2.Prenatal care and Normal Pregnancy

_ _-qualitative, detects pregnancy after missed menses

urine hCG

_ _-_ - quantitative; confirms pregnancy and follows early pregnancy progression

serum B-hCG

_ _-confirms intrauterine pregnancy, and helps exclude ectopic pregnancy

transvaginal ultrasound

a positive pregnancy test confirms _, not location

pregnancy

ultrasound confirms an _ pregnancy (IUP) and helps exclude ectopic pregnancy

intrauterine

_ _ _ (LMP) is the traditional starting point for dating pregnancy

last menstrual period

_ _ _ (EDD) is calculated from the LMP using _ rule or an obstetric calculator

estimated due date ; Naegele

_-_ ultrasound provides the MOST ACCURATE _ when LMP is uncertain or differs from ultrasound findinfs

first-trimester

_-_ length (CRL) is the preferred first-trimester measurement for dating pregnancy

crown-rump

If LMP and first-trimester ultrasound disagree beyond accepted limits, use the _ to establish the EDD

ultrasound

_ (G): total number of pregnancies (including the current pregnancy)

Gravida

_ (P): Number of pregnancies reaching >/= 20 weeks gestation, regardless of whether the infant war born alive or stillborn

Para

GTPAL system

G= _

T=_ (>/= 37 weeks)

P= _ births (20-36 6/7 weeks)

A= _ (<20 weeks, spontaneous or induced)

L= _ children

Gravida

Term

Preterm

Abortion

Living

pregnancy causes predictable changes that support fetal _ and prepare the body for _ and _

growth

labor and delivery

physiologic changes in pregnancy:

• cardiovascular: _ blood volume, _ cardiac output, mild _ blood pressure

increase, increase, decrease

physiologic changes in pregnancy:

• respiratory: _ oxygen demand, _ tidal volume, mild _

increase, increase, SOB

physiologic changes in pregnancy:

• Renal: _ renal blood flow , GFR, urinary _

increase

frequency

physiologic changes in pregnancy:

• Hematologic: plasma _ increases more than RBC _ causing physiologic _

volume

mass

anemia

physiologic changes in pregnancy:

• endocrine: hormonal changes affect nearly every organ _

system

normal cardiovascular adaptations: Hemodynamic changes

• Increase _ _ (40-50%)

• increase _ _ (30-50%)

• decrease systemic _ _

• increase maternal _ _ (10-20 bpm)

blood volume

cardiac output

vascular resistance

heart rate

common normal findings in pregnancy:

• mild physiologic _

• physiologic dilutional _

• soft systolic _ _

• mild _ lower extremity _

tachycardia

anemia

flow murmur

bilateral edema

Goals of the first prenatal visit:

• confirm a viable _ pregnancy and establish gestational _

• identify maternal and fetal _ factors

• establish _ maternal health

• begin _ care and patient education

intrauterine/age

risk

baseline

preventive

visit components:

• _ history

• _ examination

• _ testing

• _ screening discussion

• _ and anticipatory guidance

comprehensive

physical

laboratory

genetic

counseling

when gathering prenatal history, you want to ask about factors that increase maternal or fetal risk:

• medical _ (HTN, diabetes, thyroid, asthma, seizures)

• previous _ (GTPAL, preeclampsia, preterm birth, cesarean delivery)

• _, _, and _

• _ history and _ disorders

• _ history (tobacco, alcohol, drugs, intimate partner violence)

• _ disease and travel exposures

conditions

pregnancies

medications, supplements, allergies

family/inherited

social

infectious

initial prenatal labs for baseline maternal health:

• _

• _ type, _ status, _ screen

• _ and urine _

CBC

blood, Rh, antibody

urinalysis, culture

initial prenatal labs to screen for infections:

• _

• _

• Hep _

• Hep _

• _/_ (per guidelines)

HIV

syphillis

B/C

gonorrhea/Chlamydia

initial prenatal labs to assess immunity:

• _

• _

rubella

varicella

additional prenatal labs when indicated:

• _ screening

• early _ screening (High-risk patients)

tuberculosis

diabetes

some maternal infections can cross the _ and affect fetal development, early identification allows counseling, monitoring, and interventions when available

placenta

classic TORCH infections

• _

• other (_, _, _ _, others)

• _

• _ (CMV)

• _ _ _ (HSV)

toxoplasmosis

syphillis, varicella, parvovirus B19

cytomegalovirus

herpes simplex virus

possible fetal effects of TORCH

• congenital _

• fetal _ restriction

• pregnancy _ or neonatal _

anomalies

growth

loss/infection

prevention of prenatal infections begin before _ and continues throughout pregnancy with appropriate screening, vaccination, and risk-reduction counseling

conception

why these prenatal tests matter:

• Blood type, Rh status, and antibody screen → identify Rh _ and maternal _

• Complete blood count (CBC) → identify _ and _

• Urinalysis and urine culture → detect asymptomatic _

• Rubella immunity → identify patients who need postpartum _

• HIV, syphillis, and hepatitis → reduce maternal and neonatal complications through early _

incompatability/alloimmunization

anemia/thrombocytopenia

bacteriuria

vaccination

treatment

Rh factor

• Rh-positive = _ antigen present on red blood cells

• Rh-negative= _

D

absent

when is Rh factor a problem?

• Rh _ mother carrying an Rh _ fetus

fetal blood enters the maternal circulation

the mother may form _-_ antibodies

those antibodies can affect a future Rh- _ pregancy

negative/positive

anti-D

positive

_(_) _ _ (RhoGAM) prevents maternal sensitization

Rho(D) immune globulin

prenatal genetic screening estimates the risk of fetal _ abnormalities

chromosomal

in the first trimester (10-13 weeks)

• _-_ DNA (_/_)

has the highest sensitivity for trisomy _, _, and _

• _ _ ultrasound

often combined with maternal serum screening

cell-free (cfDNA/ NIPT)

21,18,and 13

nuchal translucency

second trimester (15-22 weeks)

• maternal _ _ screen

  • screens for _

  • screens for open _ _ defects

serum quad

aneuploidy

neural tube

if genetic screening is abnormal, offer _ testing such as _ _ _ (CVS) and _

diagnostic

chorionic villus sampling

amniocentesis

_ estimates risk, but _ and _ provide a diagnosis

screening

CVS/amniocentesis

diagnostic tests analyze fetal genetic material and can confirm a _ abnormality

chromosomal

_ _ (CVS) performed at _-_ weeks

samples _ tissue

earlier diagnosis

chorionic villus sampling

10-13

placental

_ is performed at _ weeks, samples _ fluid containing fetal cells

amniocentesis

15

amniotic

CVS and amniocentesis provide a _ diagnosis, usually offered after an abnormal screening test, small procedure-related pregnancy _ risk

definitive

loss

ultrasound is used throughout pregnancy for different clinical purposes

first trimester:

• confirm _ pregnancy

• confirm fetal _ activity

• establish gestational _ (crown-rump length)

• determine_ of fetuses

intrauterine

cardiac

age

number

ultrasound uses second trimester:

• detailed fetal _ survey

• evaluate _ location

• assess amniotic fluid _

anatomy

placenta

volume

ultrasound uses throughout pregnancy:

• monitor fetal _

• assess fetal _

• evaluate fetal _-_ when indicated

growth

presentation

well-being

_ trimester ultrasound is the most accurate method for pregnancy dating

first

vaccinations recommended during pregnancy

• _ (inactivated)- any trimester, during season

• _ (27-36 weeks, every pregnancy)

• _ (32-36 weeks during season)

influenza

tdap

RSV

vaccines that are contraindicated during pregnancy

• _ vaccines

  • _

  • _

  • live attenuated _ vaccine (intranasal)

live

MMR

varicella

influenza

maternal vaccination protects both mother and newborn through _ antibody transfer

passive

recommended total weight gain is based on _ pregnancy _ (singleton pregnancy)

pre

BMI

prepregnancy BMI and recommended gain

• underweight (<18.5): _-_ lbs

• normal (18.5-24.9): _-_ lbs

• overweight (25-29.9): _-_ lbs

• obese >/= 30: _-_ lbs

28-40

25-35

15-25

11-20

recommendations on weight gain balance healthy fetal _ while minimizing maternal and fetal complications from excessive or inadequate weight _

growth

gain

nutrition in pregnancy:

• _ vitamin with 400-800 mcg of _ _

  • reduces neural tube defects

• _ supplementation

  • supports increased maternal blood _

• _ and vitamin _

  • supports maternal _ health and fetal _ development

• _ diet with adequate proteins, fruits, vegetables, and whole grains

prenatal, folic acid

iron, volume

calcium/ vit D/ bone/skeletal

balanced

in pregnancy you should avoid:

• _

• _ dairy products and soft cheeses

• _ or undercooked meat, seafood, eggs

• high-_ fish (shark, swordfish, king mackerel, tilefish)

alcohol

unpasteurized

raw

mercury

most nutritional deficiencies are prevented with a _ diet plus a daily _ vitamin

healthy

prenatal

every medication should be reviewed at the first prenatal visit

• balance maternal _ against potential fetal _

• do NOT stop necessary medication without considering maternal _

• use the lowest _ dose when appropriate

• avoid known _ when possible

benefit/risk

consequences

effective

teratogens

common medications to recognize in pregnancy:

• _

• _ inhibitors/_

• _

• _ acid

isotretinoin

ace/arb

warfarin

valproic

typical prenatal care schedule:

• every _ weeks → _ to _ weeks

• every _ weeks → _-_ weeks

• _ → _ weeks until _

• as pregnancy progresses, visits become more focused on fetal weel-being and preparing for the delivery

4 weeks → conception to 28 weeks

2 weeks → 28-36 weeks

weekly → 36 weeks to delivery

in the first trimester, the common focus becomes _, prenatal , _ screening

dating

labs

genetic

in the second trimester, the common focus becomes _ ultrasound, fetal _, _ health

anatomy

growth

maternal

in the third trimester, the common focus becomes fetal _, _ _ _ screening, _ planning

position

group B strep

delivery

_ and higher order pregnancies require closer prenatal surveillance

increased maternal and fetal _

• _ birth (biggest risk)

• fetal growth _ or growth discordance

• _ disorders of pregnancy

• gestational _

twins

risks

preterm

restriction

hypertensive

diabetes

prenatal care considerations include:

• more frequent _

• closer fetal _ monitoring

• earlier referral to _-_ medicine

ultrasounds

growth

maternal-fetal

many symptoms are expected because of normal physiologic changes in pregnancy, some common complaints include:

• _ and _

• _

• urinary _

• mild _

• increased physiologic vaginal _

• mild _ _ pain or lower abdominal _

N/V

fatigue

frequency

SOB

discharge

round ligament/cramping

symptoms that ALWAYS warrant evaluation:

• vaginal _

• leakage of _

• severe abdominal _

• persistent severe _ or _ changes

• decreased fetal _ (later in pregnancy)

bleeding

fluid

pain

headache/ vision

movement

common normal symptoms that often alarm patients, but are usually normal if mild and self-limited:

• light _ early in pregnancy

• mild _

• _

• urinary _

• mild _

• physiologic _

spotting

cramping

fatigue

frequency

SOB

leukorrhea

these symptoms deserve evaluation:

• heavy _

• severe or persistent _

• _

• leakage of _

• _ or significant _

bleeding

pain

fever

fluid

syncope/dyspnea

warning signs in pregnancy that require prompt evaluation:

• heavy vaginal _

• severe abdominal or pelvic _

• persistent _ with inability to tolerate fluids

• _ (>/= 110.4/38C)

• severe _, _ changes, or _ pain

• leakage of _ (possible rupture of membranes)

• decreased fetal _ (after fetal movement is established)

bleeding

pain

vomiting

fever

headache, vision, RUQ

fluid

movement

accurate pregnancy dating guides prenatal _, fetal _ assessment, and _ timing

prenatal care is _ and follows a structured schedule throughout pregnancy

screening test estimates _ and diagnostic tests provide _ answers

routine prenatal testing identifies conditions that can change maternal or fetal _

many pregnancy symptoms are normal physiologic adaptations, but warning signs require _ eval

Rh negative patients require appropriate Rh immune globulin to prevent _

multiple gestation is a _-_ pregnancy that requires closer surveillance

testing, growth, delivery

preventive

risk/definitive

management

prompt

alloimmunization

higher-risk