Pregnancy

From 20 weeks to 36 weeks how do you determine the correct fundal height of the uterus?

*Fundal height in cm = gestational age* ***measured from pubic symph. up Ex. 34 weeks pregnant... fundal height should be 34 cm

A pt. comes in and states she is pregnant. She peed on a stick last night and it turned blue. She states her LMP was 4 weeks ago, on March 21st. How would you calculate the EDC (due date)?

1. *Naegal's Rule: LMP+7 days - 3 months* LMP= 3/21 + 7 days = 3/28 - 3 months = 12/28

How do you manage gestational diabetes?

1. 30 kcal/kg/day diet - MUST BE WATCHED 2. Blood glucose monitoring 3. If insulin depndant prior to preggoness - adjust dose as nec 4. If on oral hypoglycemics prior to preggo switch her to insulin - since insulin needs to be injected to work it doesn't affect the fetus if it crosses the placenta, where oral hypoglycem. will affect the fetal response to sugar - would be BAD

Why don't you give me some examples of High Mercury fish.

1. Albacore Tuna 2. Swordfish 3. Shark 4. Tilefish 5. King Mackeral 6. Locally caught - unknown

A diabetic patient of yours gets pregnant. You have told her previously about the unique challenges DM presents to the pregger. She gets knocked up anyway. You take a HgbA1C level on her at ther first visit. It comes back at 9. What complications can occur due to her elevated HgbA1C?

1. Congenital abnormalities - cardiac - neural tube - musculoskeletal 2. Risk of spontaneous abortion

Preggers need lots of calcium.. I mean they do need to make all of those baby bones. What might you suggest your pregnant pts eat in order to ensure lots of calcium enters their system?

1. Dairy products 2. Fish with bones (eat the bones..ewewwwe) 3. Sesame Seeds 4. Some veggies 5. Soy bean curd

What are some other ways to calculate EDC?

1. Estimate using uterine size 2. Gestational Wheel 3. Sonogram

If Intrahepatic cholestasis isn't treated what are the possible outcomes?

1. Fetal Distress 2. Fetal Death 3. Preterm delivery

A patient presents to your office at 12 weeks gestation. She is complaining of intense pruritis. Other than the marks she has made scratching herself there are no visible lesions on her skin. You decided to take a serum bile salt and ALP. It comes back as elevated. What do you Dx this patient with? What is the management of this condition?

1. Intrahepatic Cholestasis of pregnancy 2. Symptomatic Tx and fetal monitoring

A pt. of yours with a known seizure disorder announces she is pregnant. So far she has not had a seizure but you can't guarantee that she will not have one in the next 9 months. How are you going to manage this epileptic throughout her pregnancy?

1. Keep her on her anticonvulsive meds (review dosage) 2. Initiate HIOGH DOSE Folate supplmentation 3. Educate her as to the adverse affects of seizures on the fetus - Hypoxia from seizure will affect fetus adversly 4. Refer her to HIGH RISK PREGNANCY specialist 5. Refer her to neurologist

You have a pt that has been diagnosed with A1 diabetes. What do you counsel her about in regards to the affects of DM on her baby?

1. Macrosomia (BIG ASS BABY) 2. Delayed organ maturity (may be problem if early delivery) 3. Polyhydramnios (too much amniotic fluid) 4. Risk of Shoulder Dystocia

A young woman comes into your office for her first prenatal visit. She is 6 weeks pregnant today. You go through the basics like vitamins, no ETOH, blah blah, blah. What foods are you going to tell this woman to avoid?

1. Raw meat, fish, egss 2. Unpasturized dairy 3. High Mercury Fish - no more than 6 oz/week

How do you manage the pt that has risk factors for gestational diabetes?

1. Send them for Glucose Challenge Test prior to 24 weeks 2. Start with the Oral Glucose Tolerance Test

A women presents to your office for her 30 week pregnancy check-up. You measure her fundal height to be 36 cm. Youy know that it should be 30 cm based on the rule that after 20 weeks fundal height in cm=gestational age. So what are some reasons this woman's utuerus is sooo large?

1. Twins/Triplets 2. Fibroids

What does the level of hCG look like throughout the pregnancy?

1.It doubles every 2-3 days for the 1st 80 days 2.After 80 days it drops to a lower level and stays there for the pregnancy.

At a routine interval visit you measure your patient's fundal height to be midway between her pubic symphasis and her umbilicus. You note is has also dextrorotates (turns to right) What is the estimated gestational age of her fetus?

16 weeks

What is the ideal HgbA1C level for a DM pt to be at right before they get pregnant?

< 7

This hormone is produced by the fetal liver and yolk sac. Its FUNCTION IS UNKNOWN. You can use serum concentrations relative to gestational age to assess risk for fetal abnormalities. What is it?

AFP

Your pt. is officially 20 weeks pregnant. At her monthly exam you measure her fundal height to be.....

At her umbilicus

Your patient is 12 weeks pregnant. Where is the fundus of her uterus located?

At the pubic symphasis

So how much calcium does the average pregger need? And what can they do if they don't get enough?

Daily requirement is 1500 mg - can use supplments or Tums - Take with Vitamin D for better absorption

If the fundal height is measuring larger than estimated gestational age what should you do?

Get a sonogram to confirm gestational age

If your pt has a molar pregnancy what can you expect her hCG levels to be like?

Higher than normal

If your pt is carrying twins what can you expect her hCG levels to be like?

Higher than normal

Soo, what kind of fish can this preggo eat?

Low mercury fish like: 1. Shrimp 2. Canned light tuna 3. Salmon (#1 choice) 4. Pollock 5. Catfish **Limit to 12 oz/week

If your pt has an ectopic pregnancy what can you expect her hCG levels to be like?

Lower than normal

If your pt has an impending abortion what can you expect her hCG levels to be like?

Lower than normal

Your pt, who is 24 weeks pregnant, has gone for her routine Glucose Challenge Test (GCT). Every preggo takes this test around the 25 week mark. It's horrible,you drink 50 grams of a liquid sugar that tastes gross, takes an hour and you can't eat before it so you're a pretty cranky woman by the time its over. Anyway, your pt goes and does it and her results are as follows: After 1 hr her glucose level was 125. What is the next step?

Nothing - she passed, no gestational diabetes for this one

What on earth is an Oral Glucose Tolerance Test?

Ok if the GCT is aweful this one is just pure TORTURE. - Preggo is told to carbo load for 3 days. - On day 4 she fasts and then takes a fasting blood glucose - She then drinks 100 gm of glucose (IIICCCKKKYYY) - Then some lab troll punctures her arm 3 more times, once an hour for 3 hours. - If she get 2 abnormally high values during that time she's got gestational diabetes. *I suggest if you do this to a pt. don't have her come to your office that day as she will be VERY CRANKY cause she can't eat until the 3 hours are up and she has to sit around the lab for 3 hours and she has to drink that crap... trust me.. SHE IS NOT A HAPPY CAMPER when it is over... just sayin.

This hormone is released by Mom's Pituitary. It causes UTERINE CONTRACTIONS and the EJECTION of BREAST MILK. What is it?

Oxytocin

This hormone is produced by the corpus luteum for the 1st 7 weeks of the pregnancy. Between 7 and 10 weeks the production of this hormone is split between the corpus luteum and the placenta. After the 10 weeks the placenta is fully formed and it takes over production of the hormone. This hormone PREPARES and MAINTAINS SECRETORY ENDOMETRIUMfor implantation and RELAXES the MYOMETRIUM. It is derived from maternal cholesterol and is a source of precursers for fetal steroid synthesis. What hormone is it?

Progesterone

This hormone is synthesized by the endometrium and myometrium as well as the mom's and baby's PITUITARY. It helps to prepare Mom's boobs, mammary glands to be exact, for LACTATION. It also starts up MILK PRODUCTION when the baby pops out. It acts as a DIURETIC FOR FETUS and REDUCES PERMEABILITY OF AMNION. What hormone is it?

Prolactin

This hormone is mainly produced by the corpus luteum. It INHIBITS UTERINE CONTRACTIONS and causes CERVICAL SOFTENING. It RELAXES LIGAMENTS, especially those in the pubic region. What is this hormone?

Relaxin

Your pt, who is 24 weeks pregnant, has gone for her routine Glucose Challenge Test (GCT). Her results are as follows: After 1 hr her glucose level was 155. What is the next step?

Send her for an Oral Glucose Tolerance test.

You have classified your patient as having A1 diabetes. What does that mean?

She has Gestational Diabetes that is CONTROLLED WITH DIET

You have classified your patient as having A2 diabetes. What does that mean?

She has Gestational Diabetes that is CONTROLLED WITH INSULIN

A pregnant DM pt is monitoring her blood glucose like you told her too. In the morning, she takes a FBS and it comes back at 105. 1 hpp it is at 145. She takes it again 2 hours after her meal and it has only dropped to 125. How do you manage this patient?

Start her on Insulin

What happens at 36 weeks that makes fundal height not as accurate?

The fetus moves down into the pelvis

A 37 yo pt of yours has just become pregnant with twins. This is her 2nd pregnancy and her first child was 9.8 lbs at birth(macrosomia). Her pre-preggo BMI puts her in the Obese category. Her urine dipstick shows glycosuria. She tells you her mom has DM but she has never been tested for it herself. Do you suspect her of gestational diabetes?

Um.. YAH!

Your 22 yo pt is 20 weeks pregnant. She has no 1st degree relatives with DM. She herself has never been suspected of having DM. Before she got pregnant she was at a normal weight and has not gained excessive weight during her pregnancy. She has no history of either abnormal glucose metabolism nor of a poor obstetric outcome. What is the risk of this pt having gestational diabetes?

Very LOW risk

Your pt, who is 24 weeks pregnant, has gone for her routine Glucose Challenge Test (GCT). Her results are as follows: After 1 hr her glucose level was 210. What is the next step?

You treat her for gestational diabetes.. no further testing needed cause she's got it

What hormone is secreted by TROPHOBLAST, detectable in the blood 8 DAYS after the formation of the trophoblast and DOUBLES in concentration every 2-3 days for 80 days? This hormone is also responsible for maintaining the corpus luteum until the placenta takes over progesterone production.

hCG (human chorionic gonadotropin)

This hormone makes it's appearance at 6 weeks gestation. It ENCOURAGES LIPOLYSIS and INHIBITS GLUCOSE UPTAKE. It's main purpose is to switch mom's body to using fat for energy so all the glucose goes to baby. It causes INSULIN RESISTANCE and CARB INTOLERANCE in mamma. It is produced by the placenta and a bigger placenta will make more of it. What hormone am I speaking of?

hPL