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246 Cards in this Set
- Front
- Back
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When is puberty for girls
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8-13 yo
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What is the difference btw precocious and pseudoprecocious puberty
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precocious is normal pattern of puberty but just early
pseudoprecocious is from abnormal exposure to estrogen and there is no gametogenesis |
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What are the 3 stages of puberty
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1. thelarche - breast devel
2. pubarche - hair devel 3. menarche - menses |
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what are is the hormonal phase of puberty
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adrenarche: increased secretion of adrenal androgen (DHEA)
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What is DHEA and when does it peak
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Adrenal androgen - dehydroepiandrosterone
peaks at 25yo |
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What is the avg length of menses
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3-5 days (can be 1-8)
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when are there anovulatory cycles
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puberty and before menopause
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what are the effects of estrogen and progesterone on the cervical mucous
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estrogen -> thin (thinnest at ovulation)
progesterone -> thicker |
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When does the cervical mucous NOT make the fern pattern
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after ovulation and with pregnancy
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What are the measures that indicate ovulation
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increased basal body temp
increased LH |
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when to take basal body temp
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AM
BEFORE getting OOB |
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Effects of estrogen (4)
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1. breasts - duct growth, enlargement, pigment
2. weight gain/water retention (@ menses) 3. acne - decreases comedone formation 4. cholesterol - decreased plasma cholesterol |
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target sites of effects of progesterone
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uterus
breasts brain |
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relaxin
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facilitates delivery
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FSH role
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maturation of ovarian follicle
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goals of prenatal care
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enter pregnancy in optimal health
decrease risks and reduce health disparities |
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what are the 10 recommendations for preconceptual care
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folic acid supple
rubella status DM screen thyroid screen maternal PKU HIV HepB Meds?? (a,a,i) smoking ETOH or rec drugs STIs Obesity |
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What meds are screened for in preconceptual care
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antiepileptics (take off dilantin!)
anticoagulants isotretinoins |
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Why screen for thyroid?
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high or low can lead to SAB or problems with infertility
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Why screen for DM
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6-12%risk for anomalies
risk directly r/t glucose control |
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why folic acid?
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decrease risk of open neural tube defects
closes early, so important to have FA on board! low carb diet decreases folate levels! |
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Rubella and pregnancy risk?
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deafness and heart defects that are PREVentable
vaccine must be given BEFORE (or after) pregnancy |
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maternal PKU as risk for preg
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high risk, often not on their diet
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risks with obesity in pregnancy
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chronic HTN
DM macrosomic fetus |
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what is prenatal care a/w?
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decreased LBW
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rate of LBW in US & why
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8.1%
this is the highest yet b/c medical demographic, behav risk factors, increase mult births & preterm births from assisted tech |
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Define LBW
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<2500g
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% births w/o (or late) prenatal care
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3.5%
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differeniate btw presumptive, probable and positive pregnancy results
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presumtive are subjective sumptoms
probaable are observed by the physician positive are attributed only to the devel of the fetus |
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presumptive changes of pregnancy
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breast changes - mastodynia, increased glands, secondary breasts
quickening N/V - 2-12 weeks urinary irritablity - freq, nocturia, UTI increased temp over 3 weeks skin changes - cholasma, linea nigra, stretch mks, spider telangiomas |
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when does quickening occur
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multiparous: 14-16 wks
primiparous: 18-20 weeks |
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what does severe NV indicate
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multiple preg or molar preg
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what are the probable signs of pregnancy
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Cervical & Uterine changes
1. chadwicks sign 2. hegars sign 3. goodell's sign 4. leukorhea without fern-like pattern 5. relaxation of pelvic bones / ligaments ballotment positive pregnancy test = presence of hcg |
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chadwicks sign
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bluish purple discoloration of vulva, vaginal mucosa, cervix due to increased blood flow
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hegars sign
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softening / compressibility of uterine isthmus, kinda flops over
@6-8 wks |
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goodells sign
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softening of cervix
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urine pregnancy test: detection of?
predictive value when does it work |
detects hCG - requires at least 25micro IUs in urine
As early as 12-14days post conception 99.5% predictive value if positive |
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Reasons for false neg urine pregnancy test
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dilute urine
inaccurate dates - not 28day cycle ectopic pregnancy blighted ovum |
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serum pregnancy test - when can it be used? what is measured
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measures hCG
detected as early as 6 days post conception get the level |
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what are the possible meanings of hCG levels that are LOW OR FALLING over 48 hrs
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SAB
blighted ovum pregnancy >12 weeks |
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what are the possible meanings of hCG levels that are SLOWLY RISING OR LEVELING over 48 hrs
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ectopic pregnancy
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what are the possible meanings of hCG levels that are RAPIDLY INCREASING over 48 hrs
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multiple gestation
hydatiform mole |
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What are the positive signs of pregnancy
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1. FHTones
2. Fetal Movement palpated 3. Ultrasound visualization |
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When can you first see cardiac movement with US
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5-6weeks
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gravida
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# of pregnancies
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para
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# of pregancies that terminated in the birth of a fetus/fetuses that reached a point of viabilty (>20wks or >500g)
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TPAL
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Term - 37 weeks completed (38wks+)
Premature- 20-38wks Abortions- spontaneous OR induced less than 20 wks or 500g Living children |
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definition of infant
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birth -> 1 year
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definition of neonate
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birth to 28days
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definition of perinatal period
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28 wks to 7days PP
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what is the issue with 2nd trm abortion
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more risks
+ risk of future PTL |
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how is a multiple birth defined in Para?
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SINGLE parous experience
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def of immature fetus
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500-1000g at birth
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definition of premature birth
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1000-2500g at birth
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SGA definition
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less than 2 standard deviations for the gestational period
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definition of maturity at birth
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>2500g or 37 weeks
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postmaturity def
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42+ weeks
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what is the concern about a pt with a cardiac hx in pregnancy?
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increase in CO may pose a problem
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what to assess in a pregnant woman with varicosities
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for DVTs
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what should be documented at ever prenatal visit
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weight gain
BP Fundal height abdominal exam by Leopold manuever urine results - glucose and protein |
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What are you looking for with urine test at each visit
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ketones - inadequate carb intake
proteinuria - >300/24hr or 2+ is concerning for preeclampsia glucose |
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baseline lab tests at first prenatal visit
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Pap, GC/CT,
blood type/Rh/antibody titers (coombs) Syphillis - rpr or vdrl SCD screen PPD HepB surface antigen Titers: rubella; Varicella UA, C&S Hgb/Hct possible DM screen HIV offered to everyone CF carrier screen and other genetic screening offered toxoplasmosis if at risk |
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what to do if there is pyuria withOUT bacteria
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wet prep because probably GC/CT
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what is the prevalence of trich in pregnancy
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20-30% pregnant women have trich, only 5-10% have s/s
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what is assessed at the initial visit
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dating
risk status psychosocial assessment educational needs |
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4 ways of dating pregnancy
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LMP
uterine sizing US FHT COMBO is the BEST FIRST TRM is the BEST time |
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Using LMP to get EDC
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Nagele's rule:
1st day LMP + 7days - 3 months this assumes the cycle is 28days |
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Uterine sizing as an estimation of EDC
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accurate to +/- 1-2 weeks, best in first trimester
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size of uterus at 6 weeks
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tangerine
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size of uterus at 8 weeks, location
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naval orange
@ pubic symphysis |
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size of uterus at 12 weeks, location
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grapefruit
abdominal organ |
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location of uterus at 16 wks
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midway between umbil and symphysis pubis
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location of uterus at 20wks
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umbillicus
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What area is measured for the fundal height
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symphysis pubis to the top curve of the fundus
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What is measured by US to determine EDC
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<8wks - gestational sac
8-15wks - CRL >15wks - biparietal diameter, head circumference, FL, AC |
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When is US most/least helpful
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most: 1st trm
not helpful >30 wks |
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How do you use the LMP and US to determine EDC
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if date based on LMP is within 5 days +/- the US date, keep the LMP date
if it is NOT - change to the US date |
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When are FHT used for pregnancy dating
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10-12 wks with Doppler
17-20wks with fetoscope |
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when to suggest genetics testing at initial visit
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>35yo
risk factors abnormal pedigree |
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What are the components of the risk assessment (factors to always consider)
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age - teenagers or >35yo
mode of conception - ART? diseases or disorders ethnicity- are they at risk for certain disorders/syndromes past OB hx - SAB (3+), previous stillbirths/neonatal deaths, preterm births |
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What is the risk of teenagers
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preeclampsia/ eclampsia
IUGR maternal malnutrition |
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what is the risk with women >35yo
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pregnancy induced HTN
Diabetes obesity preeclampsia placental previa chromosomal abnormalities |
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what are the risk factors for spontaneous preterm birth
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history of PTL
genital tract infection nonwhite multiple gestation bleeding in the second trm low prepregnancy weight |
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how do we see the effects of mothers emotional state on the fetus
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decreased apgar score
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what is the incidence of IPV in pregnancy
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4-8%+
most common pregnancy compllication highest killer of preg women in US |
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what is tobacco use during pregnancy a/w
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low BW
IUGR placental previa placenta accreta preterm birth perinatal mortality |
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what is alcohol use during pregnancy a/w?
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malnutrition
spectrum of alcohol effects from FAE->FAS->ARBD (alcohol related birth defects) |
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what are the warning signs to watch for in pregnancy
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ROM
vaginal bleeding decreased fetal movement evidence of preeclampsia- face and hand swelling, blurred vision, HA, epi pain, convulsions chills/fever severe/unusual back pain/HA other severe medical problems |
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why is there urinary frequency in the first trm?
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vascular engorgement of the pelvis and hormonal changes
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how to deal with breast soreness
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well fitted bra 24/7
ice |
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acrodysthesia
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numbness of hands
5% women transient and resolves PP |
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how to dealw ith n/v
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light, dry foods, small frequent meals
emotional support B6 supple. prenatal vit before conception acupressure ginger C bands |
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how to dealw ith backache
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posture helps - girdle to support abdomen
2" heels local heat back massage rest back exercises |
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how to manage leg cramps
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no toe pointing
magnesium citrate may help feet flexing leg massage local heat lead with heel when walking |
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what is the rec on panty girdles or garters?
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no! b/c decrease circulation to legs
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why are we concerned with fundal height
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fetal growth retardation
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if a patient has HBP and + edema, what is the consideration
what if they have HBP with neg edema |
r/o preeclampsia
suspect underlying htn |
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hyperemesis gravidarum is a/w ___
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ketonemia
weight loss dehydration |
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differential dx for hyperemesis grav
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multiple gestation
molar preg cholecystitis pancreatitis hepatitis thyroid disease |
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What is the mgt for hyperemesis grav
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NPO, work up from ice to CLD
IVF - if ketones use dextrose manage the nausea with IV reglan -> PO at 4mg 5x/day or Zofran 4-8mg IV to PO C-bands and accupressure |
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incidence of 1st trm bleeding
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40%
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what are the vaginal etiologies of 1st trm bleed
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friable cervix due to HPV
spontaneous AB ectopic pregnancy hydatiform mole |
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def threatened AB
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vaginal bleeding
w/ or w/o pain |
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def inevitable AB
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vaginal bleeding, pain cervical dialation, ROM
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def incomplete AB
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some parts of conception remain in utero
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def missed AB
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fetus dies by POC retained 2+ weeks
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habitual AB
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3+SAB
get genetic consult |
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def of SAB
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naturally occurring termination of pregnancy prior to viability
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incidence of SAB
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10-15% of all clinically diagnosed pregnancies
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what are the most likely causes/reasons for SAB
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genetic abnormality - 75-90%
corpus luteum failure= abn progesterone levels thyroid uncontrolled DM uterine abn infx autoimmune disd |
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lab dx for SAB
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Quant beta hCG - should dbl q48hrs
progesterone level (not done) US - location, viability, uterine anomalies, ectopic? cardiac activity (6wks gest) |
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how to manage 1st trm inevitable AB
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let nature take course
give pain meds can use MVA consult with OB doc can do D&C but more risky |
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What would indicate the need to r/o ectopic preg?
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any 1st trm bleed!!
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at what level of hCG can you detect a gestational sac by US
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1500mIU
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predisposing fc for ectopic preg
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tubal ligation
IUD previous ectopic pelvic infx |
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early signs of ectopic
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vag bleed/spotting
occasional pelvic pain from blood at the cul de sac (can be referred pain) the s/s are vague and very similar to pregnancy |
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how are uterine changes diagnostic for ectopic
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they are NOT
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lab assessment/dx for ectopic
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b-hCG = slow rise or plateau
US!!! - if US cannot dx, this is a mandatory (stat) referral (NOT progesterone levels) |
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what are the 2 types of hydatiform mole
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CHM - diploid (46xx) entirely from father; has vessicles but NO fetal material
PHM - triploid (69xxx) vessicles and NONviable fetus or sac |
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what is the incidence and risk fc for molar preg
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1.5 in 1000
greater in asians (3x) greater in >45yo |
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clinical presentation of hydatiform mole
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n/v - persistent and severe
bleeding size > dates maybe no FHT preeclampsia before 24wks |
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lab assessment for r/o hydatiform mole
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rapidly rising b-hCG
US |
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what is a choriocarcinoma
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malignant GTD
develops after pregnancy/SAB/or most likely after hydatiform mole nearly 100% cure can devel with pulmonary mets |
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what is the suggestion for subsequent pregnancy after hydatiform mole?
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wait at least 1 yr
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how to manage ANY bleeding in pregnancy
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prevent Rh isoimmunization by giving RhoGam
12 or less weeks - MICRORhoGam (50ug) 12+ weeks - RhoGam (300ug) |
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What is the visit schedule for prenatal care
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0-28wks - q4wks
28-36wks - q2wks 36-40wks - every week 40+ - 2x/week |
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how is glucosuria dx for GDM?
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NOT
20% of women spill glucose in their urine during pregnancy |
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10 week visit
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doc FHT with doptone
review warning signs |
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recessive disorders to screen for
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SCD
Tay Sachs - cajun, french canadiens, ashkenazie thalessemia hemophilia duchennes G6PD CF Fragile X |
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what is the incidence of CF carrier and who should be offered screening?
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1:31
ALL couples offered screening |
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what is the screening for downs and when is it offered?
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US for nuchal translucency
biomarkers: hCG and PAPP-A (plasma protein A) offered to ALL preg women performed btw 11-13 6/7 weeks - canNOT do >14wks |
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what is nuchal translucency
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abnormal collection of fluid that is a/w lots of deformities and generally abnormal collagen formation (21st chromosome)
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what % of cases of Downs are detected with the NT/biochem marker screen
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79-90% of cases of downs
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what neural tube defects are detected by the nuchal translucency testing?
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NONE - it does not test for neural tube defects
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what do you suggest if there is nuchal translucency and + biochem markers
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can get amniocentesis (or CVS)
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what does the following indicate:
+ nuchal translucency plus negative chromosomal abnormalities |
cardiac or other structural abnormalities
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what does the following indicate:
+nuchal translucency and + biochemical markers (hCG and PAPP-A) |
at risk for anuploidies
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who do you offer SECOND trimester screening to? when?
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EVERY WOMAN
15-20 wks (up to 22wks) |
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what are the second trimester screens (genetics)
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quad screen:
MSAFP estriol hCG inhibin A |
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what are the normal values of MSAFP based on - ie what needs to be considered by lab for interpretation of values?
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gestational age
maternal age weight race (AA have higher risk false pos) DM multiple gestation |
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what does an elevated MSAFP indicate
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1. open neural tube disorder: anencephaly or Spina Bifida
2. open abdominal wall defects: gastroschisis or omphalocele 3. other: underest of gestational age, mult gestation, underweight mother, black race, increased placental size, severe oligohydramnios, fetal-maternal hemorrhage (s/p CVS, amniocentesis, trauma) |
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MTHFR
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defect in the enzyme that breaks down folic acid
these women need 10x as much FA (4grams) tend to have clotting with OCP or multiple SAB |
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is anencephaly viable?
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no
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what is the a/w other abnormalities of omphaloceles and gastroschisis?
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omphaloceles are commonly a/w other abnormalities
gastroschisis are gen NOT a/w other abn |
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what % of open neural tube disorders and open abd wall defects are detected by MSAFP
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80-85%
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what to do if anomalies found on MSAFP?
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refer to backup and
genetic counselor |
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what is DECREASED MSAFP indicate?
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DOWNS - trisomy 21
detects 40% of cases if used alone and risk increases with maternal age |
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what is indicated by LOW MSAFP and LOW hCG
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trisomy 18
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what is the MOM value
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multiple of the median
this is the way the risk is reported from the quad screen and shows both 1. risk for age 2. risk for quad screen risk is NEVER zero |
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what percent of cases are detected by the quad screen?
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70-75%
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what tests are done in each trimester (1 and 2)
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First: nuchal translucency, PAPP-A, hCG
SECOND: quad or triple screen, US markers |
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what to do if 1st trm screen is positive?
what if it is negative? |
if POS: early invasive test (amnio or CVS)
if NEG: 2nd trm testing (quad screen and US); final risk based on all markers |
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what is the % of false positives on genetic screenings
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5%
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what are the risks with amniocent
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fetal loss 0.5-1%
amnionitis - 0.1% Rh isoimmz - remember to give RhoGam!!! |
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when can CVS NOT be done
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NO CVS <10wks
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what is the # of women who show increased risk for birth defects and how many actually have babies with BD
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50 out of 1000 have show increased risk on quad screen
only 1 or 2 of these will actually have baby with NTD only 1 or 2 will have baby with Downs |
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what does the quad screen miss?
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5-10% anencephaly
20-25% SB 20-25% downs 20-40% trisomy 18 |
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PTL def
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contractions with cervical change any time from 20-37 weeks
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when do you use management strategies for PTL
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23-35 weeks because this is viable territory - only tocolyze if you can do something if birth happens
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what is the incidence of PTL in US out of all births
what is the result? |
12% of all births in US!
2nd leading cause of neonatal mortality a/w 50% of all neurological handicaps in infancy |
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risk fc for PTL
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low SES
nonwhite poor nutriotional status previous h/o PTL short interval btw preg multiple gest substance abuse uterine anomalies UTI genital tract infx polyhydramnios current psych disd |
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s/s of PTL
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new/different...
menstrual like cramps dull low back ache SP pain/pressure sensation of pelvic heaviness or pressure change in character or amt of vaginal discharge diarrhea uterine contractions: 6+/hr PROM |
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how to dx PTL
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cervical US - look for cervical length <25mm which can be a risk fc for PTL, but not necessarily a routine screen
FETAL FIBRONECTIN - not routine screen either |
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what are the guidelines for doing a fetal fibronectin
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there must NOT have been anything in the vaginal in the past 24hrs
cannot do if there is bleeding swab and HOLD for 10sec |
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how to use the results of fetal fibronectin testing
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if NEG FF - unlikely (95% pred value) that they will NOT deliver within the next 14d --> do not need to treat
if POS FF - not very helpful b/c up to 1/3rd will deliver --> if other s/s PTL then treat with steroids, etc |
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what is the risk of UTI in preg
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PTL
LBW |
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what is indicated by right hydronephrosis in pregnancy?
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normal pregnancy finding b/c the sigmoid colon pushes the uterus over
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what is the criteria for treatment of UTI in prg
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symptomatic OR assymp
on dipstick: + WBC, nitrites, protein > trace UA + for WBC, RBC, or bacteria |
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what if GBS is found in urine??
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means that there is a LOT - high colonization
must treat & prophylax for labor |
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what is the treatment reg for UTI in preg?
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Amox 500mg TID
Macrobid 100mg PO BID - best compliance Others: amp 250mg PO QID Keflex 250mg QID macrodantin 100mg PO QID Test for cure in 2 weeks ALWAYS |
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what is one of the most classic findings in BV
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lack of lactobacillis- this is also a risk of getting BV
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s/s of BV
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pH >4.5
vag dischg that is scanty, thin, homogenous, milky, gray white +/- irritation, burning, pruritis |
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risk of BV in pregnancy
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PROM
PTL endometritis post partum wound infections post c-sect |
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Amsel's criteria
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2 of 4 for BV
discharge that is milky clue cells - 20% of cells on slide + whiff test - w/ or w/o KOH pH >4.5 can also do gram stain but canNOT dx based on pap results |
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treatment for BV in preg
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metronidazole or clindamycin
metro: 2gram x1, 500mg BIDx7d, 250mg TID x7d or intravaginally with 0.75% gel BID x 5days Clinda 300mg BID x7days or 2% intravag cream qHS x7days |
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assoc btw preg and candida?
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pregancy doubles the risk of candida
increased symptoms in the 3rd trimester |
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symptoms of candida vag
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vaginal discharge - thick white cottage cheese like dc with adherent plaques or patches on the cervix or vaginal walls
intense itching vulva and vagina may be red, edematous, excoriated normal pH (4.5) no odor |
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what is the prev of false neg for candida on wet prep?
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20% false neg
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what is the treatment for candida in preg?
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7 days with topical antifungal intravag creams
do NOT use fluconazone in preg |
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what to do at the 28wk visit
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screen for medical complications
prevent Rh isoimmz fetal wellbeing |
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hgb/hct values for anemia in pregnancy
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hgb <10
hct <30% |
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what is the primary cause/type of anemia in preg
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95% iron deficiency - microcytic
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How is anemia worked up in preg
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CBC w/ diff
serum iron/ferritin TIBC Hgb electrophoresis |
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when is GDM testing done in pregnancy
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if at risk - btw 24-28 wks
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incidence of GDM
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7%
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what is the biggest risk of GDM?
|
macrosomic fetus
and if not controlled: polyhydramnios unexplained fetal demise |
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what are the screening and dx tests for GDM
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screening - glucose challenge --- random, nonfasting oral 50gram glucose load + 1hr d-stick
test - 3hr oral glucose tol test --- FBG then 100gram glucose load + dstick at 1, 2, 3 hr mark (abnormal is 2+ high values) |
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what are the cut off values for the glucose tol screening and test in pregnancy
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screening: glucose challenge:
>130 or 140 -> 2nd test >200 diagnostic for DM test: 3hr Oral GTT fasting >/= 95 1hr >/= 180 2hr >/= 155 3hr >/= 140 |
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what are the goals for blood glucose during preg
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fasting <95
1 hr PP <140 2hr PP <120 |
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what is important to monitor in the GDM mother
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fetal growth
amniotic fluid volume fetal movement counts from 34 wks at least NST and BPP from 38 wks |
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what to do if mother is Rh negative and antibody POS
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REFER - already a problem!
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when is RhoGam given
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at 28 wks
or any time there is vag bleeding |
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when is blood type and Rh tested for?
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TWICE
1st visit 28wks |
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what IS RhoGam
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Rh(D) immune-globulin
passive antibody |
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what is the rule for fundal height
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+/- 2cm from weeks gestation
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what is the most common medical disorder of pregnancy
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5-10% have HYPERTENSIVE DISD
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what is preeclampsia?
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SBP >/=140
DBP >/= 90 Proteinuria >/= 1+ |
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HELLP??
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Hemolysis
Elevated Liver enzymes Low Platelets a/w HTN in pregnancy |
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risk factors for preeclampsia
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nulliparity
trophoblastic disease multiple pregs preexisting medical disease (chronic htn, renal disease, DM) FHx Asian/AA Previous Preeclampsia |
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what are the symptoms of preeclampsia
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HA
blurry vision severe epigastric pain scotomata = flashers |
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what are the SIGNS of preeclampsia
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SBP >/=140 or DBP >/=90
EYES: papilledema, hemorrhagic areas LABS: - URINE: >/= 1+ proteinuria on dip or >/= 300mg/24hr - increased HGB/HCT (3rd spacing fluids) - decreased platelets - increased LFTs - RENAL: increased serum creatinine/BUN/uric acid; decreased creatinine clearance |
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What are the biggest risks of preeclampsia
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maternal - abruption, seizures
fetal - uteroplacental insufficiency, decreased placental crossing |
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management of preeclampsia
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PHYSICIAN referral or consult
bedrest assess labs/BP regularly assess fetal wellbing MAG SULFATE |
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3 main considerations for bleeding in the THIRD trimester
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1. placenta previa
2. abruptio placentae 3. PTL and hemorrhoids, post coital, etc |
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what is placenta previa
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malposition of the placental in the lower uterine segment extending to or covering the os
can be marginal, partial or complete |
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what is important to do/not do when there is THIRD trm bleeding
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NEVER put anything in the vagina until knowing where the placental is by ULTRASOUND
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what if the placenta is over the os in the first trimester
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this is fine, it is not yet remodeled and is not uncommon
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What are the cardinal signs of placenta previa
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sudden onset painless vaginal bleeding
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how is placenta previa diagnosed
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ULTRASOUND
and bleeding |
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what is abruptio placentae
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premature separation of the placenta
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what is the clinical presentation of abruption
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pain: mild to severe
back pain UTERINE TENDERNESS bleeding: obvious or may be concealed - PORT WINE COLORED BLOOD! uterine change: COLICKY UTERINE ACTIVITY, INCREASED UTERINE TONE btw contractions |
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how is abruption diagnosed
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clinical symptoms
US may or may not be able to diagnose based on whether it bleed is visible in front of placenta |
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mgt of abruption
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ED - likely will need to deliver
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36 wk visit
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screen for infection (GC/CT, GBS)
Fetal assessment - movement! S/S labor |
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% of women colonized with GBS
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10-30%
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what are the risks of GBS col in pregnancy
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chorioamnionitis
endometritis UTI PTL/delivery PROM neonatal risks!!! SEPSIS MENINGITIS PNEUMONIA EARLY ONSET DISEASE -> NEONATAL MORBIDITY AND MORTALITY or severe neuro consequences |
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How is testing for GBS done
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swab lower vag (no speculum)
swab rectum place both in the same container note if the woman is allergic to penicillin |
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what is the management of a woman who is colonized with GBS
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treat in labor with 2 doses of penicillin
goal is to get pcn at level to prevent infection of newborn other alt are clindamycin or erythromycin |
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when does woman start counting fetal movement
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34-36wks
or as early as 28wks |
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what to do if there are less than 3 fetal movemnt in 1 hr
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NST
if it is reactive - reinforce FMC if it is NOT reactive -> BPP OR AFI & CONSULT WITH OB |
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biophysical profile
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NST
Fetal Breathing movemnt Fetal Movement Fetal Tone Amniotic fluid volume |
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S/S of impending labor
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lightening
bloody show GI upset energy spurt increase in braxton hicks contrxn ripening of cervix |
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What are real contractions of labor as compared to braxton hicks
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real are regular and have increasing duration and intensity
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'diagnosis' of real labor
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necessary:
1. regular contractions with increasing freq/intensity 2. progressive cervical change also helpful: ROM -pooling - +nitrazine (dark blue color) -ferning |
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post maturity syndrome
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>/= 42 wks
decreased placental capacity for exchange cutaneous and nutritional problems increased size leads to increased perinatal mortality rate |
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progression of lochial flow
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rubra 3-4 days
serosa alba 2nd-3rd wk PP |
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lochia rubra
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the first phase of lochial flow
blood shreds of tissue decidua tapers to a reddish brown over 3-4 days |
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lochia serosa
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2nd phase of lochial flow
serous to mucopurulent paler malodorous |
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lochia alba
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thicker, mucoid
2nd to 3rd postpartum week yellow-white |
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what goes on at the PP visit
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4-6 wks
hx, physical, pelvic exam family planning *weight - how much retained *anemic? - check especially if anemic before or still bleeding *breasts - masses, nipples ok? proper support *vaginal dryness? do pap |
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puerperal infection: s/s & common sites
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fever, malaise, pain, malodorous lochia
sites: endometritis infected trauma of vulva, perineum, vagina, cervix c-section wound |
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treatment of PP infx
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broad spectrum abx
PO or IV |
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when should the hct be back to normal in PP period
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3-7 days
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why recommend early ambulation after pregnancy
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increases feelings of capabilty
helps with involution of uterus and uterine drainage decreases risk of PP thrombophelbitis |
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what is the recommendation about sexual activity in PP period and what is important to discuss
|
median time to sexual activity is 6 weeks but she can resume sexual activ when perineum is comfortable and bleeding is diminished
there is normal fluctuation of sexual interest in the postpartum period 50% women will have dyspareunia for gen 3 months, can last up to 1yr & is possible with c-section - should be transient and resolve spontaneously at that time |
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bladder issues in PP period
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bladder distension common
increased frequency with polyuria after birth |
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bowel issues after preg
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difficulty with BM for first few days r/t sensitivity and fear
hemorrhoids are common 5% will experience some level of anal incontinence up to 3 mo PP |
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mastitis - def? s/s?
|
infection of the breast in a lactating woman
fever, flu-like s/s, painful swollen inflamed area of the breast if suspicious of mastitis - do not wait for the sore! treat!! |
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how is mastitis treated
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if suspicious of mastitis - do not wait for the sore! treat!!
best treatment is prevention antibiotics - dicloxacillin 500mg PO QID x10days can keep BF |
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when should involution be complete and what if it isn't
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by 6wks - should be mostly complete
if it doesn't - subinvolution - there is risk of hemorrhage and needs to be managed |
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s/s of subinvolution
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increased or persistent bleeding
soft uterus, more so than normal for PP week |
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what is the most common cause of subinvolution
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retained pieces of membranes or placental fragments
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treatment for subinvolution
|
methergine 0.2mg q4hrs x3days PO
*can only use if NOT hypertensive treat with abx if s/s infx |
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who should be screened for PP depression and how?
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edinburg PP depression scale
all PP women! |
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incidence of minor PP depression
major PP depression? Psychosis |
minor - 19%
major - 12% psychosis - rare |
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how is PP depression managed
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screen for thyroid dsd
support for mild s/s refer for major, IPV or prior PPDepr |
