Pregnancy & Prenatal Care

B-hCG is only present after _____________ occurs

implantation

1 multiple choice option

urine & serum pregnancy tests both detect presence of __________________________________________________ which is produced by developing placenta

human chorionic gonadotropin (B-hCG/hCG)

urine pregnancy tests are considered reliable ___________ after the first missed period

a few days

- about 5 wks gestation

serum B-hCG starts to rise _________ after ovulation if pregnancy has occurred

8 days

when will B-hCG peak during pregnancy?

near the end of the second month

- at about 100,000 mIU/mL

- during this time, they double about every 48-60 hrs

after the peak in B-hCG, the levels drop to ____________________ & remain relatively constant

20,000-30,000

what do low or slowly rising B-hCG levels often indicate?

ectopic or probable abortion

___________ can also be used to confirm pregnancy

ultrasound

what will the ultrasound findings be at 5 wks gestational age?

- gestational sac in uterus

- if yolk sac seen, intrauterine pregnancy (IUP) is confirmed

at 5+ wks gestational age, _____ can confirm IUP

TVUS

if empty gestational sac is seen w/ TVUS at 5+ wks, what should you suspect?

ectopic

what will the ultrasound findings be at 6-7 wks gestational age?

fetal heart motion

what should B-hCG levels be at 5 wks GA?

1500-2000 mlU/mL

what should B-hCG levels be at 5+ wks GA?

3500 mlU/mL

what should B-hCG levels be at 6-7 wks GA?

6000-18000 mlU/mL

what are the most common symptoms of pregnancy?

- amenorrhea

- breast tenderness & engorgement

- nausea

- fatigue

- urinary frequency & urgency

what are the most common signs of pregnancy?

- chadwick's sign

- linea nigra

- chloasma/melasma

- palmer erythema

- telangiectasias

- piskacek's sign

- hegar's sign

- leukorrhea

- fetal heart tones

chadwick's sign =

dark bluish or purplish-red color of the vaginal cervical mucosa

linea nigra =

dark line appearing longitudinally from symphysis pubis to umbilicus

chloasma/melasma =

brown pigmentation of forehead, cheeks & nose

piskacek's sign =

asymmetrical enlargement of the uterus

hegar's (or Goodell or Ladin) sign =

softening of the cervix in early pregnancy

leukorrhea =

increase in vaginal discharge

when may fetal heart tones be detected by hand held doppler?

by approx. 10-12 wks

what is EDD (or EDC)?

estimated date of delivery or estimated date of confinement

- determined by the first day of the last menstrual period (LMP)

what is Nagele's Rule?

subtract 3 months then add 7 days to the date of the 1st day of the last menstrual cycle

* (LMP - 3 months) + 7 days

what is used to determine EDD if LMP is unknown?

ultrasound

(old) general rule of thumb:

- US in 1st trimester = accuracy w/i 1 wk of true EDD

- US in 2nd trimester = accuracy w/i 2 wks of true EDD

- US in 3rd trimester = accuracy w/i 3 wks of true EDD

accuracy of US dating ____________ as the pregnancy progresses

decreases

if an US is obtained in the 1st trimester, is the EDD obtained from the US or calculated from LMP more accurate?

US

1 multiple choice option

will subsequent ultrasounds change the EDD from the first US, despite discrepancies?

no

1 multiple choice option

10-12 wks: can hear fetal heart tones w/ ________ doppler

handheld

16-20 wks: first fetal movements are..

felt by mother

why is dating important?

- assess fetal development

- patient education for upcoming appts

- know when they're likely to deliver (due date)

what is prenatal (antenatal) care?

preventative in nature

- aims to prevent poor outcome

- emphasized risk assessment & health promotion

prenatal care involves an initial _____________ patient evaluation, followed by multiple routine _______ evals throughout the pregnancy

comprehensive ; focused

when should the initial, comprehensive visit take place?

first trimester

when do the follow-up, focused visits take place?

second & third trimesters

what does the initial patient evaluation include?

- determination of EDD (through LMP; if unknown, order US)

- comprehensive reproductive history (# of pregnancies, outcomes/complications)

- family history (genetic factors)

- social history (smoking, alcohol/drugs, domestic violence, sexual hx, seatbelt use)

- medical history (meds, diseases, surgical hx)

- nutritional assessment (BMI eval & folic acid supplementation)

- physical exam

- labs

what is the leading cause of trauma in pregnancy?

MVA

during medical history, what should you specifically ask about?

*varicella hx

- if no disease or vaccination, baby is at high risk if disease is contracted

*previous c-section

if pt had vertical incision w/ previous c-section:

do not attempt vaginal delivery of this pregnancy

if pt had low, transverse incision w/ previous c-section:

vaginal delivery can be attempted w/ this pregnancy

what does the physical exam include?

- pelvic exam w/ gonn/chalm screen

- PAP smear (if needed according to guidelines schedule)

- uterine size

- comprehensive, overall PE (including: periodontal, thyroid, heart)

fetal heart tones should be heard by doppler if the patient is ____________ gestation

10-12 wks

what labs should be ordered at initial visit (1st trimester)?

- PAP smear (according to screening schedule)

- NAAT (for gonn/chlam)

- RPR/VDRL (for syphilis)

- CBC (Hgb/Hct & MCV)

- blood type & antibody screen

- rubella antibody titer

- hep b surface antigen (HBsAg)

- UA & culture (protein & asymptomatic bacteriuria)

- HIV

- VZV (if no hx of dz or vaccine)

- aneuploidy screening

what can treating IDA (iron deficiency anemia) reduce risk of?

- preterm labor

- growth restriction

- maternal depression

what should be monitored at every routine visit (during 2nd & 3rd trimesters)?

- BP

- weight

- UA (dipstick; for protein & glucose)

- fetal HR, growth, & movement

- eval of any other complaints

- perinatal depression

- eval of normal physiological changes in pregnancy

when is maternal serum alpha-fetoprotein (MSAFP) offered?

15-18 wks

when are (level I) ultrasounds offered?

18-22 wks

when is the glucose load/challenge test (GLT/GCT) done?

24-28 wks

- one or two step method

when is antibody screen (indirect Coombs test) repeated if Rh -?

28 wks

- anti-D immune globulin (RhoGAM) is also given

when should you reassess Hgb/Hct?

28+ wks to assess for anemia

if indicated (high-risk), when should you rescreen for STDs?

28-36 wks

+ rescreen for chlamydia if

you should assess fetal presentation (breech, vertex, transverse, unknown) from ________ onward

36 wks

when should a group B strep culture be obtained?

36 wks

where is the group B strep culture obtained from?

distal vagina & anorectum

what should be done if group B strep culture is positive?

abx prophylaxis should be given to the mother at the time of delivery

- to help prevent possible sepsis, pneumonia or meningitis in the neonate

order a ___ in first trimester if hx of thyroid disease

TSH

order an _______ in first trimester if any risk factors

Hgb A1C

- this can detect undiagnosed T2DM

order a _____________________ in first trimester if hx of drug abuse

urine drug screen

order a ___ in first trimester if high risk of TB

PPD

what should you order for patients w/ SLE (lupus) in first trimester?

antirho & antila antibodies

- positive results can potentially lead to complete heart block in fetus

order ___________________ in first trimester if at high risk

Hep C antibodies

is Hep C treatment done during pregnancy?

no, & both vaginal delivery & breast feeding are okay

what is non-invasive prenatal testing (NIPT)?

eval of fetal cell-free DNA (cfDNA) from maternal blood

- can be done as early as 10 wks gestation (usually 11-14 wks)

NIPT is a __________ test that looks for specific chromosome aneuploidies

screening

1 multiple choice option

what can the NIPT detect?

- trisomy 13, 18, & 21

- gender

higher false positives in detecting:

- turner syndrome (x)

- klinefelter syndrome (xxy)

if the NIPT is negative, then invasive tests (such as, amniocentesis or chrionic villus sampling [CVS]) can be avoided, but if it's positive..

an amniocentesis or CVS is done to obtain fetal tissue

- a diagnostic microarray or FISH will then rule in or out the findings of the NIPT

what is often added if the NIPT is positive, as a further evaluative step?

nuchal translucency

what is nuchal translucency?

an echo-free (dark) area found on US at the back of the fetal neck between 10-14 wks gestation

what has increased nuchal translucency been associated w/?

congenital anomalies

what is the usual schedule for routine check-ups throughout pregnancy?

- q mo up to 28 wks

- q 2 wks from 29-36 wks

- q week after 36 wks

the WHO recommends a minimum of _____ prenatal visits

eight (8)

what is the normal maternal weight gain during pregnancy?

- 3 lbs in 1st trimester

- then, 1/2 to 1 lb/wk

- total of: 30-40 lbs

fetal heart tones can be heard on doppler after ___________

10-12 wks

fetal movement can be felt after ___________

16-20 wks

how is fetal growth evaluated?

by fundal height

what is fundal height?

from the symphysis pubis to the top of the fundus of the mother

- measured in cm

fundal height should match gestational age w/i ____ once the patient has reached 20 wks gestation

3 cm

ask about these things at each appointment to eval for possible complications!!

- HA

- visual changes

- RUQ pain

- edema

- N/V

- urinary sx

- vaginal bleeding

- vaginal leaking of clear fluid

- fetal movement

- cramping/contraction to assess for preterm labor

- mood

what sx require follow-up?

- HA that does not respond to acetaminophen

- persisting visual changes or RUQ pain (longer than a few mins)

- edema involving face

- excessive N/V

- dysuria

- rupture of membranes

- bleeding

- decreased fetal activity

what is one of the most common complications of pregnancy & postpartum?

depression

what does UTD recommend regarding perinatal depression screening?

use formal screening questionnaire once during pregnancy as well as after delivery

what does USPSTF recommend regarding if depression is detected during pregnancy or after delivery?

referral for counseling

which antidepressant has the best safety record in pregnancy & lactation?

sertraline (Zoloft)

which other antidepressant/antianxiety is also safe in pregnancy?

escitalopram (Lexapro)

what are some normal physiological changes in pregnancy?

- nausea

- back pain

- constipation & hemorrhoids

- braxton hicks contractions

- edema of feet & ankles

- GERD

- lower abdominal pain

- varicose veins

- insomia

how is nausea treated in pregnancy?

- OTC: pyridoxine (B6) & doxylamine (antihistamine/Unisom)

- Rx combo: doxylamine/pyridoxine (Diclegis or Bonjesta)

how is back pain treated in pregnancy?

- massage

- Tylenol (acetaminophen)

- heat

- mild stretching

how are constipation/hemorrhoids treated in pregnancy?

- increase water intake

- fiber

- stool softeners

- topical anesthetic & steroids on hemorrhoids

what are braxton hicks contractions?

irregular pattern of contractions

- do not lead to cervical change

how is edema of feet & ankles treated in pregnancy?

elevation

how is GERD treated in pregnancy?

- small meals

- antacids

- H2 blockers or PPIs

how is lower abdominal pain treated in pregnancy?

- stretching of the round ligament

- Tylenol (acetaminophen)

- heat

how are varicose veins treated in pregnancy?

- elevation

- pressure stockings

how is insomnia treated in pregnancy?

diphenhydramine (Benadryl)

what is a maternal serum alpha-fetoprotein (MSAFP) test?

triple or quad screens that detect possible neural tube defect (spinabifida or anencephaly), abdominal wall defects (ompohalocele or gastroschisis) or trisomy disorder

- optional

- ideally performed between 15-18 wks

- false positives are common

if MSAFP results are elevated,

repeating the test is reasonable

two elevated MSAFP results, should be followed w/ a..

level II ultrasound

- to eval for neural tube defect or another anomaly