Lecture 11: Normal Pregnancy: Antepartum Care Flashcards by Erik Hammond

When should women start folic acid supplementation when planning to conceive; what are recommended doses in someone w/ no hx of NTD vs. hx of previous child w/ NTD?

Begin at least 1 month before conception
No hx of NTD, folic acid 0.4 mg
Hx of previous child w/ NTD ↑ to 4.0 mg

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List some of the normal PE findings assoc. w/ pregnancy which may be considered abnormal in a non-preg. pt?

Systolic murmurs w/ exaggerated splitting and S3
Palmar erythema + Spider angiomas
Linea nigra
Striae gravidarum
Chadwicks sign

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What value of hCG is considered a positive test and is when most urine hCG tests can detect it?

25 IU/L

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Gestational sac is seen around how many weeks?

5 weeks when mean hCG is 1500-2000 IU/L

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What is Naegels rule for estimating the expcted day of delivery for a lady who is normally cycling every 28 day?

(LMP - 3 months) + 7 days = expected date of delivery

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What can be meaured on U/S between 6-11 weeks and can determine due date within 7 days?

Crown Rump Length (CRL)

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Based on measurement of uterine size what is indicative of 20 weeks?

20 weeks at the umbilicus

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What can be measured on U/S at 12-20 weeks and can determine due date within 10 days?

Femur length
Abdominal circumference
Biparietal diameter

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What is considered advanced maternal age when genetic counseling should be offered?

35 y/o +

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After how many spontaneous abortions should chromosomal studies (karyotyping) be done on a mother and father?

After 3 or more

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What is the most common form of inherited mental retardation?

Fragile X syndrome

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What 4 things are included in the first trimester screening for fetal aneuploidy?

Maternal age
Fetal nuchal translucency (NT) thickness
Maternal serum b-hCG
Pregnancy associated plasma protein-A (PAPP-A)

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Which finding of fetal nuchal translucent (NT) thickness is associated with both chromosomal and congenital anomalies?

Increased thickness

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Which finding of b-hCG and PAPP-A is associated with down syndrome; measurement of what can increase the detection rate?

↑ b-hCG and ↓ PAPP-A assoc. w/ Down’s Syndrome
Addition of nasal bone assessment (absence of) to nuchal translucency measurement ↑ detection rate

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What is included in the quadruple screen for second trimester testing of fetal aneuploidy?

b-hCG
Estriol
Serum AFP
Inhibin A

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When is screening for cell-free fetal DNA done and why is it so hyped?

At 9-10 weeks, looks for cell free fetal DNA, thought to be derived from apoptosis of trophoblastic cells that have entered maternal circulation
Detection rates for trisomy and sex chromosome disorders are very high

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What does cell-free fetal DNA not test for?

Does NOT test for open neural fetal defects
Continue to evaluate for NTD w/ maternal AFP or U/S

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Cell-Free fetal DNA screening should only be ordered in high risk patients, list 5 situations.

Advanced maternal age
Hx of prior pregnancy w/ a trisomy
Family hx of chromosomal abnormalities
Fetal U/S abnormalities suggestive of aneuploidy
Positive serum screening test including 1st trimester, triple or quad screen

If Cell-Free fetal DNA screen is positive what is next step in confirming results?

Proceed w/ invasive diagnostic test to confirm results:
Amniocentesis or chorionic villi sampling

The teratogen, Thalidomide, is associated with what congenital deformity?

Phocomelia

Which risk factor category for medications during pregnancy states that adequate well-controlled studies or observations in pregnant women have demonstrated a risk to fetus; but the benefits of therapy may outweight potential risks?

Category D

When is the most vulnerable stage in terms of effects of teratogens?

Day 17 to day 56 post-conception = organogensis

In general what kind of effect do teratogens have after the 4th month up to the end of gestation?

Usually results in delayed growth of organs and not in a malformation

What is the drug of choice for anxiety and depression during pregnancy?

Fluoxetine

Which anti-coagulant does and which does not cross the placenta?

- **Coumadin** **(D)** crosses the placenta --\> SAB, IUGR, CNS defects - **Heparin (B)** does **not** cross

The anticonvulsant, Diphenylhydantoin, is a known teratogen which may cause what?

Fetal hydantoin syndrome (FHS)

Which 2 anti-convulsants are associated with spina bifida?

**Valproic acid** and **Carbamazepine**

What are the 3 dose dependent effects of radiation exposure to a fetus during the critical period of 2-6 weeks post conception?

- Teratogenesis - Mutagenesis - Carcinogenesis

If radiation exposure occurs during the first 2 weeks post-conception what is the response like?

Either **all** or **none** = will be **lethal** or **no effect**

What is the rule of thumb for how much radiation to mother poses no risk to fetus?

**\<5 rads** of **exposure** = **no risk**

What are some recommendations you can give to pregnant woman who is suffering from nausea and vomiting?

- Eat **small** but **frequent** meals - **Avoid greasy, fried** foods - **Room temperature** **sodas** and **saltines** - **Accupuncture** - **Meds** = antihistamines, vit B6, and antiemetics (phenergan, zofran)

What is the cause of frequent heartburn during pregnancy?

Due to **relaxation** of **esophageal sphincter** by **progesterone**

What is the frequency of prenatal office visits throughout the pregnacy?

- Every **4 weeks** until **28 weeks** - Every **2 weeks** from **28-36 weeks** - **Weekly** until **delivery**

The first sensation of fetal movement is known as quickening and occurs on average at how many weeks gestation?

**20 weeks**

At how many weeks gestation do you obtain fetal survery ultrasound?

**20 weeks**

What routine screening and management is completed at 28 weeks gestation?

- Screen for **gestational diabetes** and **repeat hemoglobin** and **Hct** - **Rhogam injection** to **Rh negative** pt's - **Tdap** give between **27-36 weeks**

At how many weeks gestation is screening for group B strep carriers w/ vaginal culture done?

**35 weeks**

Around 28 weeks have Mom do kick counting to monitor fetal movment and what is the recommended amount she should feel?

**10 movements** in **2 hours**

What is considered a **reactive** nonstress test (NST)?

**2 accelerations** of at least **15 beats** above baseline lasting at least **15 seconds** during **20 minutes** of monitoring = **normal**

What is done if nonstress test is nonreactive?

Further evaluation is warranted w/ a **contraction** **stress test** or **biophysical profile**

What is a contration stress test (CST) and what is considered a positive test?

- Give **oxytocin** to establish at least **3 contractions** in a **10 min** period - If **late decelerations** are noted w/ the **majority** of contractions the test is **_positive_** and **delivery** is warranted!

What are the 5 components of the biophysical profile for assessing fetal well-being?

- **Nonstress test (NST)** - **Fetal breathing movements** - **Fetal movement** - **Fetal tone** - **Amniotic fluid volume**

Which score on a biophysical profile for assessing fetal well-being is reassuring, equivocal, and non-reassuring?

- **8-10** is **reassuring** - **6** is **equivocal**; deliver if pt is at term - **4 or less** is nonreassuring; consider **delivery**