14: 35yo missed period
signs of pregnancy
chadwick's sign - blue coloration of cervix from venous congestion 8-10wks of gestation
gravid uterus 10-12wks
testing - blood hCG levels double every 2.2 days and then every 3.5 days by 9 weeks. peak at 10-12 wks, decline until 22wks and rise until delivery
transvaginal U/S 4-5 weeks can see gestational sac, fetal pole at 5-6 weeks
due date - 40 wks after beginning of last period +- 2wks
gestational age - date of LMP
u/s before 20 weeks for dating for discrepancies
third trimester - fundal height. 20wks at belly button, 1cm for every week after
prenatal hx
medical, obstetric, genetic risk factors, social
screening
blood type/Rh status
chlam urine or swab
HIV
urinalysis
Hep B surface antigen to provide treatment and routine screening
hemoglobin/hct
sexually active 24 and younger or older increased risk for infection
every prenatal visit , for proteinuria, glycosuria,
pap smear and asx bacteriuria at 12-16wks
only if risk factors
hep c
varicella if no vaccine or hx
herpes - if active, need antiviral
BV
TORCH not recommended
exercise - 30min most days of wk
avoid hot tubs and saunas for 1st trimester - neural tube defects and miscarriage
avoid raw eggs, unpasteurized milk, soft cheese unwashed fruits/veg [mercury, toxoplasmosis and listeriosis, salmonella
take prenatal vitamin daily - folic acid! iron!
Prenatal f/u
10 weeks
wt gain 25-25lbs if normal and less of obese
fetal heart doppler at 10-12 wks
influenza vaccine, Rhogam at 28wks and within 72hrs after delivery. no live vaccines!
18-20weeks
u/s for anomalies
AFP, hug, unconjugated estriol, dimeric inhibitn A = neural tube defects/trisomy 21/18 done at 15-21weeks 80% sensitivity for down syndrome
fetus is moving
can see sex, hair, fingerprints
23 weeks
amniocentesis: risk of spontaneous abortion 1/300 to 1/500
complications
placenta previa
0.5% of patients, more common in older, smoking, women with multiple pregnancy or uterine surgery
later detected the higher chance it persists
marginal or incomplete previas more likely to resolve
if placenta attaches low in uterus, cover os, bleeding later in pregnancy
requires further u/s for progression/resolution
usually requires c-section
talk - breastfeeding, car seat, contraception
27 weeks
BP - chronic HTN, gestational [no proteinuria], preeclampsia [proteinuria >0.3g/24hrs], eclampsia [convulsions]
severe preeclampsia - visual disturbance, HA, RUQ pain, N/V, decreased UOP
gestational diabetes screen - >=2 of four glucose measurements over cutoffs [1hr >180; 2hrs >155; 3hr >140]
risks: preeclampsia, fetal macrosomia, birth trauma, c-secton need, neonatal mortality, newborn complications
36 weeks
testing
Group B strep. give intrapartum antimicrobial prophylaxis for prior hx. treat with penicillin or ampicillin
pregnant rashes
pruritic urticarial papules and plaques - papulovesicular on trunk and extremities
prurigo - excoriated on trunk/limbs
pruritic follifulitis - pustular appearance
treat: topical steroids, antihistamines
third trimester vaginal d/c
placenta previa
placental abruption - bleed, contractions, urgent care!
BV
candida
UTI
cervical trauma during sex
other - premature rupture of membranes, preterm labor, uterine rupture
post-partum
down syndrome
Transverse palmar (Simian) crease
Dysplasia of midphalanx of fifth finger
Anomalous ears
Dysplasia of pelvis
Hyperflexibility of joints
Hypotonia
Slanted palpebral fissures
Excessive skin at nape of the neck
Poor Moro reflex
Flat facial profile
contraception
progestin only, deposed, implanon but may affect milk so wait 6 weeks
copper IUD
no combined oral contraceptives due to milk and infant growth
depression - 15% within first 4 weeks