Prenatal Care Flashcards
(167 cards)
1
Q
When are prenatal care visits scheduled for a low-risk pregnancy?
A
Pre-conceptual counseling Prenatal visit every 4 wks for 24-28 wks every 2 weeks 28-35 wks every week from 36, 40-41 wks 2x/wk if 40+
2
Q
In a perfect world, when should women start the prenatal process?
A
before pregnancy happens!
3
Q
What occurs at preconception counseling?
A
- Folic acid-4mg per day
- Calcium and iron
- Prenatal vitamins
- Dietary concerns
- Exposures (workplace, environmental, medicinal)
- Manage chronic dz
- Switch meds if necessary to meds that are safe in pregnancy
4
Q
Pregnancy is generally considered to be ___ calendar months or ___ weeks.
A
10 mo
40 wks
**This includes the 2 “free weeks” prior to the fertilized ovulation.
5
Q
If a patient had any assisted reproduction, IUI, IVF (embryo transfer) or ovulation induction, then dates should be based on _____
A
ovulation date
6
Q
If LMP is uncertain or unreliable, what can be used to estimate how many weeks the pregnancy is?
A
U/S
7
Q
How do you use U/S to estimate how far along the pregnancy is?
A
measure fetal C-R (crown-rump)
8
Q
Fetal C-R (crown rump) length between 6-11 weeks can define gestational age to ____ days
A
+/- 7 days
9
Q
Fetal C-R (crown rump) length between 12-20 weeks: U/S should define gestational age to __days
A
+/- 10
10
Q
After 20 weeks: U/S estimate is ____ days of accuracy
A
+/- 14-20
11
Q
What Information about prior pregnancies can alert you to possible problems in the present pregnancy?
A
- Gravity and Parity
- wt and length of previous children at birth
- previous labor experience
- maternal/infant complications
12
Q
How do you write out a patient’s Gravidity and Parity?
A
G \_\_(how many times the woman has been pregnant P _1_, \_\_2_, _3_, _4\_\_
- full term delivery
- pre-term delivery
- mis-carriages
- live births
13
Q
What 6 dzs can affect the outcome of the pregnancy and must be investigated?
A
DM HTN Cardiac Pulmonary Autoimmune Renal dz
14
Q
Other than dz, what other PMHx do you need to know in a pregnant woman?
A
Prior surgeries (esp obstetric surgeries)
allergies
meds
Previous trauma (esp to bony pelvis)
15
Q
What FHx chronic dzs do you need to know about?
A
DM HTN Heart disease CA Anemia Bleeding disorders
16
Q
Why is the PE important at the initial prenatal visit?
A
- detect undx illness that can affect pregnancy
- est baseline levels (this helps guide tx later)
- eval pelvic inlet/outlet
17
Q
____ is used to determine blood type
A
Blood group
18
Q
___ is used to detect anemia
A
Hgb
Hct
19
Q
___ is used to screen for syphilis
A
Rapid plasma reagin (RPR)
venereal dz test (VDRL)
20
Q
What other infectious dz do you need to screen for?
A
rubella
chlamydia
Hep B/C (surface antigne)
HIV
21
Q
___ is used to detect infection or renal dz (protein, glucose, ketones)
A
UA
22
Q
___is used to scree for cervical neoplasia
A
papanicolaou (pap) test
23
Q
___ is used to screen for DM
A
glucose
24
Q
What other testing may you order for at risk pts?
A
- genetic testing (sickle cell)
- CF screening
- early glucose if +FHx for DM or high BMI
25
What is included in the TORCH infections you worry about?
- Toxoplasmosis-cat feces;
- Varicella
- CMV
- HIV
- Parvovirus B 19
- HSV–
- Group B strep
26
What can happen to the fetus if a mother has toxoplasmosis?
```
Blindness (cat poop on their eyes)
mental retardation (cats are retarded) (just a way to remember it people)
```
27
What can happen to the fetus if a mother has CMV?
Retinitis
28
What can happen to the fetus if a mother has HIV?
High risk of vertical transmission in vaginal delivery
| - C/S mandatory
29
What can happen to the fetus if a mother has Parvovirus B19?
hydrops (heart failure of the fetus)
30
What can happen to the fetus if a mother has HSV?
encephalopathy, blindness
31
What can happen to the fetus if a mother has Group B strep?
PNA, sepsis– (see 3rd trimester)
32
What are the autosomal recessive traits you need to screen in a pregnant woman?
- Sickle cell (AA parent)
- Thalassemia
- CF (Caucasian parent)
- Tays-Sachs and other dz (Ashkenazi, FHx)
- Sex linked disorders (e.g. Fragile X) also exist--primarily affect males. Screen if risk factors exist
33
What are potential teratogens during pregnancy that are not medications?
Alcohol
Smoking
Illicit drugs
Work exposures
34
What are teratogens during pregnancy that are medications?
Warfarin (coumadin)-- early SAB IUGR, craniofacial/CNS
Antineoplastic agents (chemo): designed to kill rapidly-dividing cells
Retinoids: Category X
DES (Diethylstilbestrol)
35
___ is prenatal alcohol exposure and central nervous system (CNS) involvement.
Fetal Alcohol Spectrum D/o
36
What are facial features of a child w/ Fetal Alcohol Spectrum D/o?
small eye openings
smooth philtrum
thin upper lip
37
What are s/s of Fetal Alcohol Spectrum D/o in the CNS? (structural vs functional)
structural
- mall brain size
- alterations in specific brain regions
functional
- cognitive and behavioral deficits
- sensory processing deficits
- motor and coordination problems
38
About __-__ % of women have reported drinking at some point during pregnancy—most typically during the 1st trimester
20 to 30%
39
> __ % of women have reported binge drinking at some time during pregnancy—most typically during the 1st trimester
8%
40
> __ % of pregnant women reported drinking alcohol in the previous month
9%
41
> __ % of pregnant women reported binge drinking in the previous month (4+ drinks per occasion)
2%
42
What sz meds can cause problems in the fetus? (x4)
Phenytoin
Valproic Acid
Carbamezapine
Phenobarbital
43
What issues occur in the fetal w/ phenytoin use?
craniofacial and limb reduction
44
What issues occur in the fetal w/ Valproic acid use?
1-2% risk of NTD
45
What issues occur in the fetal w/ carbamazepine use?
Elevated NTD risk
46
What issues can occur in the pregnancy w/ phenobarbital use?
withdrawal
| maternal/ fetal hemorrhage
47
If a woman does not take her anti-sz meds for a known sz d/o, what is she at risk for?
```
Maternal/fetal trauma from falls or burns
increased risk of premature labor
miscarriage
fetal hypoxia
lowering of the fetal HR.
```
48
What should you advise pregnant women about? (S/S of pregnancy)
```
N/V/C
Heartburn
Hemorrhoids
Varicose Veins
Leg cramps (relative hypokalemia)
Backache
HA
acne
```
49
First trimester bleeding occurs in __-__% of pregnancies.
Of those pregnancies, __-__ of pregnancy are lost.
20% to 25%
~ 25% -50%.
50
Risk of pregnancy loss or non-viability increases if: ___ or ____
- Bleeding becomes heavy
| - Bleeding is accompanied with cramping or pain
51
Risk of pregnancy loss/non-viability decreases significantly (to 3-7%) if
____
____
- Intrauterine gestation with + FHR is detected
| - BHCG values rise appropriately for gestational age (more on this later)
52
Overall weight gain in pregnancy is __-__ lbs (for a single gestation)
25-35 lbs
53
If the initial BMI is <20, how much should the woman gain?
35-45 lbs
54
If the initial BMI is >35, how much should the woman gain?
15 lbs
55
Typical wt gain is ___ lb over first 20 weeks, then ___ lb/week thereafter.
10lbs
| 1lb
56
What foods should be avoided in early pregnancy? (FYI)
```
Poorly cooked meats
Raw eggs
Cold cuts and hot dogs
Soft, mould-ripened cheeses (brie, camembert, goat cheese)
Unpasteurized cheese and milk
Sushi
King mackerel, tilefish, swordfish and shark
Restrict Caffeine
```
57
What can the following foods contain that are dangerous to a pregnancy?
- Poorly cooked meats
- Raw eggs
- Cold cuts and hot dogs
coliform bacteria
toxoplasmosis
salmonella
58
What can the following foods contain that are dangerous to a pregnancy?
- Soft, mould-ripened cheeses (brie, camembert, goat cheese)
- Unpasteurized cheese and milk
Listeriosis
59
What can the following food contain that can be dangerous to a pregnancy?
- Unpasteurized cheese and milk
- Sushi
- King mackerel, tilefish, swordfish and shark
Mercury
60
What is the recommended amount of coffee that is allowed in pregnancy?
< 200 mg/d, or one 12-oz cup of coffee
| **know it can be in other food items
61
In general, what type of vaccines are okay during pregnancy? What types of vaccines are NOT okay during pregnancy?
okay: recombinant
NOT okay: live vaccines
62
What are live vaccine examples that a woman shouldn't get?
Rubella
MMR
Varicella
63
When can live attenuated vaccines be administered around pregnancy?
Must be >3 months before/ after pregnancy
64
What is a "Blueberry muffin baby"?
A baby born with purpura due to congenital infection– think rubella, but also possible with coxsackie, toxo, hep B, CMV, EBV, and congenital syphilis
65
What are examples of vaccines that are ok to get during pregnancy?
Influenza
Tetanus
Hep B
Gardasil
66
What occurs at each visit no matter what trimester it is? (VS etc)
```
Wt
BP
U/A
Assess for edema
fundal ht at 20 wks
fetal heart tones
```
67
How is fundal ht (FH) measured?
```
# cm from pubic symphysis to top of fundus
**Watch for FH that is > 3 cm above or below gestational age
```
68
When should a fetal HR be present and what is the normal rate?
week 12
| 120-160 bpm
69
What is not commonly advised in the PE of a pregnant woman?
Routine vaginal exams
| Cervical checks
70
What should you ask about in the first trimester visits (see pt every 4 wks)
(+) heartbeat by doppler by 12 weeks (or confirm by US)
Assess: VS, weight gain/loss
Ask about: N/V, comfort, appetite, bleeding
71
What can be assessed on U/S to screen for chromosomal abnormalities?
- Normal nuchal translucency (widened is abnormal)
| - absence of nasal bones (abnormal)
72
What serum levels are used to assess fetal abnormalities?
b-hCG
| PAPP-A
73
__-__% of pregnant women experience nausea and vomiting during pregnancy (NVP)?
70-80 %
74
N and V can begin at __-__ weeks gestation and can last into ___ trimester. but usually resolves by __weeks
4-6 weeks
2nd trimester
16 weeks
75
What contributes to N/V during pregnancy?
Hormonal influences
| Hypoglycemia
76
What can you do to help a woman manage N/V associated w/ pregnancy?
- Rest
- several small meals a day
- BRAT (bananas, rice, applesauce, toast)
- carbohydrate snacks at bedtime
- Ginger
- Sea bands
77
___ is severe nausea and vomiting of pregnancy
Hyperemesis Gravidarum
78
What are s/s of Hyperemesis Gravidarum?
- Persistent V and inability to tolerate p.o.
- Wt loss >5% of pre-pregnancy wt.
- Dehydration (PE findings, orthostasis, ketonuria)
- Electrolyte abnormalities
79
If severe, how can you tx Hyperemesis Gravidarum?
- IV hydration (break the cycle)
- PO or IV antiemetics (Phenergan, Zofran)
- GI motility drugs (Reglan)
- Goal = toleration of PO liquids
- Some wt loss can be tolerated– fetus will do okay
80
IF ADMITTED for Hyperemesis Gravidarum, what should you do?
U/s to r/o multiple gestation and placental abnormalities (molar pregnancies)
Thyroid assessment to r/o Graves
81
What causes heartburn during the 1st trimester?
progesterone relaxes the cardiac sphincter of the stomach and allows reflex of gastric contents into the esophagus
82
What causes heartburn during the 3rd trimester?
pressure of the growing uterus on the stomach
83
How can you manage heartburn during pregnancy?
- Avoid lying flat
- Sleeping w/ more pillows
- lying on the right side
- Small frequent meals
- Avoid late night meals
- Antacids
- Avoid fried ,spicy, and fatty food and citrus
84
What causes urinary frequency?
Pressure of the growing uterus on the bladder
Increased GFR
85
Urinary frequency improves when the uterus rises into the abdomen after the __week.
Then, urinary frequency worsens again in __ trimester.
12th
| 3rd
86
How can you manage urinary frequency during pregnancy?
Kegel exercises
Frequent urination
Watch for S/Sx UTI
87
What causes varicosities during pregnancy?
Progesterone relaxes venous smooth muscle, then causing slowed venous return
Valves of the dilated veins become insufficient
Wt of the uterus causes partial venous compression from the legs
88
How do you manage varicosities during pregnancy?
Elevate feet
Pump leg muscles
**Watch for evidence of DVT
89
What causes constipation in pregnancy?
progesterone
| iron supplementation
90
What can you do to manage constipation during pregnancy?
```
Eat diet including fruit and green vegetables, which contain fiber
Drink a lot of water
Exercise and walking
Stool softeners
OTC laxatives (mild) prn
```
91
What should be performed during the 2nd trimester? (every 4 weeks)
Fetal Trisomy/NTD Screening
| U/S for Fetal Anatomic Assessment
92
Typically, the fundal height in cm’s should = what?
the # weeks gestation (+/- 3 cm)
93
What should you think if the fundal height is abnormal?
```
Large for gestational age (LGA)
Small for gestational age (SGA)
Too much fluid (polyhydramnios)
Too little fluid (oligohydramnios)
Abnormal fetal lie (transverse, breech
```
94
When is fetal movement first noted by the pt?
~18 - 22 weeks
| **felt earlier in subsequent pregnancies
95
When is fetal movement typically first felt by an examiner?
after 20-24 wks
96
___(fraction) pregnancies have recognizable chromosomal abnormalities
1/300
97
95% of chromosomal abnormalities are Trisomy ___, ___, ___ or changes in ___ and ___
Trisomy 21, 18, 13
| changes in X and Y
98
Most chromosomal abnormalities result in ___ syndrome
down syndrome
99
T/F: Increasing maternal age increases risk of chromosomal abnormalities
T
100
When is a woman considered to be of advanced maternal age?
>35 y/o
| **does not take partner age into account
101
Overall risk of Trisomy 21 is 1/800 at age ___; increases to 1/300 by age __
35 y/o
| 39 y/o
102
Trisomy risk overall is ___ (fraction) in the 40-45 range, and is __ (fraction) by age 46
1/80
| 1/20
103
What are the benefits of prenatal screening and dx?
parental reassurance
Prenatal dx may allow women to undertake a pregnancy they might not have otherwise undertaken
104
How are fetal screenings beneficial if an abnormality is detected?
Increased parental options
Altered obstetric management
Facilitated neonatal management
105
What is the risk of prenatal screenings?
Parental anxiety
Pregnancy complications- ROM, infxn, PTL
Pregnancy loss
106
>___% of structural and chromosomal fetal abnormalities are born to low risk women
90%
107
T/F: Maternal age alone is a reliable screening tool
F: It is a poor screening tool-- Only detects about 30% of DS cases
108
What are the options for Prenatal Screening for Down Syndrome (DS) and trisomy 18?
- Integrated Prenatal Screening (IPS)
- Serum Integrated Prenatal Screening (SIPS)
- 1st Trimester Screening (FTS)
- Quadruple maternal serum screening (Quad Screen)
- Maternal serum screening (Triple Screen)
109
What are prenatal diagnostic tests for DS and trisomy 18?
Amniocentesis/CVS
110
What are the 2 steps of Integrated Prenatal Screening (IPS)? When are they performed in terms of the pregnancy? Ideally?
1st Trimester (11-13+ 6/7 weeks – ideally week 11)
- Nuchal translucency measurement
- PAPP-A (pregnancy-associated plasma protein)
```
2nd Trimester (15-20 weeks – ideally week 15-17)
- AFP, uE3 (estriol), hCG
```
111
What is the down side of Integrated Prenatal Screening (IPS)?
A single risk assessment number is produced in second trimester – so patients learn whether or not they are at risk in the second trimester- not the first.
112
What is the most common reason for false + screening results in pregnancy?
```
#1: wrong estimated delivery date
#2: multiple gestation
```
113
What anatomical location is used in the First Trimester Nuchal Translucency screen? ( just a description)
Subcutaneous fluid-filled space located between back of fetal neck and skin
114
First Trimester Nuchal Translucency screens are measured on U/S between __-__ weeks, [measurement (is not valid/is valid) outside of this time period]
11–13 weeks
| Is not valid
115
Great if NT measurement is not available, ____ can be used and is a 2 step approach that combines first and second trimester serum markers to produce a single risk assessment
Serum Integrated Prenatal Screening (SIPS)
116
What is included in the Serum Integrated Prenatal Screening (SIPS)?
First Trimester:
PAPP-A: 11-13+6/7 weeks (11 wks is ideal)
Second Trimester:
AFP, uE3, hCG, Inhibin-A: 15–20 weeks (15-17 wks is ideal)
117
During which trimester can an anatomic survey be performed?
2nd trimester
118
What can be offered if a screen comes back (+)?
Chorionic sampling
| Amniocentesis
119
What are the risks of chorionic sampling
| and amniocentesis? (x2)
invasive
| risk for miscarriage
120
Which has a higher miscarriage risk, chorionic sampling or amniocentesis?
Chorionic sampling
121
When can chorionic sampling be performed? (weeks)
Amniocentesis? (weeks)
C: 10-13 wks
A: 15-22wks
122
When is a level 2 US performed?
What is it looking at? (FYI)
16-20 weeks
Brain, spine, face, thorax, heart, gastric bubble, intestines, kidneys and bladder, fluid, limbs, placenta, cord, cervix, and gender.
123
What is the lemon sign indicative of?
Arnold-Chiari Malformation and spina bifida
124
What causes the lemon sign (pathophysiology)?
Bones in anterior skull curve inward because of abnormal drainage in the posterior fossa
125
Estimating gestational age can be performed using what measurements?
Abd circumference
Head circumference
Biparietal diameter (BPD)
Femur length
126
In the 3rd trimester, it is recommended to have an appointment every __ weeks until 28 week(s), then every __ week(s) until 36 weeks, then every ___ week(s) until delivery
4 wks
2 wks
every week
127
At 32 weeks the baby weighs ~__ lbs and has a ___% chance that lungs will not be mature
4 lbs
| 50%
128
At 36 week the baby will weight ~___ lbs, and has a __% chance that lungs are not quite developed
6 lbs
| 1%
129
At what point would a "knot " in the cord be most likely?
At birth
| the knot has been made, but not pulled tight until labor
130
What is included in 3rd trimester appointments?
- VS including weight, BP (all trimesters!)
- FHT’s (every visit after 12 weeks)
- Evidence of labor, PTL
- Presenting part (mid to late 3rd)
- Cervical exam at 39 weeks or prn
- Fetal Movement evaluation (28-30 wks)
131
What is worrisome in the 3rd trimester (FYI) (x10)
- Vaginal bleeding (including spotting)
- Persistent abdominal pn
- Severe and persistent V
- Sudden gush of fluid from vagina.
- Absence or decreased fetal movement.
- Severe HA
- Edema of hands, face, legs and feet.
- Fever above 100 F (>37.7C).
- Dizziness, blurred vision, double vision and spots before eyes.
- Painful urination.
132
If the abdomen is longer, the fetal lie is ____ (which it is 99.5% of the time)
If the abdomen is lower and broad, the fetal lie is ___
longitudinal
transverse
133
Normal fetal heart rate is ___-___ beats/min
120-160
134
What are the Leopold Maneuvers used for?
When do they become most important?
To determine what position the baby is in
Important at ~34 wks
135
__-__% of fetuses at 24-28 weeks; __% at 36 weeks
| are in the breech position
30- 40%
| 5% (the odds of them flipping is low bc of size)
136
Breech position is associated with poor delivery outcome, _____ improves outcome over vaginal delivery,
c-section (c/s)
137
Why should you perform a leg inspection in the 3rd trimester?
What s/s are you looking for?
dx preeclampsia and DVT
- edema
- calf redness
- phlebitis
- tenderness
138
What complication is hyperreflexia associated w/ in pregnancy?
Preeclampsia
139
T/F: Mild increase in vaginal d/c is abnormal and signifies issues with the placenta
F: Mild increase in vaginal discharge is normal in pregnancy
140
STD and symptomatic BV are risk factors for ___
Pre-term labor
141
How should a pregnant pt count fetal kicks?
When should they start monitoring this?
What is normal count?
Pt should sit quietly and observe fetal movement once daily
Start monitoring after ~30 weeks
10+ movements in 2 hours
142
Absence of fetal movements usually precedes intrauterine fetal death by ___hours
48 hrs
143
Why is an U/S performed in the 3rd trimester? (x3)
Check amniotic fluid volume
Check the position of the placenta and baby
Assess fetal well-being (BPP)
144
If a baby is in the breech position, what can be done to turn the baby into the correct position?
external cephalic version
145
What could cause a loss of amniotic fluid? (x5)
When would these occur?
SROM- spontaneous rupture of membranes– usually at term during labor
PROM-premature rupture of membranes– rupture of membranes prior to the onset of labor
PPROM– preterm premature rupture of membranes– prior to 36 weeks
AROM- Artificial rupture of membranes– during labor caregiver
LOF- typically used to describe the patient perception of fluid leaking from vagina
146
What is a common cause of backache during pregnancy?
Increased lordosis during pregnancy in an effort to balance the body
RELAXIN
147
How do you manage back pain in a pregnant women?
Exercise
| Sit with knee slightly higher than the hips
148
When do you screen for Gestational DM?
at 24-28 wks gestation
149
In what patients should you screen for gestational DM prior to the regular screening time?
Screen for gestational DM prior to 24-28 weeks gestation is the pt has the following risk factors
- FHx of DM or GDM
- PMHx of metabolic syndrome
- Obesity (>30)
150
In which populations does Gestational DM most commonly occur?
Hispanic
AA
Asian
Pacific Island
151
What are complications of gestational DM
Macrosomia
Neonatal hypoglycemia
Hyperbilirubinemia
152
How do you screen for GDM? What would a positive result be?
Screen w/ 1 hour, 50-gram glucose test
Positive if > 140 (some use >135)
153
If GDM screen is abnormal, what do you do next? What would be considered a positive result?
- blood taken before intake
- test a 1/2/3 hr glucose tolerance test:
positive if 2 of the 4 levels are high, or if the FBS is high.
154
If diagnosed with GDM, the pregnancy becomes ‘___’ and visits are indicated how often?
Higher risk
| Weekly
155
____ wks is considered term
| ____ wks is considered post term
37
| 42
156
Group B Strep is associated with ___, ___, and ____ if an infant delivers through a GBS colonized birth canal
sepsis
pneumonia
death
157
A vagina swab is performed at ___ wks to screen for group B strep and, if positive, abx are required
36 weeks
158
T/F: GBStrep is a normal colonization in vaginal flora
T
159
What are Braxton hicks contractions? What is their purpose?
Runs of contractions which may be irregular, <3 per 10 minutes
** for preparation of cervix for delivery
160
____ is the disturbance of the connections between the cervix and fetal membranes. Evidence shows that this can (slow down/speed up) the onset of labor
stripping membranes
sweeping membranes
Speed up--> can go into labor w/in 48 hrs
161
What must you determine the location of prior to stripping membranes?
Determine the location of the placenta
162
Increased risk of stillbirth and neonatal/perinatal death after ___ weeks
42 weeks
163
At what week(s) do you induce? (3 different times, and why)
42 weeks
39 wks if cevix is favorable
earlier if complications exist
164
What is a Poor Bishop’s score is associated with?
Prolonged labor and risk of C-Section
165
Is it recommended to scheudle a Cesarean Delivery at Term for Suspected Macrosomia? Why or why not?
In general, no- because we are very bad at diagnosing it
166
When predicting fetal weight...
Ultrasound is better when the fetus is less than ____grams
Clinical estimate is better from the ___-___ gram range
At ____ grams, both methods are inaccurate (usually off by >__%).
2500 g
2500-4000g
4000+g
>15%
167
T/F: Postdate pregnancies = increased risk for both SGA and LGA infants.
T
