Obstetrics Flashcards
29% of exam, ~ 51 questions 1. A&P of Pregnancy 2. Prenatal Care 3. Assessment of Fetal Well Being 4. Medical & Obstetric Complications of Pregnancy (Evaluation, Diagnosis, Treatment, Referral, Counseling/Education) 5. Postpartum Care & Complications (600 cards)
1
Q
Define: gametogenesis
A
development of gametes: oogenesis or spermatogenesis
2
Q
Define: oogenesis
A
development of mature human ovum - haploid # of chromosomes
3
Q
Define: spermatogenesis
A
development of mature, functional spermatozoa - haploid # of chromosomes
4
Q
Define: meiosis
A
two successive cell divisions that yield cells/egg/sperm that have 1/2 the number of chromosomes of somatic cells
5
Q
Define: mitosis
A
somatic cell division in which the daughter cell contains the same number of chromosomes as the parent cell
6
Q
Define: haploid
A
23 chromosomes, i.e. 1/2 the number of chromosomes in a typical somatic cell (46)
7
Q
Define: fertilization
A
when the ovum and spermatazoa unite - occurs in fallopian tube usually within minutes or hours after ovulation. Typically occurs when intercourse occurs within 2 days of ovulation
8
Q
What is a zygote?
A
a diploid cell with 46 chromosomes that results when ovum is fertilized by spermatozoan
9
Q
What is a blastomere?
A
this is the product of mitotic cell division (cleavage) of the zygote wherein the daughter cells (blastomeres) have 46 chromosomes like the parent zygote.
10
Q
What is a morula?
A
the solid ball of 16 or so blastomeres that enters the uterine cavity ~3 days after fertilization
11
Q
What is a blastocyst?
A
this is when the morula has entered the uterus and fluid enters between blastomeres, converting the morula to a blastocyst. Inner cell mass @ one pole becomes embryo and the outer cell mass becomes the trophoblast.
12
Q
Embryo
A
Between fertilized ovum and fetus, exists from weeks 2-8
13
Q
Fetus
A
the developing conceptus after embryonic stage (i.e. after 8 weeks)
14
Q
Conceptus
A
all tissue products of conception: fetus/embryo, fetal membranes, placenta
15
Q
How does the blastocyst implant?
A
It adheres to the endometrial lining by eroding epithelial cells; trophoblasts burrow into endometrium; the blastocyst eventually becomes encased by the endometrium
16
Q
When/where (typically) does implantation occur?
A
6-7 days after fertilization
upper, posterior wall of uterus
17
Q
Implantation of the blastocyst provides…
A
maternal/embryonic physiological exchange until the placenta develops
18
Q
What is the chorion?
A
the outer membrane that early on is the outer wall of the blastocyst. it eventually gives rise to the chorionic villi
19
Q
What is the chorion frondosum?
A
outer chorion surface that has villi that contact the decidua basalis (the placental part of the chorion)
20
Q
What is the chorion laeve?
A
the smooth, nonvillous portion of the chorion
21
Q
What is the syncytiotrophoblast?
A
the outer layer of cells that cover the chorionic villi of the placenta and are in contact with the maternal blood or decidua
22
Q
What is the cytotrophoblast?
A
the thin inner layer of the trophoblast composed of cuboidal cells
23
Q
What is the decidua capsularias?
A
the part of the decidua that surrounds the chorionic sac.
24
Q
What is the decidua basalis?
A
the part of the decidua that unites with the chorion to form the placenta
25
What is the decidua parientalis (vera)?
the endometrium during pregnancy, except the site of the implanted blastocyst
26
What is the amnion?
the innermost fetal membrane that holds the fetus in amniotic fluid; by end of 3rd month it fuses with the chorion forming the amniochorionic sac (bag of waters)
27
What function does the placenta serve? (3)
fetal lungs, liver, kidneys until birth
28
6 anatomical components of the placenta
trophoblasts, chorionic villi, intervillous spaces, chorion, amnion, decidual plate
29
5 steroid hormones produced by trophoblasts
estradiol, estriol, progesterone, aldosterone, cortisol
30
How is blood flow to the placenta regulated?
maternal blood transverses the placenta randomly by entering the intervillous spaces, propelled by maternal arterial pressure
31
How are oxygen and glucose transported across the placenta?
facilitated diffusion
32
What are the anatomical components of the umbilical cord?
2 arteries carry fetal deoxygenated blood to the placenta
1 vein carries oxygenated blood from the placenta to the fetus
Wharton's jelly for protection
33
Typical umbilical cord measurements
0.8 - 2 cm in diameter
| length ranges from 30 - 100 cm, average is 55 cm
34
What is an extremely short cord associated with?
abruptio placenta and uterine inversion (rare)
35
What is an abnormally long cord associated with?
vascular occlusion by clots and true knots
36
What produces amniotic fluid before the 2nd trimester?
the amniotic epithelium
37
What produces and regulates amniotic fluid starting in the 2nd trimester?
fetus: swallowing, urinating, inspiring
38
Define: polyhydramnios
AFI >/= 24 cm or maximum vertical pocket >/= 8 cm
| excess of amniotic fluid
39
Incidence: polyhydramnios
1%
40
Etiology: polyhydramnios (7)
```
50-60% idiopathic
fetal anomaly
fetal infection
twin-to-twin transfusion syndrome
maternal diabetes
isoimmunization
multiple gestation
```
41
Risks: polyhydramnios (5)
```
fetal macrosomia
preterm labor
PPH
cord prolapse
erythroblastosis
```
42
Management: polyhydramnios
monitor w/ NST & BPP starting at 34 weeks
43
When is amniocentesis indicated for poly?
if AFI is >35 cm
44
Possible med tx for poly
indomethacin (thought to slow fluid production in utero...lungs/urine)
45
Define: oligohydramnios
AFI = 5 cm or max vert pocket < 2 cm
| low amniotic fluid
46
Fetal conditions associated with oligo (6)
```
chromosomal abnormalities
congenital abnormalities
growth restriction
demise
post dates
ruptured membranes or PROM
```
47
Placental conditions associated with oligo (2)
abruption
| twin-twin transfusion syndrome
48
Maternal conditions associated with oligo (5)
```
Uteroplacental insufficiency
hypertensive disorders
diabetes
drugs (ACE, prostaglandin synthesis inhibitors)
idiopathic
```
49
What could you do to treat oligo that results in repeated variable decels?
Amnioinfusion
50
When does organogenesis in the embryonic development phase begin?
3rd week after fertilization
51
How early can a serum and urine assay detect hCG?
as early as 1 week after conception
52
How long does organogenesis last in the embryonic development phase?
8 weeks after fertilization
53
What happens 4 weeks after fertilization?
heart partitioning
arm/leg buds
amnion unsheathes body stalk that becomes the umbilical cord
54
What happens 6 weeks after fertilization?
head larger than body
heart completely formed
finger/toes present
55
What happens by 8 weeks after fertilization?
All major organ systems are formed, aside from the lungs
56
When does fetal development begin?
8 weeks after fertilization (10 after LMP)
57
What happens @ 12 weeks?
uterus palpable at pubic symphysis
| fetus starts making spontaneous movements
58
What happens at 16 weeks?
sex determinable on US by experienced observers
59
What happens at 20 weeks?
fetus weighs 300 g
| weight now begins to increase linearly
60
What happens at 24 weeks?
fetus weighs 630 g
fat deposition begins
terminal sacs in the lungs are still not completely formed
61
What happens at 28 weeks?
fetus weighs 1000 g
papillary membrane has disappeared from the eyes
90% chance of survival with no abnormalities
62
What happens at 32 - 36 weeks?
fetus continues to increase in weight as more subQ fat accumulates
63
Mass and volume of normal nonpregnant uterus
70 g
| 10mL
64
@ 6 weeks, the uterus is...
soft, globular, asymmetric (Piskacek's sign)
65
@ 12 weeks, the uterus is..
8 - 10 cm
| rising out of pelvis
66
@ 14 weeks, the uterus is...
1/4 the way to the umbilicus
67
@ 16 weeks, the uterus is...
1/2 the way to the umbilicus
68
@ 20 weeks, the uterus is...
at the umbilicus
69
After 20 weeks, the number of cm from the pubic symphysis to the fundus is...
of weeks gestation, within 2 cm
70
Term pregnancy uterus mass and volume
1100 g
| 5 L
71
2 anatomical changes to the cervix during pregnancy
increased vascularity
| thick mucus plug forms
72
What is Hegar's sign?
softening of the isthmus of the cervix
73
What is Chadwick's sign?
bluish color of the cervix and vagina
74
What is Goodell's sign?
softening of the cervix
75
Biggest anatomic change for ovaries?
anovulation
| maybe produce relaxin
76
How long does the corpus luteum persist? What keeps it going?
until 12 weeks
| maintained by hCG
77
What role does the corpus luteum play?
secretes progesterone and maintains endometrium and pregnancy until placenta takes over
78
4 anatomical changes to vagina in pregnancy
Chadwick's sign
thickened mucosa
increased secretions
connective tissue loosening in preparation for birth
79
5 anatomical changes to breasts during pregnancy
increased size (mammary hyperplasia)
increased size and deepening pigmentation of areola
colostrum may be expressed after the first several months of pregnancy
Montgomery's follicles
increase in vascularity
80
4 pelvic types
anthrpoid
android (male)
gynecoid (female)
platypelloid (rare)
81
Pregnancy changes to mouth and pharynx (3)
gingivitis and bleeding of gums
increased salivation
epulis (gum swelling)
82
Pregnancy changes to esophagus (2) and biggest thing it causes
decreased lower esophageal sphincter and tone
widening of hiatus w/ decrease in tone
heartburn!
83
Pregnancy changes to stomach (3)
decreased gastric emptying time
incompetence of pyloric sphincter
decreased gastric acidity and histamine output
84
Pregnancy changes to intestines (3)
decreased tone/motility
altered enzymatic transport across villi = increased absorption of vitamins
displacement of intestines, cecum and appendix by growing uterus
85
Pregnancy changes to gallbladder (1)
decreased tone/motility
86
Pregnancy changes to liver (1)
altered production of liver enzymes, plasma proteins, and serum lipids
87
Why are pregnant people more susceptible to UTI?
because of the dilation of renal calyces, pelvis and ureters
88
What happens to the bladder during pregnancy?
tone is decreased
89
What happens to renal blood flow during pregnancy?
increases 35 - 60%
90
What happens to the renal threshold for glucose, water-soluable vitamins, calcium, and hydrogen ions during pregnancy?
decreases
91
What happens to GFR during pregnancy?
increases 40 - 50%
92
What happens to the RAAS during pregnancy? What does this result in?
All components increase, causing retained sodium and water, resistance to pressor effect, and maintenance of normal BP
93
What role do relaxin and progesterone play on the MSK system during pregnancy?
they affect cartilage and connective tissue resulting in
- the loosening of sacroiliac joint and symphysis pubis
- the 'characteristic gait' of pregnancy
94
How else does pregnancy affect the MSK system?
lordosis
95
What happens to the diaphragm during pregnancy?
Rises 4 cm because of uterine size increase
96
What happens to thoracic circumference during pregnancy and residual volume during pregnancy?
circumference increases by 5-6 cm and volume decreases
97
What occurs because of decreased PCO2 during pregnancy?
mild respiratory alkalosis
98
Nasal changes during pregnancy?
congestion!
99
RR, TV, minute ventilatory and minute oxygen uptake changes during pregnancy?
RR remains the same, but all others increase
100
What do some pregnant people experience as a result of increased TV and lower PCO2?
dyspnea
101
How does blood volume change in pregnancy?
increases 30 - 50%
102
how does plasma volume change in pregnancy? what does this cause?
plasma volume expands leading to physiologic anemia
103
Average Hgb of pregnancy?
12.5
104
T/F some women require iron supplements during pregnancy
True
105
why is pregnancy considered a hypercoagulable state?
Fibrinogen (factor 1) and factors 7-10 increase
106
How is cardiac volume affected in pregnancy?
increases by 10%, peaks at 20 weeks
107
How does resting HR change during pregnancy?
increases by 10-15bpm and peaks at 28 weeks
108
Where is the slight cardiac shift?
up and to the left because of growing uterus
109
What percent of pregnant women develop this heart sound?
90%
| systolic heart murmur
110
What other heart sounds are possible during pregnancy? (3)
exaggerated S1 split, audible S3, soft transient diastolic murmur
111
How does cardiac output change during pregnancy?
increased!
112
How does BP change during pregnancy? Why?
diastolic BP lower in first 2 trimesters
peripheral tone is relaxed by progesterone
new vascular beds are developed
both of these decrease resistance
113
Tell me 8 integumentary vascular changes that occur during pregnancy.
palmar erythema, spider angiomas, varicose veins/hemorrhoids, hyperpigmentation, chloasma/ freckles/nevi/recent scars darken, linea nigra, increased sweat/sebaceous activity, striae gravidarum
114
How does pregnancy affect hair growth?
estrogen can increase the length of growth phase of fair follicles
can also see some mild hirsutism early on
115
What are two pituitary endocrine changes during pregnancy?
prolactin 10x as high at term
| pituitary gland doubles in size
116
Which thyroid hormone(s) cross(es) the placenta?
Thyroid-stimulating immunoglobulins and TRH
117
Which thyroid hormone does not cross the placenta?
TSH
118
What happens to thyroxin-binding globulin (TBG) during pregnancy?
increases because of estrogen
119
What happens to the size of the thyroid gland?
increases ~13%
120
What happens to the adrenal glands in pregnancy?
twofold increase in serum cortisol
| size stays the same but the zona fasiculata increases
121
What 2 pancreatic changes do we see in pregnancy?
hypertrophy and hyperplasia of B cells
| insulin resistance as a result of placental hormones
122
weight gain for BMI < 18.5 during pregnancy
28 - 40 pounds
123
weight gain for BMI 18.5 - 24.9 during pregnancy
25 - 35 pounds
124
weight gain for BMI 25 - 29.9 during pregnancy
15 - 25 pounds
125
weight gain for BMI > 30 during pregnancy
11 - 20 pounds
126
How is protein metabolism altered in pregnancy?
increases
127
How do fat deposit and storage change during pregnancy?
increased to prepare for breast feeding
128
How does carb metabolism change during pregnancy?
blood glucose levels are 10 - 20% lower
129
First trimester maternal psych alterations (1 -13 weeks)
focus is on physical changes and feelings
ambivalence
adjustment
130
Second trimester maternal psych alterations (14 - 26 weeks)
focus on fetus as a person
acceptance
period of radiant health
131
Third trimester maternal psych alterations (first part 27 - 36 weeks)
focus on baby's needs
introversion
period of watchful waiting
132
9 subjective presumptive signs of pregnancy
amenorrhea, n/v, urinary frequency/nocturia, fatigue, breast tenderness/tingling/enlargement/color changes, vasomotor symptoms, skin changes, congestion of vaginal mucus, maternal belief of pregnancy
133
5 objective presumptive signs of pregnancy
continued elevated basal body temp, Chadwick's sign, Montgomery's tubercles or follicles, expression of colostrum, breast changes
134
10 probable signs of pregnancy
enlargement of abdomen, enlargement of uterus, palpation of the fettal outline, ballottment, changtes in uterine shape, Piskacek's sign, Hegar's sign, Goodell's sign, palpation of Braxton Hicks contractions, + pregnancy test
135
3 positive signs of pregnancy
FHTs (fetoscope 18-20 weeks or doppler as early as 10 weeks), sonogram, palpation of fetal movement
136
4 differential diagnoses
pregnancy, leiomyoma, ovarian cyst, pseudocyesis
137
What is Naegele's rule?
take the first day of the LMP, subtract 3 months, add 7 days and then add 1 year
138
When does quickening occur? what is it?
maternal perception of fetal movement
usually occurs 18 - 20 weeks for primaparas
14 -18 weeks for multigravidas
139
5 types of measurements that are helpful in determining GA
crown rump lenght, biparietal diameter, head circumference, abdominal circumference, femur length
140
how accurate is CRL in first trimester?
within 3 - 5 days
141
how accurate is BPD and FL in second trimester?
within 7 - 10 days
142
how accurate is BPD and FL in third trimester?
all measurements less accurate after 26 weeks
| within 14 - 21 days
143
define: fertility rate
live births/1000 females ages 15 - 44 years
144
define: birth rate
births/total population in the given year(s)
145
define: live birth
the birth of an infant showing any signs of life (spontaneous breathing, beating heart, pulsation of the cord, movement of voluntary muscles) no matter gestational age
146
define: neonatal period
28 completed days after birth
147
define: perinatal period
from the end of 22 weeks to 7 days after birth
OR
births weighing 500 g or more and ending 28 completed days after birth
148
define: fetal death
spontaneous intrauterine death of a fetus at any time during the pregnancy
149
define stillbirth:
fetal death at 20 weeks or more
150
define: stillbirth rate
ratio of fetal deaths divided by the sum of births (including live births and fetal deaths in any given year)
151
define neonatal death
early neonatal death is death during first 7 days after birth
late neonatal death is during first 7 to 28 days after birth
152
define: neonatal mortality rate
the number of neonates dying before reaching 28 days of age per 1000 live births in a given year
153
define: perinatal mortality
number of stillbirths and deaths in the first week of life
154
define perinatal mortality rate
number of stillbirths and perinatal deaths (first week of life) per 1000 total births
155
define: infant mortality
death of an infant in the first 12 months
156
define infant mortality rate
number of infant deaths in the first 12 months per 1000 live births
157
define: maternal morbidity
illness or disease associated with childbearing
158
define: maternal mortality ratio
number of maternal deaths that result from the reproductive process per 100,000 live births
159
define:abortus
fetus or embryo removed or expelled from the uterus during the first half of gestation (20 weeks or less) weighing less than 500 g
160
define: late preterm infant
34 0/7 - 36 6/7
161
define early term infant
37 0/7 - 38 6/7
162
define term infant
infant born after 37 completed weeks gestation up until 42 completed weeks gestation
163
define: post-term infant
infant born anytime after completion of 42nd week gestation
164
define: direct maternal death
death of the mother resulting from obstetric complications of pregnancy, labor, or the puerperium and from interventions, omissions, incorrect treatment, or a chain of events resulting from any of these factors
165
define: gravida
of times a patient has been pregnant regardless of outcome
166
define: para
number of pregnancies carried to 20th week or beyond OR delivery of an infant weighing more than 500 g
167
define: nulligravida
never pregnant
168
define nullipara
never carried pregnancy to 20 weeks or 500 g
169
define primigravida
patient who is pregnant for the first time
170
define primipara
patient who has carried a pregnancy past the 20th week or who is currently pregnant for the firwstw time and is carrying past the 20th week
171
define multigravida
patient who has been pregnant 2 or more times
172
define multipara
patient who has carried 2 or more pregnancies past the 20th week of gestation or who has delivered an infant weighing more than 500 g more than once
173
define grand multipara
patient who has given birth 7 times or more
174
define TPAL
term >/= 37 weeks or 2500 g
premature 20 - 36 6/7; 500 - 2499 g
abortions < 20 weeks and 500 g
living children
175
how do we measure fundal height
in cm from pubic symphysis to fundus
176
what are Leopold's maneuvers and what do they tell us?
4 abdominal palpation maneuvers that tell us the lie, presentation, position, attitude, variety (?) and estimated fetal weight
177
Components of lab testing at initial prenatal visit (18)
```
1 blood type
2 Rh factor
3 antibody screen
4 CBC
5 RPR or VDRL
6 rubella titer
7 hep B surface antigen (HBsAg)
8 urine culture/screen
9 HIV (option to decline)
10 GC
11 CT
12 wet mount
13 TSH
14 Hgb A1C
15 Pap
16 PPD skin test
17 Hgb electrophoresis
18 genetic screening
```
178
what are the two main types of prenatal genetic tests?
screening and diagnostic
179
screening tests tell us...
risk for certain genetic disorders
180
diagnostic tests tell us...
confirmatory information using cells from the fetus or placenta
181
what are the two types of prenatal screening tests?
```
carrier screening (mom or dad gets serologic or tissue testing to see if they are carriers)
prenatal genetic screening (serologic testing combined with USG performed during pregnancy to screen for aneuploidy, spine and brain defects
```
182
when is first-trimester screening performed?
between 10 and 13 weeks
183
what is involved with 1st trimester screening?
serologic testing for PAPP-A (pregnancy-associated plasma protein) and hCG, US to measure nuchal translucency. mother's age
used to calculate risk for trisomies 18 and 21
184
when is second trimester screening performed?
between 15 and 22 weeks
185
what is involved with 2nd trimester screening?
quad screening
serologic blood test to detect NTDs and trisomies 18 and 21
serologic testing looking at MSFAP, estriol, inhibin Am and hCG
can also do US 18 - 20 weeks to ID anatomic fetal defects
186
what is cell-free DNA testing?
can be performed as early as 10 weeks
| serologic testing of mother's blood for aneuploidu (trisomies 13, 18, 21)
187
what would follow a positive result from cell-free DNA testing?
possibly CVS or amniocentesis to diagnose
188
when should we screen for gestation DM?
24 - 28 weeks
189
if a patient is Rh-, what follows?
repeat antibody screen at 26 - 28 weeks
190
can repeat which labs in third trimester if indicated by history, exam findings, risk factors?
CBC/crit, RPR/VDRL, CT/GC, HIV, hep B
191
when do we screen for group B strep?
35 - 37 weeks
192
how frequently should prenatal visits occur?
Q4weeks up to 28 or 32 weeks
then until 36 weeks, Q2weeks
from 36 weeks to 41 weeks, weekly visit
193
genetic risk factors for pregnancy (4)
age >/=35
previous chromosomal abnormality
fam hx of birth defects or mental retardation
ethic/racial origins (african SS, Med/east asian B thalassemia, Jewish tay sachs)
194
other risks factors for pregnancy (4)
multiple pregnancy losses/previous stillbirth
psych/mental health disorders
history of IUGR
preterm birth(s)
195
11 risks factors for current pregnancy
```
abnormal multiple marker screening
exposure to possible teratogens
IUGR
oligo/poly
diabetes
HTN
multiple gestation
PROM
postdates
decreased fetal movement
Rh isoimmunization
```
196
4 types of possible teratogen exposure during preganncy
radiation
alcohol/meds/substances
occupational exposures
infections
197
7 risk increasing infections during pregnancy
toxo, rubella, CMV, herpes, HIV, syph, Zika
198
CDP (common discomforts of pregnancy): incidence of N/V
50% of pregnant women are affected, 25% affected by nausea only, 25% unaffected; 1st trimester
199
when should patients start taking a prenatal vitamin before trying to conceive?
3 months prior - can help reduce need for tx for N/V
200
what are some nutrition adjustments to manage N/V during pregnancy?
eat small, frequent meals Q1-2 hours
avoid spicy/fatty foods
eat protein
bland/dry foods before getting out of bed
201
other adjustments (non-food) for N/V?
```
avoid triggers (odors)
stop prenatal and iron, but continue folic acid until resolution
acupuncture/pressure (?)
```
202
3 comfort measures for breast tenderness during pregnancy
supportive bra
careful intercourse
reassurance that it will pass
203
possible differentials to consider when a pregnant patient presents with backache (5)
strain, sciatica, sacroiliac joint problem, preterm labor, UTI
204
interventions for backache related to pregnancy (9)
massage, ice/heat, hydrotherapy, pelvic rock, counseling on good body mechanics, pillow in lumbar area when sitting or between legs when laying on side, pregnancy support/girdle, supportive bra, supportive low-heeled shoes
205
what could you suggest for sacroiliac joint problems in a pregnant patient with backache?
appropriate exercises, nonelastic sacroiliac belt, trochanteric belt worn below abdomen at femoral heads to increase stability
206
interventions for fatigue related to pregnancy (6)
reassurance that it will pass (normal in 1st trimester)
mild exercise
good nutrition
planned rest periods
decrease activities
less fluid before bed to decrease nocturia
207
non-pharm/supplement interventions for heartburn during pregnancy? (3)
small, frequent meals
less fluid with meals - drink fluids in between meals
elevate head of bed 10 - 30 degrees
208
pharm/supplement interventions for heartburn during pregnancy (4)
papaya, slippery elm bark throat lozenges, antacids, PPIs and H2 blockers (preg cat B)
209
interventions for constipation during pregnancy (4)
increased fluids and fiber, prune juice or warm beverage in the morning, encourage exercise, stool softeners
210
interventions for hemorrhoids during pregnancy (7)
avoid constipation/BM straining, elevate hips with pillow or knee-chest position, sitz baths, witch hazel or epsom salt compress, reinsert hemorrhoid with lubed finger, Kegels, topical anesthetics (Preg cat C if combined with steroid)
211
interventions for varicosities related to pregnancy (4)
support stockings to be worn before getting out of bed
avoid restrictive clothing
perineal pad if vaginal varicosities
rest periods with elevated legs, avoid crossing legs
212
interventions for leg cramps related to pregnancy (7)
decrease phosphate (no more than 2 glasses of milk/day)
massage
no pointing toes - flex ankle to stretch calf
keep legs warm
walk, exercise
Ca tablets
Mg tablets
213
interventions for presyncopal episodes during pregnancy (3)
change positions slowly, push fluids and encourage regular caloric/glucose intake, avoid lying flat on back and avoid prolonged standing/sitting
214
important to do what when a pregnant patient presents with headache?
rule out migraine or other pathologic causes of headache
215
interventions for headaches in pregnancy (10)
massage, acupressure, hot/cold compress, rest, good sleep hygiene, warm baths, meditation/biofeedback, aromatherapy, smaller/more frequent meals, mild analgesic
216
important to do what when a pregnant patient presents with leukorrhea?
r/o vaginitis, STI
217
interventions for leukorrhea during pregnancy? (4)
good perineal hygiene, cotton undies and change frequently, unscented pantyliners, avoid douching and sprays
218
important to do what when a pregnant patient presents with urinary frequency?
r/o UTI
219
interventions for urinary frequency?
decrease fluids in evening to avoid nocturia
| avoid caffeine
220
interventions for insomnia?
warm bath
hot drink - warm milk, chamomile tea
quiet/relaxing activities
avoid daytime naps
221
important to do what when a pregnant patient presents with round ligament pain?
r/o other abdominal pain causes like appendicitis, ovarian cyst, placental separation, inguinal hernia
222
interventions for round ligament pain (6)
warm/ice compress, hydrotherapy, avoid sudden or twisting movement, flex knees to abdomen/pelvic tilt, support uterus with pillow when lying down, maternity abdominal support/girdle
223
interventions for skin rash
ice, oatmeal bath, diphenhydramine 25 mg Q4 hrs PRN, derm referral PRN
224
interventions for carpal tunnel syndrome
good posture, lying down, rest/elevate affected hand(s), ice/wrist splints, mild analgesic
225
what is the recommended daily caloric intake during pregnancy?
2500
226
what is the recommended daily protein intake during pregnancy?
60 g
227
underweight BMI recommended weight gain during pregnancy?
28-40#
228
normal BMI recommended weight gain during pregnancy?
25-35#
229
overweight BMI recommended weight gain during pregnancy?
15-25#
230
obese BMI recommended weight gain during pregnancy?
11-20#
231
risk factors associated with low gestational weight gain (5)
low fam income, black race, young age, unmarried, low education
232
low gestational weight gain is associated with...
growth-restricted infants
| fetal and infant mortality
233
high gestational weight gain is associated with...
```
large infant weight which can cause:
fetopelvic disproportion
operative delivery
birth trauma
asphyxia
PPH
mortality
```
234
what replaced the FDA risk factor category labelling on medications?
the PLLR which gives a more comprehensive narrative/description (pregnancy and lactation labeling final rule)
235
what were the previous FDA risk factor categories for meds during pregnancy?
```
A - safe (folic acid, levothyroxine)
B - probably safe, Zofran, amoxacillin
C - not great, sertraline, fluconazole
D - risky, phenytoin, lithium
X - contraindicated!!!! methotrexate, warfarin
```
236
are live vaccines considered safe during pregnancy?
nope
237
when can you give a live vaccine in relation to pregnancy?
4 weeks prior or during the PP period
238
which two specific vaccines are contraindicated during pregnancy?
Varicella and Rubella
239
Which vaccine is recommended every pregnancy?
Tdap
240
Which vaccine is recommended for high-risk patients who are antigen and antibody negative?
Hep B
241
Which vaccine is possibly indicated for maternal trauma?
Tetanus
242
Which vaccine is recommended during flu season?
TIV (the inactivated influenza vaccine)
243
When is amniocentesis typically performed, and why?
usually 14 -1 6 weeks for genetic evaluation or to assess NTDs
244
why might amniocentesis be used later in pregnancy?
assessing lung maturity, r/o amnionitis or fetal hemolytic disease
245
risks associated with amniocentesis (5)
infection, bleeding, preterm labor, PROM, fetal loss
246
what is a special precaution that needs to be taken with amniocentesis?
if the patient is Rh- and at risk for isoimmunization, you gotta give RhoGAM with the procedure
247
What is CVS and what is it used for?
sampling of the chorionic villi from the placenta (outer trophoblastic layer has the same genetic make up as the fetus) to look at genetic stuff
248
when is CVS typically performed?
between 10 and 13 weeks
249
risks with CVS (3)
infection, bleeding, miscarriage
250
can you do CVS in the case of maternal blood group sensitization?
nope, contraindicated
251
What is a nonstress test?
it's when we can look at fetal well-being by watching the FHR response to fetal movement
252
Why might an NST be indicated?
```
decreased fetal movement
post-term
DM
HTN
IUGR
```
253
What is a reactive NST result?
2+ accels of 15 or more bpm lasting 15 or more seconds within a 15 -20 min period for > 32 weeks
2+ accels of 10 or more bpm lasting 10 or more seconds within a 15 - 20 min period for 28 - 32 weeks
254
What is a nonreactive NST result?
Criteria unmet within 40 minutes; need further eval (could be repeat, BPP, or CST)
255
What is an inconclusive/unsatisfactory NST result?
can't tell, gotta repeat
256
what are 5 factors that can affect an NST result?
fetal sleep, smoking within 30 minutes before test, maternal intake of medications, fetal central nervous system anomalies, fetal hypoxia or acidosis
257
What is AFV?
amniotic fluid volume measurements
258
Expected range for single deepest pocket in an AFV measurement?
2 - 8 cm
259
What is AFI?
a way to measure AFV wherein you divide the uterus into 4 quads and and measure deepest verticle pocket in each and then sum them
normal is 5 - 24 cm
260
What are the five components of a BPP?
```
NST
muscle tone
breathing movements
gross body movements
AFV
```
261
how does BPP scoring work?
```
each variable gets a score from 0 (abnormal) to 2 (normal)
total it
8 - 10 = normal
6 is equivocal (repeat)
4 or less is abnormal
```
262
what do you need to see in each category within what timeframe?
```
30 minutes (after NST)
breathing = 1 or more episode(s)
body movement = 3 or more discrete movements
tone = 1 or more episodes of extension with return to flexion
AFV = 1 or more pocket >2 cm
NST = reactive
```
263
maternal effects related to consuming alcohol while pregnant (6)
```
preeclampsia
placental abruption
placenta previa
spontaneous abortion
ectopic pregnancy
PROM
```
264
infant effects related to maternal consumption of alcohol while pregnant (4)
FASD (fetal alcohol spectrum disorders): physical, behavioral, intellectual disabilities that last a lifetime
also: low birth weight/growth
heart, kidney problems
brain damage
265
What are two screening tools we can use for alcohol misuse?
CAGE & TWEAK
266
What does the CAGE screening tool stand for?
ever felt the need to Cut down on drinking?
ever been Annoyed by people criticizing your drinking?
ever felt Guilty about drinking?
ever had drink first thing in the AM (eye opener?)
267
What does the TWEAK screening tool stand for?
```
Tolerance
Worried
Eye-openers
Amnesia
Cut down
```
268
Risks associated with nicotine use during pregnancy?
higher stillbirth risk
maternal: preeclampsia, placental abruption, placental previa, SA, ectopic, PROM
infant effects: IUGR, premature birth, small for GA
269
OB complications associated with drug use
```
NAS
birth defects
low birth weigh
premature birth
small head circumference
SIDS
```
270
Symptoms of NAS
up to 14 days after birth
blotchy skin, diarrhea, CRYING, abnormal suckling reflex, fever, hyperactive reflexes, increased muscle tone, irritability, poor feeding, rapid breathing, seizures, sleep problem, slow weight gain, nasal congestion and sneezing, sweating, trembling, vomiting
271
What are the most common infections during pregnancy associated with congenital disease?
```
TORCH infx:
Toxoplasmosis
Other (syph, varicella-zoster, parvovirus B19)
Rubella
CMV
Herpes
```
272
How to prevent Toxo
```
cook meat to 145 and poultry to 160
no unpasteurized milk or cheese
avoid kitty litter
avoid untreated water
good handwashing or glove use when gardening
```
273
Preventing Varicella-Zoster (Herpes virus)
vaccinate 4 weeks prior to conception or PP
| VZIG for exposure
274
Preventing fifth disease (parvovirus)
handwashing, avoid contact with sick people, avoid touching mouth/eyes/nose
275
Prevention of rubella
vaccinate preconception or PP
276
which is the most common congenital infection?
CMV
277
CMV infant mortality rate?
30%
278
Prevention of CMV
handwashing, avoid contact with sick people, avoid touching mouth/eyes/nose
279
what type of HIV screening occurs for pregnant patients?
opt-out screening
280
biggest predictor for vertical transmission of HIV?
viral load
281
when would a c be indicated for a patient with HIV?
if viral load is > 1000; C at 38 weeks
282
is breastfeeding okay for a patient with HIV?
not recommended
283
Prevention for Zika?
avoid travel to areas with Zika
condom use for anyone with Zika or possibly exposed
protect against mosquito bites
284
types of IUGR
symmetric and asymmetric
285
when does symmetric IUGR occur?
early in pregnancy
286
what can cause symmetric IUGR? (3)
congenital infection
chromosomal abnormality
maternal drug use
287
when does asymmetric IUGR occur?
later in pregnancy
288
what are the 2 main etiologic pathways of asymmetrical IUGR?
reduced nutrition to fetus
| abnormal uteroplacental perfusion (head-sparing appearance)
289
maternal causes of asymmetric IUGR (4)
HTN, anemia, collagen disease, insulin-dependent DM
290
placental causes of asymmetric IUGR (4)
previa, abruption, malformations, infarctions
291
fetal causes of asymmetric IUGR (2)
multiple gestation, anomalies
292
definition of macrosomia
> 4000 g at birth or more than 90th percentile in weight for GA
293
dizygotic twins
2 separate ova fertilized by 2 separate sperm
294
monozygotic twins
splitting of a single fertilized egg
295
when do dichorionic diamniotic twins split?
days 0 - 3
296
when do monochorionic diamniotic twins split?
days 4 - 8
297
when do monochorionic monoamniotic twins split?
days 9 - 12
298
what happens after day 13 to MZ twins that haven't split?
conjoined twins
299
what is the definition of a postdates pregnancy?
pregnancy that continues beyond 42 weeks gestation
300
complications associated with postdates pregnancy
```
shoulder dystocia (macrosomia)
oligohydramnios
uteroplacental insufficiency
neonatal meconium aspiration
stillbirth
```
301
what do we begin at 41 weeks for possible postdates management?
biweekly NST/AFI or BPP
302
expectant management and delivery for postdates
```
consider induction when cervix is ripe
prostaglandins to promote cervical ripening
inducing labor
deliver if fetal compromise or oligo
possible meconium staining of fluid
```
303
antepartum management of obesity in pregnancy (5)
```
US 18 - 24 weeks to detect anomalies and soft markers for aneuploidy
US Q 4-6 weeks to monitor fetal growth
weekly NSTs starting at 32 weeks
prior OSA needs specialty evaluation
early GDM screening with GTT
```
304
postpartum management of obesity in pregnancy
higher risk for VTE (meds a
| nd non-pharm interventions)
305
define: hyperemesis graviadrum
persistent vomiting during pregnancy without another cause
306
incidence of HG
0.3 - 3% of pregnancies
307
theoretical considerations for etiology (3)
```
hCG correlation (peak of hCG often coinceds with severe symptoms
estrogen correlation (lower levels of estrogen associated with lower incidence of n/v in pregnancy
evolutionary adaptation to avoid certain foods that could be dangerous
```
308
risk factors for HG (4)
hx of HG in previous pregnancy, fam hx of HG, motion sickness, migraines
309
typical dx criteria for HG (4)
severe/intractable vomiting with unknown etiology
weight loss of at least 5% ofpre-pregnancy weight
ketonuria
electrolyte imbalance (thyroid/liver lab abnormalities)
310
what is the assessment tool we use for n/v during pregnancy? and what does it ask about? (3)
PUQE
length of nausea symptoms during a given day
# of times vomiting during a given day
# of times retching/dry heaving during a given day
311
what are the score break downs for the PUQE assessment tool
mild =6
moderate 7-12
severe >/=13
312
nonpharm options for HG (7)
```
multivitamins
frequent small meals
avoid spicy or fatty foods
bland foods before getting out of bed
avoiding triggering odors or other stimuli
ginger 1 g per day divided doses
acupressure/acupuncture
```
313
pharm options for HG (5)
```
Pyridoxine (B6) 10 - 25 mg QUID/TID PO
Diclegis (pyridoxine + doxylamine 10mg/10mg PO) for moderate 2 tabs before bed, for severe 4 tabs (morning, afternoon, 2 before bed)
metoclopramide 5 - 10 mg Q6-8h PO
Promethazine 25 mg Q4h rectal supp
Zofran (sketchy)
```
314
if HG unresponsive to medical therapy or weight unmaintainable, what could we do?
enteral tube feeds
315
if liquids intolerable and outpatient treatment not working for HG, what could we do?
hospitalize for IV rehydration, antiemetic therapy and nutritional support
316
define 1st trimester bleeding
bleeding that occurs within the first 12 weeks of pregnancy
317
differentials for 1st trimester bleeding (9)
implantation bleeding, threatened abortion, ectopic pregnancy, cervicitis, cervical polyps, vaginitis, trauma/intercourse, disappearing twin, autoantibody/autoimmune disorder
318
When is serum hCG positive after fertilization?
8 - 9 days
319
how does beta hCG increase with a normal pregnancy?
doubles every 2 days
320
according to the rule of 10, what is beta hCG at missed period? at 10 weeks? at term?
100, 100,000, 10,000
321
90% of ectopic pregnancies have less than ____ beta hCG?
6500
322
define spontaneous abortion
occurs without apparent cause
323
define threatened abortion
signs/symptoms of possible loss of fetus
324
define inevitable abortion
cervix is dilating and the uterus will be emptied
325
define incomplete abortion
part of the products of conception are retained in the uterus
326
define complete abortion
all products of conception have been expelled
327
define missed abortion
fetus died prior to 20 weeks, but contents were retained for 2 or more weeks
328
define recurrent pregnancy loss
3 or more consecutive abortions
329
etiology of abortion?
fetal chromosomal abnormalitiy (common)
| maternal parity, short interpregnancy interval, maternal/paternal age
330
when should an IUP be visualized transabdominally? transvaginally?
hCG 6500, 2000
331
in general, how do we manage abortion?
blood type, baseline beta hCG and repeat in 48 hrs, US, RhoGAM for unsensitized Rh- patients
332
options for managing an inevitable or incomplete abortion?
D & C (surgical or chemical)
expectant management
emotional support/anticipatory guidance
333
options for managing a threatened abortion or disappearing twin?
pelvic rest
| emotional support/anticipatory guidance
334
define ectopic pregnancy
implantation of the blastocyst anywhere other than the endometrium
335
risk factors for ectopic pregnancy (7)
STI, therapeutic abortion followed by infection, endometriosis, previous pelvic surgery, failed bilateral tubal, scarring of tubes, hormonal alteration of tubal motility/menstural reflux (functional)
336
symptoms of ectopic pregnancy (3)
amenorrhea with frequent vaginal spotting
lower pelvic/abdominal pain (unilateral)
unilateral tender adnexal mass
337
components of the clinical picture for an ectopic pregnancy (6)
```
severe abdominal pain
CMT
free fluid on US
cul-de-sac fullness
should pain s/t diaphragmatic irritation
vertigo/fainting
```
338
how to manage an ectopic pregnancy?
transfer to medical management (goal is to preserve the tube)
methotrexate
RhoGAM for Rh- patients
339
how does hydatiform mole or trophoblastic disease manifest? (6)
```
AUB
size/dates discrepancy
lack of fetal activity
HG
gestation HTN
passage of vesicular tissue
```
340
management of mole?
evacuate the uterus by suction curettage
close surveillance for persistent trophoblastic proliferation or malignant changes
rec avoid pregnancy for 1 year
serial beta hCG levels Q2 weeks until normal, then once a month for 6 mos, then Q2mos for 1 year
341
possible causes of mid-trimester SA (4)
autoimmune, cocaine, anatomic/physiologic factors, infection of cervix/vagina
342
symptoms of cervical insufficiency (4)
painless dilation, bloody show, spontaneous ROM, vaginal/pelvic pressure
343
risk factors for cervical insufficiency (3)
previous mid-trimester loss, cervical surgery, DES
344
treatment for cervical insufficiency
consultation
cerclage after 12 - 14 weeks
monitor cervical length with TV US
345
risks of cerclage
ROM and infection
346
incidence of low-lying placenta in 1st trimester
1/3
347
what are the three locations for placental abruption?
subchorionic (between placenta and membranes)
retroplacental (between placenta and myometrium, worse prognosis)
preplacental (between placenta and amniotic fluid)
348
what is predictive of fetal survival in association with abruption?
the size of the hemorrhage
349
when should you NEVER perform a digital vaginal exam on a pregnant patient?
3rd trimester bleeding UNLESS you know for sure there is no placenta previa
350
what is placenta previa?
when the placenta is located over or next to the internal oss
351
what are the degrees of previa?
partial, marginal, complete
352
risk factors for previa (3)
multiparity
previous C or uterine surgery
smoking
353
PRIMARY symptom of placenta previa?
PAINLESS vaginal bleeding
354
secondary symptom of previa?
unengaged fetal presentation and/or malpresentation
355
management of complete previa
medical management and C
356
management of partial, marginal previa?
observant until delivery
hospitalize if bleeding
possible tocolytic therapy
possible to deliver vaginally, will need immediate access to C
357
what is placental abruption?
the premature sepaation of the placenta from the uterus (can be partial or complete)
358
risk factors for abruption (6)
HTN, trauma, smoking, cocaine, multiparity, uterine anomalies or tumors
359
symptoms of abruption (4)
vaginal bleeding
uterine tenderness and rigidity
contractions or uterine irritability/tone
fetal tachy or brady
360
complications from abruption (3)
DIC
shock
fetal compromise/death
361
management of abruption (4)
COLLAB
monitor clotting studies and crit/hgb, platelets
stabilize mother
delivery as indicated by fetal or maternal condition
362
what is placenta accreta?
when the placenta invades the myometrium of the uterine wall
363
risk factors for accreta (6)
```
AMA
previous C
multiparity
prior uterine surgery
Asherman's
previa
```
364
symptoms of accreta?
often none
| sometimes vaginal bleeding
365
management of accreta
COLLAB
early dx
delivery where hemorrhage can be managed
366
possible risks/effects of epilepsy for a pregnant patient (8)
```
increase in seizure frequency and severity
increase in maternal mortality
preeclampsia
preterm labor
stillbirth
increased risk of C
increased risk of miscarriage
PPH
```
367
possible risks to fetus of epilepsy during pregnancy (2)
growth restriction/LBW
| birth defects because of medication
368
how do we manage epilepsy in pregnancy?
med therapy is key but not always effective (mono is best if possible)
adjust dose bc pharmokinetic metabolism changes in pregnancy
it's helpful to know/monitor prior to pregnancy (9-12 mos w/o seizures is promising)
don't use valproate
folic acid!!!
369
definition/range of thrombocytopenia?
low platelets, usually <150
370
managing thrombocytopenia?
draw platelets at each prenatal visit and 1-3 months PP
| consider consult if warranted
371
managing idiopathic thrombocytopenic purpura (ITP)?
corticosteroids and IV immunoglobulins may be required
372
is GERD common in pregnancy?
you bet, 40 - 80% of pregnancies are affected
373
what is GERD?
the movement of gastric contents into the esophagus
374
what causes GERD in pregnancy?
estrogen and progesterone impact the lower esophageal sphincter
enlarging uterus too
all of this increases thoracic pressure
375
risk factors for GERD in pregnancy (4)
certain foods/beverages
medications
overeating or eating quickly
lying down after eating
376
2 important differentials for GERD in pregnancy?
HELLP and preeclampsia
377
symptoms of GERD (4)
burning/pain
sleep disturbance
n/v
cough/hoarseness
378
med management of GERD (3)
Mg hydroxide or trisilicate
Histamine-2 receptor agaonists (ranitidine)
avoid sodium carbonate antacids
379
important symptoms associated with GERD to report despite medication (5)
```
interrupted sleep
difficulty swallowing
weight loss
blood in sputum/vomit
black stools
```
380
what are the physical and anatomical changes associated with pregnancy that increase VTE risk? (5)
```
hypercoaguability
increased venous stasis
decreased venous outflow
compression of the vena cava & pelvic veins from enlarging uterus
decreased maternal mobility
```
381
types of VTE
DVT most common
| PE (starts as DVT and moves to lungs)
382
risk factors for VTE (15)
```
pregnancy/PP
hx/fam hx of VTE
inheritied thrombophilia
sickle cell
autoimmune disorders
DM
HTN/preeclampsia
heart disease
BMI > 30
AMA
varicose veins
smoking
multiple gestation
C
hospitalization
```
383
effects of VTE (5) both maternal and fetal
```
recurrent thrombosis
ulceration
post-thrombotic syndrom
maternal death
fetal compromise or death
```
384
how to medically manage VTE (tx or prophylaxis)
HEPARIN no warfarin
385
what are the two main types of fetal malpresentation?
breech and shoulder
386
what are the types and descriptions of breech position?
Breech - buttocks in the lower pole
Frank = legs extended up over abdomen and chest
Complete = legs are flexed at hips and knees
Footling = one or both feet or knees are lowermost
387
etiology for breech (5)
```
uterine septum
fetal anomaly
fetal attitude
previa
conditions that result in abnormal fetal movement or muscle tone
```
388
risks associated with breech (3)
labor dystocia, cord prolapse, fetal head entrapment
389
management options for breech (4)
external cephalic version
moxibustion
C?
webster maneuvers
390
criteria for external cephalic version
normal AFI
reactive NST
EFW 2500 - 4000 g
391
can a should presentation with transverse lie be a candidate for a vaginal birth?
No
392
etiology of shoulder presentation (4)
multiparity
previa
poly
uterine anomalies
393
management of shoulder presentation
similar to breech - ECV, moxi, C?, webster
394
define: chronic htn
bp over 140/90 diagnosed before pregnany, before 20 weeks, or after 12 weeks pp
395
define: GHTN
new-onset high BP after 20 weeks gestation without proteinuria
396
define: chronic HTN with superimposed preeclampsia
1) chronic htn with new onset proteinura at more than 300 mg in 24 hrs but no proteinuria before 20 weeks
OR
2) a sudden increase in proteinuria or BP or a platelet count of less than 100.000 in women with htn and proteinuria before 20 weeks
397
define: preeclampsia
pregnancy-specific htn disorder associated with headaches, visual disturbances, epigastric pain, rapid edema development
dx: 2 BP measurements that are >/= 140/90 on 2 separate occasions at least 4 hrs apart after 20 weeks gestation
OR
BP over 160/100 a previousl normotensive woman and proteinuria >/= 300 per 24 hr urine or protein/creatinie ratio >/= 0.3
OR
outside of other quantitiative measures, dipstick 2+
OR
without proteinuria, new onset HTN with new onset:
<100,000 platelets
serum creatinie >1.1 or doubled w/o renal disease
doubling of normal liver enzymes
pulmonary edema
cerebral or visual symptoms
398
what is HELLP syndrome?
hemolytic anemia
elevated liver enzymes
low platelet count
*can be ante or post partum
399
define: eclampsia
seizures that cannot be attributed to other causes in a woman with preeclampsia
400
maintenance goal for pregnant patient with preexisting htn on antihypertensive med(s)?
120/80-160/105
401
recommendation for pregnant patient with chronic hypertension and who is at great risk for adverse outcomes?
low-dose aspirin 60 - 80 mg, PO daily, starting in late first trimester
402
if a pt with chronic htn has no other maternal or fetal complications, when is delivery indicated?
not before 38 weeks
403
first choice antihypertensives for those who require them during pregnany?
labetolol, nifedipine, methyldopa
404
how to manage preeclampsia without severe features?
assessing maternal symptoms
daily fetal movement counts
2xweekly BP checks
weekly liver and platelet checks
405
additional rec for management of preeclampsia with severe features?
MgSO4 to prevent eclampsia is recommended in the intra/post partum period
406
8 risk factors for hypertensive disorders of pregnancy
```
nulliparity
adolescent or AMA
multiple gestation
fam hx of pree or eclampsia
obesity/insulin resistance
chronic htn
limited exposure to the father's sperm
antiphospholipid antibody syndrome/thrombophilia
```
407
7 theories as to the cause of hypertensive disorders of pregnancy
```
abnormal trophoblast invasion
coagulation abnormalities
vascular endothelial damage
cardiovascular maladaptation
immunologic phenomena
genetic predisposition
dietary deficiencies or excesses
```
408
antepartum management of hypertensive disorders of pregnancy
diet assessment
adequate fluids
mayyyybe restrict activities
monitor: BP. proteinuria, edema, weight, intake/output, DTRs, subjective symptoms
409
6 lab tests associated with hypertensive disorders of pregnancy
```
creatinine
Hgb/Hct
platelets
LFTs
24 hr urine
creatinine clearance
```
410
assessing the fetus in a patient with a hypertensive disorder of pregnancy
daily movement counts
NST
AFI/BPP
US to monitor growth
411
main goal of intra and postpartum management of hypertensive disorders of pregnancy?
prevent seizures
412
main anticonvulsant used during intra/postpartum hyptersensive management?
IV mag
413
side effects of MgSO4?
flushing, somnolence
414
MgSO4 overdose signs
loss of patellar reflex
muscular paralysis
respiratory arrest
aggravated by decreased UO bc mag is excreted by kidneys
415
antidote to Mag?
calcium gluconate
416
when BP exceeds 160/100 intra or postpartum, how do we manage?
IV labetolol or hydralazine OR IR PO nifedipine (if no IV access)
417
what BP drug reserved for resistant HTN?
Na nitroprusside
418
what is not recommended for hypertensive disorders of pregnancy?
diuretics bc we are already volume depleted
419
incidence of HELLP syndrome
10% of patients with preeclampsia with severe features
420
5 diagnostics for HELLP
```
hemolysis
abnormal peripheral blood smear
increased bili >/= 1.2
elevated liver enzymes (ALT, AST, LDH)
platelets less than 100,000
```
421
6 treatment/management pieces for HELLP
```
mag
bed rest
crystalloids
albumin 5 - 25%
delivery as indicated
plasma volume expansion
```
422
eclampsia is basically...
preeclampsia with seizures
423
how to manage eclampsia? (4)
mag
O2
safety
stabilize and deliver
424
prevention of pregnancy-induced HTN? (2)
vit d and calcium if at risk and low dietary intake
| low dose aspirin can be considered in high-risk pregnancy
425
define diabetes
endocrine disorder where you have abnormal carb metabolism resulting in inadequate production/utilization of insulin
426
incidence of diabetes in pregnancy?
7%...86% are GDM
427
what is the diabetogenic effect of pregnancy?
human placental lactogen acting like an insulin antagonist, and also maybe estrogen and progesterone acting the same way
428
what do we do w/ regards to DM in pregnancy at the FIRST prenatal visit?
risk assessment
429
12 high risk factors
```
overweight/obese
physical inactivity
hx of GDM
prior babe over 9# (LGA)
>25 years old
fam hx of T2DM
AA, hispanic, american indian, alaska native, native hawaiian or pacific islander
HTN and/or hx of CVD
high HDL and triglycerides
PCOS/other insulin resistance conditions
A1C > 5.7%
being treated for HIV
```
430
6 low risk factors
```
<25 years
normal weight prior to pregnancy
ethnic group of low dm prevalence
no DM in first degree relatives
no hx of abnormal glucose tolerance
no hx of poor obstetric outcome
```
431
when do we screen all pregnant women for DM, regardless of risk?
24-28 weeks
432
when should we screen for DM in high risk pregnant patients?
ASAP
433
describe the 2 step screening approach for DM
start with 1 hour 50 g glucose tolerance test
if 130 or more (or 140 or more..??), perform diagnostic 100 g 3 hr test on another day after 8 hours of fasting
need 2 or more abnormals on that test to dx
434
describe the 1 step screening approach for DM
```
75 g 2 hr test after 8 hrs fasting
measure fasting, 1, 2 hrs
you can dx if any one of these values is abnormal:
fasting >/=95
1 hr >/=180
2 hr >/= 155
```
435
what 6 risk factors, if at least 3 of which are present, increased maternal mortality?
```
uncontrolled hyperglycemia
ketonuria, n/v
GHTN, edema, proteinuria
pyelonephritis
lack of care compliance
AMA
```
436
main objective of managing diabetes?
strict glucose levels
437
how many cals/kilo of body weight/ideal body weight?
30
438
calorie breakdown percentages by meal for DM management
b-25
l-30
d-30
snack-15
439
sources of calories percentage breakdown
p-20
f-30-35
c-45-50
440
first line treatment of GMD and why?
insulin, doesn't cross placenta
441
possible alternative to insulin?
metformin but crosses placenta
442
how do insulin requirements change during pregnancy? why?
decreased need during first trimester
increased need during second trimester
linked to HPL levels
443
what are fetal risks associated with non-gestational diabetes?
NTDs and cardiac anomolies
444
what do we monitor on US in diabetes?
IUGR, macrosomia, polyhdramnios
445
what do we begin at 28 weeks in diabetes management?
FMCs
446
if nutritional adjustments and glucose monitoring are effective, what antenatal testing is indicated?
none
447
if DM is poorly controlled or medically managed, when do we begin antenatal testing? and what?
32 weeks, BPP & NST
448
what happens pp to insulin requirements?
usually decrease 24 - 48 hrs after placenta is delivered
449
screening postpartum for dm?
75 g 2 hr test 6-12 weeks pp
450
what are the 4 most common thyroid diseases in pregnancy?
non-toxic goiter
hyper and hypo
thyroiditis
451
how signficant is the impact of pregnancy on maternal thyroid physiology?
GREAT!!
452
why does the thyroid enlarge during pregnancy?
hyperplasia
| increased vascularity
453
are TSH and T4 affected during pregnancy?
no, no change
454
how do total serum thyroxine and triiodothyronine concnetrations change in pregnancy?
both increase
455
symptoms of throtoxicosis or hyperthyroidism in pregnancy?
tachy. thyromegaly, exophthalmos, failure to gain weight
456
how do we diagnose thyrotoxicosis or hyperthroidism in pregnancy?
elevated free T4, low TSH
457
risks for untreated thyroid problems during pregnancy? (5)
preeclampsia, stillbirth, IUGR, HF, preterm birth
458
treatment for thyroid probs during pregnancy?
thioamide drug: prophylthiouracil or methimazole
459
levels for Fe-deficiency anemia during pregnancy?
1st trim: Hgb < 11.0
2nd trim: Hgb < 10.5
3rd and PP: < 11.0
460
talk about the etioogy of iron deficiency anemia during pregnancy?
poor nutrition and a consequence of expanding blood volume without proper expansion of hgb
461
risks associated with iron-def anemia
LBW, premature delivery, perinatal mortality
462
how do we manage Fe-deficiency anemia?
correct hgb mass deficit and rebuild iron stores
iron replacement therapy with vit c and folic acid
3 mo iron therapy after anemia is corrected
463
what can cause anemia from acute blood loss during pregnancy? (7)
```
abortion
ectopic pregnancy
hydatiform mole
placenta previa
abruptio placenta
placenta implantation abnormalities
pp hemorrhage
```
464
etiology of megaloblastic anemia
usually folic acid deficiency
465
signs of megaloblastic anemia
n/v, anorexia
466
fetal risks of megaloblastic anemia
NTDs
467
prevention of megaloblastic anemia
folic acid 0.4mg daily normally
| 4 mg daily prior to and during pregnancy for women with a hx of previous infant with NTD
468
how to manage ss anemia in pregnancy?
fetal surveillance after 32-34 weeks
| monitor and manage pain crises
469
definition of post partum period?
6 weeks initially after delivery
470
reviewing patient history pp: 7 pertinent diagnostic tests to know about
```
blood type/Rh
rubella titer status
hep b status
HIV status
RPR
genetic testing
group b strep
```
471
PP assessment (normal vs abnormal): tired but happy
normal
472
PP assessment (normal vs abnormal): unhappy, dissatisfied
abnormal
473
PP assessment (normal vs abnormal): 98.6-100.4 degrees
normal
474
PP assessment (normal vs abnormal): temp greater than 100.4
abnormal, consider infx, PE
475
PP assessment (normal vs abnormal): pulse 65-80
normal
476
PP assessment (normal vs abnormal): pulse >80 or < 65
abnormal, consider infx, blood loss, PE
477
PP assessment (normal vs abnormal): RR 12-16
normal
478
PP assessment (normal vs abnormal): RR < 12
abnormal, consider OD narcotics, atelactesis, pneumonia
479
PP assessment (normal vs abnormal): RR >16
abnormal, consider anxiety, pain
480
is it normal for there to be a transient increase in BP after delivery?
yes, by 5% for up to 4 days
481
PP assessment (normal vs abnormal): BP > 140/90
abnormal, evaluate for pp hypertensive disorder
482
PP assessment (normal vs abnormal): BP < 90/60
abnorma, consider blood loss, med reaction
483
PP assessment (normal vs abnormal): A&O x 3
normal
484
PP assessment (normal vs abnormal): disoriented, excessive sedation
abnormal
485
PP assessment (normal vs abnormal): no chest pain, regular HR and rhythm
normal
486
PP assessment (normal vs abnormal): chest pain, tachy, palpitations
abnormal
487
PP assessment (normal vs abnormal): no SOB, clear lung fields, breathe w/o difficulty
normal
488
PP assessment (normal vs abnormal): SOB, adventitious breath sounds
abnormal
489
PP assessment (normal vs abnormal): sore nipples
normal
490
PP assessment (normal vs abnormal): colostrum and breast fullness for 3-5 days
normal
491
PP assessment (normal vs abnormal): painful, cracked, bruised, bleedings nipples
abnormal
492
PP assessment (normal vs abnormal): no breast filling by day 5
abnormal
493
PP assessment (normal vs abnormal): BM 2-3 PP
normal
494
PP assessment (normal vs abnormal): decreased abdominal muscle tone
normal
495
PP assessment (normal vs abnormal): diastasis recti
normal
496
PP assessment (normal vs abnormal): fundus is midline and firm
normal
497
PP assessment (normal vs abnormal): n/v, diarrhea, constipation, abdominal pain
abnormal
498
PP assessment (normal vs abnormal): distended abdomen
abnormal
499
PP assessment (normal vs abnormal): unable to palpate uterus
abnormal
500
PP assessment (normal vs abnormal): non-midline fundal height, height is increasing out of line of PP day
abnormal
501
PP assessment (normal vs abnormal): signs of infection on surgical scar, not well approximated
abnormal
502
PP assessment (normal vs abnormal): diuresis
normal
503
PP assessment (normal vs abnormal): burning, retention, incontinence, lack of sensation or urge to void
normal (first 2 days)
504
PP assessment (normal vs abnormal): dysuria, persistent retention/incontinence, bladder distention, CVA tenderness
abnormal
505
PP assessment (normal vs abnormal): mild erythema, bruising, edema of the perineum
normal
506
PP assessment (normal vs abnormal): worsening perineal symptoms
abnormal
507
PP assessment (normal vs abnormal): perineal hematoma
abnormal
508
PP assessment (normal vs abnormal): episiotomy/lac repair showing signs of separation
abnormal
509
PP assessment (normal vs abnormal): malodorous lochia or excessive amounts of lochia with clots
abnormal
510
PP assessment (normal vs abnormal): pink hemorrhoids
normal
511
PP assessment (normal vs abnormal): deep blue or purple hemorrhoids
abnormal
512
PP assessment (normal vs abnormal): sore muscles in lower extremeties
normal
513
PP assessment (normal vs abnormal): bilateral, symmetric edema of lower extremeties
normal
514
PP assessment (normal vs abnormal): unilateral leg pain
abnormal
515
PP assessment (normal vs abnormal): unilateral calf tenderness
abnormal
516
PP assessment (normal vs abnormal): one leg more edematous than the other
abnormal
517
what. isinvolution
the process of the uterus returning to th epre-pregnant state
518
3 steps of involution?
1) contraction of uterus
2) autolysis of myometrial cells
3) regeneration of the epithelium
519
is involution the result of a reduction in cell number or cell size?
CELL SIZE
520
how much the fundus descends each day
1 cm
521
what might a fundus that is not midline indicate?
subinvolution, probably because of a full bladder
522
where is the uterus immediately after delivery? what size is it?
1/2 way between the umbilicus and symphysis pubis and it is the size of a grapefruit
523
where is the uterus 12 hours post delivery?
@ level of umbilicus
524
by what time after delivery should the uterus/fundus not be able to be palpated?
2 weeks
525
what happens by 6 weeks post delivery to the uterus?
returns to slightly larger than pre-pregnant size
526
what are the 3 components of lochia?
eschar, decidual cells, myometrial placental bed
527
what are the 3 stages of lochia?
rubra, serosa, alba
528
when do we see rubra?
first 3-7 days
529
when do we see serosa?
day 14-21
530
when do we see alba?
until cessation of flow 4-6 weeks post partrum
531
color of rubra, serosa, alba?
red/red-brown
pinkish-brown
yellow/white
532
content of rubra?
decidua, lanugo, meconium, necrotic placental remains, cellular remains from vernix
533
content of serosa?
blood, mucus, erythrocytes, leukocytes, decidual tissues
534
when is colostrum produced?
upon birth, sometimes even in 3rd trimester
535
when does engorgement occur?
approx. 72 hours after birth
536
where does human milk production begin and then where does it go from there?
upper-outer glands, then fills medially and inferiorly
537
when does let-down reflex develop (milk ejection)?
first 1-2 weeks
538
3 positive reactions to childbearing?
achievement, empowerment/strength, new baby thrill
539
4 negative reactions associated with childbearing?
frustration with breastfeeding if challenging
disappointment if l/d didn't go as planned
body mistrust if birth was premature or birth process wasn't completed as hoped
loss for individual self
540
what is bonding?
mother to infant connection, it is affective/behavior/chemical
541
how can we facilitate bonding?
skin to skin immediately after delivery and avoiding separation in the early/immediate pp period
542
what is attachment?
mother to infant interaction (face to face, skin to skin) how mother responds to infant's needs
543
timeline for pp blues
within 3-5 days of birth up to 1-2 weeks pp
544
etiology of pp blues
profound shifts in hormones
545
pp depression timeline
occurs anytime within 4 weeks after childbirth or 3, 6, 8, 12 months after childbirth
546
symptoms of pp depression (5)
sleep disturbance, feeling overwhelmed, anxiety, irritability, unable to perform ADLs
547
one of the differences between pp blues and pp depression (progression)
blues usually improve
| depression symptoms do not improve over time...likely to worsen
548
how do we screen for PP depression
EPDS
549
what are other (4) things we should rule out with pp depression symptoms
pp thyroiditis
anemia
infection
sleep deprivation
550
prevalence of blues, depression, psychosis
up to 80%
6.5-12%
1-2/1000 births
551
dx pp depression
DSM 5 criteria
552
tx pp depresssion, 1st line
SSRIs, usually oaky with breast feeding
553
4 symptoms of pp psychosis
hallucinations (auditory/visual disturbances), disorganized thinking, bizarre speech/behavior, delusions
554
when is it typical for ovulation to return for a patient who is non-breast feeding?
around 39 days pp
555
typical recommendation for return to sexual activity?
pelvic rest for 4-6 weeks, many return to intercourse earlier than that.
556
how long do pregnant patients continue to be ina hypercoagulable state after delivery? why?
3-4 weeks, physiologic adaptive mechanism to prevent hemorrhage
557
what should be avoided during this 3-4 weeks of hypercoaguability after birth?
estrogen
558
impact of hormonal contraception on lactation is _____
contraversial
559
can a patient be fitted/use a cap/diaphgrahm right away after birth?
no, must wait until involution is complete
560
what are the 3 criteria for the lactation amenorrhea method to be used?
no menses
infant is < 6 mos
breastfeeding Q4hrs during the day, Q6hrs at night, no solid food subs yet
561
old guidelines for pp folllow-up?
6 weeks after delivery, now ACOG suggests sooner
562
if the patient is high risk, when do we follow-up pp?
1-2 weeks after delivery
563
you have a patient who plans to breastfeed, wants long acting reversible contraception as soon as possible, and just delivered the placenta < 10 minutes ago. what BC option is best?
Cu-IUD
564
you have a patient who does not plan to breastfeed, wants long acting reversible contraception as soon as possible, and just delivered the placenta < 10 minutes ago. what BC option is best?
LNG-IUD
565
absolute contraindication to any IUD?
post partum sepsis
566
absolute contraindication to COCs?
<21 days PP and either breastfeeding or not
567
how do we diagnose urinary retention post-partum? (4)
can't void spontaneous 6-8 hrs after birth or after removal of cath
residual > 150 ml
palpable bladder
fundus displaced/not midline
568
5 risk factors for PP urinary retention
```
epidural
operative vaginal delivery
episiotomy or lac
LGA
primiparity
```
569
how might we manage urinary retention?
cath, referral to urology
570
define pospartum fever/infection
>/= 100.4 x2 during pp days 2-10
571
3 differentials for pp fever (3 common, 3 less common)
```
endometritis
wound infection
UTI
transfusion reaction
drug raction
septic pelvic thrombophlebitis
```
572
gold standard tx choice for uterine infection/endometritis
clindamycin and gentamycin
| can add vanc if staph is suspected
573
what is the leading cause of maternal mortality worldwide?
PPH
574
PPH is defined as...(ACOG)
EBL 1000mL regardless of delivery route
| blood loss accompanied by signs/symptoms of hypovolemia within 24 hrs of birth
575
traditional definition of PPH
EBL 500 vaginal
| EBL 1000 c
576
8 risk factors for PPH
```
prolonged labor/prolonged use of oxytocin
chorioamnionitis
high parity
twins. multiple gestation
polyhydramnios
macrosomia
operative vaginal delivery
precipitous delivery
```
577
7 primary etiologies for PPH
```
uterine atony
obstetrical trauma
lacs
retained placenta
placenta accreta
coagulation defects
inversion of the uterus
```
578
what part of the breast supports the shape?
cooper's ligaments
579
how many milk ducts are in each breast? where do they converge?
4-18, at the nipple
580
describe a basic glandular unit
contains 4-18 lobules, each with alveoli responsible for milk ejection
581
which part of the breast is located in the areola and are sebaceous glands that provide protective secretion/lubrication to the nipple?
Montgomery tubercles
582
when does lactogenesis 1 occur?
early pregnancy to 3rd day postpartum
583
what occurs during lactogenesis 1?
small amounts of colostrum are secreted
| 100ml breastmilk produced on postpartum day 1
584
what is contained in the fluid produced during lactogenesis 1?
immunoglobulins, lactoferrin, oligosaccharides
585
when does lactogenesis. 2occur?
pp days 2-4
586
what is lactogenesis 2 initiated by? (3)
delivery of placenta
decrease in progestin
increase in prolactin
587
how much milk is produced during lactogenesis 2 on day 4
500 ml
588
which stage of milk production do patients typically refer to their milk coming in?
lactogenesis 2
589
when does lactogenesis 3 occur?
between days 7 and 14 pp
590
characterize lactogenesis 3 (4)
mature milk
maintenance of milk
supply-demand
591
discuss the supple-demand relationship with regards to lactation
suckling stimulates nipple/areola
hypothalamus receives message to secrete prolactin and oxytocin
prolactin stimulates milk production
oxytocin stimulates let-down (contraction of myoepithelial cells)
592
contraindications to breastfeeding (3)
maternal infection
illicit drug use
meds
593
maternal infections contraindicated for breast feeding (5)
HIV
herpes, active lesion on nipples and breasts
flu
untreated TB
varicella developed 5 days prior to birth to 2 days after delivery
594
medicaitons contraindicated for breastfeeding (6)
```
antiretrovirals
anticonvulsants
chemo
radiation
retinoids
statins
```
595
interventions (5) for breast engorgement?
```
acupuncture
hot/warm before feed, cold after
cabbage leaves
breast massage
hand expression
```
596
2 possible meds for insufficient milk supply?
domperidone
| metoclopramide
597
diagnostic criteria for mastitis (3)
erythematous/edematous wedge-shaped area in the breast, unilateral
fever >/= 101.3
flu-like symptoms
598
first line treatment for mastitis
dicloxacillin or flucloxacillin 500 mg PO QID x 10-14 days
cephalexin 500 mg QID X 10-14 days
clindamycin 300 mg QID or erthromycin 250 mg or 500 mg QID X 10-14 days if allergic to penicillin
599
what is abreast abcess?
a collection of pus in the breast, surrounded by inflammation
600
how do we diagnose and treat an abscess?
exam & US for dx
surgical drainage, needle aspiration
antibiotics
