Pregnancy Flashcards
(36 cards)
1
Q
Discuss the first symptoms and subsequent diagnosis of a pregnancy
A
Presentation - missed period - nausea, vomiting, bloating - food avrsion - breast enlargement and tenderness Investigations - urine bHCG - blood bHCG (normal is <5) - doubles every 36hrs in first 30 days of pregnancy
2
Q
Discuss the methods to estimate the due date of pregnancy
A
Gestational Age:
- 1st day of womens last menstrual period
Naegele’s rule:
- 1st day of last menstrual period, minus 3 months and add 7 days
Ultrasound
- done after 6 weeks with crown-rump length to determine age
3
Q
Discuss the risk factors for a complication in pregnancy
A
- Maternal age >35
- cardiac disease, hypertension
- diabetes
- thyroid disease
- anemia
- renal disease
- obesity or low body weight
- smoking or substance abuse
- multiple gestations
- grand multiparous
4
Q
List some of the complications associated with advanced maternal age
A
- early miscarriage
- chromosomal abnormality
- placental problem
- low birth weight
- pre-term delivery
- fetal death
- multiple gestations
- C-section
5
Q
Discuss some of the lifestyle changes required for pregnancy
A
- require extra 300 calories
- folic acid 1mg daily (if epileptic, insulin dependent, obese, or family history require 5mg daily for first 3 months before conception and then 1mg throughout)
- exercise 3-4 times per week
- live vaccines (MMVR, rotavirus) not recommended
6
Q
Discuss timing of prenatal visits throughout pregnancy
A
- Every 4weeks between 0-28 weeks
- Every 2 weeks between 28-36 weeks
- Every 1 week from 36 to delivery
7
Q
What is the fundal-symphysis height?
A
- uterus first palpbale at pubic symphysis at 12 weeks
- at umbilicus at 20 weeks
- from there should increase 1cm per week
8
Q
List the 1st trimester screening tests
A
- Done once before 12 weeks
- IPS
- ultrasound for dating (after 6 weeks)
- CBC for hemoglobin and MCV for anemia (possible electropheresis)
- Blood type and Rh screen
- rubella, HBsAg, VDRL, HIV, urine culture and sensitivity, gonorrheae and chlamydia screen
- PAP test
9
Q
List the 2nd trimester screening tests
A
- morphology ultrasound at 18-20 weeks
- gestational diabetes test with non-fasting 50g glucose load at 24-28 weeks
- if <7.8 then normal
- if 7.8-11 then 75g OGT test and measure fasting (>5.3), 1 hour (10.6) and 2 hour (9.0) post
- if >11.1 than positive
10
Q
List the 3rd trimester screening tests
A
- Group B streptococcus at 35-37 weeks
11
Q
Discuss the integrated prenatal screen
A
Two tests
- ultrasound to assess for nuchal translucency and low pregnancy associated plasma protein at 11-14 weeks to detect Down Syndrome
- maternal serum screening at 15-21 weeks for free beta HCG (high in T21), alpha fetoprotein (high in neural tube defects), and unconjugated estriol (low in T21 and T18
12
Q
Discuss when you would move to invasive screening
A
- positive prior screening test
- family history of genetic disease
- maternal age >40
- specific ultrasound finding to follow up
13
Q
Discuss a chorionic villous sampling
A
- done at 11-13 weeks from the plancetal villi (1% chance of miscarriage)
- test for genetic disorders
14
Q
Discuss amniocentesis
A
- done at 15-22 weeks (<1% risk of miscarriage)
- rapid aneuploidy in 1 week and conventional chromosome analysis in 2-3 weeks
15
Q
Discuss the placental circulation
A
- have 2 umbilical arteries where have exchange in the villi capillary (fetal blood) and the intervillous space (maternal blood)
- in maternal circulation there are spiral arteries in endometrium of uterus that drain into the intervillous space. Blood comes back through endometrial veins to the maternal circulation
16
Q
Discuss the various functions of the placenta: Respiration Endocrine Immunity Nutrition Protection
A
Respiration
- transport of oxygen by high concentration in maternal blood, greater affinity of fetal hemoglobin, and oxygen dissociation curve pushed to right in maternal blood
Endocrine
- placenta synthesize and metabolize bHCG, estrogen, progesterone, thyroid, lactogen, relaxin, inhibin, GnRH, cortisol
Immunity
- placenta does not produce tissue antigens (except for HLA-G)
Nutrition
- transport nutrients and glucose into fetus
- produce hPL to reduce insulin in maternal system so as to favor transport to fetus
Protection
- act as barrier to prevent toxins from crossing
17
Q
Discuss when the placenta should be examined following delivery
A
- maternal fever, bleeding, diabetes, hypertension or prior infertility
- placental anomaly
- fetal prematurity, growth restriction, congenital anomaly, poor APGAR score
18
Q
List points of examination of the placenta
A
Umbilical cord: - short or long umbilical cord - small diameter - color (yellow suggest infection) - insertion of cord into membrane or margin - number of vessels - vessel patency (thrombosis) Placental size - normal is 500g Fetal Surface of Placenta - chorion and amnion surface Maternal surface - completeness - color
19
Q
Discuss the ultrasound findings of the placenta
A
- can visualize placenta by 8 weeks, but usually not examined until morphological scan
Placental Thickness - normal is 2-4cm in 1st and 2nd trimester and then 4-5cm in 3rd trimester
- small placenta due to insufficiency
- thick placenta due to diabetes, anemia, hydrops, hemorrhage, infection, genetic syndrome
Placental Volume - normal is 16mL at 10 weeks and 200mL at 23 weeks
Placental Implantation - determines the adequacy of the implantation to the endometrium
- acreta (invasion to myometrium)
- increta (invasion penetrating myometrium)
- percreta (invasion through uterus)
20
Q
Discuss some placental anomalies discovered on ultrasound
A
Placenta previa - placenta within 2cm of internal cervical os Placental abruption - seperation of placenta from myometrium - hyperechoic fluid inbetween Placental Insufficiency - intra-uterine growth restriction - oligohydramios - abnormal doppler utlrasound Circumvallate and Succenturiate Placenta - abnormal placenta
21
Q
List the differential for 3rd trimester bleeding
A
Pregnancy Related - placental abruption - placental previa - vase previa - uterine rupture - cervical insufficiency Non-Pregnancy Related (PALM CE) - polyps - adenomyosis - leiomyoma - malignancy - coagulopathy - endometrial dysfunction (infection)
22
Q
Discuss the presentation and management of placenta abruption
A
Risk Factors - age >35 - prior placental abruption - C-section - multi-parity - hypertension - cocaine - trauma Pathophysiology - marginal seperation - partial separation - complete separation Presentation - bleeding per vagina with pain uterine contractions - tenderness and hard uterus - fetal distress Management - stabilize - delivery (vaginal only if not in distress and fetus is mature)
23
Q
Discuss the presentation and management of placenta previa
A
Risk factors - advanced maternal age - previous previa - multi-parity - previous surgery of uterus - multiple gestation Pathophysiology - grade 1: low lying where it is within 5cm of os - grade 2: marginal, where reaches os but does not cover - grade 3: partial coverage - grade 4: complete coverage Presentation - painless bright red vaginal bleeding during 2nd half of pregnancy - no pelvic exam due to risk of sudden, massive bleeding Management - C-section
24
Q
Discuss the presentation and management of vasa previa
A
Risk Factors
- IVF pregnancy
- resolved previa, bilobed or succinturiate placenta
Pathophysiology
- fetal vessels unsupported by umbilical cord and lie over the cervix
Presentation
- triad of membrane rupture leading to painless vaginal bleeding and fetal bradycardia
- pulsating vessel in membrane
Management
- C-section
25
Differentiate between
- Pre-existing hypertension with pre-eclampsia
- Gestational hypertension
```
Pre-existing
- hypertension that was present before pregnancy or before 20 weeks gestation with >=1 of the following after 20 weeks
- resistant hypertension
- new or worsening proteinuria
- >=1 adverse condition
- >=1 serious complication
Gestational
- hypertension with evidence of >=1 of the following after 20 weeks gestation
- new proteinuria
- >=1 adverse condition
- >=1 serious complication
```
26
Discuss the definition and adverse events of pre-eclampsia
```
- pre-eclampsia is new proteinuria >300mg over 24hrs, or >1 adverse condition or >1 severe complication associated with SBP >140 and DBP >90
Adverse Condition
- thrombocytopenia
- headache, visual symptoms
- chest pain
- abnormal fetal heart rate
- IUGR
Severe Complication
- eclampsia (seizure)
- acute kidney injury
- placental abruption
- HELLP syndrome (hemolysis, elevated Liver Enzymes, Low Platelets)
```
27
Discuss the Risk Factors for pre-eclampsia
```
Maternal
- age >40
- previous pre-eclampsia
- previous miscarriage with same partner
- pre-existing hypertension
Current pregnancy
- multiple gestations
- maternal obesity
- new partner
- IVF
```
28
Discuss the pathophysiology of pre-eclampsia
- decidual immune cells and extravillous trophoblast interact and cause invasion and uteroplacental artery remodelling
- lead to inadequate placentation leading to release of mediators
- mediators result in endothelial cell activation and dysfunction within vulnerable organ systems
29
List preventative strategies for pre-eclampsia
Low Risk
- supplement with calcium and folic acid
- exercise
- abstinence from alcohol and smoking
High Risk
- low dose aspirin before 16 weeks until delivery
- L-arginine and increased rest at home within 3rd trimester
30
Discuss the management of pre-eclampsia
```
Lifestyle
- exercise
- salt reduction
Blood Pressure Control
- Methyldopa 250-500mg Q6-12H
- labetalol 100-400mg Q8-12H
- Nifedipine XL 20-60mg PO daily
- no ACE or ARB
```
31
Discuss the Management of non-severe pre-eclampsia
```
<24 Weeks
- deliver within days
24-34 Weeks
- expectant management (IV access, administration of anti-hypertensives, corticosteroids for fetal lungs, and daily fetal and maternal labs and assessments)
- possible delivery
34-37 weeks
- expectant management or possible immediate delivery
>37 Weeks
- Immediate delivery
```
32
Discuss the management of severe pre-eclampsia (>160/110 or serious complication)
- maternal and fetal continuous checks
- blood pressure control with first-line agents (nifedepine 5-10mg Q30, labetalol 20mg Q30, hydrazine 5mg Q30)
- prophylaxis against eclampsia with MgSO4 4g IV
- HELLP treatment with fresh frozen plasma
- C section
33
Discuss the Post-Partum Management of Pre-Eclampsia
Early Management (6 weeks)
- control blood pressure with anti-hypertensive (<140/90)
- same as above with possible captopril and enalapril with breast feeding
Long Management (>6 weeks)
- screening of electrolytes, creatinine, fasting glucose, fasting lipids, urinalysis, ECG
- lifestyle changes
34
Discuss the presentation and management of ectopic pregnancy
Risk Factors
- older women, African women
- uterine abnormality: fibroids, adhesions
- prior ectopic
- IUD
- PID
- surgery of fallopian tube
Pathophysiology
- 70% are located in the ampulla of the fallopian tube (next are ampulla and fimbrae)
Presentation
- abdominal pain
- vaginal bleeding
- peritoneal signs
- tenderness to bimanual examination
Investigations
- bHCG (normally doubles ever 2 days, in non-viable will have slower, plateau or decrease)
- abdominal ultrasound (bHCG greater than 6000), transvaginal (>1500) to visualize pregnancy
Management
- stabilize
- surgical abortion (>3.5cm, fetal HR present, bHCG >5000, liver or renal disease, poor follow up)
- medical abortion (<3.5cm, fetal HR absent, bHCG <5000, good follow up) - methotrexate 500mg/m2
35
Discuss the presentation and management of spontaneous abortion
- 10-15% of all pregnancies
Presentation
- abdominal cramping
- vaginal bleeding
- rupture of membranes
- passage of tissue or clots
- open cervix in incomplete, complete and missed, closed in threatended, inevitable and missed
Investigation
- bHCG and ultrasound
Management
- Rh negative then RhoGram
- septic abortion require broad-spectrum Abx
- Threatened: watch and wait
- Inevitable: retained products so require misprostol and possible dilatation and curretage
- Incomplete: retained products so require misprostol and possible dilatation and curretage
- Complete: no management required
- Missed: possible retained products so require misprostol and possible dilatation and curretage
36
List the differential for 1st trimester bleeding
- physiologic from spotting due to implantation of placenta
- abortion
- abnormal pregnancy
- trauma
- genital lesion
