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Obstetrics Study Guide

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Obstetrics Study Guide OBSTETRICS TOPICS General Anemia in Pregnancy Assessment for Pregnancy Risk • Occurs because of a greater expansion of plasma volume • Use the following tests in all women • This occurs during the late second to early third trimester o Hematocrit/hemoglobin and MCV • Hemoglobin <10.5 in the 2nd trimester = anemic o Assessment for asymptomatic bacteriuria • Usually treat with iron supplement o Rhesus type and red cell antibody screen • Also take 400-800mcg of folate o Assessment for immunity to rubella and varicella o Testing for syphilis, hepB, and chlamydia o HIV • Test used for at risk women o Thyroid function test o Gonorrhea o TB, toxoplasmisis, hepC, BV, trich, herpes, Chagas • At risk women o Thyroid issues type 2 DM, HepC, TB High Risk Pregnancies • Pre-existing maternal disorders o HTN, DM, STDs, pyelo, surgical problems, genital tract abnormalities, exposure to teratogens, exposure to mercury, prior stillbirth, prior preterm delivery, prior neonate with genetic or congenital disorder, polyhydramnios and oligohydramnios, multiple pregnancy, prior birth injury • Physical and social characteristics • Age (>35) • Problems in previous pregnancies (SAB) • Problems that develop Prenatal Care Components of prenatal evaluations Estimated date of delivery (EDD) • Week 4-28: 1 prenatal visit a month • 280 days from the onset of the LMP, and 266 days from the date • Weeks 28-36: 1 prenatal visit every 2 wks of conception • Weeks 36-40: 1 prenatal visit every week • Naegele’s Rule • Evaluations o Count back 3 months from the LMP and add 7 days o 8-12 wks IOB, physical exam, pelvic exam, blood o June 20th LMP March 27th type, hgb, STD screening, urine test (bacteriuria), pap • Ultrasound estimation of EDD in the first half of pregnancy is ▪ Maybe u/s dating if LMP is unknown superior to dating based on LMP or physical exam (and is most o Optional genetic counseling if >35 or family hx accurate in the first trimester) ▪ Talk about additional genetic screening tests, The u/s EDD should be used if it differs from that calculated from the blood tests, chorionic villus sampling, u/s, LMP by more than 5-7 days in the first trimester and by more than 10- amniocentesis 14 days in the second trimester (or by 8%) o First 2 trimester visits (up to 28 wks) ▪ Weight, BP, fetal heart beet, growth of uterus, check urine for protein and glucose o 15-20 wks ▪ Will also be offered the Quad screen test/horizon to screen for genetic and spinal cord abnormalities ▪ Anatomic u/s between 18-20wks to view baby’s organs and measure growth o 27-28 wks ▪ Glucose challenge test for GDM, hgb may be rechecked, can do a pelbic ▪ Sign up for prenatal classes o 28-36 wks ▪ Every 2 wks growth, heartbeat, position of baby o 36 wks ▪ GBS test, pelvic exam, repeat STD testing, position and size of baby o 36-40 wks ▪ Monitoring or weight and BP, size, position, heart rate, cervix dilation check Timing of routinely recommended screening & diagnostic studies • Quad Screen • Nuchal Translucency scan 11 wks to 13+6 wks o 16-18th wk – adds inhibin-A to the triple screen • GDM o Lowers the false positive rates for downs o 26-28 wks screening drink glucose solution, one hour • Amniocentesis later have a blood test to measure your blood sugar o Follow up for an abnormal triple test to determine if level, <130-140 is considered normal specific genetic disorders may be present in their baby o if positive go to the 3 hr GTT o U/s guided needle to enter the amniotic sac to remove ▪ Fast overnight, check blood sugar levels every a sample of the amniotic fluid hour for 3 hrs o Done between 14-20 wks • Fetal Non-Stress Test performed at 28 wks, tests movement, o Detects chromosome abnormalities, neural tube heartrate, and reactivity of heartrate to movement for 20-30 defects, downs, cystic fibrosis minutes o Provides access to DNA for paternity testing prior to o The test can indicate if the baby is not receiving enough delivery oxygen because of placenta or umbilical cord problems, o Miscarriage is the main risk, may lead to cramping, it can also indicate other types of fetal distress leakage of fluid, minor irritation at puncture site o Generally performed after 28 wks • First Trimester Screen o A healthy babies heart rate will respond with an o Combines AFP blood draw and u/s for nuchal increased heart rate during times of movement and will translucency decrease at rest o Can also ID cardiac disorders, but NOT neural tube o When oxygen levels are low the fetus may not respond defects normally o Performed between the 11th & 13th wk o Low oxygen can be caused by problems with the • Chorionic Villus Sampling placenta or umbilical cord o Removes chorionic villi cells from the placenta to check • Rhogam shot at 28-29 wks for chromosomal abnormalities and genetic disorders • Biophysical Profile typically after 32 wks o Guided by u/s, thin catheter is inserted through the o Combines an ultrasound eval with a non-stress test and cervix into the placenta and the villi cells are gently is intended to determine fetal health during the 3rd suctioned (can also be done through the abdomen) trimester o Very high level of accuracy o Performed if there is a question about fetal health or if o Can be done between 10 & 13 wks from LMP, can be the pregnancy is considered high risk done earlier than amniocentesis o 5 attributes studied during the test o Can also do paternity testing ▪ Breathing 1 breathing episode in 30 min o Risk of miscarriage ▪ Movement 2 or more movements in 30 • U/S min o Transvaginal during early stages (good to diagnose ▪ Muscle tone 1 or more active extension or ectopic or molar pregnancies) flexion of limbs o Fetal ECHO ▪ Heart rate 2 or more accelerations within o First trimester confirm pregnancy, confirm 20 min heartbeat, assess any abnormalities ▪ Amniotic fluid 1 or more adequate pocket o Second trimester down’s, congenital malformations, of fluid structural abnormalities, multiple pregnancies, verifies • Triple screen Test date, assesses amniotic fluid o Blood test Tests AFP (fetus), Hcg (placenta), and o Third trimester ID placenta location, fetal estriol (fetus and placenta) presentation, fetal movements, identify uterine or o Performed between wk 15-20 (but best between wk pelvic abnormalities of mother 16-18) • Urinalysis o High levels of AFP may indicate a neural tube defect o Used to assess bladder or kidney infections, DM, o Low levels of AFP and abnormal levels of hcg and estriol dehydraction, and preeclampsia may indicate a chromosomal abnormality • Blood test o Can indicate inaccurate dating of the pregnancy or o Looks for anemia, toxoplasmosis, Rh factor, glucose, multiple gestations iron, hemoglobin, immunity to rubella, STDs Weight Change Guidelines Prenatal vitamins • Dietary restriction is associated with an increased risk of low birth • Contain folic acid weight and neurologically impaired infants o 400 – 800 mcg/day for ALL women of child bearing age • Singleton o 600mcg/day for pregnant women o BMI <18.5 28-40 lbs o 4mg/day for women at high risk (previous pregnancy o BMI 18.5-24.9 (normal) 25-35 lbs with NTD, DM, anti-seizure meds o BMI 25-29.9 15-25 lbs • Prescribe to avoid neural tube defects o BMI >30 11-20 lbs o Anencephaly: severely underdeveloped brain • Twins o Spina bifida: incomplete closure of spinal cord and o Normal BMI 37-54 lbs spinal column • Neural tube closure occurs w/in 1mo of conception o Supplementation should occur 1mo prior to conception and continued at least 2-3mo into pregnancy Labor & Delivery Rupture of Membranes Meconium • AKA amniorrhexis, is the rupture of the amniotic sac • Failure to pass can be CF or Hirschsprung’s • Occurs spontaneously at full term during labor • Normally retained in infant’s bowel until after birth, if it is • When the amniotic sac ruptures, production of prostaglandins expelled prior to labor it may be a sign of fetal distress increases leading to more contractions • Meconium aspiration syndrome can occur medical staff may • SROM spontenous ROM aspirate the meconium from nose and mouth • PROM Premature ROM • First sign of CF is often a meconium ileus • AROM artificial ROM Oxytocin/Pitocin Breech Presentations • A hormone produced in the hypothalamus and secreted from the • Fetus whose buttocks are adjacent to the birth canal posterior pituitary in a pulsatile fashion • Frank Breech feet are up near head, buttocks is at the canal • Administration is a proven method of labor induction and (50-70% are in this position) produces periodic uterine contractions • Complete Breech feet are down at canal (5-10%) • First demonstrable at about 20 wks gestation, it continues to • Diagnosis made on physical exam and u/s increase until 34 wks at which point it levels off until spontaneous • Incomplete Breech straight legs (can lead entrapment of the labor begins shoulders or head because of their much larger diameters, • It is most commonly given intravenously, steady state increases the risk of hypoxic injury and delivery related trauma, concentrations are reached within 40 minutes also provides space for umbilical cord • The dose is increased until labor progress is normal or • Because the hips are flexed and the knees are extended or flexed, contractions occur at 2-3 minute intervals the thighs and trunk pass through the canal simultaneously • Low dose • Chance occurrence in up to 15% of cases • High dose (can lead to uterine tachysystole) • Risk factors • Pulsatile (rarely used) o Preterm gestation o Previous breech presentation o Uterine abnormality Two steps of labor induction o Placental abnormality, Multiparity 1.
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