Obstetrics

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thedewhub
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299613
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Obstetrics
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2015-03-31 16:46:12
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Obstetrics
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Obstetrics
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  1. Oocyte physiology
    • - meiosis- genetic variabilty, later fertilization facilitation and energy system that may support embryonic development.
    • Metaphase II- egg is released from ovary
    • Cumulus oophorus- when egg enters the fallopian tube. surrounded by clear zona pellucida- both the egg and polar body are now here
    • Spertazoa travel through the cervical mucus and unterus into fallopian tubes
    • Sperm undergo 2 changes- capacitation and acrosome rxn- sperm head changes with enzyme activation that allow it to go through the zona pellucida and cumulus oophorus
  2. Implantation
    • generally 3 days after embryo enters uterus. depends on trophpblast cells during the blastula stage. The trrophoblast cells digest away the zona pelucida and allow the embryo to implant on the uterin wall and burrow into the endometrium
    • Syncytiotrophoblast penetrat the endometrial cells
  3. most comon symptom of preg
    • amenorrhea- one or more missed periods folowing a time of sexual activiey without effective contraception are storng suggestors
    • nausea w/wo vomiting- causes may be psychological, k and fluid depletion, and metabolic alkalosis
    • breast enlargement and tenderness- increased levels of prolactin
    • polyuria and dysuria
    • fatique
  4. quickening-
    • initial fetal movement
    • typically not before 16-18 weeks in multiparous may be more around 20 in primaparous
  5. uterus growth in preg
    1 cm per week after 4 weeks of gestation
  6. week uterus and cervix soften
    6
  7. muscous membrane of vulva, vagina, and cervix congestion week? pavlovian signs....
    • 12
    • chadwick sign- bluish coloration of vagina
    • hegar sign- softening of the cervix
  8. breast changes
    • fuller and tende
    • areolar darkening
    • venous patterns visible
    • FAV breast changes!
  9. week of fetal heart activity
    detected by doppler at 10-12 weeks, earlier in thin patients
  10. cardiovascular changes
    • heart displace by enlargeing uterus
    • increased BV- increased ventricular wall size
  11. CO increase percentage?
    30-50%, may decrease later in preg secondary to occlusion of IVC by enlarging uterus
  12. Cardiovascular PE findings
    • increased second heart sound in inspiration, mild jvd, mild systolic ejection murmor
    • diastolic is never normal
    • inferior VC syndrome occurs as gravid uterus occludes IVC- leads to dizziness, light headed, syncome (1/10 women)
  13. Resp changes
    • diaphragm elevatin- enlarging uterus
    • oxygen consumption increase 20%
    • uterus and contents 50% of the increase
    • 30% by heart and kidneys
    • 18% resp muscles
  14. pH in pregnant blood
    metabolic alkalosis- compensated- ABG
  15. renal changes
    • collecting system enlarges and dilates
    • increased plasma volume- increased GFR
  16. preg pt with polyuria
    common- need to r/o UTI however
  17. Stasis in preg
    • predispsoes women for pyelonephritis
    • 20% of women will experience stress incontinence
  18. renal pe
    edema +-
  19. endocrine changes
    • euthyroid
    • hCG- may stimulate t4- subsequent transient increase in ft4
    • decline of hCG in second trimestor normalize ft4
  20. Skin changes
    • spider angiomata- upper torso, face and arms
    • palmar erythema- 50% of pts associated with estrogen regresses after delivery
    • mask of preg- aka Chloasma/ melasma
  21. fn of placenta
    • resp and metabolite exhange
    • fetal blood oxygenation
    • hormone syn and reg
  22. Single primary metabolic substrate for placental metabolism
    glucose- 70% of glucose transferred by mother is used by the placenta
  23. when is hCG released into bloodstream?
    after implantation(6-12 days after ovulation)
  24. hCG double time
    • every 29-53 hrs duting first 30 days after viable implantation
    • slow rise is indicative of abnormal preg
  25. ultrasound eval of preg
    • 4.5 to 5 weeks - transvaginal US detects gestational sac of intrauterine fluid
    • 5-6 weeks yolk sac until week 10
  26. time of hCG testing
    early morning conc is highest
  27. fetal heart tone time
    week 12
  28. gravida documentation
    • Gravida- # of preg
    • parity# of births
    • full term 38 weeks
    • prem less than 38
    • abortion
    • living children
  29. primigravida-
    first preg
  30. multigravida
    has been preg for more than one preg
  31. nulligravida
    nevr been preg
  32. primapara-
    women who is preg for first time or has given birth once
  33. multipara-
    women who has given birth to multiple children
  34. nullipara-
    women who has never been preg or had a preg progress through gestational age of an abortion
  35. estimated date of delivery
    • 280 days after LMP and 266 days after date of contraception
    • only 4% of women delivery on EDD
  36. naegeles rule
    count back 3 months from the lmp and add 7 days
  37. sonographic assessment of EDD
    • first trimester sonogram is more accurate than second
    • EDD in the first half of preg is superior to dating based on LMP or PE
  38. when is sonogram important in EDD?
    • when lmp is unknown
    • conception via hormonal methods
    • also when uterine size estimated via PE is different from that predicted by menstraul dating
  39. Most valuable tool in assessing fetal growth
    US- also potential uses for fetal dating and detecting fetal anomalies
  40. Most accurate estimate of gestational age once embryonic pole can be identified and used to determine EDD
    • Crown-rump length- longest straight line measurement of embryo measured from the outer margin of the cephalic pole to the rump
    • measurement best at 7-10 weeks
  41. bipariental parameter-
    detects gestational age w/in 7 days when measured between 14-20 weeks of gestation
  42. uterine size-
    • 12 weeks palpate abdominally above pubc symphosis
    • 16 weeks uterine fundus palpable midway between pubis and umbilicus
    • 20 weeks palpable at umbilicus
  43. Fetal well being assessment
    • maternal fetal activity- first indirect measurement
    • Non-stress test- FHR and accelerations through external transducer typically for 20 mins
  44. NSt advantage over CST
    doe snot require an IV
  45. Contraction stress test
    • oxytocin challenege test- myometrium contraction and reduced placental blood flow
    • see reflux slowing of fetal heart reveals poor fetal reserve
    • negative cst- 2 or more fhr acceleration during a cst
    • absence of accelerations on a baseline fhr tracig is associated with adverse perinatal outcomes
  46. initial visit prenatal screening
    infectious dz screens
  47. 1st tri screening
    • sonogram of nuchal translucency and biochemical markers PAPP-A and BetahCG
    • 11-14 weeks typically
  48. 2nd tri screening
  49. quad test- AFP, hCG, estriol, inhibin A
    • 15-20 weeks gestation to screen for NTD and aneuploidy 52
    • at 15 weeks maternal serum AFP- for NTDs
  50. glucose tolerance test time
    25-28 weeks
  51. beta hemolytic strep time
    35-36
  52. visits scheme time
    q 4 week until 28 weeks, then q 2 weeks until 36 weeks, then q week until delivery
  53. each visit PE
    fundal height, FHR, and Fetal presentation (leupold maneuvers)
  54. Biophysical profile
    nonstress test and US fetal assessment combined and given points for amniotic volume, fetal breathing movements, body movements, and reflex/tone/ flex extension
  55. has a direct linear correlation with fetal pH
    biophysical profile
  56. seat belt placement
    between breats and lateral to th uterus, lap belt below the uterus across the hips
  57. maternal heat exposure
    NTD
  58. unpasteurized mile
    brucelliosis
  59. neural tube closing
    18-26 days after conception
  60. folic acid dose
    400-800 mcg
  61. caffeine
    less than 200mg/ day
  62. vitamin a
    too much may be teratogenic
  63. protein consumption
    • 1.1 g/ kg/ day
    • majority should be consumed in the last 6 months of gestation
  64. carb requirements
    175 g / day compared to 130 in nonpreggers
  65. fe requirements
    • enhancement of nonheme iron enhanced by vit c, most iron comes from heme iron
    • 15 mg day to 30
  66. most important determinants of the development of toxicity are
    • timing, dosing, and fetal susceptability(what organ is forming then)
    • X- contraindicated drug
  67. drugs in preg
    • acetaminophen good in preg for pain
    • nsaids should be avoided
    • opiods- chronic should be avoided
    • abx- cephalosporins, penicillins and erythromycin are safe
  68. lamaze-
    • increase mothers confidence in her ability to give birth
    • understand how to cope with pain in ways that facilitate labor and promote comfort as labor progresses, focused breathing and movement and massage
  69. leboyer - leboring 4 aspects
    • quiet dim lit room, avoid head pulling, avoid overstimulation of infant sensorium, maternal-infant bonding encouragment,
    • unneccasry intervention is encourages, the back is massaged while cord pulsation cease, the baby is then put in a war tub of water by he father and is gently supported.
  70. braxton hicks contractions
    sporadic uterine contractions thought to be in preperation of labor. May occur multiple times for a few minutes,
  71. alleviation of braxton hicks contractions
    • hydration
    • urination
    • breathing
    • movements
  72. vitamins and nutrition
    iron supplement, folate
  73. most important aspect when assessing nutritrion and health risks for preg
    history
  74. true uterine contractions
    felt over the uterine fundus with radiation to the low back and abdomen, are of increasing strength and freq- normally leading to dilation of the cervix
  75. uterine contractions during active labor have two major fns
    • dilate the cervix
    • push the fetus throught the birth canal
  76. 3-ps of fetus successfully passing through
    • powers- uterine contraction- measured by external tocodynamometry
    • passenger- fetus- size, postion, presentation, attitude(head extension or flexion)

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