Abruptio Placentae
Pregnant woman who is in the late third trimester of pregnancy complains of sudden onset of vaginal bleeding accompanied by a contracted uterus that feels hard (hypertonic) and is very painful.
Associated with a sudden onset of dark red-colored vaginal bl
Placenta Previa
A multipara who is in the late second to third trimester complains of new onset of painless vaginal bleeding that is worsened by intercourse. Blood is bright red in color. Uterus is soft and nontender. If cervix is not dilated, treatment is strict bed res
Severe Preeclampsia
A primigravida who is in the late third trimester of pregnancy (more than 34 weeks) complains of a sudden onset of severe recurrent headaches, visual abnormalities (blurred vision, scotomas), and pitting edema. Edema easily seen on the face/eyes and finge
HELLP (Hemolysis, Elevated Liver Enzymes, and
Low Platelets) Syndrome
Serious but rare complication of preeclampsia. Classic patient is a multipara older than 25 years who is in the third trimester of pregnancy. Presence of the signs and symptoms of preeclampsia that is accompanied by right upper quadrant (or midepigastric)
Laboratory Testing
Urinalysis (Dipstick)
Obtain mid-stream urine before gynecologic exam (minimizes contamination from vaginal discharge). Check protein, leukocytes, nitrite, blood, glucose.
? Protein: trace and from 1+ to 4+ is abnormal.
? If 20 weeks of gestation or more,
Category A Drugs
Animal and human data show no risk to pregnant women. Examples are prenatal vitamins, insulin, and thyroid hormone. High-dosed multivitamins are not used during pregnancy.
Category B Drugs
Animal studies show no risk. No human data available.
? Antacids (Tums, Maalox).
? Docusate sodium (Colace). Colace is a stool softener and is approved for pregnant women. It is not a laxative. Avoid laxatives (e.g., Ex-lax, Bisacodyl), especially in the
Category C Drugs
Adverse effects seen in animal studies. No human data available.
? Sulfa drugs
- Category C in third trimester because it can cause hyperbilirubinemia. Sulfa drugs displace bilirubin from albumin. High blood levels of unconjugated bilirubin can
cross the
Category D Drugs
Evidence of fetal risk. Benefi ts should outweigh the risk of using the drug.
? Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs)
- Causes fetal renal abnormalities, renal failure, and hypotension.
- Captopril (Capot
Category X Drugs
Proven fetal risks outweighs the benefi ts.
? Accutane (isotretinoin, a vitamin A derivative)
- Used for severe cystic and nodular acne recalcitrant to treatment. Highly teratogenic.
? Methotrexate (anti-metabolite)
- Some types of autoimmune diseases (ps
Antibiotics for Pregnant Women
The antibiotics below are category B.
? Penicillins
- Amoxicillin (Amoxil), penicillin, dicloxacillin.
? Cephalosporins
- First generation: cephalexin (Keflex), cefadroxil (Duricef).
- Second generation: cefuroxime axetil (Ceftin), cefaclor (Ceclor), cefp
Use of Antihypertensives With Pregnant Women
Used for women with preexisting hypertension or for moderate-to-severe preeclampsia or eclampsia.
? Methyldopa (Aldomet)
? Hydralazine (Apresoline)
? Labetalol (Normodyne)
Live Vaccines
? Mumps, measles, and rubella (MMR), oral polio, varicella, FluMist contraindicated in pregnancy.
? Flu vaccine is inactivated virus and is safe to use in pregnant women.
- Recommend for pregnant women especially if they are pregnant during the fall and w
Teratogens
Agents that can cause structural abnormalities during pregnancy.
? Alcohol: fetal alcohol syndrome
? Aminoglycosides: deafness
? Cigarettes: intrauterine growth retardation (IUGR), prematurity
? Cocaine: CVAs, mental retardation, abruptio placentae
? Isot
HEALTH EDUCATION
? Prenatal vitamins with 400 mcg of folic acid daily (start 3 months before conception).
? Always wear seatbelt (lap belt below uterine fundus).
? Avoid soft cheeses (blue cheese, brie), uncooked meats, raw milk (listeria bacteria).
? Sex is safe except d
Weight Gain
? Most weight gained in third trimester (about 1-2 lbs per week).
? Best weight gain: 25 to 35 lbs if healthy weight before pregnancy (body mass index [BMI] of 18.5-24.9).
? For underweight patients: gain 28 to 40 lbs (BMI <18.5).
? For obese patients: ga
Positive Signs of Pregnancy
? Palpation of fetus by health provider.
? Ultrasound and visualization of fetus.
? Fetal heart tones (FHT) auscultated by health provider).
- 10 to 12 weeks by Doppler/Doptone
- 20 weeks by fetoscope/stethoscope
Probable Signs of Pregnancy
? Goodell's sign (4 weeks): cervical softening.
? Chadwick's sign (6-8 weeks): blue coloration of the cervix and vagina.
? Hegar's sign (6-8 weeks): softening uterine isthmus.
? Enlarged uterus.
? Ballottement (seen in mid-pregnancy); when the fetus is pu
Presumptive Signs of Pregnancy
These are the softest and least objective signs. Can be caused by many other conditions besides pregnancy.
? Amenorrhea.
? Nausea/vomiting (most common in fi rst trimester in the morning, usually disappears by the second trimester).
? Breast changes (swol
Exam Tips
? Palpation of fetal movements by the mother is not considered a positive sign of pregnancy (quickening). It is classifi ed as a "probable sign."
? Memorize the three "last names" of probable signs.
? Urine/serum pregnancy tests are considered probable si
Fundal Heights: 12 Weeks (Third Month)
? Uterine fundus first rises above symphysis pubis (uterus is the size of a grapefruit).
? FHT heard by Doppler by 10 to 12 weeks.
Fundal Heights: 16 Weeks (Fourth Month)
? Uterine fundus between symphysis pubis and the umbilicus.
*Quickening also starts.
Fundal Heights: 20 Weeks (Fifth Month)
? Uterine fundus at level of the umbcus.
? FHT heard with fetoscope or stethoscope by 20 weeks.
Fundal Heights: From 20 to 35 Weeks of Gestation
? Fundal height in cm = number of weeks gestation. For example, a 24-week gestation fetus should have fundal height between 23 and 25 cm.
Size and Date Discrepancy
Defined as a difference of 2 cm (or more) in uterine size from the number of weeks of gestation. If present, order an ultrasound for further evaluation.
For example, 30-week gestation with 28 cm uterus; the uterus is smaller than expected, the fetus is no
PHYSIOLOGIC CHANGES DURING PREGNANCY
Heart
The heart is displaced into a horizontal position by the larger uterus. It causes the heart to lie in horizontal position and to rotate to the left (increases the transverse diameter).
Cardiac Output
Increases by 30% to 50% and peaks at about 24 wee
Naegele's Rule
Used to estimate date of delivery (EDD) during the fi rst trimester. Assumes regular 28- to 30-day menstrual cycle. Not as useful for irregular menstrual cycles. Procedure: Subtract 3 months from the month of the last menstrual period (LMP). Then add 7 da
Exam Tips
? There is usually one question asking about the EDD (use Naegele's rule).
? The LMP month on the exam will either be: January (01), February (02), or March (03).
If LMP is: Expected EDD:
January ----> October
February ----> November
March ----> December
Gravida or "G
? Gravida or "G": The number of pregnancies of the mother (no matter what the outcome).
Para or "P
? Para or "P": The number of births more than 20 weeks no matter what the outcome (including miscarriages, stillborn). Twins and multiples are counted as one pregnancy.
Abortus or "A
? Abortus or "A": The number of pregnancies that were lost more than 20 weeks (includes both induced and spontaneous abortions).
Rh-Incompatibility Disease
In Rh-negative mothers with Rh-positive fetuses, the maternal immune system develops antibodies against Rh-positive blood if not given RhoGAM (gamma globulin against Rh factor). Give RhoGAM for all pregnancies of Rh-negative mothers�even if they terminate
RhoGAM
Also known as anti-D immune globulin. It is made from pooled IgG antibodies against Rh (rhesus) factor. It is an immunoglobulin that helps prevent maternal isoimmunization
(self-immunization) or alloimmunization (immunity against another individual of the
Coombs test
? Coombs test: detects presence of Rh antibodies in the mother (indirect Coombs test) and the infant (direct Coombs test). This test is done as part of the labs done early in pregnancy.
? RhoGAM 300 mcg IM first dose is at 28 weeks.
? Give second dose wit
Gestational Diabetes Mellitus (GDM)
Diabetes that occurs during pregnancy. GDM mothers are at high risk for type 2 diabetes. GDM has high rates of reoccurrence (33% to 50% chance) in future pregnancies. Higher rates of birth defects (neural tube defects, heart, craniofacial), birth trauma (
Diagnostic Criteria (Starts at 24 Weeks)
Diagnostic Criteria (Starts at 24 Weeks)
? Fasting: equal or >92 mg/dL
? 1 hour: equal or >180 mg/dL
? 2 hours: equal or >153 mg/dL
Gestational Diabetes Mellitus (GDM) Treatment
Treatment Plan
? First-line treatment is lifestyle (follow a meal plan and scheduled physical activity).
- Eat 3 meals per day plus 2 to 3 snacks. Limit carbohydrates.
- Exercise 30 minutes per day at least 5 days a week (total of 2 hours per week).
? Low
Exam Tips
? Do not use the 50-g OGTT test for screening. Use the 75-g OGTT.
? 75-g OGTT is now used both for screening and diagnosis of GDM (ADA, 2012).
? First-line treatment for GDM is lifestyle (correct diet and scheduled exercises).
? None of the oral type-2 an
Asymptomatic Bacteriuria
Pregnant women with asymptomatic bacteria are always treated because they are at high risk for acute pyelonephritis (20%). Diagnosis is based on a mid-stream urine C&S
results. UTIs increase the risk of preterm birth, low birth weight, and perinatal morta
Asymptomatic Bacteriuria Treatment
Medications
? Nitrofurantoin (Macrobid) every 12 hours (BID) for 5 days.
? Amoxicillin (or Augmentin) every 12 hours (BID) for 3 to 7 days.
? Cephalexin BID for 3 to 7 days
? Fosfomycin 3 g for a single dose
? Do not use sulfas (e.g., Bactrim) or nitrofur
Urinary Tract Infections
Acute cystitis can occur alone (simple urinary tract infections [UTI]) or it may be complicated by acute pyelonephritis. The most common organism is Escherichia coli (75% to 95%). The signs and symptoms includes dysuria, frequency, urgency, and nocturia.
Nitrofurantoin and Sulfa Drugs
? Nitrofurantoin and sulfa drugs should be avoided near term (38-42 weeks), during labor, and during delivery. It is also contraindicated in neonates less than 4 weeks of age.
? These drugs increase the risk of hyperbilirubinemia (immature liver).
? Compl
Exam Tips
? Always treat asymptomatic bacteriuria and UTIs in pregnant women.
? UTIs in pregnant women are classified as "complicated UTIs."
? UTI is defined as 100,000 colony forming units (CFU) or 105.
? Signs and symptoms of UTI in pregnant women are the same as
Spontaneous Abortions
Also known as a miscarriage. Spontaneous loss of the fetus before it is viable <20 weeks
Threatened Abortion
Vaginal bleeding occurs but cervical os remains closed. Most of these cases will result in an ongoing pregnancy.
Inevitable Abortion
Cervix is dilated and unable to stop process. Fetus will be aborted.
Complete Abortion
Vaginal bleeding with cramping. Placenta and fetus are expelled completely. Cervical os will close and bleeding stops.
Incomplete Abortion (Abortion With Retained Products of Conception)
Vaginal bleeding with cramping. Placental products remain in the uterus. Cervical os remains dilated and bleeding persists; pieces of tissue may be seen at the cervical os. Foul-smelling vaginal discharge (bacterial vaginosis).
Treatment: Dilation with cu
Preeclampsia (Pregnancy-Induced Hypertension)
Preeclampsia (Pregnancy-Induced Hypertension)
Most cases of preeclampsia occur in the late third trimester (34 weeks of gestation or later). It can occur up to 4 weeks after childbirth (postpartum period). Mild cases of
preeclampsia may not have symptoms
Preexisting/Chronic Hypertension
Defi ned as the presence of an elevated BP (>140/90) before the 20th week of gestation. Do not confuse this condition with preeclampsia. May be on a prescription. If on an ACEI/ARB, discontinue ASAP and monitor BP closely. Most pregnant women with preexis
Placenta Abruptio (Placental Abruption)
Premature partial to complete separation of a normally implanted placenta from the uterine bed. Rupture of the maternal blood vessels from the decidua basalis. Bleeding
ranges from mild to hemorrhage. Controllable risk factors are smoking, cocaine use, hy
Placenta Previa
An abnormally implanted placenta. The placenta implants too low either on top of cervix or on the cervical isthmus/neck. Most cases get better spontaneously (will reimplant
itself). Some cases are asymptomatic. Higher risk if previous history of placenta
Exam Tips
? Swallowing noises may be heard in breastfeeding, especially in younger babies.
? If clicking noises are heard during breastfeeding, it is abnormal. Advise the mother to use her index finger to pull down the baby's chin so that the baby's lower lip will
Breastfeeding Mastitis (Lactational Mastitis)
Most common in the first 2 months of breastfeeding. Skin fissures on the nipple(s) allow bacterial entry. Most common organism is Staphylococcus aureus (Gram-positive).
Consider methicillin-resistant staph aureas (MRSA) bacterial infection (becoming more
Uncomplicated Chlamydia Infection (Cervicitis, Urethritis)
? Treating Chlamydia trachomatis infection in the mother will help to prevent the transmission (vertical transmission) of the infection to the newborn through the birth canal.
- Example: conjunctivitis (or inclusion conjunctivitis of the newborn) and pneu