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Endo/Repro > The Normal Pregnancy: Antepartum Care > Flashcards

The Normal Pregnancy: Antepartum Care Flashcards

1
Q

What is the goal for preconception care?

A
  • Reduce risk of adverse effects for the woman, fetus, or neonate by optimizing the patients health before conception
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2
Q

What is recommended for anyone considering getting pregnant?

A
  • Identify risks and promote preconception health
  • Risk assessment: smoking cessation, ETOH, illicit drugs
  • Health promotion: nutrition, folic acid supplement, weight issues)
  • Medical interventions: diabetes management
  • Psychosocial intervention: stress reduction
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3
Q

What are some examples of preconception care?

A
  • Starting folic acid supplementation at least 1 month before conception reduces the incidence of neural tube defects
  • Adequate glucose control in diabetic patients before conception and throughout the pregnancy can decrease maternal morbidity, SABs, fetal malformation, fetal macrosomia, and IUFD
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4
Q

What is Gravidity?

A
  • Number of times a woman has been pregnant
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5
Q

What is Parity?

A
  • Number of pregnancies led to a birth at or beyond 20 weeks or an infant weight more than 500 grams
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6
Q

How can parity be broken down?

A
  • Full term (37-40 weeks)
  • Preterm (20-36+6)
  • Abortions (include all pregnancy losses prior to 20 weeks including ectopic and spontaneous
  • Living
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7
Q

What is the gravidity and parity of a women who has given birth to 1 set of twins at term and both are living?

A
  • G1P1002
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8
Q

What is the gravidity and parity of a women who has given birth to one term infant, one set of preterm twins, and has had 1 miscarriage and 1 ectopic pregnancy. She has 3 living children?

A
  • G4P1123
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9
Q

What is done at the first prenatal visit?

A
  • Obtain a thorough history including:
  • Medical (DM, HTN)
  • Reproductive (PTD, pre-e, stillbirth)
  • Family (DM)
  • Nutritional (folic acid, weight gain)
  • Social (ETOH, drugs)
  • Psychosocial (depression, anxiety)
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10
Q

What are normal findings on a PE associated with pregnancy?

A
  • Systolic murmurs, exaggerated splitting and S3
  • Palmar erythema
  • Spider angiomas
  • Linea nigra
  • Striae gravidarum
  • Chadwicks sign
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11
Q

What are some prenatal labs done at 1st visit?

A
  • CBC
  • Type and screen
  • Rubella (vaccinate postpartum if not)
  • Syphilis
  • Hep B surface Ag
  • HIV
  • Cervical cytology and gonorrhea and chlamydia
  • Screen for diabetes
  • Urine cultures
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12
Q

What are some common lab values in pregnancy?

A
  • Albumin: decreased
  • Calcium: grandual fall
  • Chloride: no change
  • Creatinine: decreased by 20 weeks
  • Fibrinogen: increased
  • Fasting glucose: gradual fall
  • Potassium: Fall by 20 weeks
  • Protein: fall by 20 week then stable
  • Sodium: decreased by 20 week then stable
  • Urea nitrogen: decreased in first trimester
  • Uric acid: decreased in first trimester then rise at term
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13
Q

What does urine chemistries show in pregnancy?

A
  • Creatinine: no change
  • Protein: increased from 150mg/day to 250-300mg
  • Creatinine clearance: decreased 40-50%
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14
Q

What are the serum enzymatic activity in pregnancy?

A
  • Amylase: increased
  • Transaminases: no change
  • Hematocrit: decreased
  • Hemoglobin: decreased
  • Leukocyte count: increased
  • Platelets: slight decrease
  • Factors 7-10 increase
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15
Q

What additional information is discussed at the first prenatal visit?

A
  • Confirm pregnancy and viability
  • Estimate gestational age and due date
  • Provide genetic counseling if needed
  • Discuss teratology
  • Advice on decreasing early pregnancy symptoms
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16
Q

What does a pregnancy test do?

A
  • Detect hCG in the serum or urine
  • hCG can first be detected in serum 6 to 8 days after ovulation
  • Most urine tests detect a level of 25 IU/L
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17
Q

What are the different levels of hCG and what do they mean?

A
  • Less than 5 IU/L is negative
  • Above 25 IU/L is positive
  • Above 100 IU/L is reached by time of expected menses
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18
Q

How much does hCG rise in the first 30 days?

A
  • Doubles every 2.2 days
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19
Q

What is seen on transvaginal ultrasound and what are the corresponding hCG levels?

A
  • Gestational sac is seen around 5 weeks (hCG is 1500-200 IU/L)
  • Fetal pole seen at 6 weeks (hCG of 5200 IU/L)
  • Cardiac activity seen at 7 weeks (hCG at 17500 IU/L)
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20
Q

What is Naegels rule?

A
  • Minus 3 months + 7 days is expected date of delivery

- Only useful in patients with regular 28 day cycles`

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21
Q

What are some ways to estimate gestational age and due date?

A
  • Last menstrual period
  • Physical exam
  • Ultrasound
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22
Q

How can physical exam be used to estimate gestational age and due date?

A
  • Size of uterus
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23
Q

How can ultrasound be used to estimate gestational age and due date?

A
  • Crown rump length (CRL) between 6-11 weeks can determine due date within 7 days
  • At 12-20 weeks measuring femur length, biparietal diameter and abdominal circumferences can determine due date within 10 days
  • In third trimester, due date can be off up to 3 weeks
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24
Q

What is crown rump length?

A
  • Length from head to toe
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25
Q

Who is assessed for genetic counseling?

A
  • Advanced maternal age (35 or older)
  • Previous child/family history of birth defects or known genetic disorder
  • Previous child with mental retardation
  • Previous baby who died in neonatal period or multiple fetus loss
  • Abnormal serum marker screening or ultrasound
  • Consanguinity
  • Maternal conditions
  • Exposure to teratogens
  • Parent who is known carrier of genetic disorder
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26
Q

What are some common chromosomal disorders?

A
  • Turners
  • Klinefelter’s
  • Balanced robertsonian translocations
  • Autosomal trisomies
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27
Q

How is maternal age related to chromosomal disorders?

A
  • Women that are age 35 and older are at increased risk of autosomal trisomies or sex chromosome abnormalities
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28
Q

What is the leading cause of down syndrome?

A
  • Due to meiotic nondisjunctional events leading to 47 chromosomes with an extra copy of chromosome 21
  • Some are due to an unbalanced translocation
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29
Q

How much of a risk is it for a couple to have another child with a chromosomal abnormality?

A
  • 1%
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30
Q

What should be done to couples after 3 or more spontaneous abortions?

A
  • Chromosomal studies (karyotyping)

- In 3-5% of these couples, there will be a diagnosis of a balanced translocation

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31
Q

What should balanced translocation couples receive?

A
  • Counseling regarding possibility of having a child with an unbalanced translocation and therefore be offered prenatal diagnosis (chorionic villus sampling/amniocentesis)
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32
Q

What are some examples of autosomal dominant disorders?

A
  • Tuberous sclerosis
  • Neurofibromatosis
  • Achondroplasia
  • Craniofacial synostosis
  • Adult onset polycystic kidney disease
  • Muscular dystrophy
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33
Q

What are some examples of autosomal recessive disorders?

A
  • Tay-Sachs
  • Sickle cell disorders
  • Alpha and beta thalassemia
  • Cystic fibrosis
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34
Q

What is done for high risk populations?

A
  • Carrier screening programs because the frequency of heterozygotes is greater than that of the general population
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35
Q

Why is genetic counseling important for cystic fibrosis?

A
  • 15% of carriers go undetected

- CF is most common in North American whites

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36
Q

Who is offered screening for CF?

A
  • All pregnant women
  • People with family history
  • Partners of known CF carriers
  • Parents with ultrasound findings of echogenic bowel
  • Sperm donors and any patient who requests screening
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37
Q

What are some examples of sex linked disorders?

A
  • Duchenne muscular dystrophy

- Fragile X syndrome

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38
Q

What is fragile x syndrome?

A
  • Most common form of inherited mental retardation

- Second most common form of mental retardation after down syndrome

39
Q

How can sex linked disorders be diagnosed prenatally?

A
  • By chorionic villus sampling or amniocentesis
40
Q

What does someone look like with fragile x syndrome?

A
  • Normal structure
  • Elongated face
  • Broad forehead
  • Large prominent ears
  • Strabismus
  • Highly arched palate
  • Hyperextensible joints
  • Hand calluses
  • Pectus excavatum
  • Mitral valve prolapse
  • Enlarged testicles
  • Hypotonia
  • Soft fleshy skin
  • Flat feet
  • Seizures
41
Q

What are multifactorial disorders? Example?

A
  • Birth defects that are inherited due to both genetic and environmental factors
  • Examples: Cleft lips/palates, congenital heart defects, pyloric stenosis, and neural tube defects
42
Q

What are some details about neural tube defects?

A
  • Incidence is 1 per 1000 births
  • Folic acid supplementation has been shown to lower risk for NTD
  • Women with affected child should take 4 mg in subsequent pregnancies before conception since neural tube closure is complete at 28 days post conception
43
Q

What does the first trimester screening include?

A
  • Maternal age
  • Fetal nuchal translucency thickness
  • Maternal serum b-hCG
  • Pregnancy associated plasma protein A (PAPP-A)
44
Q

What does the fetal nuchal translucency thickness tell?

A
  • It is the echo free area at the back of the neck between 10 and 14 weeks
  • Increased thickness associated with both chromosomal and congenital anomalies
45
Q

What in the first trimester screening would lead to a suspicion of Down’s syndrome?

A
  • Elevated b-hCG and low PAPP-A

- Nasal bone assessment (absence of) can increase detection

46
Q

What does the second trimester include?

A
  • Triple screen: b-hCG, estriol, and maternal serum alpha fetoprotein biochemical markers
  • Quadruple screen: b-hCG, estriol, AFP, and inhibin A
47
Q

When does the triple screen in the second trimester take place? What is detection rate of trisomy 21?

A
  • Takes place between weeks 16 and 20

- 70% detection week

48
Q

What is the detection rate of trisomy 21 in the quadruple screen?

A
  • 80%
49
Q

What is the noninvasive prenatal testing (cell free fetal DNA)?

A
  • Tests cell free fetal DNA, thought to be derived apoptosis of trophoblastic cells that have entered maternal circulation
50
Q

What is noninvasive prenatal testing good at detecting?

A
  • Trisomy 21 = 99.4%
  • Trisomy 18 = 99.1%
  • Trisomy 16 = 91.7%
  • Sex chromosomes = 96.2%
51
Q

What does noninvasive prenatal testing good at detecting?

A
  • Open neural fetal defects
52
Q

Who is the cell free fetal DNA test ordered in?

A
  • High risk patients such as:
  • Advanced maternal age
  • History of prior pregnancy with a trisomy
  • Family history of chromosomal abnormalities
  • Fetal ultrasound abnormalities suggestive of aneuploidy
  • Positive serum screening test including first trimester, triple or quad screen
53
Q

When is an amniocenteisis done?

A
  • 16-20 weeks

- 0.3% miscarriage rate

54
Q

When is a chorionic villus sampling done?

A
  • 11 weeks

- 1% miscarriage rate

55
Q

What is teratology?

A
  • Study of abnormal fetal development
56
Q

What is a teratogen?

A
  • Any agent or factor that can cause abnormalities of form or function in an exposed fetus
57
Q

What are some abnormalities caused by teratogens?

A
  • Fetal loss
  • Intrauterine growth restriction
  • Malformations due to abnormal growth
  • Abnormal CNS performance
58
Q

What is fetal susceptibility of teratogens?

A
  • Efficacy of teratogen is dependent on the genetic makeup of mother and fetus as well as on a number of factors related to the fetal-maternal environment
59
Q

How does the dose of a teratogen affect its effects?

A
  • Low dose: no apparent effect
  • Intermediate dose: Organ malformation
  • High dose: spontaneous abortion
  • May have different effect if taking one large dose or many small doses over days
60
Q

How is timing important in teratogens?

A
  • Most vulnerable stage is from day 17 to day 56 post conception (called organogenesis)
  • Determines which organ or organ systems are affected
  • From fourth month to end of gestation, development is mainly just increasing organ size
61
Q

Why does the nature of the teratogenic agent matter?

A
  • Under the right set of circumstances, agents can cause malformations
  • Large doses during organogenesis, susceptible fetus
  • Some agent are only teratogenic when combined with other agents
62
Q

What are some examples of teratogenic agents?

A
  • Drugs
  • Alcohol
  • Infectious agents
  • Radiation
63
Q

What is the most common teratogen a fetus is exposed to?

A
  • Alcohol

- Causes fetal alcohol syndrome

64
Q

What antineoplastic agents are teratogens?

A
  • Aminopterin (X) and methotrexate (D) are both folic acid antagonists
  • Exposure before 40 days is lethal to embryo
  • Later exposures causes IUGR, craniofacial abnormalities, mental retardation, miscarriage, stillbirth and neonatal death
65
Q

What does fetal alcohol syndrome look like?-

A
  • Growth restriction (prenatal or postnatal)
  • Facial abnormalities: low set ear, smooth philtrum, thin upper lip, shortened palpebral fissures, flat midface
  • CNS dysfunction: Microcephaly, mental retardation, and behavior disorders
66
Q

What alkylating antineoplastic agents are teratogenic?

A
  • Busulfan, chlorambucil, and cyclophosphamide
  • May result in IUGR, fetal death, cleft lip/palate, microphthalmia and limb reduction anomalies, and poorly developed external genitalia
67
Q

What anticoagulants are considered teratogenic?

A
  • Coumadin (crosses placenta)
  • Causes spontaneous abortion, IUGR, CNS defects like mental retardation, stillbirth, and craniofacial features known as fetal warfarin syndrome
  • Heparin (does not cross placenta)
68
Q

What anticonvulsants are considered teratogenic?

A
  • Diphenylhydantoin: fetal hydantoin syndrome
  • Valproic acid: 1-2% risk of open spina bifida, some association with cardiac defects, skeleton defects, and craniofacial abnormalities
  • Carbamazepine: increased risk for spina bifida, minor craniofacial defects, fingernail hypoplasia, and developmental delay
69
Q

What is seen with phenobarbital in neonates?

A
  • Usually in combination with other drugs and true teratogenic potential is difficult to access
  • Can see neonatal withdrawal and hemorrhage
70
Q

What abnormality is seen with estrogen-progesterone combinations?

A
  • Masculinization of female external genitalia
71
Q

What is diethylstilbestrol (DES) used for?

A
  • Threatened abortion
72
Q

What does DES cause?

A
  • Risk for cervical abnormalities and uterine malformations
  • Female offspring are at greater risk of vaginal cell cancer and male offspring are at risk of testicular abnormalities
  • T shaped uterus
73
Q

What malformations does accutane/retinoids cause?

A
  • CNS (hydrocephaly, facial nerve palsies, and cortical blindness)
  • Cardiovascular
  • Craniofacial defects
74
Q

What does tobacco smoking do to the fetus?

A
  • Interferes with fetal growth- weight, length, and head circumference
  • Increased risk of spontaneous abortion, fetal death, neonatal death, and prematurity
75
Q

What do illicit drugs do to a fetus?

A
  • Often unrecognized due to lack of overt symptoms or structural anomaly following birth
  • Opiate- may experience withdrawal
  • Behavioral abnormalities
76
Q

How can infectious agents affect a fetus?

A
  • Growth restriction
  • Fetal death
  • Mental retardation
77
Q

How does radiation affect a fetus?

A
  • Dose dependent

- Critical period is between 2 and 6 weeks post conception (if before 2 weeks, could be lethal or have no effect)

78
Q

What is the rule of thumb with radiation in pregnancy?

A
  • Less than 5 rads of exposure is no risk
79
Q

How can nausea and vomiting be controlled during pregnancy?

A
  • Eat small but frequent meals
  • Avoid greasy, fried foods
  • Room temperature sodas and saltine crackers
  • Acupuncture
  • Meds
80
Q

How can heartburn be controlled during pregnancy?

A
  • Do not lie down after meals
  • Elevate head of bed
  • Eat smaller but frequent meals
  • Antacids
  • H2 blockers
81
Q

How can constipation be controlled during pregancy?

A
  • Dietary changes like increasing water, fiber, fruits and veggies
  • Stool softener
82
Q

How can hemorrhoids be controlled during pregnancy?

A
  • Rest, stool softeners, sitz baths
  • Elevation of legs
  • Avoid constipation
83
Q

How can leg cramps be controlled during pregancy?

A
  • More common in last half of pregnancy
  • More frequent in calves at night
  • Massage or stretching to treat
84
Q

How can backache be controlled during pregancy?

A
  • Common in late pregnancy
  • Avoid excess weight gain
  • Exercise/stretching
  • Comfortable shoes
  • Strategic use of pillows while sleeping
  • Heat
  • Massage
85
Q

What is the frequency of prenatal office visits?

A
  • Every 4 weeks until 28 weeks

- Then every 2 weeks from 28 to 36 weeks

86
Q

What occurs at a prenatal office visit?

A
  • BP
  • Weight
  • Urine proteins
  • Measurement of uterine size
  • Fetal heart rate
  • Address fetal movement and kick counts
  • Discuss lifestyle situations
  • Educate on preterm and term labor, rupture of membranes, preeclampsia, and any other complications
87
Q

What is the first sensation of movement called? When does it occur?

A
  • Quickening and occurs near 20 weeks
88
Q

What is evaluated near term?

A
  • Fetal lie and fetal position
89
Q

What screening is done at 20 weeks?

A
  • Obtain fetal survey ultrasound
90
Q

What screening is done at 28 weeks?

A
  • Screening for gestational diabetes and repeat hemoglobin and hematocrit
  • Rhogam injections to Rh- patients
  • Tdap given between 27-36 weeks
91
Q

What screening is done at 36 weeks?

A
  • Screening for group B strep carriers with vaginal culture- treat if positive
92
Q

What is a part of the assessment of fetal well being?

A
  • Kick counting (10 movements in 2 hours)
  • Nonstress test
  • Contraction stress test
93
Q

What is a nonstress test?

A
  • Reactive- 2 accelerations of at least 15 beats above baseline lasting at least 15 seconds during 20 minutes of monitoring
94
Q

What is a contraction stress test?

A
  • Give oxytocin to establish at least 3 contractions in a 10 min period
  • If late decelerations are noted with the majority of contractions, the test is positive and delivery is warrented

Endo/Repro (31 decks)

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