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RDS Test 1 > B8.018 Prework 1: High Risk Pregnancies > Flashcards

B8.018 Prework 1: High Risk Pregnancies Flashcards

(79 cards)

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1
Q

specific pregnancy related concerns in obese gravidas

A

early screening for gestational diabetes or overt diabetes
sleep study to assess OSA
screen for pre-existing hypertension

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2
Q

how does pregnancy contribute to development of diabetes

A

human chorionic somatomammotropin (hCS) induces metabolic changes in the mother such as mobilization of fatty acids, insulin resistance, decreased glucose utilization, and increased availability of AAs
decreases maternal use of protein

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3
Q

who is at risk for diabetes in pregnancy?

A

obese
strong fam history of DM2
polycystic ovarian syndrome

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4
Q

diagnosis of overt diabetes

A

FPG = 126
A1C = 6.5%
random glucose = 200

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5
Q

adverse risks associated with diabetes in pregnancy

A 
preeclampsia
polyhydramnios
macrosomia
fetal organomegaly
maternal and infant birth trauma
perinatal mortality
neonatal respiratory problems and metabolic complications (hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia)
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6
Q

direct effect of diabetes on offspring

A

risk of any congenital anomaly increases

long term risks: obesity, metabolic syndrome, autism

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7
Q

2 step approach for GDM testing

A

1 hr GTT (50g)
-if >135, do the 3 hr GTT (100g)
-fasting >95, 1 hr >180, 2 hr >155, 3 hr >140
need 2/4 values to be abnormal to meet criteria for GDM

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8
Q

1 step approach for GDM testing

A

2 hr GTT (75g load)
-fasting >92, 1 hr > 180, 2 hr > 153
if any value is abnormal, patient meets criteria

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9
Q

what to do once a diagnosis of GDM is made?

A

patient undergoes nutritional counseling and is then asked to check their blood sugars
initially > dietary changes, if this doesn’t work patient may receive pharmacologic treatment

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10
Q

medical interventions for GDM

A

insulin > gold standard

metformin and glyburide considered to be safe, oral alternatives

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11
Q

mechanism of metformin

A
  • decreases hepatic glucose production
  • decreases intestinal absorption of glucose
  • improves insulin sensitivity by increasing peripheral glucose uptake and utilization
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12
Q

metformin side effects

A

NO RISK of hypoglycemia

common adverse reactions: diarrhea, N/V, flatulence, indigestion, abdominal discomfort, anorexia, rash

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13
Q

mechanism of glyburide

A

stimulates the release of insulin from the pancreas

-dependent upon functioning beta cells in the pancreatic islets

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14
Q

side effects of glyburide

A

hypoglycemia, nausea, stomach pain, loss of appetite, rash

rarely: jaundice, confusion, weakness, easy bruising or bleeding

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15
Q

how to monitor fetal well being during GDM

A

non stress tests 2x weekly

biophysical profile weekly

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16
Q

non-stress test

A

fetal heart rate patterns measures for 20-30 min

pattern tells provider if the baby is getting adequate oxygenation from the placenta

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17
Q

biophysical profile

A

US assessment that includes documentation of how much the baby is moving, fetal muscle tone, diaphragmatic excursions observes, and the amt of amniotic fluid that is around the baby
if all are present in sufficient amounts: baby is getting adequate oxygenation

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18
Q

advanced maternal age

A

> 35 years

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19
Q

risks with AMA

A 
aneuploidy
early onset gestational diabetes
gestational HTN/ preeclampsia
preterm delivery
stillbirth
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20
Q

what should be offered to all pregnant mothers who are AMA

A
  1. genetic screening for trisomy 21, 18, 13
    - first trimester US at 11-14 weeks
    - offer additional serologic screening vs. chorionic villous sampling/amniocentesis
  2. first trimester/early second trimester screening for GDM
  3. detailed fetal anatomy scan around 20 wks
  4. fetal growth at 32 wks
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21
Q

AMA < 40

A

in absence of gestational diabetes, HTN disorders of pregnancy, fetal growth restriction, or evidence of impending placental insufficiency, routine prenatal care is sufficient until 39 wks

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22
Q

AMA > 40

A

initiate weekly surveillance 32-34 wks

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23
Q

why are pregnancies at risk of aneuploidy?

A

VERY RARELY does fam history have any role in risk for a cytogenetic error to occur
meiotic nondisjunction in 95% of cases
>90% the extra chromosome is from the mother

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24
Q

why offer aneuploidy screening?

A

risk assessment
balance consequences of having a child with the particular disorder against the risk of an invasive diagnostic test
prenatal mental preparation
pregnancy monitoring
recommendations for delivery at tertiary center

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25
first trimester aneuploidy screening option
nuchal translucency | thicker = abnormal
26
what is cffDNA
cell free fetal DNA can be isolated from maternal plasma result of apoptosis of the placental syncytiotrophoblasts (technology relies on the premise that the fetus and placenta originate from a single, fertilized egg)
27
predictive value of cffDNA
NOT good in lower risk populations
28
carrier screening performed
CF and SMA offered to all some ethnic specific fragile X in those with personal or family history of premature ovarian failure, autism, intellectual dysfunction, movement disorders
29
delivery in AMA pregnancies
most deliver in 39th week - increased risk of stillbirth after this - low risk of neonatal morbidity/mortality at this GA
30
drugs given to premature infants to reduce risks of morbidity and mortality
corticosteroids | magnesium sulfate
31
which pregnant mothers are given corticosteroids?
patients expected to deliver prematurely (<37 wks GA)
32
function of steroids in premature birth
stimulate fetal lungs to develop type 1 and 2 pneumocytesand surfactant decreased rates of newborn mortality decrease intraventricullar hemorrhage, necrotizing enterocolitis, and infections
33
when can steroids have a positive impact on premature infants
after 22-23 wks GA
34
which steroids can be given in pregnancy
bethamethasone dexamethasone need to be fluorinated to cross the placenta
35
conditions where you should defer delivery for steroid benefit x 48 hrs
``` labor platelets <100K elevated LFTs HELLP fetal growth restriction oligohydramnios critically abnormal umbilical artery doppler indices new onset renal dysfunction or deteriorating renal function ```
36
when should you NOT delay delivery to give sterois
``` uncontrolled severe BPs eclampsia pulmonary edema GA < 23 wks placental abruption DIC non-reassuring fetal status intrapartum demise ```
37
use of magnesium sulfate in delivery
if administered within 24 hours of delivery, newborns have less incidence of cerebral palsy and lower rate of death
38
magnesium sulfate administration recommendation
any pregnancy that is threatened to delivery < 32 weeks GA | neuro morbidity decreases after 32 weeks
39
mechanism of magnesium sulfate
stabilization of cerebral circulation by stabilizing blood pressure and normalizing cerebral blood flow prevention of excitation injury by stabilization of neuronal membranes and blockade of excitatory neurotransmitters protection against oxidative injury protection against inflammatory injury via anti-inflammatory effects
40
hypertensive disorders in pregnancy
preeclampsia/ eclampsia chronic HTN chronic HTN with superimposed preeclampsia gestational HTN
41
chronic HTN (pre-existing)
documentation of systolic BP >140 or diastolic BP >90 on 2 separate occasions at least 4 hrs apart PRIOR to 20 wks GA or diagnosis prior to pregnancy altogether
42
preeclampsia
new onset HTN: systolic BP >140 or diastolic BP >90 on 2 separate occasions at least 4 hrs apart AFTER 20 wks GA + proteinuria >300 in 24 hr urine collection
43
gestational HTN
same as preeclampsia but without proteinuria
44
eclampsia
new onset tonic-clonic seizures associated with new onset HTN
45
other findings in preeclampsia
``` proteinuria -not required, don't want to delay diagnosis new onset systemic findings: -thrombocytopenia (<100K) -doubling of LFTs -doubling of Cr > 1.1 mg/dL -cerebral/visual disturbances -pulmonary edema ```
46
preeclampsia with severe features
new onset HTN criteria plus any of the following: - persistent severe BP >160/105 - thrombocytopenia - doubling of LFTs - doubling of Cr > 1.1 mg/dL - cerebral/visual disturbances - pulmonary edema - HELLP - GI symptoms
47
GI symptoms w preeclampsia w severe features
persistent mid-epigastric/RUQ pain new onset n/v severe indigestion
48
preeclampsia prevention
aspirin (81 mg) | to women w history of delivery prior to 34 wks due to preeclampsia or >1 pregnancy affected by preeclampsia
49
management of preeclampsia without severe features
``` 2x weekly visits -BP, physical 2x weekly fetal surveillance 1x weekly assessment of LFTs and platelets serial fetal growth assessment umbilical artery velocimetry ```
50
anti-hypertensives safe for pregnancy
labetalol procardia hydralazine started if persistent BP > 160/110
51
BP goals in preeclamptic pts
decrease by 10-20 mmHg | systolic 120-150
52
when should preeclampic pts be delivered
37-39 wks | if severe, no later than 34 weeks
53
role of magnesium sulfate in preeclampsia
prevents eclampsia | triggers cerebral vasodilation, thus reducing ischemia generated by cerebral vasospasm during an eclamptic event
54
when should magnesium sulfate be administered in preeclampsia
severe signs/symptoms OR is eclampsia has already occurred
55
cure for preeclampsia
DELIVERY
56
preterm labor
regular uterine contractions accompanied by a change in cervical dilation, effacement, or both initial presentation with regular contractions and cervical dilation of at elast 2 cm
57
problem w preterm labor
mild irregular contractions are normal, so its hard to distinguish true labor (results in cervical change) from false labor (contractions that do not result in cervical change)
58
preterm premature rupture of membranes
premature rupture of the amniotic membrane anytime prior to 37 weeks gestational age
59
pathophys of preterm labor
activation of the maternal or fetal HPA axis associated with either maternal anxiety and depression or fetal stress - inflammation or infection - decidual hemorrhage - pathological uterine distention
60
pathophys of PPROM
shearing forces created by uterine contractions | intraamniotic infection
61
risk factors for PTL and PPROM
``` history of PTL or PPROM UTI STI short cervical length 2nd and 3rd trimester bleeding low BMI low SES cig smoking illicit drug use ```
62
evaluation for suspected PTL/PPROM
maternal physical and vital assessment external monitors that assess for contractions and fetal heart rate sterile speculum exam digital cervical exam (if no concern for ruptured membranes) send urine culture send swab of vagina/perirectal area to assess presence of GBS
63
sterile speculum exam in suspected PTL
assess dilation assess for rupture of amniotic membranes collect samples of vaginal secretions for STI testing
64
signs of PPROM on speculum exam
fluid pooling in vaginal vault ferning: appearance of dried amniotic fluid on light microscopy nitrazine test: detects pH, amniotic fluid is basic
65
management of PTL
antibiotics for GBS prophylaxis steroids for fetal lung maturation (over 48 hrs) IV fluids
66
meds to stop contractions
tocolytics | given for 48 hrs to allow the full effect of the steroids to take place for fetal benefit
67
tocolytic options
``` COX inhibitors (indomethacin) Ca2+ channel blockers (Nifedipin) B-agonists oxytocin receptor antagonists magnesium sulfate NO ```
68
COX inhibitors mechanism
reduce prostaglandin production by inhibition of both COX 1 and 2
69
concerns about use of COX inhibitors
after 32 wks, risk of premature closure of the fetal ductus arteriosus which can result in right heart failure in utero
70
when not to use COX inhibitors
dont use after 32 weeks or for >48 hours
71
Ca2+ channel blockers mechanism
block influx of Ca2+ through cell membrane and inhibit release of intracellular Ca2+ from sarcoplasmic reticulum increase Ca2+ efflux from the cell leads to myometrial relaxation
72
risks with Ca2+ channel blockers
no known fetal side effects but can lead to maternal side effects due to vasodilatory actions - headache, nausea, hypotension - should be avoided if mothers have a pre-load dependent cardiac lesion or are already hypotensive
73
antibiotic management of PPROM vs PTL
for PPROM give for 7 days | for PTL, stop when threat has ceased
74
why use prophylactic antibiotics in PTL and PPROM?
prolong latency and reduce risk of neonatal and maternal infection
75
antibiotics used in pregnancy
Macrolides: ureaplasmas and chlamydia | ampicillin and amoxicillin: GBS and many gram neg bacilli, some anaerobes
76
delivery timing in PPROM
>34 wks GA
77
chorioamnionitis
intrauterine or intraamniotic infection | associated with maternal and newborn morbidity
78
diagnosis of chorioamnionitis
fever >39 deg C OR fever > 38 on 2 occasions 30 min apart PLUS -fetal HR >160 for >10 min -maternal WBC >15,000 w left shift -purulent appearing fluid coming from the cervical os visualized by speculum exam
79
treatment of chorioamnionitis
DELIVER

RDS Test 1 (22 decks)

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