HEHI Exam 4 - Week 5 (Lecture)

What are the 2 Invasive Fetal Test?

Chorionic Villi Sampling - (between 10 and 13 6/7 weeks) Amniocentesis - (between 15 and 17 6/7 weeks)

Effects of STIs on Pregnancy and the Fetus: STIs in pregnancy are responsible for significant morbidity and mortality Pregnancy Effects: - Premature rupture of membranes - Premature labor - Postpartum sepsis - Miscarriage Fetal Effects: - Preterm birth - Pneumonia - Systemic infection - Congenital infection - Stillbirth

Fetal Genetic Screening/Testing In Pregnancy: ►Should be universally offered to ALL patients regardless of age ►Is performed early in gestation ►False+, False‐, Pregnancy anxiety ►Should be paired with appropriate counseling if positive results ►Can be declined

Define the Type of Infection: Group of infections capable of crossing the placenta and adversely affecting the fetus

TORCH Infections: ̶Toxoplasmosis (get from kitty litter) ̶Other infections (e.g., hepatitis) ̶Rubella virus ̶Cytomegalovirus ̶Herpes simplex virus (HSV)

Types of Prenatal Care: ►Traditional (q____ week(s), then ____ week(s), then ____ week(s) ►Reduced visit frequency - World Health Organization (WHO) - at least ____ visits - In the US → trend is to individualize schedule of care ►Group/Centering ►Content vs. Number

Types of Prenatal Care: ►Traditional (q4 weeks, then 2 weeks, then q (1) week) ►Reduced visit frequency - WHO - at least 4 visits - In the US → trend is to individualize schedule of care ►Group/Centering ►Content vs. Number

What are the 5 noninvasive Fetal Test?

Ultrasound - (anytime after 6 weeks) Ultrascreen - combo of ultrasound and maternal blood - (between 9 weeks and 13 6/7 weeks) Quad Screen - serum AFP, hCG, Estriol, Inhibin-A - used to screen Trisomy - (between 15 and 21 6/7 weeks ) MSAFP - maternal serum alpha fetoprotein - (between 15 and 21 6/7 weeks) Non-Invasive Prenatal Testing - (after 10 weeks)

How many prenatal visits does the World Health Organization (WHO) recommend?

at least 4 visits

*** Fetal Test - Invasive: When should a Chorionic Villi Sampling be done?

between 10 and 13 6/7 weeks

*** Fetal Test - Invasive: When should an Amniocentesis be done?

between 15 and 17 6/7 weeks

*** Fetal Test - Non-Invasive: When should a MSAFP (maternal serum alpha fetoprotein) be done?

between 15 and 21 6/7 weeks

*** Fetal Test - Non-Invasive: When should a Quad Screen be done?

between 15 and 21 6/7 weeks

*** Fetal Test - Non-Invasive: When should a Ultrascreen be done?

between 9 weeks and 13 6/7 weeks

What STI has these Side Effects: - Infection often silent and highly destructive - Difficult to diagnose - Symptoms (purulent vaginal discharge, spotting, dysuria) Screening and diagnosis: Management:

*the "H" in cHlamydia is silent = infection often silent cHlamydia Screening and diagnosis - Testing during 1st trimester and again at 36 weeks of pregnancy if patient engaging in risky behaviors - Culture performed of the cervix or urine Management: Antibiotic therapy: - Azithromycin - Erythromycin - Amoxicillin

3rd Trimester Warning Signs: What are 4 signs of Pre-eclampsia?

- Rapid swelling - RUQ pain - Visual changes - Headache unrelieved by Tylenol

*** What are 2 supplements essential for Nutrition and Pregnancy?

- iron - folic acid -- Low risk pregnancy or potential pregnancy: 0.4 mg to 0.8 mg -- Moderate to High Risk pregnancy: 1mg to 4mg (4000 mcg)

What are 3 things you must complete during 1st visit maternal exam

- physical exam - VS - Ht/Wt

*** - If a patient is known to have HSV 2 (Herpes), acyclovir is started when (weeks)? - Why

36 weeks to prevent outbreak and allow for a vaginal birth

3rd Trimester Testing/Interventions (28 and 0/7 weeks - birth): ►Diabetes testing if not already done ►_____ testing ►Repeat HIV per state laws ►Repeat GC/CT and other STIs if at risk ►Give _____ @ 28 weeks if needed ►Monitoring the well‐being of the fetus - Additional ultrasound - BPP - Biophysical Profile

3rd Trimester Testing/Interventions (28 and 0/7 weeks - birth): ►Diabetes testing if not already done ►Group Beta Strep (GBS) testing ►Repeat HIV per state laws ►Repeat GC/CT and other STIs if at risk ►Give RhoGam @ 28 weeks if needed ►Monitoring the well‐being of the fetus - Additional ultrasound - BPP - Biophysical Profile

3rd Trimester Warning Signs: ►Bleeding ►_____ fetal movement ►Severe abdominal pain ►Rupture of membranes symptoms ►Swelling of _____ calf ►Pre‐term labor symptoms - Contractions > _____ per hour - _____ache - _____ pressure ►Pre-Eclampsia signs - Rapid _____ - _____ pain - _____ changes - Headache unrelieved by _____

3rd Trimester Warning Signs: ►Bleeding ►Decreased fetal movement ►Severe abdominal pain ►Rupture of membranes symptoms ►Swelling of one calf ►Pre‐term labor symptoms - Contractions > 5 per hour - Backache - Pelvic pressure ►Pre-Eclampsia signs - Rapid swelling - RUQ pain - Visual changes - Headache unrelieved by Tylenol

Goals of Prenatal Care by Trimester - Name the Trimester: - Monitoring for hypertensive disorders - Prevention of pre‐term birth - Monitoring of fetal health - Preparing for childbirth

3rd trimester: 28 weeks 0 days

A Routine Visit: ►Maternal concerns ►Blood pressure ►Weight ► Fundal height - 1cm per week from 20 weeks (within 2 cm) ► Fetal heart tones after 10-12 weeks ►Gestationally appropriate teaching & testing

Is there a cure for Herpes?

no cure

What is given to prevent GBS in newborns?

penicillin IV - also given in syPHILis

What weeks do providers traditionally do prenatal care?

q4 weeks, then q2 weeks, then q (1) week

What is Quad Screen used for?

used to screen for Trisomy - down syndrome

What are 5 warning signs during 1st Trimester (0-13 and 6/7 weeks)?

► Extreme Pain - Cramping is OK ► Bleeding ► Can't hold down liquids or solids for 24 hours ► Illness ► UTI Sx

*** What is recommended weight gain for overweight (25-29.9 BMI) pregnant patient?

15-25lbs

What STI has these Side Effects: If symptoms present: - Vaginal bleeding - Dysuria (painful/difficult urination) - Increased purulent vaginal discharge Screening and diagnosis: Management:

*cant GO with GOnorrhea = dysuria, vaginal bleeding, inc. discharge GOnorrhea Screening and diagnosis - Testing during 1st trimester and again at 36 weeks of pregnancy if patient engaging in risky behaviors - Culture performed of the cervix or urine Management Antibiotic therapy: - cefixime - ceftriaxone

*** What is the recommended calorie intake during pregnancy?

*set oven to 350 to cook calories 350-450 calories/day

Name the STI: Infection manifests itself in distinct stages - Primary - Secondary - Latent and Late - Neurosyphilis Screening and diagnosis Management

*(sy)Phil(is) is a strange man and manifest himself in distinct stages syPHILlis Screening and diagnosis - All patients diagnosed with another STI or HIV - Pregnant patients - 1st prenatal visit and again if high risk - Serologic tests: Rapid Plasma Regain (RPR) or Treponemal Antibody IGG - TrpAbG Management *(sy)Phil(is) writes with a pen(icilin) - Penicillin

What is the management for Syphilis?

*(sy)Phil(is) writes with a pen(icilin) Penicillin

*** What is recommended weight gain for obese (≥30 BMI) pregnant patient?

11-20lbs

*** For moderate to high risk pregnancy what is recommend amount of Folic Acid intake?

1mg to 4mg (4000 mcg)

Goals of Prenatal Care by Trimester - Name the Trimester: - Screening for maternal risk & problems - Ectopic pregnancy, HTN, co‐morbid disorders - Screening for fetal genetic ABNLs

1st trimester: 0-13 weeks 6 days

*** What is recommended weight gain for average weight (18.5-24.9 BMI) pregnant patient?

25-35lbs

*** What is recommended weight gain for underweight (< 18.5 BMI) pregnant patient?

28-40lbs

2nd Trimester Testing (14 and 0/7 weeks - 27 and 6/7 weeks): ►Anatomy ____ at 20 weeks ►____ screening if appropriate ►____ screening between 24-28 weeks

2nd Trimester Testing (14 and 0/7 weeks - 27 and 6/7 weeks): ►Anatomy Ultrasound at 20 weeks ►Genetic screening if appropriate ►Diabetes screening between 24-28 weeks

2nd Trimester Warning Signs ►Pain ►Bleeding ►Cessation of fetal ____ after quickening ►Any major illnesses ► UTI Sx ►Swelling of ___ calf

2nd Trimester Warning Signs ►Pain ►Bleeding ►Cessation of fetal movement after quickening ►Any major illnesses ► UTI Sx ►Swelling of one calf

Goals of Prenatal Care by Trimester - Name the Trimester: - Screening for fetal phenotype abnormalities - Continued monitoring of maternal/fetal health

2nd trimester: 14 weeks - 27 weeks 6 days

Define the Period: Period of physical and psychological preparation for birth and parenthood that offers opportunities for: ̶Health of the maternal patient and infant ̶Diagnosis and treatment of maternal disorders ̶Education and support for self-care and parenting

Antepartum/Prenatal Period

What is the management for Chlamydia?

Antibiotic therapy: - Azithromycin - Erythromycin - Amoxicillin

What is the management for Gonorrhea?

Antibiotic therapy: - cefixime - ceftriaxone

*** Fetal Tests: Non-Invasive: ►Ultrasound - (anytime after 6 weeks) ►Ultrascreen - combo of ultrasound and maternal blood - (between 9 weeks and 13 6/7 weeks) ►Quad Screen - serum AFP, hCG, Estriol, Inhibin-A - used to screen Trisomy - (between 15 and 21 6/7 weeks ) ►MSAFP - maternal serum alpha fetoprotein - (between 15 and 21 6/7 weeks) ►Non-Invasive Prenatal Testing - (after 10 weeks) Invasive: ►Chorionic Villi Sampling - (between 10 and 13 6/7 weeks) ►Amniocentesis - (between 15 and 17 6/7 weeks)

Fetal Tests: Non-Invasive: ►Ultrasound - (anytime after 6 weeks) ►Ultrascreen - combo of ultrasound and maternal blood - (between 9 weeks and 13 6/7 weeks) ►Quad Screen - serum AFP, hCG, Estriol, Inhibin-A - used to screen Trisomy - (between 15 and 21 6/7 weeks ) ►MSAFP - maternal serum alpha fetoprotein - (between 15 and 21 6/7 weeks) ►Non-Invasive Prenatal Testing - (after 10 weeks) Invasive: ►Chorionic Villi Sampling - (between 10 and 13 6/7 weeks) ►Amniocentesis - (between 15 and 17 6/7 weeks)

First Visit: Education: ►Nutrition (no cold deli meat, queso, raw fish) ►Physical activity ►Travel (up to 36 weeks its ok) ►Medication/herbal preparations ►Immunizations ►Alcohol (none), nicotine (reduce or stop), caffeine (in moderation), illicit drug use (none) ►Normal discomforts ►Recognizing potential complications (1st trimester warning signs)

First Visit: History ►Complete _____ history ►_____ Hx ►_____ Hx ►_____ and family history ►_____ assessment ►_____ assessment ►_____ assessment

First Visit: History ►Complete maternal history ►GYN Hx ►OB Hx ►Paternal and family history ►Psychological assessment ►Risk assessment ►Socioeconomic assessment

First Visit: Maternal Exam: Complete ____ exam + ____ and ____ ____ - HEENT - Heart - Lungs - Skin - Breasts - Abdomen - Extremities

First Visit: Maternal Exam: Complete physical exam + VS and Ht/Wt - HEENT - Heart - Lungs - Skin - Breasts - Abdomen - Extremities

First Visit: Maternal Testing: ►CBC ►Blood type, Rh, Antibody screen ►STIs - HIV - Syphilis (rapid plasma reagin: RPR or Treponemal Antibody IGG - TrpAbG) - Chlamydia - Gonorrhea ►Hepatitis B Surface Antigen → _____ ►Rubella (German Measles) → _____ ►Urine culture

First Visit: Maternal Testing: ►CBC ►Blood type, Rh, Antibody screen ►STIs - HIV - Syphilis (rapid plasma reagin: RPR or Treponemal Antibody IGG - TrpAbG) - Chlamydia - Gonorrhea ►Hepatitis B Surface Antigen → negative ►Rubella (German Measles) → immune ►Urine culture

What kind of feeding (for newborn) is recommended in HIV patients?

Formula feeding recommended - contraindicated in breastfeeding

Goals of Prenatal Care by Trimester: 1st trimester: 0-13 weeks 6 days - Screening for _____ risk & problems - _____ pregnancy, _____, co‐morbid disorders - Screening for fetal _____ ABNLs 2nd trimester: 14 weeks - 27 weeks 6 days - Screening for fetal _____ abnormalities - Continued monitoring of maternal/fetal health 3rd trimester: 28 weeks 0 days - Monitoring for _____ disorders - Prevention of _____‐term birth - Monitoring of fetal health - Preparing for childbirth

Goals of Prenatal Care by Trimester: 1st trimester: 0-13 weeks 6 days - Screening for maternal risk & problems - Ectopic pregnancy, HTN, co‐morbid disorders - Screening for fetal genetic ABNLs 2nd trimester: 14 weeks - 27 weeks 6 days - Screening for fetal phenotype abnormalities - Continued monitoring of maternal/fetal health 3rd trimester: 28 weeks 0 days - Monitoring for hypertensive disorders - Prevention of pre‐term birth - Monitoring of fetal health - Preparing for childbirth

Group B Streptococci (GBS): ►A part of the normal vaginal flora present in 20% to 30% of healthy female patients ►Important factor in neonatal morbidity and mortality ►Screening at ____-____ weeks of gestation ►Intrapartum ______ IV given to prevent GBS in the newborn

Group B Streptococci (GBS): ►A part of the normal vaginal flora present in 20% to 30% of healthy female patients ►Important factor in neonatal morbidity and mortality ►Screening at 35-37 weeks of gestation ►Intrapartum penicillin IV given to prevent GBS in the newborn

HIV: ►Screening and Diagnosis - ____ and ____ Blot ►HIV testing - Routinely performed at ____ prenatal visit - May be tested again in ____ trimester - Opt out vs. Opt in approach ►HIV and pregnancy - Perinatal transmission has decreased due to anti-retroviral prophylaxis - ____ feeding recommended

HIV: ►Screening and Diagnosis - ELISA and Western Blot ►HIV testing - Routinely performed at 1st prenatal visit - May be tested again in 3rd trimester - Opt out vs. Opt in approach ►HIV and pregnancy - Perinatal transmission has decreased due to anti-retroviral prophylaxis - Formula feeding recommended -- contraindicated in breastfeeding

*** Herpes: ►Herpes simplex virus (HSV) - Herpes simplex virus 1 (HSV-1) or Herpes simplex virus 2 (HSV-2) - Initial infection characterized by multiple _____ lesions, _____, _____, malaise, and severe dysuria ►Testing - _____ of lesions or _____ test ►Treatment - _____ cure - _____ medications given like _____ and valacyclovir given to help prevent outbreaks ►Maternal infection with HSV-2 can have adverse effects on patient and fetus - Skin, eye and mouth infections - Central nervous system disease - Disseminated disease ►Cannot deliver vaginally if _____ are present ►If patient known to have HSV 2, acyclovir is started at ___ weeks to prevent _____ and allow for a _____ birth

Herpes: ►Herpes simplex virus (HSV) - Herpes simplex virus 1 (HSV-1) or Herpes simplex virus 2 (HSV-2) - Initial infection characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria ►Testing - Culture of lesions or blood test ►Treatment - No cure - Antiviral medications given like acyclovir and valacyclovir given to help prevent outbreaks ►Maternal infection with HSV-2 can have adverse effects on patient and fetus - Skin, eye and mouth infections - Central nervous system disease - Disseminated disease ►Cannot deliver vaginally if lesions are present ►If patient known to have HSV 2, acyclovir is started at 36 weeks to prevent outbreak and allow for a vaginal birth

First Visit: Maternal Testing: What do we want Rubella (German Measles) results to be?

Immune

Induced Abortion - Complications and Care: ►With medication: dizziness, intense cramping, nausea, diarrhea, abdominal pain, mild fever or chills ►Hemorrhage ►Infection ►Injury to uterine lining or cervix → if surgical management Care considerations - Support - Consider gestational age - Pain management - Rhogam to Rh negative patients - f/u within 2 weeks if surgical management was involved - Discuss future plans for pregnancy or contraceptive → menstrual cycle will return within 1-2 months - Assess emotional well-being

Induced Abortion: ►Procedure is performed or medicine is taken to terminate a pregnancy ►Methods - Surgical -- Vacuum/suction aspiration or dilation & evacuation - Medication -- Mifepristone and Misoprostol

What 2 medications are used in an induced abortion?

Mifepristone Misoprostol

First Visit: Maternal Testing: What do we want Hepatitis B Surface Antigen results to be?

Negative

*** Nutrition and Pregnancy: ►Iron: 27mg/day ►Folic acid intake - Low risk pregnancy or potential pregnancy: 0.4 mg to 0.8 mg - Moderate to High Risk pregnancy: 1mg to 4mg (4000 mcg) ►Protein: 1.1g/kg/day ►Carbohydrates: 175g/day ►Calcium: 1000mg/day (1300mg/day 14-18yo) ►Vit D: 200-600 IU ►Prenatal/Multivitamin supplements before and/or during pregnancy ►At least ___-___ glasses of water per day --> more is better!

Nutrition and Pregnancy: ►Iron: 27mg/day ►Folic acid intake - Low risk pregnancy or potential pregnancy: 0.4 mg to 0.8 mg - Moderate to High Risk pregnancy: 1mg to 4mg (4000 mcg) ►Protein: 1.1g/kg/day ►Carbohydrates: 175g/day ►Calcium: 1000mg/day (1300mg/day 14-18yo) ►Vit D: 200-600 IU ►Prenatal/Multivitamin supplements before and/or during pregnancy ►At least 8-10 glasses of water per day --> more is better!

Other Maternal Tests: ►Human chorionic gonadotropin (HCG) ►Progesterone ►Thyroid testing ►Early diabetes testing or A1C ►Ultrasound - Dating, viability, r/o ectopic ►Pap testing (prg does not change) - Not under 21yo ►Cystic fibrosis carrier screening (once in life) ►Hemoglobin electrophoresis ►Thrombophilia tests ►Renal and liver function ►HSV testing ►Hepatitis C

Other Nutritional Considerations During Pregnancy: ►Alcohol - There is no safe amount or type of alcohol during pregnancy, and there is no time during pregnancy when alcohol consumption is without risk. ►Caffeine - Data unclear - General recommendation of no more than _____ mg of caffeine a day ►Food safety - Foods to avoid: ______, ______, high in ______ - Listeria concern ►Pica

Other Nutritional Considerations During Pregnancy: ►Alcohol - There is no safe amount or type of alcohol during pregnancy, and there is no time during pregnancy when alcohol consumption is without risk. ►Caffeine - Data unclear - General recommendation of no more than 200 mg of caffeine a day ►Food safety - Foods to avoid: raw, unpasteurized, high in mercury - Listeria concern ►Pica

Recommended Weight Gain: ►Calorie Intake - ____ to ____ extra calories per day ►Based on BMI calculated from pre-pregnant weight - Underweight (< 18.5 BMI): ___‐___ lb - Average weight (18.5 to 24.9 BMI): ___‐___ lb - Overweight (25 to 29.9 BMI): ___‐___ lb - Obese (≥ 30 BMI): ___-___ lb

Recommended Weight Gain: ►Calorie Intake - 350 to 450 extra calories per day ►Based on BMI calculated from pre-pregnant weight - Underweight (< 18.5 BMI): 28‐40 lb - Average weight (18.5 to 24.9 BMI): 25‐35 lb - Overweight (25 to 29.9 BMI): 15‐25 lb - Obese (≥ 30 BMI): 11-20 lb

Spontaneous Abortion/Early Pregnancy Failure: ►Spontaneous abortion, or miscarriage, is defined as a clinically recognized pregnancy loss before the 20th week of gestation. ►The World Health Organization (WHO) defines it as expulsion or extraction of an embryo or fetus weighing 500g or less. ►Management options (dependent on gestational age): - Expectant management - Medication - Misoprostol (800 mcg vaginally x multiple doses) - Surgical - Dilation & Curettage or Dilation & Evacuation

Define: a clinically recognized pregnancy loss before the 20th week of gestation.

Spontaneous abortion, or miscarriage

*** Fetal Test - Non-Invasive: When should Non-Invasive Prenatal Testing be done?

after 10 weeks

*** Fetal Test - Non-Invasive: When should a ultrasound be done?

anytime after 6 weeks

*** When should a patient not deliver vaginally with Herpes?

if lesions are present

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