Module 6 Study Guide Flashcards
How does the size of the thyroid gland change during pregnancy?
It enlarged up to 30% by the third trimester
Smooth enlarge gland can be felt
How do thyroid lab values (TSH, T3, and T4) adjust (rise, drop, or stay the same) during pregnancy?
TSH is lower during the first trimester because hCG decreases the release of TSH but theen normalize during the second and third trimester. High levels of hCG can result in gestational hyperthyroidism.
T3 and T4 increase due to estrogen
Free T3 and T4 remain the normal
What are the clinical signs and symptoms of hypothyroidism?
Low=slow
Fatigue, constipation, cold intolerance, weight gain, and hair loss
Relaxed DTRs, cardiac arrhythmias
What are the risks of uncontrolled hypothyroidism on the birthing person? On the fetus and newborn?
Maternal: GHTN, pre-E, abruption, PTB, cardiac dysfuntion, miscarriage/loss, infertility
Fetal: Cognitive impairment, low birth weight, prematurity, FGR
What lab test(s) should the nurse-midwife order to diagnose hypothyroidism?
TSH (high)
FT4 (low)
How should the nurse-midwife manage a patient with hypothyroidism?
New hypothyroid=collab with MD or endocrinologist referral
TSH testing q4-6weeks and adjust levo to patient requirements
Encourage iodine intake
Medication: Levothyroxine
What are the clinical signs and symptoms of hyperthyroidism?
Hyper=everything is fast
Nervousness, tachycardia, excessive sweating, heat intolerance, weight loss, elevated blood pressure, and palpitations.
What are the risks of uncontrolled hyperthyroidism on the birthing person? On the fetus and newborn?
Maternal: loss/stillbirth, cardiac arrythmias, HF, pre-E, HTN, placental abruption, thyroid storm
Neonatal: prematurity, low birth weight, FGR, tachycardia/cardiac decompensation, nonimmune hydrops, 1-5% fetal/neonatal thyrotoxicosis
What lab test(s) should the nurse-midwife order to diagnose hyperthyroidism?
TSH (low)
FT4 (high)
Total T3 (high)
Consider TPOAb testing
How should the nurse-midwife manage a patient with hyperthyroidism? What medications are used to manage hyperthyroidism?
Collaborate/refer to MD
Antithyroid Medication: Propylthiouracil (PTU) or methimazole (MMI)
Goal: Maintain FT4 slightly above/high normal
Labs every 2-4 weeks when treatment started then every 4-6 weeks
How should the nurse-midwife manage a patient with hyperthyroidism? What medications are used to manage hyperthyroidism?
Collaborate/refer to MD
Antithyroid Medication: Propylthiouracil (PTU) or methimazole (MMI)
Goal: Maintain FT4 slightly above/high normal
Labs every 2-4 weeks when treatment started then every 4-6 weeks
What is postpartum thyroiditis?
Inflammation of the thyroid gland usually within 12 month PP that can result in hyperthyroidism
Patients at risk: patients with family hx, prior hx of PP thyroiditis, positive antithyroid antibody test, autoimmune disease (DM I)
What are the clinical signs and symptoms of postpartum thyroiditis?
Hypertensive (2-6m PP): Fatigue, palpitations, anxiety, insomnia, irritability, weigh loss, goiter
Hypotensive (3-12m PP): Fatigue, impaired concentration, depression, dry skin, constipation, weight gain, goiter
What laboratory testing should the nurse-midwife use to diagnose postpartum thyroiditis?
TSH followed by FT4 if TSH is abnormal
How should the nurse-midwife manage a patient with postpartum thyroiditis?
Refer to endocrinologist. There is no recommendation for management
What is hyperemesis gravidarum?
Vomiting during pregnancy that is extremely hard to manage and treat. It often leads to weight loss and volume depletion in the pregnant person. There is no consensus on a specific definition or diagnostic criteria, but it generally refers to the most severe form of nausea and vomiting in pregnancy. The CNM must recognize the significant impact that hyperemesis gravidarum poses on the quality of life of patients
What are the diagnostic criteria for hyperemesis gravidarum? How should the nurse-midwife assess for hyperemesis gravidarum?
Hyperemesis is a clinical diagnosis made by ruling out other potential diagnoses. Symptoms generally occur before 9 weeks gestation. If newly onset nausea and vomiting occurs after 9 weeks gestation, other diagnoses should be suspected. Differential diagnoses include gestational trophoblastic disease, multiple gestation, and appendicitis or pancreatitis (if abdominal tenderness present). Hyperthyroidism may also be seen in hyperemesis gravidarum patients; however, this is often transient. If a goiter is present, thyroid disease should be suspected. However, if a goiter is not present and there is no history of thyroid disease, then further thyroid testing is not indicated and anti-thyroid medication is not recommended
When assessing a patient with hyperemesis gravidarum, CNMs should include a fetal heart rate (depending on gestational age) and an examination of fluid status during the physical exam. This includes an examination of blood pressure, heart rate, mucous membrane dryness, capillary refill, and skin turgor. A patient weight should also be obtained for comparison to previous and future weights in addition to a complete blood count and electrolyte evaluation
What effect(s) does hyperemesis gravidarum have on the birthing person? On the fetus?
Maternal: Significantly diminished quality of life and psychosocial effects, Hyponatremia, GI bleeding, Wernicke’s encephalopathy (Vit B1 deficiency)
Fetal: Determined by the severity of nausea and vomiting, Mild or moderate vomiting-little effect, FGR, Prematurity, SGA, LBW
How should the nurse-midwife manage a person with hyperemesis gravidarum?
First-line: Non-pharmacologic. Switch PNV, ginger supplements, admit if IV antiemetics and fluids required
Admission for hypovolemia (decreased UOP, tachycardia, dizzy, electrolyte imbalance, unable to hold down food/liquid
Pharm: Vit B6 is first line, then phenergan or reglan. Lastly is zofran (controversial)
What is the difference between SGA and FGR?
SGA: Same cut off as FGR but not at increased risk for increased morbidity and mortality
-Is made up of either FGR or constitutionally small (aka not at risk for adverse outcomes)
FGR (IUGR): birth weight below 10th percentile where secondary to environmental or genetic influences the fetus is prevented from reaching their expected growth potential.
What is the difference between symmetric and asymmetric fetal growth restriction?
Symmetric: here the fetal head and abdomen size are proportionally decreased. This is due to an insult early in gestation such as severe infection or chromosomal anomaly, which leads to a decrease in the overall number of cells in the body. Symmetrical FGR is associated with an increase in morbidity and mortality.
Asymmetric: “brain sparing” where the head circumference is relatively normal, compared to the smaller abdomen size. Asymmetrical FGR is more common and due to later insults such as hypertension. 75% of FGR are asymmetric and catch up of postnatal growth by three months without longterm consequences.
What are potential causes of symmetric FGR? When does symmetric FGR typically occur?
Occurs early in the pregnancy (often in 1st trimester)
Genetic disorders, infections, teratogenic insults, chronic malnutrition
What are potential causes of symmetric FGR? When does symmetric FGR typically occur?
Occurs early in the pregnancy (often in 1st trimester)
Genetic disorders, infections, teratogenic insults, chronic malnutrition
What are potential causes of asymmetric FGR? When does asymmetric FGR typically occur?
Occurs after 30 weeks of gestation. Normal number of cells by a smaller size
Chronic hypoxia, malnutrition, CHTN, Pre-E, Renal dx, abnormal placentation, multiple gestation, autoimmune dx, hemoglobinopathies, Alcohol, tobacco and drug use
What are risk factors for SGA and FGR?
Low prepregnancy weight
Poor gestational weight gain
Malabsorption
Malnutrition
What is the clinical presentation for SGA and FGR?
Slow or no increase in fundal height
Slow or no maternal weight gain
Fundal height less than 3cm or more than GA
How can the nurse-midwife diagnose SGA and FGR?
Confirm dating, assess accurate fundal height, obtain growth US, repeat U/S no sooner than 2 weeks if EFW <10%
U/S can be inaccurate under 4lb by 25%
What are the potential fetal and neonatal implications of SGA and FGR?
Prematurity, stillbirth/neonatal mortality, increased perinatal and neonatal morbidity, oligohydramnips, intrapartum asphyxia/fetal intolerance of labor
Neonatal: NEC, thrombocytopenia, polycythemia, temp instability, hypoglycemia, renal failure, delayed onset CP, Adult onset disease (DM II, obesity, HTN, osteoporosis)
What are the antenatal management options for SGA and FGR fetuses?
Confirm diagnosis and determine cause. Complete maternal HX and PE and assess fetus for anomalies/etiologies (U/S and/or genetic studies)
Address modifiable causes (decrease exercise, bed rest does not help)
Monitor FGR: U/S every 3-4 weeks (every 2w if severe FGR)
Fetal Surveillance: NST/BPP, daily kick counts, UA doppler velocimetry every 1-2 weeks
What is the midwifery intrapartum management for SGA and FGR fetuses?
FGR alone is not an indication for C/S
Continuous EFM should be used and cord ABG considered at birth
What is the midwifery management (consult/collaborate/refer) for SGA and FGR fetuses?
Collaborative care with MD and/or perinatology
How can FGR be prevented?
Regular prenatal care, healthy dies, no drinking, smoking or using drugs. Often it can’t be prevented
What is the clinical definition of oligohydramnios?
Decreased amniotic fluid with AFI <5 in 2nd or 3rd trimester or deepest vertical pocket <2
What is the clinical presentation of oligohydramnios?
Patient may be leaking fluid or be asymptomatic.
Fetal movement may be decreased.
Funal height less than 2cm than EGA or decreased pattern of growth.
Easily outlined fetus and not ballotable
May have HTN/Pre-E other problems
What are risk factors for oligohydramnios?
Pre-E or vascular disease, Medications (ACEIs, ARBs, NSAIDs), dehydration
How is oligohydramnios diagnosed?
Ultrasound for AFI or SDP
SDP is the better test to use
What are the potential fetal and neonatal implications of oligohydramnios?
Early onset (before 22-26w): hypoplastic lung, limb contractors, club foot
General: FGR, preterm birth, stillbirth or neonatal death, FHR decelerations (C/S or operative birth), thick meconium, low APGAR
What level of midwifery management (consult/collaborate/refer) is indicated in patients with oligohydramnios?
*Check for ROM
If intact, refer to MD
If ruptured, then treat as appropriate for ROM/PPROM/PROM. Con provide collaborate care in labor.
If oligo is isolated and preterm, expectant management until 36037 6/7 weeks
How accurate is ultrasound measurement in determining fetal weight for the SGA fetus?
Less than 4Lb may be 25% off
What is the difference between monochorionic/monoamniotic, monochorionic/diamniotic, and dichorionic/diamniotic multifetal gestation?
Mono/Mono: One placenta, one sac. Highest risk of loss. Usually delivered at 32-34w
Mono/Di: One placenta, two sacs. Highest risk of twin to twin transfusion. Usually delivered at 34-37w.
Di/Di: Two placentas/two sac. This is the lowest risk. Usually delivered at 38w
What are the risks of multiple gestation to the birthing person? To the fetus?
Increased rate of twins, with infertility treatment, maternal twins, taller and heavier, increased FSH, AMA, AA race
Maternal: GDM, pre-e, acute fatty liver dx, PUPP, DVT, PE
Fetus: PTB/PTL, LBW, congenital malformations, higher rates of CP, pregnancy loss (miscarriage and stillbirth
What antepartum counseling/teaching should the nurse-midwife give to a patient with a multifetal gestation?
Twins are collaboratively managed with OBGYN and MFM. CNM can deliver if vtx with MD at birth.
Increased need for monitoring, rest, nutrition, and education on PTL signs, possibility of NICU admission.
Timing of delivery depends on GA, fetal growth and any complications.
What is amnioinfusion?
The insillation of fluid into the amniotic cavity. Typically done through an IUPC. It theoretically restores normal amniotic fluid volume to cushion the umbilical cord
When is amnioinfusion indicated? When should it be avoided?
Amnioinfusion is recommended for repetitive variable decelerations. When used for this indication, amnioinfusion is associated with a reduction in variable decelerations, fewer cesarean sections, and improved neonatal outcomes.
Avoid with intraamniotic infection, polyhydramnios, uterine hypertonus, multiple gestation, category 3FHR, noncephalic presentation and placental abruption
How is an amnioinfusion performed?
AROM-> slow insertion of catheter. If resistance met, reposition and reattempt. Do not force.
Assess for amniotic fluid return.
Bolus of NS or LR 500ml in 30 minutes and an additional bolus of 250ml. Cont. infusion of 3ml/min
Monitor restine tone, FHR, and fluid return
What are the potential complications of amnioinfusion?
Overdistention of the uterus
Uterine hypertonis
Abnormal FHR
Uterine sculpture
Placental abruption
Intraamniotic infection
What is extraovular placement?
When the IUPC is placed outside the amniotic membranes. This can result in placental perforation or abruptions, uterine perforation, or FHR abnormalities. It can also result in artifactual pressure readings.
Describe maternal behaviors that may be associated with prenatal use of substances.
Depression is the most common psych issue when dealing with substance abuse.
Anxiety, eating disorders or erratic behavior, euphoric
HTN episode
Severe mood swings
Limited prenatal care
Wants to leave the hospital
Compare and contrast urine, meconium and hair samples ability to determine prenatal and perinatal drug exposure.
Urine= only current and recent use, will not detect synthetic drugs, some benzos and designer drugs
Hair follicle can detect use in the past 90 days
Meconium in the newborn if positive relates to the past 4-5 months
Describe the indirect and direct mechanisms of drugs effect on fetal brain development-
Direct - alter the neurotransmitter and neuromodulator systems resulting in an ↑risk for depression and nicotine addiction
Indirect - smoking induced anorexia, hypoxia → vasoconstriction, placental hypertrophy, ↓placental nutrient transport resulting in maternal and fetal undernutrition
Discuss the short and long term affects of nicotine on the fetus.
Short-term effect/birth outcome- ectopic pregnancy, spontaneous abortion, placenta previa, abruptio placenta, premature rupture of membranes, preterm birth, fetal growth restriction, stillbirth, and sudden infant death syndrome (SIDS).
Long-term- delayed or impaired brain development, delayed lung maturation, which diminishes lung size, volume, and function, alteration of the production and function of neurotransmitters hints at its possible role in the pathology of nicotine addiction, depression, attention disorders, and learning and behavior problems In contrast to adults, prenatal exposure to nicotine desensitizes neurotransmitter actions in the fetus. The resulting symptoms of depression, inattention, and hyperactivity in adolescents and adults appear to be partially corrected by nicotine use, suggesting a biologic basis for future smoking addiction; these babies withdrawal
Discuss the short and long term affects of alcohol on the fetus.
Short-term effect/birth outcome- miscarriage, prematurity, and stillbirth, birth defects, neurodevelopmental disorders
Long-term-Varying degrees of fetal alcohol spectrum disorder (Fetal Alcohol Syndrome (FAS) has three guidelines for diagnosis: documentation of three facial anomalies, growth deficits (below the 10th percentile), and CNS abnormalities), and long term disabilities
Discuss the short term affects of marijuana on the fetus.
Short-term effect/birth outcome- crosses placenta, growth abnormalities, adverse neurodevelopment, SB/PTB
Discuss the short term affects of opiates on the fetus.
Short-term effect/birth outcome- low birth weight, preterm birth, FGR, Withdrawal after birth
Discuss the short term affects of cocaine on the fetus.
Short-term effect/birth outcome- low birth weight, preterm birth, and small for gestational age infants (difficult to determine if cocaine is the cause due to other factors like low SES). Abruption, precipitous labor; Withdrawal.
Discuss the short term affects of PCP on the fetus.
Short-term effect/birth outcome- ALOT of congenital abnormalities, microcephaly, altered facial features, Significant withdrawal, course, floppy tremors
Methamphetamine
Discuss the short term affects of methamphetamines on the fetus.
Short-term effect/birth outcome-Some isolated defects, GHTN, pre-e, stillbirth, abruption, PTB, FGR, LBW
Discuss the short term affects of benzos on the fetus.
Short-term effect/birth outcome- No congenital abnormalities, Withdrawal, hypoventilation, floppy baby syndrome
Define neonatal abstinence syndrome
Group of conditions caused when a baby withdraws from certain drugs exposed to in the womb before birth.
-NAS is most often caused when a woman takes drugs called opioids during pregnancy.
-Drugs taken in pregnancy can pass through the placenta and cause problems
What drugs are associated with NAS?
Opiates, CNS Stimulant, NS Depressants, Cannabinoids, Hallucinogens, SSRIs, TCAs
Neonatal withdrawal - associated primarily w/opiates, sedative-hypnotics, and alcohol but most psychoactive drugs used during pregnancy- including antidepressants, antipsychotics and nicotine can produce withdrawal symptoms in the newborn
What newborn symptoms are suggestive of NAS?
Body shakes (tremors), seizures, overactive reflexes (twitching) and tight `muscle tone
Fussiness, excessive crying or having a high-pitched cry
Poor feeding or sucking or slow weight gain
Breathing problems, including breathing really fast
Fever, sweating or blotchy skin
Trouble sleeping and lots of yawning
Diarrhea or throwing up
Stuffy nose or sneezing
What non-pharm management options are there for NAS?
Early modification of environmental stimuli - including both lights and sound
Dark quiet environment
Avoid autostimulation by careful swaddling
Respond early to infant signals - comforting techniques swaying, rocking
Small frequent high calorie formula or breast milk to allow for adequate growth.
What pharm-management options are there for NAS and when are they indicated??
Indicated to relieve moderate to severe symptoms and signs of NAS-
Only offer when supportive non-pharmacologic treatments fail, neonate assessment scores remain high, seizures are observed, and dehydration is present
-Morphine
-Methadone
-Clonidine
-Phenobarbital
-Buprenorphine
What drug category are current NAS neonatal algorithms specific for?
Drugs used to define NAS algorithms are specific to neonatal opioid withdrawal
What potential complication can occur when Narcan (naloxone) is given to an opioid-dependent infant?
Hospitals used frequently by drug-dependent women may consider avoiding naloxone for fear of inadvertently precipitating neonatal withdrawal in infants delivered to previously unrecognized opioid abusers. Although the case reported is worrisome, data about the frequency of significant adverse outcomes after the use of naloxone in narcotic-habituated infants are unavailable.
Identify the drugs the American Academy of Pediatrics (AAP) consider contraindicated to breastfeeding.
Marijuana, opiates, cocaine , and methamphetamine
Supervised methadone - considered compatible w/breastfeeding and has no effect on infant or lactation
Describe Fetal Alcohol Syndrome (FAS)
Represents the most involved end of the FASD spectrum
Fetal death - most extreme outcome from drinking alcohol during pregnancy.
Might have abnormal facial features, growth, and central nervous system (CNS) problems.
Can have problems with learning, memory, attention span, communication, vision, or hearing.
Might have a mix of these problems.
Often have a hard time in school and trouble getting along with others.
Describe Alcohol-related Neurodevelopmental Disorder (ARND)
Might have intellectual disabilities and problems with behavior and learning
Might do poor in school - difficulties w/math, memory, attention, judgment, poor impulse control
Describe Alcohol-Related Birth Defects (ARBD)-
Might have problems w/ heart, kidneys, or bones or w/hearing or have a mix of these
What is the safe amount of alcohol use in pregnancy or while trying to get pregnant?
No amount of alcohol intake should be considered safe;
There is no safe trimester to drink alcohol;
All forms of alcohol, such as beer, wine, and liquor, pose a similar risk; and
Binge drinking poses a dose-related risk to the developing fetus. (AAPA)
When should substance screening be done and how?
Should be part of comprehensive obstetric care and done at first prenatal visit.
Screening should be universal
What is the medication of choice for intiation of medication assisted treatment of opiod dependency in pregnancy?
Methadone
