The Normal Pregnancy: Antepartum Care Flashcards

(94 cards)

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
Who is assessed for genetic counseling?
- 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
26
What are some common chromosomal disorders?
- Turners - Klinefelter's - Balanced robertsonian translocations - Autosomal trisomies
27
How is maternal age related to chromosomal disorders?
- Women that are age 35 and older are at increased risk of autosomal trisomies or sex chromosome abnormalities
28
What is the leading cause of down syndrome?
- Due to meiotic nondisjunctional events leading to 47 chromosomes with an extra copy of chromosome 21 - Some are due to an unbalanced translocation
29
How much of a risk is it for a couple to have another child with a chromosomal abnormality?
- 1%
30
What should be done to couples after 3 or more spontaneous abortions?
- Chromosomal studies (karyotyping) | - In 3-5% of these couples, there will be a diagnosis of a balanced translocation
31
What should balanced translocation couples receive?
- Counseling regarding possibility of having a child with an unbalanced translocation and therefore be offered prenatal diagnosis (chorionic villus sampling/amniocentesis)
32
What are some examples of autosomal dominant disorders?
- Tuberous sclerosis - Neurofibromatosis - Achondroplasia - Craniofacial synostosis - Adult onset polycystic kidney disease - Muscular dystrophy
33
What are some examples of autosomal recessive disorders?
- Tay-Sachs - Sickle cell disorders - Alpha and beta thalassemia - Cystic fibrosis
34
What is done for high risk populations?
- Carrier screening programs because the frequency of heterozygotes is greater than that of the general population
35
Why is genetic counseling important for cystic fibrosis?
- 15% of carriers go undetected | - CF is most common in North American whites
36
Who is offered screening for CF?
- 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
37
What are some examples of sex linked disorders?
- Duchenne muscular dystrophy | - Fragile X syndrome
38
What is fragile x syndrome?
- Most common form of inherited mental retardation | - Second most common form of mental retardation after down syndrome
39
How can sex linked disorders be diagnosed prenatally?
- By chorionic villus sampling or amniocentesis
40
What does someone look like with fragile x syndrome?
- 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
What are multifactorial disorders? Example?
- 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
What are some details about neural tube defects?
- 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
What does the first trimester screening include?
- Maternal age - Fetal nuchal translucency thickness - Maternal serum b-hCG - Pregnancy associated plasma protein A (PAPP-A)
44
What does the fetal nuchal translucency thickness tell?
- 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
What in the first trimester screening would lead to a suspicion of Down's syndrome?
- Elevated b-hCG and low PAPP-A | - Nasal bone assessment (absence of) can increase detection
46
What does the second trimester include?
- Triple screen: b-hCG, estriol, and maternal serum alpha fetoprotein biochemical markers - Quadruple screen: b-hCG, estriol, AFP, and inhibin A
47
When does the triple screen in the second trimester take place? What is detection rate of trisomy 21?
- Takes place between weeks 16 and 20 | - 70% detection week
48
What is the detection rate of trisomy 21 in the quadruple screen?
- 80%
49
What is the noninvasive prenatal testing (cell free fetal DNA)?
- Tests cell free fetal DNA, thought to be derived apoptosis of trophoblastic cells that have entered maternal circulation
50
What is noninvasive prenatal testing good at detecting?
- Trisomy 21 = 99.4% - Trisomy 18 = 99.1% - Trisomy 16 = 91.7% - Sex chromosomes = 96.2%
51
What does noninvasive prenatal testing good at detecting?
- Open neural fetal defects
52
Who is the cell free fetal DNA test ordered in?
- 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
When is an amniocenteisis done?
- 16-20 weeks | - 0.3% miscarriage rate
54
When is a chorionic villus sampling done?
- 11 weeks | - 1% miscarriage rate
55
What is teratology?
- Study of abnormal fetal development
56
What is a teratogen?
- Any agent or factor that can cause abnormalities of form or function in an exposed fetus
57
What are some abnormalities caused by teratogens?
- Fetal loss - Intrauterine growth restriction - Malformations due to abnormal growth - Abnormal CNS performance
58
What is fetal susceptibility of teratogens?
- 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
How does the dose of a teratogen affect its effects?
- 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
How is timing important in teratogens?
- 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
Why does the nature of the teratogenic agent matter?
- 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
What are some examples of teratogenic agents?
- Drugs - Alcohol - Infectious agents - Radiation
63
What is the most common teratogen a fetus is exposed to?
- Alcohol | - Causes fetal alcohol syndrome
64
What antineoplastic agents are teratogens?
- 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
What does fetal alcohol syndrome look like?-
- 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
What alkylating antineoplastic agents are teratogenic?
- Busulfan, chlorambucil, and cyclophosphamide - May result in IUGR, fetal death, cleft lip/palate, microphthalmia and limb reduction anomalies, and poorly developed external genitalia
67
What anticoagulants are considered teratogenic?
- 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
What anticonvulsants are considered teratogenic?
- 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
What is seen with phenobarbital in neonates?
- Usually in combination with other drugs and true teratogenic potential is difficult to access - Can see neonatal withdrawal and hemorrhage
70
What abnormality is seen with estrogen-progesterone combinations?
- Masculinization of female external genitalia
71
What is diethylstilbestrol (DES) used for?
- Threatened abortion
72
What does DES cause?
- 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
What malformations does accutane/retinoids cause?
- CNS (hydrocephaly, facial nerve palsies, and cortical blindness) - Cardiovascular - Craniofacial defects
74
What does tobacco smoking do to the fetus?
- Interferes with fetal growth- weight, length, and head circumference - Increased risk of spontaneous abortion, fetal death, neonatal death, and prematurity
75
What do illicit drugs do to a fetus?
- Often unrecognized due to lack of overt symptoms or structural anomaly following birth - Opiate- may experience withdrawal - Behavioral abnormalities
76
How can infectious agents affect a fetus?
- Growth restriction - Fetal death - Mental retardation
77
How does radiation affect a fetus?
- Dose dependent | - Critical period is between 2 and 6 weeks post conception (if before 2 weeks, could be lethal or have no effect)
78
What is the rule of thumb with radiation in pregnancy?
- Less than 5 rads of exposure is no risk
79
How can nausea and vomiting be controlled during pregnancy?
- Eat small but frequent meals - Avoid greasy, fried foods - Room temperature sodas and saltine crackers - Acupuncture - Meds
80
How can heartburn be controlled during pregnancy?
- Do not lie down after meals - Elevate head of bed - Eat smaller but frequent meals - Antacids - H2 blockers
81
How can constipation be controlled during pregancy?
- Dietary changes like increasing water, fiber, fruits and veggies - Stool softener
82
How can hemorrhoids be controlled during pregnancy?
- Rest, stool softeners, sitz baths - Elevation of legs - Avoid constipation
83
How can leg cramps be controlled during pregancy?
- More common in last half of pregnancy - More frequent in calves at night - Massage or stretching to treat
84
How can backache be controlled during pregancy?
- Common in late pregnancy - Avoid excess weight gain - Exercise/stretching - Comfortable shoes - Strategic use of pillows while sleeping - Heat - Massage
85
What is the frequency of prenatal office visits?
- Every 4 weeks until 28 weeks | - Then every 2 weeks from 28 to 36 weeks
86
What occurs at a prenatal office visit?
- 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
What is the first sensation of movement called? When does it occur?
- Quickening and occurs near 20 weeks
88
What is evaluated near term?
- Fetal lie and fetal position
89
What screening is done at 20 weeks?
- Obtain fetal survey ultrasound
90
What screening is done at 28 weeks?
- Screening for gestational diabetes and repeat hemoglobin and hematocrit - Rhogam injections to Rh- patients - Tdap given between 27-36 weeks
91
What screening is done at 36 weeks?
- Screening for group B strep carriers with vaginal culture- treat if positive
92
What is a part of the assessment of fetal well being?
- Kick counting (10 movements in 2 hours) - Nonstress test - Contraction stress test
93
What is a nonstress test?
- Reactive- 2 accelerations of at least 15 beats above baseline lasting at least 15 seconds during 20 minutes of monitoring
94
What is a contraction stress test?
- 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