Prenatal Care, Pregnancy

Front 1

Prenatal Care includes what?

Back 1

risk assessment, client education and health promotion

Front 2

How should a practitioner present risk assessment to mother?

Back 2

Careful of labeling woman as high risk as may affect her own self perception and increase anxiety. the mother’s own self-confidence, self-reliance and belief in her ability to control events often predictors of normal birth process.

Front 3

What risk factors can change with pregnancy?

Back 3

nutritional support, communication barriers, housing,); still others may require direct action by the mother with support from the health care system (i.e., personal health habits: smoking, drug abuse, nutritional habits). Help woman find ways to change to decrease risk

Front 4

Why important to accurately date pregnancy & how to do this

Back 4

need to know if woman preterm or post term.
LNMP: This method of dating a pregnancy is only accurate if the LNMP is SURE, the client has a hx of regular periods, she was not using hormonal birth control at the time of conception, was not breastfeeding at the time of conception, AND the physical exam findings (when assessing uterine size) is consistent with the reported last period. If ANY of those criteria are not met, then an USN is medically indicated to establish a more accurate EDC.
2) Vaginal US if does not meet above critera

Front 5

What objective data can confirm pregnancy dates?

Back 5

quickening (16-18 weeks multip), 18-20 wks - primip). Uterine size - 12 weeks at level of symphasis pubis, 20 weeks umbilicus (if 24 weeks can be 22-26cm)

Front 6

What is measured with US to determine dating?

Back 6

7-11 weeks crown/rump measurement, (+ or - 3-5 days) Cardiac activity seen at 6 weeks, 16-18 weeks accuracy + or - 6-10 days and uses biparietal diameter. After 20 weeks US accuracy greatly diminished

Front 7

When to do a bi-manual exam?

Back 7

1st visit if during first 6-11 weeks, 6 week uterus size of small juice orange, 8 week naval orange, 10 weeks a grapefruit

Front 8

What can influence what uterus feels like with bimanual exam?

Back 8

uterine position (anteverted - most common, midline, retroverted), bladder status, maternal habitus (obese)

Front 9

How to assess uterine size 12-20 weeks?

Back 9

by fingerbreaths, 14 weeks 2-3 above symphysis, 16 weeks halfway between symphysis and umbilicus

Front 10

How to assess uterine size after 20 weeks?

Back 10

fundal height measured with tape measure - normal finding + or - 2cm from gest weeks. Serial measurements provide better info compared to a one time measurement

Front 11

Measuring 36 weeks to birth

Back 11

still measure with tape measure, but head could descend into pelvis

Front 12

How do distinguish multiple pregnancies

Back 12

Add a 5th digit at the end G3P30131 (TPAL - term, preterm, abortion, living then TPALM (M=multiples)

Front 13

How to interpret G & P for pregnancies?

Back 13

Parity: Term and preterm indicate infants and not pregnancies

Front 14

What routine labs are indicated for a pregnant woman at first visit?

Back 14

1) CBC, Significant values: hgb < 11 1st & 3rd trimesters & < 10.5 2nd semester) HCT - < 33 1st and 3rd and < 32 2nd. MCV - < 80, MCHC < 33, Platelets: < 150,000- > 400,000. WBC > 12,000 (blacks normal 5.6-15.1) 2) ABO & RH screen & antibody screen - significant values: mother RH neg & father RH pos, Mother Rh neg and father unknown, Mother type O positive antibody 3) VDRL or RPR 4) Rubella titer sig results: <1.8 5) HBsAg 6) HIV 7) Pap Smear if not done in last year 8) chlamydia/gonorreha 9) UA sig values + nitrites, + ketones, +2 protienuria or glycosuria 10) Urine culture and sensitivity - looking for GBS, 11) selected women 1 hr OGTT >130-140 abnormal 12) selected women hemoglobin electerophoresis looks for sickle cell, Hgb C trait or disease or thalessemia disease 13) urine drug screen if indicated

Front 15

What other labs can be ordered for a woman during pregnancy?

Back 15

Optional serum genetic quad screen (any woman who wants it) @ 16-18 weeks, sig values: ↑AFP (NTD)
↓AFP, ↑inhibin A, ↑ hCG (Down)
2) 1 hour OGTT
(either routine or selective screen, will learn in NM632)
@ 24-28 weeks, Sig values: >130-140mg/dl plasma (depends on criteria used)
3) Hgb & Hct
(often routine) @ 24-28 weeks
Hgb <10.5
Hct <33.0
4) Antibody screen (Rh neg women)
@ 24-28 weeks
Sig value: positive

Front 16

How can pregnant women be exposed to lead paint?

Back 16

crumbling paint can lead to dust when surface is touched, can also be exposed to lead through drinking water if home has lead pipes, lead solder or copper or brass faucets also in well water - run water for 10-15 seconds before using it for drinking - use cold water as cold water pipes contain less lead than hot water pipes, lead in crystal and ceramics, vinyl mini blinds, old painted toys, cosmetics containing surma or kohl, lead in cans of food from other countries, candies imported from mexico,

Front 17

What is most common exposure to mercury for pregnant woman?

Back 17

eating fish - mostly large fish like swordfish, shark, king mackerel or tile fish. Limit white tuna to 6 oz/week

Front 18

What other metals are a risk to pregnant women?

Back 18

arsenic - check well water, solvents, pesticides

Front 19

Which pregnant women should not exercise?

Back 19

heart disease that compromises bld flow, preterm labor, incompetent cervix, restrictive lung disease, multiple gestation, vaginal bleeding, ROM, preeclampsia, placenta previa

Front 20

What exercise is good for the baby?

Back 20

moderate aerobic exercise for 30 min/day - may reduce risk of premature birth. exercise required more O2 intake, increases HR, alters a woman's balance, joints more susceptible to injury

Front 21

Which pregnant women should have the OGTT at 1st prenatal visit?

Back 21

obese or overweight prior to pregnancy, prior hx of baby >4000gms or hx unexplained stillbirth

Front 22

What is cultural competence continuum?

Back 22

destructiveness, incapacity, blindness, precompetence, competence, proficiency

Front 23

How does exercise with pregnancy benefit the fetus?

Back 23

increases bld volume & vascularture, improved heart function & cardiac output (helps woman get through labor), augment O2 & nutrient delivery to fetus

Front 24

What should pregnant women avoid when exercising while pregnant?

Back 24

lying on back compressing Vena cava in 3rd trimester for more than 2-3 min. Limit aerobic exercise on feet to 20-30 min for less fit and 30-45 min for more fit, avoid sudden changes of position, cooldown, rest daily in side lying position

Front 25

What are the effects of exercise and hypertensive disorders?

Back 25

Show improvement of hypertension

Front 26

How does exercise help the diabetic woman

Back 26

helps lower sugar levels by

Front 27

What are calorie requirements for pregnant exercising women?

Back 27

200-300 kcal every 2-3 hours

Front 28

How to classify activity with a pregnant woman

Back 28

inactive - no exercise, A little active: 1-3 30 min exercise over a week. Active: 30 min activity or exercise daily w/ at least 2 days of aerobic activity. Very active: more than 5 exercise day/week with regular high intensive aerobics Professional or competitive

Front 29

What considerations should be made concerning nutrition and exercise

Back 29

women need enough protien and water to produce additional bld volume & grow neurologically adequate fetus. & carbohydrate intake to meet energy requirements

Front 30

How are the trimesters divided?

Back 30

1st: 1-12 weeks. 2nd: 13-27 weeks 3rd: 28-40 weeks

Front 31

What are some signs of pregnancy

Back 31

missed period, elevated temperature r/t progesterone production, breast tenderness - inc levels of estrogen and progesterone, nausea, skin pigmentation changes of areola, stretch marks, cholasma, chadwicks sign: bluish or purplish color of vulva and vaginal mucosa & cervix, Goodells sign: softening of cervix. Hegars sign: softening nad compressibility of uterine isthmus (all seen at 6 weeks), uterine enlargement

Front 32

What does hCG test

Back 32

human chronionic gonadrotropin which is released after implantation and increases exponentially & doubling every 2 days after implantation (low in women with ectopic pregnancies & threatnened ABs & high with multiple gestations) can get false positive with massive protienuria and during onset of menopause, false neg when test done too early before 6 weeks

Front 33

What are some physiological changes that take place with pregnancy?

Back 33

bld volume increased 30-50% (more plasma than RBcs which results in hemodilution and lowered HCT), inc cardiac outpt, changes in heart sounds with murmurs, changes in renal fx to help regulate wastes from fetus, hydronephrosis which increases chance of UTI, decreased lung tidal volume d/t enlarged uterus causing dyspnea, gingvitis - estrogen increase bld flow to mouth making gums friable, decreased tone of esophageal sphincter (caused by progesterone)- causing heart burn & also causes delayed emptying of stomach & slows down intestines to allow greater absorption of nutrients for baby also causes constipation

Front 34

What are psychological changes with pregnancy?

Back 34

1st trimester: most women express feelings of not wanting to be pregnant or ambivalence, anxiety that may lose pregnancy - this resolves as woman accepts pregnancy excitement and fear of birth, feelings of being ugly and large

Front 35

When is fetus most susceptible to birth defects?

Back 35

during embryonic period - up to 8 week post implantation or 10 weeks gestation

Front 36

What is function of placenta?

Back 36

organ of metabolism, organ of transfer, and endocrine organ

Front 37

Name some presumptive s/s of pregnancy?

Back 37

Changes seen/reported by mom such as cessation of menses, N/V, breast tenderness, darkening of areoloa, appearances of Montgomerys tubercles, elevation of basal body temp, expression of colostrum, excessive salivation, Chadwicks sign, quickening, skin changes, frequent urination, fatigue

Front 38

Name some probably s/s of pregnancy?

Back 38

Changes that occur and are found by examiner & usually indicate pregnancy - enlargment of abdomen, palpation of fetal outline, ballottement, fetal movement,, change in shape of uterus, Hegar's sign, Goodels''s sign, pos pregnancy test, Piskacek's Sign

Front 39

Name some positive s/s of pregnancy?

Back 39

fetal heart tones, sonogram of fetus

Front 40

What drugs are used for medical abortion

Back 40

mifepristone (inhibits progesterone - the hormone that maintains normal pregnancy) used alone 80-85 effective and when used with prostoglandin (cytotec - misoprostol) 96% effective. Can be used up to 7 weeks of pregnancy after than surgical abortion is method of treatment If treatment fails woman must agree to surgical abortion because misoprostol is teratogenic. Take mifepristone 1st then return in 2 days to take misoprostol - remains in clinic for 4 hours & 50% expel POC then. If not return in 10-12 days

Front 41

When is a medical abortion contraindicated

Back 41

suspect ectopic pregnancy, undiagnosed adnexal mass, IUD still in place, severe anemia, coaguapathy or on anticoagulants, adrenal failure, long term steriods, severe liver, kidney pulmonary or CVD, uncontrolled seizures, unwilling for f/u

Front 42

What to expect with medical abortion

Back 42

heavy bleeding (call if soak more than 4 pads in 2 hours or heavy for >24 hours), n/v, pain, cramping, fever, HA, Rh neg need rhogam w/i 72 hrs

Front 43

What needs to be done on 1st antenatal visit?

Back 43

history, PMH, Fam hx, menstrual hx, obstetric hx, gyn hx, sex hx, contraceptive hx, douching hx, present pregnancy history, psychosocial exam, questions about abuse (look for scars, bruises), pelvic exam - speculam & bimanual, evaluate bony pelvis & physical, lab tests: pap smear, GC & chlamydia, ABO, RH, sometimes sickle cell, TB to high risk groups, VDRL or RPR, Hep B, Rubella titer, H&H or CBC, UA, GBS, HIV

Front 44

What is TPAL

Back 44

Term infants, preterm infants, abortions & living children (count infants not pregnancies)

Front 45

What is Naegles rule regarding EDB?

Back 45

7 days are added to the date of the first day of LMP nd then 3 months are subtracted from that date. Not reliable if woman has irreg periods, conception occurs while mother breastfeeding, conception occurs before regular menses after termination of pregnancy, or discontinuation of OCP

Front 46

What history to take with a revisit of pregnant woman?

Back 46

concerns, HA, visual distrubances, dizziness, fever, N/V, fetal movement, abd pain, contractions, back pain, dysuria, vag discharge or leaking, vag bleeding, constipation/hemorrhoids, varicose veins, leg pain or cramps, edema, use of meds, relationship changes, any medical care since last visit, childbirth classes

Front 47

Physical exam with revisits of pregnant woman

Back 47

b/p, weight, abd exam for fundal height, lie & presentation of fetus, eval of amniotic fluid, palpate fetal movement, estimate fetal weight, CVA tenderness, exam for edema, no need for pelvic unless c/o discharge or need to assess cervical change in last trimester

Front 48

Labs tests for revisits for pregnant woman

Back 48

voided urine for protien and glucose, OGTT @ 28 weeks, GBS at 35-37 wks

Front 49

Common discomforts in pregnancy & how to alleviate them.

Back 49

Nausea -worse when stomach empty - eat small frequent meals, eat crackers before getting up, do not brush teeth righ after eating, drink gingerl ale, restrict fats, avoid strong odor foods, - peaks at 11 weeks and begins around 5-6 weeks, Can use meds: Vit B6 or antihistamine doxylamine (Unisom) 2) excessive salivation, 3) fatigue, 4) upper backache d/t inc size of breasts - well fitting bra, 5) leukorrhea (acidic vaginal discharge - protects against infection) - do not douche, cotton underwear, 6) urinary frequency during 1st trimester d/t large uterus pressing on bladder & 3rd trimester when head sits on bladder. Also d/t fluid from dependent edema from daytime is excreted at night 7) Heartburn - 2nd & 3rd trimester - progesterone relaxes sphincter, decreases gastric mobility & stomach pushed up by growing uterus - to help eat small frequent meals, keep good posture, avoid fats, avoid fluids with meals, avoid cold or spicy foods, avoid meals before bedtime, Meds to use: antacids with alluminum hydroxide, magnesium hydroxide or mag trisilicate (Maalox, Mylanta, Gaviscon, Gelusil) Amphojel and MOM. Do not use Alka Seltzer 8) Flatulence 9) constipation - increase fluids, prunes, adequate rest, warm liquids on rising - stimulates peristalsis, Eat foods with roughage - bran, fiber, exercise, good bowel habits, mild laxatives 10) Hemorrhoids - come with constipation 11) Leg Cramps - 12) dependent edema: avoid constrictive clothing, elevate legs, lay on side 13) varicosities - support hose, avoid long standing, rest, elevate legs do not cross legs, mild exercise for best circulation, 14) Dyspareunia 15) Nocturia 16) Insomnia: warm baths, relaxing positions 17) Round Ligament pain: extension of pain into inguinal area - flex knees to abd, bend towards pain to ease stretch, pelvic tilt, warm baths, heating pad to area, support uterus with pillow, wear maternity abd support. 18) Low Back Pain - d/t shift in center of gravity & curvature of back. Worse with lax abd muscles like in multip: stoop do not bend, god posture, low heeled shoes, warm pads, massage, supportive pillows when sleeping 19) Hyperventilation (d/t progesterone) or SOA (3rd trimester): stand up and stretch arms above head while taking a slow deep breath. 20) Tingling & numbness of fingers: change in center of gravity where shoulders back and head forward causes compression on ulnar nerve or edema can cause carpel tunnel - can use wrist splints while sleeping 21) supine hypotensive syndrome - do not lie on back.

Front 50

What is best goal for growth of fetus?

Back 50

> 3000 gms. lower weights can cause babies to have lower intelligence and higher incidence of physical disabilities - disabilities can be attributed to malnutrition of fetus

Front 51

What is important regarding nutrition for a pregnant woman?

Back 51

protein and adequate caloric intake

Front 52

How many calories do pregnant women need to support their pregnancies?

Back 52

2200 calories plus an addition 300 – need 60 gm of protein each day (10 gm above nonpregnant) some studies show adolescents need 85-90 gm protein/day d/t maternal growth needs also

Front 53

What is dose of iron supplements for pregnant women

Back 53

ferrous iron 30 mg daily (150 mg ferrous sulfate, 300 mg ferrous gluconate or 100 mg ferrous fumarate. Helps meet demand for maternal and fetus hgb synthesis. Vit C 250 mg helps with absorption of nonheme iron

Front 54

What can cause woman to be overweight with pregnancy?

Back 54

fat only - too many calories
Edema only - not enough protein and caloric intake

Front 55

What is suggested weight gain for pregnant women?

Back 55

Low BMI < 19.8 need to gain 28-40 lbs or 12.5-18 kg. If normal BMI 19.8-26 then need to gain 25-35 lbs or 11.5-16 kg. High BMI > 26-29 - 15-25 lbs or 7-11.5 kg. Young adolescents need to strive to weight gain at upper end

Front 56

What foods can be added if more protein is needed in pregnant diet?

Back 56

milk, peanut butter, cheese, bread and eggs

Front 57

What to ask when a woman present with c/o of N/V in pregnancy?

Back 57

Timing/onset
– Weight loss
– Relieving/aggravating factors
– ADL effect
Investigate-make sure it is not
hyperemesis
– s/s dehydration
– Weight loss
– Urine concentrated - Ketosis
no saliva
50-80% experience N/V those who are nauseous or vomiting experience fewer miscarriages.
The diagnostic criteria for hyperemesis include a history of daily frequent vomiting in the 1st trimester (and can last up to 20 weeks gestation) with signs of dehydration, ketonuria, and at least a 5% weight loss from pre-pregnancy weight

Front 58

Teaching points for N/V

Back 58

eat small frequent meals, Vit B6 & ginger, d/c iron while vomiting, avoid strong odors, acupressure bands,

Front 59

What are some skin changes seen in pregnancy?

Back 59

hypermelanosis or darkening of the skin, changes in size and/or color of moles or nevi, development of spider angiomata, and the appearance of striae on the abdomen, hips and/or breasts. Mild hirsutism is also commonly seen in pregnancy, especially on the face. Hair thickens & nails grow faster.

Front 60

Why do pregnant women get syncope?

Back 60

most between 14-28.
, the cardiovascular system undergoes dramatic changes with increased heart rate, stroke volume and volume expansion by around 40%. Also blood pressure gradually decreases during pregnancy reaching its lowest point around 28 weeks gestation. All of these changes cause blood to pool easier - so women who stand are very prone to unexpected feeling of lightheadness and fainting

Front 61

What is Piskacek's Sign?

Back 61

asymmetric enlargement of the body of the pregnant uterus as a result of its enlargement in the cornual region, usually over the site of implantation about 10 weeks

Front 62

What is Goodell's Sign?

Back 62

softening of the cervix about 6 weeks

Front 63

What is Hegar's sign?

Back 63

. It is demonstrated as softening of the uterine consistency and the possibility to palpate or compress the connection between the cervix and the fundus. Softening and compressibioity fo the uterine isthmus. about 6 weeks

Front 64

What is Chadwicks' sign?

Back 64

bluish discoloration of vulva, vaginal mucosa and portions of cervix - seen about 6 weeks.

Front 65

Is a murmur in pregnancy worrisome?

Back 65

functional murmur normal

Front 66

What renal changes happen in pregnancy?

Back 66

hydroureter and hydronephrosis - inc risk of UTI, changes in urination patter - frequency, nighttime urination, dilute urine, timing - 1 3rd trimesters

Front 67

What are some pulmonary changes in pregnancy?

Back 67

phyusiologic dyspnea d/t inc progesterone (early 2nd trimester) 3rd trimester d/t enlarged uterus pushing on diaphram

Front 68

GI changes with pregnancy

Back 68

inc estrogen causes friable gums, gignivitis, inc reflux, slow down digestion - inc gas and constipation, all through pregnancy

Front 69

Back pain in pregnancy, causes and treatment

Back 69

`postural chagnes, overstretched abd muscles, & strained back muscles.relaxation of pelvic ligaments & movement of symphysis pubis and lumbosacral joints, compression of nerve from venous statis at night, contraction pain or UTI. Mild muscle pain responds to rest, heat, cold and analgesics, use of sacroiliac belt (maternity girdle). proper posture stand with one foot higher, daily exercise, back rubs

Front 70

Leg cramps in pregnancy causes and treatments

Back 70

cramping of calf in 3rd trimester. avoid by stretching and relaxing legs before rising. Flex & bend foot and stand on leg. Stretch before going ot bed to help prevent cramps.Reduce milk and phosphate containing foods - soft drinks & processed foods. Caused by lowered CA and inc phosphates. Need to eliminate thrombophlebitis

Front 71

Breast tenderness causes & treatments

Back 71

inc amounts of estrogen & progesterone.good support bra, nipple shells for inverted nipples

Front 72

Headache causes & treatments

Back 72

hormonal influences, vascular dilatation, sinusitis, fatigue lowered BS, eye strain, emotional tension, muscle spasm, noxious fumes, allergens, hypertension, stress. Treatment: analgesics, rest, massage, warm baths, relaxation techniques

Front 73

Ligament pain & treatments

Back 73

growing uterus causes strain on ligaments.Light finger tip massage, warm wet compress, warm bath.

Front 74

What is physiological anemia in pregnancy?

Back 74

blood volume increases between 30-50% and plasma volume accounts for 75% of this increase which causes hemodilution - most pronounced between 24-32 weeks

Front 75

What meds can be use for N/V in pregnancy?

Back 75

doxylamine - antihistamine sold as Unisom & pyridoxine (B6) 25mg QID or 50 mg BID

Front 76

Why is protein important for a pregnant woman?

Back 76

Fetal tissue growth; amniotic fluid, maternal tissue growth; placenta; maternal storage reserves for labor, birth, lactation

Front 77

Why are adequate calories important for a pregnant woman?

Back 77

Increased basal metabolic rate , fetal and placental growth

Front 78

Why is calcium important for a pregnant woman?

Back 78

Fetal skeleton, tooth bud formation; increased maternal calcium metabolism

Front 79

Why is iron important for a pregnant woman?

Back 79

Fetal liver iron storage, increased maternal blood volume; increased maternal Hgb

Front 80

Why is Vit B complex important for a pregnant woman?

Back 80

Coenzyme for protein metabolism, increased fetal growth requirement, RBC production

Front 81

What is Pica?

Back 81

crave non-food items. During pregnancy, some women develop cravings for these non-food items. Symptoms of pica usually appear in the 1st or 2nd month of pregnancy, and persist for more than one month. Women at high risk of pica are more likely to be African American, to live in rural areas, are underweight, and to have a positive childhood and family history of pica

Front 82

What are dangers of pica?

Back 82

Lead Poisoning: Eating substances that contain lead, such as soil, clay, or paint, could lead to lead poisoning. Women who live in older homes need to be aware that lead pipes in the water system is one of the most likely way to be exposed to increased levels of lead.
Bowel Obstruction: Eating non-food items, especially rocks, hair, and dirt, can cause bowel obstruction. This can lead to severe constipation, bowel inflammation, and infection.
Parasite Infection: Items from the earth, including clay, soil, and grass often contain parasites. Parasitic infection can cause pain, weight loss, and other side effects.
Dental Injury: Hard substances like rocks, clay, and ice can damage or break teeth.
Perinatal Effects: Anemia is associated with pica. It’s not clear if this is a cause or effect of pica. In extreme cases, eating non-food items can prevent absorption of essential minerals and nutrients.

Front 83

How does pregnancy diet affect the neonate?

Back 83

Affects number of fetal/neonate cells
z Affects cell growth
z Affects health of the adult
z Research = term FGR/IUGR infants
predisposed to cardiovascular disease,
kidney disease, Type II diabetes

Front 84

What nutrition is important before conception?

Back 84

Weight Achieve a normal BMI
Vitamins 400 micrograms folic acid/day prevent NTD
Avoid high doses of vitamin A (retinol)
Substance use such as smoking, alcohol or drugs - Eliminate prior to pregnancy

Front 85

How to know about how many extra calories are needed in pregnancy?

Back 85

Around 350 calories a day, but. Appropriate weight gain is a better indicator of
energy sufficiency than the amount of calories
consume

Front 86

What are the additional protein requirements in pregnancy?

Back 86

60-75 gm/day 3-4 servings/day
High protein diets not indicate din pregnancy

Front 87

Carbohydrate requirements in pregnancy?

Back 87

60% of calories, 6-9 servings - need to be complex not refined sugars - white bread, cakes - too much wide swing of bld sugar. Need to prevent ketosis

Front 88

Fat requirements in pregnancy?

Back 88

same a pre-pregnant requirements. Need Omega-3 fatty acids - DHA - essential to developing fetal brain (found in cold water fish - salmon)

Front 89

What about eating fish in pregnancy?

Back 89

avoid shark, mackerel, swordfish, tilefish & sport caught fish in lakes d/t high methylmercury and PCB levels.
good fish: Eat light tuna, haddock, cod, shrimp, herring, sardines,
pompano, whitefish, canned Alaskan salmon 2-3X per
week in the 2nd
and 3rd trimester.Fish oil capsules. Some found in nuts, flax seed, hummus

Front 90

What is the folic acid supplementation needed to prevent NTD?

Back 90

400 mcg/day preconception to 6-8 weeks, pregnancy 600 mcg/day - PNV have 800-1000 so OK. Prior HX NTD need 4000 mcg/day preconception

Front 91

What are recommendations for calcium in pregnancy?

Back 91

1000mg/day same as non-pregnant, 3-4 servings, requirements increased at 12 weeks gestation

Front 92

What are iron requirements for pregnancy?

Back 92

Pregnancy RDA = 27 mg daily
Required for RBC production, fetal and placental growth
Routine supplementation controversial CDC advises 30 mg/day supplemen. PNV has enough iron 35-60 iron - plenty iron. If HGb below 10 then need other iron . Lean red meat, dark leafy greens, enriched cereal

Front 93

What is considered underweight in pregnancy?

Back 93

BMI < 19.8 - higher risk for Preterm birth

Front 94

What is optimal weight gain in underweight pregnancy?

Back 94

28-40 lbs
5 lbs in 1st trimester
z Then 1+ lb per week

Front 95

What is normal weight in pregnancy?

Back 95

BMI = 19.9-26.0
Optimal weight gain = 25-35 lbs
Weight gain patterns
z 3 to 5 lbs. first trimester
z then 1 lb. per wee

Front 96

What is overweight in pregnancy?

Back 96

BMI =26.1-29

z Optimal weight gain = = 15-25 lbs
Weight gain Patterns
2 lbs in 1st trimester
Then 2/3 lb per week

Front 97

Risks of overweight & obesity in pregnancy?

Back 97

Hypertension
z Gestational diabetes
z Postpartum infections
z Cesarean section
z Thrombophlebitis
z Stillbirth
z NTD (double risk of normal weight women)
z Macrosomi

Front 98

What is obesity in pregnancy?

Back 98

BMI > 30
weight gain 15 lbs minimum - even obese or overweight women need to gain weight
1-2 lbs/semester then 1/3 - 1/2 lb / week

Front 99

What is important during 1st trimester with nutrition?

Back 99

Critical nutrients during this phase include:
Protein
Folic acid Vitamin B12
Zinc

Front 100

What is important about nutrition in 2nd & 3rd trimesters?

Back 100

90% of fetal growth
Protein
z Iron
z Calcium
z Magnesium
z B vitamins
z Omega-3 fatty acids, (DHA in particular

Front 101

What is gynecologic Age?

Back 101

the difference between
chronological age and the age at menarche, can be
used as an indirect measure of physiologic maturity
and growth potential. A pregnant adolescent with a
GA of two years or less may still be in a period of
growth and will have increased nutrient requirements compared to an adolescent who has finished
her growth.

Front 102

What is the risk for iron deficiency?

Back 102

twofold increased risk for
preterm delivery and a threefold increase risk for
delivering a low birth weight baby. Need 30mg iron/day in pregnancy

Front 103

What are zinc requirements for pregnancy?

Back 103

Zinc affects protein synthesis and is essential for
growth. The recommended intake during pregnancy
is 15 mg of zinc per day. Food sources: The best sources are seafood, meat, and
eggs. Less rich sources are legumes and whole grains

Front 104

Food sources for folate

Back 104

Folic acid, the synthetic form of folate,
is found in enriched bread, pasta, crackers, breakfast
cereal, and rice. Good sources of folate include: dry
beans, lentils, chickpeas, peanuts, orange juice,
oranges, strawberries, pineapple juice, kiwi fruit,
leafy greens, okra, sweet corn, beets, and broccoli. Need 400 mcg/day prenatally to decease chance of NTD

Front 105

What supplement should be taken by VEgans to prevent anemia?

Back 105

B12 - primary found in animal foods

Front 106

Obesity in pregnancy is associated with what?

Back 106

preeclampsia and c/s

Front 107

when can FHT's first be heard?

Back 107

10-12 weeks (harder with obese woman)

Front 108

How to do fundal height measurements?

Back 108

12 wks: symphysis
▫ 20 wks: umbilicus
▫ 36 wks: xiphoid
Not accurate after 36 weeks d/t fetus can drop into pelvis
20 weeks to term start using tape measure, If greater than 3 CM either way then worry about growth issue

Front 109

How to do fetal movement assessment?

Back 109

Easy, non-invasive
• Begin at ~34 weeks for low risk
women
• Tremendous variation in normal
• Important factor is baby’s norm - movements change as baby grows as not as much room to move around, but should still be moving
• Can be influenced by gestational
age, maternal smoking/meds, time
of day, glucose load…and…
▫ Fetal hypoxia
Needs to be moving at least 3x/hour

Front 110

Non stress testing - when to do?

Back 110

any maternal or fetal
complication that requires
assessment of fetal oxygenation and
neurologic health - as neurologic system matures when baby moves then the FHR should accelerate. Need 2 accel within a 20 min period. Can start NST around 28-32 weeks

Front 111

What is a Biophysical profile measuring?

Back 111

Uses EFM and US to assess fetal heart rate reactivity, fetal
behavior and amniotic fluid volume - Modified only measures the fluid volume
Well-oxygenated and neurologically intact fetus will have:
1. Muscle tone
2. Gross body movements
3. Breathing movements
4. Reactive heart rate
5. Adequate amniotic fluid
• Scoring: each component worth 2 points for total 10 point

Front 112

When can you first hear FHT's with a doppler

Back 112

10-12 weeks

Front 113

When are urine pregnancy test accurate

Back 113

1st day woman has missed her period - sensitive to HcG below 50, 8-11 days after conception, after that should double q2days, if more suspect twins, hydiform mole, dropping levels suspect loss of pregnancy, hCG will rapidly decrease between 12-16 weeks

Front 114

When is triple screening MSAFP (maternal serum alpha fetoprotein) done?

Back 114

Between 15-18 weeks - identifies neural tube defects & trisomies 21 & 18

Front 115

What 1st trimester screening is available for down syndrome detection?

Back 115

measure pregnancy associated plams protient (PAPP-A) and lower quantities of hCG. Accurate 60% of time, not widely available

Front 116

What is NT screening in 1st trimester

Back 116

US used to visualize neural tube between 10-14 weeks. Increasedsonolucent area on back of neck > 3mm increased risk of chromosomal abnormalities, heart defects, sensitivity 80% when sonographer skilled

Front 117

What does increase of MSAFP mean?

Back 117

wrong dates, multiple gestation, neural tube defects, ventral wall defects, renal anomalies, oligio, ectopic pregnancy, fetal-maternal hemorrhage, underweight mother, black race, increased placental size

Front 118

What is the triple screen?

Back 118

tests MSAFP, hCG & unconjugated estriol and has replaced the MSAPF alone. See more false positive rates the older a woman gets. Also see increase risk for stillborn and preterm baby when levels are high. Most common abnormal sare wrong dates. Do US to confirm dates and look for anomalies

Front 119

What is a QUAD screen

Back 119

adds inhibin A to screens which increases accuracy of test to 80-85% positive for Downs syndrome with just 5% false positive rate. Offer tests between 15-20 weeks

Front 120

What is Chorionic villus Sampling (CVS)?

Back 120

done in 1st trimester to test for anomalies - allows woman choice to terminate pregnancy if anomalies found, and privacy to do so before anyone knows she is pregnant. Risk for pregnancy loss. performed transcervically w/ US and villi from placental are obtained

Front 121

Should genetic testing be offered to all women?

Back 121

Advantage may catch something early so woman can prepare, but disadvantage is increase stress & anxiety put on mother. Increased cost of procedures, possible loss of pregnancy with aminocentesis

Front 122

When is a genetic amniocentesis performed?

Back 122

15-16 weeks - provides more information than CVS, performed with US, risks includes fetal loss 0.5% to 1%, amnioitis, fetal injury Rh sensitization. need to give Rhogam to rh neg moms. If done after 20 weeks reason changes from genetic to monitoring fetal lung maturity

Front 123

What can interfere with perception of fetal movement?

Back 123

polyhydramnios or oligo or by anterior placenta. Obesity not shown to interfere with maternal perception of movement

Front 124

How to do Fetal movement counts

Back 124

schedule same time each day, lay down for 1 hour and focus on baby, if fewer than 1-2 kicks then need NST, start at 34-36 weeks, high risk start at 28 weeks

Front 125

What is a NST

Back 125

20 min tracing - pos with 2 accels in 20 min. for 15 sec, 15 beat above baseline. If not reactive can wake baby and monitor for an additional 20 min. NSt done in 3rd trimester - 28 week fetus may not neurologically mature to be reactive. Usually can start NST between 28-32 weeks

Front 126

When do to a BPP?

Back 126

IUGR, oligo, insulin dependent diabetes, preeclampsia, postdates, nonreactive NST or multiple pregnancy. Score 10 perfect. > 8 OK if AFV normal - normal see at least one > 2cm pocket - Oligio associated with fetal hypoxia & uteroplacental insuffiency

Front 127

When should genetic amniocentisis be offered?

Back 127

15-16 week for women at risk for neural tube defects

Front 128

When to do an US

Back 128

the benefits must outweigh the risks to the patient. For dating 18-20 weeks (can do 15-22). Can use during 1st or 2nd or 3rd trimester for dating.

Front 129

Who is gives birth to most down syndrome babies?

Back 129

Those under 35 (80%). All women regardless of age, should be offered genetic screening for Down syndrome (ACOG, 2007). For pregnant women > age 35, invasive genetic diagnostic testing of amniocentesis and chorionic villi sampling (CVS) are offered as a 1st line testing (in other words without screening first), in addition to the above serum screening options

Front 130

What are the 3 Downs Syndrome screening options?

Back 130

1) First trimester Screening: The first-trimester screening method is done between 11-13 weeks gestation and has 2 components: 1) measurement of nuchal translucency (NT) by ultrasound 2) serum free beta human chorionic gonadotropin (ß-hCG)& pregnancy-associated plasma protein-A (PAPP-A) by blood draw. Women who screen positive with 1st trimester screening are at an increased risk for having a child with Down syndrome. These women may then decide to have a diagnostic test such as amniocentesis or chorionic villus sampling (CVS) to determine if the fetus is affected since screening tests can give false positive results. First-trimester screening offers several potential advantages over second-trimester screening. When test results are negative, it may help reduce maternal anxiety earlier. If results are positive, it allows women to take advantage of first-trimester prenatal diagnosis by CVS at 10-12 weeks or second-trimester amniocentesis (15-20 weeks). Detecting problems earlier in the pregnancy may allow women to prepare for a child with health problems. It also affords women greater privacy and less health risk if they elect to terminate the pregnancy (ACOG, 2007). This has a comparable detection rate (80-85%) for Down syndrome as the second-trimester quad serum screening discussed below. That means that 15-20% of babies with Down syndrome will not be identified with this test. About 5% of women who undergo first trimester screening will have a false positive screening test. This is not an easy concept.... here is how I explain it to women: a false positive rate of 5% means that of ALL the women tested, 5/100 will have a positive result but have a baby who is not affected. Out of the other 95/100, there will be some people who get a positive result and have an affected baby (accurate result), some that have a negative results and a non affected baby (accurate results) and a few that will have a negative result, but have an affected baby (false negative). Then…… if you look only at the group of women who get POSITIVE results, only 1/15 of all the women who get pos results will actually have an affected baby. (Listen to the gabcast down below to hear a little more about false positives.) So you can see that it’s also important to tell women that a negative result does not completely eliminate the possibility that the fetus may have Down syndrome, trisomy 18, or other chromosome abnormalities. Availability of technicians trained in nuchal translucency measurement may limit access to this for some women (ACOG, 2007).
2) Second trimester screening: In the second trimester, a test called “multiple marker screening” is offered to screen for Down syndrome, trisomy 18, and neural tube defects. This test is commonly known as the quad screening as 4 components are analyzed. The quad screen analytes are: AFP (α-fetoprotein) βhCG (beta human chorionic gonadotropin); unconjugated estriol; DIA (dimeric inhibin A). The quad screen detects about 81% of fetuses with Down syndrome (ACOG, 2007). A lower level of AFP indicates a higher risk of Down Syndrome.The quad serum screen has a false-positive rate of about 5%. This means that 5% of all women tested will have a positive test yet a normal fetus. Only 1 woman in 15 with a positive test will go on to have an affected fetus (Varney, 2004). So if a woman has a positive quad screen, remember that it most likely is not due to an anomaly. Amniocentesis is then offered for diagnosis.
3) Integrated screening: This combined both 1st trimester nuchal translucency measurement & serum markers (PAPP-A & βhCG) AND second trimester quad screen of AFP, βhCG, unconjugated estriol & DIA . Results are reported once as a combined score in the 2nd trimester. This method has a detection rate of 94-96% at a 5% false positive rate (see above) (ACOG, 2007). This test provides the highest sensitivity (true detection rate) with the lowest false positive rate, limiting the number of invasive amnio’s needing to be done

Front 131

How common are neural tube defects?

Back 131

4/1000

Front 132

What 3 screenings are offered to pregnant women?

Back 132

Downs syndrome (1st & 2nd trimester screening), NTD (2nd semester quad screen), Cystic Fibrosis (maternal Blood test 1st trimester/1st visit to see if mom is a carrier - both parents would need to be carriers for child to get CF)

Front 133

What is Chorionic villi sampling?

Back 133

is a procedure that has become more accepted in recent years. It has the advantage of earlier & faster diagnosis, which can allow for an earlier and safer pregnancy termination or in-utero intervention. In addition, if the woman chooses to continue the pregnancy, it helps the medical team, the family, and the woman to prepare for the arrival of the child. When this procedure first became available, a higher complication rate for CVS was noted than with amniocentesis. Now, this procedure carries the same risks of amniocentesis, and is often available in large medical centers. It may require some travel for many women to access centers that offer CVS

Front 134

Amniocentesis

Back 134

is the gold standard of genetic diagnosis and is offered to all women at age 35, regardless of history. This is done later in pregnancy, and also detects neural tube defects (NTD), which CVS does not detect. Early amnio (prior to 15 weeks) is no longer offered due to the increased risk of spontaneous pregnancy loss due to the procedure. One disadvantage is pregnancy termination later in gestation if that is chosen by the woman. Your module readings cover these procedures.

Front 135

What should be reviewed with the pregnant woman about genetic testing?

Back 135

her age specific genetic risk; tests offered; how they are done; risks involved; information obtained with test; when results are obtained; options in the event of a positive test; false positive test rate information; not testing is an option; and that the choice is fully hers to make without judgment.

Front 136

What is a Quad screening?

Back 136

Quad screen (replaces triple screen)
2. 1st trimester screening: serum screen PLUS nuchal translucency (NT)
3. Integrated Screening (1st & 2nd serum markers & 1st trimester NT)
4. Ultrasound (2nd trimester anomaly scan)
Best done at 16-18 weeks, but can be done 15-22 weeks
Detection rates with 5% screen positive rate
Down syndrome: 80%
NTD: 75-80%


Results indicating NTD = ↑AFP. May be dating related. Follow-up = target USN and amniocentesis
Results indicating Down syndrome = ↑inhibin A, ↑ β-hCG. Not dating related. Follow-up= amniocentisis

Front 137

What is the risk of Downs Syndrome according to age?

Back 137

At age 25, 1 in 1,250
At age 30, 1 in 1,000
At age 35, 1 in 400
At age 40, 1 in 100
At 45, 1 in 30
At 49, a 1 in 10

Front 138

How has ACOG recommendations changed regarding screenings tests?

Back 138

Offer screening tests for Downs to all women and offer screening tests first to women over 35 before offering diagnostic tests like amnioncentisis or CVS

Front 139

How much folic acid should be taken prenatally to prevent NTD?

Back 139

400 mcg