Childbearing Exam 3 SG

Homozygous Gene

Genes carrying similar traits (DD, dd)

Heterozygous Gene

Genes carrying dissimilar traits (Dd)

Autosomal Dominant

Pattern of inheritance where the gene doesn't skip generations and there is a 50% chance of expressing the trait. Example:Huntington's disease.

Autosomal Recessive

Pattern of inheritance where the gene skips a generation and there is a 25% chance of expressing the trait. Both parents must be carriers. Examples:Sickle Cell, Cystic Fibrosis.

X-linked Dominant

Pattern of inheritance where the gene doesn't skip generations. If the father has it, all daughters have it. If the mother has it, children are carriers. Example:Vitamin D Resistant Rickets.

X-linked Recessive

Pattern of inheritance more common in mother to son due to being X-linked. Examples:Colorblindness, Muscular Dystrophy.

Multifactorial

Non-Mendelian inheritance due to a combination of genetics and environment.

Monosomy

One allele missing.

Trisomy

One extra chromosome. Example:Trisomy 21 = Down Syndrome.

Fetal Movements

"Kick Counts". Count for 1 hour after a meal. If less than 3 movements in 1 hour or no movement in 12 hours, it is considered bad. Done after 24 weeks but regularly after 28

Ultrasound (US)

• In the 1st Trimester: Used to determine fetal number, size, estimated due date, abnormalities, and gestational age.

• In the 2nd Trimester: Determines viability, GA, growth, abnormalities, placenta location, amniotic fluid volume

• Later pregnancy = abdominal

• Earlier pregnancy = transvaginal

Doppler Blood Flow Analysis

• Measures blood flow through the fetus and placenta. S/D ratio should be 3 or less at 30 weeks. Higher values indicate placental insufficiency.

• Used in patients w/ HTN, diabetes, IUGR, preterm

MRI

not very helpful due to fetus moving around

Multiple Marker Screen

• Screens for Down Syndrome and Neural Tube Defects by using MSFAP markers

• Low MSFAP + high hCG = Down Syndrome

• High MSFAP = Neural Tube Defects

• Done at 16-18 weeks

Nuchal Translucency

Screens for Down Syndrome by measuring the amniotic fluid behind the neck. A measurement greater than 3mm at 11-14 weeks is considered abnormal.

Cell-Free DNA Screening

Separates fetal blood from maternal blood to screen for Down Syndrome, Trisomy 13, and Trisomy 18.

Chorionic Villus Sampling (CVS)

• Taking a sample of the placenta (10-13 weeks)

• Risks: SAB, bleeding, PROM, cramping, fever (> 100.4)

• Give Rhogham

Amniocentesis

• Taking a sample of amniotic fluid (14 weeks)

• Risks: bleeding, cramping, decreased fetal movement, fever
  (>100.4)

• Give Rhogham

Percutaneous Umbilical Sampling

• Taking blood from the umbilical vessel to test for blood disorders, karyotyping, or anemia. 1-4cc of blood is removed.

• Give Rhogham

Biophysical Profile (BPP)

Tests for fetal well-being using the acronym GRAFF (Gross body movement, Reactive HR, Amniotic fluid volume, Fetal breathing, Fetal tone). A score of 8-10 is normal, 4-6 requires further evaluation, and 0-2 requires immediate delivery.

Non-stress Test (NST)

• Tests fetal response to movement. A normal reactive test shows accelerations in fetal heart rate 2 times in 20 minutes.

• An abnormal response shows no accelerations in 40 minutes

• If the fetus is 32 weeks or older, acc = 15 bts/15 secs

• If less than 32 weeks, acc = 10 bts/10 secs

Vibroacoustic Stimulation

• Tests fetal response to sound waves if the NST is non-reactive. Done after 32 weeks.

• 3 secs, up to 3 times qmin. No reaction can mean baby is asleep

Contraction Stress Test (CST)

• Tests fetal response to contractions. Need 3 contractions lasting 40 seconds in 10 minutes. A normal test shows no decelerations.

• Abnormal is positive, late decels → give O2, change position

• Done on patients who are high risk (IUGR, HTN, DM, Preterm)

• Two types Spontaneous & Oxytocin

Preterm Labor

• Labor that occurs before 37 weeks of gestation. Risk factors include infection, high parity, history of preterm birth, premature rupture of membranes (PROM), uterine anomalies, obesity, poor nutrition, bacterial vaginosis, and twins.

• S/S: Cramping, low back pain, vaginal discharge, FFN → if positive, then at risk for preterm delivery

• Fetal Risk: Low birth weight, resp. distress, hypoxia

• Tx: Tocolytics

Tocolytics

Medications used to slow down labor and relax smooth muscles. Examples include Terbutaline, Magnesium Sulfate, and Nifedipine.

Terbutaline

• Given subq

• ADR: Tachycardia, hypotension, CP, pulmonary edema

• Interventions: measure HR and lung sounds before + after (if pulse > 120, no more doses)

• Antidote: propranolol

Magnesium Sulfate

• Given IV

• Side effects: headache, flushing, fatigue

• Toxicity: resp depression + decreased tendon reflexes

• Therapeutic lvl: 4-7.5 mEqL

• Antidote: calcium gluconate

Nifedipine

• Given PO

• DON’T GIVE WITH MgSO4 or Terbutaline

• Antihypertensive + improves contractility

Beta/Dexamethasone

• Given IM at 24-34 weeks to increase L/S ratio (2:1)

• 1 dose q24 hours. Considered completer 24 hrs after 2nd dose

• PAINFUL

PROM

• Premature rupture of membranes, where the amniotic sac ruptures at least 1 hour before the onset of labor.

• Pprom: rom < 37 weeks

• Diagnostics: fluid pooling, ferning, pos nitrazine

• Care: Monitor for infection (fetal tachy, fever, odor, tender abdomen), give antibiotics, monitor for labor

• NO VAG EXAMS

Precipitous Birth

• Labor that lasts less than 3 hours from the onset of contractions to birth.

• Maternal Risk: Uterine rupture, hemorrhage, perineal tears

• Fetal Risk: decreased O2, bruising, bleeding

• Tx: Terbutaline, turn patient L side lying

Dystocia

• Long, dysfunctional labor. Multifetal Pregnancy Dystocia is a risk factor for PROM, preterm delivery, and cesarean section in the mother, and for intrauterine growth restriction and entanglement in the fetus.

• Vag delivery can only be done if one twin is vertex and larger than the other OR if they are >32 weeks + 2000 g

Breech Presentation Dystocia

• When the baby is positioned buttocks or feet first. External version can be done to manually turn the baby around from the outside.

• Done at 37 weeks

• Use tocolytic, Ultra sound, and monitor FHR

• Need Rhogham

Induction

The process of starting labor artificially.

Bishop Score

• Want score above 9 to start labor

• Score <6 needs cervical ripening

Cervical Ripening

• Chemical: prostaglandin (Misoprostol/Cytotec), max 6 doses

• Mechanical: balloon pump instead in cervix to mimic dilation

• AROM + Pitocin

Contraindications for Induction

Herpes infection, vertical uterine incision, placenta previa, malpresentation, cephalic pelvic disproportion (fetal head won’t fit)

Forceps Assisted Birth

• Indications: Maternal exhaustion, fetal distress, fetus at 2+ station

• Risks: fetal skull/neck injury, bruising, laceration, hematoma

• Epidural recommended

Vacuum Assisted Birth

• Same indications as forceps

• Risks: Scalp injury, hematoma (less traumatic)

• Monitoring: FHR, jaundice, anemia, hyperbilirubinemia NO MORE THAN 3 pops off → OR

C-section

• Indications: Mother is a repeat c-section, fetal distress

• Complications: bleeding, infection, injuries, resp. depression (from anesthesia)

• Risk of uterine rupture if attempt to deliver vaginally after c-section. MD and OR must be available

• Interventions: Preop → NPO for 6hrs, IV patency, FHR, Bicitra & Postop → monitor v/s, uterine atony, blood loss

Post-Term Preg

• Birth occurs after 42 weeks

• Risks: Large fetus, postmaturity syndrome, meconium aspiration syndrome → pneumonia risk

• Tx: Non-stress/contraction stress test + Amnioinfusion

Shoulder Dystocia

• Unable to pass shoulders

• Interventions: McRoberts Maneuver, Suprapubic Pressure, Gaskin Maneuver

• Monitor how long head has been delivered

Umbilical Cord Prolapse

• Cord comes out first and is being compressed

• Shout for help → help patient to hands and knees → put on glove and maintain pressure off the cord → C-section

Uterine Rupture

• Uterus ruptures and is now in abdominal cavity

• Risk factors: Hx of c-section, multip, anatomical defect, twins

• Tx: C-section

• Uterine window: uterine wall is so thin that it’s see through

Amniotic Fluid Embolism

• Anaphylactoid Syndrome

• Risk Factors: eclampsia, precipitous birth

• S/S: pulmonary edema, SOB, coughing, LOC changes, hypotension, frothy bloody sputum, possible DIC

• First Action: give O2 and call for help

Gestational HTN

2 high BP readings after 20 weeks

Preeclampsia

• High BP reading after 20 weeks + other symptom

• Risk Factors: Hx chronic HTN, high parity, smoking, diabetes, race

• Mild: BP 140/90, elevated protein, mild headache, edema to hands + face

• Severe: Bp 160/110, elevated protein + creatinine, persistent headache, general edema, visual changes, epigastric pain

• HELLP: Hemolysis, Elevated Liver enzymes, Low PLTs

• Risks: SGA, preterm, fetal demise, hypoxia, maternal acute kidney injury

• Tx: Monitor fetus (NST, BPP, kick counts), MgSO4 (prevents seizures, therapeutic range 4-7.5), Antihypertensive (hydralazine, labetolol), Bed rest, L side lying, Induction (34 weeks for severe, 37 for mild)

Eclampsia

• Seizures w/ preeclampsia and no Hx of seizures

• Tx: Induction (vaginal delivery if >30 weeks and competent cervix, otherwise c-section)

• MgSO4 + seizure precautions

Chronic HTN

• high BP before 20 weeks, persists >12 weeks PP

• Tx: antihypertensives, low sodium

Chronic HTN w/ Superimposed Preeclampsia

• High BP + preeclampsia s/s before 20 weeks & low PLTs, elevated protein, elevated LFTs

SAB

• Pregnancy that ends before 20 weeks or <500g

• Early = <12 weeks, Late = 12-20 weeks

• Give rhogham for all if mother is Rh -

• Threatened: light bleeding + cramping, no tissue passage or dilation

• Inevitable: moderate bleeding + cramping, tissue passage and dilation

• Incomplete: heavy bleeding + cramping, retained tissue passage, dilated

• Complete: light bleeding + cramping, All tissue passed, cervix closed

• Missed: fetal death (no expulsion), light bleeding, decreased size of preg

  • May need uterine evac, risk for DIC

• Septic: pain, odorous/cloudy blood, monitor fetal status and for septic shock

  • More common in incomplete and missed AB

Incompetent Cervix

• Painless dilation during 2nd trimester

• D/t: Hx of cervical laceration, uterine or cervical anomalies, being a DES daughter

• s/s: leaking fluid, fetal parts in vagina, bulging water membrane

• Prophylactic Cerclage: stitching cervix to keep it closed before term. Done in 1st trimester.

Ectopic Pregnancy

• Implantation of fertilized ovum outside of uterus

• Risk Factors: Hx ectopic pregnancy, progesterone IUDs, smoking, uterine masses

• s/s: adenexal pain (near ovaries), referred shoulder pain, shock (d/t rupture + bleeding)

• Tx: transvaginal US (if hCG not btwn 1500 - 1800 = ectopic) progesterone level <5 = ectopic, surgical removal, methotrexate (IM injection, prevents cell growth)

Hydatidiform Mole

• Abnormal fertilization of ovum

• Complete Mole: sperm duplicates itself in ovum → NO FETAL PARTS, FHR, OR FM, size >GA, grape-like vesicles

• Partial Mole: 2 sperm fertilize ovum → Some fetal parts

• General s/s: abnormally high hCG, preeclampsia, snowstorm US

• Tx: D+C, pregnancy contraindicated for 1yr, NEED RHOGHAM

Placenta Previa

• Placenta is the presenting part, implanted lower

• Risk factors: multip, AMA, multi-fetal pregnancy

• s/s: painless BLEEDING, high fetal placement

• Tx: expectant mngmt, NO VAG EXAMS

• Pt ed: no sex, nothing up vag, go to ER if bleeding

Placental Abruption

• Placenta detaches early

• Risk Factors: HTN, AMA, Hx of abruption, short umbilical cord

• s/s: Triad (external/occult bleed, toned uterus, fetal distress), PAIN, decreased FM

• RISK FOR DIC so monitor coag status

• Tx: <36 wks → expectant mngmt, Term → DELIVERY

Cord Insertion

• Vasa Previa: cord is inserted into the membrane of placenta, not the tissue

• Battledore: cord inserts on the side, NOT THE MIDDLE. 

DIC

Triggered by placenta abruption, amniotic fluid embolism, severe preeclampsia/HELLP syndrome, sepsis

Substance Use

• Tx: Group care, more visits, meds to reduce use of substances

• Considerations: what pain meds pts can be given during birth, neonatal withdrawal, breastfeeding concerns, 51-a filing (state will investigate situation)

Preexisting Conditions

• Class A1 diabetes = diet controlled; Class A2 diabetes = insulin controlled

• Early preg = less insulin, Later = more insulin

Pregestational Diabetes

• Goal is HgbA1C <6 before preg

• Risks: macrosomia → PPH, preeclampsia, gestational HTN, hypoglycemia (<65), hyperglycemia (>200)

  • Routine Screening: eye exam, kidney exam, HgbA1C checks

  • Care: limit carbs, ketonuria monitoring, meals before breastfeeding, fetal monitoring

    • Glucose: normal is 65 -120 (may need insulin drip during labor). >140 = DO GTT test (also a routine test)

    • Exercise: 15-30 mins (increases insulin sensitivity) so measure glucose before + after

Gestational Diabetes

• risks and care same as pregestational. Only difference is that glucose levels will return to normal w/in 24 hrs postpartum. 

  • Do 2hr-GTT 6wks postpartum

Hyperemesis Gravidarum

• Prolonged vomiting with weight loss (>5%), dehydration, and electrolyte imbalance

• Tx: antiemetics, antihistamines (reduce vomit center activity), steroids, small frequent meals, eat before getting up, bland foods → Risk for LBW baby

Hypothyroidism

• Risks: miscarriage, stillbirth, LBW, preeclampsia

• Tx: Levothyroxine + Iron (GIVE AT DIFFERENT TIMES, iron blocks absorption of other med) 

Hyperthyroidism

• Same as hypothyroidism

• Tx: PTU, Methimazole, fluids, O2, Iodine

• Thyroid Storm: hyperthermia, tachycardia, altered LOC (agitated, restless), vomiting, HTN

Maternal Phenylketonuria

• Inability to breakdown phenylalanine due to enzyme deficiency

• Fetal Risks: LBW, seizures, microcephaly, neuro delays

• Tx: low protein diet, normal Phenylalanine level (<6mg/dL; measure weekly), Breastfeeding (held off until parents tested and then supplemented w/ phenylalinine)

CV Disorders

• Risks:HF, preterm birth, IUGR, death

• Tx: antihypertensives, stool softener, side-lying position, HOB elevated, ASSISTED DELIVERY, NO METHERGINE OR TERBUTALINE, Monitor decompensation: d/t fluid shift → lung sounds, edema, HR, SOB

Iron Deficiency Anemia

Take iron supplement, iron-rich foods, stool softener

Sickle Cell Anemia

IV fluids, opioids, O2

Asthma

Most common respiratory issue. Tx:Albuterol, monitor FHR, give epidural

CF

Monitor FHR, lung function, and infection. Give epidural

Pruritus Gravidarum

Limited to abdomen, use antihistamine/anti-itch cream

PUPPP

Use antihistamine, anti-itch, and steroid

Intrahepatic Cholestasis

Itching of hands and feet due to elevated serum bile → Med is Ursodiol

Epilepsy

Care:Anticonvulsants, seizure precautions, folic acid supplements

MS

Remission during pregnancy! Care:Vitamin D, epidural use, may have gait difficulties post-partum

Bell Palsy

• Unilateral facial weakness, difficulty closing eye, pain around ear

• Care: preventing eye injury, facial muscle massage

Lupus

Care:Steroids, limit pregnancies, follow-up with rheumatologist

Myasthenia Gravis

• Care:Steroids, assisted vag delivery (due to muscle weakness)

• Can’t use MgSO4 due to toxicity → use keppra

HIV

• Transmission:If high maternal load, prolonged ROM, chorioamnionitis

• Care: DELIVER VIA C/S BEFORE ROM, monitor for infection, Treat other STDs, newborn bath ASAP, nothing up vagina, no breastfeeding, Use Zidovudine (antiretroviral)

UTIs

Antibiotics → s/s:dysuria, pain, urinary frequency/urgency, CVA tenderness, fever, chills

Surgery

Should be delayed, but if emergent → best done in 2nd trimester

Appendicitis

Often confused with early pregnancy symptoms. Care = appendectomy + antibiotics

Trauma

• From MVA, partner, GSW, stab, falls

• Risk: miscarriage, preterm labor, PROM, hemorrhage, uterine rupture

• Assess + stabilize mother FIRST (bleeding, contractions)

• Code Order: call code → uterine displacement → CPR (if non responsive for 4-5min) → assess FHR → c/s