High Risk Pregnancy Care Flashcards
(195 cards)
1
Q
substance abuse
-alcohol
-nicotine
maternal and fetal effects
A
ALCOHOL
-maternal: preE, placental abruption, placenta previa, ectopic
-infant: fetal alcohol spectrum disorder (FASDs); physical, behavioral, intellectual disabilities; low birth weight; problems with heart and kidneys
NICOTINE
-risk of stillbirth is 1.8-2.8x higher in smokers
-maternal: preE, placental abruption, placenta previa, spontaneous abortion, ectopic, PROM
-infant: IUGR, premature birth, small for gestational age
2
Q
CAGE vs TWEAK screening
A
C: have you felt the need to cut down?
A: have people annoyed you by criticizing your drinking?
G: have you ever felt guilty about your drinking?
E: have you ever had a drink first thing in the morning to stead your nerves?
TWEAK: tolerance, worried, eye-openers, amnesia, cut down
3
Q
Neonatal Abstinence syndrome
-how long can it take for neonates to develop symptoms after birth?
A
infant goes through withdrawal at birth due to opioids
-can take up to 14 days after birth: blotchy skin coloring, diarrhea, excessive or high-pitched crying, abnormal suckling reflex, fever, hyperactive reflexes, increased muscle tone, irritability, poor feeding
4
Q
obstetric complications r/t cocaine and meth use
-maternal
-fetal
A
-maternal: migraines, seizures, PROM, placental abruption, hypertensive crisis, spontaneous abortion, PRL
-infant: low birth weight, small head circumference, shorter in length, irritable
5
Q
T/F more than half of all women experience some form of abuse at some point in their life
A
true
6
Q
Violence against women (VAW)
-physical
-emotional
-sexual
-financial
A
-physical: push, slaps, locks out of house, refuses access to medical care, destroys property
-emotional: engages in name calling or insults, isolates from family and friends, publicly humiliates, withholds affection
-sexual: forces sexual acts, jealous anger with accusations
-financial: withholds money, makes all monetary decisions, manipulates relationship through money
7
Q
infectious diseases in pregnancy
TORCH
A
T: toxoplasmosis
O: OTHER: syphilis, varicella-zoster, parvovirus B19
R: rubella
C: cytomegalovirus
H: herpes
8
Q
toxoplasmosis clinical manifestations and diagnostic tests and lab findings
A
-most are asymptomatic
-can cause spontaneous abortion, prematurity, and IUGR
LAB
-detection of toxoplasma-specific immunoglobulin (IgG, IgM, IgA, IgE) antibodies
-direct observation of the parasite in stained tissue secretions, CSF, other biopsy material
-universal screening NOT recommended
9
Q
treatment of toxoplasmosis is in collaboration with…
A
MFM
-spiramycin is rec for women whose infections were before 18 weeks
-pyrimethamine recommended for infections acquired at or after 18 weeks’ gestation or when infection in the fetus is documented or suspected
10
Q
counseling patients how to PREVENT toxoplasmosis
A
-full cook meat to at least 145 F and poultry to 160 F
-do not drink unpasteurized milk or cheese
-avoid handling and or changing kitty litter
-avoid drinking untreated water
-good hand washing following gardening
TOCOplasMOSES (food and brennans cat!)
11
Q
Varicella-Zoster (VZV)
-etiology
-the two common infections
A
herpes virus- causes two common infections:
1. Varicella aka chicken pox
- herpes zoster- shingles
12
Q
- chicken pox/varicella
- herpes zoster/shingles
-risk to mother and baby?
A
- chicken pox/varicella: rare in pregnancy, greatest risk is when mother is infected at 20 weeks
- herpes zoster/shingles: secondary infection that poses little risk to mother and baby
13
Q
how is VZV transmitted?
A
respiratory inhalation of virus particles (virus may be transmitted up to 2 days prior to rash’s appearance)
14
Q
VZV symptoms…
A
-prior to rash, adults experience: fever, malaise, myalgias, HA
-rash: maculopapular rash that becomes vesicles
-new vesicles continue for 3-4 days
-crusted by 1 week
15
Q
complications of VZV
A
- pneumonia- 14% maternal mortality
- increased risk of preterm labor and birth
16
Q
T/F maternal varicella onset between 5 days before and 2 days after delivery may result in neonatal infection;
A
TRUE!
high fatality
17
Q
VZV treatment and prevention
A
TX: antiviral agent like IV acyclovir
**if infected within 6 days before delivery: give varicella-zoster immunoglobulin (VZIG)- same for women 3 days PP
PREVENTION
-varicella vaccination for women of reproductive age (making sure its 4 weeks prior to attempting pregnancy) or postpartum
18
Q
Parvovirus B19 (Fifth’s disease)
-transmission
A
-single stranded DNA virus
TRANSMISSION
-through respiratory secretions (saliva, sputum, nasal mucus) when infected person coughs or sneezes
-through blood or blood products
-vertical transmission
19
Q
when is transmission of Parvovirus greatest risk to fetus?
A
second trimester
20
Q
clinical manifestations of Parvovirus
-healthy adults vs immunocompromised
A
health: mild rash and illness
immunocompromised: reticular rash in the trunk; painful swollen joints; severe anemia
21
Q
complications of Parvovirus in pregnancy
A
- spontaneous abortion
- severe fetal anemia
- hydrops fetalis
- stillbirth
22
Q
screening/dgx/lab findings for Parvovirus
-routine screening?
-suspected infection in pregnancy
A
-routine serologic screening NOT recommended
-if infection suspected, IgG and IgM serologies should be collected
23
Q
treatment of Parvovirus
A
-no specific antiviral drug
-NSAIDS and acetaminophen may be used for muscle and joint pain experienced; but no NSAIDS in the third trimester
24
Q
fetal assessment/management of parvovirus
A
-monitor for signs of fetal anemia or hydrops fetalis
25
prevention of Parvovirus B19 includes...
-no vaccine
-wash hands
-avoid touching eyes, mouth, nose
-avoid contact with sick people
26
Rubella pathophysiology and transmission
-rare in the US
-single-stranded RNA molecule
-acquired RESPIRATORY disease acquired through direct contact with nasal or throat secretions of infected individuals (droplets spread through sneezing or coughing)
27
rubella s/sx includes...
-discrete pinkish-red maculopapular rash
-appears first on face, then on trunk and extremities
-may also have lymphadenopathy, fever, arthralgia
-symptoms last 3 days`
28
complications of rubella infection in pregnancy
-spontaneous abortion
-stillbirth
-for neonates: IUGR, cataracts, retinopathy, heart defects like patent ductus arteriosus, hearing impairment
29
when is risk of long term complications from CRS highest?
when infection of mother is infected in first trimester
30
what does a recent rubella infection look like on labs?
specific IgM in the fetal blood
M = mother; new infection
31
rubella prevention includes...
-vaccination of susceptible reproductive-age women preconception or postpartum (give at least four weeks prior to attempting pregnancy)
32
Cytomegalovirus (CMV)
-incidence
*the most common congenital infection
-from double stranded DNA herpes virus
33
CMV transmission
1. sexual contact
2. direct contact with blood, urine, saliva
3. vertical transmission from transplacental infection, exposure to genital secretions, at delivery, or breastfeeding
34
clinical manifestations of CMV and complications in pregnancy
-adults are usually asymptomatic
-may experience mono-like syndrome: fever, chills, malaise, myalgias, abnormal LFTs, lymphadenopathy
-approx. 30% of infants who are severely infected with CMV die and 65-80% of those who survive experience serious neurologic morbidity
35
CMV diagnostic and laboratory findings
-CMV specific IgG and IgM serologies
-PCR of infected blood, urine, saliva, breast milk
36
T/F no vaccine or medicine can prevent CMBV infection
TRUE
37
HIV pathophysiology
-DNA retroviruses called human immunodeficiency viruses include HIV-1 and 2, although most cases worldwide are HIV-1
-retroviruses have genomes that encode reverse transcriptase, allowing the virus to make DNA copies of itself in the host cells
38
HIV transmission: pregnant person to infant
-rate of vertical transmission with and without antiretroviral therapy during pregnancy
-without antiretrovirals: rate is between 15-25%
-WITH antiretrovirals: less than 1% when viral load undetectable at delivery
39
initial HIV infection s/sx
a. incubation period from exposure to clinical disease: days to weeks
b. acute viral illness syndrome lasts 10 days or less: fever, night sweats, fatigue, rash, headache, lymphadenopathy, diarrhea
40
what is the average time it takes HIV t progress to AIDS?
10 years
41
clinical manifestations of AIDS
-generalized lymphadenopathy
-oral hairy leukoplakia
-apthous ulcers
-thrombocytopenia
-opportunistic infections
42
T/F a separate written consent for HIV testing is required
FALSE
-general consent for medical care should be considered sufficient to encompass consent for HIV testing
43
if HIV status is unknown during labor and delivery what is recommended?
rapid HIV testing
44
HIV testing
-recommended screening test
enzyme immunoassay (EIA or ALISA) checks for proteins that the body makes in response to the presence of the virus
aka the HIV-1/2 antigen/antibody combination immunoassay
45
T/F the Western blot as form of confirmatory testing is no longer recommended
true
46
what is recommended if you suspect an acute retroviral syndrome or recent infection? what type of screening should be done???
a direct viral screen!
aka a nucleic acid test
47
if the enzyme immunoassay comes back + or recent infection is suspected, you should confirm with...
a subsequent antibody differentiation test to document seroconversion
48
a negative or indeterminate specimen from differentiation immunoassay (antibody differentiation/determining type of HIV) should be followed up with
HIV-1 NAT
49
CD4 counts
-what are CD4 cells?
-a CD4 count of _____ is a definitive diagnosis for HIV
type of WBC that plays vital role in the immune system!!
HIV attacks CD4 cells and damages them
a CD4 count < 200 cell/mm is definitive diagnosis for HIV
50
Viral load
-high
-low
-what does each indicate?
a. high viral load: indicates increased # of HIV particles in blood; a recent transmission, untreated, or uncontrolled HIV
b. low viral load: well controlled, few copies of HIV in person's bloodstream
51
management of HIV-positive pregnant patients
-additional labs?
1. prevention of transmission
2. initial labs- HIV antibody, CD4 count, viral load
3. refer to infectious disease, MFM
52
prevention of vertical transmission
-strongest predictor for vertical transmission?
-viral load = strongest predictor!!!
-multi agent ARV therapy during pregnancy (start after first trimester if mother does not need treatment)
53
what medication is given during labor and delivery to HIV + mothers?
IV zidovudine
54
at what viral load and how many weeks should c/s be considered?
at 38 weeks if viral load > 1000 copies/mL
55
treatment in the antepartum period
-goals
GOALS: treatment of maternal infection and reduction of risk for perinatal transmission
Highly Active Antiretroviral therapy (HAART)
a. two nucleoside analogues: zidovudine, didanosine, zalcitabine
b. protease inhibitor: indinavir, ritonavir
c. start after first trimester unless pregnant person needs treatment
56
treatment- intrapartum
Zidovudine IV throughout labor and delivery for vaginal birth
Zidovudine IV starting 3 hours before c/s and through delivery
57
concurrent disease concerns with HIV-infected women
-syphilis
-TB
-HPV
-hepatitis B
-pneumococcal infection
58
T/F breastfeeding is NOT recommended in HIV-infected mothers in the US
TRUE
there is a 16% transmission risk of HIV infection to the infant
59
Zika
-transmission
1. mosquito bite
2. sexual intercourse with infected symptoms
60
s/sx of zika infection in adults vs infants
adults: mild, lasting days to weeks: fever, rash, headache, joint pain, conjunctivitis, muscle pain
infants: microcephaly and severe brain damage
61
screening and testing for Zika
-prevention recommendations
NAAT test and IgM antibody testing
-no vaccin
-condom use, avoid travel to Zika outbreak areas, avoid mosquito bites
62
IUGR and SGA
definitions
IUGR, FGR, and SGA are terms used interchangeable to describe a fetus or newborn whose size is smaller than the norm
a. IUGR: a prenatal diagnosis baed on u/s measurements, used to describe impaired or restricted intrauterine growth
b. SGA: infant below 10the percentil
c. Low birth weight: older term; used to classify growth by an absolute weight < 2500g
63
symmetric growth restriction
-likely occurs in...
-causes
-insult likely occurs in first trimester resulting in decreased number and size of cells --> affects growth pattern for body and head --> symmetric reduced growth
causes:
a. congenital infections
b. chromosomal abnormalities
c. maternal drug use
64
asymmetric growth restriction
-the two main etiologic pathways
1. reduced nutrition to fetus --> diminished glycogen stores --> decreased liver volume --> decrease in abdominal circumference
2. abnormalities in uteroplacental perfusion --> increased right cardiac afterload --> CO diverted toward left ventricle --> increase in blood and nutrient supply to vital organs of the body --> asymmetrical head-sparing appearance
65
causes of asymmetrical growth restriction
-maternal
-placental
-fetal
maternal: HTN, anemia, collagen disease, insulin-dependent diabetes mellitus
placental: previa, abruption, malformations
fetal: multiple gestation, anomalies
66
fetal effects of IUGR
-signs
-fetus will conserve energy and decrease metabolic demands (less movement)
-fetus stops growing
-risk of demise
67
management of IUGR
-fetal assessment?
-labs?
-MFM, serial growth u/s, serial NSTs and AFI or BPPs (weekly or twice weekly)
-umbilical artery doppler
-TORCH titer, including Zika testing
-if able to identify cause: decrease smoking, nutrition evaluation, maternal positions that facilitate uteroplacental blood flow (left lateral or sitting)
68
LGA/Macrosomia
-definition
newborns weighing more than 4000 g at birth or over the 90th percentile in weight for gestational age
69
risk factors for macrosomia
-obesity
-previous LGA
-size of father
-diabetes or history of GDM
70
multiple gestations
-mono vs dizygosity
monozygotic: identical twins- division of single fertilized egg
dizygotic: fraternal twins- fertilization of two separate ova by two separate sperm
71
when is chorionicity of multiple gestations most accurate?
the first trimester
72
time of zygote division in monozygotic/identical twins determines membrane development
a. days 0-3
b. days 4-8
c. between days 9-12
d. after day 13
a. days 0-3: dichorionic, diamniotic
b. days 4-8: monochorionic, diamniotic
c. between days 9-12: mono, mono
d. after day 13: conjoined twins
73
s/sx of multiple gestation
-fundal height > dates
-earlier or exaggerated discomforts of pregnancy
74
T/F thirty six percent of multiple gestations deliver before 36 weeks
TRUE
and 50% before 37 weeks
75
potential complications of multiple gestations
-hyperemesis
-PTL, PROM, preterm birth
-twin-to-twin transfusion
-oligohydramnios
-preeclampsia
-postpartum hemorrhage
-maternal anemia
-placental problems: previa, abruption
-fetal anomalies
76
T/F twin pregnancies require increased nutritional and iron needs
TRUE
77
Blood incompatibilities: D(Rh) Isoimmunization Types
1. ABO incompatibility
2. maternal serum contain anti-a or anti-b
3. sensitization caused by minor agents
4. Kell
5. Duffy
1. ABO incompatibility:
-20-25% of pregnancies
-isoimmunization causes 60% of fetal hemolytic disease
2. maternal serum contain anti-a or anti-b
-rarely causes fetal anemia with mild to moderate neonatal hyperbilirubinemia in first 24 hours of life
-caused by IgM crossing placenta poorly
3. sensitization caused by minor agents
-believed to be the result of incompatible transfusion
4. Kell
-may have mild to serve disease with hydrops (K KILLS!)
5. Duffy
-mild to severe disease with hydrops
78
pathogenesis for Rh isoimmunization
three requirements:
1. fetus must be D+ and mother D-
2. mother must be able to be sensitized
3. sufficient quantities of fetal cells must gain access to mother's bloodstream
79
how is blood shared between mother and fetus for isoimmunization to occur?
-incompatible blood to mother before pregnancy
-delivery, spontaneous or induced abortion, amniocentesis. ectopic pregnancy, placental abruption
80
maternal vs fetal complications with isoimmunization
-maternal: no significant risk
-fetal: mother produced anti-D antibodies (IgG) which cross the placenta causing hemolysis of fetal red blood cells
-fetal anemia
-enlargement of fetal liver and spleen
-hydrps fetalis
-fetal loss/death
81
newborn isoimmunization may manifest as...
hyperbilirubinemia (from maternal IgG attacking RBCs and the RBC's breaking down and the fetal liver being immature and unable to clear RBCs)
ultimately causing: KERNICTERUS
82
Management
1. unsensitized pregnancy (mother Rh negative with negative antibody titer)
2. sensitized pregnancy (mother Rh negative with positive antibody titer (> 1:4))
1. unsensitized pregnancy (mother Rh negative with negative antibody titer)
-ABO/D group and antibody titer at first visit
-repeat antibody screen at 28 weeks and give RhoGAM if remains unsensitized
-Rho(D) immunoglobulin is protective for 12 weeks
-if infant is Rh positive, give mother RhoGAM again after delivery
2. sensitized pregnancy (mother Rh negative with positive antibody titer (> 1:4))
-seek consultation/co-manage
-serial u/s to assess for signs of ascites
-follow titers
83
post-term pregnancy (postdates pregnancy) definition and potential complications
pregnancy continuing beyond 42 completed weeks gestation
*asx wtih increased morbidity and mortality for bother pregnant person and fetus
complications: should dystocia, oligohydramnios, uteroplacental insufficiency, neonatal meconium aspiration, stillbirth
84
management of postdates pregnancy
1. continue fetal movement counts between 40-41 weeks
-@ 41 weeks: begin biweekly NST/AFI or BPP
-BPP if abnormal NST
2. expectant management and delivery
-consider induction
-prostaglandins to promote cervical ripening
-deliver if any indication of fetal compromise or oligohydramnios****
85
obesity in pregnancy definition and effects on pregnancy/increased risks
classified on BMI; obesity is defined as BMI greater or equal to 30
risks:
-pregnancy loss and stillbirth
-NTD
-hydrocephaly
-GDM
-macrosomia
-longer labor
-preE
-VTE
86
obesity in pregnancy management
-antepartum/prenatal
a. standard u/s between 18-24 weeks
b. u/s every 4-6 weeks to monitor fetal growth
c. weekly NSTs beginning at 32 weeks
d. pt with OSA should be evaluated by sleep or medicine specialist
e. early GDM screening
87
hyperemesis gravidarum (HG)
-definition
-diagnosis (4)
-persistent vomiting during pregnancy u/r to other causes (believed to be linked to hCG and estrogen; lower estrogen asx with lower incidence of N/V)
DGX:
a. severe and intractable vomiting with unknown etiology
b. weight loss of at least 5% of pre-pregnancy weight
c. ketonuria
d. electrolyte imbalance, thyroid and liver lab abnormalities
88
T/F HG is the number on reason for hospitalizations in the first trimester?
TRUE
89
risk factors for HG
-hx of HG
-genetic link
-motion sickness
-migraine headaches
90
assessment tool for severe N/V: Pregnancy-Unique Quantification of Emesis and Nausea (PUQE)
3 questions; scored from 1-5; mild: 6 or less; moderate NPV: 7-12; severe NVP 13 or more
1. how long do you feel nauseated or sick to your stomach
2. how many times/day do you vomit?
3. how many times do you retch or dry heave without bringing anything up?
91
management of HG
-non pharm
multivitamins, frequent, small meals every 1-2 hours, avoid spicy or fatty foods, bland dry foods (high protein, crackers before getting out of bed), ginger 1 g per day in divided doses
92
management of HF
-pharm therapies
a. pyridoxine (vitamin B6) 10-25 mg QUID or TID orally; maximum dose of 200mg/day
b. Diclegis: combined pyridoxine 10 mg and doxylamine 10 mg orally; two tables for moderate N/V before bedtime; for severe NVP, four tables (one morning, one afternoon, two at bedtime)
c. metoclopramide 5-10 mg q 6-8 hours PO
d. promethazine 25 mg q4hr per rectal suppository
e. Ondansetron
93
Tuberculosis (TB)
-who is most at risk??
-interpreting a positive TB test (5mm, 10mm, 15mm)
-HIV infected women
-people who abuse alcohol and illicit IV drugs
- 5 mm is positive for very high risk: HIV positive, abnormal chest radiograph, recent contact with active case
-10 mm i positive for hight risk (low income populations, foreign-born individuals)
-15mm is positive for persons with none of these risk factors
94
s/sx of TB
-cough with minimal sputum production
-low grade fever
-hemoptysis
-weight loss
95
T/F untreated TB poses greater risk to fetus than treatment does
TRUE
96
Latent TB infection treatment
1. Isoniazid (INH) daily or twice weekly using directly observed therapy for 9 months
2. supplementation with 10-25 mg/day of pyridoxine (Vitamin B) recommended
97
active TB disease treatment in pregnany
initial tx: INH, rifampin, and ethambutol daily for 2 months; then INH and rifampin daily or twice weekly for 7 months
98
T/F breastfeeding is not contraindicated with TB treatment
true
99
first trimester bleeding (bleeding in first 12 weeks of pregnancy)
-40% of women have some bleeding first trimester and 90% of pregnancies with bleeding continue to term after FHT observed
100
differential diagnoses for first trimester bleeding
-implantation
-threatened abortion: inevitable, complete, incomplete, missed
-ectopic pregnancy
-cervicitis
-cervical polyp
101
lab diagnosis for first trimester bleeding
-hCG
-positive after how many days post-fertilization?
-doubles every how many hours?
-rule of 10? (at missed menses, at 10 weeks, at term)
-hCG is + 8-9 days after fertilization
-beta-hCG doubles every 48 hours with normal IUP
RULE OF 10
B-hCH = 100 at time of missed menses
B-hCG = 100,000 at 10 weeks (peak)
B-hCG at term = 10,000
102
T/F 90% of ectopic pregnancies have B-hCG less than 6500
true
103
types of abortion
1. spontaneous
2. threatened
3. inevitable
4. incomplete
5. complete
6. missed
1. spontaneous: occurring without apparent cause
2. threatened: appearance of signs and symptoms of possible loss of fetus (vaginal bleeding)
3. inevitable: cervix is dilating; uterus will be inevitably emptied
4. incomplete: an abortion which part of the POCs has been retained in the uterus
5. complete: all POCs have been expelled
6. missed: the fetus died before completion of 20 weeks gestation, but POCs are retained for prolonged period of time (2 or more weeks)
104
recurrent pregnancy loss
three or more consecutive abortions
105
#1 cause of spontaneous abortions
chromosomal abnormalities
#1: autosomal trisomy
#2: Turner's syndrome
106
general management of abortion
1. blood type
2. serum B-hCG
3. repeat B-hCG in 48 hours
4. u/s
5. should be able to visualize an IUP transvaginally at hCG of 6500; transvaginally at 2000
6. RhoGAM for unsensitized Rh- women
107
management specific to type of abortion
1. inevitable or incomplete
a. D&C
b. chemical D&C
c. expectant management
108
management of threatened abortion or disappearing twin
a. pelvic rest
109
ectopic pregnancy definition
implantation of the blastocyst anywhere other than the endometrium
110
where do most ectopic pregnancies occur
in the fallopian tube (95%)
111
risk factors for ectopic pregnancy include...
1. STI- especially chlamydia or gonorrhea
2. endometriosis
3. abortion followed by infection
112
symptoms of ectopic pregnancy
-amenorrhea but frequently vaginal spotting
-lower pelvic and or abdominal pain; UNILATERAL
-unilateral tender adnexal mass
-some patients have no sxs
PRESENTATION: severe abdominal pain, CMT, free fluid on u/s, cul-de-sac fullness, shoulder pain s/t diaphragmatic irritation, vertigo or fainting
113
diagnosing an ectopic
-serum B-hCG levels
-90% of ectopic have B-hCG less than 6500; abnormal interval increases
-u/s
114
T/F ectopic pregnancies do not require RhoGAM in Rh- mothers
false :)
give the RhoGAM!
115
Hydatidiform Mole (trophoblastic disease)
-clinical manifestations
-management
-abnormal uterine bleeding, size/dates discrepancy, lack of fetal activity, HG, gestational HTN
MNGMNT:
-suction curettage
-close surveillance for persistent trophoblastic proliferation or malignant changes
-serial B-hCG levels every 2 weeks until normal, then once a month for 6 months, then every 2 months for 1 year
116
what is recommended following hydadtidform mole/patient education?
recommend avoiding pregnancy for 1 year
117
second trimester bleeding
-may be r/t...
-management/treatment
less common during this time in pregnancy
r/t: cocaine use, autoimmune disease, infection in cervix or vagina
-cervical cerclage after 12-14 weeks
-monitor cervical length via transvaginal u/s
118
placental anomalies
-low lying placenta
-1/3 have low lying in first trimester, only 1% have previa in the third trimester; if placenta is
119
three locations for placental abruptions; size of hemorrhage is predict of fetal survival
a. subchorionic
b. retroplacental
c. preplacental
a. subchorionic: between placenta and membranes
b. retroplacental: between placenta and myometrium; worse prognosis
c. preplacental: between placenta and amniotic fluid
120
Third trimester bleeding
-what is responsible for 20% of third-trimester bleeds?
placenta previa
121
T/F its okay to perform a digital vaginal exam on a woman's cervix in the presence of third-trimester bleeding
FALSEEEEE
do NOT do digital exam in presence of bleeding in the third trimester
only unless you are 100% certain there is no placenta previa
122
s/sx of placenta previa
primary and secondary
a. primary: painless vaginal bleeding
b. secondary- unengaged fetal presentation and or malpresentation
123
if patient with previa is bleeding, the next step would be to...
hospitalize them
124
placental abruption definition
premature separation of the placenta from the uterus, partial or complete; cause of 30% of third-trimester bleeds
125
risk factors for placental abruption
-HTN (chronic or gestational)
-trauma
-smoking
-cocaine use
-multiparity
126
s/sx of placental abruption
1. vaginal bleeding
2. uterine tenderness and rigidity
3. contractions or uterine irritability and or tone
4. fetal tachycardia or bradycardia
127
placenta accreta is when the placenta is...
invading the myometrium of the uterine wall
128
risk factors for placenta accreta
-previous c/s; risk increases with number of c/s performed
-AMA
-multiparity
-prior uterine surgeries
-Asherman syndrome (intrauterine adhesions)
-placenta previa
129
s/sx of placenta accreta
none usually!
130
epilepsy in pregnancy
-maternal effects
-fetal effects
-maternal: increase in seizure frequency and severity, maternal mortality, preE, PTL, stillbirth, increased risk of c/s
-fetal: growth restriction, LBW, birth defects (r/t medication exposure)
131
how many months seizure-free is good indicator of prenatal course?
9-12 months `
folic acid supplementation strongly recommended prior to conception
132
T/F antiepileptic drug (AED( monotherapy is preferable to decrease fetal effects
true
133
T/F Valproate should be avoided in pregnancy
true
-teratogenic
134
thrombocytopenia
-defined as... in pregnancy
serum platelet count < 150 x 10^9 in pregnancy
135
T/F gestational thrombocytopenia is often asymptomatic
true
136
how long should neonate be observed in mother with thrombocytopenia?
2-5 days
due to slight risk for neonatal thrombocytopenia
137
GERD
-dominates in...
-patho
-third trimester
-r/t effect of increasing estrogen and progesterone on the LES and enlarging uterus, which increases thoracic pressure
138
when GERD is suspected, what needs to be ruled out?
hypertensive disorder! get a BP!
139
medication therapy for GERD
1. magnesium hydroxide or trisilicate (aluminum hydroxide; Mylanta)
2. histamine 2 receptor agonists (ranitidine/Zantac)
3. AVOID antacids with sodium carbonate (can cause maternal or fetal alkalosis)
140
stillbirth definition
-weeks, weight
fetal death at 20 weeks gestation or greater OR weight greater than 350 g if gestational age unkown
does NOT include fetal loss due to termination or IOL for pre-viable fetuses
141
T/F non hispanic black women are disparately affected and have twice the rate of stillbirth compared to non-hispanic white women
true
142
stillbirth is diagnosed when...
cannot detect a fetal heartbeat
143
maternal effects of stillbirth
1. with retained POCs greater than 2-4 week
fever, DIC, ROM, onset of labor
144
management of stillbirth includes...
(maternal screening)
-B-hCG levels
-CBC
-type and screen
-Kleihauer-Betke test
-HbA1c
-TORCH panel
145
expectant management: beyond 2 weeks and no longer than 4-5 weeks
a. consider lab work: CBC, PT/PTT, fibrinogen
b. monitor for fever and DIC
146
active management
a. second trimester
b. induction of labor
-prior to 28 weeks
-after 28 weeks
a. second trimester: D&C
b. induction of labor
-Misoprostol 200-400 mcg vaginally every 4-12 hours prior to 28 weeks gestation
-after 28 weeks: cervical ripening (misoprostol(, cervical dilation, induction (oxytocin)
147
postpartum care and follow up following stillbirth
-routine immediate pp care (2 and 6 weeks)
-RhoGAM if indicated
-lactation suppression
148
Thromboembolic disorders are defined as
VTE resulting from physical and anatomic changes associated with pregnancy and postpartum that create an increased thrombotic state:
1. hypercoagulability
2. increased venous stasis
3. decreased venous outflow
4. compression of vena cava by enlarging uterus
5. decreased maternal mobility
149
types and signs of VTE
-DVT
-PE
DVT: lower extremities; SX: pain, swelling, change in calf circumference unilaterally
PE: infrequent, results when DVT breaks loose and travels to the lungs; SX: dyspnea, tachypnea, tachycardia, chest pain, cough, fever, anxiety
150
management for treatment or prophylaxis of VTE
first line: Heparin
pros vs cons
1. Heparin (LMW)
-does not cross the placenta
-increased renal excretion and protein binding in pregnancy
-shorter half life and lower peak plasma concentrations
CON: higher dose and more frequent administration required
**get PTT
151
T/F warfarin is safe in pregnancy
FALSE
teratogenic!!!
also avoid: direct thrombin inhibitors, factor Xa inhibitors
152
Malpresentations
1. breech
1a. frank
1b. Complete
1c. footling or incomplete
BREECH = longitudinal lie with buttocks in the lower pole
1a. frank: legs are extended up over the fetal abdomen and chest
1b. Complete: legs are flexed at hips and knees
1c. footling or incomplete: one or both feet or knees are lowermost
153
diagnosis with Leopold's
-what will you feel in the fundus vs the lower pole
1. fetal part in the fundus is round, hard, freely movable and ballotable
2. find back and small parts
3. part in lower pole is large, nodular body
4. determine degree of engagement
154
vaginal findings of breech presentation:
no fetal skull sutures or fontanels, round indentation (anus), tissue texture is softer than head
toes or feet if footling presentation
155
treatment of breech
-ECV criteria
external cephalic version has a success rate of 35-86%
-consider maternal Rh status
-antenatal monitoring post-ECV
CRITERIA
1. normal amniotic fluid volume
2. reactive NST
3. EFW between 2500-4000 g
other tx: moxibustionsh
156
shoulder presentation is a ______ lie, which the....
transverse lie in which the shoulder or arm is found in the lower pole; CI to vaginal birth
157
hypertensive disorders of pregnancy
1. chronic HTN
2. GHTN
3. chronic HTN with superimposed preE
4. preeclampsia
5. HELLP syndrome
6. eclampsia
1. chronic HTN: bp >140/90 mm Hg diagnosed before pregnancy, before 20 weeks, or after 12 weeks PP
2. GHTN: new onset BP elevation after 20 weeks without proteinuria
3. chronic HTN with superimposed preE: chronic HTN with new-onset proteinuria (>300 mg in 24 hours)
4. preeclampsia: pregnancy-specific hypertensive disorder asx with symptoms such as HA, visual disturbances, epigastric pain, rapid edema development with BP >140/90 on two occasions at least 4 hours apart after 20 weeks gestation OR bp > 160/100 in a women who was previoualy normotensive and proteinuria > 300 mg per 24 hour urine collection or p/cr > 0.3 OR if other quantitative methods are unavailable, a dipstick result of 2+ OR in the absence of proteinuria, new-onset HTN with the new onset of following severe features:
a. thrombocytopenia (platelets < 100,000)
b. renal insufficiency (creatinine > 1.1)
c. impaired liver function: doubling of normal levels
d. pulmonary edema
e. cerebral or visual symptoms
5. HELLP syndrome: hemolytic anemia, elevated liver enzymes, low platelet count
6. eclampsia: seizures that cannot be attributed to other causes in woman with preE
158
diagnostic preeclampsia criteria (ACOG update)
Systolic blood pressure of 140 mm Hg or more or diastolic blood pressure of 90 mm Hg or more on two occasions at least 4 hours apart after 20 weeks of gestation in a woman with a previously normal blood pressure
Systolic blood pressure of 160 mm Hg or more or diastolic blood pressure of 110 mm Hg or more. (Severe hypertension can be confirmed within a short interval (minutes) to facilitate timely antihypertensive therapy).
and
Proteinuria
300 mg or more per 24 hour urine collection (or this amount extrapolated from a timed collection) or
Protein/creatinine ratio of 0.3 mg/dL or more or
Dipstick reading of 2+ (used only if other quantitative methods not available)
Or in the absence of proteinuria, new-onset hypertension with the new onset of any of the following:
Thrombocytopenia: Platelet count less than 100 ,000 × 10 9/L
Renal insufficiency: Serum creatinine concentrations greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease
Impaired liver function: Elevated blood concentrations of liver transaminases to twice normal concentration
Pulmonary edema
New-onset headache unresponsive to medication and not accounted for by alternative diagnoses or visual symptoms
159
pregnant women with chronic hypertension already on antihypertensive meds should have bp maintained between...
120/80 and 160/105
160
recommended delivery for CHTN patients vs gestational hypertension patients
38-39 weeks
delivery before 38 weeks in women with chronic HTN without other complications is not recommended
GHTN: 37 and 0/7
161
first line antihypertensives for women who require pharm therapy include (3)
-labetalol
-nifedipine
-methyldopa
162
what should you administer to women with preE with severe features to prevent eclampsia in the intrapartum-postpartum period?
-s/sx of overdosage
-antidote?
magnesium sulfate
mag overdose: loss of patellar reflex, muscular paralysis, respiratory arrest
antidote: calcium gluconate
163
risk factors for hypertensive disorders in pregnancy
-nulliparity
-adolescent or AMA
-multiple gestation
-family hx
-obesity and insulin resistance
-chronic HTN
164
theory of causes behind preE
-abnormal trophoblast invasion
-coagulation abnormalities
-vascular endothelial damage
165
laboratory tests for hypertensive disorders in pregnancy
-CBC (hgb/hct, platelets)
-24 hour urine
-CMP (LFTs, creatinine)
166
fetal assessment in hypertensive disorders of pregnancy
-daily fetal movement assessment
-NST
-AFI/BPP
-u/s with doppler studies for growth
167
antihypertensives when BP exceeds 160/100
a. first line therapies
IV labetalol, IV hydralazine, IR oral nifedipine (most appropriate when IV access has not been established)
168
T/F diuretics are NOT recommended in pregnant patient with high BP
true!! pregnant person is already volume depleted
169
HELLP syndrome
-diagnosis
-treatment
dgx: hemolysis, abnormal peripheral blood smear, increased bilirubin >1.2, elevated liver enzymes, platelet count < 100,000
tx: magnesium sulfate, crystalloids
170
prevention of pregnancy-induced hypertension
low-dose aspirin initiation at 12 weeks for all high risk pregnancies (AMA, hx of preE, etc.)
calcium and vitamin D supplementation if at risk and has low dietary intake
171
GDM patho
-hPL, estrogen, progesterone
-results from the diabetogenic effect of pregnancy: hPL acts as insulin antagonist, estrogen and progesterone may also act as insulin antagonists
172
high risk for GDM
-overweight and obese
-physical inactivity
-prior hx of GDM
-prior LGA infant weighing more than 9 lbs
-T2DM fam hx
-HTN
-PCOS
-HgbA1c > 5.7%
173
low risk for GDM
< 25 years, normal weight
174
screening
-high risk
-all pregnant women regardless of risk
high risk: as soon as possible
all pregnant: screen at 24-28 weeks using the two step approach
175
the two step OGTT approach
1. screen with a 1 hour 50 g (90% sensitive) glucose challenge test
2. if 130 or more, or greater than 140, perform diagnostic 100 g 3 hour OGTT on another day after an overnight 8 hour fast
3. dgx of GDM can be made if two of the results from the 3-hour testing are abnormal
fasting: 95
1 hour: 180
2 hour: 155
3 hour: 140
176
one step approach GTT
1. perform a 75 g 2 hour OGTT after an overnight 8 hour fast
2. measure fasting gluocse at 1 and 2 hours
DGX CRITERIA
fasting: 95
1 hour: 180
2 hour: 155
177
chance of perinatal mortality with GDM is greatly increased if....
-uncontrolled hyperglycemia
-ketonuria, N/V
-GHTN, edema, proteinuria
178
GDM management
1. co manage
2. diet: 30 kcal/kg of actual or ideal body weight; breakfast 25%, lunch 30%, dinner 30%, snack 15%
Protein: 20%, fat 30-35%, carbs 45-50%
179
Medications for GDM
-first line
first line is insulin since it does not cross the placenta but it is not easy to use!! most times we use:
oral hypoglycemics: metformin
180
maternal monitoring in GDM patients for...
GHTN, changing insulin requirements, HgbA1c
181
how do insulin needs change over pregnancy
-first trimester
-second trimeter
-first trimester: need decreases because of low hPL levels
-second trimester: need increases because of increasing hPL levels
182
fetal monitoring
-preexisting diabetes
-gestational diabetes
-NTD and cardiac anomalies asx with pregestational diabetes
-u/s for IUGR, macrosomia, and polyhydramnios
-FMC starting at 28 weeks
-antenatal surveillance (NST, BPP) beginning at 32 weeks if poorly controlled or requires medication therapy
183
T/F antenatal monitoring is not indicated if nutritional modification and glucose monitoring alone are effective
TRUE
antenatal surveillance is only recommended in poorly or medication controlled diabetes
184
immediately postpartum GDM patient should be monitored for...
changing insulin requirements; usually decrease 24-48 hours after placenta delivered
185
GDM patient in the postpartum period should be screened for...
-patient education regarding lifetime risk
diabetes!
75-g 2 hour OGTT at 6-12 weeks PP
screen for diabetes annually
186
normal thryoid changes in pregnancy
thyroid enlarges somewhat because of hyperplasia and increased vascularity
thyroid hormones in pregnancy (TT4 and TT3) increase; TSH and FT4 are not affected
187
thyrotoxicosis or hyperthyroidism s/sx
-tachycardia
-elevated sleeping pulse rate
-thyromegaly
-exopthalamos
-failure to gain weight
188
diagnosis and treatment of hyperthyroidism
TSH: low
elevated T4
TX: propylthiouracil
189
acquired anemias
1. iron-deficiency anemia
dgx
hemoglobin less than 11 first trimester, 10.5 second trimester, 11 third trimester and pp
r/t poor nutrition resulting in inadequate iron stores; also a consequence of expanding blood volume
dgx: CBC, serum ferritin
190
management and treatment of iron deficiency anemia
a. iron replacement therapy
b. ferrous sulfate, ferrous gluconate
c. include vitamin c and folic acid
d. IM or IV therapy if patient unable to take oral or severely anemic
e. if just low iron: daily iron supplement, recheck ferritin in 4 weeks
191
megaloblastic anemia definition
-U.S cause is usually r/t...
group of hematologic disorder characterized by blood and bone marrow abnormalities caused by impaired DNA synthesis
*RARE in the US: r/t folic acid deficiency due to lack of consumption of green leafy vegetables
prevent with .4 mg daily folic acid for women of childbearing age! 4 mg daily prior to and during pregnancy for women with history of previous infant with NTD
192
inherited anemias:
a. sickle cell anemia
b. sickle cell-hemoglobin C disease
c. sickle cell-beta thalassemia disease
all inherited, need both genes
-1 in 12 AA has sickle cell trait (we screen for this on our carrier screen)
*sickle cell is the worst in pregnancy; sickle cell crisis occurs more frequently, infections and pulmonary complications are more common
193
s/sx of sickle cell anemia
-hgb < 7
-intense pain of crisis esp in third trimester, labor, pp
-fever due to dehydration or infection
194
management of inherited anemia
-weekly fetal surveillance?
-consult and co-manage
-starting at 32-34 week
195
