Pregnancy

A patient has a positive pregnancy test that she performed from an over the counter kit. It has been 6 weeks since her last menstrual period. What are the chances that she is pregnant?

>90% The over the counter urine pregnancy kits have very high sensitivity and specificity. Consequently, their results can be trusted. A positive urine tests will correlate with the serum results. The tests identify hCG in the specimen.

A pregnant patient is found to have positive leukocytes and positive nitrites in her urine. What medication should be given?

Nitrofurantoin

A 17 year-old female is found to be pregnant. What is the most important part of her initial screening?

STDs and HIV Routine prenatal screening is important for all pregnant women. As a sexually active adolescent, she is at high risk for STDs and should be screened. These screenings include the most common STDs as well as HIV, hepatitis B and C. Hepatitis A is not transmitted to the fetus. Iron deficiency anemia is very common but is easy to correct. Toxoplasmosis is contracted after exposure to feces of cats and undercooked meats.

A patient was diagnosed today with pregnancy. Her last pregnancy was 3 years ago. At that time she had a protective rubella titer. What should be done about evaluating a rubella titer today?

She does not need one because it was protective 3 years ago Standard practice across the United States is to insure that a protective rubella titer exists in women who are pregnant now. If a pregnant patient had a protective rubella titer in a previous pregnancy, re-evaluation is not necessary. A protective titer is usually 1:10 or greater. If she was found at any time during pregnancy to have a negative rubella titer, she should be vaccinated AFTER delivery.

Few pregnant patients actually deliver on their due dates. Why is a due date established?

To determine timing of maternal/fetal screenings Accurate dating is critical so that maternal and fetal screening tests may be done at the most appropriate time. If a screening test is supposed to take place at 20 weeks, and it is done too early, the opportunity to identify an abnormality may be missed. In the U.S., if a last menstrual period (LMP) cannot be established, or a woman becomes pregnant while taking contraceptives, an ultrasound should be performed.

Routine screening for gestational diabetes:

at about 24-28 weeks The routine time for screening is at 24-28 weeks. This has been identified as the ideal time because she is more likely to exhibit elevations in glucose at 24-28 weeks due to placental hormones that increase insulin insensitivity. This is also a good time to initiate interventions that will decrease complications in the fetus associated with glucose elevations. If the pregnant patient has risk factors or symptoms of diabetes, she can be screened earlier in pregnancy, routinely at 24-28 weeks, and later if warranted.

A pregnant patient in her second trimester will probably have a decrease in her:

blood pressure A decrease in blood pressure is commonly observed in pregnant women in their second trimester. This is part of the normal cardiovascular changes that take place during pregnancy. In fact, sometimes pregnant women can become symptomatic if their blood pressure drops below 80 or 90 mm Hg systolic.

Persistent, intractable vomiting during pregnancy is:

hyperemesis gravidarum Hyperemesis gravidarum (HEG) is a severe form of nausea and vomiting which occurs during pregnancy. In contrast, morning sickness is significantly milder. A common definition used to define HEG is persistent vomiting which produces a weight loss exceeding 5% of pre-pregnancy body weight. The etiology of morning sickness and HEG is unknown.

Ultrasounds are commonly performed during the first trimester of pregnancy because they help estimate gestational age and:

identify fetal malformations Ultrasounds are excellent tools in the first trimester of pregnancy because they can help identify fetal malformations. They are helpful in detecting multiple fetuses, status of the placenta, and help assess gestational age. While it may be argued that ultrasound use improves outcomes in the fetus or mother, this is not why they are commonly performed during the first trimester. There is no evidence that performing an ultrasound early in pregnancy eliminates or reduces the need for ultrasounds later in pregnancy.

The most effective way to decrease the incidence of neural tube defects in pregnant patients is to:

increase folic acid Folic acid has been found to drastically decrease the incidence of neural tube defects (NTD). Folate plays an essential role in synthesis of amino acids and DNA. Since these are critical in cell division and adequate amounts should be on board when cell division begins, folic acid should be taken pre-conceptually. Since this is the second most common congenital anomaly, folic acid should be initiated pre-conceptually.

The need for thyroid replacement during pregnancy:

increases Thyroid hormone needs in pregnant patients with a history of hypothyroidism increase during pregnancy. This occurs in nearly 80% of pregnant hypothyroid women. Since low circulating thyroid hormone can drastically affect growth, TSH levels should be monitored frequently. Needs can increase by up to 50%.

The rubella vaccine is contraindicated in pregnant women because:

it can cause rubella in the infant The rubella vaccine is contraindicated in pregnant patients because it crosses the placenta. Pregnant women should be advised to avoid pregnancy for 28 days after immunization with MMR. It should not be given during pregnancy. However, CDC has collected data on women who have accidentally received the immunization while pregnant and there has been no documented injury to the offspring. The vaccine is safe for women who are breastfeeding even though the rubella virus is excreted in breast milk.

A pregnant patient asks why she must take calcium during pregnancy. The nurse practitioner replies that:

it will strengthen the bones and teeth in your fetus Calcium supplementation during pregnancy is for the fetus, not the pregnant mother. Calcium supplementation will provide extra calcium that is needed during fetal development. It is hypothesized that adequate amounts of calcium will reduce the risk of pregnancy-induced hypertension. Generally, 1000 mg daily is recommended.

In order to establish pregnancy, a pregnancy test of the urine or blood is routinely performed. This test assesses for:

presence of beta hCG Whether performed on urine or blood, the presence of the beta subunit of human chorionic gonadotropin (hCG) indicates pregnancy. This can be found in detectable quantities in the first morning urine or at any time in a serum sample from a pregnant woman. Both tests are highly sensitive. However, if the pregnancy is very early and first morning urine is NOT used, the urine test could be negative in a pregnant patient. A serum specimen will indicate pregnancy at any time of day if it is present. Quantifying the beta hCG level is not necessarily used to diagnose pregnancy, but may be used to determine whether a pregnancy is progressing as expected since beta hCG levels are predictable during pregnancy.

Naegele's rule is calculated by adding 7 days to the last menstrual period and:

subtracting 3 months Naegele's rule is an accepted means of predicting gestational age of the fetus. This is based on an average length of pregnancy of 280 days. If the maternal history is not reliable, ultrasound becomes the standard.

A pregnant patient complains of lower extremity edema and asks for a "fluid pill". The NP explains that:

this is best treated with rest and elevation of the legs It is very common during pregnancy to have lower extremity edema. While this should be monitored to make certain that other more serious conditions are not occurring (pre-eclampsia, heart failure, etc.), this is best treated with rest and elevation of the legs. Lower extremity edema is no longer considered a criterion for pre-eclampsia.

A pregnant patient asks if engaging in sexual activity will place her fetus at increased risk. The nurse practitioner responds:

this may increase the risk of pre-term labor Sexual activity during pregnancy could precipitate pre-term labor because the lower uterine segment may be physically stimulated. Additionally, oxytocin is released which may precipitate pre-term labor. However, in the absence of complications associated with the pregnancy, sexual activity is not contraindicated. If vaginal discharge or bleeding occurs; or rupture of membranes occurs, sexual intercourse should be avoided until assessed by the patient's provider.

A pregnant patient is 30 weeks gestation. She wants to travel to a higher elevation in order to go on a hiking trip. She will fly in an airplane. The nurse practitioner knows:

traveling to a city of high altitude can precipitate pre-term labor There is no risk for the pregnant patient (prior to 35-36 weeks) who is traveling in an airplane with a pressurized cabin. Travel to a city of moderate or high altitude may impose the risk of pre-term labor and bleeding complications. She may be allowed to hike at higher elevations but she should be apprised of the potential risks to her and the fetus. These include dehydration, shortness of breath, tachycardia, pre-term labor, and increased risk of bleeding complications. Practically speaking, serious trauma could occur if she falls. Her balance may be compromised at 30 weeks and falling might be likely. In any event, she should have adequate time to acclimate at this higher elevation before engaging in physical activities like hiking.