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General
Anemia in Pregnancy Assessment for Pregnancy Risk
• Occurs because of a greater expansion of plasma volume • Use the following tests in all women
• This occurs during the late second to early third trimester o Hematocrit/hemoglobin and MCV
• Hemoglobin <10.5 in the 2nd trimester = anemic o Assessment for asymptomatic bacteriuria
• Usually treat with iron supplement o Rhesus type and red cell antibody screen
• Also take 400-800mcg of folate o Assessment for immunity to rubella and varicella
o Testing for syphilis, hepB, and chlamydia
o HIV
• Test used for at risk women
o Thyroid function test
o Gonorrhea
o TB, toxoplasmisis, hepC, BV, trich, herpes, Chagas
• At risk women
o Thyroid issues type 2 DM, HepC, TB
High Risk Pregnancies
• Pre-existing maternal disorders
o HTN, DM, STDs, pyelo, surgical problems, genital tract
abnormalities, exposure to teratogens, exposure to
mercury, prior stillbirth, prior preterm delivery, prior
neonate with genetic or congenital disorder,
polyhydramnios and oligohydramnios, multiple
pregnancy, prior birth injury
• Physical and social characteristics
• Age (>35)
• Problems in previous pregnancies (SAB)
• Problems that develop
Prenatal Care
Components of prenatal evaluations Estimated date of delivery (EDD)
• Week 4-28: 1 prenatal visit a month • 280 days from the onset of the LMP, and 266 days from the date
• Weeks 28-36: 1 prenatal visit every 2 wks of conception
• Weeks 36-40: 1 prenatal visit every week • Naegele’s Rule
• Evaluations o Count back 3 months from the LMP and add 7 days
o 8-12 wks IOB, physical exam, pelvic exam, blood o June 20th LMP March 27th
type, hgb, STD screening, urine test (bacteriuria), pap • Ultrasound estimation of EDD in the first half of pregnancy is
▪ Maybe u/s dating if LMP is unknown superior to dating based on LMP or physical exam (and is most
o Optional genetic counseling if >35 or family hx accurate in the first trimester)
▪ Talk about additional genetic screening tests, The u/s EDD should be used if it differs from that calculated from the
blood tests, chorionic villus sampling, u/s, LMP by more than 5-7 days in the first trimester and by more than 10-
amniocentesis 14 days in the second trimester (or by 8%)
o First 2 trimester visits (up to 28 wks)
▪ Weight, BP, fetal heart beet, growth of
uterus, check urine for protein and glucose
o 15-20 wks
▪ Will also be offered the Quad screen
test/horizon to screen for genetic and spinal
cord abnormalities
▪ Anatomic u/s between 18-20wks to view
baby’s organs and measure growth
o 27-28 wks
▪ Glucose challenge test for GDM, hgb may be
rechecked, can do a pelbic
▪ Sign up for prenatal classes
o 28-36 wks
▪ Every 2 wks growth, heartbeat, position of
baby
o 36 wks
▪ GBS test, pelvic exam, repeat STD testing,
position and size of baby
o 36-40 wks
▪ Monitoring or weight and BP, size, position,
heart rate, cervix dilation check
Timing of routinely recommended screening & diagnostic studies • Quad Screen
• Nuchal Translucency scan 11 wks to 13+6 wks o 16-18th wk – adds inhibin-A to the triple screen
• GDM o Lowers the false positive rates for downs
o 26-28 wks screening drink glucose solution, one hour • Amniocentesis
later have a blood test to measure your blood sugar o Follow up for an abnormal triple test to determine if
level, <130-140 is considered normal specific genetic disorders may be present in their baby
o if positive go to the 3 hr GTT o U/s guided needle to enter the amniotic sac to remove
▪ Fast overnight, check blood sugar levels every a sample of the amniotic fluid
hour for 3 hrs o Done between 14-20 wks
• Fetal Non-Stress Test performed at 28 wks, tests movement, o Detects chromosome abnormalities, neural tube
heartrate, and reactivity of heartrate to movement for 20-30 defects, downs, cystic fibrosis
minutes o Provides access to DNA for paternity testing prior to
o The test can indicate if the baby is not receiving enough delivery
oxygen because of placenta or umbilical cord problems, o Miscarriage is the main risk, may lead to cramping,
it can also indicate other types of fetal distress leakage of fluid, minor irritation at puncture site
o Generally performed after 28 wks • First Trimester Screen
o A healthy babies heart rate will respond with an o Combines AFP blood draw and u/s for nuchal
increased heart rate during times of movement and will translucency
decrease at rest o Can also ID cardiac disorders, but NOT neural tube
o When oxygen levels are low the fetus may not respond defects
normally o Performed between the 11th & 13th wk
o Low oxygen can be caused by problems with the • Chorionic Villus Sampling
placenta or umbilical cord o Removes chorionic villi cells from the placenta to check
• Rhogam shot at 28-29 wks for chromosomal abnormalities and genetic disorders
• Biophysical Profile typically after 32 wks o Guided by u/s, thin catheter is inserted through the
o Combines an ultrasound eval with a non-stress test and cervix into the placenta and the villi cells are gently
is intended to determine fetal health during the 3rd suctioned (can also be done through the abdomen)
trimester o Very high level of accuracy
o Performed if there is a question about fetal health or if o Can be done between 10 & 13 wks from LMP, can be
the pregnancy is considered high risk done earlier than amniocentesis
o 5 attributes studied during the test o Can also do paternity testing
▪ Breathing 1 breathing episode in 30 min o Risk of miscarriage
▪ Movement 2 or more movements in 30 • U/S
min o Transvaginal during early stages (good to diagnose
▪ Muscle tone 1 or more active extension or ectopic or molar pregnancies)
flexion of limbs o Fetal ECHO
▪ Heart rate 2 or more accelerations within o First trimester confirm pregnancy, confirm
20 min heartbeat, assess any abnormalities
▪ Amniotic fluid 1 or more adequate pocket o Second trimester down’s, congenital malformations,
of fluid structural abnormalities, multiple pregnancies, verifies
• Triple screen Test date, assesses amniotic fluid
o Blood test Tests AFP (fetus), Hcg (placenta), and o Third trimester ID placenta location, fetal
estriol (fetus and placenta) presentation, fetal movements, identify uterine or
o Performed between wk 15-20 (but best between wk pelvic abnormalities of mother
16-18) • Urinalysis
o High levels of AFP may indicate a neural tube defect o Used to assess bladder or kidney infections, DM,
o Low levels of AFP and abnormal levels of hcg and estriol dehydraction, and preeclampsia
may indicate a chromosomal abnormality • Blood test
o Can indicate inaccurate dating of the pregnancy or o Looks for anemia, toxoplasmosis, Rh factor, glucose,
multiple gestations iron, hemoglobin, immunity to rubella, STDs
Obstetric Complications
Septic abortion Malposition/malpresentation
• Complicated form of SAB accompanied by an intrauterine • See breech
infection • Transverse fetal lie curvature of spine goes over cervix or
• Uncommon with SAB, more frequent with induced abortions anterior trunk goes over cervix
• Management • Very unstable
o Assess hemodynamic stability, give fluids or blood • Diagnosis can be made with leopold maneuvers
products if needed • Most will need c-section delivery
o Obtain blood and endometrial cultures
o Administer broad-spectrum IV antibiotics (usually the
same as PID abx)
o Surgical evacuation of the uterine connects, risk of
perforation is high (evacuation should begin promptly)
PROM Post-partum Fever
• ROM prior to the onset of regular uterine contractions • Postpartum febrile morbidity is defined as a fever of >100.4 or
• Management depends on gestational age >38 on any two of the first 10 days postpartum (excluding the
• Diagnosis is based upon characteristic history (water breaking) first 24 hrs)
and a speculum exam visualizing the os) • If fever is present, a physical exam should be performed to find
o Can also test the fluid pH, amniotic fluid has a range of the source and optimal therapy
7-7.3 (vagina is usually 3.8-4.2 and urine is 5-6) – this is • Surgical site infections may occur at episiotomy, lacerations, or c-
called the nitrazine section
o Fern test amniotic fluid dries like a fern on the slide • Typical physical exams will show cellulitis with redness and
• If between 23-34 wks, give a corticosteroid for RDS induration, may be accompanied by tenderness, purulent
• Give antibiotics incisional drainage
• Urgent delivery if: • The following should be considered:
o Intrauterine infection, placenta abruption, o UTI, wound infection, mastitis or breast abscess,
nonreassuring fetal testing, high risk of cord prolapse endometritis, septic pelvic thrombophlebitis, drug
reaction, c. diff, complications related to anesthesia
• Parts of normal pregnancy: morning sickness, dizziness, weight gain, swelling in the feet, acid reflux
• Hyperemesis Gravidarum (0.5%, greatly under-reported)
Hypertension Gestational Diabetes (5%)
• Chronic HTN in pregnancy • Glucose intolerance first recognized in pregnancy
o Present prior to conception and/or before 20th week of o Postprandial hyperglycemia resulting from impaired
gestation insulin release and increasing insulin resistance
o R/o secondary causes: kidney dz, renal artery stenosis, facilitated by pregnancy hormones
lupus, thyrotoxicosis • Incidence as high as 9.2% in some areas of US
o Requires closer monitoring to ensure that HTN does not • Risk for developing diabetes later on in life
progress • Screening @ 24-28wks gestation
▪ Greatest risk: 25% develop superimposed o 50g oral glucose test, randomly ingested
preeclampsia ▪ Abnormal >140 mg/dL Proceed to 3hr Oral
o Management Glucose Tolerance Test
▪ Optimize diet, exercise, control weight gain ▪ Gestational DM >200 mg/dL
▪ Continue safe pharmacotherapy only if • Management
indicated (determined by specialist) o Strict diet control
• Gestational HTN o Patient monitor BS
o After 20th week of gestation o Insulin in needed
▪ Systolic BP >/= 140 • Monitor w/frequent US for fetal growth
▪ Diastolic BP >/= 90 o Macrosomia: fetal weight greater than 90 th percentile
▪ No proteinuria, no end-organ damage or over 400gm
o Occurs in 6-17% nulliparous women, 2-4% multiparous o Complications: hypoglycemia, hyperbilirubinemia,
▪ Most commonly occurs in first pregnancies, delayed pulmonary maturation (induced early birth),
depends on health status, diet, stress, etc. birth injury – shoulder dystocia (C sections minimize
o Mild-moderate HTN has good prognosis and usually injury to mother and baby)
requires no treatment
▪ If maintained at 140/90 and no end-organ
damage no immediate tx indicated
• When taking BP follow correct techniques – pregnant patient
should be sitting for at least 15min, right size cuff, confirmation
with 2-3 readings
• Treatment
o Treatment of HTN in non-pregnant patient is to prevent
adverse effects in 5yrs
o Duration of conditions is finite and relatively short so
that no maternal benefits could be expected from
antihypertensive therapy for mild chronic HTN during
9mo pregnancy
o Treat both chronic HTN and gestational HTN
o Consider risks vs. benefits of tx
Preeclampsia
• HTN after 20wks and signs of end-organ damage in previously normotensive patient
▪ >140/90 confirmed on repeat exam
▪ >160/110 confirmed dx
• End organ damage
▪ Proteinuria >0/3g in 24hrs
▪ Platelet count <100,000/mcL
▪ Serum creatinine >1.1 mg/dL (or doubling of baseline)
▪ LFT evaluation, Pulmonary edema, Cerebral or visual sx’s
• Evaluation (important to prevent impaired uteroplacental blood flow or placental infarction)
▪ Urine dipstick for proteinuria (1+), edema unresponsive to position, edema in face/hands
▪ Sudden weight gain, HA, blurry vision, hyper-reflexive or ankle clonus (hypertensive crisis)
▪ Measure fundal height (to check for intrauterine growth restriction) If blood flow restricted, fetus will not grow
• Diagnosis
▪ Difficult to dx, no effective method for screening, important to establish baseline and prevent from progressing
▪ Most common in first pregnancies
• 25-60% recurrence rate of preeclampsia
• Recurrence usually less severe
• Common <25yo and >35yo, pre-existing HTN, obesity, DM, thyroid dz
• Pharmaceutical tx (Consider risk vs. benefit, informed decision)
▪ Medications to use in moderate-severe cases: aldomet, nifedipine, labetalol
• Medications usually avoided in 1st trimester, pts typically monitored closely before medications used
• Tx if worried about HTN crisis or progression to eclampsia (3% will progress if not treated, w/tx progression 0.6%)
▪ Do NOT use HCTZ (do not diuresis pregnant patients, will cause further volume depletion)
▪ Refer to OB specialist for high risk pregnancy
▪ Tx of HTN crisis Hydralazine 10mg IV or Labetalol 20mg IV
Eclampsia Vaginal bleeding in first trimester
• Preeclampsia w/seizure, coma, or death • DDx
• Prevention (most important) o Normal implantation of embryo (short-lived, lasts 1
▪ Close monitoring, bed rest in L lateral day)
▪ If BP >160/110, initiate IV therapy o Post-coital bleeding
▪ Hydralazine 10mg IV, then drip o Vaginal, vulvar, cervical lesions or lacerations
▪ Delivery only definitive cure o Non-pregnancy bleeding, rectal bleeding
• Seizures o Spontaneous abortion (miscarriage)
▪ Tonic clonic, short duration o Ectopic pregnancy
▪ If status results use what is necessary to stop seizure o Gestational trophoblastic disease
▪ Resuscitate mom to resuscitate baby Rh (-)
• Maternal Type and Screen for Rh factor for all pts w/vaginal
• Management of seizures bleeding
▪ Magnesium sulfate IV 6gms o If Rh (+) do not need Rho-Gam
• Does not abort current seizure, used to o If Rh (-) needs Rho-Gam
prevent subsequent seizures (10% will have ▪ Will have normal first pregnancy, develop Abs
subsequent) ▪ If second pregnancy Rh (+) Abs attack infant
• Safer than phenytoin, diazepam blood
• Low cost, no cardiac monitoring, no sedation • Rh Immunoglobulin (Rho-Gam) administered @ 28-29wks to all
• Decreases risk of cerebral palsy in offspring Rh (-) mother as prophylaxis
▪ If overdose, calcium gluconate 1g IV and supportive tx o Blood product – must get informed consent
• Immunoglobulin also indicated for any other condition that
• HELLP syndrome causes maternal and fetal mixing of blood
• Hemolysis, elevated liver enzymes, low platelets o Ectopic pregnancy
• Sx’s: edema of face and hands, HA, visual changes, N/V, RUQ o Spontaneous/therapeutic abortion
pain, decreased urine output o CVS, amniocentesis
o Trauma (MVC, domestic abuse)
• If Rho-Gam not given, severe fetal anemia (hemolytic anemia of
new born), fetal hydrops, fetal death can occur
Abortion Cervical insufficiency
▪ Termination of pregnancy <20wks ▪ Painless dilation of cervix
▪ Spontaneous abortions o Often in 2nd trimester, accounts for 15% second
• Premature expulsion of products of conception trimester loss
• 10% of all clinically recognized pregnancies, rate much o Fetal membranes may become exposed to vaginal flora,
higher than medically documented (1/5) infection, PROM
• 80% occur in 1st trimester ▪ RF’s
▪ RF’s: smoking, infection (rubella, toxoplasmosis, CMV), maternal o Prior trauma to cervix: lacerations at delivery, LEEP,
systemic dz (uncontrolled DM, thyroid storm), immunologic cone biopsy
abnormalities of fetus, drug abuse (cocaine) o Connective tissue disorders
Types of abortion o In utero exposure to DES (diethylstilbestrol – synthetic
Threatened AB estrogen)
▪ Serial Quantitative hCG titers q48hrs ▪ Last prescribed in 1971, can cause clear cell
▪ Serum progesterone, Serial US adenocarcinoma (CCA) – rare vaginal and
▪ Blood type and Rh status cervical cancer
Abortion (miscarriage) ▪ Dx: hx, PE, US
▪ Natural AB ▪ Management:
o Allow products to pass naturally o Can perform cervix suturing to prevent in patients who
o Typically <10 weeks gestation, can take days-wks are at risk or suspected cervical opening, in subsequent
o Heavy bleeding, serial hCG titers pregnancies in pts with known cervical insufficiency
o F/U US to confirm completion of abortion o If cervical insufficiency not treated, pregnancy will self
o F/U pelvic exam terminate and end in fetal demise
▪ Dilation and curettage o Cerclage
o Single-step, clears POC
▪ Endometritis Hyperemesis Gravidarum
o Infection s/p abortion • Dry bland food/oral rehydration are first line
o Treat w/IV abx, hospitalization (treat sepsis) • Then antiemetics and IV fluids
▪ All Rh (-) receive immunoglobulin o Meds pyridoxine/doxylamine, promethazine
Etiology of AB o Odanestron (but it may lead to cleft palate)
▪ Most common reason unknown o Metoclopramide can also be used
▪ If etiology known, usually due to genetic abnormalities of fetus
▪ Environmental: drug use, toxic exposure, Uncontrolled endocrine
disorders: DM, thyroid dz, Uterine defects
▪ Infection: CMV, parovirus, rubella
▪ Autoimmunities: anti-phospholipid ab’s (can cauase placental
thrombosis and infarction)
Vaginal bleeding in second & third trimester
• DDx
• First trimester reasons, vasa previa, placenta previa, placentral abruption
• Evaluation: transvaginal US for bleeding Assess cervix, placenta, cord (Doppler flow)
Placental Abruption Vasa Previa
▪ RF’s: increased age and parity, HTN, PROM, prior abruption, ▪ Fetal vessels course through membranes, present at internal os
cocaine use, cigarette smoking, thrombophilias, trauma ▪ Compression of umbilical cord - 2 arteries, 1 vein (O2 to baby)
▪ Types of abruption ▪ Obstetrical emergency (high fetal mortality)
• Partial abruption most common falls, insult to ▪ Occurs in 1:2500 births w/fetal mortality rate 95% if not dx
uterus prenatally
▪ Dx via Doppler US
• Hematoma concealed may not have bleeding but
▪ Close monitoring, delivery via C section if possible
can still have fetal distress, abdominal cramping
Placenta previa
▪ Management
▪ 100% mortality if patient does not have C section
• Varies on gestational age and status of mother and
▪ Should be suspected w/bleeding in second half of pregnancy
fetus If fetus viable, C section ASAP
▪ Bleeding can vary (small amounts vs. full hemorrhage shock)
• Always stabilize mother first
▪ RF’s: prior C section/uterine surgery/curettage, maternal age,
• Expectant mangemmet in preterm infant
multiparty, uterine abnormalities (fibroids), smoking, IVF,
o Betamethasone – steroids to for lungs
multiple gestation pregnancy
o Tocolysis – stop contractions
▪ Dx: Transabdominal US evaluation (Sn 95%)
o Bed rest
▪ Vaginal exam and speculum exam CONTRAINDICATIED
o Fetal monitoring
o Can cause hemorrhage and death
o Mode of delivery if fetus viable (C section)
o If pt presents w/bleeding and unknown Hx of prenatal
care, DO NOT perform pelvic
o Stabilize with IV access and trans-abdominal US