Management of Pregnancy

Most important factor in neonatal mortality?

Low birth weight (LBW) is the strongst predictor

What medications are commonly contraindicated?

Isotretinoin (Accutane), NSAIDs (ibuprofen, naproxen), tetraclycline, warfarin

What is Isotretinoin (Accutane)

Used to treat severe acne, but causes serious congenital abnormalities if exposed during pregnancy → cleft palate, heart, hearing loss, microcephaly

Risk factors for negative pregnancy outcomes

Alcohol, drugs, smoking, certain medications, poor health, STIs

Health related risk factors for negative pregnancy outcome

Diabetes, folic acid deficiency, obesity

What is the recommended folic acid intake per day?

400-800 mcg/day prevents neural tube defects

Disease risk factors for negative pregnancy outcomes

HIV/AIDs, Hep B, STIs, rubella seronegativity (no antibody)

What is Naegele’s Rule?

First day of LMP subtracted by 3 months, add 7 days, and adjust year; ultrasound most accurate to date pregnancy

Preeclampsia

Pregnant person develops high blood pressure after 20 weeks of pregnancy with signs that kidneys/liver/brain, can lead to eclampsia (seizure)

What are signs of organ involvement in preeclampsia?

↑ BP, proteinuria, RUQ/epigastric pain

What should patient do before initial physical examination?

Put on gown and empty bladder; a clean-catch urine specimen is collected

What heart changes are expected in pregnancy?

HR increases 10-15 BPM and CO/BV increase but BP maintained; soft systolic murmur is normal

What is fundal height used for?

To estimate gestational age and monitor fetal growth

When does fundal height become useful for assessing pregnancy progression?

After about 12 weeks, when uterus rises out of the pelvis; at symphysis pubis

What is fundal height around 20 weeks?

Fundus is at umbilicus, approximately 20 cm

From about 20-36 weeks, how should fundal height compare with gestational age?

Fundal height in cm = gestational weeks

What is fundal height around 36 weeks?

Just below xiphoid process, fundal height and gestational age stop correlating after

What can fundal height suggest?

Fetal growth restriction (FGR) if too small; excessive amniotic fluid or multiple gestation if too large

Why is early or excessive edema concerning?

Can be sign of preeclampsia as it causes vasoconstriction and increased vascular permeability, esp. if it’s sudden swelling OR HTN

Favorable to nonfavorable pelvic type

Gynecoid → arthropoid → android → platylpelloid

How often should pregnant patient follow-up until 28 weeks?

Every 4 weeks

How often should pregnant patient follow-up until 29-36 weeks?

Every 2 weeks

How often should pregnant patient follow-up until 37 weeks to birth?

Every week

What lab is scheduled for weeks 13-15?

AFP, a SCREENING test to identify fetus risk for neural tube defects (NTDs) or trisomy (chromosomes)

What lab is scheduled for weeks 24-28?

Glucose challenge screens for gestational diabetes from insulin resistance during pregnancy

One-step GTT

Patient receives 75g glucose load and blood glucose measured afterward

Step 1 of Two-step GTT

Patient receives 50g glucose challenge, then blood glucose 1 hr later to see body with sudden increase in glucose; non-fasting

Step 2 of Two-step GTT

If results elevated, patient receives 100g glucose load, then 3-hr glucose test (hr 0, hr 1…hr 3)

What is normal fetal HR?

110-160

What should nurse teach about fetal kick counts?

Count 10 movements during fetus’s usual active period; 10 movements within 2 hours is reassuring generally

What lab is scheduled for 28 weeks?

Rh-status — Rh-negative mother can develop antibodies against Rh-positive fetal RBCs

What does Rho(D) immune globulin (RhoGAM) do?

Prevents unsensitized Rh-negative patient from developing anti-D antibodies; if sensitized then closely monitor!

What lab is scheduled at 36 weeks?

GBS culture (group B streptococcus) collected from vaginal/rectal area to prevent transmission during labor

What does RPR screen?

Syphillis

What does GC screen?

Gonorrhea

What does CHL screen?

Chlamydia

What are normal, routine follow-up assessments?

Weight, BP, urine, fundal height, quickening (week 16), fetal HR

Ultrasound

Non-invasively assesses fetal anatomy, heart, gestational age, presentation, amniotic fluid (1L), placental location

Indications of ultrasound

1st trimester — confirms intrauterine pregnancy

2nd trimester (18-20 weeks) — anatomy scan/congenital abnormalities

3rd trimester (32-36 weeks) — amniotic fluid

Nuchal translucency screening

First-trimester (weeks 11-14) ultrasound SCREENING that measures fluid behind the fetal neck, increased indicates RISK of chromosomal abnormality (trisomy 21, 18, 13)

Amniocentesis

Invasive diagnostic test where amniotic fluid is withdrawn with needle for genetic/chromosomal testing; used with ultrasound guidance

Indications for Amniocentesis

OFFERED around 15-20 weeks when concern with abnormal genetic screening, hx/risk of chromosomal abnormalities, advanced maternal age (AMA)

Preparation for Amniocentesis

Have patient empty bladder immediately before procedure to reduce chance of bladder injury; RhoGAM may be administered if Rh-negative

Risks of Amniocentesis

Discomfort, rupture of membrane (ROM), fetal injury, infection, SAB; low chances

Non-invasive perinatal screening (NIPS)

Noninvasive screening that analyzes cell-free fetal DNA from pregnant women’s blood for increased risk of certain chromosomal abnormalities (cffDNA)

Non-stress Test (NST)

Evaluates fetal heart rate response to fetal movement as indicator of fetal oxygenation/well-being

What is a healthy finding in NST?

Fetal movement should cause HR acceleration, indicating adequate oxygenation (reactive!) w/ 2 accelerations of >15 bpm lasting >15 seconds within 20 minutes (15 × 15 × 2 in 20 mins)

What does nonreactive NST mean?

Doesn’t automatically mean fetal distress; fetal sleep, medications, immaturity or fetal problems leading to further testing

Biophysical profile (BPP)

Combination of NST + ultrasound to assess fetal well-being by checking fetal breathing, movement, tone, amniotic fluid, and NST (0-10; 8-10 is good)

Why is amniotic fluid important in the BPP?

Amniotic fluid is largely from fetal urine, so oligohydramnios can indicate reduced fetal urine production from placental insufficiency

Common causes of pregnancy discomforts

Hormonal changes, enlarging uterus, increased blood volume/fluid retention, increased metabolic demands

First trimester discomforts

Hormonal changes → urinary frequency, fatigue, N/V, breast tenderness, epistaxis/stuffiness, leukorrhea, constipation

Second trimester discomforts

Uterus expanding and applying pressure → backache, varicosities of vulva and legs, hemorrhoids, flatulence (easier trimester)

Third trimester discomforts

Enlarging uterus, increasing hormones, and metabolic demands of fetus → SOB, indigestion, dependent edema, Braxton hicks contractions

What hygiene teaching should be given during pregnancy?

Keep perineal area clean and dry, wear breathable cotton underwear, and do not douche (infection risk)

Why should pregnant patients avoid saunas and hot tubs?

Excessive maternal heat can increase maternal temperature and affect fetus

Why should tight knee-high stocking be avoided?

Interferes with lower-extremity circulation and increase venous stasis

Benefits of exercise during pregnancy

Improves circulation, constipation, gestational diabetes, HTN, strength/posture if done about 150 minutes of moderate activity per week (30 mins daily)

Is sexual activity safe during uncomplicated pregnancy?

Yes, unless there’s unexplained vaginal bleeding, ruptured membranes, preterm cervical changes or preterm contractions

What should patients do during long flights/travel?

Walk periodically, perform calf exercises, consider support hose to reduce stasis/DVT

How should pregnant patient wear a seat belt?

Lap belt across hips/below abdomen; shoulder belt between breasts; airbag should be on

What vaccines should be generally avoided during pregnancy?

Measles, mumps, rubella (MMR), varicella, and live attenuated influenza nasal spray are all live; should be addressed AFTER pregnancy

What vaccines are fine during pregnancy?

Influenza, Tdap, Covid 19, Hep B, and RSV are fine because they are not live

Placenta previa

Placenta implants low in uterus and partially or completely covers the cervix (painless, bright-red vaginal bleeding in 2nd or 3rd trimester)

Lamaze Method

Focuses on controlled breathing and relaxation techniques to manage pain and anxiety with focal point (remain quiet) and imagery

Bradley Method

Focuses on natural childbirth with partner coaching through childbirth with partner learning massage, comfort techniques, assisting with breathing, etc.