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Indications for complete genetic eval

AMA, personal or family hx of defects, abnormal screening

indications for hcg

high: hydatidiform mole
low rising: ectopic pregnancy
dropping: loss or pregnancy greater than 12 weeks

what is included in first trimester screening

biochemical makers:
hcg,
PAPP-A, high in down's syndrome
NT screening: increase = fetal aneuoploidy, cardiac, others

what time frame is first trimester screening completed?

between 9 weeks and 13 weeks. NT can only be done between 11 weeks through the end of week 13

what is included in second trimester screening

AFP- yolk sac and fetus liver, increases to 20 weeks then declines
multiple marker screening (triple) - MSAFP (maternal AFP), hcg, unconjugated estriol
integrated screen: quad and NT

on a multiple marker screening an elevated hcg is indicative of

down syndrome

when is the multiple maker screen completed?

between 15 and 18 weeks and should be down with first trimester screens (combination is a integrated or sequential screening)

on a multiple marker screening an elevated AFP is indicative of

neural tube defect like spina bifida (associated with increased levels of actylcholinesterase in amniotic fluid, or omphalocele, or gastroschisis, or multiple gestation

what is added to Multiple marker screen to make it a quad?

inhibin - an elevated level is suggestive of down's syndrome

what is an elevated AFP indicated?

underestimation of gestational age, neural tube defects, renal anomalies, oligohydramnios, ectopic pregnancy, fetal maternal hemorrhage, underweight mother, black race, increased placenta size

what does a low AFP indicate?

down's syndrome

how do you test for neural tube defects?

amnio for AFP, acetylcholinesterase testing, karyotyping

When do you do a CVS?

between 8 and weeks, not after 10

what are some disadvantages for CVS

increased risk of pregnancy loss, oligohdraminios, ROM, subchorionic hematoma, limb reduction

What are indications for cordocentesis?

rapid DNA karyotyping of fetus, assessment and tx of Rh isoimmunization, measurement of blood gases for severe IUGR, fetal infection dx

What are some indications for BPP?

IUGR
postdates
Non reactive NST
multiple pregnancy
IDDM

What is tested on BPP

fetus oxygenated and neurologically intact,
movement, muscle tone, respiratory activity

what level on BPP is delivery indicated?

4/10

What can cause low amniotic fluid volume?

uteroplacental insufficiency, fetal hypoxia, fetal genitourinary or lung anomalies

What can cause a high amniotic fluid volume?

chromosomal abnormalites, structural anomalies, neural tube defect, CNS malformations, maternal DM, maternal substance abuse

what is doppler velocimetry

fetal umbilical arteries, velocity of flow through the fetal umbilical arteries to the plactenta
IUGR -> vessels narrow -> increase in ratio between systolic and diastolic

What are some high risk factors in pregnancy?

Diabetes
thyroid disease
active TB
chronic lung disease
severe asthma
epilepsy
clotting abnormalities
Rh with antibodies
severe anemia
acute viral infections
congenital heart disease
renal disease
extreme obesity

What is naegeles rule?

LNMP + 7 days - 3 months, majority of women delivery within 10-14 days, longer cycles, add the number of days to the due date and opposite for shorter periods

What should be included in the medical history?

obstetrical hx - including history of abortion, previous c-section
Gyn hx - fibroids, surgeries
contraceptive history - (IUD may have led to anemia or scarring of uterus). PID,
Family history - HTN, DM, CA

what is the deal with Toxoplasmosis

causes severe neurological damage to the fetus, but only if contracted after 10 weeks (uncooked meats and cat feces)

why is pyelonephritis so risky in pregnancy

can cause premature labor

What is included in first visit?

establish due date
weight
urine
BP
pulse
temp
DTRs - to establish baseline
breast exam
pelvic assessment (may be postponed)
fundal height
perform uterine/ fetal palpation
FHTs

What do you need to assess on initial pelvic assessment

cervix - consistency, length, patency and position
bimanual exam - size of uterus
pelvic pelvimetry

5 steps of pelvimetry

assess the depth of the sacral curve
assess the size of pelvic inlet
assess diagonal conjugate/assess obstetrical conjugate
assess contour of, and distance between, the ischial spines/interspinous diameter
assess angle, width of pubic arch (done on outside)

iron should be dosed below

100mg/d
recommend 75 mg per day

how much folic acid should a pregnant women take

800mcg

how much protein? how much water

80g of protein
two quarts of water

What lab work is needed

CBC - hbg, hct
VDLR/RPR
Hep B
HIV
rubella titer
blood type with Rh
UA

What causes morning sickness

elevated estrogen and hCG

doses of B6 for morning sickness

50 mg BID

what is happening with itchy palms and soles

intrahepatic choestasis

cause of varicose veins

progesterone relaxing smooth muscle, hindering venous return to throughout the body - 800 IU Vit E

Three layers of the uterus

external - longitudinal
internal- circular
middle - connective

what is a caruncle

hymenal skin tags that occur after birth

anemia definition

HCT- below 33
HBG- below 10

Weight gain

10 lbs by twenty weeks and 1 lb a week after that

What percentage of women bleed in first trimester

25%

What is a women at risk for with retained products of conception from missed abortion?

DIC

how many miscarriages before it is habitual?

>3

what is the time in weeks that an ectopic pregnancy is likely to rupture?

between 8-10

what puts a woman at increased risk for ectopic pregnancy

PID, severe GI upset, appendicitis

Two types of hydatidiform mole

complete - no fetus (abnormal sperm inactivating the chromosomes of the ovum)
partial - fetal tissue present - with abnormal numbers of chromosomes

What is a abnormal development of the chorionic villi?

molar pregnancy

What is a classic symptom of molar pregnancy

light brown bleeding

What age is more at risk for molar pregnancy?

over 40

some signs and symptoms of molar pregnancy

uterus is large for dates and feels woody hard or doughy to touch
abnormally high hCG
elevated hCG can lead to HTN and proteinuria
hyperemesis

is there pain with concealed placental abruption

yes - acute abdominal pain with a persistent location

Risks for placenta previa

previous uterine surgery
endometriosis
multiparity
pregnancies with short intervals between
maternal age over 35

4 types of placenta previa

total
partial
marginal
low lying placenta

should you do a vaginal exam with bleeding in late pregnancy?

no never - could be a placenta previa

what are some consequences of gestational diabetes

macrosomia
fetal respiratory distress- due to increased insulin interrupts production of surfactant
pre-eclampsia
polyhydramnios
greater risk for PPH
newborn at risk for hypoglycemia/hypocalcemia

To diagnosis essential HTN, what are the parameters for BP readings

two elevated readings 6 hours apart

what is a consequence of gestational HTN

prolonged HTN can lead to IUGR- secondary to vasoconstriction and decreased O2 getting to fetus
increased risk for placental abruption
preeclampsia and eclampsia

signs and symptoms of preeclampsia

occurring after 26 weeks
hemoconcentration, hypertension, generalized edema, sudden and excessive weight gain, protein in urine

What may be the first sign of preeclampsia

hemoconcentration seen by an abnormally high HCT

pitting edema grading

+1 = 2mm depression
+2 = 4mm depression
+3 = 6 mm depression
+4 = 8 mm depression
(greater than +2 is sign of preeclampsia)

6 symptoms of preeclampsia

severe HA
epigastric pain
visual disturbances
decreased urine output
extreme nervous irritability
decrease in fetal movement

Causes of polyhydramnios

multiples
Rh incompatibility
diabetes
fetal anomalies (esophageal atresia, hydrocephaly, anencephaly or spina bifida)

what is the classic sign of polyhydramnios?

fluid thrill (like for ascites)

what are some underlying conditions of oligohydramnios?

IUGR, postmaturity syndrome, congenital anomalies

what is TTTS

Twin to twin transfusion syndrome -the "donor" baby is at risk for growth restriction and other complications

What are some signs of RDS (respiratory distress syndrome)

cyanosis, tachypnea, grunting, retractions, nasal flaring - all due to insufficient surfactant

Causes of premature labor

vaginal or urinary infection - chorioamnionitis
PROM
incompetent cervix
polyhydramnios
multiples
uterine abnormalities
faulty implantation of the placenta
substance abuse
short interval between pregnancies
malnutrition
fetal death
extreme or chronic stress

When do you suspect IUGR

when normal growth occurs up to 24 weeks and then drops off

Causes of IUGR

malnutrition, anemia, chronic HTN, substance abuse, fetal malformation or infection, abnormalities of placenta or cord, prolonged pregnancy, chronic stress

blood glucose below what, is an indication to call physician

45

What blood issue does IUGR put the baby at risk for?

polycythemia - then jaundice

Causes of LGA

miscalculated dates, molar, diabetes, twins, polyhydramnios, maternal obesity, hereditary predisposition for big babies, fetal anomalies, baby high in fundus due to placenta previa or abnormal muscle tone, fibroids, postmaturity

ways to assess fetal well-being in post dates period

fetal kick counts ( every day for an hour), NST
BPP

what is evaluated in BPP

fetal muscle tone, breathing movements
amniotic fluid volume and NST results

what level on BPP is delivery indicated?

less than 7 (heart and hands)

What do you do to manage shock?

provide oral fluids
position mother flat with legs elevated
administer O2
Keep mother warm, avoid overheating
administer non-allopathic remedies
encourage deep, calm, centered breathing
administer or refer for IV fluids
activate EMS
prepare to transport

What should you look for in the urine of a woman who may have exhaustion in labor

ketones

what can you give a woman with ruptured membranes to decrease chances of infection?

fluid - she will continue to make fluid to flush the vaginal area
Vitamin C (250 mg q 2 hours)

When does implantation bleeding occur?

6-12 days after ovulation

when does quickening occur?

around 18 weeks

fundal height standard measurements

12 weeks - level of symphysis pubis
16 weeks - 1/2 between pubis and umbilicus
20 weeks - 1 finger below umbilicus
36-38 weeks - 2-3 fingers below xiphoid process

recommended weight gain according to BMI

<19.8 = 28-40 lb
19.8 to 26 = 25-35 lb
>26 = 15-25 lb

causes of first trimester bleeding

ectopic, severe cervicitis, cervical lesions, cervical polyp, postcoital bleeding, implantation, subchorionic blood, demise of a twin, rarely h. mole

Causes of second trimester bleeding

ruptured cervical polyp, placental abruption, placenta previa

What is the BP changes that are indicative of pregnancy induced hypertension

usually develops post 28 weeks systolic by 30, diastolic rise by 15, medical intervention needed at 160/100

what is variable decelerations (type III)?

dips in FHTs well below 80 and above 160 during a contractions - caused by cord entanglement or cord compression, the degree of which varies according to the strength of a contraction and the resulting tension or pressure exerted on the cord - change maternal position

what is late deceleration (type II)

dip in FHTs late in contraction, placental insufficiency or maternal ketoacidosis - not enough oxygen reaching the baby,

how dilated does a cervix need to be to determine position

6cm

which fontanelle is smaller

posterior and triangular and the size of a fingernail

what shape is the anterior fontanelle

diamond, size of a thumbnail

what can the mother do before entering second stage do decrease chances of PPH

urinate

what are early decelerations (type I) a sign of

head compression, FHTs return to normal by the end of the contraction

how long is second stage when it becomes prolonged

2 hours

at what FHT rate does birth need to happen ASAP

60 bpm

when the head is visible what is a good way to determine if baby is getting adequate oxygen

press the baby's scalp
white/blue is bad

is suction on the perineum considered mandatory if the baby has passed meconium

yes
it is standard of care

Why do you not want to massage or rub a uterus with a placenta still in it?

is can result in partial separation or hemorrhage

what is considered guarding a uterus according to heart and hands

place a hand on fundus of uterus immediately post delivery and leave it there until delivery of placenta - to prevent concealed hemorrhage

What is it called when the vessels are suspended in membrane alone (without wharton's jelly) occurs right near insertion?

velamentous cord insertion

what is an extra lobe like piece of placenta called

succenturiate lobe

what is a birth red tone to the baby's skin a sign of

polycythemia - usually a sign of prematurity

what is lanugo

fine hair covering the body

two colorings that are abnormal at birth and require immediate transfer

jaundice and circumoral cyanosis

What does a cephalhematoma look like

abnormal, lumplike swelling confined to a particular area of the head and does not cross suture lines, it is internal bleeding between the scalp and the skull

at what level should the ears be in relation to the corner of the eye of a newborn

top of ear equal with corner of eye, lower ears are a sign of kidney problems or other anomalies

what is the concern if the newborn's femoral pulses are not symmetrical

congenital heart defect

what should a babies toes do with a babinski reflex

fan out

How to do you diagnose clinical exhaustion

ketonuria, elevated temperature and elevated pulse

what is fetal overlap

when the fetal head bulges over the pubic bone

What is inlet disproportion

arrest of labor at 6cm dilation, lack of descent past -3 or -2 station, asynclitism, and cervix not well applied to the head

What is midpelvic disproportion

the head generally engages without trouble, dilation proceeds normally, but second stage is prolonged

what is deep transverse arrest

the head gets wedged behind the ischial spines and cannot rotate to the antero-posterior position

what is out outlet disproportion

prolonged second stage, but more commonly affects the perineal phase, causing severe early decels or bradycardia, delayed delivery and tears of the bulbocavernous muscle or perineum

Cord nipping is?

when the cord is periodically pinched between the head and pelvic bones, causing variable decelerations in the Fetal Heart Rate

What can cord nipping lead to in second stage

cord compression

what is an occult cord prolapse

it is when the cord is low enough in the pelvis to be increasingly compressed by the head as it descends, but not low enough to be at the os of the vagina

what are some associations with complete cord prolapse

polyhydramnios, multiple pregnancy, breech or compound presentation and transverse lie

When does a woman push during a breech delivery

not until the body is born

What are the two principle causes of intrapartum bleeding

placenta previa and placenta abruption

definition of third stage bleeding

loss of 500cc of blood after the birth of the baby

three main causes of third stage bleeding

partial placenta separation, cervical lacerations, vaginal tears

what actions should you take with partial placenta separation

immediately give the mother tincture of angelica, begin vigorous nipple stimulation, administer 10 to 20 units of pitocin by IM injection

Why do you not need to worry about pitocin closing the cevical os before the placenta is delivered

because it only contracts the longitudinal fibers of the uterus, not the circular ones

what can you inject into a cut cord to encourage placental seperation

10 units of pitocin mixed with 10 units of saline

How soon can you administer pitocin to attempt to get a placenta out after the initial dose

8 minutes

does methergine close the cervical os

yes

what is fourth stage hemorrhage

blood loss of 500cc or more after the placenta is delivered but within 24 hours of birth

what is the major cause of 4th stage hemorrhage

uterine atony

what is one of the first things you should check with a fourth stage hemorrhage

a full bladder then sequestered clots

what is the difference between placenta accreta and percreta

accreta - placenta implants on myometrium
percreta - placenta invades the myometrium (occurs after cesarean)

what are the two categories of neonatal depression

primary apnea - describes the baby that has not been hypoxic for long, but has made gasping/respiratory efforts while in utero
secondary apnea - baby has dad a greater degree of apnea, and has made a second round of gasping/respiratory efforts - will not try again, needs ventiliation

baby with apgar at 6 needs?

suction, warmth, and stimmulation via immediate firm massage

if a an apgar is less than 7 how often do you do apgar scores after that

every 5 minutes until two in a row are 8 or higher

When doing CPR when do you stop doing chest compression

when the heart rate reaches 60 bpm

at what weight does a stillborn baby need to be in, that a coroner must be notified

500g + (the coroner signs the death certificate)

things to address at PP visits

nipples/breastfeeding
uterus involution
lochia
perinuem healing
mother temp/pulse/BP
baby's cord stump
baby's color, skin consistency
baby's elimination patterns/nursing patterns

What do you need to address at the last visit

the uterus
the cervix - PAP smear
internal muscle tone
lacerations or episiotomy
abdominal muscle tone
breasts - tenderness and lumps
hemoglobin/hematocrit
diet
adjustment to parenting

baby hypoglycemia is at what level

50 - 60 is normal, anything below 30 is serious

What babies are at risk for hypoglycemia

LGA
SGA
premature
postmature
babies of diabetic mothers

what are some symptoms of hypoglycemia

apathy, irregular respirations, inability to regulate body temperature, refusal to nurse, irritability, and tremors

treatment suggestion for baby at glucose of 45

nurse as often as possible and water with a little molasses (1 tsp/cup)

flaring, grunting and retractions are signs of

respiratory distress syndrome

what is the cause of transient tachypnea

delayed absorption of fetal lung fluid

what is associated with transient tachypnea

respiratory distress syndrome

meconium aspiration
sepsis
how do septic babies present?

lethargy, irritability, jitteriness, fever, dehydration

when does physiologic jaundice manifest

second or third day

can ABO incompatibility cause jaundice?

yes, similar to the way Rh sensitization does

what is breast milk jaundice

non-threatening condition caused by a hormone in the mother's milk that can interfere with the baby's ability to process bilirubin - manifests after the milk comes in

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