1
Q
Gestational Age (GA)
A
age in days/weeks from the last menstrual period
2
Q
Embryo
A
from time of fertilization to 8 weeks (GA 10 weeks)
3
Q
Fetus
A
after 8 weeks to time of birth
4
Q
Infant
A
time between delivery and 1 year old
5
Q
First trimester
A
1st 14 weeks
6
Q
Second Trimester
A
14-28 weeks
7
Q
Third Trimester
A
28 weeks until after delivery
8
Q
Previable
A
infant delivered before 24weeks
9
Q
Preterm
A
24-37 weeks
10
Q
Term
A
37-42 weeks
11
Q
Post term
A
past 42 weeks
12
Q
Gravidity
A
number of times woman has been pregnant
13
Q
Parity
A
number of pregnancies led to birth after 20 weeks (or >500g infant
Term, Preterm, Abortions, Living Children
14
Q
Goals of Prenatal Care
A
- accurate estimate of gestational age
- deliver healthy, term infant without impairing maternal health
- identify and treat high risk patients
- patient education
15
Q
Maternal Physiology: Cardiology
A
Output increases
stroke volume increases
pulse increases (15-20BPM)
systolic ejection murmur and S3 gallop common
PVR falls
Fall in BP in 2nd trimester, return to normal in 3rd trimester
16
Q
Maternal Physiology: Respiratory System
A
- Unchanged: RR, VC, Inspiratory reserve volume
- Decreased: functional residual capacity, expiratory reserve volume, residual volume, TLC
- Increased: IC, TV
17
Q
Maternal Physiology:
Renal System
A
- increased kidney size and weight, ureteral dilation, bladder becomes intra-abdominal organ
- GFR increases 50%
- CrCL increases 150-200cc/min
- BUN and serum Cr decrease by 25%
- increase in tubular reabsorption of sodium
- marked increase in renin and angiotensin but reduced vascular sensitivity to their hypertensive effects
- increased glucose excretion
18
Q
Maternal Physiology:
Hematologic System
A
- plasma volume increase 50%
- RBC volume increase 30%
- WBC count increases
- platelet count decreases ( But still WNL!)
- increases fibrinogen, factors 7-10 (hypercoaguable state)
- placenta produces plasminogen activator inhibitor
19
Q
Maternal Physiology: GI system
A
decreased motility (due to progesterone) reduced gastric acid secretion
20
Q
Maternal Physiology: Uterus
A
weight increases (70-110g) blood flow increases to about 750cc/min or 10-15% of CO (significant: risk during c-section)
21
Q
Maternal Physiology: Cervix
A
increased water content and vascularity
increases cervical mucous secretions
22
Q
Diagnosis of Pregnancy
A
Confirm –>HCG (urine as sensitive as serum)
-can be positive 1wk after fertilization
Viable pregnancy
- TVUS shows gestational sac as early as 5wks or 1500-2000HcG
- shows fetal HR as early as 6wks or 5000-6000HcG
23
Q
First questions to ask pregnant female
A
Was it planned?
Are you planning to continue this pregnancy?
24
Q
History of Prenatal Patient
A
Menstrual Cycle
Previous pregnancies–>complications
Dating
PMH: HTN, DM, asthma, depression, bladder or kidney infections, bleeding/clotting disorders, anesthesia problems
PSH: C-sections, cervical procedures, abdomino-pelvic surgeries
Allergies
Genetic Hx
25
High Risk for Pre eclampsia
```
High BP (chronic or in prior pregnancy)
DM1 or 2
Twins/triplets
Renal disease
Autoimmune disease
```
26
Moderate Risk for Pre eclampsia
```
1st baby
BMI>30
mother/sister with it
AA
receive public health insurance (low ses)
35 or older
Hx of LBW
previous miscarriage/complicated pregnancy
>10yrs since last pregnancy
```
27
Prevention of Pre eclampsia
81mg daily ASA orally from 12 weeks until delivery if:
- any high risk factor
- 2 or more moderate RFs
28
Important Questions to ask Prenatal Patient
Financial concerns
Domestic Violence
-homicide leading cause of pregnancy-associated death in 90s
-RFs: age <20, AA, late/no prenatal care
Other Stressors
-access to healthcare
-unplanned pregnancy
-substance abuse (5 Ps Screening Tool!!!)
29
Chadwick's sign
bluish discoloration of vagina and cervix
30
Hegar's sign
softening of uterine consistency and ability to palpate/compress the connection between the cervix and funds
31
Goodell's sign
softening and cyanosis of the cervix at or after 4 wks
32
Ladin's sign
softening of uterus after 6 weeks
33
Other pregnancy signs
Breast swelling/tenderness
Linea nigra
Telangiectasias
Palmar erythema
34
Pregnancy Sx
```
Amenorrhea
N/V
Breast pain
Fatigue
Quickening (fetal movement)
```
35
Initial PE
```
Vitals
Thyroid
Heart
Lungs
Breast (teach BSE/discuss BF)
Abdomen
Pelvic (pap, GC/CT, bimanual)
Extremities: edema
Influenze Vax
+/-US
```
36
Nagele's Rule
Dating Pregnancy
Calculate EDC by subtracting 3 mos from LMP + 7 days
Uncertain LMP-->US to determine EDC
- most accurate in 1st trimester
- measure by crown-rump length in the 1st half of 1st trimester (usually accurate to within 3-5 days)
37
1st Trimester Labs
```
CBC
Blood type and screen
RPR/VDRL
Rubella antibody screen
Hep B surface antigen
VZV titer
HIV
Gonorrhea and Chlamydia cultures
Pap smear
Urinalysis and Culture
+/-PPD
GTT if BMI>30
+/- CF, Taysachs, SMA, other genetic tests
```
38
CBC
```
Initial labs and 28wks
Slightly evaluated WBC normal
Dilutional anemia normal
-start iron and colace when Hct <32%
Consider Thalassemia if MCV is low
Thrombocytopenia can be normal
-caution <100!
```
39
Type and Screen
* if Rh negative -->patient will need Rhogam at 28wks or anytime she has vaginal/uterine bleeding
* Ab screen positive: consult perinatologist
- ->Rh antibodies can destroy fetal RBCs causing hemolytic anemia (can be fatal to fetus)
40
GDM Screening in 1st Trimester
- BMI>30
- prior pregnancy with GDM or previous infant >4000g (9lbs)
- high risk ethnicity: AA, latino, Native American, asian American, Pacific Islander)
- HgbA1c>5.7% or hx of known impaired glucose metabolism (PCOS, DM)
- physical inactivity
- 1st degree relative with DM
- HTN
- Hx of CVD: HDL <35mg/dL or Triglyceride >250mg/dL
41
GDM Screening Results
* Pass 1st trimester-->repeat at 24-28weks
* Fail 1st trimester, 3hr GTT is done
* passes 3hr GTT-->repeat GTT at 26-28 weeks
* Fails 3hr GTT-->dx of GDM
* 1st trimester DS>200, dx of GDM
42
GDM Screening (all patients)
24-28wks
GLT: glucose loading test
GTT: glucose tolerance test -->DIAGNSOTIC
43
GLT : Glucose Loading Test
50g oral glucose loading dose and check serum glucose 1 hr later
>130mg/dL-->do GTT
44
GTT: Glucose Tolerence Test
DIAGNOSTIC
- fasting serum glucose
- 100g oral glucose loading dose
- serum glucose at 1, 2, 3 hrs after oral dose
- elevation of 2/more values=GDM
45
RPR/VDRL
rapid plasma regain/venereal dz research lab --> SYPHILLIS
*pregnancy is a risk for false positive
* if reactive -->check FTA-ABS
- fluorescent treponemal antibody-absorption
- consult perinatologist
- 50% untreated syphillis leads to infected baby
- risks: miscarriage, stillbirth, neonatal death, baby with severe neurological problems
46
Rubella
administer vaccine post partum if non-immune
47
HBsAg : Hep B surface antigen
detects 1-12 weeks post exposure
* HBsAb=recovery and immunity
* HBeAg= acute infection
- diagnosed with IgM HBcAB
chronic infection diagnosed by IgG HBcAB (no IgM)
*if pt. infected-->notify Peds
48
Gonorrhea and Chlamydia
DNA probe, swab mucus and insert into os
* if positive-
- treat patient and partner, -promote abstinence during treatment
- test of cure 4wks after tx
49
CF Carrier Screening
* offer at pre conceptual or new OB visit
* increased change of carrying if close relative affected or being white
* tests for 33 mutations on chromosome 7
50
Tay Sachs
* mutations in HEXA gene
* AR inheritance
* accumulation of gangliosides in CNS causes early childhood death
* carrier testing should be offered when at least 1 parent is
- Ashkenazi Jewish (1/30 carrier frequency)
- Pennsylvania Dutch
- Southern Louisiana Cajun
- Easter Quebec French Canadian Descent
51
Spinal Muscular Atrophy
* progressive muscle weakness and paralysis
* 1 in 50 regardless of ethnicity are carriers of gene
* both parents carries -->1 in 4 chance
52
Screening for Fetal Chromosomal Abnormalities
should be offered to all women before 20 weeks regardless of maternal age
type of screening is patient dependent (risks/desires)
53
Maternal Serum Screening
offered to all, most important for AMA
MS-AFP, First screen and NIPT testing
54
Sequential Screening
1a: Blood test for serum levels of PAPP-A and free B-hCG (11-13wks)
1b: US for nuchal translucency (11-13wks)
Part II: blood test for serum levels of MS-AFP, estriol, B-hCG, and inhibit (15-18wks)
* part I detects 70% DS, 80% trisomy 18
* part II detects 95% DS, 90% t18 and 80% NTD
* detection of DS in twins (dizygotic) 80% and monozygotic 93% (no T18)
* not recommended for triplet +, fetal anomaly or reduction of fetus
55
Alternatives for patients late to prenatal care (fetal chromosomal anomaly screening)
* MSAFP (16-18wks)
- elevated: increased risk of NT defects
- decreased: DS/aneuploidies
*NIPT
* US (18-20weks)
- fetal survey, amniotic fluid volume, placental location and gestational age
56
Quad Screen
* MSAFOP, HCG, estriol, inhibin A
* detects Trisomy 21, 18, and NTD
* between 15-18wks (up to 20)
* cannot be used for multiple gestations, screening test only
* positive:
- refer to genetic counseling
- high resolution US
- +/-amniocentesis
57
Advanced Maternal Age (AMA)
women 35 or older at time of delivery
offer maternal serum screening
offer NIPT
offer genetic counseling with possible diagnostic test
-CVS or amniocentesis
58
NIPT Recommendations
* AMA (>35)
* Fetal US findings indicating increased risk of aneuploidy
* HX of prior pregnancy with trisomy
* + test result for aneuploidy (1st trimester, sequential or quad screen)
* parental balanced robertsonian translocation with increased risk of fetal trisomy 13 or 21
59
NIPT: Non-invasive Parenteral Testing
*cell-free fetal DNA (cfDNA) testing for fetal trisomies (21, 18, 13) in maternal blood
* 99% detection for DS
* 98% for trisomy 18
* 70-90% Trisomy 13
* detection of abnormal # of sex chromosomes 99%
60
NIPT additional considerations
* no in twins (including vanishing twins)
* should not substitute other diagnostic testing
* indeterminate result?
- genetic counseling
- detailed US
- other diagnostic testing
- risk with obesity >200lbs
61
Ultrasound
* at initial visit to measure CRL if uncertain LMP
* 1st trimester bleeding
* anatomy survey b/t 18-20wks
* any time fundal height is >3cm discrepant from Ga
* confirm presentation at or after 37 wks
62
Amniocentesis
* 15-20wks to obtain fetal karyotype
* procedure related loss 1 in 300-500
* complications: transient vaginal spotting, amniotic fluid leakage, preterm labor, chorioamnionitis, and rarely needle injury to fetus
* <15wks not recommended (high risk)
63
Chorionic Villus Sampling
* obtains fetal karyotype 10-13wks (99%)
* catheter placed intrauterine cavity, sm amount of chorionic villi aspirated from placenta
* fetal loss rate same (ish) as amniocentesis
64
Cordocentesis
* percutaneous umbilical blood sampling (PUBS): puncture umbilical vein under direct US guidance
* karyotype analysis of fetal blood w/in 24-48hrs
* pregnancy loss rate <2%
* rarely needed, may be useful to evaluate chromosomal mosaicism discovered after CVS or amniocentesis is performed
65
3rd Trimester Diagnostics
*27-29wks
CBC
GLT
RPR/VDRL
* if high risk-->repeat GC and CT, also HSV screening
* CXR if PPD+
* group B strep (36 wks)
66
Group B Streptococcus
screen all patients at 36wks
culture lower vagina and anus (must go through sphincter)
PCN allergy, ask for sensitivities
67
Routine Prenatal Vistis
* BP
* weight
* urine dipstick (protein and glucose)
* fundal height, weight and fetal position
* auscultation of fetal heart tones
68
Frequency of visits
less than 28wks: every 4wks
28-36: every 2 wks
>36: every week
69
1s trimester questions
cramping or bleeding?
| N/V?
70
2nd trimester questions
Cramping/bleeding?
| fetal movement?
71
3rd trimester questions
contractions, leaking of fluid, bleeding?
| fetal movement?
72
Routine Problems
* N/V
* LBP
* constipation
* contractions
* dehydration
* edema
* GERD
* hemorrhoids
* PICA
* round ligament pain
* urinary frequency
* varicose veins
* carpal tunnel syndrome
73
Prenatal Supplements
* 800mcg folic acid
- most effective when given 2 mos prior and during 1st months
- green leafy veggies, oranges cantaloupe, bananas, milk, grains and organ meat
*avoid excessive fat soluble vitamins (D, A, K, E)
74
prenatal nutrition : what to avoid and limit
caffeine : 500mg/day
Fish: mercury risk
-avoid shark, swordfish, king mackerel and tilefish
-limit shellfish and sm. ocean fish to 12oz/wk
-limit other fish to 6oz/wk
-limit canned tuna to 6 oz/wk
75
prenatal nutrition: calories
* calories: increase 15%kcal/day (2200 cal)
* protein: add 10-30g/day (75g total)
* Iron: supplement 30-60mg/day
* Ca: 1200mg/day
Nutritional Referral (WIC referral maybe)
- inadequate weight Gian
- PICA
- eating disorder
76
weight gain
avg: 25-35 pounds
15 lbs if obese
40lbs if underweight
77
exercise
* continue at usual level
* HR goal: 70% of 220-age (140)
* limit new exercise
* avoid over heating
* avoid supine
* avoid scuba, skiing, contact sports after 1st trimester
78
2nd trimester counseling
* birthing classes
* preterm labor risks after viability
* breastfeeding
* rhogam at 28wks if negative
79
3rd trimester counseling
* analgesia/anesthesia in labor
* operative vaginal delivery or C section
* travel
* fetal kick counts
* L&D tour
* pediatricion
* GBS
* HSV
* what to Bring to hospital
* circumcision
80
genital HSV in pregnancy
* IgG Toc
* HSV-1 positive- could be oral or genital infection
* IgM not helpful
Most women with newborn who acquires neonatal herpes DO NOT have a history of clinically evident herpes
81
Prevention of Neonatal herpes
1. prevent acquisition of genital HSV during late trimester
2. avoid exposure of neonate to herpetic lesion and viral shedding during delivery
3. avoid vaginal intercourse if partner is + (during 3rd trimester)
4. verbally screen for genital herpes
5. examine all women for sx
6. C-section if sx present (risk not fully elminated)
7. suppressive therapy in women at 36wks if recurrent genital herpes
- Valacyclovir 500mg BID or Acyclovir
8. BF not C/I unless lesion on breast
9. universal precautions with active oral HSV
82
Vaccines recommended ALL
Flu during flu season
| Tdap 27-36wks
83
Vaccines safe if indicated
pneumococcal, hep A or B, rabies, polio typhoid
84
Vaccines C/I
MMR, varicella, live virus vaccines
85
Post partum contraception
* discuss 3rd trimester
* consent required tubal ligation
* importance of inter-pregnancy interval (esp. w/ C-section)
86
prior C -section?
* document uterine scar
* discuss risk/benefits of VBAC vs. repeat C-section
* have pt sign consent
* schedule c-section (39wks )
87
Fetal movement assessment
Indication
-maternal perception of decreased/absent fetal movement
Technique: mother counts kicks during specific time
-have mom eat/drink something then lay still
88
Non stress test
* measurement of fetal HR with movement
* Reactive (normal)= 2/more fetal HR accelerations within 20mins
* Nonreactive=insufficient fetal HR accelerations over 40mins
- acidotic, neurologically depressed
89
Contraction Stress Test
looking for presence/absence of late Fetal HR decelerations in response to uterine contractions
Late decels= decals that reach nadir after the peak of contractions and usually persist beyond the end of the contraction
Variable decels= cord compression
-think oligohydramnios
90
Biophysical Profile
*NST, fetal breathing movements, fetal movement, fetal tone, AFI
each component =2 or 0
normal: 8 or 10
equivocal: 6
abnormal: 4 or less
*oligohydramnios-->warrants further evaluation regardless fo score
91
Amniotic Fluid Index (AFI)
summation of the largest cord-free vertical pockets of the 4 quadrants of an equally divided uterus
92
Oligohydramnios
no US measured pocket of fluid >2cm or AFI of 5cm or less
* BAD: anomalies or placental dysfunction
* requires close maternal/fetal surveillance or delivery
93
Polyhydramnios
AFI >24cm (or equal)
can be normal, cause Prom or malpresentation
94
Post partum Visits
Vaginal Delivery: 6wks
C-section: 2 (incision check) and 6 weeks
Consider sooner/follow-up if complications (3/4th degree tear, HTN)
Clin Med
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