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Clin Med > Prenatal Care > Flashcards

Prenatal Care Flashcards

1
Q

Gestational Age (GA)

A

age in days/weeks from the last menstrual period

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2
Q

Embryo

A

from time of fertilization to 8 weeks (GA 10 weeks)

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3
Q

Fetus

A

after 8 weeks to time of birth

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4
Q

Infant

A

time between delivery and 1 year old

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5
Q

First trimester

A

1st 14 weeks

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6
Q

Second Trimester

A

14-28 weeks

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7
Q

Third Trimester

A

28 weeks until after delivery

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8
Q

Previable

A

infant delivered before 24weeks

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9
Q

Preterm

A

24-37 weeks

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10
Q

Term

A

37-42 weeks

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11
Q

Post term

A

past 42 weeks

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12
Q

Gravidity

A

number of times woman has been pregnant

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13
Q

Parity

A

number of pregnancies led to birth after 20 weeks (or >500g infant
Term, Preterm, Abortions, Living Children

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14
Q

Goals of Prenatal Care

A
  • accurate estimate of gestational age
  • deliver healthy, term infant without impairing maternal health
  • identify and treat high risk patients
  • patient education
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15
Q

Maternal Physiology: Cardiology

A

Output increases
stroke volume increases
pulse increases (15-20BPM)
systolic ejection murmur and S3 gallop common
PVR falls
Fall in BP in 2nd trimester, return to normal in 3rd trimester

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16
Q

Maternal Physiology: Respiratory System

A
  • Unchanged: RR, VC, Inspiratory reserve volume
  • Decreased: functional residual capacity, expiratory reserve volume, residual volume, TLC
  • Increased: IC, TV
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17
Q

Maternal Physiology:

Renal System

A
  • increased kidney size and weight, ureteral dilation, bladder becomes intra-abdominal organ
  • GFR increases 50%
  • CrCL increases 150-200cc/min
  • BUN and serum Cr decrease by 25%
  • increase in tubular reabsorption of sodium
  • marked increase in renin and angiotensin but reduced vascular sensitivity to their hypertensive effects
  • increased glucose excretion
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18
Q

Maternal Physiology:

Hematologic System

A
  • plasma volume increase 50%
  • RBC volume increase 30%
  • WBC count increases
  • platelet count decreases ( But still WNL!)
  • increases fibrinogen, factors 7-10 (hypercoaguable state)
  • placenta produces plasminogen activator inhibitor
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19
Q

Maternal Physiology: GI system

A 
decreased motility (due to progesterone)
reduced gastric acid secretion
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20
Q

Maternal Physiology: Uterus

A 
weight increases (70-110g)
blood flow increases to about 750cc/min or 10-15% of CO (significant: risk during c-section)
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21
Q

Maternal Physiology: Cervix

A

increased water content and vascularity

increases cervical mucous secretions

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22
Q

Diagnosis of Pregnancy

A

Confirm –>HCG (urine as sensitive as serum)
-can be positive 1wk after fertilization

Viable pregnancy

  • TVUS shows gestational sac as early as 5wks or 1500-2000HcG
  • shows fetal HR as early as 6wks or 5000-6000HcG
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23
Q

First questions to ask pregnant female

A

Was it planned?

Are you planning to continue this pregnancy?

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24
Q

History of Prenatal Patient

A

Menstrual Cycle
Previous pregnancies–>complications
Dating
PMH: HTN, DM, asthma, depression, bladder or kidney infections, bleeding/clotting disorders, anesthesia problems
PSH: C-sections, cervical procedures, abdomino-pelvic surgeries
Allergies
Genetic Hx

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25
Q

High Risk for Pre eclampsia

A 
High BP (chronic or in prior pregnancy)
DM1 or 2
Twins/triplets 
Renal disease 
Autoimmune disease
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26
Q

Moderate Risk for Pre eclampsia

A 
1st baby
BMI>30
mother/sister with it 
AA
receive public health insurance (low ses)
35 or older 
Hx of LBW
previous miscarriage/complicated pregnancy 
>10yrs since last pregnancy
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27
Q

Prevention of Pre eclampsia

A

81mg daily ASA orally from 12 weeks until delivery if:

  • any high risk factor
  • 2 or more moderate RFs
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28
Q

Important Questions to ask Prenatal Patient

A

Financial concerns
Domestic Violence
-homicide leading cause of pregnancy-associated death in 90s
-RFs: age <20, AA, late/no prenatal care
Other Stressors
-access to healthcare
-unplanned pregnancy
-substance abuse (5 Ps Screening Tool!!!)

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29
Q

Chadwick’s sign

A

bluish discoloration of vagina and cervix

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30
Q

Hegar’s sign

A

softening of uterine consistency and ability to palpate/compress the connection between the cervix and funds

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31
Q

Goodell’s sign

A

softening and cyanosis of the cervix at or after 4 wks

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32
Q

Ladin’s sign

A

softening of uterus after 6 weeks

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33
Q

Other pregnancy signs

A

Breast swelling/tenderness
Linea nigra
Telangiectasias
Palmar erythema

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34
Q

Pregnancy Sx

A 
Amenorrhea 
N/V
Breast pain 
Fatigue 
Quickening (fetal movement)
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35
Q

Initial PE

A 
Vitals 
Thyroid 
Heart 
Lungs 
Breast (teach BSE/discuss BF)
Abdomen 
Pelvic (pap, GC/CT, bimanual)
Extremities: edema 
Influenze Vax 
\+/-US
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36
Q

Nagele’s Rule

A

Dating Pregnancy

Calculate EDC by subtracting 3 mos from LMP + 7 days

Uncertain LMP–>US to determine EDC

  • most accurate in 1st trimester
  • measure by crown-rump length in the 1st half of 1st trimester (usually accurate to within 3-5 days)
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37
Q

1st Trimester Labs

A 
CBC
Blood type and screen 
RPR/VDRL 
Rubella antibody screen 
Hep B surface antigen 
VZV titer 
HIV 
Gonorrhea and Chlamydia cultures 
Pap smear 
Urinalysis and Culture 
\+/-PPD 
GTT if BMI>30
\+/- CF, Taysachs, SMA, other genetic tests
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38
Q

CBC

A 
Initial labs and 28wks 
Slightly evaluated WBC normal 
Dilutional anemia normal 
-start iron and colace when Hct <32%
Consider Thalassemia if MCV is low 
Thrombocytopenia can be normal 
-caution <100!
39
Q

Type and Screen

A
  • if Rh negative –>patient will need Rhogam at 28wks or anytime she has vaginal/uterine bleeding
  • Ab screen positive: consult perinatologist
  • ->Rh antibodies can destroy fetal RBCs causing hemolytic anemia (can be fatal to fetus)
40
Q

GDM Screening in 1st Trimester

A
  • BMI>30
  • prior pregnancy with GDM or previous infant >4000g (9lbs)
  • high risk ethnicity: AA, latino, Native American, asian American, Pacific Islander)
  • HgbA1c>5.7% or hx of known impaired glucose metabolism (PCOS, DM)
  • physical inactivity
  • 1st degree relative with DM
  • HTN
  • Hx of CVD: HDL <35mg/dL or Triglyceride >250mg/dL
41
Q

GDM Screening Results

A
  • Pass 1st trimester–>repeat at 24-28weks
  • Fail 1st trimester, 3hr GTT is done
  • passes 3hr GTT–>repeat GTT at 26-28 weeks
  • Fails 3hr GTT–>dx of GDM
  • 1st trimester DS>200, dx of GDM
42
Q

GDM Screening (all patients)

A

24-28wks
GLT: glucose loading test
GTT: glucose tolerance test –>DIAGNSOTIC

43
Q

GLT : Glucose Loading Test

A

50g oral glucose loading dose and check serum glucose 1 hr later

> 130mg/dL–>do GTT

44
Q

GTT: Glucose Tolerence Test

A

DIAGNOSTIC

  • fasting serum glucose
  • 100g oral glucose loading dose
  • serum glucose at 1, 2, 3 hrs after oral dose
  • elevation of 2/more values=GDM
45
Q

RPR/VDRL

A

rapid plasma regain/venereal dz research lab –> SYPHILLIS

*pregnancy is a risk for false positive

  • if reactive –>check FTA-ABS
  • fluorescent treponemal antibody-absorption
  • consult perinatologist
  • 50% untreated syphillis leads to infected baby
  • risks: miscarriage, stillbirth, neonatal death, baby with severe neurological problems
46
Q

Rubella

A

administer vaccine post partum if non-immune

47
Q

HBsAg : Hep B surface antigen

A

detects 1-12 weeks post exposure

  • HBsAb=recovery and immunity
  • HBeAg= acute infection
  • diagnosed with IgM HBcAB

chronic infection diagnosed by IgG HBcAB (no IgM)

*if pt. infected–>notify Peds

48
Q

Gonorrhea and Chlamydia

A

DNA probe, swab mucus and insert into os

  • if positive-
  • treat patient and partner, -promote abstinence during treatment
  • test of cure 4wks after tx
49
Q

CF Carrier Screening

A
  • offer at pre conceptual or new OB visit
  • increased change of carrying if close relative affected or being white
  • tests for 33 mutations on chromosome 7
50
Q

Tay Sachs

A
  • mutations in HEXA gene
  • AR inheritance
  • accumulation of gangliosides in CNS causes early childhood death
  • carrier testing should be offered when at least 1 parent is
  • Ashkenazi Jewish (1/30 carrier frequency)
  • Pennsylvania Dutch
  • Southern Louisiana Cajun
  • Easter Quebec French Canadian Descent
51
Q

Spinal Muscular Atrophy

A
  • progressive muscle weakness and paralysis
  • 1 in 50 regardless of ethnicity are carriers of gene
  • both parents carries –>1 in 4 chance
52
Q

Screening for Fetal Chromosomal Abnormalities

A

should be offered to all women before 20 weeks regardless of maternal age

type of screening is patient dependent (risks/desires)

53
Q

Maternal Serum Screening

A

offered to all, most important for AMA

MS-AFP, First screen and NIPT testing

54
Q

Sequential Screening

A

1a: Blood test for serum levels of PAPP-A and free B-hCG (11-13wks)
1b: US for nuchal translucency (11-13wks)

Part II: blood test for serum levels of MS-AFP, estriol, B-hCG, and inhibit (15-18wks)

  • part I detects 70% DS, 80% trisomy 18
  • part II detects 95% DS, 90% t18 and 80% NTD
  • detection of DS in twins (dizygotic) 80% and monozygotic 93% (no T18)
  • not recommended for triplet +, fetal anomaly or reduction of fetus
55
Q

Alternatives for patients late to prenatal care (fetal chromosomal anomaly screening)

A
  • MSAFP (16-18wks)
  • elevated: increased risk of NT defects
  • decreased: DS/aneuploidies

*NIPT

  • US (18-20weks)
  • fetal survey, amniotic fluid volume, placental location and gestational age
56
Q

Quad Screen

A
  • MSAFOP, HCG, estriol, inhibin A
  • detects Trisomy 21, 18, and NTD
  • between 15-18wks (up to 20)
  • cannot be used for multiple gestations, screening test only
  • positive:
  • refer to genetic counseling
  • high resolution US
  • +/-amniocentesis
57
Q

Advanced Maternal Age (AMA)

A

women 35 or older at time of delivery

offer maternal serum screening

offer NIPT

offer genetic counseling with possible diagnostic test
-CVS or amniocentesis

58
Q

NIPT Recommendations

A
  • AMA (>35)
  • Fetal US findings indicating increased risk of aneuploidy
  • HX of prior pregnancy with trisomy
    • test result for aneuploidy (1st trimester, sequential or quad screen)
  • parental balanced robertsonian translocation with increased risk of fetal trisomy 13 or 21
59
Q

NIPT: Non-invasive Parenteral Testing

A

*cell-free fetal DNA (cfDNA) testing for fetal trisomies (21, 18, 13) in maternal blood

  • 99% detection for DS
  • 98% for trisomy 18
  • 70-90% Trisomy 13
  • detection of abnormal # of sex chromosomes 99%
60
Q

NIPT additional considerations

A
  • no in twins (including vanishing twins)
  • should not substitute other diagnostic testing
  • indeterminate result?
  • genetic counseling
  • detailed US
  • other diagnostic testing
  • risk with obesity >200lbs
61
Q

Ultrasound

A
  • at initial visit to measure CRL if uncertain LMP
  • 1st trimester bleeding
  • anatomy survey b/t 18-20wks
  • any time fundal height is >3cm discrepant from Ga
  • confirm presentation at or after 37 wks
62
Q

Amniocentesis

A
  • 15-20wks to obtain fetal karyotype
  • procedure related loss 1 in 300-500
  • complications: transient vaginal spotting, amniotic fluid leakage, preterm labor, chorioamnionitis, and rarely needle injury to fetus
  • <15wks not recommended (high risk)
63
Q

Chorionic Villus Sampling

A
  • obtains fetal karyotype 10-13wks (99%)
  • catheter placed intrauterine cavity, sm amount of chorionic villi aspirated from placenta
  • fetal loss rate same (ish) as amniocentesis
64
Q

Cordocentesis

A
  • percutaneous umbilical blood sampling (PUBS): puncture umbilical vein under direct US guidance
  • karyotype analysis of fetal blood w/in 24-48hrs
  • pregnancy loss rate <2%
  • rarely needed, may be useful to evaluate chromosomal mosaicism discovered after CVS or amniocentesis is performed
65
Q

3rd Trimester Diagnostics

A

*27-29wks
CBC
GLT
RPR/VDRL

  • if high risk–>repeat GC and CT, also HSV screening
  • CXR if PPD+
  • group B strep (36 wks)
66
Q

Group B Streptococcus

A

screen all patients at 36wks

culture lower vagina and anus (must go through sphincter)

PCN allergy, ask for sensitivities

67
Q

Routine Prenatal Vistis

A
  • BP
  • weight
  • urine dipstick (protein and glucose)
  • fundal height, weight and fetal position
  • auscultation of fetal heart tones
68
Q

Frequency of visits

A

less than 28wks: every 4wks

28-36: every 2 wks

> 36: every week

69
Q

1s trimester questions

A

cramping or bleeding?

N/V?

70
Q

2nd trimester questions

A

Cramping/bleeding?

fetal movement?

71
Q

3rd trimester questions

A

contractions, leaking of fluid, bleeding?

fetal movement?

72
Q

Routine Problems

A
  • N/V
  • LBP
  • constipation
  • contractions
  • dehydration
  • edema
  • GERD
  • hemorrhoids
  • PICA
  • round ligament pain
  • urinary frequency
  • varicose veins
  • carpal tunnel syndrome
73
Q

Prenatal Supplements

A
  • 800mcg folic acid
  • most effective when given 2 mos prior and during 1st months
  • green leafy veggies, oranges cantaloupe, bananas, milk, grains and organ meat

*avoid excessive fat soluble vitamins (D, A, K, E)

74
Q

prenatal nutrition : what to avoid and limit

A

caffeine : 500mg/day
Fish: mercury risk
-avoid shark, swordfish, king mackerel and tilefish
-limit shellfish and sm. ocean fish to 12oz/wk
-limit other fish to 6oz/wk
-limit canned tuna to 6 oz/wk

75
Q

prenatal nutrition: calories

A
  • calories: increase 15%kcal/day (2200 cal)
  • protein: add 10-30g/day (75g total)
  • Iron: supplement 30-60mg/day
  • Ca: 1200mg/day

Nutritional Referral (WIC referral maybe)

  • inadequate weight Gian
  • PICA
  • eating disorder
76
Q

weight gain

A

avg: 25-35 pounds
15 lbs if obese
40lbs if underweight

77
Q

exercise

A
  • continue at usual level
  • HR goal: 70% of 220-age (140)
  • limit new exercise
  • avoid over heating
  • avoid supine
  • avoid scuba, skiing, contact sports after 1st trimester
78
Q

2nd trimester counseling

A
  • birthing classes
  • preterm labor risks after viability
  • breastfeeding
  • rhogam at 28wks if negative
79
Q

3rd trimester counseling

A
  • analgesia/anesthesia in labor
  • operative vaginal delivery or C section
  • travel
  • fetal kick counts
  • L&D tour
  • pediatricion
  • GBS
  • HSV
  • what to Bring to hospital
  • circumcision
80
Q

genital HSV in pregnancy

A
  • IgG Toc
  • HSV-1 positive- could be oral or genital infection
  • IgM not helpful

Most women with newborn who acquires neonatal herpes DO NOT have a history of clinically evident herpes

81
Q

Prevention of Neonatal herpes

A
  1. prevent acquisition of genital HSV during late trimester
  2. avoid exposure of neonate to herpetic lesion and viral shedding during delivery
  3. avoid vaginal intercourse if partner is + (during 3rd trimester)
  4. verbally screen for genital herpes
  5. examine all women for sx
  6. C-section if sx present (risk not fully elminated)
  7. suppressive therapy in women at 36wks if recurrent genital herpes
    - Valacyclovir 500mg BID or Acyclovir
  8. BF not C/I unless lesion on breast
  9. universal precautions with active oral HSV
82
Q

Vaccines recommended ALL

A

Flu during flu season

Tdap 27-36wks

83
Q

Vaccines safe if indicated

A

pneumococcal, hep A or B, rabies, polio typhoid

84
Q

Vaccines C/I

A

MMR, varicella, live virus vaccines

85
Q

Post partum contraception

A
  • discuss 3rd trimester
  • consent required tubal ligation
  • importance of inter-pregnancy interval (esp. w/ C-section)
86
Q

prior C -section?

A
  • document uterine scar
  • discuss risk/benefits of VBAC vs. repeat C-section
  • have pt sign consent
  • schedule c-section (39wks )
87
Q

Fetal movement assessment

A

Indication
-maternal perception of decreased/absent fetal movement

Technique: mother counts kicks during specific time
-have mom eat/drink something then lay still

88
Q

Non stress test

A
  • measurement of fetal HR with movement
  • Reactive (normal)= 2/more fetal HR accelerations within 20mins
  • Nonreactive=insufficient fetal HR accelerations over 40mins
  • acidotic, neurologically depressed
89
Q

Contraction Stress Test

A

looking for presence/absence of late Fetal HR decelerations in response to uterine contractions

Late decels= decals that reach nadir after the peak of contractions and usually persist beyond the end of the contraction

Variable decels= cord compression
-think oligohydramnios

90
Q

Biophysical Profile

A

*NST, fetal breathing movements, fetal movement, fetal tone, AFI

each component =2 or 0

normal: 8 or 10
equivocal: 6
abnormal: 4 or less

*oligohydramnios–>warrants further evaluation regardless fo score

91
Q

Amniotic Fluid Index (AFI)

A

summation of the largest cord-free vertical pockets of the 4 quadrants of an equally divided uterus

92
Q

Oligohydramnios

A

no US measured pocket of fluid >2cm or AFI of 5cm or less

  • BAD: anomalies or placental dysfunction
  • requires close maternal/fetal surveillance or delivery
93
Q

Polyhydramnios

A

AFI >24cm (or equal)

can be normal, cause Prom or malpresentation

94
Q

Post partum Visits

A

Vaginal Delivery: 6wks

C-section: 2 (incision check) and 6 weeks

Consider sooner/follow-up if complications (3/4th degree tear, HTN)

Clin Med (2 decks)

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