Prenatal Care Lecture Powerpoint Flashcards
If a patient has sex with 2 different men 3 days apart can you tell who the father is?
No its too close together with too much variablility, will need genetic testing upon birth
Goals of prenatal care
To have all patients receive some form, and preferably in the first trimester
4 stages of prenatal care
- Preconception care (basic medical care esp. for those with chronic medical conditions and staying up to date on vaccines)
- prompt diagnosis of pregnancy (confirm they didn’t read an at home test wrong)
- initial presentation for pregnancy care (initial pelvic exam, height of fundus, etc)
- followup prenatal visits
Supplementing with folic acid prior to conception (typically done in all bread purchased) has allowed for a decrease in…
….neural tube defects (spinal bifida)
1 and #2 structural birth defects
congenital heart anomalies, neural tube defects
Domestic partner abuse occurs in ___ pregnant women
1/6
Tdap in pregnancy
Used in every pregnant woman for every pregnancy to help lower prevalence of whooping cough in infants as infants don’t receive Dtap until 6 months of age, given at 27-36 weeks to promote passive antibody transfer
Signs and symptoms of pregnancy (4)
- cessation of menses (not as reliable now due to obesity and birth control)
- changes in cervical mucus and softening
- breast tenderness
- urine or serum pregnancy tests gold standard
Parturient
Meaning just having delivered
Estimation of duration of pregnancy
Mean is 266 days from conception, 279-282 from first day of last menstrual period
Neagle rule
Estimated date of delivery = 1st day of last menstrual period + 7 days, - 3 months + 1 year
If the uterus fails to grow as expected, what should be considered?
Intrauterine growth restriction (IUGR)
1st trimester ultrasound
Best method possible to predict due date by measuring crown rump length, when done earlier in pregnancy more accurately predicts due date*** (further in gestation more biological variation we get)
Pelvimetry
Measurement of the diagonal conjugate from posterior inferior edge of symphysis pubis to sacral promontory to estimate the inlet of the pelvis, normally >12.5cm, can determine if a lady can deliver a baby at term without complication
Lab tests in prenatal care (11)
- pap smear (not before 21 regardless of pregnancy status)
- GC and chlamydia screen (regardless if monogomous)
- HIV screen
- syphilis screening
- hepatitis screening
- rubella antibody titer (congenital rubella syndrome)
- ABO and antibody screen
- urinalysis and culture
- cystic fibrosis screen
- fifth disease (in high risk populations, mother can get it from being around kids)
- glucose tolerance tests (determine diabetes)
- thyroid studies
- Quad screen (oh lawdy)
Signs of fetal life (3)
- Transvaginal ultrasound 6-8 weeks gestation
- doppler ultrasound 10-12 weeks gestation
- palpation of fetal movements
Diagnosis of fetal death (5)
- more common early in pregnancy (1/6 ends in miscarriage)
- regression of signs of pregnancy despite hCG remaining high for weeks after
- failure of uterine growth
- ultrasound primary method**
- failure to feel fetal movement after having felt it before
Scheduling of routine prenatal visits
Every 4 weeks thru week 28, every 2 weeks weeks 28-36, every week from 36 to delivery, 2x per week for postdates >42 weeks
12, 14-16, 20, 24, 28, 32-36, 36-40, 40+ week visits
- 12 (review prenatal lab tests, assess fetal heart beat with doppler)
- 14-16 (assess growth, order some genetic tests and order amniocentesis)
- 20 (auscultate fetal heart with fetoscope (old school) ultrasound for fetal anatomy)
- 24 (maternal education and review signs and symptoms for preterm labor)
- 28 (repeat antibody screens, administer Rh immune globulin, perform glucose screen, perform cervical assessment, TDaP administration)
- 32-36 (assess the cervix, GBS culture)
- 36-40 (assess fetal position, cervical exam for dilation each visit)
- 40+ (perform cervical assessment, institute fetal surveillance, typically WILL induce by end of 41 weeks)
Weight gain during pregnancy
a woman at ideal body weight requires total 24-28 lb weight gain, less for those over or more for those under ideal weight to meet goal requirements (might have to modify diet)
Weight loss during pregnancy is not advised except in those with…
…very high BMI
Weight retention after pregnancy
Average retained pregnancy weight of 3 lbs, see loss over 6 months progressively due to natural diuresis of excess volume
Smoking and pregnancy complications (6)
- bleeding
- premature birth
- low birth weight
- neonatal absence syndrome
- congenital anomalies
- low IQ of childhood
Alcohol and pregnancy complications (2)
- low birth weight
- fetal alcohol syndrome
Best advice regarding alcohol and pregnancy
Complete abstience
Fetal alcohol syndrome features (6)
- growth restriction
- behavioral disturbances
- brain defects
- cardiac defects
- spinal defects
- broad upper lip, facial distortions
Caffeine in pregnancy
Ideally none, but risks not as obvious as smoking and alcohol
Cell free fetal DNA (cffDNA)
A maternal phlebotomy study that is often done on screening in the first trimester to determine sex of child and test for aneuploidy, these DNA fragments increase in conc. in bloodstream thruout pregnancy and quickly diminishes upon delivery
Nucchal fold translucency
Ultrasound screen done most often in the first trimester to visualize fetus, can be found alone in 62% of down syndromes and 30% of spontaneous abortions
AFP testing
Alpha fetoprotein, a sometimes recommended 2nd trimester screen that finds 20% of down syndrome patients and neural tube defects
Pregnancy associated protein A (PAPPA)
Screening done during first trimester alongside nucchal fold translucency on ultrasound to increase rate of determining presence of down syndrome (positive in both up to 73% certainty)
Amniocentesis
a relatively low risk .5% of fetal loss test done during 2nd trimester for chromosome analysis, AFP, DNA markers, etc, not done as screening but for diagnosis and evaluation
Work conditions which increase risk of low birth weight, preterm labor, and delivery (4)
- physically intensive employment
- standing for long periods of time
- increased pulling, pushing, or lifting
- decreased rest periods
Recommended favorable working conditions for pregnant women (4)
- only 8 hour shifts
- no more than 48 hrs a week
- limit work between 6am and midnight
- avoid jobs that require good sense of balance
Saunas, hot tubs, and whirlpools use while pregnant
Advise not to use while pregnant, temp already elevated by the baby
Travel while pregnant
Best taken during 2nd trimester, many airlines have regulations
Common pregnancy complaints and how are they treated? (8)
- nausea and vomiting (first trimester usually resolves 16 weeks, morning sickness), treated with zofran
- constipation, treated with bulking agents (mirilax)
- hemorrhoids, treated with prevention or topical anesthetic
- fatigue (particularly early on), supplemental iron if anemic
- urinary frequency or incontinence (differentiate from rupture of amnion also known as water breaking), treated with kegals
- headaches, treated with acetaminophen
- syncope (due to blood flow to fetus does see drastic drop in blood pressure), treated with resting in lateral recumbent position, change position gradually, hydrate
- edema (common, as long as bilateral can be physiologic and not concern for DVT or heart failure and is relieved by raising legs)
Live vaccines and pregnancy
Contraindicated (MMR, V, and live influenza!)
Nulligravida
Never having been pregnant
Nullipara
Never having given birth
In measuring the fundus, if smaller than expected may be due to these 2 conditions. If larger, than these 3
- earlier gestation
- oligohydraminos
- later gestation
- polyhydramnios
- twins
Intrauterine growth restriction
When the unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb, putting it at risk of certain health problems and complications during pregnancy (potentially even death), delivery, and after birth
Quad screen
One lab test performed in patients prenatal care based on history at 15-19 weeks, includes AFP, hCG, estriol, and inhibin A to assess neural tube defects and genetic defects
Group B infection in neonates vs 1 month old
Because it is ubiquitous and commensal with mother not generating antibodies, the 1 month old is too often colonized and asymptomatic but neonates do not have immune function and can get septic from infection
Standard of care for screening in first trimester (2)
- ultrasound
- blood test for pregnancy associated protein A
Chorionic villous sampling
Removal of part of the placenta to take for chromosomal testing either abdominally or vaginally, NOT often utilized because of high risk of fetal loss and is pretty much obsolete
Exercise while pregnant
Good 3-4x a week but not starting anything new they haven’t already been doing, should avoid hot humid conditions or when febrile, sports injuries much higher due to ligmaent tissue loosening due to circulating relaxin levels
Round ligament pain in pregnancy
Prior to 28 weeks can have a lot of pain especially on the right side as it is pulled and hurts with activity but subsides with rest differentiating it from acute appendicitis
