Mod 5-6 Flashcards
(137 cards)
1
Q
Associated Risk Factors for \_\_\_\_\_: Preeclampsia Macrosomia Chronic Type II GDM Stillbirth Shoulder Dystocia Neonatal Hypoglycemia
A
GDM
2
Q
Always check these things in GDM patient
A
fundal height + kick counts
3
Q
If 1 hr screen is >_____, do not do 3 hr GTT because patient is diagnosed with GDM.
A
200
4
Q
number of times to tell GDM patient to check blood sugar
A
4x- fasting and 2 hrs after each meal
5
Q
If no _________ are present, the patient may decline GDM screening.
A
risk factors
6
Q
In the 3 hour GTT, ___ results must be elevated in order to diagnose GDM
A
two (2)
7
Q
If GDM is diagnosed, the first step is:
A
diet and lifestyle modifications
8
Q
EARLY 1 hr GDM screen:
GDM diagnosis is made if result is >_____
A
140
9
Q
If early screen is normal, still order ________ @ _____ weeks
A
1 hr GTT @ 24-28 weeks
10
Q
first line treatment for GDM management when diet therapy alone has not worked
A
insulin
11
Q
Does insulin cross the placenta?
A
No
12
Q
reasonable alternative for GDM patients who cannot take insulin or decline it
A
Metformin
13
Q
gestational age of diagnosis that means diabetes is gestational and NOT pregestational
A
24
14
Q
If EARLY GDM screen is elevated (>140), midwife should:
A
order 3 hr GTT
15
Q
With diet-controlled GDM, recommendation for delivery is expectant management until:
A
40.6 weeks
16
Q
With insulin-dependent GDM, recommendation for delivery is induction at:
A
39.0-39.6 weeks
17
Q
If 1 hr and 3 hr GTT are all abnormal, the midwife should:
A
screen for Type II DM in the PP period
18
Q
for PP GDM screening, use:
A
75 gm, 2 hr GTT
19
Q
study algorithm for glucose in neonates!
A
put in the cards
20
Q
hydatidiform mole, gestational trophoblastic disease
A
molar pregnancy
21
Q
Treatment for \_\_\_\_\_\_\_\_\_\_\_: check dates maybe repeat US check for rising hCG wait for miscarriage vs D&C or aspiration
A
blighted ovum
22
Q
Treatment for ___________:
D&C
follow hCG for until level is 0 (may take 6 mo-1 year)
delay subsequent pregnancy for at least 6 months after hCG is 0
A
molar pregnancy
23
Q
anembryonic pregnancy (empty sac)
A
blighted ovum
24
Q
poor quality sperm or egg, wrong # of chromosomes causes this:
A
blighted ovum
25
sometimes called a "chemical pregnancy"
blighted ovum
26
causes hCG rises slowly and stay low (patient may have no symptoms and may miscarry without knowing it)
blighted ovum
27
chromosomal error- all from father or 2 sets from father and only 1 from mother (too many chromosomes from father)
molar pregnancy
28
```
Symptoms of __________:
bleeding/spotting
usually size>dates on US
extra pregnancy symptoms
hyperemesis severe
```
molar pregnancy
29
fetus size for which clinical palpation is most accurate for estimating fetal weight
2500-4000 gm
30
SGA is diagnosed by:
a weight scale
31
Size
fundal height
32
IUGR is diagnosed by:
Ultrasound
33
normal deepest vertical pocket for amniotic fluid
> 2 cm
34
normal AFI
5-20 cm
35
complete loss of flow in the umbilical artery (from fetus to placenta) during diatole = abnormal flow = ill baby
absent end diastole flow
36
blood flows backwards from placenta to umbilical artery = very ill baby = needs to be delivered NOW
reversed end diastolic flow
37
A1GDM
diet-controlled GDM
38
A2GDM
medication-dependent GDM
39
before ___ weeks, cells are MORE responsive to insulin so blood sugar may be lower than normal
20
40
As placenta grows, human placental lactogen (hPL) and other diabetogenic hormones ______________ which creates cellular resistance to insulin causing BG to rise
increase
41
peak effect of hPL is at ___-___ weeks, which is why we screen for GDM at this gestation
26-28
42
incidence of GDM in U.S. ___-___%
3-9%
43
Higher incidence of GDM in these populations
Hispanic, African American, Native American, Asian, and Pacific Islander
44
Risk Factors for _____________:
--Non-modifiable
Increased age, >/=40
Race/Ethnicity - Hispanic, African American, Native American, Asian, and Pacific Islander
Medical Hx of GDM, impaired glucose metabolism, glycosuria, PCOS, HTN, CVD, A1C >/= 5.7%, Lipids - HDL < 35, triglyceride > 250, acanthosis nigricans
Meds that increase BG
Family Hx of Type 2 DM- especially 1st degree relatives
Obstetric Hx - previous GDM, infant >/= 4000g, stillbirth, congenital anomalies
--Modifiable
Weight gain - pre-pregnancy, early adulthood, gestational, between pregnancies
Obesity - higher BMI, prepreg BMI >40
Sedentary lifestyle
GDM
45
Factors that lower risk for _________:
No known diabetes in 1st degree relatives
Age < 25
Weight normal before pregnancy, at birth
No hx of abnormal glucose metabolism
No hx of poor obstetrical outcome
Ethnicity with lower prevalence of GDM - caucasian
GDM
46
Increase of risk for _______ after pregnancy:
10% in the first months postpartum
50% by 5 years
70% by 10+ years
GDM
47
Fetal Implications of _________:
**Increased risk w/ poor glycemic control
Anomalies - If DM predates pregnancy and was undiagnosed/not controlled-- significant risk
IUFD
jaundice
hypoglycemia
hyperbilirubinemia
shoulder dystocia
Macrosomia
Birth trauma- body changes can change hip/waist ratio “football shoulders”
GDM
48
```
Neonatal Implications of ______:
NICU admission
Long-term--
risk for developing childhood obesity
type 2 diabetes
metabolic syndrome
Short-term--
respiratory distress syndrome
metabolic complications
hypoglycemia
```
GDM
49
________ Screening Approaches for women with GDM Risk Factors:
HbA1c
Fasting glucose
75 gram glucose load w/ 2 hr postprandial
1st Trimester
50
__________ Approach for GDM Testing:
1. Screen w/ 50 gram 1 hr glucose challenge (w/o fasting)
- -If blood glucose elevated beyond practices/guidelines values...
2. Diagnosis made by 3 hr GTT
Two-Step
51
Glucose load of 50 grams (w/o fasting)
Results >/= ______-______ @ 1 hr
Move to diagnostic 3 hr GTT
130-140
52
```
Carpenter/Coustan Threshold Values
100 gm glucose load
Fasting >/= ____
@ 1 hr >/= ____
@ 2 hr >/= ____
@ 3 hr >/= ____
```
95
180
155
140
53
GDM is diagnosed in the 3 hr GTT with ____ or more abnormal values
two or more
54
```
NDDG Threshold Values
100 gm glucose load
Fasting >/= ____
@ 1hr >/= ____
@ 2 hr >/= ____
@ 3 hr >/= ____
```
105
190
165
145
55
```
__________ Approach for GDM Testing:
75 gm glucose load
Fasting >/= 92
@ 1hr >/= 180
@ 2 hr >/= 153
```
One-step
56
```
One-Step Approach for GDM Testing:
75 gm glucose load
Fasting >/= ____
@ 1hr >/= ____
@ 2 hr >/= ____
```
92
180
153
57
GDM is diagnosed in the One-Step approach with ____ or more abnormal values
one or more
58
```
Reasons for ___________:
BMI > 25
Asian + BMI >23
AND one additional risk factor:
HTN
PCOS
Hx GDM
Hx macrosomic infant
1st degree relative w/ DM
```
1st Trimester GDM Screening
59
_____________ Screen for GDM:
50 gm glucose (fasting)
BG tested @ 1 hr
24-28 Week
60
Patient is at risk for GDM if 24-28 Weeks Screen 1 hr value is >/= ____-____
130 (20-25% of positive tests capture 90% of GDM)
-
140 (13-18% of positive tests capture 80% of GDM)
61
```
___________ Screening for GDM:
Do not screen:
Age < 25
If NOT Hispanic, AA, Native American, East Asian, Pacific Islander
BMI < 25
Negative abnormal glucose intolerance
Negative Hx adverse OB outcomes
Negative 1st degree relative w/ DM
(Sensitivity 84%, Specificity 72%)
```
Selective
62
```
Diagnostic for ________:
1st PNV:
FBG (fasting BG) >/= 126
RPG (random BG) >/= 200 with HbA1c confirmation
HbA1c >/= 6.5
```
Overt DM
63
Diagnostic for ________:
1st PNV:
FBG (fasting BG) >/= 92 but < 126
GDM
64
If 1st PNV GDM screen is normal, midwife should:
screen again at 24-28 weeks
65
75 gm 2-hr GTT
FBG (fasting BG) >/= ____
@ 1 hr >/= _____
@ 2 hr >/= _____
92
180
153
66
Why does ACOG support a 2-step testing vs. 1-step?
It increases the number diagnosed GDM w/o improvement in outcomes
67
ACOG Requirement for ________ GDM Screening:
Consider if overweight or obese w/ BMI > 25; Asian-Americans BMI > 23 PLUS 1 or more of following:
-Physical inactivity
-**1st degree** relative with DM
-High risk race/ethnicity - African/Asian/Native American, Latino, Pacific Islander
-Hx of infant >/= 4000gm (9 lbs)
-Hx of GDM
-Hx CVD
-HTN - 140/90 or hypertension therapy
-Lipids - HDL<35; triglyceride >250
-PCOS
-HbA1C >/= 5.7%
-impaired glucose tolerance
-impaired fasting glucose on previous testing
-Other conditions associated w/insulin resistance (i.e. pre-pregnancy BMI > 40, acanthosis nigricans)
Early
68
May newly diagnosed GDM patients be cared for by midwife?
yes, if controlled with diet and exercise
69
GDM NOT controlled by diet/exercise and controlled Type 2 DM is within midwifery scope of practice along with:
collaboration w/ MD
70
Referral is indicated for ______ DM or Type ___ DM
overt; Type 1
71
Normal weight patients need _____ kcal/kg
30-36
72
Overweight patients need ____ kcal/kg
24
73
Diet should be ______% carbohydrates
_____% protein
_____% fat
33-40% carbs
20-30% protein
40% fats
74
GDM patient should keep ___________ for several weeks after dx to help assess dietary control - in conjunction w/ dietician
diet diary
75
GDM should check BG levels _______ and ___-___ hour postprandial levels daily
fasting; 1-2 hours postprandial
76
BG level check @ home should be:
Fasting = ____
Postprandial 1 hour = ____
Postprandial 2 hour (more commonly used) = ____
95
140
120
77
First/Best choice for GDM medication
insulin
78
These meds can be added to insulin if needed for GDM patients
Metformin (first), Glyburide
79
If medications are required for GDM patient, midwife needs to involve:
an MD
80
Medication:
Does not cross placenta
Can achieve tight control
Physician managed - midwives can continue to collaborate for other areas of care
Insulin
81
1st line PO med for GDM (due to better outcomes)
**Sometimes supplemental insulin still needed
Better compliance than insulin
Reasonable alternative if patient unable to safely administer/afford insulin
**Crosses placenta
Usually start at 500mg QHS for 1 week then increase to 500mg BID
Max dose 2500-3000mg/day in 2-3 divided doses
Contraindicated in chronic renal disease - check baseline creatinine
Adverse effects - abdominal pain, diarrhea
Metformin
82
```
Studies _____________ show
maternal weight gain
increase in PTB
less severe neonatal hypoglycemia
Less NICU admits
```
Metformin to Insulin
83
Some physicians prefer to start w/ this med - but generally agreed should not be first choice
Not FDA approved but ACOG SAYS OK
**Crosses placenta
Previously thought to increase macrosomia and hypoglycemia - now known only to increase hypoglycemia
Contraindicated with sulfa allergy
Usually 2.5-20mg daily in divided doses, up to 30mg/day may be necessary
Glyburide
84
If patient on Insulin or GDM PO meds:
NST ___x/week starting at ___ weeks
and daily ________
2x/week @ 32 weeks
| daily fetal kick counts
85
this should be initiated at 32 weeks w/ pregestational diabetes, GDM and poor glycemic control or those w/ pharm therapies added to improve glycemic control (ACOG)
antenatal fetal surveillance
86
If GDM is diet controlled, no risk for stillbirth, so antenatal testing may not indicated until ____ weeks
40
87
GDM patients should have growth US @ ____ weeks
28-32 weeks
88
IOL:
| Diet/exercise controlled GDM - expectant management up to _____ weeks
40 + 6/7
89
IOL:
| Well-controlled medication-dependent GDM- induce at ____ - _____ weeks
39 0/7 - 39 6/7
90
symmetric fetal growth restriction occurs in _______ pregnancy
early
91
assymetric fetal growth typically occurs in _______ pregnancy
late
92
assymetric fetal growth typically occurs due to:
uteroplacental abnormalities (placental function, perfusion)
93
maternal drug use, infections, teratogens cause ____________ fetal growth restriction
symmetric
94
oligohydramnios in early pregnancy is due to:
renal abnormality
95
oligohydramnios in late 3rd trimester pregnancy is due to:
placental insuffiency
96
```
for ___________ at 34 weeks:
physician communication
encourage IV/PO hydration
dopper flow studies
fetal surveillance (NST and BPP)
```
oligohydramnios
97
hypERthyroidism is pregnancy is diagnosed by:
elevated free T4 levels
98
hypERthyroidism: low _____, elevated _____
low TSH, elevated free T4 levels
99
enlarged thyroid on exam without nodules/symptoms/hx of thyroid problems is: _________
What does midwife do?
normal; only order TSH if symptomatic
100
```
Associated with __________ in pregnancy:
Low birth weight
Preterm birth
Preeclampsia
Fetal growth restriction
Fetal thyrotoxicosis
```
thyroid disorder in pregnancy
101
at 14 weeks, patient reports hair loss and cold intolerance, what should midwife do?
order TSH, if abnormal- order further testing
102
What does maternal free T4 do in pregnancy?
aids in brain development during entire pregnancy
103
How does thyroid function change during pregnancy?
total T3 and T4 increases
| TSH decreases
104
trimester in which TSH levels are the lowest
1st trimester
105
low TSH but normal free T4 =
subclinical hyperthyroidism
106
Treatment for _________ in pregnancy?
| Levothyroxine 125 mcg PO daily
hypothyroidism
107
Treatment for _________ in pregnancy?
Proplthiouracil (PTU) 200 mg PO TID
Methimazole (MMI) 5 mg PO BID
hyperthyroidism
108
After patient starts Levothyroxine for hypothyroidism, the midwife should:
Recheck TSH q4-6 weeks
| Adjust dose until TSH is within lower limit of normal + 2.5 mu/L
109
Patient presenting with hypERthyroidism symptoms and low TSH, what should midwife do?
just order total T3 and T4
110
Check ACOG algorithms for hypo/hyperthyroidism
!!!!!!
111
```
Associated with _________ gestation:
PUPPS
Preeclampsia
Preterm birth
Fetal growth restriction- Assymetric
```
multifetal
112
twin-to-twin is common with __________ twins
mono-mono
113
Management of __________:
more frequent prenatal visits
growth US q3-4 weeks
collaborative physician care
Twin gestations
114
```
Management of ____________:
provide breastfeeding anticipatory guidance
screen for depression
consult mental health resources
consider serial growth US q3-4 weeks
```
opioid dependency
115
IP Management of ___________ patients:
| consult anesthesia for epidural placement
opioid dependent
116
Women with a history of GDM have a ________-fold increased risk of developing type 2 diabetes compared to women without a history of GDM.
seven
117
ACOG recommends that women with a GDM history have their glycemic status evaluated every __-__ years in addition to providing weight loss and physical activity counseling as needed.
1-3 years
118
polyhydramnios is diagnosed with AFI >/= ____ or DVP of >/= ____
24; 8
119
Risk Factors for ___________:
Age > 30
Hx SAB / PTB
Family Hx thyroid dysfunction
Hypothyroidism
120
```
Symptoms of ___________:
cold intolerance
hair loss
muscle cramps
edema
prolonged relaxation of DTRs
**common to pregnancy:
fatigue
constipation
weight gain
dry skin
```
Hypothyroidism
121
```
Symptoms of ___________:
Heat intolerance
excessive sweating
tachycardia
palpitations
weight loss
insomnia
```
Hyperthyroidism
122
high levels of hCG can decrease ____ levels to low-range normal
TSH
123
TSH levels progressively __________ with advancing gestational age
increase
124
normal TSH level in 1st trimester
0.1 - 4.0
125
normal TSH level in 2nd trimester
0.2 - 4.0
126
normal TSH level in 3rd trimester
0.3 - 4.0
127
if TSH is abnormal, draw _____
Free T4
128
If TSH level > 2.5, order:
TPOAb antibody status
129
High TSH + Low Free T4 =
Overt HypOthyroidism
130
```
Untreated __________ in Pregnancy Sx:
spontaneous abortions
low birth weight
placenta abruption
preterm birth
preeclampsia
fetal death
```
HypOthyroidism
131
How to take Levothyroxine
in the morning on empty stomach and delay eating for 30-60 min after
132
After therapy started for hypothyroidism, check TSH + Free T4 levels q___ weeks
q4 weeks
133
Levothyroxine should be adjusted by ___-___ mcg increments until TSH levels are at the lower half of the trimester-specific pregnancy ranges
25-50
134
ATA guidelines recommend drawing TSH q___ weeks until midgestation then at least once @ ____ weeks
q4 weeks
| @ 30 weeks
135
Neuroteratogen:
Nicotine
136
Causes autonomic instability in neonate:
cocaine
137
Risk Factors for ___________:
Oligohydramios
