell)
- CF screening
- early glucose if +FHx for DM or high BMI
What is included in the TORCH infections you worry about?
- Toxoplasmosis-cat feces;
- Varicella
- CMV
- HIV
- Parvovirus B 19
- HSV–
- Group B strep
What can happen to the fetus if a mother has toxoplasmosis?
Blindness (cat poop on their eyes) mental retardation (cats are retarded) (just a way to remember it people)
What can happen to the fetus if a mother has CMV?
Retinitis
What can happen to the fetus if a mother has HIV?
High risk of vertical transmission in vaginal delivery
- C/S mandatory
What can happen to the fetus if a mother has Parvovirus B19?
hydrops (heart failure of the fetus)
What can happen to the fetus if a mother has HSV?
encephalopathy, blindness
What can happen to the fetus if a mother has Group B strep?
PNA, sepsis– (see 3rd trimester)
What are the autosomal recessive traits you need to screen in a pregnant woman?
- Sickle cell (AA parent)
- Thalassemia
- CF (Caucasian parent)
- Tays-Sachs and other dz (Ashkenazi, FHx)
- Sex linked disorders (e.g. Fragile X) also exist–primarily affect males. Screen if risk factors exist
What are potential teratogens during pregnancy that are not medications?
Alcohol
Smoking
Illicit drugs
Work exposures
What are teratogens during pregnancy that are medications?
Warfarin (coumadin)– early SAB IUGR, craniofacial/CNS
Antineoplastic agents (chemo): designed to kill rapidly-dividing cells
Retinoids: Category X
DES (Diethylstilbestrol)
___ is prenatal alcohol exposure and central nervous system (CNS) involvement.
Fetal Alcohol Spectrum D/o
What are facial features of a child w/ Fetal Alcohol Spectrum D/o?
small eye openings
smooth philtrum
thin upper lip
What are s/s of Fetal Alcohol Spectrum D/o in the CNS? (structural vs functional)
structural
- mall brain size
- alterations in specific brain regions
functional
- cognitive and behavioral deficits
- sensory processing deficits
- motor and coordination problems
About __-__ % of women have reported drinking at some point during pregnancy—most typically during the 1st trimester
20 to 30%
> __ % of women have reported binge drinking at some time during pregnancy—most typically during the 1st trimester
8%
> __ % of pregnant women reported drinking alcohol in the previous month
9%
> __ % of pregnant women reported binge drinking in the previous month (4+ drinks per occasion)
2%
What sz meds can cause problems in the fetus? (x4)
Phenytoin
Valproic Acid
Carbamezapine
Phenobarbital
What issues occur in the fetal w/ phenytoin use?
craniofacial and limb reduction
What issues occur in the fetal w/ Valproic acid use?
1-2% risk of NTD
What issues occur in the fetal w/ carbamazepine use?
Elevated NTD risk
What issues can occur in the pregnancy w/ phenobarbital use?
withdrawal
maternal/ fetal hemorrhage
If a woman does not take her anti-sz meds for a known sz d/o, what is she at risk for?
Maternal/fetal trauma from falls or burns increased risk of premature labor miscarriage fetal hypoxia lowering of the fetal HR.
What should you advise pregnant women about? (S/S of pregnancy)
N/V/C Heartburn Hemorrhoids Varicose Veins Leg cramps (relative hypokalemia) Backache HA acne
First trimester bleeding occurs in __-__% of pregnancies.
Of those pregnancies, __-__ of pregnancy are lost.
20% to 25%
~ 25% -50%.
Risk of pregnancy loss or non-viability increases if: ___ or ____
- Bleeding becomes heavy
- Bleeding is accompanied with cramping or pain
Risk of pregnancy loss/non-viability decreases significantly (to 3-7%) if
____
____
- Intrauterine gestation with + FHR is detected
- BHCG values rise appropriately for gestational age (more on this later)
Overall weight gain in pregnancy is __-__ lbs (for a single gestation)
25-35 lbs
If the initial BMI is <20, how much should the woman gain?
35-45 lbs
If the initial BMI is >35, how much should the woman gain?
15 lbs
Typical wt gain is ___ lb over first 20 weeks, then ___ lb/week thereafter.
10lbs
1lb
What foods should be avoided in early pregnancy? (FYI)
Poorly cooked meats Raw eggs Cold cuts and hot dogs Soft, mould-ripened cheeses (brie, camembert, goat cheese) Unpasteurized cheese and milk Sushi King mackerel, tilefish, swordfish and shark Restrict Caffeine
What can the following foods contain that are dangerous to a pregnancy?
- Poorly cooked meats
- Raw eggs
- Cold cuts and hot dogs
coliform bacteria
toxoplasmosis
salmonella
What can the following foods contain that are dangerous to a pregnancy?
- Soft, mould-ripened cheeses (brie, camembert, goat cheese)
- Unpasteurized cheese and milk
Listeriosis
What can the following food contain that can be dangerous to a pregnancy?
- Unpasteurized cheese and milk
- Sushi
- King mackerel, tilefish, swordfish and shark
Mercury
What is the recommended amount of coffee that is allowed in pregnancy?
< 200 mg/d, or one 12-oz cup of coffee
**know it can be in other food items
In general, what type of vaccines are okay during pregnancy? What types of vaccines are NOT okay during pregnancy?
okay: recombinant
NOT okay: live vaccines
What are live vaccine examples that a woman shouldn’t get?
Rubella
MMR
Varicella
When can live attenuated vaccines be administered around pregnancy?
Must be >3 months before/ after pregnancy
What is a “Blueberry muffin baby”?
A baby born with purpura due to congenital infection– think rubella, but also possible with coxsackie, toxo, hep B, CMV, EBV, and congenital syphilis
What are examples of vaccines that are ok to get during pregnancy?
Influenza
Tetanus
Hep B
Gardasil
What occurs at each visit no matter what trimester it is? (VS etc)
Wt BP U/A Assess for edema fundal ht at 20 wks fetal heart tones
How is fundal ht (FH) measured?
# cm from pubic symphysis to top of fundus **Watch for FH that is > 3 cm above or below gestational age
When should a fetal HR be present and what is the normal rate?
week 12
120-160 bpm
What is not commonly advised in the PE of a pregnant woman?
Routine vaginal exams
Cervical checks
What should you ask about in the first trimester visits (see pt every 4 wks)
(+) heartbeat by doppler by 12 weeks (or confirm by US)
Assess: VS, weight gain/loss
Ask about: N/V, comfort, appetite, bleeding
What can be assessed on U/S to screen for chromosomal abnormalities?
- Normal nuchal translucency (widened is abnormal)
- absence of nasal bones (abnormal)
What serum levels are used to assess fetal abnormalities?
b-hCG
PAPP-A
__-__% of pregnant women experience nausea and vomiting during pregnancy (NVP)?
70-80 %
N and V can begin at __-__ weeks gestation and can last into ___ trimester. but usually resolves by __weeks
4-6 weeks
2nd trimester
16 weeks
What contributes to N/V during pregnancy?
Hormonal influences
Hypoglycemia
What can you do to help a woman manage N/V associated w/ pregnancy?
- Rest
- several small meals a day
- BRAT (bananas, rice, applesauce, toast)
- carbohydrate snacks at bedtime
- Ginger
- Sea bands
___ is severe nausea and vomiting of pregnancy
Hyperemesis Gravidarum
What are s/s of Hyperemesis Gravidarum?
- Persistent V and inability to tolerate p.o.
- Wt loss >5% of pre-pregnancy wt.
- Dehydration (PE findings, orthostasis, ketonuria)
- Electrolyte abnormalities
If severe, how can you tx Hyperemesis Gravidarum?
- IV hydration (break the cycle)
- PO or IV antiemetics (Phenergan, Zofran)
- GI motility drugs (Reglan)
- Goal = toleration of PO liquids
- Some wt loss can be tolerated– fetus will do okay
IF ADMITTED for Hyperemesis Gravidarum, what should you do?
U/s to r/o multiple gestation and placental abnormalities (molar pregnancies)
Thyroid assessment to r/o Graves
What causes heartburn during the 1st trimester?
progesterone relaxes the cardiac sphincter of the stomach and allows reflex of gastric contents into the esophagus
What causes heartburn during the 3rd trimester?
pressure of the growing uterus on the stomach
How can you manage heartburn during pregnancy?
- Avoid lying flat
- Sleeping w/ more pillows
- lying on the right side
- Small frequent meals
- Avoid late night meals
- Antacids
- Avoid fried ,spicy, and fatty food and citrus
What causes urinary frequency?
Pressure of the growing uterus on the bladder
Increased GFR
Urinary frequency improves when the uterus rises into the abdomen after the __week.
Then, urinary frequency worsens again in __ trimester.
12th
3rd
How can you manage urinary frequency during pregnancy?
Kegel exercises
Frequent urination
Watch for S/Sx UTI
What causes varicosities during pregnancy?
Progesterone relaxes venous smooth muscle, then causing slowed venous return
Valves of the dilated veins become insufficient
Wt of the uterus causes partial venous compression from the legs
How do you manage varicosities during pregnancy?
Elevate feet
Pump leg muscles
**Watch for evidence of DVT
What causes constipation in pregnancy?
progesterone
iron supplementation
What can you do to manage constipation during pregnancy?
Eat diet including fruit and green vegetables, which contain fiber Drink a lot of water Exercise and walking Stool softeners OTC laxatives (mild) prn
What should be performed during the 2nd trimester? (every 4 weeks)
Fetal Trisomy/NTD Screening
U/S for Fetal Anatomic Assessment
Typically, the fundal height in cm’s should = what?
the # weeks gestation (+/- 3 cm)
What should you think if the fundal height is abnormal?
Large for gestational age (LGA) Small for gestational age (SGA) Too much fluid (polyhydramnios) Too little fluid (oligohydramnios) Abnormal fetal lie (transverse, breech
When is fetal movement first noted by the pt?
~18 - 22 weeks
**felt earlier in subsequent pregnancies
When is fetal movement typically first felt by an examiner?
after 20-24 wks
___(fraction) pregnancies have recognizable chromosomal abnormalities
1/300
95% of chromosomal abnormalities are Trisomy ___, ___, ___ or changes in ___ and ___
Trisomy 21, 18, 13
changes in X and Y
Most chromosomal abnormalities result in ___ syndrome
down syndrome
T/F: Increasing maternal age increases risk of chromosomal abnormalities
T
When is a woman considered to be of advanced maternal age?
> 35 y/o
**does not take partner age into account
Overall risk of Trisomy 21 is 1/800 at age ___; increases to 1/300 by age __
35 y/o
39 y/o
Trisomy risk overall is ___ (fraction) in the 40-45 range, and is __ (fraction) by age 46
1/80
1/20
What are the benefits of prenatal screening and dx?
parental reassurance
Prenatal dx may allow women to undertake a pregnancy they might not have otherwise undertaken
How are fetal screenings beneficial if an abnormality is detected?
Increased parental options
Altered obstetric management
Facilitated neonatal management
What is the risk of prenatal screenings?
Parental anxiety
Pregnancy complications- ROM, infxn, PTL
Pregnancy loss
> ___% of structural and chromosomal fetal abnormalities are born to low risk women
90%
T/F: Maternal age alone is a reliable screening tool
F: It is a poor screening tool– Only detects about 30% of DS cases
What are the options for Prenatal Screening for Down Syndrome (DS) and trisomy 18?
- Integrated Prenatal Screening (IPS)
- Serum Integrated Prenatal Screening (SIPS)
- 1st Trimester Screening (FTS)
- Quadruple maternal serum screening (Quad Screen)
- Maternal serum screening (Triple Screen)
What are prenatal diagnostic tests for DS and trisomy 18?
Amniocentesis/CVS
What are the 2 steps of Integrated Prenatal Screening (IPS)? When are they performed in terms of the pregnancy? Ideally?
1st Trimester (11-13+ 6/7 weeks – ideally week 11)
- Nuchal translucency measurement
- PAPP-A (pregnancy-associated plasma protein)
2nd Trimester (15-20 weeks – ideally week 15-17) - AFP, uE3 (estriol), hCG
What is the down side of Integrated Prenatal Screening (IPS)?
A single risk assessment number is produced in second trimester – so patients learn whether or not they are at risk in the second trimester- not the first.
What is the most common reason for false + screening results in pregnancy?
#1: wrong estimated delivery date #2: multiple gestation
What anatomical location is used in the First Trimester Nuchal Translucency screen? ( just a description)
Subcutaneous fluid-filled space located between back of fetal neck and skin
First Trimester Nuchal Translucency screens are measured on U/S between __-__ weeks, [measurement (is not valid/is valid) outside of this time period]
11–13 weeks
Is not valid
Great if NT measurement is not available, ____ can be used and is a 2 step approach that combines first and second trimester serum markers to produce a single risk assessment
Serum Integrated Prenatal Screening (SIPS)
What is included in the Serum Integrated Prenatal Screening (SIPS)?
First Trimester:
PAPP-A: 11-13+6/7 weeks (11 wks is ideal)
Second Trimester:
AFP, uE3, hCG, Inhibin-A: 15–20 weeks (15-17 wks is ideal)
During which trimester can an anatomic survey be performed?
2nd trimester
What can be offered if a screen comes back (+)?
Chorionic sampling
Amniocentesis
What are the risks of chorionic sampling
and amniocentesis? (x2)
invasive
risk for miscarriage
Which has a higher miscarriage risk, chorionic sampling or amniocentesis?
Chorionic sampling
When can chorionic sampling be performed? (weeks)
Amniocentesis? (weeks)
C: 10-13 wks
A: 15-22wks
When is a level 2 US performed?
What is it looking at? (FYI)
16-20 weeks
Brain, spine, face, thorax, heart, gastric bubble, intestines, kidneys and bladder, fluid, limbs, placenta, cord, cervix, and gender.
What is the lemon sign indicative of?
Arnold-Chiari Malformation and spina bifida
What causes the lemon sign (pathophysiology)?
Bones in anterior skull curve inward because of abnormal drainage in the posterior fossa
Estimating gestational age can be performed using what measurements?
Abd circumference
Head circumference
Biparietal diameter (BPD)
Femur length
In the 3rd trimester, it is recommended to have an appointment every __ weeks until 28 week(s), then every __ week(s) until 36 weeks, then every ___ week(s) until delivery
4 wks
2 wks
every week
At 32 weeks the baby weighs ~__ lbs and has a ___% chance that lungs will not be mature
4 lbs
50%
At 36 week the baby will weight ~___ lbs, and has a __% chance that lungs are not quite developed
6 lbs
1%
At what point would a “knot “ in the cord be most likely?
At birth
the knot has been made, but not pulled tight until labor
What is included in 3rd trimester appointments?
- VS including weight, BP (all trimesters!)
- FHT’s (every visit after 12 weeks)
- Evidence of labor, PTL
- Presenting part (mid to late 3rd) - Cervical exam at 39 weeks or prn
- Fetal Movement evaluation (28-30 wks)
What is worrisome in the 3rd trimester (FYI) (x10)
- Vaginal bleeding (including spotting)
- Persistent abdominal pn
- Severe and persistent V
- Sudden gush of fluid from vagina.
- Absence or decreased fetal movement.
- Severe HA
- Edema of hands, face, legs and feet.
- Fever above 100 F (>37.7C).
- Dizziness, blurred vision, double vision and spots before eyes.
- Painful urination.
If the abdomen is longer, the fetal lie is ____ (which it is 99.5% of the time)
If the abdomen is lower and broad, the fetal lie is ___
longitudinal
transverse
Normal fetal heart rate is ___-___ beats/min
120-160
What are the Leopold Maneuvers used for?
When do they become most important?
To determine what position the baby is in
Important at ~34 wks
__-__% of fetuses at 24-28 weeks; __% at 36 weeks
are in the breech position
30- 40%
5% (the odds of them flipping is low bc of size)
Breech position is associated with poor delivery outcome, _____ improves outcome over vaginal delivery,
c-section (c/s)
Why should you perform a leg inspection in the 3rd trimester?
What s/s are you looking for?
dx preeclampsia and DVT
- edema
- calf redness
- phlebitis
- tenderness
What complication is hyperreflexia associated w/ in pregnancy?
Preeclampsia
T/F: Mild increase in vaginal d/c is abnormal and signifies issues with the placenta
F: Mild increase in vaginal discharge is normal in pregnancy
STD and symptomatic BV are risk factors for ___
Pre-term labor
How should a pregnant pt count fetal kicks?
When should they start monitoring this?
What is normal count?
Pt should sit quietly and observe fetal movement once daily
Start monitoring after ~30 weeks
10+ movements in 2 hours
Absence of fetal movements usually precedes intrauterine fetal death by ___hours
48 hrs
Why is an U/S performed in the 3rd trimester? (x3)
Check amniotic fluid volume
Check the position of the placenta and baby
Assess fetal well-being (BPP)
If a baby is in the breech position, what can be done to turn the baby into the correct position?
external cephalic version
What could cause a loss of amniotic fluid? (x5)
When would these occur?
SROM- spontaneous rupture of membranes– usually at term during labor
PROM-premature rupture of membranes– rupture of membranes prior to the onset of labor
PPROM– preterm premature rupture of membranes– prior to 36 weeks
AROM- Artificial rupture of membranes– during labor caregiver
LOF- typically used to describe the patient perception of fluid leaking from vagina
What is a common cause of backache during pregnancy?
Increased lordosis during pregnancy in an effort to balance the body
RELAXIN
How do you manage back pain in a pregnant women?
Exercise
Sit with knee slightly higher than the hips
When do you screen for Gestational DM?
at 24-28 wks gestation
In what patients should you screen for gestational DM prior to the regular screening time?
Screen for gestational DM prior to 24-28 weeks gestation is the pt has the following risk factors
- FHx of DM or GDM
- PMHx of metabolic syndrome
- Obesity (>30)
In which populations does Gestational DM most commonly occur?
Hispanic
AA
Asian
Pacific Island
What are complications of gestational DM
Macrosomia
Neonatal hypoglycemia
Hyperbilirubinemia
How do you screen for GDM? What would a positive result be?
Screen w/ 1 hour, 50-gram glucose test
Positive if > 140 (some use >135)
If GDM screen is abnormal, what do you do next? What would be considered a positive result?
- blood taken before intake
- test a 1/2/3 hr glucose tolerance test:
positive if 2 of the 4 levels are high, or if the FBS is high.
If diagnosed with GDM, the pregnancy becomes ‘___’ and visits are indicated how often?
Higher risk
Weekly
____ wks is considered term
____ wks is considered post term
37
42
Group B Strep is associated with ___, ___, and ____ if an infant delivers through a GBS colonized birth canal
sepsis
pneumonia
death
A vagina swab is performed at ___ wks to screen for group B strep and, if positive, abx are required
36 weeks
T/F: GBStrep is a normal colonization in vaginal flora
T
What are Braxton hicks contractions? What is their purpose?
Runs of contractions which may be irregular, <3 per 10 minutes
** for preparation of cervix for delivery
____ is the disturbance of the connections between the cervix and fetal membranes. Evidence shows that this can (slow down/speed up) the onset of labor
stripping membranes
sweeping membranes
Speed up–> can go into labor w/in 48 hrs
What must you determine the location of prior to stripping membranes?
Determine the location of the placenta
Increased risk of stillbirth and neonatal/perinatal death after ___ weeks
42 weeks
At what week(s) do you induce? (3 different times, and why)
42 weeks
39 wks if cevix is favorable
earlier if complications exist
What is a Poor Bishop’s score is associated with?
Prolonged labor and risk of C-Section
Is it recommended to scheudle a Cesarean Delivery at Term for Suspected Macrosomia? Why or why not?
In general, no- because we are very bad at diagnosing it
When predicting fetal weight…
Ultrasound is better when the fetus is less than ____grams
Clinical estimate is better from the ___-___ gram range
At ____ grams, both methods are inaccurate (usually off by >__%).
2500 g
2500-4000g
4000+g
>15%
T/F: Postdate pregnancies = increased risk for both SGA and LGA infants.
T
