N370 T1 Part 2 (Weeks 4 and 5)

When is first fetal movement felt by mom

16-20 weeks known as quickening and will occur earlier with second baby

Ultrasound dating of the fetus is best done

<24 weeks

Gravida

=pregnant

What is considered a normal amount of fetal movements in an 2 hours

> 10

Abrnormal levels of protein excretion in pregnancy

>300mg/24hr

POST term

>42 weeks

Abnormal AFB levels? What factors may influence this?

AFB >2.5 is abnormal. AFB <0.5 is associated Tri 21 Factors influencing( gestational age, weight at time of blood draw, maternal diabetes, fetal anomaly, race( higher in black women), fetal viability

Risk assessment in first trimester

Age, alcohol use, smoking, genetics, family history, multiple sexual partners, safety( infections, abuse, CMV)

Preterm

Baby is at least 20 weeks but was delivered before the 37 wk mark

Threatened miscarriage

Condition that suggests a miscarriage might take place before the 20th week of pregnancy -The cervix is slightly opened; heart activity may or may not be present . Some bleeding

Physiologic anemia in pregnancy

Decrease in hemoglobin and hematocrit values caused by dilution of erythrocytes from expanded plasma volume rather than by an actual decrease in erythrocytes or hemoglobin.

Which hormones stimulation lactation

Decreased progesterone levels after birth and presence of prolactin. as well as oxytocin

Early term

Delivered between 37 wks and 38 weeks and 6 days

Full term

Delivered between 39 and 40 weeks and 6 days

Types of closed vs. open miscarraiges

Determined via pelvic exam Closed: threatened, missed, complete Open: inevitable, incomplete

What is the most common chromosomal disorder

Down syndrome (trisomy 21)

When is bleeding most common

During the 1st trimester

Which hormones are responsible for uterine growth early on? Later on?

Early: Increased estrogen and progesterone which supports growth of new muscle fibers and stabilizes the endometrium. The enlarged muscle requires vascular support so new vessels are formed. Later: Uterus continues to grow but is due to mechanics due to a growing fetus Around 7 weeks, uterus is the size of an egg. Around 10 weeks, an orange. And around 12 weeks, a grapefruit

How does the fundus change during pregnancy

Enlarges as pregnancy progresses. Typically follows the week of gestation. Around 20 weeks, the funds should be the height of the umbilicus. The fundal height begins to drop as pregnancy progresses towards labor. Each week, the fundus changes about 1 cm.

T or F: Not accepting a pregnancy indicates that mom will not love or accept the child

FALSE! It takes some time to adjust to fact of being pregnant

T or F: Once a vasectomy occurs, there will not be sperm remaining in the ducts

FALSE! Should be using protection for an additional 3 months afterward with frequent sperm sample checks

T or F: Antibiotics have no role on contraceptive effectiveness

FALSE! They can decrease effectiveness

Antepartum testing methods focus on_____

FHR patterns that are aimed at determining the respiratory function of the placenta and fetal reserve

Which vitamins should be avoided in excess in pregnancy

Fat soluble( A,D,E,K)

Fetal surveillance in high risk patients: what effects the fetal health?

Fetal health will depend on maternal cardiac output, uterine blood supply, placental respiratory function, state of umbilical cord

What is Alpha fetoprotein and what does it measure? When is it primarily measured?

Fetal specific globulin that is synthesized by fetal yolk sac, GI tract and liver. -Unknown function. -Measured in the 2nd trimester and is helpful in determining neural tube defects -One component of screening for Downs

Psychological adaptation during the first trimester

Focus is on the self Begins to do a cost analysis and weighs benefits and the worries -May be unsure and scared/moody -Watches analyzes body image for physical changes -Ambivalence is a common train even when planned

Which nutrient is key in preventing neural tube defects

Folic acid! best to take prior to pregnancy begins

What changes occur in the breasts during pregnancy

Fullness, tingling, nipple sensitivity -Pigment darkens on nipple and areola -Increased vascularity with prominent blood vessels -Montgomery tubercle becomes more prominent( bumps around the nipple) -Lubrication decreases infection risk -Possible striae -Colustrum easily expressed in 3rd trimester

GTPAL for 1st pregnancy

G: 1 T: 0 P:0 A:0 L:0

GTPAL for 3rd pregnancy, 31 week twins who are now 2 yrs old

G: 3 T: 0 P:1 A:1 L:2

Risk factors for DIC

Gestational HTN HELLP( severe preeclampsia) Retained dead uterus -Amniotic fluid embolism -Sepsis, Hemorrhage

What changes are expected in a pregnant woman's cervix

Goodell sign -Friable tissue resulting in easier bleeding -Parous vs. nulliparous cervix -Chadwick sign -Leukorhhea -Mucus plug

What is the P and G for someone who has found she is pregnant, has two sets of twins at home from her prior 2 pregnancies

Gravida: 3rd time being pregnant Parity: had two pregnancies >20 wks( because she has just found she is pregnant, she would not yet be a 3) 3/2

Positive pregnancy

HEAR, SEE(ultrasound), FEEL fetal heart beat, active fetal movement palpated by experienced examiner

What lab work is typically done during pregnancy

Hematocrit is drawn at 28 and 36 weeks to monitor for anemia and infection -At 24-28 weeks, women undergo a diabetes screening( 1 hr test--> if positive will take an addition 3 hr test) -Rh antibody screen( if negative, will be given Rhogam at 28 weeks) At 35-37 weeks, Group Beta strep(GBS) vaginal, rectal cultures and others are done as necessary

Which ethnicity has a higher risk of having a child with neural tube defects

Hispanic woman

How is placenta previa managed

If less than 36 weeks and normal FHR, no contractions and mild bleeding, can be managed with expectant/wait it out. Mom may be hospitalized for observation and baby may be on continuous FHR monitoring. NO vaginal exams. Multiple ultrasounds If mom has persistant bleeding, onset of labor, or fetal distress--> EMERGENT! Likely to need to deliver via C-section

Musculoskeletal changes during pregnancy

Increase in body weight and distribution--> lordosis, compensatory anterior head flexion, increased weight of breasts and impact of shoulders - Ligaments relax which increases the back pain and relaxes the symphysis pubsis and SIJ resulting in a waddling gait -Diastasis recti

What respiratory changes occur during pregnancy?

Increased estrogen levels cause the ligaments of the rib cage to relax -Displacement of the diaphragm by up to 4cm to accommodate the growing uterus and fetus -Increased BMR due to increased O2 demands and greater O2 consumption -Shift from abdominal breathing to chest breathing -Increased vascularity causes congestion in the upper airways

Effect of a pre-pregnancy BMI of 40

Increased risk of pregnancy loss, preeclampsia, gestational diabetes and preterm delivery Labor and delivery complications( prolonged stages and passive descent) Cesearean delivery: more at risk for complications and delayed healing incision Postpartum complications: postpartum anemia, early termination of breastfeeding, postpartum weight retention, and postpartum depression

What happens with the increased vascularity of the vulva/vagina that occurs during pregnancy

Increased tactile sensitivity, increased sexual interest(particularly during the 2nd trimester) Also can cause varicose veins and hemorrhoids as a result of the increased pressure and tissue relaxation

Renal changes during pregnancy

Increased urine volumes and slower flow rates as a result of ureter dilation and renal pelvis dilation -Urinary frequency increases from increased pressure on the bladder -GFR increases -Increased resorption of sodium( supports the blood volume)--> results in edema and swelling - Impaired glucose resorption -Increased protein excretion

When is surgery indicated for an ectopic pregnancy and what are the options?

Indicated when symptoms indicate a rupture: hemodynamic instability, signs of intraperiotneal bleeding Options: Done laparoscopically: salpingostomy or salpingectomy( won't be determined until opened--> depends on size of pregnancy)

Risk factors for ectopic pregnancy

Infection/PID, previous ectopic pregnancy, previous tubal surgery, current IUD user, Prior tubal ligation/ sterilization procedure Major risks: Tubal scarring from chylymydia infections

What is a hydatidiform mole pregnancy? What is a significant diagnostic finding that is seen?

It is the result of an error in fertilization that yields an abnormal zygote( no heart tones) -It implants and proliferates in to grape like clusters and secretes higher B-hCG levels than a regular pregnancy. Bleeding occurs between 6-16 weeks

how does pre-pregnancy weight affect ability to concieve and deliver

Low BMIs have more difficult time conceiving and may be at risk for pregnancy loss, pre-term labor and SGA

Non-reactive non stress test

May not be bad. May indicate baby is sleeping. It CAN indicate immature fetus, maternal smoking, cardiac or neurogenic fetal anomaly, fetal sepsis

Medical management for ectopic pregnancies

Methotrexate therapy to dissolve the tubal pregnancy. It Nisan antimetabolite and folic acid antagonist( avoid folic acid and gas forming foods) After therapy: pelvic rest until B-hCG are undetectable Avoid NSAIDS but can be given acetaminophen for pain

Medical management associated with miscarriages

Misoprostol to compete the miscarriage -Dilation and Curretage where the cervix is dilated and a curette is inserted to scrape and remove remaining contents -Oxytoxin to prevent hemorrhage

What happens if hyaditiform mole is diagnosed

Must be removed. It can become a malignant HcG tumor. Should be treated with Dilation and Curettage and continued monitoring of HcG levels

Contraction stress test interpretation

Negative: NORMAL( no late fetal decelerations with contractions) Positive( abnormal): late deceleration with 50% or more of the contractions Equivocal: intermittent late or variable decels Unsatisfactory: < 3 contractions in 10 min.

Explain what nulli, primi, and multi indicate in terms of gravida and parity

Nulli=never pregnant or no births delivered >20wks Primi: first time pregnant or first birth that is delivered >20 wks Multi: 2 or more pregnancies; 2 or more births>20 weeks

Parous vs. nulliparous changes in the cervix

Nulliparous cervix: smooth and rounded external os Parous: uneven and wide( similar to a fish mouth); more bulky

As the uterus grows, the ligaments holding the uterus are stretched. What does this cause?

PAIN! Heavy weight supported by thing ligaments

Braxton hicks

Painless, irregular contractions that are usually relieved with walking, Will not cause cervical dilation and typically begin occurring around 4 mo

Cultural prescriptions vs. proscriptions

Prescriptions: pregnancy is a "condition"( they are incapable of certain activities) Also refers to what the expectant mother is capable of doing -Proscriptions: taboo; things that should not be done. Having a C- section is bad.Certain people in room are bad. Islamic traditions of no one speaking during the labor except for the father after birth

Why is it essential for the cardiovascular system to adapt to pregnancy

Protect woman's normal physiologic functioning -meet metabolic demands of pregnancy -Meet needs for fetal growth and development

Pregnancy is a state of (Respiratory/Metabolic) (Acidosis/Alkalosis)?

Respiratory alkalosis: increased sensitivity--> increased tidal volume--> PCO2 decreases, base excess and pH Increases

Placental abrutption risk factors and common signs

Risk factors: maternal hypertension, cocain use, blunt external abdominal trauma, multiple gestation, or prior abrution. Anything that increases blood pressure significantly! S/S: vaginal bleeding varies with degree of separation. Abdominal pain, uterine tenderness, contraction/uterine tonicity **BOARDLIKE UTERUS Baby will have a higher mortality rate than mom

If a woman tests negative for Rubella antibodies, what happens?

She will be given an immunization postpartum. Because Rubella is a live vaccine, she cannot be given it while pregnant

Classic signs of placenta previa and diagnosis?

Signs: painless, bright red, vaginal bleeding in 3rd trimester Diagnosis: Done via Trans abdominal ultrasound.

striae gravidarum

Stretch marks, which can develop over the abdomen, breast, and thighs

Nutrient recommendations regarding energy in pregnancy

There is an increased metabolic(BMR) need( recommended increase of 340-452 calories per day in 2nd and 3rd trimester)

Reactive non-stress test

This is good! IF under 32 weeks: acceleration is 10 beats over 10 seconds IF older than 32 weeks, 2 or more accelerations of at least 15BPM above baseline, lasting at least 15 seconds with moderate variability

Ectopic symptom triad? Diagnostics?

Triad: pelvic pain, missed/late period; spotting Diagnostics: quantitative B-hCG and transvaginal ultrasound( ectopic pregnancies have lower HcGs than a regular pregnancy On TVUS: tubal mass <3.5cm, absence of fetal cardiac activity and the mass is intact

Triple and Quad screenings during 2nd trimester

Triple: done at 16-18 weeks for trisomy 21 Quad screen: triple screen and inhibin A( increases accuracy in woman < 35 yrs) . Has slightly lower detection rate and slightly higher false positive rate

T or F: Psychoscocial problems for prenatal care are associated with another cause?

True! Associated with biophysical problems

T or False: Long acting reversible contraception methods have similar efficacy rates as sterilization

True! Implants and IUDS are equally as effective as tubal ligation

Cervical insufficiency

Typically a 2nd trimester problems Cervix softens and dilates( shortens to less than 25mm) but there are no associated uterine contractions and is painless. Typically diagnosed in the second pregnancy after discovering cause of the first pregnancy.

Typical first trimester prenatal care

Weeks 1-12 and 6 days: comprehensive physical and history -Confirmation of EDC based on menstrual history, S/S, and/or ultrasound -FHR Physical exam to assess baseline BP, pelvic dimensions, uterine size/position, general health status, and screening labs

3rd trimester prenatal care

Weeks 27-40 May have visits every 2 weeks and after 38 weeks, weekly. -Continued monitoring of blood pressure, weight gain, fundal height, education/support regarding S/S of labor onset

3 phases of pregnancy adaptation

Woman accepts biologically that she is pregnant and that baby is a part of her -woman accepts fetus as distinct from herself -Woman prepares for birth and parenting

Implantation bleeding

a bleed that occurs at the time in which the conceptus implants into the decidualized endometrium. This occurs about 9 days after ovulation It is a spotting type of bleeding that is link pink or brownish discharge. It is not like the usual menses. May also have some cramping

Contraction stress test

a stress test used to evaluate the ability of the fetus to tolerate the stress of labor and delivery. This test is not to be done on a pre-term infant because this can induce preterm labor. Contractions are either stimulated by nipple stimulation or IV oxytocin. Requires 3 contractions of 40 seconds duration in 10 minute timeframe

Most common site for an ectopic pregnancy

ampullary site( Fallopian tube)

When does the height of the fundus reach the umbilicus

around 20 weeks

When are Fetal Heart tones first listened for

around 8-9 weeks

When are fetal heart tones first heard

between 8-10 weeks

Chadwick sign

bluish discoloration of cervix that occurs normally in pregnancy at 6 to 8 weeks' gestation

Biophysical profile( BPP) is composed of ___ and ___ and monitors______

composed of ultrasound and non-stress test -Monitors hypoxia assessment by visualizing baby and measuring breathing movements, body movements, and fetal tones. The ultrasound measures amniotic fluid volume. The BPP score correlates with the fetal pH Score of 8-10 is normal. A score of 6-8 should be repeated again in 6 hrs. A score of 4 or less requires immediate attention.

Naegele's Rule

count back 3 months from first day of last menstrual period and add 7 days and 1 year

Danger signals in the 3rd trimester

decreased fetal movements and bleedings

Late term

delivered in 41st weeks

Indications for non-stress tests

diabetes, hypertension, IUGR, multiple gestations, oligohydraminos, decreased fetal movement, previous fetal demise, renal disease, cholestasis, SLE. Best done when mom can feel fetal movement, i.e > 20 weeks.

What are some of the reasons women choose not to breastfeed?

dislike it( highest in African American woman); partner doesn't want mom to( Hispanics)

Basic fetal surveillence: what is monitored at each visit

done at each visit Monitors the fetal heart rate, fetal activity, and fetal growth as reflected by fundal height

EDC

expected date of confinement (birth) -most accurately determined during the first trimester and routinely calculated based on LMP

Presumptive diagnosis of pregnancy

experienced by the woman( fatique, breast changes, nausea, missed period) - Not 100% accurate determination because symptoms could be due to other factors

Non-stress tests assesses

fetal oxygenation! It assesses the FHR in response to movement. An acceleration is associated with fetal movement 85T% of the time

Missed miscarriage

fetus has died or is not developing. There is no bleeding or tissue passed.

Variability

fluctuations of 2 cycles/minute or greater in baseline FHR

Hyaditiform mole hCg levels

higher than normal which leads to hyperemisis gravid arum, hyperthyroidism, ovarian cysts, and pre-eclampsia

Mucus plugs are composed of

immunoglobulins and act as a protective barrier from the outside world. Helps fill in the gaps of the tip of the cervix

Feelings towards the 3rd trimester

increasing intensity and feelings of vulnerability -Feels alone -Focus is on labor and delivery process and the uncertainty of it -wats to hear birth stories -Childbirth classes increase knowledge base -increasing discomfort

Linia nigra

line extending down the middle of the stomach

What causes decreases in utero-placental blood flow?

low maternal arterial pressure, contractions of the uterus, and maternal supine position

Inevitable and incomplete miscarriages

moderate to heavy bleeding with an opened cervix. Tissue may be present. There is moderate cramping. Inevitable is often accompanied by rupture of membranes and cerbvical dilation. Incomplete: expulsion of the fetus but retention of the placenta

What occurs during the 2nd trimester

mom begins to feel movement and mom is interested in producing a healthy baby and looks for ways to ensure this. -Mom feels best out of the three trimesters. Develops narcissistic self love( she and baby are one) -May become involved in feminine activities - Tends to seek out other pregnant women -May increase or renew contact with own mother -Begins to question what baby will be like -Increasing feelings of protectiveness

GI changes in pregnancy

nausea during first trimester as a result of increased HcG levels - poor motility and relaxation of the smooth muscle which results in heartburn and constipation -Increased risk for gallstones as a result of gallbladder distention, increased bile emptying time, and elevation in cholesterol -Abdominal pain( multiple possibilities)

Probable diagnosis of pregancy

perceived by the examiner Positive pregnancy test, Chadwic, Goodell and hegar signs, uterine enlargement -These findings may be attributed to something other than a positive pregnancy

Amniocentesis

process of extracting amniotic fluid to obtain fetal cells. Fetal cells are karytotyped and used to determine if there are metabolic or fetal anomalies -Assesses AFP levels -After 32 weeks, used to assess fetal lung maturity

spider nevi

red elevations of skin with lines radiating from center

Chorionic Villus Sampling: What does it measure? What are problems that can occur? When is it indicated? When is it performed?

small samples of placenta obtained for prenatal genetic diagnosis. Performed in `1st trimester around 10-12 weeks. Can induce miscarriage. Indications include: Maternal age> 35, prior child with genetic disorder, parent is carrier, mom is sex-linked disorder, congenital anomaly on ultrasound, abnormal results

Goodell sign

softening of the cervix A normal unpregnant cervix feels like the tip of your nose. Becomes mushy like your lip as you get closer to labor

What are the major danger signs associated with 2nd/3rd trimester

sudden gush of fluid from the vagina, vaginal bleeding, severe abdominal pain, persistent vomiting, epigastric pain, edema of face and hands, severe persistant HA that is not relieved with medication, blurred vision or dizziness, chills with fever over 100.4, painful or reduced UO, decreased fetal movements **Pre-eclampsia, placenta previa, infection, abruption

Which hormones effect the decrease in systemic vascular resistance

vasodilatory effects of progesterone, prostaglandins, and relaxin SVR decreases due to the large percentage of blood volume

2nd trimester( wks 13 to 26 and 7 days) prenatal care

visits every 4 weeks -Monitoring fetal growth and well-being; maternal weight gain, ongoing education regarding physical changes; preparation for nursing, and blood pressure monitoring

Calcium requirements during pregnancy

1000-1300mg daily

This assay is recommended as primary screening for maternal obesity or ultrasound is not accessible

alpha-fetoprotein

pruritis gravidarum

itching during pregnancy

Parity

pregnancy >20 wks! This is different from gravida which means pregnant

What cardiovascular changes occur during pregnancy

-Increased blood volume by 30-45%( primarily increased in plasma) as a protective mechanism to allow for blood loss Mild cardiac hypertrophy Increased heart rate -Split S1/S2 and systolic murmurs due to more blood flow -Blood pressure usually remains the same but may drop slightly -increased coagulability

Standard dose of folic acid administered for prevention of neural tube defects

0.4mg

Where does most of the weight gain in pregnancy go

Baby weighs about 7.5 lbs -Placenta weighs about 1.5 Amniotic fluid is about 2 Blood volume increases to about 4 Increase fluid volume to about 4 Increased uterine weight to 2 lb Body fat and energy stores= 7lb Increase in weight of the breasts: 2lb Total gain: about 30 lb

Which fetal genetic test has higher risk for miscarriage?

CVS and then amniocentesis

Late Preterm

Delivered between 34 weeks and 36 weeks and 6 days

Which medications are more associated with pregnancy loss

Itraconazole( fungal infections) -Methotrexate( for Rheumatoid arthritis) -NSAIDS -Retinoids( acne) -Paroxetine( antidepressant) -Venlafaxine

Ballottement

a sharp upward pushing against the uterine wall with a finger inserted into the vagina for diagnosing pregnancy by feeling the return impact of the displaced fetus; Positive( ?) sign of pregnancy

What is considered Viable?

capacity for extrauterine life; around 22-25 wks

Management of cervical insufficency

cerclage: suture palced around 13-14 weeks

The consent process for a sterilization procedure is determined by

insurance

Which 3 sources are used to measure AFP

maternal serum AFP( levels rise in early pregnancy and peak in the 2nd trimester) -Amnitioc fluid -Fetal plasma

What can fish prevent in pregnancy

may be a preventative factor for congenital GI tract atresia( malformation where part of the intestine is very narrow or disconnected from the rest of the gastrointestinal tract)

Placenta previa? What are the risks for development?

occurs when the placenta implants in lower uterine segment near or over the internal cervical os Risk increases with: previous previa, multiple gestation, closely spaced pregnancies, maternal age >35, prior C-section, D&C, cigarette smoking, uterine abnomalies, or fibroids

Heterotopic pregnancy

occurs when you have a normal pregnancy within the uterus but also an ectopic pregnancy at the same time.

Cholasma

pigmentary skin discoloration usually occurring in yellowish brown patches or spots; referred to as the "mask of pregnancy"

What physical changes should mom be educated about regarding danger signs to look out for in the 2nd trimester

preterm labor, hypertensive conditions, and bleeding

Purpose of folic acid. What is the recommended dosage?

prevents neural tube defects Reccomended dosage: 0.3-0.8mg daily -Also needed in DNA synthesis and maternal production of RBCs

Protein needs in pregnancy

recommended about 1.1g/kg per per day

Iron needs in pregnancy

supplementation may be required rot make the RBCs and for fetal stores Requirements: 30-120 mg daily

Foods to avoid in pregnancy/ recommendations

undercooked meat, Eli meat, undercooked eggs - Pasteurized milk is better than unpasteurized Risks of salmonella, listeria, and toxoplasmosis

Leukorrhea? Why is it produced?

white discharge from the vagina; often a response to elevated progesterone/estrogen