Prenatal Care and Disorders Flashcards
1
Q
Definition of Pre-conception Care
A
a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management
2
Q
Purpose of Pre-conception Care
(4)
A
goals for advancing pre-conceptional care
- improve knowledge, attitudes, and behaviors of men and women related to pre-conceptual health
- assure all women of childbearing age receive pre-conceptual care services to enterpregnancy at OPTIMAL health:
- evidence-based risk screening
- health promotion
- interventions
- interconceptual interventions to prevent or minimize risks from previous adverse pregnancy
- reduce disparities in adverse pregnancy outcomes
3
Q
Elements of Pre-conception Care
A
- reproductive life plan (more children)
- past reproductive history
- PMH - conditions that could affect preg.
- meds (teratogens?)
- infections/immunizations
- genetic screening/family hx
- nutritional assessment (BMI, eating d/o, anemia)
- substance abuse
- environmental toxins/teratogens
- psychosocial (depression, violence)
- PE - oral, thyroid, heart, breasts, pelvic
- labs - prenatal
4
Q
Contraindications to Exercise in Pregnancy
A
- preeclampsia or pregnancy induced HTN
- severe anemia
- restrictive lung disease
- hemodynamically significant heart disease
- premature rupture of membranes
- premature labor during prior or current preg.
- incomptent cervix or cerclage
- persistent 2nd or 3rd trimester bleeding
- placenta previa after 26 weeks
- intrauterine growth restriction (IUGR)
5
Q
3 Main Components of Prenatal Care
(ideally before pregnancy)
A
- early and continuing risk assessment
- health promotion
- medical and psychological interventions and follow-up
6
Q
Trimester Weeks
A
- First: weeks 1 - 13
- Second: weeks 14-27
- Third: weeks 28-40
- Post dates/term beyond week 40 (42)
7
Q
First Prenatal Visit - History
A
- medical/surgical
- reproductive
- menstrual
- OB/GYN
- sexual
- contraceptive
- meds
- allergies
- family/genetic
- nutritional
- psychological
8
Q
First Prenatal Visit - Labs
A
- CBC
- blood type / Ab
- rubella, syphilis, Hep B, HIV
- gonorrhea, chlamydia
- early diabetes screening if indicated
- TB if indicated
- UA (proteinuria, WBC)
9
Q
First Prenatal Visit - PE
A
- pap smear
- pregnancy and dating confirmation
- education about what to expect
10
Q
Confirmation of Implantation/Viability - Tests
A
- 30-40% implantation bleeding
- hCG (human chorionic gonadotropin) hormone detected in urine or blood
- used to eval. abortion, ectopic, molar (slower rise)
- transvaginal US to predict viability early
11
Q
reproductive age women w/ abnormal bleeding
what should be done
A
pregnancy test
12
Q
when do serum hCG levels double
A
every 2.2 days for 30 days
13
Q
when do serum hCG levels peak
A
10-12 weeks
14
Q
when can hCG levels be detected
A
- urine
- >25 IU/L
- blood
- Beta subunit from syncytiotropoblast 8 days after fertilization and detected 8-11d after conception/21-22d after LMP
15
Q
when do hCG levels return to normal
A
normal (<5 mIU/mL) 21-24 days after delivery/loss
16
Q
Confirmation of Pregnancy/Viability - Physical**
A
- amenorhhea - abrupt cessation of menstruation when otherwise normal
- lower tract changes
- Chadwick sign
- cervical softening
- uterine changes
- anteroposterior growth
- doughy/elastic to bimanual exam
- Hegar sign
-
breast and skin changes
- increased pigmentation
- abdominal striae
17
Q
bluish-red vaginal mucosa and cervix
A
Chadwick sign
18
Q
firm cervix w/ softened fundus and isthmus
A
Hegar sign
19
Q
Confirmation of Pregnancy/Viability - Transvaginal Sonagraphy Findings
A
accurately est. gestational age and confirm preg.
- gestational sac
- small anechoic fluid collection w/in endometrial cavity
- implants eccentrically
- 1st sonographic evidence of preg.
- seen w/ TVUS by weeks 4-5
- double decidual sign
- decidua parietalis (outer ring)
- decidua capsularis (inner ring)
- pseudogestational sac / pseudosac
- fluid collection in endometrial cavity
- implants midline
- sign of ectopic pregnancy
20
Q
Indications for 1st Trimester US
A
- confirmation of intrauterine pregnancy
- evaluation of suspected ectopic pregnancy
- define cause of vaginal bleeding
- evaluate pelvic pain
- estimate gestational age
- confirm cardiac activity
- assist w/ chrionic villus sampling, etc.
- assess fetal anomalies like encephaly
- evaluate maternal pelvic masses/uterine abno.
- measure nuchal translucency
- evaluate suspected gestational trophoblasic disease
21
Q
Indications for 2nd/3rd Trimester US
(maternal)
A
- vaginal bleeding
- abdominal/pelvic pain
- pelvic mass
- suspected uterine abnormality
- suspected ectopic pregnancy
- suspected molar pregnancy
- suspected placenta previa and surveillance
- suspected pleacental abruption
- premature membrane rupture/labor
- cervical insufficiency
- adjunct to cervical cerclage, amniocentesis
22
Q
Indications for 2nd/3rd Trimester US
(fetal)
A
- gestational age estimation
- evaluate fetal growth
- significant fetal size/clinical date discrepancy
- suspected multifetal gestation
- fetal anatomical evaluation
- fetal anomaly screening
- abnormal biochemical markers
- fetal presentation determination
- suspected hydramnios/oligohydramnios
- fetal well-being evaluation
- suspected fetal death
23
Q
Calculating Due Date
(alternate term)
A
estimated date of confinement (EDC)
based on 40 weeks
- Naegele’s rule: 1st day LMP + 7d - 3m + 12m
- 6-11w: crown-rump length
- GA within 7d
- 12-20w: biparietal diam., femur len., ab and head circumference
- GA within 10d
- third trimester
- GA withing +/-3w
24
Q
anatomy/growth US performed
A
~20 weeks
25
glucose tolerance, CBC, syphilis, Coombs performed
24-28 weeks
26
Tdap vaccine recommended
27-36 weeks
27
GBBS (Group B strep), GC/chlamydia if indicated
35-37 weeks
28
education and risk factor screenings performed
each visit
29
checked at each visit
| (5)
* BP
* weight
* urine dip: protein, glucose, ketones
* uterine size (fundal height)
* monitor growth and amniotic fluid volume
* weeks 20-34 height in cm approximates age in weeks
* fetal heart sounds/rate
30
normal fetal HR and when heard
110-160 bpm
heard with Doppler at about 10 weeks
31
assessed at each visit
| (5)
* fetal movement
* bleeding
* contractions
* suspected loss of amniotic fluid
* low back pain/pelvic pressure
32
when fetal movement expected
* primiparous: 18-20 weeks
* multigravida: 14-18 weeks
33
when uterus is palpable above pubic symphesis
8 weeks
34
when uterus becomes and abdominal organ
12 weeks
35
when uterus is midway between
pubic symphesis and umbilicus
16 weeks
36
when utererus is palpable at umbilicus
20 weeks
37
when uterine size (fundal height) in cm from pubic symphesis correlates with gestational age
18-34 weeks
38
education topics at visits
* preterm labor symptoms \<37 weeks
* symptoms of labor \>37 weeks
* symptoms of preeclampsia
* fetal movement counts
* lifestyle, breastfeeding, contraception
39
when depression screenings done
* initial OB visit
* 3rd trimester
* postpartum
relationship between Vit D and depression
40
manual assessment of fetal size and position
Leopold maneuvers
41
when Leopold maneuvers indicated
after 26 weeks
(checking for abnormal lie late in pregnancy)
42
appearance of cervix in nulliparous woman
closed external cervical os
43
appearance of cervix in multiparous woman
greater opening/dilation of external cervical os
44
what to check in women with previous spontaneous preterm birth
transvaginal US to check
* cervical dilation
* cervical shortening (\< 3-4 cm)
45
Steps in Leopold Maneuver
maneuvers
* first - palpate superior fundus
* shape, consistency, mobility
* second - palpate both sides
* determine direction back is facing
* third - palpate inferior fundus
* determine part of fetus at inlet and its mobility
* fourth
* determine fetal attitude and degree of extension into the pelvis
46
Follow-up Visit Labs
when are fetal aneuploidy screenings done
11-14 weeks and/or 15-20 weeks
(check for abnormal number of chromosomes)
47
Follow-up Visit Labs
when screenings for neural-tube defects offered
15-20 weeks
48
Follow-up Visit Labs
when hematocrit/hemoglobin and syphilis repeated
28 and 32 weeks
49
Follow-up Visit Labs
when HIV tested if increased risk
third trimester - before 36 weeks
50
Follow-up Visit Labs
when tested if high risk HBV
at time of hospitalization for delivery
51
Follow-up Visit Labs
when Rh testing done for Rh- mother
weeks 28-29
administer anti-D Ig if mother remains unsensitized
52
Frequency of OB Visits
| (3 time periods)
* up to 28 weeks: every 4 weeks
* 28-35 weeks: every 2 weeks
* 36+ weeks: weekly until delivery
53
Warning Signs in First Trimester
* vaginal bleeding
* persistent NAV
* fever, chills
* dysuria, hematuria, inability to void
54
Warning Signs in Second/Third Trimester
* leaking fluid, change in vaginal discharge
* sudden abdominal pain/cramping
* vaginal bleeding
* pelvic pressure, persistent backache
* persistent HA unrelieved by OTC treatments
* generalized edema
* visual changes
* decreased fetal movement
* fever, chills
* dysurea, hematuria
* protrusion of umbilical cord from vagina
55
Education Topics at Visits
* work accomodations (restrictions, FMLA, etc)
* exercise
* travel risks
* sexual activity
* breastfeeding
* postpartum contraception
* social needs
* parenting classes
* vaccines
56
how is fetal well-being assessed
* HR
* breathing
* fetal movement
* fetal tone
* amniotic fluid volume
57
Measuring Fetal Kick Count
* patient counts movements starting at 9am until 10 movements perceived
* count done daily
* alerts physician if:
* \<10 movements w/in 12h on 2 consec. d
* no movements in 12h in a single d
58
Non-stress Testing (NST)
Reactive vs. Non-reactive
reactive
* acceleration of 15 bpm above baseline for 15 seconds 2x in 20 min with movement
59
excessive vs. inadequate amniotic fluid
* polyhydramnios (AFI \> 23cm) - excessive
* oligohydramnios (AFI \< 5cm) - inadequate
60
normal fetal breathing
_\>_1 episode of rhythmic breathing
lasting _\>_30 sec within 30 min
61
normal fetal movement
_\>_3 discrete body or limb movements
withing 30 min
62
normal fetal tone
_\>_1 episode of extremety extension
and subsequent return to flexion
63
scores of the fetal activities and actions
(biophysical profile)
amniotic fluid volume (AFV) - 2x2cm pocket norm.
* 8/10 w/ normal AFV - normal, repeat testing
* 8/10 w/ decreased AFV - deliver
* 6 - possible asphyxia
* abnormal AFV- deliver
* normal AFV, \>36w, favorable cervix- deliv.
* repeat test _\<_ 6- deliver
* repeat test \> 6- observer, repeat per prot.
* 4 - probable asphyxia- repeat same day, _\<_6 del.
* 0-2 - almost certain asphyxia- deliver
64
nutritional requirement of pregnancy
| (kcal/day, weight gain)
* increase 300 kcal/day
* recommended weight gain per BMI
* \<19 28-40lbs
* 19-24.9 25-35lbs
* 25-29.9 15-25lbs
* _\>_30 11-20lbs
65
percent of spontaneous abortion
10-15%
66
hCG present in blood 7-10 days after ovulation but menses begins as expected
increases rate of loss up to 50% with most occurring 14 days following ovulation
biochemical pregnancy
67
pregnancy bleeding prior to 20 weeks
threatening abortion
68
vaginal bleeding, cramping, partially dilated cervix
inevitable abortion
69
only passage of some products of conception
incomplete abortion
70
passage of all POC, cramps and bleeding stop, cervix closes, uterus normal size, preg. test normal
complete abortion
71
fetus has died but remains in uterus \> 6 weeks
missed abortion
72
3 spontaneous abortions
recurrent abortion
73
causes of recurrent abortions
| (general)
* infections- mycoplsma, listeria, toxoplasma
* smoking & alcohol
* psychosocial stress
* medical
* diabetes
* hypothyroidism
* lupus (affects 40% of preg.)
* age
74
causes of recurrent abortions
| (local maternal factors)
uterine abnormalities
* cervial incompetence
* congenital abnormal uterus
* fibroids
* intrauterine adhesions
75
scar tissue that develops following procedures
(like D&C)
Asherman syndrome\*\*
76
recurrent abortions
| (MCC)
genetic abnormality of the fetus\*\*
77
recurrent abortions
| (placental factors)
* conversion of cortisol to inactive corticosterone by 11Beta-hydroxylase between 22-24 weeks
* protective factor
* genetic polymorphisms can reduce enzyme production
* leptin resistance if obsese
* increases risk of fetal IUGR
78
management of threatened abortion
US, reassurance
79
management of incomplete abortion
* heavy bleeding: IV access, type and cross
* POC removal and sent to pathology
* tx delays can lead to sepsis
80
management of missed abortion
confirm by US, manage pain
81
management of recurrent abortion
* parental testing
* hysteroscopy to eval. uterine cavity
* pelvic US
* Vit D considerations
* future cerclage
82
indications for genetic counseling
| (must have informed consent)
* A previous child with or family history of birth defect, chromosomal abnormality or known genetic disorder
* A previous child with undiagnosed mental retardation
* A previous baby who died in the neonatal period
* Multiple fetal losses
* Abnormal serum marker screening results
* Consanguinity
* Maternal conditions predisposing the fetus to congenital abnormalities
* A current pregnancy history of teratogen exposure
* A fetus with suspected abnormal ultrasound findings
* A parent that is a known carrier of a genetic disorder
83
Genetic Screening for Autosomal Recessive D/O
cystic fibrosis screening should be offered to all according to current recommendations
* CF (whites)
* sickle cell (AA)
* tay-sachs (Jews, French, Canadians)
* thalassemia (mediterranean, southeast asians)
84
prevention of spina bifida
4mg folic acid prior to conception
85
first trimester screening
nuchal translucency
86
second trimester screening
weeks 15-20
* serum triple screen
* alpha-fetoprotein (low = Downs)
* hCG
* unconjugated estriol (UE3)
* US if increased risk
* quad screen
* triple + inhibin A for Downs
* amniocentesis and AChE (neural tube defect)
87
triple screen indications\*\*
_AFP__hCG__uE3_
high
all low
high n/a n/a
Down Syndrome
Trisomy 18 (Edwards)
NTDs (ex. spina bifida)
88
combined 1st and 2nd trimester screening
(integrated screening)
elevated hCG -or- AFP
+
low pregnancy plasma protein A -or- estriol
=
preterm birth, IUGR, preeclampsia
89
drug classifications
* A - no evidence of fetal risk
* B - animal studies no risk or minor risk
* C - animal shows risk, use w/ caution only if benefits outweigh risk
* D - positive fetal risk, use only in life-threatening emergency
* X - do not use in pregnancy
90
common teratogenic drugs
methotrexate, coumadin, dilantin, valproic acid
91
good seizure med, safer alternative for Coumadin
Keppra, heparin
92
leading cause of maternal mortality in U.S.\*\*
pre-eclampsia
93
triad of preeclampsia\*\*
* hypertension (140/90)
* proteinuria (_\>_ 3g / 24h after 20 weeks)
* generalized edema
highest risk in 1st pregnancy
cure is delivery, anti-hypertensives to tx HTN
94
signs of severe pre-eclampsia
* severe HTN (\>160/110)
* renal insufficiency
* cerebral/visual disturbances
* pulmonary edema
* epigastric or right upper quadrant pain
* elevated liver enzymes (AST/ALT 2x+ norm)
* thrombocytopenia (\<100K platelets)
95
HELLP Syndrome
* hemolysis
* elevated liver enzymes
* low platelets
96
what is HELLP syndrome
varient of severe preeclampsia
* multiparous
* age \> 25
* \< 36 weeks gestation
* HTN presence varies
* 20% no change
* 30% mild elevation
* 50% severe elevations
97
pre-eclampsia with new onset grand mal seizures
eclampsia
98
when to consider other underlying causes of seizures
atypical presentation
* underlying seizures
* hypertensive encephalopathy
* hypoglycemia
* hyponatremia
* CNS hemorrhage
* thrombosis
* tumor
* infection
99
know HTN before preg. or dev. before 20 weeks
chronic hypertension
(most are essential,
secondary gets collaboratoin w/ high risk physician)
100
when to treat chronic HTN
BP _\>_ 160/105
| (many improve in 2nd trimester)
101
drug of choice for chronic hypertension
&
what NOT to use
* DOC:
* Aldomet (Methyldopa)
* hydralazine, labetalol, nifedipine 2nd line
* NO ACE-inhibitors (teratogenic)
102
chronic hypertension w/ superimposed preeclampsia
symptoms
chronic HTN w/ new proteinura after 20 weeks
-OR-
preexisting HTN and proteinuria that dev. suddenly
(significant increase in BP or proteinuria)
103
HTN w/out proteinuria after 20 weeks or within
48-72 hours after delivery and resolves by 12 weeks
gestational hypertension
| (baby does well but mom fails)
104
leading cause of obstetric hemorrhage
in 2nd and 3rd trimester
placental abruption -
premature separation of placenta from uterine wall
105
symptoms of placental abruption
back discomfort
abdominal cramping
vaginal bleeding
severe abdominal pain
106
when prophylactic given for Rh incompatibility
rhogam/rhophylac
* bleeding in pregnancy
* at 28 weeks
* after birth with Rh positive newborn (2nd preg.)
107
pregnancy implanted outside endometrial cavity
ectopic pregnancy
108
S/s of ectopic pregnancy
* missed period, then intermittent light bleeding
* cramping/pelvic pain
* adnexal enlargement/tenderness on pelvic exam
* +pregnancy test
* US confirmation of implantation location
109
Tx of ectopic pregnancy
methotrexate to preserve fallopian tube
surgery if emergent
110
when to surgically intervene w/ ectopic pregnancy
* rigid abdomen
* severe tenderness
* involuntary guarding
* evidence of hypovolemic shock
* tachycardia, orthostatic BP changes
111
inability of cervix to retain pregnancy in 2nd trimester
incompetent cervix
| (\> 30mm considered normal)
112
symptoms of incompetent cervix
* vaginal bleeding
* pelvic pressure
* back pain
* abdominal cramping
113
Tx of incompetent cervix
Cerclage
17-hyroxyprogesterone
114
placenta implants over cervical os
| (sudden painless bleeding common sx)
placenta previa
(low-lying placenta safe for labor and vaginal birth)
115
benign neoplasm w/ potential to become malignant
gestational trophoblastic disease
| (hydatidiform mole)
116
rare condition preceeded by hydatididform mole
choriocarcinoma
117
S/s of molar pregnancy
* large for dates uterus
* uterine bleeding evident by 12th week
* SOB
* enlarged tender ovaries
* no fetal heart tones
* no fetal activity
* PIH, preeclampsia, eclampsia before 24w
118
risk of gestational diabetes
* hyperglycemia in 1st trimester teratogenic
* macrosomia and fetal demise later in preg.
119
when gestational diabetes treated
serum glucose \> 200 mg/dL
120
max blood glucose levels in OGTT
* fasting: 95
* 1 hour: 180
* 2 hour: 155
* 3 hour: 140
121
risk factors of GDM
* age \> 35
* previous baby \> 9lbs
* obesity
* AA
* hispanic
* GDM in prev. preg.
* recurrent infections
122
Tx of choice for GDM
insulin
123
GDM follow-up
75gram OGTT at 6-12 weeks postpartum to ensure glucose levels return to normal
124
hyperthyroid disease
contraindications and drugs used\*\*
* contraindication
* radioactive iodine treatment
* drugs
* Propylthiouracil (PTU) 1st trimester
* Methlmazole 2nd and 3rd trimesters
125
complications of untreated hypothyroid
* mom: fatigue, cold intolerance, weight gain
* increased spontaneous abortion
* preeclampsia
* abruption
* low birth weight
* stillborn
* lower cognitive function
126
mitral stenosis MC condition
higher risk CHF
MS worsens as pregnancy advances
higher risk a-fib
rheumatic heart disease
127
highest risk for pts. with primary pulmonary HTN or cyanotic heart disease
congenital heart disease
128
significant pulmonary HTN w/ contraindication to pregnancy
Elsnemenger's syndrome
129
palpitations common in pregnancy
cardia arrhythmias
130
ischemic heart disease avoidances
ACE-I or lipid lowering agents
131
1. Development of cardiac failure in the last month of pregnancy or within 5 months after delivery
2. Absence of an identifiable cause for the cardiac failure
3. Absence of recognizable heart disease prior to the last month of pregnancy (monitor after pregnancy)
4. Left ventricular systolic dysfunction demonstrated by classic echocardiographic criteria, such as depressed ejection fraction or fractional shortening along with a dilated left ventricle
peripartum cardiomyopathy
| (cardomegaly w/ LVEF \< 45%)
132
spread via mosquito or sex and causes microcephaly
zika
