OB PD Lab

melasma

"mask of pregnancy" Skin darkening that occurs on the cheeks Often interchangeable with chloasma

pelvic types

(best to worst for vaginal deliveries) 1. Gynecoid 2. Anthropoid 3. Android 4. Platypelloid

common 3rd trimester concerns

Bleeding symphysis pubis dysfunction elevated BP preterm labor or labor

anatomical changes to the breast during pregnancy

1. Increased vascularity 2. Glandular hyperplasia 3. Nipples and areola get darker 4. Nipples enlarge 5. Venous markings more visible 6. More prominent Montgomery's glands

anatomical changes to the vagina and cervix during pregnancy

1. Increased vascularity 2. Leukorrhea 3. Lower vaginal pH (greater presence of Lactobacillus acidophilus) 4. mucous plug

anatomical changes to the uterus during pregnancy

1. Muscle cell hypertrophy 2. Increased fibrous and elastic tissue 3. Increased vascularity and lymphatics 4. Hegar's sign

cardiovascular changes during pregnancy

1. blood volume increases and H/H slightly decreases 2. Cardiac output increases, pulse may rise 10 beats/min 3. Mammary souffle

anatomical changes to the abdomen while pregnant

1. striae 2. Linea nigra 3. Diastasis recti

frequency of OB visits

1/month until 28 weeks every 2 weeks froom 28-36 weeks weekly from 36 weeks-birth *may vary if multiple gestations or complex hx*

appropriate caloric intake increase

1st trimester: increase by 100 calories/day 2nd trimester: increase by 200 calories/day 3rd trimester: increase by 300 calories/day

appropriate weight gain in pregnancy (based on BMI)

<19.8 = 28-40 lbs 19.8-26 = 25-35 lbs 26-29 = 15-25 lbs >29 = no more than 15 lbs

Leopold's Maneuvers

A series of four maneuvers designed to help determine the fetal lie in relation to the mother's back (transverse or longitudinal) and help determine presenting part

common 2nd trimester concerns

Bleeding elevated BP glucose tolerance testing preterm labor

A 26-year-old telephone operator comes to your office for her first prenatal visit. This is her first pregnancy. Her last period was about 2 months ago. She has no current complaints. She is eating healthily, taking vitamins, and exercising. She has a past medical history of an appendectomy as a teenager. Her mother had three children vaginally with no complications. On examination she appears healthy and her vital signs are unremarkable. Her head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are also unremarkable. By speculum examination, her cervix appears bluish in color and highly vascular. A bimanual examination reveals a soft cervix and a 12-week-sized uterus. No masses are felt in either adnexal area. Results of her Pap, cultures, and blood work are pending. What clinical sign is responsible for her blue, highly vascular cervix? A) Chadwick's sign B) Hegar's sign C) Leopold's sign D) Leo's sign

A) Chadwick's sign

A woman in her third trimester complains of shortness of breath on occasion, without other symptoms. She has a normal examination. The most likely cause of this symptom is: A) Hormonal B) Asthma C) Pulmonary embolus D) Infection

A) Hormonal

Which of the following is the major effect of placental hormones? A) Insulin resistance B) Increased tidal volume C) Relative hypercortisolism, which may trigger labor D) Decreased lower esophageal sphincter tone

A) Insulin resistance

During cardiac examination you notice a new parasternal systolic murmur of 2/6 intensity. On palpation, the PMI is slightly higher than usual. What do you suspect? A) Mammary souffle B) Mitral stenosis C) Mitral regurgitation D) Aortic insufficiency

A) Mammary souffle

A young mother presents with a pregnancy confirmed by urine HCG. Her LMP was June 20. Using Naegele's rule, you estimate what day of delivery? A) March 27 B) April 13 C) February 20 D) February 13

A) March 27

A 20-year-old college student comes in with symptoms of fatigue, nausea, and an increase in urination. Her last period was 3 months ago (June 20, 2008). She is sexually active and always uses condoms. Her past medical history is unremarkable. On examination you see a young, anxious-appearing woman. Her vital signs are unremarkable. Her head, eyes, ears, throat, neck, thyroid, cardiac, pulmonary, and abdominal examinations are unremarkable. On pelvic examination a soft cervix is palpated and a 14-week-sized uterus is palpated. A urine pregnancy test is positive. You then inform the patient that she is expecting and, using Naegele's rule, give her the estimated date of confinement (EDC, or due date). What was the due date you gave her? A) March 27, 2009 B) March 13, 2009 C) September 27, 2009 D) March 20, 2009

A) March 27, 2009

You are performing a routine examination on a pregnant woman who is at 24 weeks' gestation. She had early prenatal care, no medical problems, and an uncom- plicated pregnancy to date. Her last menstrual period (LMP) correlates with the gestational age of her pregnancy. You would expect the following to be true at her 24-week checkup: A) The patient will feel the baby move. B) The fundal height will be 20 cm. C) The fetal heart rate will be 60 bpm. D) The uterus will be anteverted and pear-shaped.

A) The patient will feel the baby move.

A woman in her 30th week has a cervical length estimated at 1 cm. Should you be concerned? A) Yes; she may be at risk for preterm labor. B) Yes; she most likely has a bicornuate uterus. C) No; this is a normal measurement for this gestational age. D) Yes; it likely indicates the fetus is in the breech position.

A) Yes; she may be at risk for preterm labor.

A 25-year-old pregnant woman (G1, P0) at 12 weeks' gestation presents to your office for routine prenatal care. When you ask her about how she is feeling, she states that she has been unable to keep down food and that food tastes "funny" to her. You look at her vital signs; she has lost 5 pounds since her previous visit. The fetal heart tones are normal, and the rest of her examination is unremarkable. What step should you take next with this patient? A) You reassure her that pregnancy-related nausea usually lasts only for the first trimester and that most likely her nausea and appetite will improve soon. B) You are concerned about a peptic ulcer and want to start her on medication. C) You are concerned about hyperthyroidism and obtain a thyroid-stimulating hormone (TSH) level. D) You diagnose her with hyperemesis gravidarum and proceed with further diagnostic workup.

A) You reassure her that pregnancy-related nausea usually lasts only for the first trimester and that most likely her nausea and appetite will improve soon.

A 22-year-old clerk, primigravida, comes to your office for a prenatal visit. She is in her second trimester and has had prenatal care since she was 8 weeks pregnant. Her only complaint is that she has a new brownish line straight down her abdomen. On examination her vital signs are unremarkable. Her urine has no protein, glucose, or leukocytes. With a Doptone the fetal heart rate is 140, and her uterus is palpated to the umbilicus. Today you are sending her for congenital abnormality screening and setting up an ultrasound. What physical finding is responsible for her new "brown line"? A) Corpus luteum B) Linea nigra C) Linea alba D) Diastasis recti

B) Linea nigra

chloasma

Areas of the skin become darker and most often occurs on sun exposed skin Can be seen with pregnancy, OCPs, or estrogen HRT

When is GBS test done in pregnancy?

At 36 weeks

You are examining for fetal heart tones with a fetoscope and are unable to hear any. Using a Doptone, you measure the rate as 164. Which gestational age is most likely? A) 8 weeks B) 14 weeks C) 20 weeks D) 26 weeks

B) 14 weeks

Mrs. Kelly comes to you for her usual prenatal check-up. You measure the fundal height at 24 cm. What would you estimate the length of her gestation to be? A) 20 weeks B) 24 weeks C) 28 weeks D) 32 weeks

B) 24 weeks

A 26-year-old white female comes to your clinic at 38 weeks, complaining of intermittent contractions. They last for 30 seconds and are coming every 10 minutes. Her prenatal course has so far been uneventful. You send her to labor and delivery for a labor assessment. On vaginal examination she has effaced 4 cm, but you cannot feel a presenting part. You admit her for active labor; however, you wish to assess if she is vertex (baby's head is down), so you do the Leopold's maneuver. Palpating the upper pole with your hands, you feel a firm round mass. Placing your hand along the right side of her abdomen, you feel a smooth firmness. Palpating your other hand along the left side of her abdomen, you feel irregular bumps. Above the pelvic brim you feel a firm irregular mass. While awaiting ultrasound to confirm your diagnosis, you write the pertinent orders. How is this fetus presenting? A) Vertex B) Breech C) Transverse

B) Breech

A 22-year-old college student presents to your office because she has not menstruated in 3 months. She is sexually active in a monogamous relationship. You per- form a physical examination and determine that she is pregnant. What did you see and feel on examination of the cervix and uterus? A) Pink cervical os; firm to palpation B) Cyanotic cervical os; soft to palpation C) Pink cervical os; soft to palpation D) Cyanotic cervical os; firm to palpation

B) Cyanotic cervical os; soft to palpation

A 24-year-old cashier comes to your clinic for her first OB visit. She had her last period 10 weeks before, which would mean she is 12 weeks pregnant. She did a home pregnancy urine test a month ago and it was positive. She has had some fatigue and nausea, but not in the last week. She has had no cramping or bleeding. Her vital signs, head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are all unremarkable. On speculum examination her os is closed and there is a pinkish hue to the cervix. On bimanual examination the cervix is soft and the uterus is enlarged to the pelvic brim. Despite 20 minutes of trying, you cannot find heart tones. You repeat a urine pregnancy test and it is negative. A serum pregnancy test is ordered and is positive. You send the patient for a vaginal ultrasound. What is the most likely explanation for her presentation? A) Earlier than 12 weeks B) Fetal demise (missed abortion) C) False pregnancy

B) Fetal demise (missed abortion)

Jeannie is a 24-year-old pregnant woman who asks you today if her frequent urination is normal. Which of the following hormones is most likely responsible for this? A) TSH B) HCG C) Oxytocin D) Estradiol

B) HCG

You are performing a routine checkup on a pregnant woman who is at 37 weeks' gestation. Her blood pressure is 110/65 mm Hg. The size of the uterus is appropriate for her dates; the fetal heart rate is in the 140s. She has trace pedal edema. You perform an examination for the size of the fetus and its position. What is this maneuver called? A) Nagele's maneuver B) Leopold's maneuvers C) Bickley's maneuver D) Bates' maneuver

B) Leopold's maneuvers

components of subsequent "belly checks"

BP urine dip fundal height fetal heart tones fetal movements fetal position 1 hour glucose screening type and screen if Rh negative GBS test

breast symptoms during pregnancy

Breast tenderness Discharge

A 19-year-old childcare worker comes to you for her first prenatal visit. She cannot remember when her last period was but thinks it was between 2 and 5 months ago. When she began gaining weight and feeling "something" moving down there, she did a home pregnancy test and it was positive. She states she felt the movement about a week ago. She has had no nausea, vomiting, fatigue, or fevers. Her past medical history is remarkable only for irregular periods. She has been dating the same young man for a year. She says they were not using condoms. On examination you see an overweight young lady appearing her stated age. Her head, eyes, ears, nose, throat, neck, thyroid, cardiac, and pulmonary examinations are unremarkable. Her abdomen is nontender, with normal bowel sounds, and the gravid uterus is palpated to the level of the umbilicus. Fetal tones are easily found with Doptone, and with the fetoscope a faint heart rate of 140 is heard. By speculum examination the cervix is bluish and by bimanual examination the cervix is soft. Results of Pap smear, cultures, and blood work are pending. You give the patient her due date and how far along she is, based on your clinical findings. An OB ultrasound to confirm her dates is ordered. With only the clinical examination, how many weeks pregnant did you tell this patient she is? A) 6 to 8 weeks B) 12 to 14 weeks C) 18 to 20 weeks D) 24 to 26 weeks

C) 18 to 20 weeks

A 32-year-old attorney comes to your office for her second prenatal visit. She has had two previous pregnancies with uneventful prenatal care and vaginal deliveries. Her only problem was that with each pregnancy she gained 50 lbs (23 kg) and had difficulty losing the weight afterward. She has no complaints today. Looking at her chart, you see she is currently 10 weeks pregnant and that her prenatal weight was 130 lbs (59 kg). Her weight today is 134 lbs (60.9 kg). Her height is 5'4", giving her a BMI of 22. Her blood pressure, pulse, and urine tests are unremarkable. The fetal heart tone is difficult to find but is located and is 150. While you give her first trimester education, you tell her how much weight you expect her to gain. How much weight should this patient gain during pregnancy? A) Less than 15 pounds (less than 7 kg) B) 15 to 25 pounds (7 to 11.5 kg) C) 25 to 35 pounds (11.5 to 16 kg) D) 30 to 40 pounds (12.5 to 18 kg)

C) 25 to 35 pounds (11.5 to 16 kg)

A pregnant woman finally comes in for her prenatal checkup. She complains today of headache and abdominal pain of several months' duration. She appears somewhat hurried or nervous. What question would you ask next? A) Do you have a family history of thyroid disease? B) Have you been eating properly and taking a prenatal vitamin? C) Do you feel safe at home? D) How much activity have you been able to fit into your schedule?

C) Do you feel safe at home?

A 35-year-old bus driver comes to your office for a prenatal visit. She is approximately 28 weeks pregnant and has had no complications. She is complaining only of heartburn and has had no fatigue, headaches, leg swelling, contractions, leakage of fluid, or bleeding. On examination her blood pressure is 142/92 and her urine shows no glucose, protein, or leukocytes. Her weight gain is appropriate, with no large recent increases. Fetal tones are 140 and her uterus measures 32 cm from the pubic bone. Looking back through her chart, you see her prenatal blood pressure was 120/70 and her blood pressures during the first 20 weeks were usually 120 to 130/70 to 80. What type of blood pressure is this? A) Normotensive for pregnancy B) Chronic hypertension C) Gestational hypertension D) Preeclampsia

C) Gestational hypertension

A 29-year-old homemaker who is G4P3 comes to your clinic for her first prenatal check. Her last period was 2 months ago. She has had three previous pregnancies and deliveries with no complications. She has no medical problems and has had no surgeries. Her only current complaint is of severe reflux that occurs in the mornings and evenings. On examination she is in no acute distress. Her vitals are 110/70 with a pulse of 88. Her respirations are 16. Her head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are unremarkable. On bimanual examination her cervix is soft and her uterus is 10 weeks in size. Pap smear, cultures, and blood work are pending. What is the most likely cause of her first-trimester reflux? A) Increasing prolactin levels B) Increasing ADH (antidiuretic hormone) levels C) Increasing progesterone D) Enlarged gravid uterus

C) Increasing progesterone

A young woman comes in for a routine wellness examination. You notice that her vaginal walls have deep rugae and are slightly bluish in color. She also has a thicker white discharge. What should you suspect? A) Hypoxia B) Varicosities C) Pregnancy D) Sexually transmitted infection

C) Pregnancy

A 26-year-old stewardess comes in for a third trimester prenatal visit. She has had prenatal care since her sixth week of pregnancy. She has no complaints today and her prenatal course has been unremarkable. Today her blood pressure and weight gain are appropriate and her urine is unremarkable. You have a first-year medical student shadowing you, so you ask the student to get Doptones and measure the patient's uterus in centimeters. The student promptly reports fetal heart tones of 140, but he is having difficulty obtaining the correct measurement. He knows one end of the tape goes over the uterine fundus. From what inferior anatomic position should the tape be placed? A) Vagina B) Clitoris C) Pubic symphysis D) Umbilicus

C) Pubic symphysis

A woman in her 24th week of pregnancy notices she feels faint when lying down for a period. What would you suspect as a cause for this? A) Adrenal insufficiency B) Orthostatic hypotension C) Supine hypotensive syndrome D) Hypoglycemia

C) Supine hypotensive syndrome

prenatal labs at initial exam

CBC Hep B surface antigen syphilis HIV blood type and antibody screen rubella immunity varicella immunity lead (if necessary)

purpose of initial prenatal care visit

Confirm pregnancy (w/ US) Consider how pt feels about pregnancy Review health hx Review family hx Review OB hx Review risk factors

Hormonal changes during pregnancy

Corpus luteum remains (6-7 weeks) to provide progesterone support Human chorionic growth (HCG) increases Progesterone increases Estradiol increases

A pregnant woman is concerned by the recent onset of a midline swelling. It is soft and nontender. What does this represent? A) Linea nigra B) Chadwick's sign C) Round ligament pain D) Diastasis recti

D) Diastasis recti

Which of the following is worrisome in Melissa, a woman in her 26th week of pregnancy? A) Generalized hair loss B) A hyperpigmented rash over the maxillary region bilaterally C) Nosebleeds D) Facial edema

D) Facial edema

Lucille is in her 24th week. You notice a new onset of high blood pressure readings. Today's value is 168/96. Her urine is normal. What do you suspect? A) Preeclampsia B) Chronic hypertension C) Supine hypotensive syndrome D) Gestational hypertension

D) Gestational hypertension

A woman has a positive pregnancy test and comes to you with left lower quadrant pain. On bimanual examination, you feel a tender mass. Which of the following should you suspect? A) Threatened abortion B) Appendicitis C) Ovarian cyst D) Tubal pregnancy

D) Tubal pregnancy

A 35-year-old pregnant woman (G4, P3) at 24 weeks' gestation presents to your office for routine prenatal care. Her major concern is a backache that began 2 weeks ago and has not gone away. She denies dysuria, fever, and chills but does admit to urinary frequency. She is taking a mild over-the-counter analgesic for the pain and is using a heating pad. You obtain a urinalysis, for which the results are normal. What step should you take next for this patient? A) You give her antibiotics for her pyelonephritis. B) You diagnose her with a kidney stone and ask her to strain her urine and increase her fluid intake. C) You diagnose her with meningitis and admit her to the hospital for treatment with intravenous antibiotics. D) You reassure her that this is a normal part of pregnancy because the hormones are causing relaxation of the joints and ligaments, which changes the normal curvature of the lower spine.

D) You reassure her that this is a normal part of pregnancy because the hormones are causing relaxation of the joints and ligaments, which changes the normal curvature of the lower spine.

interspinous diameter

Distance between ischial tuberosities Should be >10cm Measured by palpating the ischial tuberosities and noting the distance between them

diagonal conjugate

Distance from sacral promontory to symphysis pubis Should be >11.5cm Measured by placing tip of middle finger at the sacrum prominence and noting point where hand contacts symphysis pubis

mammary souffle

Exaggerated splitting of S1 Systolic murmur that disappears after delivery

third maneuver

Facing the woman's head and using the palm of one hand palpate just superior to the symphysis pubis, note if your hand comes together (like a triangle) or stays apart (like a U shape) to determine if the presenting part is descending into the pelvis

T/F: colostrum is *true* milk

False

Ex: G4P2113

G → 4 pregnancies P → 3 labors - T: 2 full term - P: 1 preterm - A: 1 abortion - L: 3 living

Ex: G6P3033

G → 6 pregnancies P → 3 labors - T: 3 full term - P: 0 preterm - A: 3 abortions - L: 3 living

gestational hypertension

HTN after 20 weeks of pregnancy

preeclampsia

HTN and proteinuria (> 300 mg/dL)

chronic hypertension

HTN before 20 weeks of pregnancy

components of physical exam and initial visit

Head/face - Conjunctivae, gingiva, dentition Neck Heart Lungs Breasts Abdomen Genitalia - Pap smear, STD testing, pelvimetry Extremities

common 1st trimester concerns

Hyperemesis gravidarum bleeding constipation

second maneuver

Place one hand on either side of the woman's abdomen capturing the fetus between them - fetal back feels smooth and the arms and legs feel irregular

nutritional needs in pregnancy

Increased protein Modest increased caloric intake Assess need for supplemental financial/food help like WIC

Naegele's rule

LMP + 7 days - 3 months + 1 year = EDD

Anthropoid

Long, oval pelvis with long diagonal conjugate and interspinous distance not as wide as gynecoid

metabolic changes in pregnancy

Mild postprandial hyperglycemia Pregnancy-induced insulin resistance - allows for more glucose available for fetus

exercise during pregnancy

Most women already exercising can continue their exercise regimen - low to moderate intensity - no lying flat on back after 20 weeks - no jumping or exercises to lose balance - no contact sports Women who were not active prior to pregnancy should be encouraged to be active with light exercise Maintain good fluid intake to avoid dehydration

quickening

Movements of the fetus that can be felt by the mother around 20 weeks

importance of folic acid in pregnancy

Neural tube defects!!!! All women in child bearing age (especially not on BC) should take a women's daily vitamin with folic acid

Platypelloid

Oval pelvis with narrow sacrum, short diagonal conjugate, and wide interspinous distance Worst for vaginal deliveries

expected date of delivery (EDD)

Projected birth date of the infant Calculated with Naegele's Rule

Gynecoid

Rounded pelvis with long diagonal conjugate, wide interspinous distance Best for vaginal deliveries

domestic and intimate partner violence in pregnancy

Screen *every* woman at the first visit and every trimester Screen *without* their partner present Pregnant women are at higher risk for violence against them

first maneuver (upper pole)

Stand at bedside facing the woman's head and keeping fingers together, palpate with fingertips which fetal part is in upper pole - fetal buttocks will feel firm and irregular whereas the fetal head feels globular

Android

Wedge or heart shaped pelvis, widest part of pelvis is posterior Prominent ischial spines

fourth maneuver

With dominant hand, grasp the part of fetus in the lower pole and feel the upper pole with your non-dominant hand to help confirm presenting part

gestational age

age of fetus from LMP

When is type and screen for Rh negative patient done in pregnancy?

at 28 weeks if Rh negative: anti-D immunoglobulin is indicated

When is a glucose tolerance test done in pregnancy?

at 28 weeks passing is < 139 if pt fails → must do 3 hour glucose test

renal changes during pregnancy

increased GFR kidneys grow about 1 cm urinary frequency

chadwick's sign

bluish discoloration of the cervix, vagina, and labia while pregnant that results from increased blood flow

purpose of mucous plug in pregnancy

copious cervical secretions fill the cervical canal and forms a barrier between the outside environment and inside the body to protect the fetus

pulmonary changes during pregnancy

decrease in FRC (diaphragm elevation)

ways to assess pelvic shape

diagonal conjugate interspinous diameter

colostrum

discharge from breast that occurs later in pregnancy "the first milk"

possible bleeding causes in 1st trimester

ectopic pregnancy spontaneous abortion

BP monitoring at subsequent "belly checks"

gestational hypertension chronic hypertension preeclampsia

components of urine dip at initial exam

glucose leukocytes ketones blood protein

anemia in pregnant patients

hemoglobin <11 g/dL is considered anemia H/H is lower than normal

anatomical changes to the skin during pregnancy

hyperpigmentation chloasma melasma linea nigra striae (breasts, hips, thighs) lower extremity edema

preconception counseling

ideally want to make sure everything is as well-controlled as possible BEFORE becoming pregnant: - Chronic diseases - medications - Reproductive planning - family/genetic hx - Folic acid supplements - Immunizations - Trauma screening - Social/behavioral hx - STI risks - Weight

placenta previa

implantation of the placenta over the cervical opening or in the lower region of the uterus

Why should a pregnant woman not lay flat on her back after 20 weeks?

increased pressure on IVC

position of the uterus during pregnancy

located at pubic rim at 12-14 weeks located at umbilicus at 20 weeks

measurement of height of fundus

measurement of the height of the fundus is roughly equal to the number of weeks of gestation becomes inaccurate measurement after 36 weeks

leukorrhea

normal thickening of vaginal secretions

parity

number of labors divided into TPAL

gravida

number of pregnancies

hegar's sign

palpable softening at the isthmus as uterus loses some firmness in early pregnancy

endocrine changes during pregnancy

pituitary gland enlargement prolactin levels increase growth hormone increase

possible bleeding causes in 2nd trimester

placenta previa

possible bleeding causes 3rd trimester

placenta previa placental abruption

hyperemesis gravidarum

severe form of morning sickness

pelvic exam during pregnancy

speculum and bimanual exams performed - inspect cervix - palpate uterus and assess size - assess pelvic shape

clinical significance of the round ligament during pregnancy

stretching of ligaments causes some achy pain around iliac crests

TPAL

term preterm abortion living

hyperpigmentation in pregnancy

thought to happen due to increased melanocytes-stimulating hormone

potential risk factors in pregnancy

tobacco, ETOH, or illicit drug use environmental exposures nutritional intake intimate partner violence maternal chronic health conditions

conception age

two weeks less than gestational age point of conception is often unknown

initial prenatal care visit timing

usually between 8-10 weeks

growth of uterus during pregnancy

uterus grows almost 20x its original size 2 oz to 2 lbs

test done at initial exam

vitals (BP), weight, height, BMI urine dip physical exam fetal viability prenatal labs