There are 65 questions on this last test. Here is the break down:
Antepartum: 10 questions. Know about TPAL, Nagel’s rule, signs of pregnancy,
toxoplasmosis, exercise, cultural considerations, warning signs in the first trimester,
quickening, measuring fundal height, beginning signs of labor.
Common complaints of pregnancy (you know all those reasons women get
pregnant!!): 4 questions. Know about N &V, constipation, leg cramps and
heartburn
Nutrition (eating for two): 9 questions. Know how to assess for nutritional intake,
absorption of iron, fluid intake, weight gain and calorie intake in pregnancy, protein
intake and pica.
Screening tests: 5 questions. Know when to do the screening tests for NTD and
Down’s, how and when to screen for diabetes, (3 questions) and insulin changes in
pregnancy.
Testing fetuses: 3 questions: NSTs, amniotic fluid volume, and amniocentesis
High Risk antepartum: 12 questions. Know about hyperemesis gravidarum,, risk
factors for PTL, what tocolytics are used and how, major risk factor for a preterm
infant, BP changes in pregnancy.
Bad stuff that happens earlier in the pregnancy: 6 questions. Know about
hydatiform moles, the LMP question!, ectopic pregnancy, treatment options for
ectopic, kinds of miscarriages.
Domestic violence: 4 questions: the effects abuse can have on a pregnancy, asking a
question that facilitates disclosure of DV, our role in documenting. (I know we
haven’t covered this yet, but the questions are basic)
Contraception: 6 questions. What to do if a woman misses 3 birth control pills,
emergency contraception timing, IUD risks, basal body temperature method, and
general things you want to ask a woman when counseling her on a type of
contraceptive (only 1 question).
STIs: 6 questions. Risk factors for STIs, complications of GC in pregnancy, most
common bacterial and viral STIs, the STI health care providers are most at risk for
getting (NOT a personal question!!), treatment for PID in pregnancy.
There are 65 questions on this last test. Here is the break down:
Antepartum: 10 questions.
Know about TPAL,
Gravida-pregnant woman; Para- number of pregnancies where the fetus reached 20 wks,
or that have, “reached 20 weeks.” To say a woman is gravida 1, para 1, means she’s
either had one kid or maybe triplets b/c you’re counting pregnancies. Only says you
carried a kid (or several at once) past 20 weeks.
What do the terms: G, T, P, A and L mean?
GTPAL= gravidity, term births; preterm births; abortions/miscarriage; living children
 Gravidity: number of times pregnant, including a current pregnancy, no matter
what the outcome
 Term: term births: with kids that cooked until 38-42 weeks gestation
 Parity- number of pregnancies where the fetus or fetuses reached 20 weeks or
beyond. Outcome also doesn’t matter here—if the kid was born term, preterm,
still born, etc. But if you had an abortion before 20 weeks, that wouldn’t count in
the parity section. However, you can distinguish preterm births if you account for
all these numbers. When you start using GTPAL, it seems that “P” really means
“preemies”
 Abortions/Miscarriages: whether intentional or not.
 Living: kids still alive.
What would it mean if a woman was 3-0-2-0-3?
 3 pregnancies-0 term births-2 preemies-0 abortions-3 living children
Nagele’s rule
How long are ya pregnant? 280 days, 38-42 weeks, etc. Count from 1st day of LMPwhich is also ridiculous.
Describe Nagele’s Rule.
 Nagele’s rule- from the 1st day of LMP subtract 3 calendar months, add 7 days
and 1 year OR add 7 days to LMP & count forward 9 months (assuming that she
has 28 day cycle)
If a woman’s LMP was 10/23/07 what is her EDC, EDB or EDD?
 LMP (last menstrual period):
10/23/07 (-3+7+01)
 EDC (estimated date of confinement: means delivery date)
 EDB/ EDD (estimated date of birth/ delivery)
07/30/08
Only 5% of women deliver on their Nagele’s date.
Signs of pregnancy
How soon can an hCG be positive? What can interfere with the results?
 hCG is: Human chorionic gonadotropin, begins secretion at conception, reaching
detectable levels by day 7-10.
 It is the earliest biomarker for pregnancy

Detected as early as 7-10 days after conception; increases & peaks at 60-70 days
then declines at 80 days, remaining stabl until 30 weeks and then increases till
term.
 Higher levels: mean twins, abnormalities [like Downs’ sydrome]
 Low or decreasing levels may mean ectopic pregnancy, impending miscarriage.
 Best urine collection: first of the morning.
Interference: doing the test too early; substance abuse or medicationsanticonvulsants & tranquillizers cause false-positive results, diuretics &
promethazine can cause false-negative results; Improper collection of specimen;
hormone producing tumors & laboratory errors= false results
3. What are presumptive and probable indicators of pregnancy? (I don’t know why
anyone cares with hCG tests being so accurate, but it is one of those old procedures that
refuses to die. Kinda like clinical pelvimetry!) p 336- table 14.2
 Presumptive indicator- changes felt by the woman- amenorrhea, fatigue, n/v,
breasts, peeing all the time, fatigue. Quickening [fetal movements].
o Other things: objective signs like abd enlargment, changes in vagina, striae
gravidarum, dark areola, linea nigra, chloasma [pregnancy mask].
 Probable indicators- observed by examiner- still aren’t perfect positives [like a
pregnancy test isn’t always right]
o uterine enlargement
o Pregnancy test (Hcg)
o BH ctx
o Uterine soufflé: sounds like a murmur in your uterus on ascultation, from
increased blood flow.
o Ballottement (A method of diagnosing pregnancy, in which the uterus is
pushed with a finger to feel whether a foetus moves away and returns
again),
o Goodell Sign: softening of cervical tip @ 6wks in normal unscarred
cervix; from increased vascularity, slight hypertrophy & hyperplasia=
loose, edematous, elastic, increase in volume & looks velvety
o Chadwick Sign: @ 6-8 wks- increased vascularity gives violet-bluish color
of cervix & vaginal mucosa
o Hegar sign @ 6 wks softening & compressibility of uterine isthmus=
exaggerated uterine anteflexion= gotta pee q 15”
Positive indicators- presence of fetal signs- heartbeat, palpating or seeing fetal
movement, US images
Why isn’t Hcg a positive sign of pregnancy? It’s not perfect, and it can indicate a molar
pregnancy.
Toxoplasmosis
What’s a TORCH screen?
TORCH infections can affect a pregnant woman and her fetus. Toxoplasmosis, other
infections, rubella, cytomegalovirus, and herpes form a collection of organisms capable
of crossing the placenta and adversely affecting fetal development, are teratogenic,
and/or could cause miscarriage. Generally, all these organisms produce flu-like
symptoms in the mother, but more severe fetal and neonatal effects.
 Toxoplasmosis: protozoal infection associated with the ingestion of infested raw
or undercooked meat and with poor hand washing after handling infected cat
litter, also loves infecting pregnant women. Miscarriage may occur. Treatment
with medications are potentially harmful to the fetus, but worth the risk.
 JK From lecture: toxoplasmosis lives in cat feces—it’s a virus (she’s wrong),
it survives cat guts. Prenatal teaching is good here, you don’t want mom
getting the virus for the 1st time during pregnancy (probably also wrong)—
causes CNS/learning, hearing, visual disabilities. If you get infected in 1st tri,
30% of babies are affected, but in 3rd tri 60% affect, so that’s backwards from
the norm. Most people are already immune to it. It’s airborne after about 3
days in feces, so don’t inhale. Also wear gloves when gardening.
 Other: Hepatitis, GBS, Varicella, and HIV (text). gon, syph, chicken pox, heb b,
HIV, 5ths disease (lecture).
 GBS: common vag flora, causes neonatal pneumonia,
 Gonorrhea: blindness in kiddo
 Chlamydia: causes blindness in neonate just like gonorrhea, in pregnancy
infection is assoc with miscarriage, stillbirth, PTL, PP endometritis.
 Syphilis: Can cross placenta or transmit by lesion on vagina during
delivery. Results in stillbirth, infected babes will have neuro problems just
like tertiary syphilis, and lesions etc—symtpoms may appear at birth, or
within 2 year of life…some not until they are 20 yrs old! We test people
in 1st tri and high-risk people later on too. Need to treat and follow w/
serial syphilis tests if mom’s got it.
 Varicella; less of this lately, but in tri 1 can cause fetal demise, also IUGR,
limb and eye and neuro abnormalities.
 Hep B: liver thing, pretty much vaccinating all kids for it. Doesn’t cause
malformations or stillbirth, but does cause PTL/PTB.
 HIV: in pregnancy: can get passed to the baby and they can die. Rapid
HIV screen is being used when admitted to L&D. Mom has to be treated
during pregnancy b/c it passes the placenta—this treatment works really
well. Most cases occur at or near time of delivery—C/S for women off
meds helps decrease transmission. Also transmitted through lactation.
You get little kids w/ HIV and opportunistic infections, etc.
 5ths: parvo-virus, carried in daycare by children, get generalized rashes, or
the bitch-slap rash on the face. Causes trouble before 18 weeks.
 Rubella: transmitted by droplets. Rash, muscle aches, joint pain, and mild
lymphedema. Miscarriage, congenital anomalies, and death occur in fetus.
Vaccination of a pregnant woman is contraindicated due to live vaccine.
Postpartum vaccine is given with instructions to use contraception for at least 1
month after.
 CMV: similar to mono, transmitted by close contact or body fluids and placental
tissues. 60% of pop is immune to it already. Fetal infection can cause
microcephaly, IUGR, eye, ear, and dental defects, and mental retardation and a
crazy purple spot rash. No treatment is available during pregnancy.

Herpes simplex. 2 kinds, 1 and 2, used to say 1 was above the waist, but now we
know that’s really not true. H1 is not as bad as H2 for fetus or grownups—I call
HSV2 “herpes not-so-simplex. Primary herpes is bad for fetus, is the first infection,
usually a systemic infection: if 1st tri, the baby will die. If after tri 1, she’s at risk for
SGA and preterm labor, can have encephalitis. For women who have secondary
infection, at about 36 weeks we recommend women will use prophylactic antivirals to
prevent shedding so she doesn’t have a lesion at delivery. Some hospitals will cut a
CS if she’s got an outbreak, others will deliver vaginally and treat baby with IV anti
virals.
Exercise
Kegels are good for strengthening pelvic floor, improves stretching and contraction at
time of delivery. Also helps prevent PP urinary incontinence and improves sexual
gratification. Deliberate contraction & relaxation of pubococcygeus muscle: strengthens
muscles of pelvic floor: vagina & urethra
Physical activity promotes circulation, relaxation, counteracts boredom, helps w/ low
back pain esp in 2tri. Weight bearing exercise isn’t so good, but swimming, cycling, and
stretching, and walking are best. Exercise a little every day to create stamina—30 mins.
Don’t push it—decrease your activity as pregnancy progresses. Lay on your side for 10
mins to relax after workout. Other stretches to prepare for delivery include squatting
stretches.
Cultural stuff on exercise: different groups have different ideas: Filipinos encourage
women to do nothing but incubate the kid, some asian and native Americans keep her at
work until near delivery. In Japan, I understand women are not allowed even near sewing
machines and often live at mom’s during pregnancy doing little activity.
Cultural considerations
Prenatal care as we know it is a US phenomena that is radically foreign to many moms.
Some women are more modest—and need female care providers. Some think doctors are
for sick people, not pregnant people.
Each culture has its prescriptions and proscriptions about prenatal care—you should
know them for your clients. These include diet, sex, exercise, etc.
Food: You can gain the same amount of weight in pregnancy eating good foods or bad
foods—one mom will be healthier. The kid gets what you give it.
The Hispanic paradox: Latina women tend to fall in lower SES, but their pregnancy
outcomes are often as good or better than Caucasian women’s. There’s something about
the diet that really works. Unless we’re talking Latina women who are DM. It’s also
often 1st generation Latinas and 3rd gen Latinas that do well, but the 2nd gen are into
McDonald’s and stuff.
Warning signs in the first trimester
Common discomforts of pregnancy: think about these and then look for some w/
pathological [bad] reason that’s causing them.
Box pg 399 says panic if:
Tri 1; severe n/v [hyperemesis grav], chills/fever and or diarrhea [infection],
burning on peeing [UTI], abd cramps/vag bleedeing [miscarriage, ectopic pregnancy]. I
add heartburn b/c of HELLP.
 Other times to panic: vag bleeding, alteration in fetal movements, symptoms of
preeclampsia, PROM.
Quickening
What is quickening?
 First recognition of fetal movement “feeling life”; multi- 14-16 wks; nulli- 18 +
wks. multips feel it at 14-16 weeks, primips 16-20 weeks. If no quickening by 22
weeks there’s a problem.
Measuring fundal height
4. How is fundal height measured (also called McDonald’s measurement)? P398
 Uterine enlargement- to estimate duration of pregnancy; w/ paper tape, have her
empty her bladder, upper border of symphysis pubis to upper border of fundus w/
tape measure held in contact with the skin
6. About how many weeks pregnant is a woman if her uterus is at her umbilicus
(considering she only has one fetus and everything is normal)?
 @ 22-24 wks (text pg 336)
9. If a woman is 28 weeks pg, what will her fundal height be (check out ATI and p. 398
in text!)?
 28 cm @ 28 weeks. From 18-32 weeks, the fundus is at the same height in cm
as the woman is in weeks!
At 15 weeks pregnant: somewhere between symphysis pubis and umbilicus
20-22 weeks fundus is at umbilicus (picture)
Beginning signs of labor.
(signs of preterm labor pg 416): tightening of the fundus that can be felt with a hand on
the abd., see if ctx continue while laying down over 1 hr to r/o Braxton-hicks ctx—not
normals to have ctx 1-10 mins apart for an hour pre-term, that’s when you should call.
Sign of preterm labor: “Do you have a ‘balling up’ feeling in your lower abd?” That’s
a really predictive question/sensation for preterm
 Signs preceeding labor [pg 459]: lightening, low backache, brax-hix ctx that are
strong but irregular, bloody show, PROM, weight loss of 1 kg caused by water loss
and peeing like crazy, surge of energy [and corresponding nesting],
5. What is lightening?
 Btwn 38 & 40 wks, fundal height drops as fetus begins to descend & engage
(nullipara 2 wks before onset of labor; multip- lightens at the start of labor).
Called lightening because you have more room to breathe [literally.]
8. When do Braxton-Hicks contractions commonly occur? (p337)
 After 4 mos- ctx are felt in abdominal wall. Good b/c: they assist uterine blood
flow thru intervillous spaces of placenta & oxygenates fetus; usually stop with
exercise/walking; mistaken for true labor (but they don’t increase in intensity or
frequency or cause cervical dilation). Not painful, not regular.
Common complaints of pregnancy (you know all those reasons women get
pregnant!!): 4 questions. Know about N &V, constipation, leg cramps and
heartburn
N/V: all of these on pages 412-415 in a nice table!
 Happens in 50-75% of women esp in tri 1. Cause unknown, may be from hormones
or HcG. Could lead to alkalosis. Old wives’ tale says it’s from ambivalence about
pregnancy.
 Whaddydo for a mom w/ n/v in tri1: peppermint, ginger, acupressure bracelets, salty
crackers esp when you 1st wake up. Graze and eat small meals. Try not to eat and
drink at the same time. Call MD if it’s really really bad.
Heartburn: Heartburn is d/t a lack of room, but it could indicate HELLP.
18. Why do pregnant women get heartburn (other than HELLP!!)
 Incr progesterone causes less tone & motility of smooth muscles = esophageal
regurgitation, slower emptying time of stomach & reverse peristalsis = acid
indigestion/ heartburn/pyrosis. Starts at 1st trim & intensifies through 3rd. Let’s
hear it for Jessica Ezra, my dear friend who’s pregnant and whose heartburn
started early and still has not let up.
 Why does progesterone do that? It relaxes all smooth muscles and aids in
preventing miscarriage.
 Good news: More estrogen production causes less hydrochloric acid secretion=
no more peptic ulcer formation or flare up—these women often get relief from
symptoms during their pregnancies.
 What to do: eat simple foods that aren’t spicy or fatty, small meals, good posture,
sip milk, hot herb tea, maybe an antacid, do call MD to r/o HELLP.
Leg cramps/gastrocnemius spasm
 Due to compression of nerves supplying lower extremities b/c the big ol uterus is
sitting on them. Or low calcium b/c your fetus is eating all of it trying to build a
whole new skeleton. Or high phosphorus. Or poor circulation, or pointing toes when
stretching or walking, or from drinking more than 1 L of milk a day. What?
 What to do: check homan’s sign to r/o clots, then use massage and heat pad. Stand on
a cold floor? What? Oral supplementation of Ca+ per MD, get rid of excess
phosphorus by eating aluminum gel [that’s weird].
Constipation:
 Same thing as heartburn: ↑constipation (hypoperistalsis) due to progesterone slowing
things down and relaxing smooth muscle, also mom eating iron supplements, etc.
Does make her absorb more water, but also makes hemorrhoids worse.
 Do this: drink a ton of water, incr fiber, moderate exercise, make a regular schedule
for BM, relax. Call MD for laxitive, stool softener, enema, etc.
Nutrition (eating for two): 9 questions.
Why care about prenatal nutrition? LBW and preterm kids, and neural tube defects are
really weird looking/lethal.
Why do you need so much of this stuff? The growing kid, placenta, boobies, uterus, incr
blood volume w/ more plasma and RBC’s, and women’s metabolic rate is up by 20%.
Nutrient: Amount
Source:
Significance
needed:
Protein:
46 g
↑+25g
(during
pregnancy)
Meats, eggs cheese, yogurt,
legumes, nuts & grains
Amino acids are the building blocks; synthesis
of products of conception, growth of maternal
tissue & expansion of blood volume, secretions
of milk protein during lactation
Milk, cheese, yogurt, sardines, deep Skeletal development & tooth formation;
Calcium: 1300 <19yo
green vegetables, tofu, baked beans, maintains material of bone & tooth
(mg)
1000 19-50
tortillas
mineralization
Fat: (mg)
25-35% of
Olive or flax oil, fresh nuts and
caloric intake seeds, avocados
To absorb fat soluble vitamins A,D,E,K
Anti-oxidents, cellular protection
Folic
acid:
(mcg)
600
Fortified cereals & grains, green
leafy vegetables, oranges, broccoli,
asparagus, artichokes, liver
Prevents neural tube defects- spina bifida &
anecephaly; supports increased amount of
maternal RBC formation
Iodine:
(mcg)
220
Iodized salt, seafood, milk products,
yeast breads, donuts
Increased maternal metabolic rate
Iron:
(mg)
30
Liver, meats, whole grains, deep
Maternal hemoglobin formation, fetal liver
green vegetables, legumes, dried fruit iron storage
Fluids:
(L)
Water, beverages, frozen desserts,
3 total; 2.3
fruit, fresh vegetables (especially
in beverages
lettuce)
Expands blood volume; Facilitates exchange
of nutrients & wastes; Milk secretion; Regular
bowel function; Substance of cells blood,
lymph, amniotic fluid; Maintains body
temperature
1. What vitamin is crucial in the prevention of neural tube defects?
 Folic acid- synthesized ~folate- found naturally in foods [liver, beans, dark green
veggies, wheat germ [whole wheat products] etc.
Know how to assess for nutritional intake
Lecture; How do you know if someone is eating well? You ask them what they ate in
the last 24 hours. Ask her about water and protein. Ask her what she’s allergic to and
what she does and doesn’t like to eat. You can’t talk anyone into eating liver if they just
don’t like it. Also figure out how she gets to a decent market to get well priced food,
how much she has to pay for food, what kind of shop n’ robs are in her neighborhood and
if they have produce. How many buses is she away from a Safeway?
Absorption of iron
Iron is best absorbed by the body in combination with Vitamin C—found in citrus,
strrawberries, melon, tomatoes. Heme Iron in meats is easy to absorb.
Bran, tea, coffee, milk, egg yolk, oxylates [in spinach and swiss chard] decrease iron
absorption—so don’t eat them with your iron vitamin
Iron is best absorbed w/ empty stomach, so take it btwn meals. Bedtime works too if you
get pukey btwn meals.
Don’t double dose one day if you forgot to take it yesterday.
Might make your poop green or black, might make you constip. Eat your fiber!
Iron:
(mg)
30 mg
Liver,
meats,
whole
Maternal hemoglobin formation,
fetal liver iron storage
grains,
deep green
vegetables,
legumes,
dried fruit
4. Why is an adequate supply of iron such a big deal? (p362)
 Required for expansion of maternal RBC mass & transfer of adequate iron to
fetus
 10% of nonpregnant women are iron deficient. Women w/ iron deficiency are
unable to handle hemorrhage at time of birth & are at risk of preterm birth &
LBW (most common problem in teenagers, black moms, & lower socioeconomic
status)
 Overdoing iron: puts women at risk of gest DM
 Recommend 30 mg of iron after week 12 [most women have too much n/v in 1st
tri] and plenty from food.
Which vitamins and mineral require the greatest increase in pregnancy? Any change in
requirements on p. 356-357 that surprise you?
 Iron, Zinc, folate, iodine, vit C, B6 . Surprise was incr. in iodine otherwise not
really surprising at all.
Fluid intake
 8-10 glasses/ day
 keeps away constipation, helps exchange of wastes/nutrients
Water,
Expands blood volume; Facilitates
beverages,
8-10
exchange of nutrients & wastes;
frozen
glasses/ 3L
Milk secretion; Regular bowel
Fluids:
desserts,
total; 2.3
function; Substance of cells blood,
(L)
fruit, fresh
in
lymph, amniotic fluid; Maintains
vegetables
beverages
body temperature. Prevents
(especially
cramping, ctx, and preterm labor
lettuce)
weight gain and calorie intake in pregnancy
2. What is an adequate weight gain? What influences "adequate?"
 It’s not known precisely. Adequate weight gain is 11-14kg (25-35lbs); Adequate
nutrients & calories to avoid (SGA) & maternal/ fetal risks in pregnancy
 better mom be nutritionally sound & neither over or underweight before
becoming pregnant. Bad things happen if you gain too much or too little weight
during pregnancy.
o Normal weight and skinny moms: risk for IUGR, SGA
o Overweight moms: risk for big kid and instrumental birth, PPH, gest DM,
preeclampsia.
2) The need for calories: Increases to an extra 340- 462 per day
a) How many calories does a pregnant woman need a day: At least 2,500 kcal.
b) A pregnant woman should never eat less than _1,800_ calories a day.
c) What is the current recommended weight gain during pregnancy?
For singleton pregnancies in normal mommy:
 25lbs (11.3kg)- 35lbs (15.9kg) overall.
 1st trimester, up to 4lb (1.8kg),
 2nd & 3rd trimesters 1lb (0.5kg) per week
For singleton pregnancies in underweight mommy:
 12.5-18 kg (28-40 lbs)
For singleton pregnancies in fat mommy:
 7-11.5 kg (15-26 lbs)
For singleton pregnancies in adolescent mommy:
 Gain close to 18 kg (40lbs) b/c teen’s growing body and growing baby
compete for food.
Protein intake
 It is the nutritional element basic to growth of fetus, uterus, placenta, boobies, blood,
etc. Find it in animal products, legumes, grains, nuts. Most Americans overeat
protein and no increase is usually needed. Teens, underweight women, impoverished
women, and vegetarian/vegan/macrobiotic people need good education and resources.
Meats,
Amino acids are the building
eggs
46 g
blocks; synthesis of products of
cheese,
↑+25g
conception, growth of maternal
Protein:
yogurt,
(during
tissue & expansion of blood
legumes,
pregnancy)
volume, secretions of milk protein
nuts &
during lactation
grains
Pica
5. What is pica?
 Cravings for non nutritional food substances or excessive amounts of crap.
7. What are some indications we get that women are not eating an adequate diet during
pregnancy (this is a summary question... reflecting on what you gleaned from this
chapter!)?
 Optimal maternal nutrition = optimal foundation for supporting fetal G&D
 Indicators of poor nutrition: anemia, N/V, pica, small for gestational age or
intrauterine growth restriction, preemie
Screening tests: 5 questions.
Know when to do the screening tests for NTD and Down’s,
 NTD is a: CNS anomaly d/t incomplete closure of the neural tube.
 Causes: genes, ETOH, valproate [anti convulsant], methotrexate [chemo], mom is too
hot [like febrile, hot-tub,] folic acid deficit, 30% of folic-acid resistant pregnancies.

Some can be diagnosed by US, or elevated alpha fetoproteins in amniotic fluid and
mom’s plasma.
11. What an AFP? Just know the basics! There is a longer description on page 777.
Alphafetoprotein (AFP) is made in the kid’s liver, and it shows up in the waters and in
mom’s blood. High AFP levels in maternal plasma/amniotic fluid help confirm the
diagnosis of an NTD such as spina bifida or anencephaly or an abd wall defect such as
your guts all hanging out.
 We sample mommy’s blood [MSAFP—maternal serum AFP] to measure AFP and
can find 80% of open NTDs and open abd trouble at 15-22 weeks gestation w/ good
reliability. If MSAFP is high (meaning bad), we’ll send her to amniocentesis and
US for confirmation.
Down Syndrome
Triple Marker test: Test it at 16—18 weeks.
Triple marker tests this stuff in mom’s blood, finds 60% of Down cases:
 MSAFP: low AFP indicates Down and other autosomal trisomies
 Unconjugated estradiol: low=Down
 hCG [human chorionic gonadotropin]: high indicates Down
If your triple marker comes back funky, you will be sent to amnio and US to confirm.
Screening tests: how accurate are they? They aren’t fool proof, and they err on the side
of false positives. It’s important to warn people about that [usually AFP or
Integrated or PAPPA (80% of people will not have a Down’s baby)] these aren’t
100%.
How and when to screen for diabetes, (3 questions)
 All moms should be screened by hx, risk factors, or by labs, but some women are so
low risk a lab test is not cost effective.
 Should be ‘screened’ at 1st prenatal visit: women w/o risk are <25 yo, normal weight,
no personal or fam hx of DM or glucose intolerance, not in racial group of high risk,
and no hx of GDM.
 Women should be re-screened at 24-28 weeks gest if the initial screen is negative.
 Glucola Screening/ oral glucose tolerance test/OGTT is: 50 g oral glucose load w/o
fasting, and 1 hr later you get a plasma determination [like a finger stick?] If <140,
you’re ok. If more than 140, move ahead to:
 A 2hr/75g or a 3hr/100g oral glucose tolerance test after an overnight fast and 3
days of non-restrictive diet and physical activity, w/o TOB or caffeine for 12hrs
before the test. The 3hr OGTT is the gold standard, and includes fasting glucose,
than you give her the 100 g, then you check glucose 1, 2 and 3 hours later. If two
or more sticks are above the following, you get gest DM:
 Fasting level= < 95
 1 hr
= <180
 2 hr
= <155
 3 hr
= <140

If mom ends up with gest DM, diet and exercise are the mainstay treatment. Women
should monitor BS daily to ensure they are ok. Fasting and post-prandial should be
taken weekly. If fasting is not <105, mom starts on insulin.
13. In a diabetic woman what two things must be carefully controlled for in labor?
 Hydration status and glucose levels.
14. What three conditions are diabetic women at increased risk for during the
postpartum period?
 Preeclampsia, eccplampsia, infection, and hemorrhage.
15. What are some potential problems for infants of diabetic mothers? This is actually a
review question!
 See above. Type 2 DM or impaired glucose tolerance and obesity in childhood or
adolescence. SAB, hydramnios, PProm, PTL,
16. Some people think of gestational diabetes mellitus (GDM) as being a self-limiting
disease. Why is that not a true statement?
 GDM is likely to recur in future pregnancies, and women with GDM are at
significant risk for developing glucose intolerance later in life.
18. What is done once a woman is diagnosed with GDM?
 Treatment begins immediately. Diet, exercise, blood glucose monitoring, insulin
therapy, fetal surveillance.
19. A pregnant woman with GDM keeps her blood sugars within the normal range with
lifestyle changes alone. Is she at increased risk for complications during her pregnancy?
 She is at low risk for fetal complications.
 Still increased risk for macrosomia and stillbirth, but less so
Insulin changes in pregnancy.
1. Review what the differences are between Type 1 and Type 2 (pregestational diabetes)
and gestational diabetes.
 Type 1: primarily caused by pancreatic islet beta cell destruction and are prone to
ketoacidosis.
 Type 2: most prevalent form includes individuals who have insulin resistance and
usually relateve rather than absolute insulin deficiency.
 GDM: any degree of glucose intolerance with the onset or first recognition
occurring during pregnancy.
19. What happens to a pregnant women’s insulin production in the first half of the
pregnancy and then in the last half?
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1st trimester: insulin will be reduced.
o Glycemic control is improved
o Insulin dosage reduced to avoid hypoglycemia
nd
2 trimester: insulin needs are increased
o Insulin dosage adjusted to avoid hyperglycemia
rd
3 trimester: insulin needs may double or quadruple
o Similar to 2sn trimester
Breastfeeding
o Lactation uses maternal glucose, therefore the breastfeeding mothers’
insulin requirements will remain low during lactation. On completion of
weaning, the mother’s prepregnancy insulin requirements are
reestablished.

Early: pancreas decreases production of insulin- because maternal insulin
doesn’t cross placenta- fetus gets glucose by depleting the mother’s stores &
decreases her ability to synthesize glucose by siphoning off her amino acids. So,
if the kid wants to steal her sugars, it needs more in the bloodstream. How do you
keep sugar in the bloodstream? Lower her insulin production like the parasite you
are! How are her blood sugars managed? By that greedy monster sucking all the
sugar out of her—who needs insulin when you’ve got a hungry fetus?
 Later: Insulin resistance; Growing placenta produces hCS, estrogen, &
progesterone. The adrenals pump out more cortisol. Those 4 hormones decrease
mother’s ability to use insulin (although cortisol makes you pump out insulin, it
makes your cells less responsive to it.) Protective mechanism for fetus to get
supply of glucose. In this case, mom has to kick up her insulin in order to
maintain. Normal beta cells of islets of Langerhans can handle this demand.
From Lecture: Insulin sensitivity or resistance. There’s resistance in the first half of
preg and then in 2nd half. In 1st half, women need less insulin usually, so if a mom is
already using insulin she’ll need to cut back to prevent hypoglycemia. 2nd half: need
more insulin, and tend towards hyperglycemia. DM mom’s at this point need to
increase their insulin, if they are saying they need less and less, then we freak out and
throw a NST on her b/c the baby is probably dying and needing less glucose.
Infection: makes DM pts hyperglycemic.
Testing fetuses: 3 questions: NSTs, amniotic fluid volume, and amniocentesis
1. We know utero-placental insufficiency shows up as late decelerations in labor. What
other serious things does it cause (check out Box 29-2 also)?
 Fetal growth restriction, Intrapartum death, intrauterine death, Intrapartum fetal
distress, and various types of neonatal morbidity.
3. In general what are ultrasounds used for (Table 29-2)?
 1st: confirm pregnancy, viability, gestational age, r/o ectopic, multiple gestations,
visualization during chorionic villus sampling, maternal abnormalities.
 2nd: confirm dates, viability, AFI, congenital anomalies, placenta placement,
visualization for amnio.
 3rd: confirm gestational age, viability, macrosomia, congenital anomalies, IUGR,
fetal position, placenta previa or abruptio placentae, visualization for amnio or
external version, BPP, AFI Doppler flow studies, placental maturity.
NSTs
14. What’s a nonstress test (NST)? What would be a good result?
ATI: Do it in tri 3, checks fetal HR r/t fetal movement—we want accels r/t movement.
We put both a tocotransducer [for ctx, in case she has them] and a FHR monitor on mom.
If she feels fetal movement, she pushes another button. The FHR is read when she feels
movement. If she has ctx, that’s ok but no necessary, if the baby is asleep you have to
wake them up, that’s why it’s better to do NST’s after mom eats: the baby is jacked up on
sugar and mom’s belly gurgling keeps them awake.
Reactive result: Is good. means FHR acceleration of 15 bpm for at least 15 sec,
and occurs 2+ times in 20 minutes. This assures that the placenta is adequately perfused
and the fetus is well-oxygenated and has an intact nervous system.
Nonreactive: is bad. FHR does no accel adequately w/ fetal movement, or there
are no fetal movements w/in 40 minutes. If test is non reactive, do a Contraction Stress
Test or biophysical profile and make sure things are ok. There are a high rate of nonreactive stress tests b/c of sleeping fetuses, fetal immaturity, TOB use, and medications,
so kids look bad when things are just fucking fine.
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Movements of baby through 20 minute
Kid is alive and neurologically intact and how much reserve the baby has (I might
say that the reserve is actually tested with a contraction stress test and not the
non-stress test—CST measures response to ctx and reserve after ctx [and late
decels=insufficient reserves)!
Reactive, equivocable, non-reactive
2+ accelerations of 15 bpm for 15 seconds in 20 min
The goal of 3rd trimester testing is to determine weather the intrauterine environment
continues to be supportive to the fetus. The testing is often used to determine the timing
of childbirth for women at risk for UPI. The basis for the NST is the principle that the
normal fetus will produce characteristic HR patterns in response to fetal movement.
15. What is vibroacoustic stimulation?  It’s a buzzer thing that makes noise, we use it to wake the kid up during NST if
they are sleeping. If we buzz them they should react to it with an acceleration.
The buzzer happens to be a larygngeal stimulator thing but it just goes buzz.
16. What’s a contraction stress test (CST)? What two methods are used? What would be a
good result?
We create ctx either w/ a little PIT or nipple stim—we measure how the kid tolerates ctx
to determine how they will tolerate the labor process. Ctx cause lack of blood flow to
fetus and we want to see normal [early decels] with ctx rather than late decels [placental
insufficiency]. We want 3 ctx w/in 10 mins with a duration of 40-60 seconds. There’s
lots of crap to know about how much playing with the nipples you do and that PIT can
lead to preterm labor.
Negative test is GOOD: baby survived ctx with no late decels
Positive test is BAD: means ‘positive for late decels, or variable decels’, or
persistent and consistent late decels on more than ½ of the ctx in the test. Late suggests
uteroplacental insufficiency, variable decels means cord compression (think VEAL
CHOP).
The risk: uterine hyperstim and preterm labor.
 stimulate baby, don’t want late decels.
 Pitocin or nipple stimulation
 Negative is good. No late decels, with minimum of 3 uterine ctx lasting 40-60 sec
within 10 minute period.
Purpose is to identify the jeopardized fetus that was stable at rest but showed evidence of
compromise after stress. Uterine contractions decrease uterine blood flow and placental
perfusion. If this decrease is sufficient to produce hypoxia in the fetus, a decel in FHR
will result, beginning at the peak of the contraction and persisting after its conclusion
(late decel). The CST provides an earlier warning of fetal compromise than NST with
fewer false positive results.
Amniotic fluid volume
8.What’s an AFI and what is normal?  Amniotic fluid index based on pockets. Abnormalities usually associated with
fetal disorders.
 This is in a pocket, not the whole BOW: <5mL means not enough (oligo), 5-19
normal, >19 too much (hydram).
 Placenta ages and decreases nutrients and decreases fluid.
11. What are oligohydramnios and hydramnios?
 oligo: <300ml, associated with fetal renal abnormalities.
 oligo early: baby renal problems
 oligo late:
 hyda: >2 L, associated with GI and other malformations.
12. What is the purpose of Wharton’s Jelly in the umbilical cord?
 Prevents compression of the blood vessels and ensures continued nourishment of
the embryo/fetus.
9. Review biophysical profiles. Pg 772 What is it used for?
 8-10 normal score
 5 things: US, breathing, gross movement, tone, AFI, then FHR and NST.
 Physical exam of the fetus including VS.
Amniocentesis
10. What are some complications of having an amniocentesis?
 Maternal: PROM, PTL, hemorrhage, infection, amniotic fluid embolism, abruptio
placentae, Rh isoimmunization and coinciding hemorrhage.
 Fetal: death, hemorrhage, infection, direct injury, miscarriage, preterm labor,
leakage of amniotic fluid.
 Assess for 1 hour after, tell them about what to look for, Rh type for Rhogam
needs,
High Risk antepartum: 12 questions.
Know about hyperemesis gravidarum,
Hyperemesis gravidarum: barfin so much you lose at least 5% of weight, electrolyte
imbalance. Diff btwn normal n/v and hyperemesis: screwy electrolytes, dehyration.
20. How is hyperemesis gravidarum different than nausea and vomiting in pregnancy?
 Excessive, peaking around 8-12 weeks gestation.
 Loss of 5% weight, and accompanied by electrolyte imbalance, ketosis, and
acitonuria.
 Difference is sign of dehydration.
21. What are some of the suspected etiologies?
 Nulliparous, increased body weight, hx of migraines, pg with twins or
hydatidiform mole.
22. In general what are the goals of treatment for hyperemesis gravidarum?
 Correction of fluid and electrolyte imbalances, NPO until hydration and no emesis
for 48 hours.
 Bland foods, vitamin B6, phenergan, unisom.
Risk factors for PTL
 PTL is preterm labor, meaning labor starts btwn 20 and 37 weeks! I guess before 20
weeks that’s a miscarriage/abortion.
 Risk Factors [ati]
 Infection of vag, UTI, chorioamnionitis.
 Previous PTL
 Multiple fetuses
 Poly-Hydramnios
 Mom younger than 17 or older than 35
 Low SES
 TOB, drugs
 DV
 Hx of many miscariges of abortions
 DM or HTN
 No prenatal care
 Incompetant cervix
 Placenta previa, abruption
 PPROM
 Short interval btwn pregnancies
 Uterine abnormalities [like barb’s NICU kid: mom had heart shaped uterus that
the placenta didn’t stick to very well]
 DES exposed mom’s [like barb again]—agent used from 1950 to 71 to prevent
miscarriage, daughters of these women exposed in utero have problems w/
reproduction. I think we use it as chemo now—actually, that’s probably
thalidomide I’m thinking of.
2. What is the technical difference between miscarriage, fetal death, stillbirth, and
newborn death?
 A baby younger than 20 weeks is considered a product of conception, whereas
embryos, uterine tubes removed with an ectopic pregnancy, and tissue from a
pregnancy obtained during a dilation and curettage are all considered tissue.
 Miscarriage: spontaneous abortion, referring to the loss of the fetus before 20
weeks.
 Fetal death: death of a fetus after 20 weeks of gestation and before birth, with
absence of any signs of life after birth.
 Stillbirth: birth of a baby after 20 weeks and 1 day of gestation or weighing 350

gms that does not show any signs of life.
Newborn death: neonatal death: death of a newborn within the first 28 days after
birth.
1. What are the definitions of preterm labor and preterm birth?
 PTL: cervical changes (effacement of 80% or cervical dilation of 2 cm or greater)
and uterine ctx occurring between 20-36/37 weeks.
 PTB: occurs before the completion of 37 weeks.
2. Why isn’t a neonate’s birth weight a good indication of his/her gestational age?
 LBW babies can be, but are not necessarily, PT, LBW can be caused by
conditions other that PTB such as IUGR. Various pg complications that interfere
with uteroplacental perfusion such as gestational HTN or poor nutrition, may give
birth to a baby at term who is LBW due to IUGR.
4. What are some signs (including. biochemical markers) and symptoms (box 36-3) of
preterm labor?
 Uterine ctx every 10 min or more frequently and persisting for 1 hr. or more
(painful or not).
 Lower abd cramping similar to gas pains, may be accompanied by diarrhea.
 Dull, intermittent low back pain.
 Painful menstrual like cramps.
 Suprapubic pain or pressure
 Pelvic pressure or heaviness
 Urinary frequency
 Change in character or amount of vaginal discharge
 ROM
 Fetal fibronectin presence in cervix between 24-34 weeks.
 Salivary estriol increasing.
5. What is antenatal glucocorticoid (Betamethasone) used for?
 Given to accelerate fetal lung maturity.
 #1 risk for babies RDS. Surfactant, Lecithin/Sphinglemeylin ratio lung maturity,
if greater than 2:1 amnio then lungs are mature.
6. If a woman calls with symptoms of preterm labor, what would you want to ask her?
 Gestation, uterine ctx, cervical changes?
 How long been feeling like this, balling up in lower abdomen
 Diarrhea or other flu like symptoms
 Not normal discomforts of pg, if they don’t go away-Come in!
 Stability of social and child support
 Financial status, insurance
 Assistance at home with children and household tasks
7. What are the plusses to bedrest and HUAM in preterm labor? (Trick question!)
 No evidence to support.
 Use and effectiveness controversial.
9. What’s the major complication that can occur with PPROM?
 Infection, chorioamnionitis-pneumonia, sepsis, meningitis, sepsis, cord prolapse,
oligohydramnios-cord compression, endometritis.
What tocolytics are used and how
8. What are tocolytic agents? What are some of the classifications of drugs that are used?
Check out the medication guide starting on page 933. There’s our old buddy MgSO4!
Medications that suppress uterine activity.
 Magnesium Sulfate: MOST COMMONLY USED b/c of less side effects.
Relaxes smooth muscle including uterus.
 Beta-Adrenergic Agonists (Ritodrine/Yutopar, Terbutaline/Brethine): relaxes
smooth muscle, inhibits uterine activity, causes bronchodilation. We use
Ritodrine first.
 Which is not off label??? Ritodrine/Yutopar (don’t use though)
 Terbutaline side effects: tachy, hypo, SOB, tremor, check VS, warn her, listen to
lungs
 Mag preeclampsia, same dose piggyback
Ca channel blockers, Procardia or prostaglandin inhibitor: Indocin, both pose the risk of
ductus closing when you still need it open!!
 Ca Channel Blockers (Nifedipine/Procardia): relaxes smooth muscle including
uterus by blocking entry of calcium.
 Prostaglandin Synthetase Inhibitors (NSAIDS) (Indomethacin/Indocin): relaxes
uterine smooth muscle by inhibiting prostaglandins.
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When we use them:
 to delay PTL only before 34 weeks [risk/benefit issue]. PTL cant be stopped
indefinitely. We think the best reason for it is to buy time to administer
betamethasone for lung devel of the kid and to get mom to a hospital with a
NICU.
 to mellow out the effects of overboard PIT.
How we administer Terbutaline/Ritidine: they are not fun, so warn her what you’re
giving her and that it will make her feel crappy. Get VS of mom/baby ahead of time,
listen to her lungs first b/c risk of pulm edema. Also restrict fluids to 15002500mL/day b/c ritidine, terbutaline, and mag sulf cause retention that gets in
the lungs—listen for crackles, monitor orthopnea. Pit will do the same thing but I
guess not so badly.
Ritidine and terb make you tachy and nervous and palpitation-y, so not for moms w/
preeclampsia, PIH, HTN, heart problems, hyperthyroid, uncontrolled DM etc. Stop
infusion if too low BP, too much tach, or pulm edema. Have betablocker
[propanolol] on hand as antidote.
Also make sure she’s really in PTL [before 34 weeks] before you give it.
Conditions in which immediate delivery is indicated [chorioamnionitis, cord prolapse,
etc] means you should not extend labor.
Major risk factor for a preterm infant: pg 1053
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organs underdeveloped, no reserves of nutrients.
Mostly a pulmonary thing to start with, in the form of apnea and resp distress, bc: less
alveoli functioning, low surfactant, smaller lumen of bronchioles, their ribs are
collapsible, they are made of cartilage still, friable capillaries in lungs, the alveoli are
too far away from the capillary bed that gets the O2 into circulation.
Can’t maintain body temp
Can’t eat and don’t absorb food from the gut well—many need TPN/IV food.
Patent ductus: leads to crackles, cyanosis, murmur, tach, hepatomegaly
NEC: all the common problems of NICU kids, plus infection, and early enteral
feedings, seem to lead to NEC
BP changes in pregnancy.
Oh fuck I have 3 different answers. I will email Ms Koshar.
Normal changes in pregnancy:
ATI: Inc blood volume and increased CO in the form of higher heart rate (15 bpm higher after 20 weeks).
 BP @ pre-preg level tri1
 BP is lower (5-10 less both syst and diast) tri 2
 BP is back to pre-preg level after 20 weeks
 Don’t take her BP while lying on her back—lay her on left side and take it, or stitting,
etc
12. What does the blood pressure typically do during pregnancy?
Juliana, the bottom line is that due to the physiologic anemia and the hormonal
effects of relaxing blood vessels the blood pressure is not higher than pre-pregnancy
levels. An elevation above pre-pregnancy levels bears watching. Hope that helps,
Jeanette Koshar

Pg 341 Text: Systolic remains the same but may also decrease slightly as
pregnancy advances. Diastolic begins to decrease 1st tri & continues to drop til
24-32 wks then gradually increasing to pre-pregnancy state by term
The left lateral recumbent position is the best indicator of accurate BP b/c the uterus likes
to hang out on the R side of the body.
BP changes influenced [both up and down] by the following:
inc blood volume, vaso dilation, less vascular resistance, lower BP and MAP, inc cardiac output and HR d/t
high blood vol, inc O2 needs. High clotting factors [predisposes to DIC], low albumin causes low colloid
osmolarity, causing edema. High renal plasma flow and GFR. High estrogen causes higher RAA activity,
high progesterone blocks aldosterone effects [the salt saver], inc vasodilator prostaglandins cause resistance
to Angiotensin II [lower BP]
Why HTN in pregnancy is bad [what happens if]:
Can cause; placental abruption [placenta falls off too soon], preterm birth, renal and liver failure, mom or
baby death
Bad stuff that happens earlier in the pregnancy: 6 questions.
Know about hydatiform moles,

Hydatiform moles can cause hyperemesis grav! Amazing! Also causes funny HcG
levels.
7. What is the major physical risk with a hydatidiform mole?
We already discussed
previas and abruptions. Just remember to be aware these can occur anytime, but are most
likely to occur in the third trimester
 Really rare. Rates seem to vary a lot by ethnicity.
 Major risk factor is choriocarcinoma (complete moles especially). Only 2-6% of
molar pregnancies have ‘complete’ moles.
 Complete and partial. Complete when sperm and empty ovum, no placental tissue,
embryonic tissue. Partial is normal ovum but 2 sperm.
What do you do: we d/c, and check to see if it’s cancerous and may need to treat them
immediately. Need to test them of HcG for at least a year b/c the mole can metastizise to
the lungs, and don’t want them pregnant during that time so that their HcG is a clear test
for wandering moles.
 Serial HcG levels, postpone pg for at least 1 year.
 Uterus is really larger than expected at duration of pregnancy, moles can grow very
fast, mom can present with HTN and dark bleeding. Any symptoms of gestational
HTN before 24 weeks may suggest hydatidiform mole.
 Maternal blood has no placenta to receive it, therefore hemorrhage into the uterine
cavity and vagina occurs (anemia, N/V, cramping, distention, preeclampsia).
The LMP question: I’m not sure what this is about.
1. How long are women pregnant for (and you wonder why patients get confused)?
 9 months (10 lunar months of 28 days)= 40 wks, 280 days
2. When are the weeks for the 1st, 2nd and 3rd trimesters?
 1st = weeks 1-13
 2nd= weeks 14-26
 3rd= weeks 27-40
 Term = 38-40 weeks
3.Describe Nagel’s Rule. If a woman’s LMP was 10/23/07 what is her EDC, EDB or
EDD?
 Nagele’s rule- from the 1st day of LMP subtract 3 calendar months, add 7 days
and 1 year OR add 7 days to LMP & count forward 9 months (assuming that she
has 28 day cycle)
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LMP (last menstrual period) :
EDC (estimated date of conception)
EDB (estimated date of birth)
EDD (estimated date of delivery)
10/23/07 (-3+7+01)
07/30/08
Ectopic pregnancy
6. What are the signs of an ectopic pregnancy? What are the major risks? What other
conditions can this life threatening pregnancy look like?
Pg 812
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
Look at our case study #3.
Signs: missed period, adnexal fullness, tenderness to pain, N/V, temperature,
dark red or brown bleeding,--50-80% of women have this, referred shoulder pain,
cullen’s sign (ecchymotic blueness around the umbilicus).
 Pain, can look like appendicitis, GI problems, UTI, salpingitis, tortion of the
ovaries, molar preg.
 Risks are not mutually exclusive, they can have different things at the same time.
 10% maternal mortality r/t hemorrhage.
 Talk about getting them to a provider asap, don’t be alone.
Ruptured ectopic=emergency situation, needs surg, laparotomy to repair tissue damage
and hemorrhage.
Ectopic preg are leading cause of tri1 maternal morb& mortality, may cause more
miscarriages or infertility. Needs help coping with the loss. Needs advice about having
kids in the future or not.
95% of ectopics are implanted in the fallopian tube, but can also be in the cervix, or
abdomen, etc.
Treatment options for ectopic
 Removal by salpingostomy: A salpingostomy is a surgical incision into a
fallopian tube. This procedure may be done to repair a damaged tube or to
remove an ectopic pregnancy (one that occurs outside of the uterus).
 Methotrexate post op: dissolves remaining tissue post op in unruptured cases.
 If the pregnancy is abdominal and requires delivery by laparotomy. The
placenta is usually sucking off the liver or other vital organ, and is left in place
to be dissolved with methotrexate. Sometimes these babies survive, but they
are 40% likely to have deformities. So weird.
kinds of miscarriages
Chapter 31 pp. 804-815
1. What are some causes of spontaneous abortions (SAB)?  The kid is not right—most are early, and half of miscarriages are due to the kid’s
chromosomal abnormalities. Other things: endocrine imbalance, immunologic
factors, infections, systemic disorders, genetic factors, advanced maternal age or
parity, premature dilation of the cervix, inadequate nutrition, drug use, and
trauma.
2. Look at table 31-1 p. 807. What are the differences among threatened, inevitable and
incomplete, complete, missed and septic SABs?
 Threatened: slight spotting, mild cramping, no tissue or dilation, hasn’t happened
yet.
o We do: bed rest, sedation, avoid stress and sex/orgasm, treat pain w/
Tylenol.
 Inevitable: moderate bleeding, mild to severe cramping, no tissue, there is
cervical dilation, sometimes with ROM, miscarriage will occur.
o We do: bed rest if no pain, fever or bleeding. If she’s in pain, has signs of
infection, PROM, bleeding, then we do a d&c promptly.
 Incomplete: heavy bleeding, severe cramping, passage of tissue with dilation,
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expulsion of fetus with retention of the placenta.
o We do: suction or d&c, or maybe just c if she’s dilated.
Complete: slight bleeding, mild cramping, passage of tissue with no dilation, all
fetal tissue is passed.
o Probably don’t need to do much unless hemorrhage or infection; may
suction or curettage if suspect tissue remaining.
Missed: No blood or maybe spotting, no cramping, tissue, or dilation, the fetus is
dead but the products of conception remain in utero for several weeks.
o If the baby isn’t ‘born’ in 1 month, then a therapeutic abortion of some
variety. Risk for DIC increases w/ deaths after 12 weeks and retention of
fetus for 5+ weeks. Get them out of there seems like the best action.
Septic: bleeding varies and is usually malodorous, cramping and tissue passage
also vary, there is usually dilation, severe abdominal tenderness are indicators and
surgical evacuation is required.
o Terminate immediately w/ an appropriate method. Culture of the bug,
broad-spectrum antibiotics and management of septic shock prn! Yuck!
Recurrent: Habitual, 3+ in a row.
3. How are the symptoms different among threatened, inevitable and incomplete SABs?
 They all include bleeding and pain with threatened being least, inevitable being
moderate and incomplete being the most [kinda like Goldilocks and the 3 Bears?
Saying inappropriate things make me happy when I’m this tired]
 Only incomplete has passage of tissue
 Only threatened is without cervical dilation.
Why would it be important that we accurately gather information from the patient about
her symptoms?
 Risk factors such as hemorrhage and infection.
 Stop if threatened: rest, medication, folic acid.
 Binge drinkers greater risk!
 Treatment may differ depending on the type of miscarriage.
Domestic violence: 4 questions: the effects abuse can have on a pregnancy,
 Mom gets killed. Might start DV at pregnancy, also 3x more likely to be murdered
during pregnancy then non-pregnant DV women
 Incr risk of miscarriage, preterm labor, abruption, stillbirth, LBW (might be r/t drugs,
tob, etoh to cope). Usually it’s the baby that dies.
 Mom less able to bond, likely to abuse child whether or not she stays with her
attacker.
 Risk for STI, bleeding, UTI, genital trauma.
 Risk for Substance abuse, depression, PTSD
There is a relationship btwn preterm labor and DV. Kicks to abd are more common DV
injuries when a woman is pregnant. 4-30% of preg women are beaten according to the
book, and 8% of pregnancies are complicated by DV—BUT JK thinks that’s much
higher. Most women who are killed have seen a health care provider in the last 6 months.
Asking a question that facilitates disclosure of DV,
 Ask: “people have a hard time with expressing anger and dealing w/ conflict. How is
this going in your household?” Also ask directly: does your partner threaten/hurt you,
has anyone slapped, kicked, etc you in the last year or during pregnancy, has anyone
forced you to have sexual contact that didn’t feel right?
our role in documenting. (I know we haven’t covered this yet, but the questions are
basic)
Mandated reporting: we have to report what? If you read the law it’s really fuzzy on
reporting if she admitted to it. You have to report rape, you have to report if you treated
her for an injury, but she didn’t have an injury, and so we don’t really have to report it.
Reporting is to the police w/in 24 hours.
Yes, there is a connection btwn substance abuse and DV, but its like a chicken and egg
issue.
Some PCP’s won’t report b/c they have to be called to testify, they lose money, it’s
stressful, etc.
Contraception: 6 questions.
What to do if a woman misses 3 birth control pills,
 If she is a Sunday starter, have her take 1 pill daily until Sunday and then start a new
pack. If she had unprotected sex, she should call MD, otherwise use backup methods.
 If she is a day 1 starter, throw away the rest of the pack and start a new pack. If she
had unprotected sex, she should call MD, otherwise use backup methods.
Emergency contraception timing,
17. How soon after unprotected intercourse should emergency contraception be
prescribed?
 ASAP, but with 120 hours.
 Mom will need antiemetic, evalute her for pregnancy if no menses for 21 days.
Don’t use if bleeding or if she’s pregnant.
 Or you can insert a copper IUD w/in 8 days of unprotected sex.
IUD risks,
 Risk of PID, uterine performation, ectopic.
 Pt reports: change in string length, bleeding, fever/chills, foul discharge.
IUDs for monogamous relationships, had baby before, no PID within 5 years, don’t want
baby soon
18. How does the copper IUD work and how does the progesterone IUD work?
Copper serves as a spermicide and inflames the endometrium, preventing fertilization.
Progesterone IUD releases levonorgesterel from its reservoir, which impairs sperm
motility, irritates the lining of the uterus, and has some anovulatory effects.
Basal body temperature method,
3. What is involved in using natural family planning?
 Abstinence, or Avoidance of intercourse during fertile periods: 4 days before and
3-4 days after ovulation.
4. What is the physiology behind using the BBT method?
 Basal body temperature is the lowest temp of a healthy person, taken immediately
after waking and before getting out of bed. The fertile period is defined as the
day of first temp drop of about 0.5C, or 1 F, which some women may not have.
This is followed by elevation of about 0.5C or 1 F through 3 consecutive days of
elevated temp. her temp remains higher until menses. The decrease and
subsequent increase in temp is referred to as the thermal shift and is associated
with ovulation.
 Risks: pregnancy. However, it is inexpensive, no SE’s. Both partners need to
abstain, she needs to document well, etc
And general things you want to ask a woman when counseling her on a type of
contraceptive (only 1 question).
 JK makes them repeat back what they know about how to use it, it’s advantages,
risks, what it does or doesn’t protect them from, etc.
1. What is our responsibility for informed consent for women choosing a form of
contraception?
 BRAIDED: benefits, risks, alternatives, inquiries, decisions, explanations,
documentation.
 Preferences of birth control, expected outcomes, when they do want to have
babies,
 Before oral contraceptives are prescribed and periodically throughout treatment,
women should be alerted to the S&S to report to their health care provider.
 Abdominal pain, Chest pain, Headaches, Eye problems, Severe leg pain.
STIs: 6 questions. Risk factors for STIs,
 Sluttiness, risky protection methods, at risk partners, risky drug use, working in a bar
or brothel [just kidding.] Who is most at risk? A woman who engages in oral, anal,
and vaginal sex with more than 1 partner without protection, uses unclean needles,
and also has a junkie boyfriend and 1 bisexual boyfriend and sleeps with African
monkeys. I don’t know. Sounds pretty good, right?
Complications of GC in pregnancy,
I think GC means Gonorrhea. Pg 198: intraamniotic infection, PTL, PPROM, postpartum
endometritis, SAB. Fetus; sepsis, PTL, conjunctivitis—most common cause of blindness.
8. What are the symptoms of gonorrhea in women?
Often asymptomatic. There may be purulent endocervical discharge or not.
Menstrual irregularities may be presenting symptom. C/CO of chronic or acute
pain in pelvis or lower abdominal area that increases during menses, dysuria or
low back pain may occur. Itching, fullness, pressure, signs of infection may
occur.
Most common bacterial and viral STIs,
3. What is the most common STD?
 Chlamydia, viral is HPV
6. What kinds of symptoms do women have when they have chlamydia? (This is a sneaky
question!)
 If they are present, because it is often asymptomatic, they are nonspecific. Some
women experience spotting or postcoital bleeding, mucoid or purulent cervical
discharge, or dysuria.
 Men get drip and pain on urination.
10. Which organisms are most commonly the causes of PID?
 Chlaymidia now, used to be gonorrhea, also anaerobes.
 Can look like ectopic, appendicitis, miscarriage.
Not good for women with PID to choose IUD.
Most common STI in women in US: Chlamydia. JK is big on Chlam. Sometimes the
scarring from chlam in the pelvis is incredible, you can have infertility, chronic pelvic
pain, pain w/ intercourse. Most women and men are asymptomatic in chlam. That’s why
we screen women.
the STI health care providers are most at risk for getting (NOT a personal
question!!),
 I’m sticking with Hep B.
Treatment for PID in pregnancy.
We hospitalize her. If a mom is preggers w/ PID its much worse. Likely to go septic,
recommended to go into hosp on IV antibiotics.
We treat pregnancy PID with iv: Doxycycline, and Rochephin (aka Cefotetan or
Ceftoxin/ Ceftriaxone) (pg 185)
Lecture: Treat with rocephin and other abx. Pg makes PID more serious, we will
hospitalize and put on IV abx. If severe symptoms. Semi-fowlers to decrease
ascending bacteria.
Most common viral STI in women in US: HPV
Don’t do lots of pelvic exams.
Immunizations: preggers not allowed to get an MMR vaccine, no chicken pox, no
rubella, basically no live vaccines.