CNM Random 2013 Flashcards
term
37 0/7 - 41 6/7 (or 42 0/7 ?) weeks
preterm
32 0/7 - 36 6/7 wks
very preterm
28 0/7 - 31 6/7 wks
extremely preterm
23 0/7 - 27 6/7 wks
Dx of preterm labor
regular uterine contractions
cervical change
cervix 2cm or greater and/or 80% or greater effaced by U/S
Etiology of PTL: pregnancy factors
infection (ex: pyelonephritis) uterine bleeding (ex: abruption) multiple pregnancy & hydramnios uterine abnormalities (Asherman's syndrome) incompetent cervix
Etiology of PTL: epidemiologic factors
race (AA) maternal age (younger) socio-economic status (unmarried, low SES) working smoking psychological factors (stress, anxiety) previous OB hx nutritional status ???unknown causes
regarding PTL: an “injury” or inflammation (ischemic, infectious, traumatic, ?allergic) do what?
increase cytokine production that elicit production of prostaglandins
regarding PTL: prostaglandins do what?
stimulate myometrial contractions and may initiate release of protease that can injure the membranes and decidua
interactive risk factors
intensity and duration of insult, gestational age, nutritional status, immune function may affect risk of PTB
s/s of PTL
change in Braxton Hicks abdominal cramping menstrual-like cramps low back pain intermittent pelvic pressure change in character or amount of vaginal discharge \+ffn short cervical length
fFN
glycoprotein normally found in fetal membranes and decidua.
found in cervicovaginal fluid BEFORE 16-18 wks.
NOT USUALLY PRESENT 22-37 weeks!!!
negative fFN in a woman with preterm contractions
99% accurate for predicting no PTB in next 7 days
transvaginal sonographic cervical length
effective marker for predicting PTB, particularly in women symptomatic of preterm labor or at a higher risk of spontaneous PTB.
The greater the degree of funnelling measured, the more accurate sonography was in predicting PTB
guidelines for dx of PTL
s/s of PTL
Monitoring for fetal well-being and uterine activity
Transabdominal U/S for placental location, amniotic fluid volume, fetal presentation, EFW
Sterile spec
digital exam
sterile speculum exam in r/o PTL
fibronectin swab, GC/CT, fern, pooled fluid, cultured for GBS
Dx of BV
presence of clue cells
vaginal pH >4.5
profuse white discharge
fishy odor when d/c exposed to potassium hydroxide
sequelae of BV
1..5-3 fold increase in PTB (unsure why)
Black women have BV 3x more than white women
Tx of PTL: criteria for use of tocolytics
20-34 wks
contractions have effects on cervix
regular contractions
tocolytic choices in PTL
beta agonists magnesium sulfate anti-prostaglandins Ca channel agonists oxytocin antagonists progesterone
beta-adrenergic agonists in PTL
B1 receptors: heart, intestines
B2 receptors: myometrium, blood vessels, bronchioles
Terbutaline (sq, may be given IV)
S/E: maternal tachycardia, N/V, HA, dyspnea, nervousness, anxiety, fetal tachycardia, neo hypotension, hyperglycemia with consequent hypOglycemia, may increase incidence of intraventricular hemorrhage
Magnesium sulfate in PTL
Diminishes excitability of muscle fibers and relaxes uterus, alters myometrial contractility
S/E: maternal sweating, drowsiness, depressed reflexes, hypotension, respiratory arrest, depressed cardiac function, neonatal hypotonia, lethargy, weakness, low APGAR score
Prostaglandin synthase inhibitors in PTL
Block action of prostaglandin which are involved in myometrial contractility: Indomethacin (PO, PR)
-compared with beta-agonists, is more effective in delaying delivery by 48 hours and has fewer side effects
S/E: maternal N/V, heartburn, rare GI bleed, thrombocytopenia, increase BP in hypertensive women
-cannot be used for long-term management because it may produce closure of ductus arteriosus, necrotizing enterocolitis, intracranial hemorrhage
Ca channel blockers in PTL
Reduces Ca++ [ ] and inhibits contraction
Nifedipine
S/E: maybe maternal hypotension and decreased uteroplacental perfusion, HA, flushing
Progesterone in preventing PTL
17 alpha-hydroxyprogesterone acetate
Promising new tool to prevent PTB, for now restricted its use to previous unexplained spontaneous preterm birth
Reduction in the risk for PTB (<34 wks)
Reduction in LBW
Glucocorticoid rx in PTL
to accelerate lung maturation in fetus (<34 wks)
Effective in preventing RDS and neonatal mortality
A SINGLE course of steroids:
Betamethasone 12 mg IM, 2 doses q 24 hours -OR-
Dexamethasone 6 mg IM , 4 doses q 12 hours
Not sufficient evidence for repeated doses
Hydration in PTL
insufficient data to support hydration as a specific tx
Two studies did not show any advantage, even in the initial period after admission
Women with evidence of dehydration may benefit from this intervention
Psychologic factors with PTL/PTB
Stress (anxiety, perceived stress, psychological distress) assoc with increased risk of PTL/PTB
Stress stimulates HPA axis and increases production of cortisol and cytokines which have been correlated with PTL/PTB
Stress mgmt
PROM
after 37 weeks ROM at least 1 hr before onset of labor 8% of pregnancies 50% deliver within 5 hours 95% deliver within 28 hours If not in labor, proceed with induction
PPROM
BEFORE 37 weeks 3% of pregnancies Responsible for 1/3 of PTB 50-60% deliver w/i 1 wk 13-60% of intraamniotic infxn 2-13% postpartum infection 4-12% abruption placentae
Possible mechanisms of PPROM
choriodecidual infection collagen degradation decreased membrane collagen content localized membrane defects membrane stretch (uterine overdistention) programmed amniotic cell death
Risk factors for PPROM
amniocentesis cervical cerclage cervical insufficiency chronic abruption cigarette smoking LEEP prior PTB prior PTL prior PPROM low SES working in pregnancy
perinatal morbidities r/t PPROM
chorioamnionitis
umbilical cord compression d/t oligohydramnios
abruption
preterm birth (50-70% deliver w/i 1 week)
morbidities r/t PTB
RDS necrotizing enterocolitis intraventricular hemorrhage sepsis antepartum fetal death
dx for PROM
clinical presentation free flow pooling nitrazine paper testing ferning test U/S indigo carmine (1ml in 9ml NS)
Amnionitis
maternal or fetal tachycardia maternal fever leukocytosis uterine tenderness regular contractions decreased glucose level positive Gram stain by amniocentesis
antibiotics to prolong pregnancy in PPROM
= reduction in chorioamnionitis, postpartum endometritis, neonatal infection and sepsis, infants requiring O2 and surfactant Initial parenteral followed by PO therapy: Ampicillin 2gm IV q 6 hr x 48 hours THEN Amoxicillin 250 mg PO q 8 hr x 5 days AND Erythromycin 250 mg IV q 6 hr x 48 hr THEN Erythromycin 333 mg PO q 8 hr x 5 days
abdominal pain labs
For acute pain: CBC with differential electrolytes serum chemistries: bicarb, BUN, creatinine, serum glucose, amylase, lipase liver function tests: AST, ALT, alkaline phosphatase, bilirubin U/A coag labs Pregnancy test
pyelonephritis
E. coli often the cause
back/flank pain
fever/chills
malaise
N/V
U/A: hematuria, cloudy/foul-smelling/WBC/bacteria
dysuria/incr frequency/urgency
RX: abx x 7 days, at first in hospital, then PO at home
Nonpreg: cephalosporins (Rocephin), quinolones (Cipro), trimethoprim/sulfa (Bactrim)
PREGNANT: ampicillin plus gentamycin, cefazonlin (Ancef) and ceftriaxone (Rocephin)
infant with palpable liver and spleen
very common in infancy
small red papules on trunk of menopausal woman
cherry angiomas?
Campbell de Morgan spots
anemia
occurs when you have less than the normal number of red blood cells in your blood or when the red blood cells don’t have enough hemoglobin(protein that carries O2 from lungs to all parts of body).
Turner syndrome
Most girls are born with 2 X chromosomes, but girls with Turner are born with only 1 x or are missing part of 1 x chromosome. Affects 1 in every 2500 girls. Short stature(average 4’ 7’), ovaries don’t develop properly, nearly all will be infertile. Other physical features include:
•a “webbed” neck (extra folds of skin extending from the tops of the shoulders to the sides of the neck)
•a low hairline at the back of the neck
•drooping of the eyelids
•differently shaped ears that are set lower on the sides of the head than usual
•abnormal bone development (especially the bones of the hands and elbows)
•a larger than usual number of moles on the skin
•edema or extra fluid in the hands and feet
threshold for HTN and what to do about it
Blood Pressure Category Systolic (mm Hg) Diastolic (mm Hg)
Normal less than 120 and less than 80
Prehypertension 120-139 or 80-89
Hypertension. Stage 1 140-159 or 90-99
Hypertension. Stage 2 160 or higher or 100 or higher
High blood pressure usually has no symptoms. That’s why it’s called the “silent killer.”
Diet, weight reduction, physical activity, salt reduction, medication.
Graves
immune disorder that results in overproduction of thyroid hormones. Most common among women and before age 40.
Hep B
virus that causes liver disease, spread through blood and other bodily fluids.
degenerative discs
normal changes in spinal discs as you age. Most often occurs in lumbar and cervical region.
postpartum bleed but firm - now what?
a
RPR + then tx, still +
unchanged or rising results can mean a persisting infection. Longer tx with penicillin
know where all hormones come from
a
thyroid
a
basal body temp
a
luteal phase
After you ovulate, you begin the second half of your fertility cycle known as your luteal phase.
produces progesterone. Progesterone helps to thicken the lining of the uterus for your egg to implant. The corpus luteum only lasts for about 12-14 days
gall bladder
if elevated direct bilirubin, suspect liver is conjugating it normally, but there is an obstruction, ie gallstones.. Increased alkaline phosphatase = same.
mastitis
inflammation of tissue in one or both mammary glands inside the breast.
•An area of the breast becomes red.
•The affected area of the breast hurts when touched.
•The affected area feels hot when touched.
•A burning sensation in the breast which may be there all the time, or only when breastfeeding
which muscle affected in 2nd degree laceration
bublocavernosus, transverse perineal
Magnesium Sulfate
for prevention of eclamptic seizures.
Magnesium sulfate is sometimes used as a tocolytic medicine to slow uterine contractions during preterm labor. But studies show it does not stop preterm labor and it may cause complications for both mother and baby.
how do you know if med can get into breastmilk
The amount of drug excreted into milk depends on a number of kinetic factors:
1) the lipid solubility of the drug,
2) the molecular size of the drug,
3) the blood level attained in the maternal circulation,
4) protein binding in the maternal circulation,
5) oral bioavailability in the infant, and the mother, and
6) the half-life in the maternal and infant’s plasma compartments.
- See more at: http://www.infantrisk.com/content/drug-entry-human-milk#sthash.9JMrBP10.dpuf
breathing problems in the neonate
a
indication/MoA of oxytocin
To assist in labor, elective labor induction, uterine contraction induction
Oxytocin promotes contractions by increasing the intracellular Ca2+, which in turn activates myosins light chain kinase.. Oxytocin has specific receptors in the muscle llining of the uterus and the receptor concentration increases greatly during pregnancy, reaching a maximum in early labor at term.
Binds the oxytocin receptor which leads to an increase in intracellular calcium levels. The oxytocin-oxytocin receptor system plays an important role as an inducer of uterine contractions during parturition and of milk ejection.
GBS
a
retained placenta in a birth center
Can try nipple stim, empty bladder, noncoital lovemaking, intraumbilical oxytocin (10 IU of Pit diluted with 20 cc saline in umbilical vein.) If these do not work, TRANSFER for manual removal to a HOSPITAL.
deep transverse arrest
a
cephalhematoma
Usually last about 8 wks.
Soem occur with linear skull fractures, most of which heal well. clear sign if fx is depressed area of fetal skull, particularly over parietal bones. Midwifery care = careful positiononing of newborn on side opposite affected area and consultation with pediatric team.
A usually benign swelling formed from a hemorrhage beneath the periosteum of the skull and occurring especially over one or both of the parietal bones in newborn infants as a result of trauma sustained during delivery
Does NOT cross suture lines.
why epi in local
For the local anesthetic, 1% lidocaine often is used with 1:200,000 or 1:100,000 EPI. The latter prolongs the anesthetic effect of lidocaine as a result of its vasoconstrictive properties.
fentanyl
narcotic (opioid)
grapefruit juice may interact with fentanyl
Ritgin maneuver
a way to control the birth of the head
pH of BV
> 4.5
(normal vaginal ph is 3.8-4.5)
trich also >4.5 (maybe as high as 6 or 7)
molar pregnancy
genetic error during the fertilization process that leads to growth of abnormal tissue within the uterus. It has the appearance of a large and random collection of grape-like cell clusters.
HIV
a
meds contraindicated in pregnancy/lactation
Category x ACE inhibitors anticoags heparin, warfarin estrogen, androgens thyroid: methimazole, carbimazole, radioactive iodine Anticonvulsants: carbamazepine, phenytoin, phenobaritone, trimethadione, sodium valproate, Antidepressants : lithium NSAIDS aspirins and other salicylates Ciprofloxacin ... Sulfonamides methotrexate ... http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2810038/
PIH vs HELLP
PIH: >140/90 after 20 wks, wnl by 6 wk pp
Pre-E: PIH with proteinuria (300/+ mg/24 hr)
Severe Pre-E: HELLP
HELLP:160/110, proteinuria >5gm/24 hr, oliguria <500ml/24 hr,
Microangiopathic hemolysis
Thrombocytopenia
End organ systems: CNS, visual, hepatic
lactose intolerance - what should midwife encourage?
a
BMI
Body Mass Index [weight(kg) / (height(m) x height(m))]
IUDs
a
fundal heights at various stages, esp s/p delivery continuing for weeks out
a
protein threshold in urine
a
Rh negative stuff
a
anti-Kell, etc
a
when to send for colpo
\+HPV >30 yr ASCUS, +HPV LSIL ASC-H HSIL AGC, -AEC ...
latest for Rhogam
a
asherman’s syndrome
a
Piskacek’s sign
uterine asymmetry with a soft prominence on the implantation side; may also be associated with uterine tumors.
direct Coombs test
used on newborn’s blood sample, usually in the setting of newborn jaundice.
Looks for foreign antibodies already adhered to infant’s RBCs, a potential cause of hemolysis. Two most commonly recognized: Rh or ABO incompatibility.
indirect Coombs test
done on mother’s blood prenatally.
AKA antibody screen.
Identifies long list of minor antigens that either cause problems in newborn or mother if transfusion is necessary. Should id which antibodies are present.
Kleinhauer-Betke
measures amount of fetal hemoglobin transferred from fetus to mother’s bloodstream, usually for purpose of determining amt of Rhogam to give.
Normal range:
Newborn fullterm: Hg F >90%
Adult: Hg F <0.01%
pyuria
pus in the urine
cholestasis
bile cannot flow from liver to duodenum
Obstructive: mechanical blockage in duct system, as with gallstone
Pregnancy: preg hormones affect gallbladder fxn, resulting in slowing or stopping of flow of bile; gallbladder holds bile that is prdx in liver, (nec for breakdown of fats in digestion). Buildup in liver = spills into bloodstream
s/s: itching on hands, feet; dark urine color; light coloring of bowel movements; fatigue or exhaustion; loss of appetite, depression (less often: jaundice, URQ pain, nausea)
Tx: often induction
Dandelion Root, Milk Thistle support liver fxn
cholecystitis
inflammation of gallbladder caused by blockage/back up of bile as the result of a gallstone stuck in cystic duct.
S/s: RUQ pain that may radiate to back or R shoulder blade
N/V, fever, Murphy’s sign
pain for >6 hrs, particularly after meals
Tx for acute cholecystitis: cholecystectomy
cholelithiasis
Gallstones
s/s: sudden and rapidly intensifying pain in URQ/center of abdomen/back pain between shoulder blades/right shoulder pain
Pain may last minutes to hours
caused by???: too much cholesterol/bilirubin in bile
Tx: asymptomatic = no tx
symptomatic = cholecystectomy; meds if unable to have surgery
Pancreatitis
s/s: intense, constant abdominal pain that usually requires hospitaliztion
progesterone side effects (alone or in combination with E)
breast tenderness
HA
HTN
decreased libido
Categories for birth control use
1 - conditions for which no restriction on use
2 - advangtages of using method generally outweigh theoretical or proven risk
3 - theoretical or proven risks usually outweigh advantages of using method
4 - condition that represents unacceptable health risk if method is used
Category 4 for COC risk: DO NOT USE IF:
- Smoker >35 yo, 15+ cig/day
- Multiple risk factors for arterial CV dz
- HTN (160/100+) or HTN w vascular dz
- Acute DVT or PE
- hx DVT or PE and 1+ risk factors for recurrence
- Major surgery with prolonged immobilization
- Known thombogenic mutations
- hx of or current ischemic heart dz, stroke, complicated valvular heart dxz
- Migraine HA w aura at any age; migraine HA at 35+ yo w/wo aura
- brCA in last 5 yrs
- DM w nephropathy, retinopathy, or >20 yr
- Active viral hepatitis, severe cirrhosis, hepatocellular adenoma, malignant hepatoma
- SLE with + or unknown antiphospholipid antibodies
- Peripartum cardiomyopathy - normal or mildly impaired cardiac fxn and <6 months pp; mod/severely impaired cardiac fxn
- Solid organ transplant with complications
Drugs that may decrease effectiveness of COC
Rifampin, lamotrigine, phenobarbital, phenytoin, topirimate, carbamazepine, primidone, St. John’s wort, some antiretroviral drugs
COC may potentiate action of which drugs?
benzodiazepines
anitinflammatory corticosteorids
bronchodilators
ACHES
Abdominal pain (severe) Chest pain (sharp, severe, SOB) Headache (severe, dizziness, unilateral) Eye problems (scotoma, blurred vision, blind spots) Severe leg pain (calf or thigh)
POP MoA
Inhibits ovulations through suppression of FSH and LH
Produces atrophic endometrium
Thickens cervical mucus
Slows ovum transport through fallopian tube
May inhibit sperm capacitation
Category 4 for POP use
do not use if br CA within past 5 yrs
Missed pill on POP
if >3 hrs late taking pill, use backup method for 48 hrs
POP warning s/s
severe low abdominal pain
no bleeding after series of regular cycles
severe HA
Depo Warning Signs
Frequent intense HA Heavy, irregular bleeding Depression Abdominal pain (severe) Signs of infxn at injection site (prolonged redness, bleeding, pain, d/c)
Implanon MoA
Suprresses LH - ovulation in habited in almost all users
Produces atrophic endometrium
Thickens cervical mucus
Warning signs of Implanon
Abdominal pain (severe) Arm pain or signs of infection Heavy vaginal bleeding Missed menses after period of regularity Onset of severe HA
IUD warning signs
Period late/missed; abnormal spotting/bleeding Abdominal pain Infection - vag d/c Not feeling well: fever, aches, chills String missing/shorter/longer
Leave spermicide in place for how long after intercourse?
6 hours (no douching)
Diaphragm warning signs
(toxic shock) high fever N/V, diarrhea syncope, weakness joint/muscle aches rash resembling sunburn
advantage of continuous combined HT over continuous cyclic HT
lower cumulative dose of progestin
squamous metaplasia of the cervix occurs within the
transformation zone
A beta subunit radioimmunoassay (RIA) pregnancy test is reliable when?
7-10 days postconception
is used to measure quantitatively
A woman treated for primary syphilis 1 yr ago now has the following test results: VDRL nonreactive and FTA-ABS +. These findings indicate:
shemost likely was tx adequately for her syphilis and has not become reinfected
on average, cognitive development is completed with formatin of formal operational throught by age
16
Increased production of ???? is associated with primary dysmenorrhea
prostaglandin
What is NOT an FDA-approved indication for use of HT?
preventions of CV dz
Calendar method
subtract 18 from SHORTEST cycle
subtract 11 from LONGEST cycle
The anatomical area that contains the urethral/vaginal openings, hymen, skene’s glands and bartholin glands is called the
vestibule
a decreased risk in cervical cancer is NOT a benefit of what common birth control method?
COC
what are some noncontraceptive benefits of COC?
decrease in risk for benign breast disease
decr in risk for endometrial cancer
decre in risk for ovarian cancer
a woman who weights 200 lbs or greater may have decreased effectiveness with which contraceptive method?
transdermal
hormone that stimulates synthesis of milk is
prolactin
endocervical curettage is performed to evaluate abnormalities of the
glandular epithelium
mechanism of action of mifepristone in inducing abortion is
antiprogesterone effect on the endometrium
