Flashcards in Chapter 6: Preconception and antepartum care Deck (45)
How much folic acid should a woman trying to become pregnant be taking?
Taking 0.4 mg Folic Acid per day up through first trimester for prevention of NTDs. 4mg daily if prior NTD pregnancy or taking meds that interfere with folate metabolism
African Americans should be screened for what genetic disorders?
Mediterranean or Southeastern Asian folks should be screened for what genetic disorders?
Ashkenazi Jews should be screened for what genetic disorders?
Tay-Sachs, Canavan disease, Familial dysautonomia, Cystic fribrosis
How long should you wait to become pregnant after having a live vaccine?
Avoid conception within a month of receiving a live vaccine like Rubella
What general physical exam findings and 3 signs do we note with someone who is pregnant?
a. Softening and enlargement of the pregnant uterus 6 or more weeks after LNMP. 12 weeks uterus is substantially larger and palpable on abdominal exam in lower abdomen.
b. Chadwick sign: Bluish discoloration of the vagina
c. Hegar sign: Softening of the cervix
d. Circumlinear striae on abdominal wall secondary to progesterone and dermal stretching
What is quickening and when does it occur?
Quickening: 16-18 weeks, this is the initial feeling of fetal movement (as late as 20 weeks for first time mothers)
How should hCG change during pregnancy?
hCG should double every 1.5-2 days
What tools can we use to detect fetal heart beat and when are they accurate?
Fetal heart beat at 18-20 weeks with acoustic fetoscope,or with electronic Doppler at 12 weeks.
On an initial prenatal visit, what are some labs and tests we want to consider ordering?
Labs: Blood type, D (Rh) Type, Antibody screen, CBC, VDRL/RPR, Urine Cx/Screen, HBsAg, HIV, Chlamydia, Gonorrhea when indicated.
Supplemental: Hgb, PPD, PAP, Cystic fibrosis, HPV, Tay-Sachs/Canavan Disease, Early Diabetes screen, Familial dysautonomia
What is Gestational age and how do we calculate it
Gestational age: number of weeks since first day of LMP. Calculate this along with an estimated date of delivery using Naegele’s rule (add 7 days to the first day of the LMP, subtract 3 months, add a year.
What else can be added to help assist with calculating gestational age?
US dates overrule LMP/Naegele's Rule calculations, and can be done 5-6 weeks (Abd US) after first day of LMP (bHCG levels of 5,000 – 6,000. Transvaginal at 3-4 weeks (1,000 – 2,000) as probe is placed in posterior fornix of vagina only a few cm from the uterus.
When do we check for gestational HTN?
After 20 weeks, check for gestational HTN
What are weight gain recommendations for pregnancy?
What is the goal of fundal height measurements?
After 20 weeks, fundus palpable at umbilicus. From 16-18 to about 36 weeks, fundal height in cm equals the week number approximately. After that, fetus moves down to prepare for labor so the number isn’t reliable.
What should we be thinking about with uterine palpation during visits?
What's the baby doing?
95% at term will be cephalic, 3.5% breech
Do Leopold maneuvers
If Breech persists at 36-38 weeks, do external cephalic version
What screening do we do during the first trimester?
First trimester: 10-13 weeks: PAPP-A, B-hCG, US for nuchal.
What screening do we do during the second trimester?
Second: 15-20 weeks: Triple (maternal serum AFP, estriol, hCG) or Quad (Triple + inhibin)
You can also do first and second at once during second trimester
Third Trimester Screening?
Third: Glucose challenge test, GDM (24-28 weeks), GBS (35-37 weeks), and potential re-screening for Rh antigens and HIV
How do we assess for growth changes in the fetus?
US for growth changes. If abnormal, consider amniotic fluid issues, macrosomia, hydatiform mole, incorrect dating, abortion, or multiple pregnancies.
Fetal Monitoring besides growth restrictions is best done with what tests?
BPP or modified BPP
How does an NST work?
Nonstress Test: NST: Measures fetal heart rate, patterns and accelerations, monitored on a transducer for at least 20 minutes while button is pressed with fetal movements
How does a CST work?
CST: Whereas the NST evaluates the fetal heart response to fetal activity, the CST measures response of fetal heart rate to stress of uterine activity. Use a tocodynamometer for 20 minutes and use oxytocin if there are no contractions for 10-20 minutes. High false positive results so correlate with other tests appropriately.
How does a BPP work?
BPP: Biophysical profile: Use when you have a bad NST. Score of 8-10 is reassuring. 0 points for absent, 2 points for present
1. NST: 0 = bad, 2 = good
2. Fetal breathing movements (At least one or more episodes of fetal rhythmic breathing movements of 30 seconds or more within 30 minutes
3. Fetal movement: Three or more discrete body or limb movements within 30 minutes
4. Fetal tone: One or more episodes of fetal extremity extension with return to flexion, or opening or closing of hand within 30 minutes
5. Amniotic fluid volume: Pocket of amniotic fluid that measures at least 2 cm in two planes perpendicular to each other
- Decreases when fetus is stressed and shunts blood from kidneys = less pee
What's a modified BPP?
Modified BPP: NST with AFI (fluid at 4 quadrants)
What all do we look at to assess if the fetus is maturing properly?
Sequentially, lungs are the last thing to develop, so many of our maturity tests look at lung development.
Surfactant is key.
What is surfactant?
Collection of phospholipids that maintain patency of alveolar sacs and can be measured in amniocentesis
What two phospholipids do we look at specifically?
Two phospholipids specifically can also be detected, lecithin and sphingomyelin, in an LS ratio, to determine fetal lung maturity
What is phosphatidylglycerol and when do we look at it?
Phosphatidylglycerol is a phospholipid present with complete lung maturity present after 35 weeks
What happens if we delivery before lung maturity?
Delivery before lung maturity can lead to respiratory distress syndrome (grunting, chest retractions, nasal flaring, hypoxia) that can lead to acidosis and death. Administer surfactant if needed.
What is Pica? Why do we care?
Pica, abnormal eating, associated with anemia so watch for this
What mineral supplementation is needed during pregnancy?
Except iron, you don’t need to supplement minerals. Vitamins only if diet is not substantial. 27 mg of iron is recommended
Are there travel restrictions when pregnant?
Travel up to 36 weeks by air unless with HTN, DM, sickle. After 36, you could give birth, so don’t be in the sky. Move around to prevent DVT/PE
What do we worry about with exercise in pregnancy?
Workout during and after pregnancy as long as you don’t have stress such as heart or lung disease, multiple gestations, placenta previa after 26 weeks, ruptured membranes, preeclampsia, GDM. Limit supine exercises after first trimester to minimize circulatory changes brought on by IVC pressure. Avoid saunas and extreme heat due to potential harm of hyperthermia on fetus.
Other than meds, what do we do as far as other teratogens?
Other than meds, there are a ton. Tell patients to visit Organization of Teratology Information Services to find out more (www.otispregnancy.org) or use yourself if patient is curious
How does the FDA classify meds as teratogens?
A: Controlled human studies demonstrate no risk in any trimester
B: Animal studies show no fetal harm but no pregnant lady studies, OR, abnormal animal studies with normal pregnant lady research
C: Animal studies with adverse effect with no adequate human studies OR No animal or human studies performed
D: Good human studies show BAD results to fetus. HOWEVER, benefits may outweigh risks
X: Don’t use, it’s real bad. Absolutely contraindicated if pregnant or want to become pregnant.
Side effects on baby with tetracycline use
Tetracyclines: Yellow brown baby teeth with doxycycline and minocycline
Side effct of sulfonamides on baby
Sulfonamides: Hyperbilirubinemia due to displacement of bilirubin from protein binding sites. Avoid near delivery date
Warfarin vs. Heparin in pregnancy
Warfarin: Crosses placenta REAL easy. Nasal and midface hypoplasia with stippled vertebral and femoral epiphyses is exposed in weeks 6-9. Late exposure associated with hemorrhage related fetal abnormalities like hydrocephalus
Heparin/low molecular weight heparin: Anticoag of choice for use in pregnancy because large polar molecules don’t cross placenta.
Mercury during pregnancy
Mercury: You can consume fish low in mercury (shrimp, canned light tuna, salmon, Pollock, catfish), up to 12 ounces per week. Avoid large fish (that accumulate mercury from eating smaller fish) like Large tuna, shark, king mackerel.
CT during pregnancy?
Radiation: Keep is below 5 rads. One CT is about 3rads for pelvis, 1 rad for head.
Alcohol during pregnancy
Alcohol: Exposure is at its worst in first trimester. No established safe levels, and dose responses are linked to mental retardation, developmental delays and abnormalities.
FAS: Growth restriction, facial abnormalities (shortened palpebral fissure, low set ears, midfacial hypoplasia, smooth philtrum, thin upper lip), CNS dysfunction (microcephaly, mental retardation, behavioral disorders like attention deficit disorders)
What the hell is round ligament pain?
Round ligament pain: RLQ pain that looks like appendicitis. Just stretching and spasm of round ligament. Limit quick movements. Analgesics not indicated.
What do we do about the N/V seen during pregnancy?
Nausea/Vomiting: First trimester very bad for morning sickness. Edit diet and lifestyle changes. If serious, use antihistamine H1-receptor blockers and phenothiazines. Most severe form is hyperemesis gravidum which occurs in 2% of pregnancies. Fluid, electrolytes and hospitalization may be needed