Normal pregnancy and labor Flashcards
(163 cards)
1
Q
What is the definition of pregnancy?
A
The state of having products of conception implanted normally or abnormally in the uterus or occasionally elsewhere
2
Q
how to dx pregnancy?
A
- otc pregnancy test, test the beta subunit of hCG
- viable pregnancy can be confirmed w US. May show gestational sac at 5w og hCG 1500-2000. Fetal heart motion may be seen on TVS at 6w or at hCG of 5000-6000
3
Q
definition of embryo
A
pregnancy until 8w
4
Q
definition of fetus
A
> 8w until birth
5
Q
infant
A
From delivery to 1y
6
Q
define the trimesters
A
1st is up to 12w (14 GA)
2nd 12- 24 (28 GA)
3rd is 24/28 until birth
7
Q
Viable infant
A
> 24, before is previable
8
Q
preterm
A
24-37w
9
Q
term
A
37-42
10
Q
post term
A
> 42
11
Q
gravidy (G)
A
Refers to number of times a woman has been pregnant
12
Q
parity (P)
A
number of pregnancies that led to birth at or beyond 20w GA or >500g BW
13
Q
what is the G/TPAL
A
- Gravida= total nr of known prgenancies regardless of outcome
- Term= nr of pregnancies that resulted in term delivery (>37w)
- Preterm= nr of pregnancies that resulted in a preterm delivery
- Abortus= nr of pregnancies that resulted in spontaneous or induced abortion
- Living= the nr of live infants born
14
Q
how is the GA measured
A
Is the age in weeks and days measured from the last menstrual period (LMP)
15
Q
what is the developmental age of the fetus (DA)
A
Is the conceptional age or embryonic age. The number of weeks and days since fertilization. Usually 2 weeks less than GA
16
Q
what is the Nagele rule for calculating the estimated date of confinement?
A
Subtract 3 months from LMP and add 7 days. A pat w lmp 16/1/19 would have the EDC 23/10/19
17
Q
How to calculate if known ovulation date (as in ART) ?
A
Add 266 days
18
Q
How to determine EDC in ultrasound
A
Should not differ from LMP more than 1w in 1st TM ,2w in 2nd TM and 3w in 3rd TM. It is done with crown-rump length (CRL).
19
Q
What clinical measures can be used to estimate EDC
A
- Auscultation on fetal heart rate (FH) at 20w by nonelectronic fetoscopy or at 10w by Doppler
- Maternal awareness of fetal movement “quickening” occuring at 16-20w
20
Q
what are the sx of pregnancy
A
- Amennorhea
- N/V
- Breast tenderness/swelling
- Fetal quickening
21
Q
what are the clinical signs of pregnancy
A
- Linea nigra at 22w
- Bluish color of vagina and cervix (Chadvix sign)
- Softening and cyanosis of cervix at 4w (Goodell sign)
- Telangiectasia
- Palmar erythema
- Softening of uterus at 6w (Ladin sign)
22
Q
What are the cardiovascular changes is pregnancy?
A
- CO decrease increase by 30-50%. It is due to both increased stroke volume and HR
- Systemic vascular resistance decrease, resulting in fall in BP w 5-10 in systolic and 10-15 diastolic. Nadir at 24w, then slowly return to normal
- Is a high output, low resistanc state!
23
Q
What are the pulmonary changes in pregnancy?
A
- Tidal volume increase 30-40%
- Minute ventilation increases 40%
- Residual volum decreases 20%
- PaO2 increase and PaCO2 decrease
- Oxygen consumption goes up
- Dyspnea of pregnancy occurs in 60-70% of pat
- A state of resp. alkalosis compensated by increased renal bicarbonate excretion
24
Q
What are the GI changes in pregnancy?
A
- N/V in 70% “morning sickness”, attributed to elevation in estrogen, progesterone and hCG. May also be due to hypoglycemia
- Prolonged gastric emptying time, GES has decreased tone
- Large bowel has decreased motility, which leads to increased water absorption and constipation
25
What is hyperemesis gravidarum ?
Severe form of morning sickness ass w WL more than or 5% of pregnancy weight and ketosis
26
What is the renal changes in pregnancy?
- Kidney size increase w 100%
- Ureters dilate + urine glucose = more susceptible for UTI and pyelonephritis
- Increase in GFR by 50%
- BUN, Cr, uric acid decrease by 20%
- RAAS is activated = total body sodium increase
- Lightening makes it easier to breathe but increase urinary urgency and frequency
27
What are the hematologic changes in pregnancy?
- Plasma volume increase with 50%
- RBC volume increase w 20-30%
- Hematocrit decrease (dilution)
- WBC increase slightly
- plt a bit decreased (dilution)
- Pregnancy is a hypercoagulable state, elevation of fibrinogen and factors 7-10
28
What are the pregnant pat w hypercoagulability predisposed for?
- Placental vascular thrombosis incresing risk for:
- Incresed risk for preeclampsia
- gestational HT
- fetal complications
- 5-fold incresed risk for DVT
29
How is the hCG in pregnancy fluctuating?
- Peak at 10-12w
- Declining to reach a stedy state after 15w
- Acts to maintain corpus luteum to produce progesterone
30
What kind of hormonal state is pregnancy?
Hyperestrogenic! It is produced by placenta, derived from circulating precursors produced by maternal adrenal glands. Fetal well being is correlated w estrogen levels.
31
What fetal conditions are ass w low levels of estrogen
Anencephaly and fetal death
32
what are the alpha subunit of hCG similar to?
LH, FSH and TSH
33
progesterone during pregnancy
First produced by corpus luteum, then taken over by placenta. Corpus luteum progress to corpus albicans. Levels of progesterone increase over the corse of pregnancy. Cause relaxation of smooth muscle that affects GI, CV and Gu systems
34
What is hPL
Human placental lectogen, also called human chorionic somatomammotropin. It is important for ensuring a constant nutrient supply to the fetus. Induce lipolysis which increase circulating free fatty acids. Act as insulin antagonist having a diabetogenic effect. Leads to increased level of insulin and protein synthesis.
35
How is prolactin during pregnancy?
Increased markedly. Decrease after delivery, but again increase in response to suckling.
36
How are the thyroid hormones during pregnancy?
- Estrogen stimulate TBG, lead to elevated total T3 and T4. Free T3 and T4 remain constant
- hCG have a weak stimulating effect on thyroid (alpha = TSH). Leads to slight increase in T3 and T4 and decrease in TSH
- Pregnancy is a euthyroid state
37
how to tx hyperemesis gravidarum ?
frequent snacking ant antiemetics
38
what are the skin changes in pregnancy?
Spider angioma, hyperpigmentation of nipples, umbilicus, abd. midline, perineum and face (melasma /chloasma). Striae gravidarum. Palmar erythema.
39
What are the musculoskeletal changes in pregnancy?
Shift in posture, lower back strain. Ass. w carpal tunnel sd
40
what is the nutritional intake requirements in pregnancy
About 300kcal increased. It is 500kcal per day when breastfeeding. Increased requirement for protein, iron, folate(double) , calcium and other vitamins and minerals.
41
what is the recommended schedule fore prenatal visits
Every 4 w from dx until 28w. Every 2w until 36w. Every week after this.
42
what are the goals of prenatal care
- dx of pregnancy and estimation of GA
- identification of any potential complication
- ongoing estimation of health status of mother and baby
- anticipation of prblems and intervention
- pat education and communication
43
what should be included in history during first initial prenatal visit?
- LMP and sx during the pregnancy
- prior pregnancies, date, outcome, SAB, TAB, ectopic pregnancy, term delivery, mode of delivery, length of time in labor
- BW, any complications
- medical, surgical, family and social history
44
PE in initial prenatal visit
Pelivc exam w pap (unless one was done in past 6m), culture for gonorhea and chlamydia. On bimanual, size of uterus (if consistent w GA and LMP). If size and LMP not consistent, should be done US.
45
what are the diagnostic evaluation done at initial prenatal visit
CBC, blood type, antibody screen, rapid plasma reagin (RPR) or VDRL (syphillis), Rubella antibodies, hep B surface antigen, urinalysis, urinculture. If no hx of chickenpx VZV titer should be taken. PPD for TB in high risk pat. Urine hCG if not sure. Often toxoplasma. Conseling of HIV.
46
what is done on all routing prenatal visits
BP, weight, urine dipstick, measurement of the uterus, auscultation of FH.
47
At what fundal heigh should there be done an US?
If fundal height is decreasing or is 3 cm less than GA.
48
What sx should the pregnant women be asked about at every visit?
Vaginal bleed, vaginal discharge, leaking fluid, urinary sx. After 20w ask about fetal movements and contractions.
49
What may vaginal bleed be a sign of in pregnancy?
Possible miscariage, ectopic pregnancy in 1st TM. Placental abruption or placenta previa as pregnancy advances.
50
What may vaginal discharge be a sign of in pregnancy?
Sign of infection or cervical change. Leaking fluid can indicate ruptured fetal membranes.
51
What may cantractions be during third tm?
- Irregular (Braxton Hicks) are common throughout 3rd tm
| - Regular contractions more than 5 or 6 per hr may be a sign of preterm labor, and should be assessed.
52
How should changes in fetal movement be evaluated?
Changes or ansence of fetal movement should be evaluated by auscultation of FH in the previable fetus, and further testing as a nonstress test or biophysical profile in viable fetus
53
What can be done at end of 1st tm (1st tm screen)
- US
- Maternal serum hCG
- AFP
- PAPP-A
54
What vaccines is not safte in pregnancy?
- MMR!
- Polio
- Varicella
- Yellow fever
Any live vaccine
55
screen in African American, Southeast Asian, MCV<70
Sickle cell prep, Hgb electrophoresis
56
screen in fhx of genetic disorder (e.g. hemophilia, fragile X, maternal age >35)
Prenatal genetics referral
57
Screen in Prior GDM, fhx of DM, Hispanic, Native American, Southeast Asian
Early GLT
58
Screen in Pregestational DM, unsure dates, recurrent miscarriage
Dating sonogram at first visit
59
Screen in HT, renal disease, pregestDM, prior preeclampsia, renal transplant, SLE
BUN, Cr, uric acid, 24hr urine collection for protein and creatinine clearance
60
Screen in PregestDM, prior cardiac disease, HT
ECG
61
Screen in pregestDM
HbA1c, ophthalmology
62
Screen in Graves disease
Thyroid-stimulating immunoglobulin (can cause fetal disease)
63
Screen in All thyroid disease
TSH, free T4
64
Screen in PPD+
CXR after 16wga
65
Screen in SLE
AntiRo, antiLa antibodies, can cause fetal complete heart block
66
What are common complaints during pregnancy
- Breast enlargement
- N/V
- Fatigue
- Gingival bleed
- Migraine like headache
- Dizziness
- Spotting/bleed occur in 20% of pregnancies, 50% progress normally
67
What is the most common complication of pregnancy?
Spontaneous abortion
68
What food should be avoided in pregnancy?
High mercury fish, liver, anything undercooked, saccharin. Avoid chamomile, licorice, peppermint, raberry leaf
69
What are the recommended vitamin supplementation?
Folate 800ug/day, Iron 18/27mg/day
70
What tests can be done in 2nd tm
- MSAFP/triple or quad screen
- US
- Amniocentesis for women interested in prenatal dx
71
What test should be done in 3rd tm
Hct, RPR/VDRL, GLT, Group B strep culture
72
What weight gain are appropriate in pregnancy?
11,5 - 16 kg (normal BMI)
Overweight 7- 11kg
Underweight 12- 18 kg
73
What safety measures should be taken w pregnancy?
- Home, NB! Physical abuse
- Tobacco cessation and EtOH abstinence
- Seat belt use
- Exercise is okey, but avoid strenous activity if there has been certain complications (>3 SAB, PROM, PT, cervical insufficiency, placenta previa, IUGR)
74
What should be avoided in pregnancy?
- Child w chickenpox
- Kittenlitter
- Hot tub/ sauna
- Contact sports
- Rollercoaster
75
What is correlated w MSAFP
AFP is the major serum glycoprotein of embryo. Peaks at 30w. Immature dating is the most common cause of abnormal AFP. Neural tube defect >2,5, Down sd <0,85. Decreased w Turner. If US confirms age, amniocentesis to determine karyotype.
76
What is checked in 2nd tm US screen?
Common fetal abnormalities, amniotic fluid volume, placental location and GA.
- Fetal cardiac activity
- Fetal number
- Fetal biometrics
- Anatomy of major organs
- Placental appearance and locatio n
- Uterine/adnexal anatomy
77
What are the 4 biomarkers of quad screen?
Performed btw 16-18. AFP, Estriol, hCG, Inhibin A(not in tripple)
78
What are other disorders ass w AFP > 2,5
- Multiple gestation
- NT defect
- Ventral wall defect
- Pateu sd
- Fetal renal disease
79
What are the quad test result for Down sd
Low AFP, low estriol, high hCG, high inhibin A (HIgh)
80
What are quad test result for Edwards
normal AFP, low estriol, low hCG, norm Inhibin A (HEdwards low)
81
What are the quad test result for Pateu sd
high AFP, norm estriol, norm hCG, norm inhibin A (AFPatau is high)
82
Turner quad test
low AFP, low estriol, very high hCG, very high inhibin A (HIgh)
83
How to estimate fetal weight on US
- Head circumference
- Biparietal diameter
- Abdominal circumference
- Femur length
84
How to evaluate the nucal fold on US
- Should be <0,5 mm
- Ass w Down sd, Turner sd
- Cystic hygroma, from lymphatics
85
What are the normal events of 2nd tm
- Improved sense of well being
- Mild pelvic pain
- Quickening: 18-20w w primigravida, 16-20w for multigravida
- Back pain, breast pain
- Unwanted hair growth, skin changes
- Hemorrhoids (increased venous pressure)
86
What may be complications during 2nd tm
Cervical insufficiency, PPROM, PT
87
What are done at 3rd tm visit?
- FHT (fetal heart tones)
- Fundal height
- Leopold maneuvers (check position, at top, sides/spine, bottom)
88
When is gest DM screen
24-28w
89
When is GBS screen?
36w
90
What is GLT?
Glucose loading test. No need for fasting.
| Give 50g glucose loading dose and checking serum glucose 1 hr later. If greater or equal to 140 a GTT should be done.
91
What is GTT?
Glucose tolerance test. Done w overnight fasting glucose serum first taken. Given 100g oral glucose loading dose. Dx of gestDM if 2 or more of the following values. Impaired glucose tolerance if one abnormal value.
- fasting glucose 95 mg/dL
- 1hr = 180 mg/dL
- 2hr = 155 mg/dL
- 3hr = 140 mg/dL
92
What should be done in 3rd tm in women w latent HSV inf?
Antiviral prophylaxis at 36w. If active HSV it is indication for c-section
93
How to evaluate Hct in 3rd tm?
At 27-29w it is reaching nadir. If below 32% (Hb <11) are started on iron supplements
94
What are the normal events in 3rd tm
- Moves into presenting position (Leopold)
- US at 35-36w to confirm position
- External cephalic version may be performed at 37-38w
- Around 36-40w fetal head descends in the pelvis causing lightening (easier breathing, increased urinary frequency)
- Mild cramping
- Mild lower edema (NOT face or arms)
- Round ligament pain (late 2nd, early 3rd tm) form rapid expansion
95
What are the complications in 3rd tm
- PPROM, PROM
- PT labor and delivery
- Abruptio placenta
- Placenta previa and vasa previa
- Preeclampsia
- UTI (always tx)
- Gestational anemia
- Gestational DM
96
Which vaccines should women have in 3rd tm
- Tdap regardless of interval
- Influenza
- HepB if no prior immunity
97
What do you check in the biophysical profile (BPP)?
- Amniotic fluid volume, fetal tone, fetal activity, fetal breathing movements and nonstress test( NST)
- Points of 0-2 per measure, point of 8-10 or better is reassuring
- Done in 3rd tm for high risk pregnancy
98
What are you looking for in Doppler flow studies?
The umbilical cord. A decrease, absence or reversal of diastolic blood flow is worrisome for placental insufficiency and resultant fetal compromise.
99
What is the pupose of electrical fetal monitoring?
Assess fetal weel-being during labor
100
What does the cardiotocometry consist of?
Uterine tocometer + external fetal heart monitor
101
What is normal fetal HR
110-160 bpm
102
What is definition of fetal bradycardia?
<110bpm
| - Normal w fetal sleep
103
What are maternal causes of fetal bradycardia
Supine position, hypotension, hypoglycemia
104
What are the maternal-fetal interface causes of fetal bradycardia?
Poor uterine perfusion. Umbilical cord prolapse.
105
What are fetal causes of fetal bradycardia?
Arrhythmia, Vagal stimulation
106
What are drugs causing fetal bradycardia?
Opioids, anesthesia, Magnesium sulfate, beta blockers
107
What is fetal tachycardia?
>160bpm. Normal w fetal movement and stimulation.
108
Maternal causes of fetal tachycardia
Stress and anxiety, fever, thyrotoxicosis, anemia, hypoxia
109
Maternal-fetal interface causes of fetal tachycardia
Chorioamnionitis, abruptio placenta
110
Fetal factors causing fetal tachycardia
Arrhythmia, anemia, acute blood loss
111
Meds causing fetal tachycardia
Anticholinergics, sympathomimetics, illicit drugs e.g. cocaine, amphetamine
112
What is variability (CRT) ?
A fluctuation of the baseline in amplitude and frequency of more than or 2 cycles/min.
113
What is non-reassuring variability in CRT
Absent varibility
114
What is considered low variability?
Under or 5bpm
115
What is considered moderate variability?
6-25 bpm (reassuring)
116
What is considered marked variability?
Over 25bpm. Can be ass. w fetal hypoxia
117
What is accelerations?
A periodic increase in FHR of 15 bpm, sustained at least 15 sec. Always reassuring.
118
What is decelerations?
Is a drop in FHR >15bpm w onset to nadir >30 sec duration.
119
What is early decelerations?
Inconsequential. Coincide w contractions. Ass w head compression
120
What is variable decelerations?
Decelerations variable in relation to contraction. Abrupt. Are ass. w cord compression (mild/15-40 to moderate/40-60) or acidosis (severe/>60bpm). Non-reassuring when severe.
121
What is late decelerations?
Decelerations beginning after contraction, more gradual. Ass. w. uteroplacental insufficiency. Always non-reassuring!
122
What is the pathophysiology of late decelerations?
1) Uteroplacental oxygen delivery to fetus decreased- marked fetal anemia - myocardial depression - deceleration
2) Decreased oxygen delivery to fetus- hypoxemia- chemoreceptor - sympathetic center - alpha adrenergic HT - baroreceptor - parasympathetic (vagal tone)
123
What are the pathophysiology of early deceleration?
Head compression - vagal stimulation - parasympathetic drive - deceleration
124
What do we want on CTG?
- Normal baseline FHR 110-160
- Accelerations 15 x 15
- Moderate variability
- No decelerations or want to have early deceleration
125
What do we fear to see on CTG?
- Severe, persistent TC/BC
- Absent variability
- Severe variable or late decelerations
126
What are the non-reassuring features on CTG?
- Fetal bradycardia
- Loss of variability
- Repetitive late decelerations or severe variable deceleration
127
How to Mx non-reassuring fetal heart pattern?
- Consider non-hypoxic cause (anesthesia/meds)
- Intrauterine resus procedure: D/C oxytocin, high flow oxygen, facemask, change in position from supine, vaginal exam, scalp stimuli
- Re-assess EFM strip
- Consider fetal scalp pH assessment
- Prepare for prompt delivery if normalization does not occur
128
What is PUBS?
Percutaneous umbilical blood sampling. Performed by needle transabdominally into the uterus and phlebotomizing the umbilical cord. Used for fetal Hct (esp w Rh isoimmunization), fetal anemia, hydrops. May be used for fetal transfusion, karyotyping and assessment of fetal plt in alloimmune thrombocytopenia.
129
When is RhoGAM adviced to be given
Given to Rh-minus mothers in 3rd tm
130
How do you assess the fetal lung maturity?
- Amniotic fluid sample w amniocentesis. Lecithin to sphingomyelin (L/S) ratio , as lecitin increase with lung maturity and sphingomyelin decrease beyond 32w
- Other: Phosphatidylglycerol (PG), saturated phosphatidyl choline (SPC), presence of lamellar body count, surfactant to albumin ratio (S/A)
131
What is PROM
Premature rupture of membranes, in 10%
132
What is prolonged PROM
Rupture of membranes before 18hrs prior to labor
133
how to confirm dx of PROM
Gush of fluid leaking from vagina. Confirmed by pool, nitrazine and fern test. Oligohydramnios.
134
What is bishop score?
Cervical examination that determines if pat is in labor, and how it is progressing. It consist of dilation, effacement /length(%), fetal station (ischial spines), cervical position and cosistency of cervix.
135
What are the dilations of cervix
0-10cm. 10cm is fully dilated.
136
What is vertex position
head first, also called cephalic
137
what is breech
Buttom first, og legs. Complete= flexed, frank breech= feet in face, footling breech=extended (stand on cervix)
138
What is compund presentation
More than one presenting part eg vertex + arm
139
What are common reasons for induction of labor
postterm, preeclampsia, DM, non-reassuring fetal CTg, and IUGR
140
Which agents are used to ripen the cervix?
PGE2 gel/pessary or PGE1M/misoprostol
141
What are CI for ripening agents?
Asthma and glaucoma. Prior c-section. Non-reassuring fetal testing.
142
What can be used if CI to ripening agents
30cc or 60cc Foley bulb. 2-3cm within 4-6hrs
143
What are the contractions defining labor
Every 5min lasting 30 sec accompanied by cervical change
144
Amniotomy
Amnio hook to pucture amniotic sac
145
When is fetal scalp ph non-reassuring?
Indeterminant when 7,25-7,20. If under 7,2o is non-reassuring
146
What defines stage 1 of labor?
Closed to full dilation
147
What are the parts of stage 1 labor?
- Latent: closed to 3-4cm, prima <20t , multi<14t
| - Active:3-4cm to full dilation. Cardinal movements begin to occur. Prima <5-6h, multi<4-5t
148
What defines stage 2 of labor
From full dilation to delivery of baby. Prima<2hr, multi<1t
149
What defines stage 3 of labor?
Delivery of fetus to delivery of placenta. 30 min
150
What defines stage 4 of labor
The 2 hrs following delivery
151
What are the cardinal movements of labor
1. Engagement: enter pelvis OT
2. Descent: fetal part descends in pelvis OT
3. Flexion: Smallest diameter of fetal head presents OT
4. Internal rotation: from transverse to ant/post position OA
5. Extension
6. External rotation
152
What are indication and CI for episiotomy?
Is an incision made in the perineum to facilitate delivery. Indication: need for hasten delivery or ongoing shoulder dystocia.
Relative CI: There will be large perineal damage
153
What types of episiotomy are there?
Median: midline, most common
Mediolateral: oblique at 5 or 7 o clock. More pain and wound infections.
154
What are complications of forceps?
Bruising on face and head, lacerations on head, cervix, vagina and perineum. Facial nerve palsy, skull fracture, ICH
155
What are the complications with vacuum delivery?
Scalp laceration and cephalohematoma, subgaleal hemorrhage (EM)
156
What are maternal-fetal indication for c-section
- Cephalopelvic disproportion
| - Failed induction of labor
157
Maternal indication for c-section
- Active genital herpes
- Untreatet HIV(elevated viral load)
- Cervical cancer
- Prior c-section or full-thickness myomectomy
- Prior uterine rupture
- Obstruction to birth canal: fibroids, ovarian tumor
158
Fetal indications for c-section
- Non-reassuring fetal testing: BC, absence og variability, scalp pH <7,20
- Cord collapse
- Malpresentation: breech, transverse lie, brow
- multiple gest: nonvertex first twin, higher order multiples
- Fetal anomaly: hydrocephalus, osteogenesis imperfecta
159
Placental indications for c-section
- Placenta previa
- Vasa previa
- Abruptio placenta
160
What are 1st degree tear
Superficial, the mucosa
161
What is 2nd degree tear
Into body of perineum, not anal sphincter
162
3rd dergree tear
Into anal sphincter
163
4th degree tear
Into rectum
