Week 8 Obstetrics & Prenatal care Flashcards
Which hormone is initially secreted by the blastocyst and later by the placenta?
HcG
In pregnancy E3 estriol is the primary estrogen produced by the placenta.
true or false?
true
The withdrawal of which of these hormones leads to contractions and onset of labor?
progesterone
Which hormone works in combination with relaxin to soften ligaments, widen the pelvis, and facilitate birth?
Progesterone
What is a diploid cell containing 46 chromosomes known as?
zygote
The cytotrophoblast helps establish nutrient circulation between the embryo and the mother.
true or false
false
What is the process through which genetically controlled cell groups become organized and specialized from stem cells into specific cell types?
morphogenesis
Presumptive Pregnancy signs
Signs: nausea with vomiting, fatigue, amenorrhea, breast tenderness, urinary frequency, cholasma
Probable pregnancy signs
Signs: positive Chadwick’s sign, positive pregnancy test, abdominal enlargement
Positive Pregnancy signs
Correct
Signs: audible fetal heart tones intrauterine pregnancy on ultrasound
Naegel’s rule is based on which of the following assumptions (select all that apply)?
No hormonal contraception is being used, and a typical menstrual period is 28 days long.
A second trimester ultrasound uses a crown-rump length to estimate an EDD within 7 days.
True or false?
false
Define multipara
Woman has had two or more pregnancies beyond 20 weeks, given birth more than once—counting multiple births as one event
define primapara
One pregnancy beyond 20 weeks, has given birth once
define nullipara
A woman who has not remained pregnant beyond 20 weeks
define para
Number of times a woman has given birth to a fetus of at least 20 gestational weeks, viable or no,t counting multiple birth as one birth event
Define primigravida
Woman pregnant for the first time
define nulligravida
Never has been pregnant
define gravida
Total number of pregnancies regardless of outcome, includes current pregnancy
When is amniotic fluid produced?
Last half of pregnancy and in form of lung fluid and urine
Fluid is swallowed and removed by placenta
Polyhydramnios
What
S/S #5
Complications #4
Management
What: Excessive fluid around fetus; AFI >24cm
S/S:
- Uterus larger than expected
- Dyspnea
- Vulvar edema
- GI upset
- Difficulty auscultating fetal heart tones
Complications
- Preterm labor
- Fetal cord prolapse
- Placental abruption
- Hemorrhage
Management
- US to confirm
- Gestation DM screening
- Refer
Oligohydramnios
What
S/S
Complications 4
Management
What: Between 24-36 weeks expect abnormalities!!!!
AFI <5cm
S/S
- Fetus easy to palpate
- Variable Heart decibels during labor d/t cord compression w/ contractions
Complications
- Fetal demise
- Pressure deformities
- Pulmonary hypoplasia
- IUGR
Management
- US to confirm
- R/o SROM (spont rupture of membranes)
- Refer
- Hydration
Intrauterine growth restriction
Definition
Associated with #4
Risk factors for IUGR #3
Fetal weight <10th percentile
Associated with:
- stillbirth
- perinatal mortality
- Abnormalities
- Learning disability
Risk Factors
- HTN
- Poor weight gain
- lagging fundal height
When are all major organs developed
How long is the corpus lutetium acting as the placenta?
10 weeks
10 weeks
What is human placental lactogen?
secreted by placenta by week 2 gestation
Metabolism regulation: breaks fats more efficiently
Insulin resistance: decreases maternal glucose reuptake to free up sugar for the fetus
Prepares mammary gland for lactation
What secretes progesterone? ‘
What is its role in pregnancy?
What about when the fetus is “at term”
Secreted by corpus luteum and placenta
Maintains myometrium - relaxes smooth muscles
Mediates immune system fxn
Inhibits production of prostaglandins in the uterus
At term - progesterone withdrawal (sharp drop) leads
to uterine contractions and onset of labor
Progesterone supplementation can be given to moms
who experience bleeding during pregnancy
What is the role of Estrogen during pregnancy? 4
(Estradiol, estrone, estriol) Estriol is primary during pregnancy
Prepares breasts for lactation
Promotes uterus growth
Increases uterine blood flow
Involved in onset/timing of labor
What is the role of Relaxin in pregnancy?
What is it secreted by?
Secreted by: CL then uterus & placenta
Role:
- implantation & placental growth
- Inhibits uterine activity during pregnancy
- Softens ligaments for SI joint to expand
What is the role of Oxytocin in pregnancy?
thins and dilates the cervix
facilitates milk release during BF
What secretes HcG?
When can this be detected in the urine? the blood?
Describe how the levels rise
Embryo
- Urine Detection: 2 weeks
- Blood Detection: 10 days
Doubles every 48-72 hours in 1st month
Excessive higher with multiple gestation or molar pregnancy
What is the role of HcG in pregnancy?
Describe the different levels of HCG
Increases progesterone production
LEVELS:
- Increase 1st trimester 100,000
- Peaks at 8 to 12 weeks
- declines & plateaus at 20,000
What are risk factors for hyperemesis gravidum?
- Thyroid
- GI
- Vestibular disorders
- Obesity
- Pregnant with multiples
- Nulliparous
- Previous history
- Psych disorders
How do you manage hyperemesis gravidum?
What are approved antiemetics for pregnancy?
Supportive care
- Fluid replacement NO DEXTROSE OR THIAMINE (B1)
- NPO 24-48 hours
- Ice chips
Antiemetics
- Promethazine
- Prochlorperazine
What is a molar pregnancy?
Risk Factors
What: *hydatidiform mole*
- Growth trophoblastic cells from abn fertilized egg
- implants INSIDE placenta = proliferation placental tissue
- Benign, could become malignant
Risk Factors
- <21 years or >35years
- history miscarriage
- hx molar pregnancy
Symptoms Molar Pregnancy 8
S/S
- severe persistent N/V
- Uterine bleeding
- Grape like fluid cysts
- Large for date uterus
- Enlarged tender ovaries
- Elevated HcG
- Preeclampsia prior to 20 weeks gestation
- No fetal heart tones
How to work up molar pregnancy?
How to manage Molar pregnancy?
Work up:
- US “snow storm” pattern
- Fluid filled vesicles in “grape like” patter
- Obtain HCG level
Management
- D&C
- Hysterectomy
- F/U
- monitor gestational trophoblastic neoplasia
- HCG levels to 0
- No conception for up to 1 year
What is the single most important risk factor for infant morbidity and mortality?
Preterm labor that happens before 37 weeks of pregnancy
What is the definition of preeclampsia?
Systolic BP >140/90 in 2 measurements taken 4 hours apart AND 1…
- PLT <100,000
- Elevated LFTs (2x norm)
- Pulmonary edema
- H/A, visual disturbance
- Proteinuria >300 in 24 hours
- Elevated creat
- Protein-creat ratio >0.3
What is the definition of severe preeclampsia?
Severe HTN after 20 weeks gestation
Severe BP >160/110 in single episodes TREAT WITHIN 15 MINS
Any signs of HELLP syndrome
What are the signs of HELLP syndrome?
Hemolysis
Elevated LFT
Low PLT
Who is at risk for developing preeclampsia?
- Nulliparous
- >35 yrs
- Obestity
- FMH
- HTN
- CKD
- Pre-gestation DM
- AAmer
- Multiple gestations
- Molar pregnancy
- Vascular/connective tissue disease
preeclampsia
S/S
Management
s/s
- Nonspecific
- proteinuria
- HELLP
- HA/ vision disturbances
- GI
- Decreased UO
- SOB
Management
- Refer to OB
- Delivery of baby
What is Cell free DNA (“non invasive prenatal testing” NIPT)
1st trimester screening 9-10 weeks
Blood sample
Detects trisomies, sex chromosome abnormalities
What is the Quad screen
What does it look at?
Done at 15 to 18 weeks, up to 22 weeks
- HCG
- AFP
- estriol
- Inhibin A
- Neural tube defects
- Trisomy 18 & 21
What prenatal labs are you taking at the first prenatal visit?
- Blod type, RH, antibody screen
- CBC
- Hep B surface antigen
- HIV /STI screening
- Rubella & Varicella titers
What is the timing for subsequent prenatal visits?
- Every 4 weeks until 28 weeks
- Every 2 weeks until 36 weeks
- Every week until delivery
When do you do the glucose tolerance test?
24 to 38 weeks
Preterm labor diagnostic criteria
S/S
diagnostic
- Labor between 20 to 37 weeks
- Uterine contractions
- Effacement of 80%
- Cervical dilation over 1cm
Symptoms
- Frequent contractions
- Low dull backache
- abdominal cramping
- Pelvic pressure
- Increased vaginal discharge/bleeding
- Rupture membranes
Preterm labor risk factores
- Uterine overdistension
- Infection
- Cervical disease/LEEP
- Stress
- Decline in progesterone
- Low socioeconomic status
Hedgar’s sign
Softening of lower uterine segment
Goodell’s sign
softening of cervix 6 weeks
What are the definitive positive signs of pregnancy?
US
Audible fetal heart tones
Fetal movement felt by provider
What are the risk factors for diabetes that would make you obtain an A1C and fasting glucose at the initial visit?
- Hx gestational diabetes or glucose intolerance
- BMI >25
- Hx macrosomia or still birth
- 1st degree relative w/diabetes
- Non white race
When do you do the 1 hour glucose tolerance test for gestational diabetes?
24-28 weeks
When do you do Group B strep screening?
36 to 38 weeks
When do you do US for dating and anatomical survey?
18 to 20 weeks
When do you start folic acid supplementation?
How much?
How much if history of infant with NTD?
3 months prior
400mcg
4mg/day if prior
What medications can you take for nausea
Vitamin B6 and Doxylamine (unisom)
Diclegis (+urine screen)
Explain GTPAL
Gravida: # pregnancys regardless outcome includes current pregnancy
Term: # pregnancies delivered at or after 37 weeks
Preterm: # pregnancies delivered from 20 to 36 weeks
Abortion: # pregnancies ending before 20 weeks
Living: # living children
What is lochia? how long does it last?
shedding of uterine lining after delivery: blood mucous and uterine tissue
Lasts for 4 to 6 weeks after childbirth
What is/length of time
Lochia rubria
Lochia Serosa
Alba
Rubra: 3-4 days after birth, blood clots
Serosa: Days 4 to 10; Mucus/Pinkish/Brown; less volume, few clots
Alba: days 10 to 28; whitish, no odor, no real flow
What is uterine involution?
How long does this take?
Uterus transforms to nonpregnant state
Takes 5 to 6 weeks
Fundal height decreases 1cm/day
No longer palpable by day 10
When do you provide Rhogam to a RH negative mom that had an abortion?
within 72 hours
What symptoms should the patient report when having an abortion?
Saturating more than 1 pad/hour
Temp >100.4/chills
Passing clots larger than golf ball/50cent piece
What is the Nuchal Translucency US and blood draw for free beta HCG and PAPP-a do?
When is it done?
10 - 14 weeks
Looks for Down’s syndrome
High false positives
What is the nasal bone calcification evaluation and when is it done?
first-trimester screening
Increases chances of detecting trisomy 21
What are the life threatening conditions you need to r/o with bleeding during pregnancy?
- Ectopic pregnancy
- maternal hemorrhage
NEXT
- determine fetal viability
- origin of bleeding
What are some differentials for bleeding during pregnancy?
- ectopic
- cervicitis
- cervical polyps
- implantation
- subchorionic hemorrhage
- vulvar varicosities
- hemorrhoids
- cystitis
- molar pregnancy
How to work up bleeding during pregnancy
- HCG levels
- Q1.5 days until week 5
- Q 2days until week 6
- Q 2-2.5 days until week 7
- HCG should plateau and fall weeks 8 to 10
- CBC
- Progesterone level
- STI testing
- Transvaginal US
What are the signs of ectopic pregnancy?
Risk factors
Symptoms
- Spotting/bleeding
- lower sharp abdominal pain
- Tender adnexal mass
Risk Factors
- Previous history
- Hx PID or surgery
- <25 or >35
- 3.5x more common in June and Dec
How do you manage Ectopic Pregnancy?
Diagnose early to preserve fertility
Hospitalization
What is Vasa Previa?
Fetal blood vessels cross cervical opening that can result in hemorrhage
Can palpate pulsating cord
What is placenta previa?
What if it does not improve by 28 weeks?
Malposition of the lower uterine segment and extends across the cervical os
Hallmark sign: Sudden onset painless vaginal bleeding
*no improvement within 28 weeks = c section
Abruptio Placentae
What
Cause
Signs
What: Placenta separates prior to birth
Associated with:
- Uterine scar from c/s
- smoking
- Advanced maternal age
- multiple gestations/parity
- hypertension
Signs
- mimic labor
- Blood discharge
- firm tender abdomen
Management of low lying placenta and partial previa
f/u at 24 to 28 weeks gestation
Management of complete previa
serial US and pelvic rest
Management of vasa previa
antenatal corticosteroids 28 to 32 weeks
hospitalization at 30 to 34 weeks
C section at 35 to 37 weeks
Naegele’s rule
EDD +/- 5 days
Count back 3 months and add 7 days
How long until an ultrasound can measure EDD?
13 weeks
What are complications for mother that gestational diabetes can cause? 6
- pregnancy loss
- HTN/preeclampsia
- increased chance of c/s d/t macrosomia
- prolonged labor
- risk of DM 2 within 10 years
- pyelonephritis
What are complications for the baby if the mother has gestational diabetes?
- fetal anomalies
- IUGR
- premature birth
- hypoglycemia
- hyperbilirubinemia
- obesity & type 2 diabetes in adulthood
What is the screening process for gestation diabetes?
Screened at 24 to 28 weeks gestation
50g oral glucose
1hr test >130 —- needs 3 hour test
if 1 hr test >180 —— Dx GESTATIONAL DIABETES
