Midterm Flashcards
1
Q
Human Chorionic Gonadotropin (hCG)
A
- Secreted into maternal circulation after implantation (5-7 days after fertilization)
- Doubles every 29-53 hours (or 2-3 days) for 30 days after implantation
- Serial hCG testing every 3 days
- Not useful in determining gestational age
- Urine test becomes positive around missed menses
- Serum test becomes positive around 9 days after conception (more sensitive; quantitative or qualitative)
2
Q
Basic lab tests done during pregnancy
A
- hCG
- US
3
Q
Lab tests done during the initial obstetrical visit
A
(around 10 weeks, ideally)
- CBC
- ABO-rh
- Ab screen
- Rubella
- Syphilis
- Hep B
4
Q
Lab tests done for at-risk pregnancies
A
- HIV
- Varicella
- Thyroid
- DM
- others if symptomatic
5
Q
Lab tests done at standard obstetrical visits
A
- Urine chemistry at every visit
- Glucose screening, CBC, and Ab screen at 24-28 weeks
- CBC, Ab screen, and GBS probe at 36 weeks
6
Q
When/how pregnancy can be diagnosed
A
- Serum hCG after implantation, about 9 days after conception
- Urine hCG after first missed menses
- TVUS at 5-6 weeks
- Transabdominal US at 7-8 weeks
- Fetal heart tones at 10-13 weeks
7
Q
Indications for US in pregnancy
A
- Irregular menses
- Unknown LMP
- Patients who conceive while on hormonal contraception
- When physical findings differ from EDD based on LMP
8
Q
Naegle’s Rule
A
- To calculate EDD
- LMP minus 3 months plus 7 days
> LMP = 6/16
> 6/16 - 3 months = 3/16 + 7 days = 3/23
> EDD = 3/23
9
Q
Why is an accurate due date important?
A
- To know what medications are safe and appropriate
- To determine if the fetus is growing appropriately
- To determine eligibility for an out-of-hospital birth (don’t want to deliver a preemie at home)
- To determine IUGR (intrauterine growth restriction)
- To determine the appropriate timing for tests and procedures
> TAB
> Amniocentesis
> 1st or 2nd trimester genetic tests (Down’s or chromosomal testing)
10
Q
DDx for early bleeding
A
- Not always pathological; most often maternal source
- Spontaneous abortion/miscarriage
- Ectopic pregnancy (most serious to r/o)
- Placental bleeding/abruption/hematoma
- Trophoblastic disease
- Vaginitis, cervicitis, trauma, cancer, warts, polyps, fibroids
- Cervical ectropion
- Physiologic or implantation bleeding
11
Q
Nausea and vomiting - mechanism
A
- B-hCG slows peristalsis
- Progesterone slows peristalsis and decreases HCl in stomach
- N/V contribute to placental growth b/c low energy intake stimulates placental growth in early pregnancy
12
Q
Nausea and vomiting - diet treatment
A
- Dry crackers before getting out of bed
- Foods high in B vitamins (kale, brewer’s yeast, blackstrap molasses, wheat germ)
- Light protein snack at bedtime
- Small frequent meals every 1-2 hours; avoid full stomach
- Eat easily digested foods
- Fluids are better between meals to avoid diluting HCl
- Avoid food sensitivities
- Almonds
- Yogurt or kefir with added cinnamon
- Barley or oat broth
- Hard candies
- 1 tsp apple cider vinegar with 8oz warm water - first thing in the morning or with meals
13
Q
Nausea and vomiting - lifestyle treatment
A
- Not opening eyes before getting out of bed
- Fresh air
14
Q
Nausea and vomiting - botanical treatment
A
- Zingiber (ginger)
- Dioscorea villosa (wild yam)
- Tea of raspberry leaf, peppermint, black horehound, catnip, and/or meadowsweet
- Cardamom
- Umboshi paste
15
Q
Nausea and vomiting - supplment treatments
A
- Vitamin B6
- Vitamin K
- Vitamin C
16
Q
Nausea and vomiting - other treatments
A
- Homeopathy
- Acupuncture/acupressure
- Reflexology
- Hypnosis
17
Q
Hyperemesis gravidarum - mechanism
A
- Hormonal changes
- Psychological and social stresses
- Thyroid issues
18
Q
Hyperemesis gravidarum - treatment
A
- Homeopathy
- Drainage
- Counseling
- Liver and support (silybum)
- Acupuncture
19
Q
Heartburn - mechanism
A
- Progesterone relaxes the cardiac sphincter
- Progesterone decreases gastric motility (including esophageal peristalsis)
- Stomach is displaced up and to the right
- Increased intragastric pressure and decreased intraesophageal pressure
20
Q
Heartburn - treatment
A
- Relaxed meals eaten slowly and chewed fully
- Avoid trigger foods (coffee, chocolate, alcohol, fats)
- Avoid cold foods and drinks, carbonated drinks, processed foods, sugar, and cigarettes
- Pat of butter at start of meal
- Increase raw foods
- 1 Tbsp apple cider vinegar 3 hrs after eating
- Good posture, wear loose-fitting clothing
- Raw almonds, yogurt, dry popcorn
- Papaya or digestive enzymes, liquid calcium magnesium
- Antacids, antisecretory antihistamines
21
Q
Dyspepsia, flatulence, eructations - diet treatments
A
- Consume 4+ fruits and vegetables/day, steamed instead of boiled
- Avoid gas-forming foods
- Avoid carbs and proteins in same meal
- Yogurt, kefir, probiotics
22
Q
Dyspepsia, flatulence, eructations - lifestyle treatments
A
- Exercise
- Abdominal massage
23
Q
Dyspepsia, flatulence, eructations - pharmaceutical/natural treatments
A
- Simethicone
- Homeopathy
> Carbo veg
> Nux vomica - Digestive enzymes
- Botanicals
> Dill
> Ginger
> Fennel
> Papaya enzymes
24
Q
Constipation - mechanism
A
- Progesterone slows peristalsis
25
Constipation - diet/lifestyle treatments
- Increase fruit, vegetables, and fiber in diet
- Prunes and dried fruits
- Fruit juice (esp prune juice)
- Exercise
- Decrease stress
- Increase rest
- 8 glasses decaffeinated fluids/day (ideally water)
- Regular bowel habits
- Avoid laxatives
26
Constipation - medical interventions
- Natural Bulk laxatives (like Metamucil or Citrucel)
- Avoid Colace or other stool softeners unless natural alternatives were unsuccessful
- Digestive enzymes
27
Constipation - natural treatments
```
- Homeopathy
> Sepia
> Nux vom
> Calc carb
> Sulphur
> Pulsatilla
> Kali-carb
> Merc
- Botanicals
> Yellow Dock
> Dandelion tea
> Psyllium seeds (1-2 tsp soaked in water)
```
28
Ptyalism - mechanism
- Excess saliva
- Excess acidity in mouth
- Can be stimulated by starchy foods
- Often in cycles with nausea
29
Ptyalism - treatment
- Decrease starch intake
- Avoid dairy products
- Increase fruit intake
- Homeopathy
> Ipecac
> Merc
> Kreosotum
> Coffea
> Helonias
> Kali-iodum
30
Diarrhea - treatment
- Increase bulk/fiber
- Raspberry tea (esp root)
- For infx - charcoal
31
Pica - treatment
- Improve diet
- Treat nutritional deficiencies
- Homeopathy
> Chelendonium
> Mag carb
> Lyssin
> Nitric acid
32
Lab results indicating anemia
- CBC - Hgb, HCT, and MCV
- Serum B12
- Ferritin
33
Anemia - treatment
- Depends on underlying cause
| - Usually supplementation with nutritional support
34
How to facilitate oxytocin release
- Released in adequate amounts when feel safe and supported in private
- Released pulsatilely to be effective
- Optimal circumstances for oxytocin release
> Dim light
> Privacy
> No threat or perceived danger or stress
> Talk - use of language
35
Why is smoking bad - direct effects/risks
- Benzoid pyrene affects protein transport into placenta and is associated with learning disorders
- Nicotine causes release of ACh, Epi, NE, and ADH, which lead to tachycardia, increased CO, peripheral vasoconstriction, increased BP, and changes in fat and carb metabolism
> Leads to decreased blood flow to the placenta (for up to 15 minutes after a cigarette)
- CO can cross placental barrier and prevent binding of oxygen to fetal blood
> Leads to increased risk of SAB, placental abruption, placenta previa, bleeding, premature rupture of membranes, low birth weight, and fetal and neonatal death
36
Why is smoking bad - maternal complications
- COPD
- Cervical cancer
- Infertility
- Early menopause (eggs die)
- Ectopic pregnancy
37
Why is smoking bad - effects on infants (increased risk for)
- Growth and intellectual deficiencies
- ADD/ADHD
- Less responsive to sound
- SIDs
- Respiratory diseases (pneumonia, bronchitis, asthma)
- Cancer (non-Hodgkin's lymphoma, ALL, Wilm's tumor)
- Strabismus
38
Fetal Alcohol Syndrome
- Must have at least one feature from each of the following three categories:
- Prenatal or postnatal delay in child's weight or head circumference
- Distinct physical characteristics, at least 2 of the following:
> Small head, small eyes or short eye openings, narrow lip w/o center groove, short upturned nose or flattened mid-facial area, abnormal testes in males
- Abnormalities of CNS, signs of brain dysfunction, delays in behavioral development, and/or cognitive impairment
39
When most susceptible to teratogens
- Fetus is most susceptible during organogenesis (weeks 5-10)
40
Other things to avoid during pregnancy
- Ibuprofen
- Aspirin
- Decongestants
- Vitamin A
41
Goal of prenatal care
- Healthy parent and child
42
Components of prenatal care
- Early accurate estimation of gestational age
- Identification of patients at risk for complications
- Ongoing health status evaluation of both parent and fetus
- Anticipation of problems and intervention to prevent or minimize morbidity
- Patient education and communication
43
Timing of prenatal care
- Patients interview in first trimester
- First prenatal appt by ten weeks of gestations
- Prenatal visits monthly until 32 weeks
- Prenatal visits biweekly from 32-36 weeks
- Prenatal visits are weekly from 36 weeks - delivery
44
Initial prenatal visit
- Prenatal history
- Establish EDD
- PE
- Lab testing
45
Standard prenatal visit
- History
- PE
- Lab testing
46
Prenatal patient education
- Travel
- Seat belts
- Nutrition
- Food choices
- Weight gain
- Vitamins
- Vices
- Exercise
- Recreation
47
Ectopic pregnancy
```
- Occurs when a developing blastocyst becomes implanted at a site other than the endometrium of the uterine cavity
> Sites of implantation
-> Fallopian tube (MC)
-> Ovary
-> Abdomen/pelvic region
-> Cervix
```
48
Risks of ectopic pregnancy
- Risk of rupture leading to hemorrhage and maternal shock and potentially death
- Leading cause of pregnancy-related maternal death in the 1st trimester
- Accounts for 4-10% of all pregnancy-related maternal death
- Untreated ectopic pregnancies are often fatal
49
High risk factors for ectopic pregnancy
- Previous ectopic pregnancy
- Previous tubal ligation
- Tubal pathology
- In utero DES exposure
- Current IUD use (worse w/ Mirena vs Paraguard)
50
Moderate risk factors for ectopic pregnancy
- Infertility
- Previous cervicitis (GC/CT)
- History of PID
- Multiple sexual partners
- Smoking
51
Low risk factors for ectopic pregnancy
- Previous pelvic/abdominal surgery
- Vaginal douching
- Early intercourse (<18 yo)
52
Clinical manifestations of ectopic pregnancy
- Typically appear 6-8 weeks after LMP, but can occur later
> Majority of ruptures occur by 6-12 weeks
- Normal pregnancy symptoms
- Abdominal pain (99%), may present as acute abdomen
> More likely to be one-sided
> Achey, pressure, sharp, nagging
> Likely to be constant pain
- Amenorrhea (74%)
- Vaginal bleeding (56%)
- Should be suspected of any patient of reproductive age with these symptoms
53
PE for ectopic pregnancy
- Vitals
- Low grade fever
- Adnexal, CMT, and/or abdominal tenderness
- Adnexal mass
- May be unremarkable
54
Spontaneous abortion
- Miscarriage
- Pregnancy that ends before the fetus has reached 20 weeks (after 20 weeks is a still birth)
- Subcategories
> Threatened miscarriage
> Inevitable miscarriage
> Complete miscarriage
> Incomplete miscarriage
> Missed abortion
55
Risk factors for SAB
- Advancing maternal age
- Previous SAB (risk increases proportional to number of SABs)
- Smoking > 10 cigarettes/day
- Cocaine
- NSAIDs, excluding acetaminophen
- Low or high maternal BMI
- Celiac disease (if eating gluten)
56
Etiology of SAB
- Chromosomal abnormalities (50%)
- Congenital anomalies
> Genetic or chromosomal abnormalities
> Extrinsic factors
> Exposure to teratogens
- Trauma or invasive procedures
- Host factors
> Uterine abnormalities
> Maternal infection
> Endocrinopathies
> Acquired thrombophillias and abnormalities of immune system
> Unexplained
57
Clinical presentations/history of SAB
- Amenorrhea
- Vaginal bleeding
- Pelvic pain
