The Pregnant Patient Flashcards
Things to note on breast exam documentation
symmetry
tenderness
masses
skin changes
nipple changes
axillary and lymph node exam
Quadrants of the breast
Upper outer quadrant
upper inner quadrant
lower outer quadrant
lower inner quadrant
Gravida
a woman who is or has been pregnant (regardless of outcome of pregnancy)
Nulligravida
a woman who has never been pregnant and is not currently pregnant
Primigravida
woman who is pregnant for the first time or has been pregnant once
Multigravida
woman who has been pregnant more than once
Nullipara
A woman who has never given birth or never had a pregnancy beyond 20 weeks
Primipara
woman who has given birth only 1 time (one delivery of a fetus born alive or dead with a gestation of 20 weeks or more)
Multipara
A woman who has given birth 2 or more times (past 20 weeks)
What is the marker for para designation
20 weeks
What does primigravida and nullipara mean
A woman who was pregnant but the baby did not reach 20 weeks gestation
What does G stand for?
Gravida: # of pregnancies
What does P stand for?
P: Para # of births after 20 weeks
GTPAL
Gravida
Term deliveries (after 37 weeks)
Preterm
Abortions (spontaneous/therapeutic < than 20 weeks or <500 grams)
L: number of living children
What does G2P2002 mean
2 pregnancies, 2 term deliveries (after 20 weeks), no abortions, no preterm, 2 living children
What are the 3Ps for sign of pregnancy
Presumptive (better not tell you now)
Probable (most likely)
Positive (without a doubt)
Presumptive signs of pregnancy are
Subjective, a patient describes to the provider, may not be due to pregnancy
What are examples of presumptive signs of pregnancy
missed or unusual bleeding pattern
nausea/vomiting
breast changes, size, tenderness, increased sensation
increased urinary frequency
What are examples of probably signs of pregnancy
enlargement of uterus
Hegar’s sign
Chadwick’s sign
Goodell’s sign
Piskacek’s sign
Positive UPT
Melasma
When do presumptive signs of pregnancy come into play?
women who are multipara
Hegar’s sign
softening of the uterine isthmus
Chadwick’s sign
Bluish or cyanotic appearing cervix and upper vagina due to increased vascularity
Goodell’s sign
Softening of the cervix due to increased vascularity
Piskacek’s sign
assymmetric bulge or soft prominence of uterus caused by placental development
Positive signs of pregnancy
fetus identified by ultrasound
fetal heartbeat detected by doppler or auscultation
objective detection of fetal movement by healthcare provider
DELIVERY OF THE BABY
Symptoms of early pregnancy
amenorrhea
early spotting in pregnancy can be confused for menses
N/V
breast enlargement/tenderness
fatigue
urinary frequency
pelvic discomfort/pressure
What physical exam signs can you see at 6+ weeks
engagement and softening of uterus
What physical exam signs can you see at 12+ weeks
uterus palpable above symphysis pubis in the lower abdomen
Which occurs first? Chadwick’s sign or hears sign?
Chadwick’s sign
What lasts longer? Chadwick’s sign or hears sign?
Hegar’s sign
When can you detect fetal heart tones?
6 weeks fetal cardiac activity detected by ultrasound
12 weeks heart tones detected by Doppler (may be as early as 9 weeks)
When can you detect intra uterine pregnancy on ultrasound?
may be as early as 4-5 weeks gestation (gestational sac)
When does fetal quickening occur
18-20 weeks in a primigravida
14-18 weeks in multigravida
What are some skin findings of pregnancy
mask of pregnancy/melasma (2nd or third trimester)
Linea Nigra
darkening of the midline of the abdomen (beginning late 1st trimester)
Pregnancy must be confirmed by
testing
What are definitive examples of pregnancy
Positive urine or serum hCG
Identification of pregnancy by ultrasound
Detection of fetal heart tones by doppler
What does CRL mean
crown to rump length
What kind of test is a UPT?
Qualitative, it will say yes or no
What kind of problems happen with UPT?
his false negative rate (says negative but the patient is pregnant)
Benefit of serum hCG
more sensitive
positive earlier than UPT
qualitative (yes or no) and quantitative (how long?)
what is a quant/qual hCG?
serum hCG
How quickly does hCG double in early pregnancy
double ever 48-72 hours increases every after 6 weeks double every 96
When does hCG levels peak?
first 8-11 weeks of pregnancy and then declines and levels off
of a hCG level peaks before 8 weeks what does that mean?
possible ectopic or lost pregnancy
Home pregnancy test should
be confirmed in the office
What is menses day 1?
first day of bleeding of LMP
How do you estimate gestational age
number of weeks since first day of LMP, NOT presumed time of conception
EDD
Estimated date of delivery
What is the average pregnancy
Average is 280 days from first day of LMP
What is the other name for EDD?
EDC estimated date of confinement
Naegele’s Rule
Add 7 days to first day of LMP subtract 2 months, add a year
What ultrasound is the most accurate in gauging EDC
first trimester ultrasound
When do you get the first ultrasound?
before 22 weeks to confirm dates
What is it called if the ultrasound is done after 22 weeks
“sub-optimally dated”
When is the first prenatal visit done?
8 to 10 weeks gestation, ideally 1st trimester
What is done at the first prenatal visit?
confirm the pregnancy, destine estimated date of delivery and gestational age
determine desire for pregnancy/attitude for pregnancy
What are questions to ask about about attitude of pregnancy during 1st prenatal visit
how does she feel?
was it planned?
Is it desired?
Does she plan to continue to term?
What type of education and counseling is provided at the 1st prenatal visit?
scope of care provided in the office and expected schedule of visits
Counseling (risk factors, complications, diagnostics, genetic screening)
Discussion of current symptoms as well as anticipated symptoms
Offer reassurance that most symptoms will improve
health maintenance
barriers to care
When do pregnancy symptoms improve
usually 2nd trimester when other changes typically reverse by 6 weeks postpartum, some immediately after delivery
What are important health maintenance issues for a pregnant person
weight gain, nutrition, seat belts, vaccinations
How often should prenatal care occur
total 14 visits (every 8-10 weeks of pregnancy)
4 weeks during the 1st 28 weeks
2-3 weeks until 36 weeks
every week after 36 weeks
What physical exam during 1st prenatal comprehensive visit
vitals, especially blood pressure
weight (including BMI)
heart, lung, thyroid, basic neuro
breast pelvic exam
PELVIMETRY
assessment of cervix
uterine size, shape and consistency
What is included in pelvimetry measurement
public arch, ischial spines, sacrum, diagonal conjugate
What is pelvimetry
description of bony pelvis adequate for vaginal delivery
Size of the uterus at 12 weeks
at symphysis pubis
Size of the uterus at 16 weeks
halfway between pubis and umbilicus
Size of the uterus at 20 weeks
at umbilicus
Size of the uterus after 20 weeks
1 cm for every week of gestation
Normal pregnancy 10 weeks obstetric findings
fetal heart beat detectible by 9-10 weeks via Doppler (often closer to 10-12 weeks)
Normal pregnancy 12 weeks obstetric findings
Uterus palpable in abdomen by 12 weeks
Normal pregnancy 18 weeks obstetric findings
fetal movement felt by mom “quickening” between 18-20 weeks
Normal pregnancy 20 weeks obstetric findings
fundus reaches umbilicus at 20 weeks
Normal pregnancy 24 weeks obstetric findings
fetal movement observable by examiner/partner after 24 weeks
What should BP be like in pregnancy?
Low
any high BP during pregnancy is bad
Normal pregnancy 36 weeks obstetric findings
fundus reaches max height at the level of the xiphoid process around 26 weeks
If someone has low BMI how much weight gain is recommended during pregnancy
28-40lb gain recommended
If someone has normal BMI how much weight gain is recommended during pregnancy
25 to 35 lb gain recommended
If someone has a high BMI how much weight gain is recommended during pregnancy
15-25 lb gain recommended
If someone is obese how much weight gain is recommended during pregnancy
less than 15 lbs recommended
What are routine labs that should be done during the comprehensive 1st prenatal visit
ABO, Rh typing, antibody screen
CBC (anemia, platelet count)
Genetic and infectious disease testing (CF, hemoglobinopathy, hereditary diseases)
What infectious disease testing is recommended during comprehensive 1st prenatal visit
Hepatitis B, Hepatitis C (recommended for each pregnancy)
Rubella, varicella, syphilis and HIV (unless declined)
If a patient is high risk
includes gonnorrhea and chlamydia
What are routine diagnostic studies during comprehensive 1st prenatal visit
cervical cancer screening
urine culture and sensitivity
urine dip for protein and glucose
gestational diabetes screening (if high risk)
TSH (if indicated)
What is in a prenatal vitamin
folic acid (helps prevent neural tube defects)
Vitamin D
iron
Calcium
What are foods to avoid during pregnancy d/t risk of listeria
Unpasteurized milk/soft cheese
hot dogs/lunch meat (unless they are steamed hot just before eating)
Pate/meat spread
smoked seafood
unwashed raw produce
raw and undercooked seafood/eggs/meat/poultry
DO NOT EAT SUSHI MADE WITH RAW FISH
What to know about eating fish in pregnancy
mercury
What are low mercury seafood?
shrimp, salmon, catfish, pollock
What are high mercury seafood?
shark, swordfish, king mackerel, Marin tilefish
limit white (albacore) tuna to 6oz per week
What immunizations do you need before pregnancy
Every pregnancy TDAP (27-36 weeks)
Inactivated flu vaccine, one dose annually
What are examples of live attenuated vaccines
MMR
Varicella
Zostavax
live attenuated flu
What vaccines should be delayed in pregnancy?
Shingrix
HPV
What woman are considered high risk for STI testing in pregnancy?
under age 25
sex work
IVDU
multiple partners
What should you be doing during every prenatal visit
emphasize healthy habits and assess risks
Protein in urine can show
ecclampsia
glucose in urine can show
gestational diabetes
When does the height of the uterus become unreliable for a measure of gestation
36 weeks
What are Leopold’s maneuveres
helps to determine fundal height
Pawlick’s grip
both hands on upper and lower poles of fetus to determine presentation- allows estimation of fetal size
Leopold’s first maneuver
what is in the fundus, what is the height
Leopold’s second maneuver
where is the back and extremities
Leopold’s third maneuver
what direction and degree of flexion of the head
Leopold’s fourth maneuver
what is the presenting part? Has it descended into the pelvis
What do you screen for at 24-28 weeks?
gestational diabetes
antibody screen Rh negative
repeat H&H
How do you test for gestational diabetes
50-gram one hour glucose challenge test as a screen (1 hour GTT)
If abnormal: 100 gram 3-hour glucose tolerance test: diagnostic (3hr GTT)
What do you screen for at 35-37 weeks
screen all women for group B beta hemolytic streptococcus (GBS)
Where do you swab for GBS
lower vagina and rectum
What do you screen for in the 3rd trimester?
repeat screening HIV and other STI in patients at increased risk
Aneuploidy
abnormal number of chromosomes
Prenatal screening: What are maternal serum testing
hCG, pregnancy-associated plasma protein A, alpha fetoprotein (AFP), fetal ultrasound, carrier testing
Prenatal genetic testing: when is carrier testing done
done at any time during pregnancy but ideally done before pregnancy
Blood or tissue from inside the cheek
Prenatal genetic testing: when do you screen for Down syndrome and trisomy 18
weeks 9-12
What does integrated screening and sequential screening do
10-22 weeks
combines first trimester and second trimester screening test results
Down syndrome, trisomy 18, trisomy 13 and Neural tube defect
What does cell-free DNA screening do
10 weeks and beyond
blood test
Down syndrome, trisomy 18, trisomy 13
When do you do CVS (chorionic villus) screening
10-13 weeks
tests fetal cells in a sample of chorionic villi
Detects Down syndrome, trisomy 13, trisomy 18, inherited disorders requested for testing but not neural tube defect
What does group B strep cause in infants during vaginal delivery
fatal meningitis
When do you do an amniocentesis
15-20 weeks
tests fetal cells in amniotic fluid
tests for Down syndrome, trisomy 13, trisomy 18, inherited disorders for which you request testing, certain types of neural tube defects
When is quad screening performed
15-22 weeks
blood test
screens for Down syndrome, trisomy 18, trisomy 18 and neural tube defect
When do you perform first-trimester screening
10-13 weeks
blood test plus nuchal translucency ultrasound exam
screens for Down syndrome and trisomy 18
When do you perform a standard ultrasound exam
timing 18-22 weeks
screens for some physical defects
