Exam 2

human reproduction, adaptations to pregnancy, prenatal diagnostics, nutrition in pregnancy

regular physical activity throughout pregnancy

helps control weight, labor is more comfortable, reduced risk of PPD

obese pre-preg weight

inc risk for gestational diabetes, preeclampsia, C/S, more difficult birth

baby at risk for congenital anomalies, stillbirth, prematurity, macrosomia, childhood obsesity

insufficient weight gain during pregnancy can cause

low birth weight baby (

excessive weight gain during pregancy can cause

macrosomia

c/s

low apgar scores

hypoglycemia

inc weight gain retention in children-overweight children

expected weight gain pattern

around 1-5 lbs during 1st tri, and 1lb/week during remainder of pregnancy

teens weight gain during preg

gain at the upper end of range for their pre-preg BMI

caloric needs for pregnancy

2200 cal/day

\*no inc in cal necessary in 1st tri (unless severely underweight or hyperemesis)

300cal/day increase over pre-preg req during 2nd and 3rd tris

(one additional serving of millk, bread, fruits/veggies, protein//adolescents need one more serving of dairy)

myplate

helps pregnancy women customize eating plan based on age, weight, height, physical activity, gestational age

emphasizes quality of food (not just more calories)

make half of plate fruits and veggies, half of grains should be whole, switch to fat free or low fat milk

compare sodium in foods and choose lower numbers

drink water instead of sugary drinks

carbohydrates

primary source of energy and fiber

if intake is inadequate, body will use protein which can lead to ketosis

protein

inc need of 71g/day (compared to 46g/day) (65g when bf)

important for amino acids, feta development and maternal needs

fat

20-30% total caloric intake

essential fatty acids and omega 3 important for CNS fetal development

dairy

2-3 servings/day

vit A, D, E, K (fat soluble)

recommended PNV, no megadosing

folic acid (folate)

CDC recommends all women of childbearing age (15-45) take 400mcg/day

prevents neural tube defects in early pregnancy

B vitamin found in green leafy veggies, beans, fruits, liver, peanuts, whole grains

mother must supplements with folate 400mcg/day at least 1 mo before conception to at least 13 weeks after

iron

deficiency is one of most common disorder in pregnancy

associated with risk of preterm birth, low birth weight baby, inc mortality for both, fetal brain development

many women need to supplement but dont want to (GI upset, constipation, black stool)

teaching: take on empty stomach, or orange juice at bedtime, do NOT take with Ca, milk, tea, coffee bc they can dec absorption.

high iron foods: meat, dark leafy veggies, eggs, whole grains, dried fruit, legumes, shellfish, molasses

preventing Fe def anemia

start on 30mg/day at beginning of pregancy and eat iron rich diet

inc to 60-120 PO/daily if anemia dx

caffeine

< 200 mg/day

changes the absorption or excretion of Ca, thiamine, and Fe

(coffee=100mg, tea=36mg, cola=35-50mg, cocoa=4mg)

general nutrition in pregnancy

sugar substitutes are safe

drink 8-12 glasses of fl/day, 4-6 should be water

mercury in fish

large fish (shark, swordfish, marline, tilefish, mackerel) have high levels which can damage CNS

shrimp, salmon, herring, trout, pollack, catfish= low levels, no more than 12 oz in 2 meals/week

canned tuna= chink light lower than white, up to 6oz/week

raw fish avoided (toxoplasmosis)

bacteria that pose a threat to women and fetus

salmonella

listeria (deli meats, unpasteurized milk)

\*avoid eating foods that contain raw eggs

\*can cause miscarriage, preterm birth, newborn infection

Listeria prevention

reheat deli metas to steaming/160F

keep fridge at 40F, freezer at 0F

refridgerate leftovers within 2 hours of eating/prep

avoid soft cheeses (unpasteurized milk)

no smoked salmon, canned pates or smoked seafood is safe

Fetal alcohol syndrome (FAS)

facial anomalies

CNS disorders: mental retardation, hyperactivity, delayed gross motor skills,

growth restriction

Kosher

no pork or shellfish

no consuming milk/dairy in same meal

anorexia nervosa

fear of weight gain, distorted body image, very restrictive dietary intake, often excessive exercise, extremely underweight

bulemia nervosa

binging and purging, often normal weight

orthorexia nervosa

reject a variety of foods bc not “pure enough”, fixation on righteous eating

Pica

persistent craving/eating of substance having little/no nutritional value d/t deficieny of mineral or nutrient like Fe or Ca

must stop behavior STAT

anemia is a cause of this disorder

options like powdered milk/popcicles

nutritional risk factors

low SES

adolescence (eating disorders)

vegetarian diet

lactose intolerance

anemics

pica

multiparity

frequent offenders of gassy baby

onions, cabbage, chocolate, spices, turnips

smoking risks

dec apetite, speeds metabolism, inc risk of SIDS

\#1 cause of gynecologic cancer deaths

ovarian cancer

\*no early detection test, pap smear will no detect it

sx= bloating, feeling full quickly, pelvic/abd pain, urinary frequency

factors that inc risk of ovarian CA

family hx, BRCA mutation, more menstrual cycles, obesity, post-menopause, endometriosis, inc age, hx of breast/uterine/colon/rectal CA

factors that dec risk of ovarian CA

pregnancy, breastfeeding, oral contraceptive use, removal of fallopian tubes/ovaries, tubal ligation

3 indication for prenatal diagnostics

detect congenital anomalies

evaluate condition of fetus in high risk pregnancy

to provide baseline info like more accurate gestational age

ultrasonography

high freq sound waves aimed in specific direction, deflected by objects in path and return echoes

converted to 2 or 3d images

real time scanning allows fetal heartbeat, breathing and body movements

widely used bc lots of into during any tri

* transvaginal done 1st tri
* transabdominal 2nd and 3rd tri

Pros: clear visualization, safe, non invasive, immediate results

cons: no prenatal care in 1st tri lose accurate dating, can NOT identify every fetal structural defect, high cost w/o insurance, anxiety if abn findings

transvaginal US

done at 1st tri (8wks)

structures are DEEP in pelvis

assesses: gestational sac, crown-rump length, presence of heartbeat, fetal #, maternal anatomy, cervix eval

\*fetal viability confirmed with observation of heartbeat

empty badder, lithotomy position

most accurate gestational age during 1st tri

crown-rump measurement

transabdominal US

uterus is out of pelvis and accessible to evaluate, done around 20 wks (2nd tri)

bladder should be full, semi fowler, drink 1-1.5 quarts of h2O 2 hrs before

assesses: fetal lie # and presentation, presence of abnormal HR or rhythm, fetal anatomy, gestational age, suspected IUGR (size vs gestational age), cervix, amniotic fl vol, placental location, umbilical cord and # of vessels, uterine anatomy

\*also guide needle placement for AMNIOCENTESIS or PERCUTANEOUS umbilical cord sampling

maternal serum alpha-fetoprotein (MSAFP)

level changes with age

if crown to rump measurement is missed during 1st tri, what estimate of gestational age is used

biparietal diameter (most accurate at 12-20 weeks)

others include: femur length, abdominal circumference which is +/- 7-14 days accurate

quantitative beta hCG

secreted by embryo, present in bloodstream 10-14 days after conception

\*in early pregnancy, doubling of 2 quant beta hcg levels drawn 48hrs apart is a good test for VIABILITY

\* if levels are low or remain stable, consider ectopic or non-viable

progesterone

main hormone of pregnancy

low levels assoc may impact fertility, with miscarriage and ectopic

normal levels >25ng/mL

If lower

1st trimester screen

non invasive test offered to all pregnant women

screens for trisomy 18, 13, 21, and Turner syndrome

done at 11-13 weeks

combination of blood test (abn high or low HCG and PAPP-A) and US(nuchal translucency

85% accurate

PAPP-A

pregnancy associated plasma protein A

abn high or low levels in babies with trisomy found in 1st tri screen

nuchal translucency test

US of fetal neck measuring thickness of the fold

babies with trisomy 13 and 18 have more fluid

not diagnostic but screening tool done with 1st tri or quad marker blood test

if abn, more testing like amniocentesis

cell-free fetal DNA (cffDNA)

non-invasive prenatal testing done at or after 10 weeks, maternal blood test

looks for fetal DNA in maternal blood, can identify chromosome abnormalities

screen for trisomy

recommended for AMA, family hx, hx or similar birth

results back in 2 weeks

no risk to fetus

quad marker screening

aka multiple marker screening aka AFP

high sensitivity blood test, low specificity

done at 15-25 wks

screening rather than diagnostic

usually done for women who do not receive prenatal care in 1st tri

shows inc risk of trisomy 18,21 and neural tube defects

tests for: alphafetoprotein (AFP), unconjugated estriol, hCG, inhibin-A

advantages of quad marker screening (AFP)

simple blood sample

least invasive/most economic

prenatal dx allows parents time to examine options/prepare

disadvantages of quad/AFP

if abnormal, first step of many

benign conditions can result in apparently abn levels

limited time frame

glucose tolerance test

screens for gestational diabetes, done at 24-28 weeks (earlier if high risk)

non fasting 50 g oral glucose load, 1hr venous G test

if >140 need further testing

(GDM caused by insulin resistance from hormones)

amniocentesis

aspiration of amniotic fl from amniotic sac for examination; sterile needle inserted into uterine cavity through abdomen

done during 2nd (chromosomal or biochemical abn) or 3rd tri (fetal lung development)

placed in left lateral tilt position w wedge under right hip, no anesthesitic, guided by US, 20-30mL taken, FHR monitored 20-30min after, and right before, monitor TOCO, RH neg women need Rhogam\*

* Pros= simple, safe, painless
* CONS= small time frame (15-20 wks), results take 2-4 weeks, risk of preterm labor, can NOT guarantee perfect baby

indication of 2nd tri amniocentesis

identify chromosomal abnormalities

dx amnionitis (intrauterine infection)

test amniotic fl when AFP is abnormal

indication for 3rd tri amniocentesis

fetal lung maturity

* if delivery probably < 37 wks
* evaluates presence of lethicin/sphingomyelin (L:S ratio**)= lipoproteins that makeup surfactant (2:1 indicates mature fetal lungs**\*)

determine fetal hemolytic disease

* fetal bilirubin to determine Rh sensitization (rh neg antibodies destroy rh pos fetal RBCs and release bilirubin)

reduction amniocentesis

* in polyhydramnios

evaluation of amnionitis and fetal condition

chorionic villus sampling (CVS)

microscopic projection from outer membrane (chorion) that develop and burrow into endometrial membrane as the placenta is formed

evaluation reflects chromosomal and genetic makeup of fetus

done by 10-12 wk

indicated for AMA, hx of previous anomalies, genetic defect carrier

procedure: transcervical or transabd, sample of placenta aspirated, rhogam given if rh neg

* Pros= results in 24-48 hrs, options for earlier decision making
* Cons= risk of spontaneous abortion (2x of amnio), higher risk of limb reduction defects if done

amniotic fluid index (AFI)

US measures vertical depth of largest pocket of amniotic fl in 4 uterine quadrants

5-20cm normal, measuring end organ perfusion\*

* Pros= noninvasive, less costly, outpatient, immediate results, nurses can perform
* Cons= more research needed to refine interpretation of test

kick counts

maternal assessment of fetal movement

starts at 28 wks (3rd tri)

\*10 in 2 most popular (count movement daily for an hour, if

antepartum fetal surveillance

only high risk

3 types: NST, CST, BPP

equipment= bedside monitors, external TOCO, and fetal HR monitor, paper strip

looking at FHR in relation to braxton hicks, HR should inc/react to contraction/stressors of environment

nonstress test (NST)

evaluates fetal heart ability to accelerate with fetal movement= well oxygenated fetus

done after 30-32 wks

fetal monitoring only/ fetus not challenged

indicated for: dec movement, postdates, high risk, maternal anemia, hx of stillborn

results: reactive, non-reactive

* pros= noninvasive, painless, no risk
* cons= false positives (fetal sleep), may have to wait 40 min, acoustic stim may be needed, inc maternal glucose to wake up baby

reactive NST

normal baseline

2 FHR accelerations within 20 min, lasting 15 sec and peak 15 BPM above baseline

extension of time to 40 min to account for fetal sleep

NO DECELERATIONS

before 32 wks= 10x10

contraction stress test (CST)

contraction is stimulated (pitocin or nipple stimulation) for 2 min, 5 min resting period, watching for decels

follow up test of nonreactive NST

negative is normal

* pros= allows md to analyze options for STAT delivery
* cons= can not be done if UCs contraindicated (placenta previa, previous classical c/s), uterine hyperstimulation reduce placental perfusion, time consuming, expensive, tedious, requires hospital setting, errors in interpretation are common

biophysical profile (BPP)

indications= bleeding, chronic conditions, GDM, gestational HTN, preeclampsia, oligo/polyhydramnios, multiple gestation, postdates

done by MD via US

assess 5 parameters of fetal wellbeing indicative of good neuro function and oxygenation


1. FHR accels (NST)
2. fetal breathing movements
3. gross fetal movements (large trunk)
4. fetal tone (small/fine body movements like limb extension/flexion/sucking)
5. amniotic fluid vol

scoring= 0-10; 8-10/10 is reassuring (0-2 point for each 5 parameter for total of 10 points)

intrapartum fetal monitoring

FHR- strongest indicator of fetus tolerating labor (via doppler or fetal scalp electrode= 2cm dilated, ROM)

mothers ctx= assess frequency, duration, intensity

may be external (TOCO) or internal (IUPC)

may be cont (perm record, reduced mobility, difficult to monitor fluffy pts, controversial) or intermittent (low tech, mobility 4 mother, req 1:1 nursing, auscultation FHR and palpation utcs)

\*toco placed over fundus, IUPC inserted past presenting part and must be dilated 2-3cm, ROM

amnioinfusion

warmed sterile NS or LR put into utereus by an IUPC

indications= thick mec, prevent cord compression (oligohydramnios)

also gives accurate info about strength of ctx unlike toco

factors required for adequate fetal oxygenation

1. normal maternal blood flow and volume
2. normal o2 sat and CO2 in placenta
3. open circulatory path between placenta and fetus through umbilical vessels (o2 blood in umbilical vein, deo2 blood in umbilical arteries)
4. normal fetal circulatory and o2 carrying functions
5. pathological influences on fetal o2= HTN, tachysystole, placental abruption

effects of gradual hypoxemia and worsening fetal acidosis

late decels = 1st sign

accels disappear

fetal breathing movement stops

fetal movement stops (late sign)

fetal tone absent (fetus already compromised)

variability

in normal fetus, there is interplay between sympathetic (accels) and parasympathetic (decels) in control of the heart

describes the flucuations in baseline FHR (irregular wavelike line rather than smooth line)

helps clarify how fetus is tolerating stress of labor and factors that cause hypoxia

\*\*SINGLE MOST IMPORTANT FACTOR OF ADEQUATELY OXYGENATED FETUS

causes of decreases in variability

benign causes= fetal sleep, narcotics or sedative (MgSO4), alcohol, gestation

accelerations

temporary inc in FHR at least 15bpm above baseline for 15 secs

often occur w fetal movement, show good oxygenation= reassuring, good variability

episodic= not associated w ctx; d/t fetal movement/stimulation, reassuring

periodic= assoc with utcs

decelerations

dec in FHR by at least 15 bpm lasting 15 sec

early= d/t fetal head compression during ctx, benign

variable= abrupt dec below baseline U,V, W shaped, not consistent w ctx, suggest cord compression

late=occur after acme and cont past end of ctx, suggeset utero-placental insufficiency= FETAL DISTRESS

interventions for variable decels

cord compression

trendelenburg position/ knee to chest position

administer O2

vag exam to feel for prolapsed cord and intervene

c/s may be necessary if not corrected

interventions for late decels

fetal distress/uteroplacental insufficiency

place woman on left side

admin O2 at 8L/mask

inc IVF

vag exam

call MD if not resolved

interventions for non-reassuring HR

identify cause of non-reassuring pattern (maternal VS, vag exam, narcotic given?)

inc placental perfusion (reposition, inc IVF)

inc o2 sat (100% o2 at 8-10L/mask)

reduce cord compression (reposition, amnioinfusion)

4 additional tests to evaluate how fetus is tolerating labor

fetal scalp stimulation

vibroacoustic stimulation

fetal oxygen sat monitoring

fetal scalp blood sample

\*umbilical cord blood gasses after birth

early term

37-38 6/7weeks

full term

39-40 6/7 weeks

late term

41-41 6/7 weeks

postterm

>42 weeks

preterm labor

labor between 20-37 weeks

postterm labor

labor >42 weeks

primigravida

woman pregnant for the first time

gravida

pregnant women

any pregnancy regardless of duration, including current pregnancy

para

woman who have given birth after 20 wks gestation, regardless if born dead or alive

stillbirth

fetus born dead after 20 wks gestation

abortion

birth occuring < 20 wks gestation, or the birth of a fetus who weighs

Gravida/para method

G- number of pregnancies regardless of duration

P- number of pregancies of 20 weeks gestation or more \*multiple infants=single para

GTPAL

gravida/term/ preterm/ abortions/ # of currently living children

presumptive signs of pregnancy

least reliable

subjective things felt by woman: amenorrhea, N/V, fatigue, urinary frequency, breast changes, fetal movement

probable signs of pregnancy

more reliable

usually observed by practitioner

uterine changes: Hegars sign (softening of lower uterine segment), ladin sign, Mcdonald sign, braun von fernwald sign, enlargement, ballotement (baby bounces up and down after vag exam), braxton hicks, palpation of fetal outline, uterine souffle (blood circulation through placenta)

skin changes: linea nigra, areola darkening, chloasma (face), abd striae

vaginal/cervical changes: chadwicks sign (blue color over cervix/labia) caused by increased vascularity; goodells sign (cervical softening)

abd enlargement

positive pregnancy test (hcg, still not certainty, drugs may affect accuracy, urine may be too dilute, ectopic pregnancy)

positive signs of pregnancy

most reliable, woman is pregnant

only viable pregnancy is an IUP (intrauterine) confirmed by US (gestational sac) as early as 4-5 weeks, and fetal heart movement at 6 weeks

fetal heartbeat (detected w doppler at 10-12wks)

fetal movement felt by examiner at around 20 wks

common antepartum labs

blood grouping with Rh factor and antibody screen= possible blood incompatibility

antibody titer (indirect coombs)= Rh neg women, determine if they have antibodies; if negative repeat at 28 weeks

CBC= infection and anemia

hemoglobin= anemia

VDRL/RPR= syphilis

Rubella titer= determine immunity, immunize PP if not immune

TB test= if positive refer to more testing

Hep B= HbsAg should be neg, if positive newborns should be given Hep immune globulin and vaccine after birth

HIV screen= voluntary,

UA= renal disease or infection, assess further is positive for trace protein (preeclampsia), ketones (dehydration, fasting), bacteria (infection)

PAP test= screen for cervical neoplasia

cervical culture= GBS and STIs, tx GBS during labor

sickle cell= screen for african descent

illicit drug screen

glucose challenge test= gestational diabetes 20-24 wks

menstrual history

necessary to obtain EDC, EDB, EDD= all mean estimated date of delivery

during 2nd trimester fundal height is an indicator of

fetal growth, also given gross estimate of fetal gestation

can indicate IUGR or multiple gestation or LGA

should match weeks gestation with cm +/- 2cm

centering pregnancy prenatal visits

8-10 women group prenatal visits

still have individual shorter exam with OB

helps normalize experience

group remain intact throughout pregnancy

begin at 12-16 wks gestation and end with an early PP visit

at beginning of each meeting, measure own BP, weight, urine dips

fetal HR and fundal height obtained by nurse

pros= dec in low birth weight babies, inc in breastfeeding rates

frequency of antenatal visits conception- 28 wks

q4wks

frequency of antenatal visits 29-36 wks

q2wks

frequency of antenatal visits 37 wks-birth

qweek

någeles rule

1st day of last period + 7 days - 3 moths= due date

can be off by 2 weeks

uterus changes in pregnancy

before size is a pear (2.5oz), full term is watermelon (can hold 5L)

hypertrophy (inc production of E and progesterone) primarily in fundus

at 12 wks fundus rises above symphysis pubis and moves intestine upward

stretching sensation= broad and round ligaments supporting uterus

by 20 weeks, fundus is at umbilicus

fundus reaches highest point at xiphoid process

during 3rd tri, it presses on diaphragm (SOB, alleviated during lightening)

uteroplacental blood flow changes

50% inc in CO established by end of pregnancy

maternal blood volume increases by almost 50%

braxton hicks contractions

uterus contracts during pregnancy

during 3rd tri, may increase and be felt by woman

tightening of uterine wall that does not results in cervical changes, preparing for labor