Test #2 "The final Muthafuka" Flashcards
Fetal Growth and Development:• Understand how to evaluate fetal growth
•Establish GA as early as possible –Using hx, LMP, early US •Monitor weight gain •Measure fundal height at each visit •Serial US as needed
Describe the risk factors, causes, morbidity and mortality for macrosomia
Large Gestational age (LGA) •Birth weight >95th percentile, usually over 4000g (8lbs 13oz) •Risk factors –large mother –GDM –Postdates –H/o large babies
LGA Complications
Cephalopelvic disproportion –Labor dystocia/prolonged labor –Shoulder dystocia –Maternal soft tissue damage –Increased c/s •Postpartum hemorrhage •Stillbirth •Neonatal complications –Low Apgar –Hypoglycemia Hematologic abnormalities
• Describe the risk factors for intrauterine growth restriction (IUGR)
•Risk factors –Poor nutrition/weight gain –Vascular disease/HTN –Renal disease –Infection –Genetic abnormality –Multiple gestation –Placental problems –Pregestational diabetic (type I) –Drug use/ smoking/etoh –Hypoxemia/anemia –Late onset prenatal care –Low socioeconomic status –Prothromibc disorders -ART
Describe the causes, morbidity and mortality for intrauterine growth restriction (IUGR)
IUGR
•Impaired or restricted intrauterine growth
•Significant because there is an inverse relationship between fetal/neonatal weight percentile and perinatal mortality
•Not to be confused with Small-for-gestational age (SGA)
–neonatal diagnosis of size below the 10th percentile
•Usually genetic or due to inadequate nutrition
• IUGR Classifications=Describe the difference between concentric and head-sparing IUGR and complications; Understand preferential perfusion in the fetus
•Symmetrical=70%, nutrition based
–Compromised growth in length, head circumference and weight
•Asymmetrical= other factors cause this
– Decreased length and weight, but normal head circumference aka head-sparing
•Complications
–Increased risk fetal distress
–Meconium staining
–Increased perinatal morbidity and mortality
When to be suspicious of IUGR and management
Watch for “progressive” growth •<2cm in 4 wks is suspicious •If possible, single, consistent examiner –2 sonos 4 wks apart to confirm • esp head and abdominal circumference •AFI check to r/o oligohydramnios -MANAGEMENT- limit activity/bedrest nutrition cessation of smoking fetal surveillance= repeat sonos q4-6wks
• Discuss commonly used substances including cigarettes, and understand the basic pathophysiology of how these substances affect both mother and fetus
- Smoking and Pregnancy
- •The most important modifiable risk factor associated with adverse outcomes
- •Adverse effects of tobacco
- –Infertility (maternal)
- –Low birth weight (LBW)
- –Miscarriage
- –Stillbirth
- –Preterm premature rupture of membranes
- –Placental abruption/previa
- –Preterm delivery
- –Congenital malformations
- –Postnatal morbidity
- –Preeclampsia
• –Impaired fetal oxygen delivery
• •Placentas of smokers show structural changes that may contribute to abnormal gas exchange
• –Carbon monoxide exposure
• •Carboxyhemoglobin clears slowly from fetal circulation and diminishes tissue oxygenation
• –Direct damage to fetal genetic material
• –Directly impair lung development
• –Sympathetic activation leading to accelerated heart rate and reduction in fetal breathing movement
• –genetics
higher insidence of SIDS.
• Discuss commonly used substances including alcohol and understand the basic pathophysiology of how these substances affect both mother and fetus
- Alcohol= affect CNS development(3rd trimester)
- Crosses the BBB. Physical changes small head circumference, small eye opening, thin upperlip, vent septal defect.
- •Fetal alcohol spectrum disorder (FASD) describes the broad range of adverse sequelae
- –No effect, normal
- –Fetal alcohol effects (FAE)
- –Alcohol related birth defects (ARBD)
- Fetal alcohol syndrome (FAS)
• Discuss commonly used substances including opiates and understand the basic pathophysiology of how these substances affect both mother and fetus
Opiates= •S/sx of high-risk chemical abuse
–Late to prenatal care
–Multiple missed appts
–Impaired school/work performance
–Past OB h/o sab, IUGR, premature birth, placental abruption, stillbirth, precipitous delivery
–Children w/ neuro-developmental problems
–H/o drug/etoh problems
• Discuss commonly used substances including cocaine understand the basic pathophysiology of how these substances affect both mother and fetus
Cocaine
–Less women than men use the drug but numbers are growing
•Especially with crack cocaine use
–Effects related to dose and stage of pregnancy
•Decreased birth weight, length and head circumference
•Increased risk prematurity, placental abruption, sab, fetal death
•Readily crosses placenta
–Major mechanism of fetal and placental damage is vasoconstriction
–Maternal cocaine use tests positive in neonatal urine within 2 days of delivery and is excreted within 12-24 hrs
•Meconium stays positive for 3 days and hair for months
• Discuss commonly used substances including methamphetamines, and marijuana, and understand the basic pathophysiology of how these substances affect both mother and fetus
Marijuana
–Most commonly used illicit substance taken during pregnancy
–Impact unknown
•Not significantly related to any growth measures at birth, prematurity or congenital anomalies
•Children of heavy uses had smaller head circumferences at all ages
–Associated with etoh and cigarette use
•Methamphetamine
–A neurotoxic agent that damages ending of brain cells containing dopamine
3.5 times more likely to be SGA
Discuss the management of abusive substances while preg
Management
•Screen all pregnant women for etoh and substance use
•Counsel regarding risks of specific substance used
•Use behavioral therapy and/or pharmacotherapy to treat addiction
•Test for STDs and treat
•Schedule frequent visits to monitor maternal and fetal status
•Obtain early US to confirm GA and establish accurate baseline for growth
•Begin antepartum fetal surveillance if there is evidence of pregnancy complications
Identify patients at increased risk of complications before pregnancy
Age: >35 at increased risk
•Diet: folic acid, MVI; avoid EtOH, tobacco/drugs, caffeine, medications(Warfarin, aspirin are bad)
•Vaccinations: Varicella, Rubella, Hep B(live vaccines are bad)
•Medical history: DM, mental health, STD, etc
•Weight: under or overweight discussed
When does all of the important stuff for the fetus develop?
: In the 1st trimester is when all of the important stuff happens.
Discuss the importance of B-Hcg levels and Progesterone
Serum HCG levels are the gold standard
–Quantitative B-HCG radioisotope test used for serial testing
•Level doubles every 48 hrs the first 3-4 wks
•Level peaks at 60-70 days then level off
•Level should be 50 to 250 mIU/mL at the time of the first missed period
–Qualitative results are read as pos or neg
(good to just see if there is pregnancy)
Discuss the importance of Progesterone levels
Progesterone Levels
-Remain constant through first 9-10 weeks
-Non viable pregnancies have lower levels
-Highly predictive of pregnancy outcomes
-Performed if frequent SAB
-If level < 20, Progesterone vaginal suppository
(Prometrium 100-200 mg inserted vaginally)
Diagnosis of Pregnancy, like GA?
Gestational sac appears at about
4 weeks gestational age
-Grows at 1 mm a day through the
9th week of pregnancy
-Gestational sac seen at the
4th – 5th week of gestation
-Serum hCG levels 1000-1500 mIU
Risk factors for Ectopic.
Prior tubal pregnancy
•Tubal reversal surgery
•Endometriosis
•Intrauterine device
–decreases the risk of ectopic because it decreases the risk of pregnancy; if pregnant, more likely ectopic
•Once IUP seen on sono, patient can be reassured
Preg Category C
tell patients that the benefits out weight the risks
What is evaluated at each visit concerning pregnancy?
Weight gain
–Evaluate fetal growth
–Nutritional intake
•BP: screen for pregnancy induced hypertension (PIH)
•Fundal Height : evaluate fetal growth
•Leopold’s Maneuver : determine fetal position
•Fetal heart tones (FHR): evaluate fetal well being
•Edema: screen for PIH
•Urinalysis: glucose and protein
Symptoms: identify problems, discomforts
whats involved with 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
What are the Milestone Visits (timing of prenatal visits)
6-12 wks: confirm pregnancy, discuss CVS, initial labs, complete Hx and PE
•10-12 wks: determine fetal age by ultrasound; CVS
•11-14 wks: 1st trimester screen
•15-20 wks: Quad screen, Ultrasound, Amnio if high risk
•24-28 wks: GTT for GDM, Antibody screen if Rh-, Hgb/Hct
35-37 wks: GBS screen
Hegar’s sign?
softening of the cervix, 4-6wks after conception)
Chadwicks sign
blue vagina
is a bluish discoloration of the cervix, vagina, and labia caused by the hormone estrogen which results in venous congestion. It can be observed as early as 6-8 weeks after conception[1], and its presence is an early sign of pregnancy.
OB physical exam?
Complete physical examination •Explanation of what to expect •Baseline vital signs: BP, weight •Breast exam •Abdominal exam –Note surgical scars –Fundal height in cm(not until 20wks) –Fetal Heart Rate(not done till later) •Pap Smear •Chlamydia Gonorrhea
Uterine size by bimanual exam •Adnexal tenderness or enlargement •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
assessing fetal growth
•Positive signs
–Fetal heart
•Fetoscope auscultation 17-20 weeks
•US 5-8 weeks for cardiac activity
–Movement
•Palpation of active fetal motion (quickening) at 18-20 weeks
•Crown Rump Length (CRL) up to ~14 weeks: ± 5-7 days accuracy
Visualization of the fetus
•US – fetal pole seen 5-6 weeks
(Different slide)
•10-12 WK: fundus at symphysis pubis
•16 WK: fundus midway btw symphysis pubis and umbilicus
•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
Symptoms of Pregnancy
- •Nausea and Vomiting
- •Breast Tenderness
- •Abdominal pain or cramping
- •Vaginal discharge or bleeding
- •Urinary frequency
- •Headache
- •Nosebleeds, gums bleed • •Heartburn
- •Back Pain
- •Quickening(baby moving)
- •Skin changes
- •Ptyalism
- •Absence of menses
- •Constipation
- Fatigue
why N & V Common in first trimester
. Unknown etiology. Maybe related to high HCG levels.
Frequent, consistent vomiting: dehydration, weight loss, electrolyte imbalance, poor appetitie 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.
Ptyalism = excessive secretion of saliva
• Explain antepartum patient education including hydration, wt gain, food faddism
•Prenatal Vitamins
•Lab tests
•Exercise(walking, prenatal yoga)(stop if palpitation SOB dizziness, abd. pain bleeding numbess, tingling no FM
avoid standing or sitting for long periods).
•Nutrition(not eating for 2 if fetus is size of a gram)
•Sex
•Outline of care
•Handouts, books
•Grooming, dental hygiene(very important), travel(no travelling after 36wks, 28wks O.K)
•Drink plenty of water/fluids
•Get plenty of rest
•Exercise
•Nutrition: Assess Risk Factors
–Encourage appropriate weight gain 25-30 lbs
–Pre-pregnant weight less than 90% (of ideal body wt)or greater than 135%
–Adolescent(eat shitty diets) less than 15
–Two or more pregnancies during 2 years
–Breast feeding
–Multiple gestation
–Food faddism, smoking, drugs, or alcoholism
–Therapeutic diet for chronic systemic disease
What are the specifics for the idetary needs of the pregnant woman.
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 (Lactose intolerance?) 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
Warning Signs During Pregnancy
Vaginal bleeding –Miscarriage, SAB, Ectopic •Fluid leaking from vagina –PROM •Persistent headache, dizziness, edema, RUQ pain, HELLP syn, –PIH •Decreased Fetal movement –Fetal compromise •Fever, chills –Infection •Recurrent Vomiting –Hyperemis gravidum
ABO Incompatibility
40-50% of ABO incompatibility occurs in first pregnancies
•Majority occurs in Type O mothers carrying type A or B fetus
Ehat are the risks for a Rh- mom?
•Pt produces IgG antibodies in response to Rh+ fetal RBC in maternal circulation
Sensitization through previous pregnancy
•IgG crosses placenta
Rh+ mom has antigens same as Rh+baby
(Coated erythrocytes destroyed in reticuloendothelial system causing fetal hemolytic anemia)
1st and 2nd Trimester Screening
All women should be offered screening for Down syndrome and other genetic abnormalities,
Nuchal Translucency
•An ultrasonic examination to measure the amount of fluid accumulation behind the baby’s neck(•Identify increased risk for Down syndrome)
Amniocentesis
Detects most chromosomal disorders with high degree of accuracy: Down syndrome, Tay-Sachs disease, Neural tube defects, spina bifida, and more
What happens in the 1st trimester (Patho for GDM)
1st trimester
•Early in pregnancy maternal estrogens and progesterone increase and promote beta cell hyperplasia and increased insulin release.
• Increase in peripheral glucose utilization and glycogen storage with reduction in hepatic glucose production results in lower fasting glucose levels.
what happens in the 2nd/ 3rd trimester as far as patho for GDM
2nd/ 3rd trimester
•Placental steroids and peptide hormones (ie. human chorionic sommatomammotropin, cortisol, prolactin, progesterone and estrogen) rise linearly throughout second and third trimesters.
•These hormones increase tissue insulin resistance and so the demand for insulin increases.
This becomes apparent between 24th-28th week
•The pancreas releases 1 ½ - 2 ½ times more insulin to respond to the increase in insulin resistance.
•Patients with normal pancreatic function are able to meet these demands.
•Borderline pancreatic function leads to inadequate insulin secretion in the presence of increasing insulin resistance.
Meticulous glucose control during pregnancy ?
has been shown to reduce the risk of macrosomia=Big gestational babies.
what do you doe for Detection?
Detection? •Risk assessment should be done at the first prenatal visit. •Women with clinical characteristics consistent with high risk should undergo testing ASAP: –advanced maternal age –morbid obesity –history of GDM – glycosuria – strong family history of DM
what about low risk pts?
Low risk requires no glucose testing but must meet all the following criteria:
•Age <25yrs
•Weight normal before pregnancy
•Member of an ethnic group with a low prevalence of GDM
•No known diabetes in a first degree relative
•No history of abnormal glucose tolerance
•No history of poor obstetric outcome or macrosomic infant
how do you make a GDM Dx?
Perform a diagnostic 3hr oral glucose tolerance test (OGTT) without prior plasma or serum glucose screening.
•Two-step approach for women at average risk at 24-28wks:
–Screen by measuring the plasma glucose concentration 1 hr after a 50g oral glucose load.
–If >140mg/dl then schedule a 3 hour OGTT (this identifies 80% of patients with GDM)
–If criteria of >130mg/dl is used this identifies 90% of patients with GDM).
The 3 hr OGTT does not need to be performed on patients with a 1hr 50g glucose screen >185mg/dl or a fasting >126mg/dl.
The 100g, 3 hour OGTT: Must be done after 3 days of an unrestricted carbohydrate diet and while the patient is fasting. Venous plasma glucose is measured at 1, 2 and 3 hours after a 100g glucose load. A positive test requires that 2 values be met or exceeded. One abnormal value should be followed with a repeat test one month later.
•Criteria of positive 100gm OGTT •Fasting glucose: 95mg/dl •1 hour glucose: 180mg/dl 2 hour glucose: 155mg/dl •3 hour glucose: 140mg/dl
Short and longterm risks of GDM
Immediate risks:
–Increased incidence of cesarean section (30%)
–Preeclampsia (20-30%)
–Polyhydraminos (20%)
•Long term risks:
–Recurrent GDM and high risk for developing diabetes (8%/yr)
Screening for diabetes should be done at the 6wks post partum visit
Short term risks for the baby
Macrosomia due to excessive fetal insulin due to increased delivery of glucose and amino acids to the fetus via maternal circulation.
–Typically defined as birth weight above 90th percentile for gestation age or greater than 4000g (8.8lbs).
Shoulder dystocia due to macrosomia
•Neonatal hypoglycemia
•With extremely poor glucose control increase risk of fetal mortality due to fetal acidemia and hypoxia.(must keep blood sugar levels controlled before delivery!!!)
Treatment options for GDM
Dietary therapy is the foundation for the treatment of GDM.
(Cold cereal and milk can cause a huge burden on the pancrease for insulin production)
•Post prandial values have been more strongly associated with the risk of macrosomia
–modest carbohydrate restriction 45% of total calories, may blunt postprandial glucose excursion.
Exercise is an adjuvant therapy in GDM
Treatment options for GDM like medications?
No oral diabetes medications are currently approved for use in pregnancy
Glyburide has been shown to not cross the placenta No other oral medications should be used
•Targets
– fasting 60-90mg/dl
–1 hr PPG < 130mg/dl
try to control the bedtime blood sugar rising with a long lasting insulin=
•NPH, Regular, aspart, Lispro and detemir are category B
Exercise is an adjuvant therapy in GDM
Long term risk for baby from mom with GDM?
Increased risk of adolescent obesity
•Increased risk of developing Type 2 diabetes
•The goal of management of third trimester pregnancies in women with diabetes are to prevent still birth and asphyxia.
Vaginal Bleeding risk factor
Rh+father and Rh- mom=risk for the fetus.
Vaginal Bleeding management
Management= Misoprostel (Cytotec) Highly effective in missed SAB No benefit in incomplete SAB Completes first trimester SAB within 2 weeks: 66% •Dilatation and Curettage Indications •Gestational age 8 to 14 weeks
•Dilatation and Evacuation (D&E) - 2nd trimester procedure
Threatened Abortion. what is it?
Bleeding before 20 weeks’ gestation in the presence of an embryo with cardiac activity and CLOSED cervix
Complete abortion ?
Incomplete abortion ?
Complete passage of all products of conception
•Incomplete abortion - Occurs when some, but not all, of the products of conception have passed
Missed abortion= Embryonic demise
An embryo larger than 5 mm without cardiac activity
•Retained non-viable conception products up to 4 weeks
•Additional definitions
Septic abortion
Incomplete abortion associated with ascending infection of the endometrium, parametrium, adnexae, or peritoneum
Inevitable abortion
Bleeding in the presence of a dilated cervix; indicates that passage of the conceptus is unavoidable
