TCP: Pregnancy Lectures Guide/Knowledge check

How is hCG used in the diagnosis of pregnancy?

-Secreted by trophoblast early in pregnancy

-Pregnancy test detects hCG in serum or urine:

neg if < 5 IU/L

pos if > 25 IU/L

-may be low in ectopic pregnancy/spontaneous abortion

-may be high in multiple gestation or choriocarcinoma

What are the functions of progesterone during pregnancy?

-Prod. by corpus luteum then by placenta @ 6/7 wks

-Relaxes smooth muscle (uterus) → egg can implant

-Inhibits uterine contractions → prevent spontaneous abortion

-Possibly plays role in immune tolerance for products of conception

What is Naegele's Rule and how is it used to calculate EDC?

1st day of LMP - 3 m/o + 7 days + incr. the year by 1 = EDC (est. date of confinement aka delivery)

What are the signs and symptoms of an ectopic pregnancy?

-Abnormal bleeding/spotting → usually 7-14d after missed period

-Pain → stabbing/dull unilateral pelvic pain; w/ intra-abd hemorrhage and blood under diaphragm shoulder pain is common

-Internal bleeding due to rupture may lead to shock → 1st sx in 20% of ectopic preg.

Physical findings of an ectopic pregnancy

-shock → hypotension, tachycardia

-adnexal mass or tenderness in adnexa (ovaries, tubes, connective tissue)

-peritoneal signs → unilateral abd. pain, guarding, rebound tenderness

-uterus = normal size

What are the different components of GTPAL system?

GP = Gravida and Parity

Gravida/Term-Preterm-Abortion-Living

G = total # of preg incl. current one

T = # of preg terminating after 37 wks

P = # of preg terminating 20-36 wks

A = # of preg terminating before 20 wks (incl. spontaneous, therapeutic, ectopic)

L = # of living children

What are the recommended weight gain guidelines during pregnancy?

1st tri = 3.5-5 lbs

2nd tri = about 1 lb/wk

3rd tri = about 1 lb/wk (mostly fetal wt)

Rec. total gain for nl wt (pre-preg) pt = 25-35 lbs

obese pt (all classes) = 11-20 lbs

What is the recommended important nutritional information during pregnancy?

-300 additional calories/day per fetus

-500 additional calories/day during lactation

-Folic acid supplement to prevent neural tube defects

-Iron supplementation to prevent anemia

-Prenatal Vitamins (PNV)

Describe Rh status and when one does/doesn't administer Rhogam

If pt is Rh negative → RhoGAM @ 28 weeks and post-birth to prevent sensitization

-RhoGAM is given to prevent dev. of antibodies against Rh+ fetus in a Rh- mother (usually seen in 2nd preg. b/c they developed after exposure to 1st Rh + fetus)

What are the different types of (spontaneous) abortions and corresponding patient presentations.

Threatened abortion → vaginal bleeding before 20 wks, cervix is closed

Inevitable abortion → vaginal bleeding, cramping, dilated cervix

Incomplete abortion → bleeding, cramping, passage of products of conception

Complete abortion → passage of all products of conception has occurred and cervix begins to close, uterus is usually firm

Missed abortion → fetal death in-utero w/o expulsion by the uterus

Recurrent abortion → 3 successive spontaneous abortions

What are some vaccines that are safe to administer in pregnant patients and which vaccines would be given to after delivery?

Safe in pregnancy: Flu, COVID, RSV, and can give Hep B during if at high risk

Post-birth: Rubella

if Rh(-) : RhoGAM @ 28 wks + post birth to prevent sensitization

What are the differences between true labor and false labor?

True labor: regular intervals btwn contractions, intensity gradually incr., back + abdomen discomfort, progressive dilation of cervix, sedation does not affect contractions (more tolerable tho)

False labor: irregular intervals, steady intensity, lower abdomen discomfort, NO changes in cervix, contractions relieved/stopped w/ sedation

*big difference = cervical dilation in true labor*

Stage 1 of labor: duration

labor onset → 10cm dilated cervix

longest stage: primipara 6-18hrs; multipara 2-10hrs

-divided into 3 stages: latent (0-3cm dilation), active = (4-7 cm; 1cm/hour) , transition = 8-10 cm.

Stage 1 of labor: management/important considerations

-Assess fetal position via PE and/or ultrasound

-Encourage side-lying position in bed

-NPO or clear liquids; begin IV fluids

-Maternal monitoring: vitals (incl. intake + output), uterine activity, vaginal exam check dilation/progress

-Pain mgmt/support

-Fetal monitoring

Stage 2 labor: duration

-stage of expulsion of fetus; begins when dilation is complete and ends w/ delivery

-primipara: 30 mins-3hrs

-multipara: 5-30 mins

Stage 2 of labor: management/important considerations

-Avoid supine maternal position

-Encourage bearing down w/ contractions

-Continuous fetal monitoring (head, position, etc.)

-Vaginal exams to document descent

-Position mother, antiseptic scrub, drape (delivery is not sterile!)

Stage 3 of labor: duration

-separation and expulsion of placenta

-begins immediately after delivery → delivery of placenta and fetal membranes

-primipara/multipara: 0-30 mins

Stage 3 of labor: management/important considerations

-Examine cervix/perineum for lacerations

-Gentle traction on cord to facilitate expulsion

-Counter pressure between symphysis & fundus to prevent descent of uterus

-Prevention of uterine bleeding (uterine massage, 20U of oxytocin added to IV)

-Examine placenta to ensure complete removal

-Repair episiotomy/lacerations as indicated

What are the cardinal movements of labor?

Engagement: 0 station→BPD (presenting part) passes through pelvic inlet

Descent: presenting part descends into pelvis

Flexion: fetal chin into contact w/ fetal thorax

Internal rotation: head rotates from transverse to anterior → occiput moves towards pubic symphysis or posteriorly

Extension: head extends w/ crowning so it can pass

External rotation: head returns to transverse orientation

Expulsion: delivery of the anterior and posterior shoulders and torso of the baby

What is the purpose of Leopold's maneuvers and the MacDonald's method?

Macdonald's @ each prenatal visit: measure fundal height for predicting pattern of uterine growth (btwn upper border of pubic symphysis + top of the fundus)

Leopold's maneuvers: to assess position, presentation, and engagement of fetus during 3rd trimester (see slides for hand positioning)

What are the signs of placental separation in the third stage of labor?

-typ. w/i 2-10 mins

-uterus becomes globular in shape + firm

-uterus rises upward in abdomen

-umbilical cord lengthens

-sudden gush of blood

What is lochia and how does it change postpartum?

vaginal d/c that rids uterus of debris post partum made of mucus, blood, and uterine tissue

birth to 3d → lochia rubra = dark red

4d-10d → lochia serosa = pinkish brown

11d-21d → lochia alba = white to yellow (think alba = albino = white)

**Foul odor (+ fever) → suggests endometritis

What are the benefits of breastfeeding for both mother and baby?

transfers antibodies → protects bb from infxs (diarrhea, ear infx, pneumonia)

↓ rates of asthma

↓ risk of breast + ovarian cancer in mothers who breast feed

What are the indications for induction of labor?

when risks of continuing pregnancy outweight risk of delivery

-confirm lung maturity

-common reasons: post-term pregnancy, maternal reasons (preeclampisa or diabetes), fetal issues (growth restriction, decreased amniotic fluid)

-higher bishop score = more likely to have successful induction

What interventions are recommended for late decelerations on fetal monitoring?

Left side

O2

Stop oxytocin

↑ IV fluids

Consider tocolytic (suppress contractions): mag sulfate, terbutaline

What are some risk factors for preterm labor?

Dehydration

Maternal smoking

Maternal substance abuse

Excessive uterine enlargement: polyhydramnios, multiple gestation

Incompetent cervix

Placental abruption

Placenta previa

Infections: chorioamnionitis, UTI, STDs

What are some key features of preeclampsia?

Pre-eclampsia risk factors: 1st pregnancy before 20 y/o, women w/ advanced maternal age, hx of multiple pregnancies, diabetes!

Sx triad manifests after 20th wk - gradual onset of HTN, edema, protein in urine

What are some key features of eclampsia?

-presence of tonic-clonic seizures in a woman that are not attributable to any other cause; hard to tx b/c drugs can cause fetal distress

-Tx: mag sulfate is recommended, ativan or valium may be used if available quickly

-Complications: placental abruption, hemorrhage, disseminated intravascular coagulation

How is prolonged premature rupture of membranes (PPROM) diagnosed?

via speculum exam:

-Fern test (fluid sample on slide dried; ferning = +ROM (literally looks like fern tree leafs)

-Nitrazine test (fluid put on nitrazine paper; if pH > 7 = +ROM (paper turns blue)

What are the signs and symptoms of cervical insufficiency?

Abdominal cramping

Pelvic pressure, abdominal pressure

New low back pain

Increased or change in vaginal discharge → mucus plug, bloody, ROM (amniotic fluid)

What is the clinical presentation of placenta previa?

painless onset of bright red vaginal bleeding!

placenta may be partially or fully covering the cervical os

mean gestational age is 30 wks

dx by ultrasound

What are the risk factors of placental abruption?

Maternal hypertension

Previous abruptio

Trauma

Polyhydramnios that rapidly decompress

PROM

Short umbilical cord

Tobacco use

Folate deficiency

What are the symptoms of placental abruption?

Painful!

Severe abd., pelvic, or back pain

Hard and rigid uterus

Hypercontractibility

Fetal distress is common

Vaginal bleeding +/-

Dx is clinical

Complications of abruptio placenta

severe hypovolemia and shock

DIC

Acute renal failure

What is uterine atony and how is it managed?

failure of uterus to contract post-birth → post-partum hemorrhage

tx: uterine massage, administer oxytocin

Postpartum hemorrhage treatment

IV with fluids

Uterine massage

Breast feeding → stimulates oxytocin

Medication - Methergine, Hemabate, Pitocin

Causes of postpartum hemorrhage

Prolonged labor or multiple gestation

Retained products of conception

Placenta previa

Full bladder

What are common postpartum infections and their risk factors?

UTI: distention/delayed emptying, catheterization/trauma during delivery

Wound: C-section scars, episiotomy, lacerations

Risk factors: PROM, vaginal exam (multiple in labor), endometriosis-retained placenta, C-section, long labor, intrauterine monitoring, intercourse after ROM

Extragenital causes of postpartum infections

Respiratory - atelectasis esp. those with anesthesia

Pyelonephritis

Thrombophlebitis in lower limbs

Mastitis - from blocked milk duct or bacteria entering breast from skin or baby's mouth; most cases w/i 1st 6-12 weeks postpartum

What is hyperemesis gravidarum and how is it treated?

-Pregnancy complication, exact cause is unklnown, related to hCG levels

-Persistent and severe N/V often leads to dehydration and malnutrition

Tx includes:

Start IV: NS, D5LR, LR, Banana Bag

Labs: check blood glucose lvls, orthostatic vitals, ECG, thyroid levels

Medications - Zofran, Phenergan, Reglan, Vitamin B6

What are the diagnostic criteria for gestational diabetes using the 3-hour glucose tolerance test?

Give 100 gm glucose load; abnormal when 2 or more levels equal or exceed:

-Fasting 105

-1 hour 190

-2 hour 165

-3 hour 145

What are the maternal complications associated with diabetes in pregnancy?

Polyhydramnios - incr. amniotic fluid

Preeclampsia - incr. blood pressure

Hypoglycemia

Ketoacidosis and coma

Cardiac, renal, ophthalmic and peripheral vascular

What are the fetal complications associated with diabetes in pregnancy?

CV: atrial and ventricular septal defects, transposition of great arteries. coarctation of the aorta, PDA (patent ductus arteriosus)

Macrosomia (big baby)

CNS: neural tube defects, microcephaly

Intrauterine growth restriction

What is the first-line treatment for gestational diabetes?

-Insulin is best choice for pregnant patients

-dietary control

-oral hypoglycemic medications: glyburide does not cross placental/fetal barrier

Why is iron deficiency anemia common in pregnancy, and how is it treated?

Natural ↓ in Hct during 2nd half of pregnancy b/c newly formed Hgb and RBC mass don't keep pace w/ expansion of maternal blood volume; preg women need additional 800 mg of iron

Tx: Ferrous sulfate 300 mg TID

Why are urinary tract infections treated even if asymptomatic during pregnancy and what ABX options are safe to use?

If infx passed to newborn can cause: respiratory problems, pneumonia, septic shock, meningitis

Also can progress to pyelonephritis and cause preterm labor

E.Coli m.c. agent

Safe Tx: Amoxicillin (but ↑ resistance), Cephalosporins and Nitrofurantoin

What are the risks of untreated bacterial vaginosis during pregnancy?

Premature birth

Low birth weight

Pelvic inflammatory disease

What are the potential effects of syphilis on a fetus?

Still born or babies that die shortly after birth

Blindness

Developmentally delayed

How is HIV managed during pregnancy to reduce vertical transmission?

-administer multiple IV drugs during labor and delivery to ↓ viral load

-C section if > 1000 copies of virus

What is HELLP syndrome and what does the acronym stand for?

Variant of preeclampsia categorized by:

Hemolysis

Elevated Liver enzymes

Low Platelets

Incr. Uric Acid

What are the risks associated with tobacco use during pregnancy?

Placental abruption

Placenta previa

Prematurity

SIDS

Low birth weight