Antepartum - Second Tri Mgmt

Front 1

What are the dates of 2nd tri?

Back 1

13-28 wks gestation

Front 2

How often should patients be seen for regular appointments?

Back 2

monthly visits

Front 3

What is the appropriate patient education for 2nd tri?

Back 3

1) fetal movements awareness
2) PTL and preeclampsia precautions

Front 4

What are some signicant findings/tests during the 2nd tri?

Back 4

1) quickening
2) genetic screening
3) US for anatomy
4) gestational DM screening
5) Rhogam & antibody screening

Front 5

What are the risk factors for hypertensive disorders during pregnancy?

Back 5

1) primigravida
2) multipara with new partner
3) maternal age <19 or >40
4) GTD
5) multfetal gestation
6) preexisting disease (HTN, DM, chronic renal disease)
7) family hx preclampsia/eclampsia
8) previous h/o preeclampsia
9) ethnicity (Afro-Am or Asian)

Front 6

What is gestational HTN?

Back 6

elevation of BP in pregnancy with onset >20 wks in previously normotensive woman

> or = 140 systolic (or >30 mmgHg above baseline)
> or = 90 diastolic (or 15 mmHg above baseline)

Front 7

What is preeclampsia?

Back 7

gestational HTN with proteinuria
> or = 0.3 g in 24 h specimen (1+)

Front 8

What is the "triad" of signs associated with preeclampsia?

Back 8

1. HTN
2. proteinuria
3. edema*

*edema is not criteria for dx

Front 9

What are the sxs of preeclampsia?

Back 9

1. headaches
2. visual changes
3. epigastric pain
4. elevated BP
5. sudden excessive weight gain
6. hand and face edema
7. proteinuria

Front 10

What are the criteria for severe preeclampsia?

Back 10

1. BP >160/110
2. protein >2g in 24 h (2+ to 3+)
3. symptomatic
4. abnormal labs: elevated liver enzymes and creatinine, decreased platelets
5. oliguria (<400 cc/24 h)

Front 11

How should elevated BP be evaluated?

Back 11

1. EGA at onset
2. repeat BP
3. proteinuria
4. symptoms
5. extremities

Front 12

Which labs should be ordered for suspected preeclampsia?

Back 12

1. 24 hr urine collection (total protein)
2. serum albumin
3. BUN
4. CBC
5. LFTs
6. kidney fxn tests
7. coagulation profile

Front 13

What fetal evaluation tools should be used for gestational HTN (PIH)?

Back 13

1. US for growth and AFI at dx
2. NST at dx
3. kick counts

Front 14

What fetal evaluation tools should be used for preeclampsia?

Back 14

1. US for growth and AFI at dx, repeat ~q3wk
2. NST/BPP at dx, repeat weekly with normal results; if IUGR/oligo, repeat biweekly

Front 15

How should we manage mild preeclampsia?

Back 15

1. patient rest in LLP periodically
2. high protein diet (?)
3. kick counts

Front 16

How should we manage severe preeclampsia?

Back 16

1. Hospital and bed rest
2. Decreased environmental stimulation
3. I & O
4. fetal assessment (NST/BPP)
5. Mag sulfate

Front 17

What is eclampsia?

Back 17

preeclampsia with convulsions

Front 18

What should be done to prevent convulsions?

Back 18

Mag sulfate therapy

Front 19

What is HELLP syndrome?

Back 19

H- hemolysis
E - elevated
L - liver enzymes
L - low
P - platelets

*signs of eclampsia*

Front 20

What are some possible fetal complications of hypertensive disorders of pregnancy?

Back 20

1. growth restriction
2. poor compensation during labor
3. death

Front 21

What follow-up should be done postpartum for patients who had hypertensive disorders of preg?

Back 21

1. evaluate BP
2. counsel on lifestyle factors
3. future risk of CV disease if: a) early and severe onset oof preeclampsia; b) h/o preeclampsia as nullip with HTN in subsequent preg; c) multips with preeclampsia

Front 22

What is gestational diabetes?

Back 22

carb intolerance with onset or initial dx in pregnancy

*occurs in 4% of all preg
*50% will develop glucose intolerance later in life

Front 23

What is the patho of GDM?

Back 23

decreased sensitivity to insulin in pregnancy, which typically occurs after 20 wks

*effect of hPL -- peaks at end of 2nd tri

Front 24

What are the risk factors for GDM?

Back 24

1. Maternal age > 25
2. obesity
3. family history of IDDM
4. previous baby weighing >4000 g
5. polyhydramnios
6. previous unexplained stillbirth or congenital anomalies
7. sxs of diabetes
8. recurrent glucosuria noted on dipstick

Front 25

Under what circumstances should early GDM screening (before 24-28 weeks) be scheduled?

Back 25

for any high risk factor:
1. obesity
2. h/o GDM
3. strong family hx
4. h/o infant >4000 g at birth
5. h/o congenital anomalies, SABs
6. recurrent glucosuria

Front 26

If a patient is at high risk for developing GDM, when should she be screened?

Back 26

As soon as high risk is identified -- she should be screened using the glucose challenge test

Front 27

When is the Glucose Challenge Test (GCT) usually administered?

Back 27

Between 24-28 weeks when the natural shift in glucose metabolism occurs

Front 28

What is an elevated Glucose Challenge Test result?

Back 28

>130 mg/dL (or >140*)

*cutoff decided by provider

Front 29

How is the Glucose Challenge Test administered?

Back 29

Patient does NOT have to fast -- comes in to office and drinks 50 g glucose solution and has blood glucose testing after 1 hour

Front 30

Why is the Glucose Tolerance Test used?

Back 30

as follow-up to elevated glucose challenge test

**DIAGNOSTIC**

Front 31

How does the Glucose Tolerance Test work?

Back 31

Patient MUST fast at least 8 hours before test.

1) Fasting blood glucose measured
2) Patient drinks 100 g glucose solution and has blood glucose levels measured at 1 hr, 2 hr, and 3 hr

Front 32

What values are diagnostic of GDM?

Back 32

- GCT value > 200 mg/dL
OR
-2 abnormal values on GTT
*Fasting: > or = 95-105
*1 hr: > or = 180-190
*2 hr: > or = 155-165
*3 hr: > or = 140-145

**Not a range -- provider picks one set of numbers (high or low for all time points)

Front 33

How does WHO's diagnostic criteria differ?

Back 33

1) Fasting blood glucose level
2) Patient drinks 75 g glucose solution then one blood glucose level 2 hours after

Front 34

What is the goal for management of GDM?

Back 34

Glucose control!

Diet changes preferred over medications

Front 35

When patients self-monitor their blood glucose, what levels are ideal?

Back 35

Fasting BG: < 95 (or 105) mg/dL
2h post-meal: <120 mg/dL

Front 36

Name some management plans for patients with GDM.

Back 36

1. Self-monitoring of BG
2. Encourage exercise (20-30 min walking if no regular exercise routine)
3. Nutritional consult
4. Observe for potential complications
5. Appts q2 weeks from dx to 36 weeks
6. Postpartum follow-up to rule out DM Type II

Front 37

What are the maternal risks a/w GDM?

Back 37

1. HTN/preeclampsia
2. Shoulder dystocia (delivery)
3. C-section
4. Future development of DM

Front 38

What are the fetal/neonatal risks a/w GDM?

Back 38

1. Still-birth
2. Birth trauma (from shoulder dystocia or C-section)
3. Neonatal hypoglycemia
4. Macrosomia

Front 39

What is cervical incompetence?

Back 39

cervix dilates without ctx

characterized by painless vaginal bleeding with pelvic pressure

Front 40

What may contribute to cervical incompetence?

Back 40

May have h/o:
* "late" miscarriage
* cervical laceration
* prolonged 2nd stage with cervical trauma
* multiple surgical TOPs
* DES exposure (from mother's use during pregnancy)
* cone biopsy

Front 41

How is cervical incompetence managed in a current pregnancy?

Back 41

1. rescue cerclage
2. hospitalization

Front 42

How is cervical incompetence managed for future pregnancy?

Back 42

prophylactic cerclage

Front 43

What is placenta previa?

Back 43

placenta partially or completely covers cervical os

characterized by painless 2nd or 3rd tri bleeding/spotting

Front 44

What medical or gyn history is a/w placenta previa?

Back 44

h/o of:
1. previous previa
2. previous c-section
3. multiple gestation
4. closely-spaced pregnancies
5. advanced maternal age
6. smoking

Front 45

Which aspects of routine prenatal care are contraindicated with placenta previa?

Back 45

NO digital or speculum exam unless previa is "ruled out"

Front 46

How is placenta previa managed?

Back 46

1. decrease activity level
2. possible bed rest
3. nothing per vagina (NPV)
4. evaluate fetal well-being
5. NEVER do a vaginal exam
6. follow-up US in 3rd tri
7. c-section

Front 47

What is placental abruption?

Back 47

premature separation of the placenta from the uterine wall

may be painful with or without visible vaginal bleeding

Front 48

What medical or gyn conditions may be a/w placental abruption?

Back 48

possible hx of:
1. HTN
2. advanced maternal age
3. high parity
4. poor nutrition
5. chorioamnionitis
6. acute abdominal trauma
7. previous abruption
8. cocaine/crack use

Front 49

How is placental abruption managed?

Back 49

Depends on acute vs. chronic and mild vs. severe

General goals:
1. stabilize mother and fetus
2. prepare for possible tx of shock
3. possible delivery (vag or c/s)
4. follow-up with US and NST/BPP if stable

Front 50

Why is the GCT screening performed between 24-28 wks?

Back 50

That is the peak of the metabolic shift in glucose metabolism --- only owmen at risk will respond by becoming hyperglycemic

Front 51

Who MUST we perform early GDM screening for if they have a high risk factor?

Back 51

Women with h/o:
1. GDM
2. infant >4000 g

Front 52

What are the advantages vs. disadvantages of a lower GCT cutoff (>130 mg/dL)?

Back 52

Detection rate of 90% of patients with GDM

Disadvantage: more false-positives

Front 53

What medication is used for women with DM prior to pregnancy?

Back 53

glyburide

Front 54

What medication is becoming more commonly used for women diagnosed with GDM?

Back 54

glyburide

Front 55

Why does neonatal hypoglycemia occur when a fetus has a mother with GDM?

Back 55

Hyperglycemia causes fetus to produce higher levels of insulin in utero. Once neonate is born, the hyperglycemic environment is gone but high levels of insulin still exist endogenously

Front 56

What postpartum measures should be taken when a woman has GDM?

Back 56

1. Testing for DM at 4-6 wk postpartum visit -- GTT according to WHO standards
2. Other options for DM dx include Hg a1c testing or GCT (with GTT follow-up if GCT is abnormal)

Front 57

How does antepartum care change when a woman has GDM?

Back 57

1. more frequent NST (weekly)
2. more frequent BPP toward end of pregnancy (oligohydramnios a/w GDM)
3. periodic fetal wt. measurements to estimate growth/size

Front 58

Is miscarriage possible in 2nd trimester?

Back 58

less likely but still possible up to 13-14 weeks

Front 59

Why might a woman feel pelvic pressure with cervical incompetence?

Back 59

products of conception or fetus are pressing on cervix

Front 60

What happens if a woman needs a rescue cerclage?

Back 60

admitted to the hospital for the procedure and for monitoring of infection and fetal growth

Front 61

What are the risks of performing a rescue cerclage?

Back 61

1. piercing of amniotic sac
2. suturing of membranes

Front 62

When is a prophylactic cerclage placed?

Back 62

between 12-14 weeks gestation before cervical incompetence develops

Front 63

What patient education is important when a cerclage is in place?

Back 63

instruct patient on symptoms of preterm labor and to report PTL immediately -- ctx can cause laceration of cervix

Front 64

When is a cerclage usually removed?

Back 64

36 wks

Front 65

What is placenta accreta?

Back 65

placenta implants more deeply than normal into uterine tissue

Front 66

What puts a woman at increased risk for placenta accreta?

Back 66

hx of previous c-section and a low placenta

--> consultation necessary

Front 67

If a patient presents with placenta previa will it remain that way throughout pregnancy?

Back 67

placenta may migrate with uterine growth and move more toward fundus, however, it may remain near cervical os and consultation/referral will be necessary

Front 68

What are the sxs of acute placental abruption?

Back 68

1. severe pain
2. rigid, washboard stomach
3. bleeding
4. fetal effects

Front 69

What is chronic placental abruption?

Back 69

small abruptions

Front 70

What should we do if a patient has symptoms of preeclampsia but BP is acceptable?

Back 70

follow-up with patient in a few days to 1 week (at latest)

Front 71

How is preeclampsia diagnosed?

Back 71

Must have two separate elevated BP readings at least 6 hours apart

Front 72

What clinical manifestations might be present if patient has preeclampsia?

Back 72

1. hyperreflexive deep tendon reflexes
2. clonus

Front 73

What measures should be taken to evaluate the fetus with gestational HTN?

Back 73

1. NST at dx (must be 26-28 wks for NST to be possible)
2. encourage patient to monitor kick counts

Front 74

What is the risk to the fetus with gestational HTN?

Back 74

Greater resistance in placenta causing lower perfusion:
1. decreased fetal heart tones
2. growth restriction
3. may cause intrauterine fetal demise

Front 75

What is a possible maternal complication of eclampsia?

Back 75

increased risk for stroke from seizure and spikes in BP