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93 Cards in this Set

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What are the dates for the third trimester?
29 weeks to term
What kind of anticipatory guidance should be provided to patients in the third trimester?
1. Preparation for delivery (birth)
2. Preparation for newborn
3. Parenting
What are the possible reasons that there is a discrepancy between the size of the uterus and the dates of gestation?
1. fetal size
2. amniotic fluid volume
Why might size be less than dates?
1. IUGR
2. SGA
3. oligohydramnios
What is IUGR?
Pathological progress in which decreased oxygen and/or nutrients are available to fetus
What is symmetric IUGR?
Fetus is small in all parameters including head development

Represents chronic/long-term "insult"
What is asymmetric IUGR?
Small body with large head -- "head sparing"

Represents late-occurring/short-term deprivation
Which type of IUGR (symmetric vs. asymmetric) has better prognosis?
Asymmetric ("head sparing") IUGR
What are the risk factors for IUGR?
1. poor nutrition or maternal wt. gain
2. maternal vascular disease
3. preeclampsia
4. multiples
5. smoking
6. genetic disease
7. drug/alcohol abuse
8. anemia
How does SGA differ from IUGR?
SGA is not pathological

Fetus is constitutionally small but follows growth trend. Differentiated from serial evaluation of ultrasounds (retrospective)
What is oligohydramnios?
Abnormall small amount of amniotic fluid (AFI < 5 cm)
What major concern is associated with oligohydramnios?
Increased risk for perinatal morbidity and mortality
What factors are a/w oligohydramnios?
1. congenital anomalies
2. IUGR
3. PROM
4. post-maturity
How is oligohydramnios managed?
1. bed rest
2. hydration
3. encourage good nutrition
4. assess fetal well-being (kick counts, AFV, BPP)
5. induction and delivery if severe and fetus is mature
What are some possible causes for size greater than dates?
1. macrosomia
2. LGA
3. multifetal pregnancy
4. fibroid uterus
5. polyhydramnios
What is polydramnios?
excessive amount of amniotic fluid (AFI > 20 cm)
If a patient has oligohydramnios what do we want to rule out?
1. GDM (even if previous GCT screen was okay)
2. ABO/Rh disease
What are some difficulties a/w polyhydramnios?
1. difficulty auscultating fetal heart tones and palpating fetus
2. unstable fetal lie
What are the risk factors a/w polyhydramnios?
1. multiples
2. uncontrolled GDM
3. fetal malformations
4. chromosomal abnormalities
What are the complications of polyhydramnios?
1. fetal malpresentation (b/c of unstable fetal lie)
2. placental abruption
3. uterine dysfunction during labor
4. postpartum hemorrhage
5. cord prolapse
6. preterm labor
What is PROM?
premature rupture of membranes -- before onset of labor
What is PPROM?
pre-term premature rupture of membranes -- before 37 wks gestation
What is prolonged ROM?
ROM that occurs > 24 hrs before birth
What are the differential diagnoses for reports of "water breaking"?
1. urinary incontinence
2. vaginal or cervical discharge
3. increased leukorrhea
4. semen
What questions will you ask a woman when she reports water breaking?
1. time of fluid leak
2. color -- should be clear
3. odor -- foul-smelling is a sign of infection; does it smell like urine?
4. amount of fluid -- large amount and now still dribbling?
5. time of last intercourse
6. control of flow -- if it seems controllable, is probably urine
What will you complete for an in-office physical if woman reports water breaking?
1. abdominal exam
2. pelvic exam--> STERILE speculum
*visualize os for dilation, fetal parts or cord, fluid leaking
*pooling in vault
*collection of fluid/secretions
What cultures would be taken if infection was suspected (based on finding mucopurulent discharge)?
Gonorrhea and chlamydia, Group B strep
Why would a wet mount be ordered?
Bacterial vaginosis suspected
What is the fern test?
Test to determine if fluid is amniotic fluid

1. Fluid is collected from pool in vaginal vault
2. Make a dry slide
3. Observe under microscope

*cervical mucus = false positive
What does nitrazine test for?
whether amniotic fluid is present (pH of amniotic fluid is basic vs. acidic vaginal secretions)
What situations can cause false positives with a nitrazine test?
1. vaginal infections (BV, trichomoniasis)
2. cervical mucus
3. semen
4. blood
What are the requirements for prescribing expectant outpatient mgmt for patients with PPROM?
1. documented PPROM > 72 hr (risk of delivery decreases after 3 days)
2. cervical dilation < 3 cm
3. no sxs of infection
4. no sxs of PTL
5. client willingness to comply
6. no breech or transverse presentation
What self-assessment measures must be taken for outpatient mgmt (PPROM patients)?
1. Temp q4h (when awake)
2. monitor sxs of infection
3. assess for uterine ctx
4. daily kick counts
What activity modifications must a PPROM patient on expectant outpatient mgmt make?
1. modified bed rest
2. nothing per vagina (NPV)
3. proper hygiene
4. no tub baths
5. take antibiotics as prescribed
What fetal assessments will be made when a PPROM patient is under expectant outpatient mgmt?
Weekly NST, AFI, BPP
What is preterm labor (PTL)?
documented uterine ctx and cervical change btwn 20 and 37 wks gestation
How often does PTL lead to preterm birth?
12% of cases of PTL
When does mgmt of PTL begin?
begins in ambulatory setting with screening for women at risk
What are the maternal risk factors for PTL?
1. low SES
2. non-white race
3. poor nutritional status
4. h/o preterm birth
5. one or more second tri SABs
6. short interval btwn preg
7. multiple gestation
8. anemia
9. infection
10. high stress
11. tobacco use
12. no prenatal care
13. age: < 18 or > 40
What are the causes of PTL?
unknown and assumed to be multifactorial?
Which infections can cause PTL?
1. bacterial vaginosis
2. chlamydia
3. gonorrhea
4. UTI
What are the symptoms of PTL?
1. pelvic pressure
2. low, dull backache
3. menstrual-like cramps
4. suprapubic pain or pressure
5. change or increase in vaginal discharge
6. uterine ctx occurring every 10 min
7. intestinal cramping with or without diarrhea
According to the "Preterm Prediction Study" what factors have the strongest associations with preterm labor & birth?
1. Positive fetal fibronectin
2. shortened cervix
3. bacterial vaginosis
Where and when is fetal fibronectin found?
Found in cervical secretions at two different times:
1) 20-22 weeks gestation
2) prior to labor onset
How does fetal fibronectin service as a predictive factor?
has a high NEGATIVE predictive value (NPV) and low POSITIVE predictive value (PPV)

*best identifies women who will not experience preterm birth (NPV = 95-99%)
How does h/o preterm birth affect prenatal care?
1. screen asymptomatic bacteriuria (ASB)
2. treat vaginal or cervical infections
3. diet and nutritional counseling prn
4. screen for substance abuse
5. serial vaginal exams?
6. pt education:
*stress reduction
*change or reduce workload
*condoms (semen can promote uterine ctx)
*avoid breast or nipple stimulation (promote uterine ctx)
If a woman presents complaining of PTL, what do you want to ask?
1. LMP/EDD/EGA
2. sxs PTL
3. sxs UTI
4. sxs vaginitis/cervicitis/STI
5. sxs infection
6. sxs ROM
What components of a physical exam will you perform on a woman complaining of PTL?
1. vital signs
2. FHR
3. abdominal palpation (fluid/lie/ctx)*
4. CVAT*
5. evaluate low back pain*
6. suprapubic tenderness*
7. pelvic*
What lab testing should be done for a woman presenting with complaints of PTL?
1. urinalysis
2. urine culture & sensitivity
3. wet mount
4. cultures (group B strep, any lesions)
5. CBC with diff
6. fern test
7. nitrazine test
What is the diagnostic criteria for PTL?
1. EGA 20-37 weeks
2. evaluate ctx
*q 5-8 min
*4 ctx in 20 min
*8 ctx in 60 min
3. progressive cervical change (> or = 3 cm)
What should be done if preterm labor is ruled out?
Advise:
1) decreased activity
2) pelvic rest (NPV)
3) monitor for sxs PTL
4) return visit after 1 week for follow-up evaluation
--> prenatal care per routine thereafter
What is post-term pregnancy?
pregnancy that extends beyond the 42nd week of gestation
What is the cause of post-term pregnancy?
Cause is unknown
What are the clinical manifestations of post-term pregnancy?
1. maternal weight loss
2. decreased uterine size
3. meconium in amniotic fluid
4. advanced bone maturation of the fetal skeleton with a hard skull
What are the risks to the mother with post-term pregnancy?
1. dysfunctional labor
2. perineal trauma
3. postpartum hemorrhage
4. infection
5. interventions (forceps, vacuum, c/s) are more likely to be necessary
6. emotional stress
What are the risks to the fetus with post-term pregnancy?
1. macrosomia
2. birth trauma (from assistive devices, etc.)
3. distress
4. hypoxia/asphyxia
How do we manage women with post-term pregnancy?
1. Biweekly BPP, NST, FMC
2. cervical assessment for ripeness
3. induction of labor
What is "post-dates" pregnancy?
gestation >280 days from LMP (>40 weeks)
What are the concerns of post-dates pregnancy?
1. increased infant morbidity and mortality
*utero-placental insufficiency
*macrosomia
2. increased maternal morbidity
*interventive birth
*c-section
How do we manage the patient who is 40-42 weeks gestation?
1. Begins in early pregnancy with obtaining RELIABLE DATES
2. prenatal visits weekly
3. kick counts daily
4. anticipatory guidance/reassurance (how care will proceed and when IOL will occur if labor does not begin spontaneously before 42 weeks)
5. NST/BPP biweekly after 40-41 wks
6. issues to consider:
*LGA
*decreasing amniotic fluid
What are the indications for IOL with postdate pregnancy?
1. non-reassuring fetal testing (BPP)
2. oligohydramnios
3. preeclampsia
4. IUGR
5. h/o previous stillbirth at term
6. 42 weeks* (will depend on provider preferences for IOL - may induce sooner)
What is PUPPPs?
Pruritic Urticarial Papules and Plaques of Pregnancy
What is ICP?
Intrahepatic Cholestasis of Pregnancy
What should you be asking/thinking when a woman presents with pruritis?
1. Are there others in the household with the same symptoms?
2. Onset and accompanying symptoms?
3. Lesions?
4. h/o atopy or psoriasis?
5. Evaluate changes in: a) environment, b) allergens, c) hygiene, d) diet, e) meds, f) pets
What is the most common dermatosis of pregnancy?
PUPPPs
How does PUPPPs appear/begin?
lesions begin in linea striae (stretch marks) and spread to extremities, thighs, and buttocks
What are some facts about PUPPPs?
1. pathogenesis unknown
2. no known complications
3. not a/w fetal morbidity or mortality
4. more common in primigravidas and with multifetal pregnancies
What can be done to relieve symptoms of PUPPPs?
1. oatmeal bath
2. calamine lotion
3. avoid restrictive clothing
4. topical corticosteroids -- start with OTC and move to prescription-strength if necessary
5. antihistamines (benadryl or atarax q6h)
When would you consult with a MD regarding PUPPPs?
1. to confirm dx of PUPPPs
2. r/o other derm conditions
3. consult for systemic steroids -- prednisone -- if topical corticosteroids are not effective
What are the facts about ICP?
1. generalized pruritis without lesions
2. onset in third trimester
3. resolves postpartum
4. may recur in subsequent pregnancies
5. increased neonatal morbidity?
6. increased risk IUFD
What are the clinical manifestations of ICP?
1. may have h/o ICP
2. severe itch
3. jaundice
4. steatorrhea
5. elevated bile acids*
6. liver fxn tests may be elevated
7. bilirubin elevated if jaundiced
How is ICP managed?
MUST consult with MD
What symptom management can you prescribe?
1. oatmeal baths
2. avoid restrictive clothing
3. antihistamines
4. systemic therapy
When would IOL occur if patient has ICP?
Decision of consulting MD
* term without jaundice
* 36 wks with jaundice
How is fetal surveillance affected if mother has ICP?
1. kick counts daily from 28 weeks on
2. modified BPP from 32 weeks on
How often are prenatal visits in the third tri?
q2 weeks until 36 wks

at 36 wks, visits weekly
What are the options if Leopold's maneuver finds that the fetus's presentation is not cephalic?
1. Wait-and-see: option until 36-37 wks when referral should be made
2. External cephalic version (ECV) by specialized provider
3. C-section -- if ECV fails or it is too late to perform ECV
What cultures should be taken during the third tri?
1. Gonorrhea/chlamydia
2. Group B strep --> if positive, IV prophylactic antibiotics, beginning with: 1) onset of labor OR 2) ROM
What is lightening?
Fetus drops into pelvis
How do discomforts change once lightening occurs?
Old discomforts from pressure of fetus on abdominal contents are relieved

New discomforts include urinary frequency and pelvic pressure
If height of fundus does not equal weeks of gestation, what should first assessment be?
Observe trend of fundal height through pregnancy -- was she always higher or lower before?
How does increased maternal hydration help treat oligohydramnios?
Can increase amniotic fluid volume
How does the extra fluid of polyhydramnios put the fetus at risk?
Fetus floats in fluid instead of settling into pelvis; increased risk for:
1) cord entanglement
2) prolapsed cord (when membranes rupture)
How does the extra fluid of polyhydramnios affect the woman?
Hyperextension of uterus, increasing risk for:
1) placental abruption
2) labor difficulties (interferes with muscle coordination of uterine ctx)
3) PP hemorrhage r/t muscle incoordination
What is leukorrhea?
Vaginal discharge that increases during pregnancy because of increased estrogen
What might suprapubic pain or pressure indicate?
1. Preterm labor
2. UTI
Why does fetal fibronectin have a high negative predictive value?
In a study, fibronectin samples were taken from women who had symptoms of PTL. The fibronectin results were negative and they did not have preterm birth (followed for 3 wks after sample). NPV is 95-99%
Why is hypoxia/asphyxia a fetal risk in post-term pregnancy?
1. placental function decreases
2. oligohydramnios increases (less amniotic fluid)
If a woman is post-date and has non-reassuring NST or BPP, how might that change her IOL plan?
Poor NST or BPP may necessitate IOL that same day
Where does ICP occur?
Often generalized but most severe in palms of hands and soles of feet
How common is ICP in subsequent pregnancies?
60-70% recurrence rate in subsequent pregnancies
What does UDCA do?
helps treat ICP by breaking up fats
How does a dx of ICP affect management of pregnancy/labor?
98% of fetal demise occurs after 38 wks when a mother has ICP --> if labor does not begin naturally before 38 wks, provider should induce by 38 wks