Fetal heart tones can be detected by:
10 - 12 weeks
When is the fundus at the symphysis pubis?
Where is the fundus at 20 weeks?
at the umbilicus
What are Leopold maneuvers? when are they possible?
systematic palpation to determine fetal positioning possible after 20 weeks
During which trimester is fetal movement typically felt?
What is lightening and when does it typically occur?
lightening is when the baby settles lower into the pelvis usually 2-4 weeks before labor
What weeks are the second trimester?
14 to 26 weeks
What are two indications for amniocentesis?
family history of chromosomal abnormalities
advanced maternal age
When is amniocentesis typically performed?
15 - 20 weeks
When is triple or quad screen (aka multiple marker test) performed?
15 - 20 weeks
What tests are included with triple or quad screens?
What types of disorders are the triple/quad screen looking for?
chromosomal abnormalies and neural tube defects
When is the ORAL GLUCOSE TOLERANCE TEST typically performed? When might it be performed early?
28 weeks (which is early in the 3rd trimester)
can be done at 20 weeks if family history of diabetes or in obese mother ( > 200 pounds)
When is RhoGAM given?
When is hgb/hct measured?
28-36 weeks depending on previous levels
When is an elevated alpha-fetoprotein NOT a concern?
In multiple births, an elevated value is expected.
What weeks are the every-two-week visits?
28 to 36 weeks
prior the visits are every 4 weeks
after the visits are every week
How is the due date calculated?
Naegele's rule LMP - 3 months + 7 days =
Typical bleeding in ectopic pregnancy?
dark brown to tarry
What named SIGN may be found in ectopic pregnancy?
Hegar's sign softening of cervico-uterine junction
What four diagnostic tests are performed by the NP in ectopic pregnancy and what is the motivation?
Preparing for surgery
Where do 95% of ectopic pregnancies occur?
the fallopian tubes
Approximately what percentage of pregnancies will result in spontaneous abortion (miscarriage)?
What is the cause of the majority of losses in the first trimester?
random chromosomal abnormalities
What are some causes of fetal loss in the second trimester? (3)
o cervical incompetence
o uterine abnormalities
Fetal age of viability
Medications used for medical abortion
o mifepristone (blocks progesterone)
o misoprostol (prostaglandin that relaxes uterus)
What is another use for misoprostol?
it is used to prevent NSAID related ulcers (it is a prostaglandin)
What is the definition of PREGNANCY INDUCED HYPERTENSION?
BP > 140/90
OR systolic rise > 30 mm/Hg or diastolic rise > 15 mm/Hg
at least 2 readings, a minimum of 6 hours apart
What are the five risk factors for PREGNANCY INDUCED HYPERTENSION?
o youngest and oldest moms
o newest and most experienced moms (1st, 5th+)
o personal or family history of PIH, HTN, renal, CV
o autoimmune (like lupus)
How is a patient with PIH monitored for progression to HELLP syndrome?
Liver Function Tests
How is a patient with PIH monitored for progression to pre-eclampsia?
24 urine for protein
Why might an ultrasound be done on a patient with PIH?
to monitor for lag in fetal growth as a result of PIH
If rest at home is unsuccessful in patient with PIH, and condition worsens, what bedrest position will be used?
left lateral recumbent
What is a common initial sign of PRE-ECLAMPSIA?
sudden weight gain - can't get rings OFF or shoes ON
PIH + PROTEINURIA + generalized EDEMA after 20 weeks gestation
Parameters for weight gain in PRE-ECLAMPSIA
greater than 2 lbs / wk or 6 lbs / mo
What effect does pre-eclampsia have on DTRs and what is the significance?
WNL progressing to 3-4+ this indicates a pre-seizure state (which would signal progression to eclampsia)
What are four means of monitoring the health of the baby in PRE-ECLAMPSIA?
- weekly non-stress tests
- biophysical profile
- kick counts
- ultrasound - fetal growth and placental condition
What may be given to stimulate lung maturity as maternal condition worsens? Up to what gestational age? How many doses?
B-methasone x 2 doses given to those under 34 weeks gestation
PIH + Pre-eclampsia + SEIZURE
What three prodromal symptoms may occur before seizure in ECLAMPSIA?
- severe, unrelenting headache
- vision changes
- worsening RUQ or epigastric pain
What is the usual blood pressure in ECLAMPSIA?
consistently 160/90 (stage 2 HTN)
What is the anticipated testing for eclampsia?
systems of concern? (3)
specific tests (6)
Examination of liver, coagulation, and kidney status:
- LFTs with full chem profile
- coagulation profile
- 24 hour urine for protein
- creatinine clearance
- uric acid
What is used to "break" a seizure in a paitent with eclampsia?
second line: valium
What does HELLP stand for?
H EL LP
Liver enzymes &
What does a person with HELLP sydrome look like?
"a person with liver failure that might bleed.. and that's exactly what they are."
Signs and symptoms of HELLP (4)
nausea, maybe vomiting
What are typical LFTs in HELLP?
normal AST and ALT = 35 - 40
in HELLP, will be in the 100s
Which is PAINFUL -
previa or abruption?
Abruption is painFUL
Previa is painLESS
When does previa often occur?
Late second, early third trimester
Often after intercourse
Increased incidence of previa is seen in patients with one or more of these three very uterine-focused factors:
- previous C section or previa
- malpresentation (breech or transverse)
How great is the risk to the fetus in placenta previa?
often little risk
except if bleeding is severe
or other cause of distress exists
What diagnostic and monitoring tools are used for placenta previa?
- external fetal monitor
- CBC if bleeding is continuous or severe
What is the vaginal management of placenta previa?
NO bimanual exam
Speculum only to determine extent of bleeding
Is hospitalization expected when bleeding from placenta previa?
How is the health of the fetus monitored during bleeding with placenta previa?
When does placental abruption usually occur?
second or third trimester
Is abruption an obstetrical emergency?
risks both to mother and fetus
including the risk of death
What syndrome might uncontrolled hemorrhage
caused by abruption result in?
disseminated intravascular coagulation (DIC)
What are four contributing factors to abruption?
think of the abruption picture
- cocaine, alcohol, cigarette use
- uterine tumor or structural abnormality
(think crack head with uterine tumor who gets hit in the belly...and already had HTN...how could she not have an abruption??)
Is placental abruption painful?
Is heavy, bright red bleeding always
apparent in placental abruption?
No, if it is concealed there may be
minimal to moderate bleeding
but then the uterus will be rigid
Is there usually fetal compromise
associated with abruption?
very much so
fetal heart tones may be absent
fetal death is very likely unless mom was already hospitalized at the time
Can an abruption be diagnosed by ultrasound alone?
What bloodwork would be ordered for placental abruption?
- coagulation profiles
preparing for surgery and transfusion
What is the time frame associated with premature labor?
21 - 36 weeks gestation
Risk factors for premature labor?
the long list that can result in premature labor
several in common with abruption risk factors
- history of preterm labor
- UTI / STD
- multiple gestation
- low income
- poor weight gain / poor nutrition
- cocaine, smoking
- uterine structural abnormalities
- cervical trauma
- adolescent or advanced maternal age (like PIH)
Are cervical changes associated with the contractions of premature labor?
diliation and/or effacement
What tocolytic therapy may be utilized in premature labor?
which is a beta agonist