1
Q
gravida
A
of pregnancies
2
Q
multigravida
A
woman who has had previous pregnancy
3
Q
para
A
live births
4
Q
primipara
A
woman having her 1st birth
5
Q
multipara
A
woman who has had previous birth
6
Q
what does G4P2 mean?
A
4 pregnancies in total, 2 live births
7
Q
who are primary care providers for pregnant women?
A
midwives
GPs
obstetricians
NOT NDs
8
Q
why are NDs not primary care providers for pregnant women?
A
don’t have access to order ultrasound & other imaging
9
Q
where can midwives attend births?
A
hospital, home, birthing centres (Ontario)
10
Q
FHx questions?
A
- down syndrome
- NTDs
- hemophilia
- hemoglobinopathies & other birth defects
- mental retardation
- diabetes
- HTN
- TB
- seizures
- multiple pregnancies
- mental illness
11
Q
Personal MHx questions
A
esp:
- CV
- renal
- metabolic
- infectious
- abdominal/pelvic trauma or operations
- recent blood transfusions
- hx current/past trauma/stressors
- STIs
12
Q
Menstrual hx
A
- determine if woman is actually ovulating
- determine if fertile mucus present (when you should be having intercourse)
13
Q
obstetric hx
A
- prev. neonatal death, stillbirth, pre-term birth
- if has been trying to conceive for some time, what procedures has she already been through? (diagnostics, labs, fertility treatments, etc)
14
Q
hx methods of contraception
A
family planning & birth spacing
15
Q
other hx questions
A
medications & supplements
occupation
diet & lifestyle
alcohol, smoking, illicit drugs
16
Q
What are characteristics of a higher risk pregnancy?
A
- extremes of age (teens & women >35yo)
- genetic risk when father >55yo
- African, Asian, Mediterranean descent - screen for heritable hemoglobinopathies (sickle cell ds & thalassemias)
- Jewish/French Canadian heritage (Tay-Sachs ds, Canavan’s ds, CF)
- lower socioeconomic status
- drug & alcohol abuse
- tobacco & caffeine use
- experience of mental, emotional or physical abuse
- occupational hazards (exposure to reproductive toxins, heavy physical exercise or stress)
17
Q
Health promotion topics?
A
- smoking, alcohol & drug cessation
- avoidance of teratogenic meds & supplements (risks vs benefits; e.g. anti epileptics @ high doses = teratogens but seizures can also cause problems)
- avoidance of environmental toxins
- avoidance of occupational hazards (legal rights of pregnant workers; childcare options)
- safe sexual practices & STD prevention
- family planning & pregnancy prevention (contraception & birth spacing)
- optimal management of medical problems
- stress reduction & social support
18
Q
Female P/E
A
- height, weight
- BP - every visit w/pregnant women!
- blood type & Rh & other antibodies
- CBC, ferritin (no gold standard for anemia), B12, Vit D (bacterial vaginosis)
- thyroid panel 1.5-2.5 for pregnant women
- fasting blood glucose - HbA1C in high risk groups
- rubella immunity; parvo-virus B19 (Fifth’s ds)
- VDRL (syphilis - veneral ds research lab), HIV, Hep B
- genetic screen for Tay-Sachs, Canavan’s ds, CF as applicable to certain populations
- TB in areas of prevalence
- FSH day 3 & progesterone day 21 for >35 or who’ve been trying to conceive >1yr
- urinalysis - protein, glucose, leukocytes, blood
- cervical (pap) smear, vaginal swab, cultures for gonorrhea & chlamydia
19
Q
Male P/E
A
- semen analysis
20
Q
Pre-conception physical exam
A
- full screening physical
- BP & cardiac
- height & weight
- breast exam
- pelvic exam - estimate uterine size & palpate cervix for abnormalities; pap smear; culture for gonorrhoea & chlamydia; swab for bacterial vaginosis
21
Q
DDx vaginal discharge
A
- leukorrhea (normal) = whitish d/c of mucus & exfoliated vaginal epithelial cells - will increased w/pregnancy; odour can change too
- bacterial vaginosis - predom. Gardnerella vaginalis. pH elevated (>4.5; fishy odour)
- candida - thick white, curd-like d/c; causes pruritis & excoriation. Sour odour, esp. w/hormone increase in pregnancy
- trichomonas vaginalis - thrives in alkaline environment; profuse & grey-green; frothy malodorous d/c
22
Q
women of colour are how many times more likely to have BV than white women?
A
3x
23
Q
Why are women of colour more likely to have BV than white women?
A
darker skin pigmentation prevents adequate cutaneous synthesis of cholecalciferol from casual sunlight exposure
24
Q
vitamin D dosing during pregnancy?
A
1000-4000 IU
25
BV is associated with negative pregnancy outcomes, especially?
preterm birth
26
body temperature peaks at which point during a woman's cycle?
ovulation
27
How do you know when day 1 of your cycle is?
- not quite spotting, not quite bleeding
| - very light spotting is not day 1
28
What are the phases (as correlated to day) of the cycle?
menstrual 1-7
follicular 4-14
ovulation 14-ish
luteal 14-28
29
acupuncture principles for menstrual phase?
move Blood & Qi
smooth LV
remove obstruction/stagnation
stop pain
30
acupuncture principles for follicular phase?
build Yin & Blood
tonify SP & KD
regulate water passages/resolve damp
31
acupuncture principles for ovulation
promote smooth movement of Qi
32
acupuncture principles for luteal phase
```
Move Qi & Blood
tonify Yang
tonify SP
Smooth LV Qi
regulate water passages/resolve damp
```
33
foods that decrease blood stagnation?
```
eggplant
turmeric
chives
leeks & scallions
garlic & ginger
basil
rosemary
nutmeg
spearmint
chesnut
```
avoid spicy, pungent, greasy foods to limit mucus burden prior to conception
34
symptoms of too much estrogen?
```
blood clots
impaired blood sugar
water retention
depression
anxiety
headaches
breast tenderness
```
35
conditions seen with too much estrogen?
```
early puberty
uterine fibroids
uterine cancer
ovarian cysts
ovarian cancer
breast cysts
breast fibroadenoma
breast cancer
PMS
endometriosis
hypothyroidism
autoimmune diseases
increased risk of gallbladder disease
```
36
where is estrogen metabolized?
liver - phase I & II
37
what does B-glucoronidase do?
Cleaves glucoronic acid molecules attached to estrogen in the stool, allowing intestinal oestrogen to be re-absorbed into bloodstream
38
what is B-glucoronidase produced by?
pathogenic gut bacteria
39
why take probiotics for estrogen modulation?
probiotics will compete with b-glucoronidase and therefore LOWER circulating oestrogens
40
what herb can increase progesterone?
vitex
41
nutritional/supplemental interventions for hormonal regulation, day 1-14
2 tbsp ground flax & 2 tbsp pumpkin seeds/day
| 2 x 1000mg sutra-sea 3:1 fish oil capsule BID [EPA for phase 1 detox]
42
nutritional/supplemental interventions for hormonal regulation, days 15-28
2 tbsp. sesame & 2 tbsp sunflower seeds/day
| 2 x 500mg Genestra evening primrose oil BID
43
why take a multi B 1qd ?
- help elim intermediary liver metabolites
- replace depletion caused by OCP
- increase energy
- aid stress reduction
44
what foods help eliminate excess estrogen?
cruciferous veggies (cauliflower, brussels sprouts, broccoli)
seaweeds - nori, wakame, kelp
fibre (whole grains, veg, brown rice, legumes, flax)
lean protein - tofu, beans, lentils, salm, turkey, chicken
filtered water/herbal tea 2L/day
45
what foods to decrease/eliminate to eliminate excess estrogen?
```
all animal products
sugar, caffeine, alcohol, chocolate
pesticides
additives
*avoid over-consumption of cold/raw foods esp in winter
```
46
what medical conditions can have adverse effect on pregnancy outcomes & that have evidence that effect can be impacted by preconception care?
```
HTN
diabetes
SLE
epilepsy
anemia
thyroid disease
```
47
what is the m/c pre-existing medical condition in pregnancy? Why is it important to control this?
diabetes
| glycemic control should be achieved b/c teratogenic effects of hyperglycaemia occur during organogenesis (1st trimester)
48
what is macrosomia?
birth weight >8 lbs, 13oz (4000 gm) regardless of gestational age (~9% babies born worldwide)
risks increase greatly when birth weight is >9 lbs, 15 oz (4500 gm)
associated fetal complications:
- abnormalities of spine & skeleton
- CV system (4X greater)
- renal system
49
folic acid supplementation reduces the risk of?
```
heart defects
urinary tract abnormalities
oral facial clefts
pyloric stenosis
limb defects
```
50
what minerals are altered with OCP use?
copper levels raised
| zinc levels reduced
51
what vitamin levels are altered with OCP use?
```
def:
folate (B9)
B complex
vitamin c
increase: vitamin A
```
52
Dose of folic acid for a woman at low risk of having a baby with NTD w/healthy diet incl. leafy greens & whole grains
0.4mg (400 mcg) - 1mg / day
should be taken after several months preconception, until about 4-6 weeks after breastfeeding stops
53
dose of folic acid for a woman w/poor supplementation, poor dietary habits, &/or previous child w/NTD
5mg/day
54
risk factors for bearing children with NTDs? = need for 5mg/d
```
insulin dependent diabetes
epilepsy
obesity
prev child born w/NTD
fam hx of NTD
sikh or celtic ethnicity
born in northern china
```
55
when & for how long should a woman supplement with folic acid?
at least 3 months pre-conception & continue until 12 weeks post-conception
after that, regular recommended dosage can be continued
56
preconception supplements?
- prenatal vitamin w/low or no iron
- vit D 1000-4000IU/d; depending on serum status & risk factors
- folic acid, 1-5mg/d depending on risk factors
- CoQ10, 200-600mg/day (women at risk of HTN & infertility)
- fish oil 1-3gm/day
- cortisol regulation
57
which vitamin to AVOID?
high dose vit A: retinol form
| as low as 3000IU/d has been shown to be teratogenic
58
why should you not consume caffeine when pregnant?
- caffeine metabolism slows during 2 + 3 trimesters
- immature liver systems = half life of 80-100 hours
- heavy intake of caffeine >400mg assoc. w increase SIDS & increased risk of spontaneous abortion
- ACOG (American Congress of Obstetricians and Gynecologists) concludes moderate caffeine consumption (<200 mg/d) does not appear to be a major contributing factor is miscarriage or preterm birth
59
what is the mechanism of action of FAS?
unknown
60
how much is risk of still birth in pregnant women increased with alcohol consumption 5 drinks/wk from <1 drink/wk?
1 drink = 1.37/1000
| 5 drinks = 8.83/1000
61
what is the harm of cannabis during pregnancy?
- no evidence of increased risk premature birth,miscarriage, major physical abnormalities
- prenatal exposure has subtle adverse effects beginning at approx 3 yo on cognitive function, behaviour, mental health & subsequent substance use in offspring
62
risks of cocaine use during pregnancy?
- increased risk placental abruption
- decreased birth weight, length & head circumference
- in newborn: jittery tremor, high pitched cry, hyper-alert state, irritability & excessive sucking reflex
63
what is Canavan disease?
- affects myelin
64
what is Tay Sachs disease?
- affects neuron
65
what is a "low risk pregnancy"?
none of the social or demographic risks exist
66
which labs would you do for a woman w 3rd pregnancy, feeling exhausted?
Went vegetarian between 2nd & 3rd pregnancy.
Ferritin (CBC)
b12
vit D
67
what is the best TCM action for luteal phase?
tonify yang
