Term
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Definition
usually occurs in the fallopian tube
sperm attaches to the receptor on the outer layer of the egg (zona pellucid) and makes the egg nonresponsive to other sperm
the sperm releases enzymes that allow the sperm to penetrate and reach the egg's cell membrane
sperm and egg cell membranes merge to create a single cell "zygote"
zygote travels for 2 days will cell division occurring
by day 3 it reaches the uterus and continues cell division for another 2-3 days before implanting
approximately 6 days after fertilization, the mass is called "blastocyst" and hCG starts being produced
from fertilization to implantation takes ~10 days |
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Term
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Definition
when the blastocyst sheds the zona pellucid initiating growth into the endometrial wall
by 10 days post fertilization, the blastocyst is implanted under the endometrial surface and receives nutrition from maternal blood - now called an "embryo"
approximately 50% of embryos survive with process
most losses occur in the first 2 weeks (many before they realize they are pregnant)
of the survivors, 15% spontaneous loss still occurs |
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Term
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Definition
| age of the embryo or fetus beginning with the FIRST DAY OF LAST MENSTRUAL PERIOD (2 weeks prior to fertilization) |
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Term
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Definition
the ability to produce congenital abnormalities
major: incompatible with life or may require corrective surgery
minor: ear tags, extra digits, etc.
other complications: premature or delayed labor, abortion, altered fetal growth, functional deficit, carcinogenesis |
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Term
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Definition
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Term
| interpret gravidity and parity and provide appropriate documentation |
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Definition
gravidity is the number of times a women has been pregnant
parity is the number of pregnancies exceeding 20 weeks gestation:
number of term deliveries
number of premature deliveries
number of aborted and/or ectopic pregnancies
number of living children
EXAMPLE:
pregnant 4 times, 2 term deliveries, 1 premature delivery, 1 ectopic, 3 living children = G4P2113 |
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Term
| discuss the role of hCG in relation to pregnancy monitoring |
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Definition
the primary role of hCG is to keep the corpus luteum functioning so that the corpus luteum continues to produce estrogen and progesterone
pregnancy test:
quantitative (blood) = hCG levels
qualitative = yes or no
first response can detect urine hCG levels as low as 6.5 mlU/ml (6 days prior to missed period) while others are >/= 30 mlU/ml
hCG levels double every 48-72 hours ***the rise is more important than the number***
around 5-6 weeks gestation age a gestational sac and yolk can be seen on ultrasound
levels peak and start declining at 8-12 weeks |
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Term
| common pregnancy signs and symptoms |
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Definition
1st Trimester:
frequent urination
fatigue
morning sickness
food cravings
breast swelling/tenderness
weight loss/gain
presence of hCG
cessation of menses
changes in cervical mucus
bluish discoloration of vaginal mucosa
anatomic breast changes
2nd Trimester:
edema
varicose veins
stretch marks
acne
breast swelling
nasal congestion/rhinitis
leg cramps
bladder infections
3rd Trimester:
backaches
Braxton Hicks contractions
SOB
weight gain
swelling |
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Term
| maternal pharmacokinetic changes in regards to ADME |
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Definition
pharmacokinetic changes begin in the 1st trimester and peak in the 2nd trimester
INCREASED:
plasma volume
cardiac output
glomerular filtration (30-50% or higher, potentially lowering concentration of renally cleared drugs)
body fat - volume of distribution of fat soluble drugs may increase
gastric pH - affect absorption of weak acids and bases
estrogen and progesterone levels may alter liver enzyme activity and increase elimination of some drugs and accumulation of others.
DECREASED:
plasma albumin - increases volume of distribution of highly protein bound drugs; offset by more rapid clearance of unbound drugs
vomiting/delayed gastric emptying may alter absorption |
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Term
| requirements of prenatal vitamins |
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Definition
FOLIC ACID:
prevents neural tube defects which usually develop the first 28 days of pregnancy
Spina bifida - spinal cord is exposed
anecephaly - severe underdevelopment of the brain
DOSE - 400 mcg-600 mcg daily starting at least 1 month prior to pregnancy
DHA:
may have better mental, visual, social, and motor development
DOSE - at least 200 mg daily
avoid fish high in mercury (shark, swordfish, king mackerel, tilefish)
IRON:
demands increase with increased blood volume and anticipated blood loss of delivery
DOSE - 30 mg daily unless deficient
CALCIUM:
body will steal mothers calcium to give to baby, presenting complications later in life for mom
DOSE - require 1000 mg daily from diet and/or supplement |
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Term
| requirements of prenatal vitamin D |
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Definition
2011 Clinical Practice Guidelines: pregnancy leads to high risk of vitamin D deficiency = increased risk of preeclampsia and C-sections
prenatal vitamin of 400 IU + additional supplement of 1000 IU daily |
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Term
| demonstrate understanding of Rh- mother |
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Definition
if mom is Rh- and dad is Rh+ the baby could be +/-
if + mom's body will produce antibodies: hemolytic disease of the newborn
usually resulting in death of infant
usually not during first Rh+ pregnancy but the second one due to increased antibodies
Rh immune globin IM at 28 weeks of pregnancy and following delivery if baby is Rh+ (RhoGAM, Rhophylac, MICRhoGam, etc.) |
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Term
| factors that increase likelihood of placenta transfer |
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Definition
most drugs move from maternal ciculation to fetal circulation by diffusion
lipid solubility - lipophilic cross easier than water soluble
electrical charge - fetal pH is more acidic allowing weak bases to easily cross the placenta, becomes ionized and less likely to cross back
molecular weight - 1000 do not cross in significant amounts
degree of protein binding - maternal albumin decrease while fetus increase = higher concentration of protein bound drugs in fetus |
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Term
define the current FDA pregnancy risk categories
HAVE TO KNOW THESE!! |
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Definition
A
adequate and well controlled studies in pregnant women have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of a risk in later trimesters)
B
animal reproduction studies have failed to demonstrate a risk to the fetus and there are no studies in humans
AND
the benefits from the use of the drug in pregnant women may be acceptable despite its potential risks
OR
animal studies have not been conducted and there are no studies in humans
C
animal reproduction studies have shown an adverse effect on the fetus, there are no studies in humans
AND
the benefits from the use of the drug in pregnant women may be acceptable despite its potential risks
OR
animal studies have not been conducted and there are no studies in humans
D
there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans
BUT
the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risk (for example, if the drug is needed in a life-threatening situation or serious disease for which safer drugs cannot be used or are ineffective)
X
studies in animals or humans have demonstrated fetal abnormalities
OR
there is positive evidence of fetal risk based on adverse reaction reports from investigational or marketing experience, or both
AND
the risk of the use of the drug in a pregnant women clearly outweighs any possible benefit (for example, safer drugs or other forms of therapy are available) |
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Term
| references for pregnancy and lactation |
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Definition
www.motherrisk.org
LactMed: www.toxnet.nlm.nih.gov
Drugs in Pregnancy and Lactation (Briggs)
primary literature searches
Medications in Mother's Milk (Bood)
Reprotext, reprotox, Shepard's and Teris through Micromedex |
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Term
| identify methods of minimizing risk of teratogenicity |
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Definition
PRECONCEPTION PLANNING:
folic acid 400 mcg/day or up to 4 mg if high risk
elimination of alcohol or drugs
smoking = preterm labor, low birth weight
nicotine replacement controversial (theoretically less risk); intermittent delivery system
vaccines - rubella and hepatitis B preconception
reviewing potential risk of current chronic medications
SAFE MEDICATION USE:
identifying best medications for condition during pregnancy (risk vs. benefit)
eliminating nonessential drugs
discourage self-medication
minimize exposure of harmful agents
adjust doses accordingly (lowest dose possible for the shortest amount of time) |
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Term
| therapy for constipation during pregnancy |
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Definition
light exercise, increased fluids and fiber
1st line: supplemental fiber and/or stool softener
osmotic laxative (POLYETHYLENE GLYCOL, lactulose, sorbitol, and magnesium and sodium salts) for occasional use only
AVOID castor oil and mineral oil |
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Term
| therapy for GERD during pregnancy |
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Definition
small frequent meals, trigger avoidance, elevation of bed etc.
1st line: antacids (aluminum, calcium, or magnesium preparations) or sucralfate
ranitidine > cimetidine
metoclopramide if unresponsive to H2 blockers
PPIs reserved for complicated or intractable
avoid sodium bicarb and magnesium trisilcate |
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Term
| therapy for hemorrhoids during pregnancy |
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Definition
dietary fiber, increased fluids, sitz baths
topical anesthetics, skin protectants, and astringents can be used
last line: rubber band ligation, sclerotherapy, and surgery |
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Term
| therapy for N/V during pregnancy |
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Definition
small frequent bland meals, avoid fatty foods, acupressure of wrist
1st line: MVI, B6, doxylamine
phenothiazine and metoclopramide generally safe
ginger
hyperemesis gravidarum: unrelenting vomiting causing weight loss of more than 5% prepregnancy weight and ketnuria
treated with ondansetronn with other treatments fail
corticosteroids effective but small increase risk of oral clefts during 1st trimester |
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Term
| therapy for gestational diabetes |
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Definition
1st line: daily SMBG, dietary modifications, and exercise
indications for therapy: FBG > 99, 1-h post prandial > 140, or 2-h post prandial > 127
pharmacotherapy:
human insulin (NPH and regular) > Lispro and Aspart
glyburide has supported evidence with minimal placenta transfer
metformin less studied and does cross the placenta |
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Term
| therapy for HTN during pregnancy |
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Definition
CALCIUM 1G/DAY FOR ALL PREGNANT PATIENTS reduces RR of HTN and preeclampsia
activity restriction, psychosocial therapy, biofeedback: no evidence
drug therapy indicated if BP >/= 160/110 - therapy before this has not shown conclusive benefits
commonly used drugs: METHYLDOPA > labetalol and CCB
avoid ACE-I/ARBs
preeclampsia: only cure is delivery
magnesium sulfate can prevent eclampsia and treat eclamptic seizures
eclampsia = preeclampsia + seizures
magnesium sulfate
avoid diazepam and phenytoin |
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Term
| therapy for VTE during pregnancy |
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Definition
heparin or LMWH throughout and 6 weeks post delivery
recommended drug monitoring however not clinically seen
avoid warfarin |
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Term
| therapy for UTI during pregnancy |
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Definition
most common pregnancy infection
cephalexin
nitrofurantoin until weak 37
avoid fluoroquinolones and tetracyclines
3-14 days
treat asymptomatic
if asymptomatic: repeat culture monthly |
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Term
| therapy for headaches during pregnancy |
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Definition
relaxation, stress management, and biofeedback
1st line: tylenol
codeine or other narcotic analgesics if not responding
limited caffeine may help
avoid ASA or NSAIDs during 1st or 3rd trimesters
avoid triptans, ergotamine, and dihydroergotamine
chronic prevention reserved for 3-4 severe episodes per month and non-responsive
risk vs. benefit: propranolol, CCB, antidepressants |
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Term
| therapy for the common cold during pregnancy |
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Definition
fluids, saline, steam, etc. if possible
tylenol, dextromethorphan, diphenhydramine, and guaifenesin can be used if necessary
avoid pseudoephedrine in 1st trimester |
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Term
| treatment of asthma during pregnancy |
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Definition
trigger avoidance
step therapy is needed for pharmacotherapy
1. short acting B2 agonist for everyone
2. inhaled corticosteroids - budesonide preferred but may continue previous meds
3. long acting B2 agonists considered safe
4. not preferred: cromolyn, leukotriene receptor antagonists, and theophylline
5. systemic corticosteroids for the most severe |
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Term
| treatment of allergic rhinitis in pregnancy |
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Definition
1ST LINE: INTRANASAL CORTICOSTEROIDS (beclomethasone and budesonide)
alternate: 1st generation antihistamines (chlorpheniramine or hydroxyzine) |
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Term
| treatment of epilepsy during pregnancy |
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Definition
avoid valproic acid (major malformations)
monotherapy with other agents: major malformations
SAFEST: CARBAMAZEPINE AND LAMOTRIGINE
lamotrigine, phenytoin, and carbamazepine may cause cleft palate
phenobarbital: cardiac malformations
best to optimize therapy prior to pregnancy - medication changes during pregnancy to minimize teratogenicity is not recommended
minimize risk: lowest dose possible, blood levels if possible, monotherapy; highest risk during 1st trimester
if attempt withdrawal, do so at least 6 months prior to pregnancy
FOLIC ACID 4-5 MG DAILY BEFORE PREGNANCY UNTIL AT LEAST THE END OF THE 1ST TRIMESTER!!! |
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Term
| treatment of dermatologic conditions during pregnancy |
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Definition
if treatment can't be delayed, topical agents such as bacitracin, benzoyl peroxide, clindamycins, and erythromycin can be used
avoid: isotretinoin, acitretin, and fluorouracil |
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Term
| treatment of mental health issues during pregnancy |
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Definition
monotherapy if possible
depending on psychiatric illness:
1st line SSRIs (2 in 2,000 births affected with major malformation)
avoid paroxetine
ECT considered safe and effective for major depression, bipolar, and schizophrenia
depending on illness: evaluate drug choices as they all have fetal concerns |
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Term
| 4 categories of HTN in pregnancy |
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Definition
1. chronic or pre-existing
2. gestational (without proteinuria)
3. preeclampsia (with proteinuria)
4. preeclampsia on chronic HTN |
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Term
| use of antenatal corticosteroids |
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Definition
for fetal lung maturation supported by Cochrane review
pregnant women 26-34 weeks gestation at risk for preterm delivery within 7 days: betamethasone 12 mg IM every 24 hours for 2 doses or dexamethasone 6 mg IM every 12 hours for 4 doases
benefits begin within 24 hours |
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Term
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Definition
postpone delivery long enough to maximum effect of antenatal steroids
allow transportation to equipped facility
prolong pregnancy when there are underlying conditions not likely to cause recurrent preterm labor
does NOT reduce the number of premature deliveries
CONTRAINDICATED: fetal demise, fetal anomaly, intrauterine infection, fetal distress, severe preeclampsia, vaginal bleeding, or maternal instability
4 classes with similar effectiveness in prolonging from from 48 hours to 1 week:
BETA AGONISTS:
terbutaline 250-500 mcg SQ every 3-4 hours
high incidence of maternal SE: hyperkalemia, arrhythmias, hyperglycemia, hypotension, and pulmonary edema
IV MAGNESIUM SULFATE:
controversial with Cochrane review not supporting effectiveness
CCB:
nifedipine has fewer SE (hypotension)
5-10 mg SL every 15-20 minutes for 3 doses: if no evidence of dilation, 10-20 mg orally every 4-6 hours
NSAIDS:
indeomethacin oral or rectal dose of 50-100 mg followed by oral 25-50 mg every 6 hours
premature constriction of ductus arteriosus |
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Term
| define importance of Group B Strep |
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Definition
10-20% of women are colonized
associated with invasive disease in newborn: bacteremia, pneumonia, meningitis, and fatality
increased risk of pregnancy loss, premature delivery, and transmission to infant |
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Term
| medications and screening conducted in newborns |
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Definition
VITAMIN K SHOT:
"hemorrhagic disease of the newborn" or "vitamin K deficient bleeding"
vitamin K is necessary for synthesis of factors II (prothrombin), VII, IX, and X
undetectable in cord blood
lactobacillus (primary gut flora in breastfed babies) does not synthesize vitamin K
breast milk contains only small amounts of vitamin K (formula has more)
ERYTHROMYCIN:
erythromycin ophthalmic ointment is the only product available in the US that is recommended for prophylaxis against ophthalmia neonatorum, Chlamydia trachomatis, or neonatal conjuctivitis
HEPATITIS VACCINE
APGAR:
quick assessment of overall newborn well being
used immediately following the delivery of the baby
scores recorded at one minute and five minutes of life
evaluating color, heart rate, reflex, muscle tone, and respiratory effect
HEARING:
all infants should be screened prior to discharge
otoacoustic emission (OAEs) or auditory brainstem response (ABR)
OAE: small probe placed in ear canal; soft tones or clicks; if cochlea is functioning normally, otoacoustic emission (or echo) is measured by the probe and analyzed by a computer
ABR: probe or couple releases click sound; sound reaches 8th nerve in brain; electrical response from that nerve is picked up by electrodes placed on head |
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Term
| benefits of breastfeeding |
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Definition
baby: growth, immunity, and development; decreased incidence and severity of diarrhea, respiratory infections, and ear infections
mom: reduction in postpartum bleeding, earlier to return to prepregnancy weight, reduced risk of premenopausal breast cancer, and reduced risk of osteoporosis |
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Term
| ways to minimize risk during lactation |
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Definition
general considerations:
avoid drugs if possible
topical therapy if possible
typically safe for breastfeeding if safe for pediatrics
not always safe if pregnancy and breastfeeding
pump and dump
medication selection:
shortest half-life and highest protein binding
well studied in infants
poorest oral absorption
lowest lipid solubility
medication dosing:
administer single daily dose just before the longest sleep interval for infant usually after bedtime feeding
breast feed immediately before medication dose when multiple daily doses needed. |
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Term
| medications to increase milk supply |
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Definition
galactagogues to increase milk supply:
doperidome
metoclopramide
fenugreek |
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Term
| Mom presents to the OB clinic for her 28 week follow-up. Chart review indicates mom blood type A- and dad is unknown. what is the correct plan? |
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Definition
administer RhoGam IM
should not risk a miscarriage
since the mom is Rh-, the mom should get a shot just in case. |
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Term
| Mom presents to the OB clinic for routine follow-up. Patient has new onset mild constipation, GERD, and hemorrhoids. Which of the following is the most appropriate to initiate at this time? |
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Definition
TUMS prn (1st line for heartburn
not miralax (short term, not daily); not rubber band ligation (last line) |
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Term
Mom presents at 26 weeks gestation in preterm labor. Vitals: BP 90/68, HR 62 - Labs: K 5.0 which of the following is the best choice?
terbutaline
nifedipine
magnesium sulfate
indomethacin |
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Definition
indomethacin
avoid terbutaline b/c of increasing K and hypotension
avoid nifedipine b/c of hypotension
magnesium is not supported in the data
given the mother's vitals/labs indomethacin is the best option |
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