OB shelf - antepartum, intrapartum, postpartum

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jknell
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221402
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OB shelf - antepartum, intrapartum, postpartum
Updated:
2013-05-28 00:09:14
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OB shelf
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OB shelf exam
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  1. Prenatal care
    timeline
    • <28 wks - every month
    • 28 to 36 wks - every 2 to 3 weeks
    • 36 to delivery -  every week till delivery
  2. Prenatal visits
    labs, landmarks, tests
    • First visit: labs (Hct/Hgb, Rh factor, blood type/screen, Pap smear, Gonorrhea and Chlamydia, UA, infection screen)
    • 6-8 weeks: Fetal heart tones
    • 16-18 weeks: Pelvic sonogram, triple screen (serum AFP, Estriol, beta-hCG), amniocentesis (if indicated)
    • 26-28 weeks: Diabetes screen, give Rhogam if Rh negative
    • 36 weeks: Group B strep culture
    • 38 weeks: cervical exam (controversial)
    • 40 weeks: Fetoplacental functional tests (if indicated)
  3. Gestational age
    Time of pregnancy counting from first day of LMP
  4. Developmental age
    Time of pregnancy counting from fertilization
  5. trimesters
    • First: 0 to 14 weeks
    • Second: 14 to 28 weeks
    • third: 28 weeks to term
  6. Embryo vs fetus
    • Embryo: <8 weeks
    • Fetus: 8 weeks to birth
  7. Previable, preterm, term
    • Previable: before 24 weeks
    • Preterm: 24 to 37 weeks
    • Term: 37 to 42 weeks
  8. Nägele's rule
    • Calculate the estimated date of confinement (due date) +/- 2 weeks
    • LMP - 3 months + 7 days + 1 year
  9. Triple screen: MSAFP
    • Maternal Serum Alpha-Fetoprotein (MSAFP): normally begins to rise at 13 weeks, peaks at 32 weeks; produced by placenta
    • -inaccurate GA is most common reason for abnormal screen

    • Higher levels:
    • -Neural tube defects
    • -Abdominal wall defects (gastrochisis and omphalocele)
    • -Fetal death
    • -Placental abnormalities (abruption)
    • -Multiple gestations

    • Low levels:
    • -Down's syndrome (trisomy 21)
    • one
  10. Triple screen: Estradiol
    • Low levels:
    • Trisomy 21: down's syndrome
    • Trisomy 18: Edward's syndrome
    • Possibly low in trisomy 13 (patau's)
  11. Triple screen: hCG
    • High levels: Trisomy 21
    • Low levels: Trisomy 18, anencephaly
  12. Rh sensitization
    causes
    Rh- mother and Rh+ fetus; antibodies cross the placenta and attack the fetal RBCs

    • Causes:
    • -Amniocentesis
    • -Miscarriage/threatened abortion
    • -Vaginal bleeding
    • -Placental abruption/previa
    • -Delivery
    • -Abdominal trauma
    • -Cesarean Section
    • -External version
  13. Rh screening and treatment
    • Screening: early in pregnancy with indirect Coombs' test
    • -unsensitized: antibody screen at 0, 24-28 weeks; if negative, give 300 RhIgG to prevent development of antibodies
    • -sensitized: antibody screen at 0, 12 to 20 weeks; check antibody titer; amniocentesis at 16 to 20 weeks

    Treatment: RhoGAM (RhIgG); given at 28 weeks, and at birth if baby is Rh+
  14. Kleihauer-Bettke test (KB test)
    • Tests the amount of fetal RBCs in the maternal circulation
    • Adjustments are made to the amount of Rhogam given
  15. Erythroblastosis fetalis
    • Hemolytic deases of newborn/fetal hydrops occur when the mother lacks an antigen present in the fetus
    • Fetal RBCs trigger immune response when they reach maternal circulation
    • Antibodies attack fetal RBCs → hemolysis and anemia → fetal hyperbilirubinemia → kernicterus → heart failure, edema, ascites, pericardial effusion
  16. Ultrasound
    • Intrauterine pregnancy seen via
    • -vaginal US when beta-hCG > 1,500
    • -abdominal US when beta-hCG >6,000
  17. Amniocentesis
    Indications
    Procedure
    Risks
    Performed at 15 weeks' GA when amniotic fluid is 200ml

    • Indications:
    • -Fetal anomaly suspected on US
    • -Abnormal MSAFP
    • -FHx of congenital abnormalities
    • -Offered to all patients > 35 years of age

    • Procedure:
    • -30 mLs of amniotic fluid is removed
    • -biochemical analysis is performed (amniotic fluid AFP levels, fetal cells can be grown for karyotyping or DNA analysis)

    • Risks:
    • -Pain/cramping
    • -Vaginal spotting/amniotic fluid leakage in 1 to 2% of cases
    • -Symptomatic amnionitis in <1/1,000 patients
    • -Rate of fetal loss <0.5%
  18. Chorionic villus sampling
    timing
    risks
    • Typically done between 9 and 12 weeks' GA
    • Allows chromosomal status, fetal karyotyping, and biochemical assays or DNA tests to be done earlier than amniocentesis

    • Risks:
    • -0.5% rate of complications
    • -Preterm delivery
    • -Premature rupture of membranes
    • -Fetal injury
  19. Cordocentesis
    Indications
    Performed after 17 weeks

    • Indications:
    • -Fetal karyotyping because of fetal anomalies
    • -To determine the fetal hematocrit in Rh isoimmunization or severe fetal anemia
  20. Fetal abdominal measurements
    Determine proportionality to the fetal head and assess fetal growth
  21. Amniotic fluid index (AFI)
    • Total linear measurements of the largest amniotic fluid pockets in each of the four quadrants of the amniotic fluid sac
    • Reduced: AFI <5 (oligohydramnios)
    • Excessive: AFI >20 (polyhydramnios)
  22. Genetic testing
    Indications
    • FISH: specific DNA probe with a fluorescent label that binds homologous DNA
    • Karyotyping: allows visualization of chromosomes size, banding pattern, and centromere position

    • Indications:
    • -Advanced maternal age
    • -Previous child with abnormal karyotype
    • -Parental chromosome rearrangements
    • -Fetal structural abnormalities on sonogram
    • -Unexplained intrauterine growth retardation (IUGR)
    • -Abnormally low MSAFP
  23. Vitamins in pregnancy
    • 400 μg/day folic acid
    • 30mg elemental iron per day is recommended in T2 and T3
    • Recommended calcium intake is increased to 1,200mg/day
    • Recommended dietary intake for zinc is increased from 15 to 20mg/day
  24. Caffeine in pregnancy
    foods that contain
    adverse maternal effects
    • Coffee, tea, chocolate, cola beverages
    • Adverse maternal effects: insomnia, acid indigestion, reflux, urinary frequency
  25. Exercise
    contraindications
    No data that indicates pregnant women must decrease intensity of her exercise

    • Contraindications:
    • -IUGR
    • -Persistent vaginal bleeding
    • -Incompetent cervix
    • -Risk factors for preterm labor
    • -Rupture of membranes
    • -Pregnancy-induced hypertension
  26. Nausea and vomiting
    • NV in T1 in 50% of pregnancies
    • Management: watch the foods you eat
    • Management of severe cases: antihistamines, promethazine, metoclopramide, IV droperidol
  27. Varicosities, leg cramps, backach, round ligament pain
    • Common in pregnancy, particularly in lower extremities and vulva
    • Hemorrhoids: rectal veins
    • Leg cramps: 50% of pregnant women, typically at night in T3; calves most commonly
    • Backache: progressive in pregnancy; minimize standing time, acetaminophen
    • Round ligament Pain: sharp, bilateral, frequently in T2,
  28. Immunizations
    • Avoid live vaccines:
    • -Measles
    • -Mumps
    • -Rubella
  29. First stage of labor
    phases, duration
    Labor: uterine contractions of sufficient frequency, intensity, and duration to result in effacement and dilation of the cervix)

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