Flashcards in Pregnancy Deck (155):
Abnormally high AFP can indicate ___?
Neural tube defect
Abnormally low AFP can indicated___?
abdominal wall defect
esophageal and duodenal atresia
renal and urinary tract anomalies
Abnormally low estriol can indicate___?
What is HCG?
hormone produced in the placenta
When do the levels in HCG rise?
4-16 weeks of pregnancy then gradually lessen
Abnormally high HCG can indicate____?
Where is estriole produced?
When is estriol detected in blood?
9th week of pregnancy
What does an abnormally low level of estriole indicate?
Where is Inhibin A produced?
fetus and placenta
Abnormally high inhibin A can indicated____
Abnormally low level of inhibin can indicate?
What are the Triple/Quadruple screen?
AFT,Estriol,Ihibin A hCG
What syndrome is indicated when hCG, estriol and AFP are all low?
When is NFTU done?
Nuchal fold translucency Ultrasound is done between 11-14 weeks gestation
If nuchal fold is thicker than normal can indicated
If NFTU is VERY HIGH? 99%?
congenital heart disease
When is CVS done?
When is amniocentesis done?
Why is amnio done in 30 weeks?
fetal lung maturity
Non Invasive Prenatal Testing-NIPT-when done?
after 9 weeks of pregnancy
What does NIPT screen for?
trisomy 13-patau syndrome
triplody and microdeletion
sex chromosome deletion
baby's rh blood type and gender
has very high specificity
When is glucose challenge done?
24-28 weeks-1 hr glucose results>135 mg/dl >3 hr GTT
When is Vaginal Group B strep done?
When is Hgb and Hct done?
initial, then 24-28 weeks. If anemic, every 4-6 weeks to evaluate for iron replacement
When are STI's tested?
initial, prior to EDC and wet mount as needed
What are presumptive-subjective signs of pregnancy?
perception of fetal movement
increased skin pigmentation
What are probably-objective pregnancy signs?
abdominal and uterine enlargement
Hegar's signs: softening of lower uterine segment palpate manual exam
Chadwicks signs-bluish discoloration of vaginal mucosa
Goodells signs-softening of cervix
Braxton Hicks contraction-4th month
Pregnancy test-HcG-blood or urine
What are positive signs of pregnancy?
Absolute confirmation of pregnancy
detection of fetal heartbeat
perception of fetal movement by examiner
visualition of fetus bu U/S
6 week sac by U/S
8 week fetal plate and cardiac activity by U/S
Chadwick, Hegar and Goodells signs-presumptive, probably or positive?
How often are visits from 28-37 weeks?
every two weeks
What is documented at every pregnancy visit?
weight, B/P, fundal height, FHT, fetal movement, urine for protein glucose and ketones and pregnancy problems, if any
Which vaccinations are contraindicated?
which vaccinations should be received during pregnancy?
Dtap and inactivated bacterial vaccines
What is Rubin's pregnancy task?
Two of the four tasks are directed toward the outer world during pregnancy on behalf of her child: ensuring safety and acceptance of her unborn child. The other two tasks are directed toward the formation of the maternal role and relationship: developing the capacity to give and binding‐in to the as yet unborn child.
what is ideal weight gain for pregnancy?
What is ideal weight gain for 1st trimester?
What is ideal for weight gain in second and 3rd trimester?
.8-1 lb weekly
how many calories over norm should be added during pregnancy?
How many calories should be added during breastfeeding?
how much calcium daily?
how much protein for pregnancy daily?
What is caffeine limit during pregnancy?
1200 mg-one 12 oz cup of coffee
how much folic acid daily?
30 mg daily
What are the warning signs to call provider about during 1st trimester?
abdominal pain, vaginal bleeding, passage of tissue, syncope
What is assessed during second second trimester
fetal movement quickening
when does quickening start?
what are the s/s of preterm labor?
infection, ischemia, unknown causes, abdominal pains
or cramping. low backache, change in vaginal discharge, diarrhea
pelvic pressure, contractions-or something not right
3rd trimester-what is done?
repeat VDRL ad Hgb, reevaluate antibody screen titer
Rh d immune globulin (RhoGam) to unsensitized Rh mother at 28 weeks
review s/s of alvor
perform cervical assessment
assess fetal lie and presentation during 36-40 weeks
Group B guidelines CDC 2020
PG w GBS bacteriuria, 10K colony forming units and women w previous affected infants receive intrapartum anbx prophylaxis and no need to be screened 3rd trimester
pg with asymptomatic gbs bacteriuria tx w 3-7 day course anbx to prevent pyelonephritis
al other pg women recto-vagina gbs screening 35-37 weeks
all women + for GBS should receive intrapartum prophylaxis at time of labor or PROM
1st line tx for GBS
Penicillin G 5 million followed by 2.5 million units every 4 hours until birth
What are the fetal well being tests?
BPP-biophysical profile-real time U/S +NST to assess
fetal heart rate
score is a total of possible 10
8-10 is normal
if less, abnormal and consider delivery
Contraction stress test-CST
What is reactive NST?
Non stress test is reactive and appropriate heart rate acceleration as opposed to non reactive NST which is an absence of appropriate heart rate acceleration of 40 minutes-add testing
What is a positive CST?
late decelerations following 50% or more of contractions deliver or do further testing
no late or variable decelerations-observe mother and fetus
late decelerations in <50% of contraction. repeat in 24 hours or do biophysical profile
What can be given for nausea?
B vitamin 10-25 mg po tid
if no relief, add dyoxylamine succinate-unisom 12.5 mg po qid or after meals only
wheat germ molasses, brewers yeast
if giving IV hydration, what do we add to normal saline/
100 MG THIAMINE TO FIRST IV LITER OF FLUIDS
therapeutics for constipation
citrucel 1 tbs in 8 oz water 1-3x daily
metamucil 1 tsp and same as above
fibercon 1-2 tabs and same as above
stool softener recommendations?
docusate sodium 50-100 mg 1 tab po daily or BID
senekot 1 tab @HS MOM
hi fiber-dried fruit, prune juice, whole grains
hot liquid, more liquids and exercise
what is pityalism?
PPI during pregnancy?
aciphex, nexium, or prevacid
h2 blockers during pregnancy?
What is PAPP-A test?
protein produced by the placenta in early pregnancy. Abnormal levels are associated with an increased risk for chromosome abnormality
uterine size at 12 weeks
fundus at symphysis pubis-orange
uterine size at 16
fundus midway between symphysis pubis and umbilicus-grapefruit
uterine size at 20 week
fundus at umbilicus-honey dew
uterine size over 20 weeks
abdominal measurement of fundal height
When does auscultation of FHT begin?
What is the difference between the tripe and quad screen?
Inhibin A added
When is ultrasound done during pregnancy?
Normal Hcg level when first pregnant?
What is RIA fir>
quantitative result of HCG with levels as low as 5mlu/ml tand doubles til it reaches 10000 mIU/mg
high AFP, and all other hormones are normal can indicated
open spina bifida
what is a threatened abortion
suggests miscarriage might take place before the 20th week of pregnancy
what are the s/s of threatened abortion?
vaginal bleeding with absent or minimal pain
closed, long cervix
positive pregnancy signs/symptoms
What is spontaneous abortion?
spontaneous expulsion of products of conception
What is a missed abortion?
when embryo or fetus has died, but a miscarriage has not yet occurred
The pregnancy is lost and the products did not leave the body
What is septic abortion?
when the lining of the uterus and any remaining products of conception become infected
occurs when the tissue from a missed or incomplete miscarriage becomes infected
the infection of the uterus carries risk of spreading the infection and is a grave risk to the life of the woman-septicemia
What is an inevitable abortion?
symptoms of miscarriage cannot be stopped and miscarriage will occur
vaginal bleeding-moderate to profuse with pain
cervical dilation and or effacement
symptoms of pregnancy may be decreased or absent
what is an incomplete abortion?
when only some of products of conception leave body
moderate to perfuse vaginal bleeding for several weeks
may pass tissue
painful uterine cramping, contractions
symptoms of pregnancy may be absent
what is complete abortion
all products of coception leave the body
PASSAGE OF TISSUE AND LARGE CLOTS
ABDOMINAL CRAMPING OR UTERINE CONTRACTIONS
Diagnostics of vaginal bleeding in 1st trimetester
transvaginal ultrsonography should detect a viable IUP hcg level over 3000
Transabdominal ultrasonography should visualize a viable IUP
cbc with diff and platelets
blood type/cross match, RH status
PT PTT, firinogen
Doppler U/S fetal heart tones?10-12 weeks
abdominal shoulder pain?
What is Kleihauer-Betke Test
Kleihauer–Betke ("KB") stain, Kleihauer test or Acid elution test, is a blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother's bloodstream.
What is abruptio placenta
Placental abruption is the separation of the placenta from the uterine lining. This condition usually occurs in the third trimester but can occur any time after the 20th week of pregnancy.
what are s/s of abruptio placenta?
sudden onset of dark red vaginal bleeding or no bleeding hypertonic uterus-rigid and tender
abdominal pain mild-severe
back pain maybe
check fetal heart tones
What is placenta previa?
a condition in which the placenta partially or wholly blocks the neck of the uterus, thus interfering with normal delivery of a baby.
s/s of placenta previa?
painless vaginal bleeding spotting to frank blood
gush of fluid-sudden vaginal bleeding
uterus is soft and non-tender
may have cramping or uterine conractions
check fetal heart tones
treatment for placenta previa
maternal positioning to avoid vena cava compression
vital signs, FHR and uterine activity
consult/refer to physician
contractions: may start mag sulvate iv
What is ectopic pregnancy
fertilized egg implants in the tissue outside of the uterus and the placenta, and the fetus begins to grow there
s/s of ectopic pregnancy
amenorrhea or irregular vaginal bleeding
unilateral or generalized pain
vertigo and syNcope possible
shoulder pain with irritation of phrenic nerve
lower back pain
hemodynamic changes in vital signs (SHOCK)
What are the findings in an abdominal exam for ectopic pregnancy?
masses:softness and tenderness
abdominal wall distention
What are the symptoms of a patient who has ectopic pregnancy?
sudden acute localized pain with signs of internal henorrhage-rupture of fallopian tube
palpate uterine size
pelvic: tender adnexa with palpable mass-positive cervical motion tenderness
Diagnostic tests for ectopic pregnancy
pregnancy test serum b hcg, serial tests
cbc, platelet, type and crossmatch, Rh, PTT
transvaginal U/S IU gestational sac with hCG at 1500MIU/ml
Transabdoinal U/S IU gestation sac with hCG at 6000 IU/ML
Doppler U/S for fetal heart tones>10-12 weeks
endometrial histology, laproscopy
Management of ectopic pregnancy
mild pain meds
repeat ultrasound as needed
What happens with serial hcg during ectopic pregnancy
rises slowly or plateaus
what happens with serial hcg with IUP
level doubles every 2.7 days
What happens with complete abortion serial hcg levels?
levels fall quickly
PIH-what are triad of symptoms
hypertension in 1st semester-U/S for gestational trophblastic disease (Molar pregnany-also known as hydatidiform mole — is a rare complication of pregnancy characterized by the abnormal growth of trophoblasts, the cells that normally develop into the placenta)
Proteinuria-urinary excretion of .3g protein or greater in 24 hour urine specimin
can include brisk DTR or clonus
What is the hallmark of PIH?
Generalized vascular endothelial damage
What is the increase of systolic mm hg and diastolic with PIH
30 mm hg systolic and 15 mm hg diastolic over baseline or BP at fist prenatal visit
in order to diagnose pre eclampsia what is blood pressure?
150/90 two separate visits 6 hours apart or bp greater or equal to 140/90 after 20 weeks gestation
What is eclapsia
convulsions in patient with preeclampsia
what is considered mild hypertension?
140/90 on two occasions 6 hours apart
1-2+ on dipstick on two specimins in absence of UTI or at least 300 mg of protein in a 24 hour urine sample
what are other symptoms of preeclapsia
headache unrelieved by alagescs
severe heart burn
nausea and vomiting
edema-generalized and sudden weight gain
visual disturbances-blurred vision, pailledema, vessel narrowing
deep tendon reflexes-clonus
Small fundal height for gestational age
oligohydraminosis a condition in pregnancy characterized by a deficiency of amniotic fluid. It is the opposite of polyhydramnios.
what is HELLP syndrome
severe hypertension-multiple organ involvement
s/s of hellp syndrome
elevated liver enzymes
what are symptoms?
abnormal coagulation profile
grand mal seizures
physical exam with hypertension? what to look for
Did patient gain more than 2 lbs per week?
inspect pedal, hand and facial edema
can she wear rings and shoes?
check fundal height
palpate abdomen for hepatosplenomegal, and RUQ tenderness
observe bilateral lower edema and pitting edema
percuss liver enlargement
perform neurologic exam-hyperreflexia
What are the diagnostic tests for pregnancy induced hypertension?
CBC, platelets, liver function tests, (ast/sgot/alt/sgpt/ldh)
coagulation studies, fibrinogen, PT, PTT
renal function tests (serum uric acid, serum albumin, serum creatinine, BUN, collect 24 hour urine-protein and creatinine clearance,
fetal evaluation, (NST AND BPP-BIWEEKLY)
u/s to rule out IUGR, oligohydraminios (Intrauterine growth restriction )
what is the classic triad of hypertension during pregnancy?
hypertension, edema, proteinuria
Can a pregnant patient take ACE ARBS or diuretics during pregnancy?
no because oftetrogenic effect
What does the ACOG recommend for previous preeclampsia pregnancy?
low dose aspirin, 81 mg
calcium supplementation if low calcium
hospitalization if client worsens
magnesium sulfate-seizure prphylaxis
monitor input and output
what is therapeutic mgso4 level?
what are the s/s of magnesium toxicity?
nausea, thirst, flushing, oliguria
depression of reflexes
calcium gluconate at bedside for magnesium toxicity
when does magnesium sulfate stop?
24 hours after delivery
What is first line antihypertensives for diastolic BP over 110mg?
hydralazine, or labetalol or nifedepine
What are contraindications in antihypertensive drugs and pregnant drugs with asthma?
what can enhance fetal lung maturity prior to delivery in patients with severe hypertension?
What are the cervical ripening agents?
prostaglandins or Misoprostol and/or oxytocin induction of of labor
What is the treatment for hypertensive disorder during pregnancy?
narcotics for severe headacht relief
NO DIAZEPAM for seizures r/t newborn thermoregulation problems
delivery is only cure
What is diabetes mellitus related to especially during pregnancy
older than 40 yo and overweight
peripheral insulin resistance\increased hepatic production of glucose
relative pancreatic insufficiency of insulin production
what is the white classification of diabetes in pregnancy?
-increase insulin resistant is r/t secretion of human placental lactogen and placental growth hormone
-using insulin prior to pregnancy may need to double their insulin requirements during pregnancy
-elevated levels of circulating estrogen, progesterone and rolactin may diminish peripheral sensitivity to insulin during pregnancy
What are complicating factors of pregnancy diabetes mellitus
increased body weight
increased fat deposition
higher caloric intake
diminished physical activity can decrease insulin sensitivity during a normal pregnancy
What are risk factors for gestational diabetes?
history of previous GD pregnancy
large for gestational age infant>4100 gm
BMI .28 kg\m2
25 years and older
family history of type 2 diabetes
preious unexplained fetal demise
polycystic ovarian syndrome
when should women be tested for gestational diabetes?
between 24-28 weeks
If hi risk, immediately and if normal retest at 24-28 weeks
what are some therapeutic strategies during pregnancy?
daily glucose monitoring
How is diagnosis of gestational diabetes made?
check page 12 for serum glucose results
Diabetes mellitus screening_measure plasma or serum glucose
-two step-1 hour 50 gm non fasting oral GTT
-130 mg/dl or> is 90% sensitivity
-140 mg/dl or > is 80% sensitivity
3 hour diagnostic 100 gm OGTT on another day after an overnight 8 hour fast
-3 hour gtt
3 day COH-LOADING DIET
- eat at least 150 g COH daily prior to the test date
NPO except water 10-12 hours prior to the test and until the test is complete
FBS is drawn first
100G GLUCOSE LOAD GIVEN
blood then drawn at 1 hour, 2 hours, 3 hours
what is the preferred hemoglobin a1c in pregnancy?
< 6 %
What is diagnostic criteria of gestational diabetes?
fasting equal or > 92 mg/dl
1 hour equal or >180
2 hour equal or > 153
3 hour equal or > 140 mg
what percentage of carbs should compromise less than daily caloric intakes for GD
less than 50%
how many servings of protein is recommended for gestational diabetes?
2-3 servings daily
What is the glucose monitoring level for fasting?
what is glucose monitoring 1 hour post prandial?
less or = to 130 mg/dL
what is glucose monitoring preferred for two hours post prandial?
What diabetes medications is safe and commonly used for GD
metformin and glyburide
what are guidelines for insulin therapy?
FBS > 95
1 HOUR post prandial BG >140
2 hour post prandial BG > 120
When does weekly BPP testing begin for GD (Gastrointestinal Pathogen Panel)
32-34 weeks depending on glucose control
when does NST startd for GD?
32 weeks depending on glucose control
how often is U/S done for GD?
What should practitioner evaluate at visit?
fetal growth, fetal weight, malformations,(polyhydramniosis a medical condition describing an excess of amniotic fluid in the amniotic sac. It is seen in about 1% of pregnancies. It is typically diagnosed when the amniotic fluid index (AFI) is greater than 24 cm.)
what are the fetal effects of GD?
- birth asphyxia dystocia, brachial plexus
-fracture of the clavicle and humerus
-increase need for forceps delivery and C/S
+develop neonatal hypoglycemia (glucose <40 mg/dL)
+respiratory distress syndrome, hypocalcemia and hyperbilirubinemia
+congenital malformation-seen in infants with mothers who had poor glycemic control at conception and throughout first trimester
+seen in type 1 and 11 diabetes?
ventricular and atrial septal defects
transposition of the great vessels
gi atresias, neural tube defects
urinary tract malformations
+association between 1st trimeter spontaneous abortions and DM
What is the problem with patient with GD and ph of pregnancy says mild alkalosis?
patient may still be in DKA with a pH of 7.4 or greater
pregnant patient can be hyperglycemis with a serum bG of only 200mg/dL
how to treat Diabetic ketoacidosis during pregnancy?
fluids and volume monitoring
fetal heart monitoring-may have uterine contractions but dont treat unless cervical dilation is evident
post partum treatment for GD
self monitor-FBS AND TWO HOUR POST PRANDIAL BS X 7 DAYS
evaluate for DM FBS> 120 mg/dL
2 hour post prandial BS> 160mg/dL
test at least every 3 years afterwards
when is eye exam done for GD?
prior to conception and during 1st trimester
how does pregnancy asthma present?
tight chest symptoms- worse at night
what will the NP find during physical assessment of pregnancy asthma?
high blood pressure
increased respiratory rate
chest: diminished breath sounds
wheezing, rhonchi, prolonged expiratory phase,
maybe utilizing accessory muscles
complications of asthma during pregnancy
hyperemesis, preeclampsia and hemorrhage
Diagnostic for pregnanyc asthma
leukocyte count with differential may show eosinphilia
Pulmonary function test-obstructige pattern
peak flow meter
TX for asthma during pregnancy
02 (paO2 level < 60 mm/hg or 95% O2 saturation)
give beta agonist-albuterol via nebulizer as needed
terbuline-2 inhalations every 4 ho urs up til 8 inhalations daily-if regular daily use, additional daily meds needed
Cromolyn-2 inhalations 4x daily
immunomodulators: singulair, xolair
oral predisone if all fail: 1 week of 40mg daily then 1-2 weeks tapering
what is the mainstay of treating exacerbations of asthma during pregnancy?
beta adrenergic agonists
How to treat moderate persistent asthma during pregnancy?
beta adrenergic agonist cobined with an inhaled anti inflammatory agent or inhaled corticosteroid is recommended