MODULE 8-10 NM621 study guide

Question 1

Fetal Alcohol Spectrum Disorder

Answer 1

• a group of conditions that can occur in a person whose mother drank alcohol during pregnancy. These effects can range from mild to severe. They can affect each person in different ways and can include physical problems and problems with behavior and learning. (CDC)

Question 2

FAS fetal alcohol syndrome

Answer 2

•	the severe end of FASD spectrum
•	IS a diagnosis
•	has three distinct features
a.	facial abnormalities
b.	growth deficits
c.	CNS abnormalties

Question 3

FAE (fetal alcohol effects)

Answer 3

negatively affect a child’s growth, cognition, physical appearance, and behavior over the lifespan. (Mengel)

Question 4

incidence of FAS

Answer 4

• 1-3% of live births in the US. “one in 30 women who know they are pregnant reports “risk drinking” (7 or more drinks per week or 5 or more drinks on any one occasion). At least 1 in 10 women will continue to consume alcohol during pregnancy. (LT and Mengel)
  • FAS Incidence 0.5-1.5/1000 births; the incidence of FASD is thought to be at least 3X the incidence of FAS (CDC link in LT)

Question 5

FAS Screening methods

Answer 5

• Quantity/Frequency questions
• days per week of drinking
• average number of drinks per day
• max number of drinks consumed in 1 day during past month
• TWEAK
• Tolerance:
a. How many drinks does it take before you feel high (the first effects of alcohol)? or
b. How many drinks can you hold? (How many drinks does it take before the alcohol makes you fall asleep or pass out? If you never pass out, what is the largest number of drinks you have?)
• Worried: Have your friends or relatives worried about your drinking in the past year?
• Eye opener: Do you sometimes take a drink in the morning when you first get up?
• Amnesia: Are there times when you drink and afterwards can’t remember what you said or did?
• K/Cut Down: Do you sometimes feel the need to cut down on your drinking?
• Receive 2 points if they can hold 5 drinks before passing out, 2 points if yes to “worry”, 1 pt for every other category. Any total score 2 or over=referral for further evaluation/treatment

Question 6

• T-Ace

Answer 6

• Tolerance: How many drinks does it take to make you feel high?
• Annoyed: Have people ever annoyed you by criticizing your drinking?
• Cut Down: Have you ever felt that you needed to cut down on your drinking?
• Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
• Because of social desirability, some pregnant women, particularly heavy drinkers, may be more likely to reliably report their actual alcohol use in a computerized or “pencil and paper” task rather than through a face-to-face interview.
• Receive 2 points if answer to Tolerance questions is 2 or more drinks, 1 pt for every other category. Any total score 2 or over=referral for further evaluation/treatment

Question 7

• Know factors associated with drinking alcohol,

Answer 7

• age >30, caucasian, Hx binge drinking or long hx of drinking, college educated, low or high SES, special education population, poor Native Americans, Hx of physical/sexual abuse ever, Hx physical abuse in last year, heavy drinking by male partner or any family member, loss of children to foster/adoptive care, poly-drug use/cigarette smoking, previous child with FAS, major depressive d/o, unmarried, early age of drinking onset.

Question 8

how to counsel women on drinking alcohol in pregnancy

: assessment first #1

Answer 8

Brief intervention
• Assessment alone seems to reduce alcohol consumption. Among pregnant women, formal screening with tools such as the T-ACE alone, reduces prenatal consumption. Physician advice or written educational information improves patients’ knowledge of the risks of drinking during pregnancy. Providing information alone may reduce the risk of an alcohol-exposed pregnancy through reduced consumption or increased use of effective contraception. Information’s beneficial effects on reducing risk may persist for up to 9 months. It is likely that when coupled with education and advice, assessment may be adequate to prevent further drinking during pregnancy among most patients.

Question 9

Counsel women: Motivational interviewing (MI) #4

Answer 9

Motivational interviewing (MI), a counseling model developed for health risk behavior, has also demonstrated success in reducing prenatal alcohol use—particularly among heavier drinkers.

Question 10

counseling women : brainstorming #3

Answer 10

After establishing drinking goals; the patient is encouraged to “brainstorm” environmental triggers (eg, socializing with friends who are drinking) and develop behavioral alternatives for these at-risk periods. Counseling is augmented by written patient educational material such as self-paced workbooks. Keeping a drinking diary, recording the number of alcoholic drinks, and drinking circumstances each day, is often recommended.

Question 11

counseling women : providing information #2

Answer 11

• After completing an initial screening and providing general information about the risks for drinking during pregnancy, at-risk patients should receive individualized feedback. The physician explains how the patient’s drinking compares with other pregnant women or those of childbearing age. If possible, the physician then describes risks specific to the patient. Next, the physician and patient establish drinking goals, complete cessation of drinking during pregnancy is recommended.

Question 12

• Know the trends and prevalence of smoking in pregnant women

Answer 12

o Currently, 11% of women in the United States smoke during pregnancy. It is estimated that worldwide up to 30% of pregnant women smoke during pregnancy. The highest rates of smoking during pregnancy occur in underdeveloped and poor countries, where access to prenatal care and education about smoking risks are less likely to be available.

Question 13

• Know the physiological effects on the placenta, fetus and newborn, and prenatal complications of smoking

Answer 13

o Placenta- previa, abruption, decrease placental weight, adverse morphological changes
o Fetus- Increased FGR and low birth weight, PROM (#1 way to prevent LBW is to increase smoking cessation rates)
o Newborn- Increased risk for SIDS, lower offspring IQ, increased childhood respiratory d/o such as chronic asthma, earaches, learning and behavior problems
o Prenatal complications- Increased first trimester loss, ectopic pregnancy, preterm birth
o CO2 & CO1 decrease available of O2 to fetus, nicotine is neurotoxic to fetal brain, nicotine cause adverse maternal CV changes that results in decreased placental blood flow and ultimately decreased O2/nutrient to fetus.

Question 14

know the strategies to promote smoking cessation in pregnant women and their families : 5 A’s

Answer 14

o The 5A’s and R’s The 5 A’s: the primary approach to quitting (nurse managed intervention)
• Ask about tobacco use
• Advise to quit- Clear, strong, personalized advice to quit
• Assess willingness to make a quit attempt
. If willing move on to assist
a. If not willing move on to the 5 R’s
• Assist in quit attempt
• Arrange f/u

Question 15

the 5 R’s

Answer 15

• The 5 R’s: to be used when patients don’t want to quit
• Relevance- have pt identify why quitting might be personally relevant
. ie: children in home, need for money, hx of smoking related illness
• Risks- ask if she knows about risks of smoking during pregnancy, reiterate benefits for her and baby
• Rewards- baby gets more O2 after just 1 day, clothes and hair smell better, she will have more money, food will taste better, she will have more energy
• Roadblocks- negative moods, being around other smokers, triggers and cravings, time pressures
. to overcome: smoke on hard candy, engage in physical activity, express yourself with writing or talking, relax, think about positive pleasant things, ask for support, ask friend to quit with you, ask others not to smoke around you, assign nonsmoking areas, leave room when others smoke, keep hands and mouth busy
a. Cravings will lessen within a few weeks, anticipate triggers, change routine (brush teeth immediately after eating), distract yourself with pleasant activities, change lifestyle to reduce stress, increase physical activity
• Repetition
o Hypnosis-Has not been proven for cessation, may help decrease amount of smoking
o Nicotine replacement- not well studied but considered better than cigarettes b/c of all of the chemicals inhaled with smoking. recommend that nicotine gum, sprays, or inhalers should be used rather than patches; a patch provides a higher total dose because it is on the woman continuously. ACOG states these should only be considered once other interventions have failed and/or those that are heavy smokers (>1ppd)

Question 16

• Know the trends and prevalence of street drug use in pregnant women

Answer 16

o The common perceptions of substance abuse as a problem of the poor, ethnic minority, and adolescent are inaccurate. These perceptions may often be acted upon by health care professionals in a prejudicial manner. Studies show similar rates of substance abuse during pregnancy by women of all racial, socioeconomic status and age categories. Demographic features are only related to the type of substance used with Black and poorer women most likely to use illicit substances, especially cocaine, while White women and better educated women tend to use alcohol.
o About 1 in 20 women (5%) take street drugs during pregnancy

Question 17

Marijuana sign and symptoms

Answer 17

tachycardic
lung infection
trouble paying attention
memory problems
trouble thinking clearly
clumsiness/poor balance

Question 18

marijuana maternal effects

Answer 18

reduced fertility (street drugs in pregnancy)

Question 19

marijuana : fetal effects

Answer 19

crosses the placenta, PTB, LBW, unclear evidence, CNS effect in children-changes in brain activity, sleep patterns, and behavior (street drugs in pregnancy)

Question 20

cocaine signs/ symptoms

Answer 20

affects CNS
• loss of smell r/t (snorting)
• change in eye sight, sound and touch
stomach pain, nausea, anorexia, weight loss, tremors, HA, restless, scared, angry, heart attack, stroke, resp failure

Question 21

cocaine maternal effects

Answer 21

local anesthetic, CNS stimulant (street drugs in pregnancy

Question 22

cocaine fetal effects

Answer 22

Placental abruption, preterm birth, lower birth weight, respiratory distress, bowel infarctions, cerebral infarctions, fetal growth restriction and increased risk of seizures, early pregnancy loss, birth defects, CNS problems when the child is older, readily crosses the placenta and metabolizes slowly in the fetus, newborn withdrawl (street drugs in pregnancy)

Question 23

Amphetamines s/sx

Answer 23

insomnia, tachycardia, sweating, hallucinations, dizziness, brain death/coma, death

Question 24

amphetamines maternal effects

Answer 24

Stimulant (tachycardia, insomnia, anorexia..). Dextramphetamine (Desoxyn) is rx, appears to carry no risk but no studies in pregnant women (street drugs in pregnancy)
Dextramphetamine is used to treat ADHA, sleep disorders, or as an appetite suppressant→ NOT recommended for use in pregnancy

Question 25

Amphetamine fetal effects

Answer 25

Preterm birth, LBW, NAS, SAB, FGR, placental abruption, lifetime neuro/cognative issues, neonatal withdrawal, possibly cleft lip and palate (street drugs in pregnancy)
NOTE: It is thought that ecstasy has similar adverse outcomes as amphetamines

Question 26

heroin maternal effects

Answer 26

affects CNS--itchy, sleepy nausea
resp failure
infection
needle sharing leads to HIV or hepatitis
kidney disease, liver disease, coma

Question 27

heroin fetal effects

Answer 27

abruption
PTB, low birthweigh
FGR
NAS (neonatal abuse syndrome) 
stillbirth 
SIDS
DO NOT quit “cold turkey” as in doing so you can harm fetus perhaps leading to stillbirth (one of recommend methods to stop heroin is the use of methadone-refer for comprehensive drug treatment program)
Heroin is a significant factor for late neuro and developmental problems

Question 28

when compare METH to Cocaine

Answer 28

METH is:
• Is stronger, last longer, has more toxic effects
• Causes a 3 fold release of dopamine in the brain and has a half-life of 12 hours compared to cocaine’s half life of 1 hour
• Can produce a high for 8-24 hours compared to a 20-30 minute high with cocaine
• Is less expensive than cocaine (street drugs in pregnancy)

Question 29

Cycle of Domestic Violence (DV)

Answer 29

o Cycle
• (Espinosa, p. 305) Domestic violence has been defined as “a pattern of coercive behavior designed to exert power and control over a person in an intimate relationship through the use of intimidating, threatening, harmful, or harassing behavior
• physical injury often results from the pattern of behavior used by abusers, it does not always occur in relationships affected by domestic violence.

Question 30

o Scope and factors associated with DV/IPV in pregnancy

Answer 30

Women: more likely to use violence as a means of self-defense or retaliation for violence inflicted by a male partner
Prenatal Care: May start prenatal care late in pregnancy (3rd trimester) due to the controlling behavior of their partners.

Question 31

• Men: associated with DV

Answer 31

: more likely to use violence as a method of coercion and control

Question 32

• Younger women associated with DV

Answer 32

more at risk for domestic abuse during pregnancy within a larger context of violence, related to their vulnerability and inexperience with interpersonal relationships; may become involved with males who have dangerous lifestyle behaviors (history of police involvement or use of illegal substances) May lack the life experience that could forewarn them of the seriousness of becoming involved with dangerous or violent individuals. Nonconformist attitudes could also make dangerous behaviors seem attractive; facilitating an adolescent female’s involvement with a violent male

Question 33

• Substance Abuse associated with DV

Answer 33

cigarette smoking, alcohol use, and history of drug use were associated with a history of domestic violence but were not associated with increased rates of domestic violence during the current pregnancy. Pregnant domestic violence victims were more likely than nonabused pregnant women to report abuse of multiple substances, including alcohol, cigarettes, and other drugs; more likely to continue substance abuse during pregnancy; higher rates of physical abuse for women who smoked cigarettes during the third trimester of pregnancy. Victims of domestic violence may be self-medicating with alcohol and other substances. Increased risk of domestic violence among women whose partners used marijuana, cocaine, had drinking problems, smoked, or had a history of police involvement, and legal problems related to the use of alcohol and other drugs

Question 34

Prenatal Care associated with DV

Answer 34

May start prenatal care late in pregnancy (3rd trimester) due to the controlling behavior of their partners.

Question 35

• Depression and Anxiety: as risk factor associated with DV

Answer 35

concurrently experience depression and anxiety. Feel less happy about being pregnant, and to have had a history of depression and attempted suicide.

Question 36

• Social support: as risk factor associated with DV

Answer 36

Usually nonfamilial support people rather than family members; feel a lack of support during pregnancy; have fewer people with whom they could “get together” or discuss personal issues

Question 37

• Other factors Associated with DV

Answer 37

low maternal weight gain, infections (including symptomatic bacteriuria, rubella, and cytomegalovirus), anemia, short interpregnancy interval, and bleeding during the first or second trimesters; housing problems and lack of tangible items such as a crib, refrigerator, or the presence of a stove in the home. Less likely to be married, more likely to be participants of WIC, and were more likely to have unintended pregnancies; more likely to seek an elective abortion without the partner being aware or supportive of this option; violent partners sometimes prohibit their partners from using contraceptive methods

Question 38

primary intervention of DV

Answer 38

o Primary interventions- address the societal underpinnings of domestic violence and include political activism in areas such as welfare reform and child custody legislation, as well as political efforts to end insurance discrimination directed toward victims of domestic violence, efforts to decrease pornography and violence, the promotion of healthy images of women in the media, and support for increased penalization of abusers. Safe options for child care as well as birth control options for women should be advocated, and women should be informed about services available to them. Another way that clinicians can participate in primary prevention is through participation in domestic violence public awareness campaigns.

Question 39

secondary intervention of DV

Answer 39

o Secondary intervention (screening and treatment)- includes prompt identification of DV and referrals for safe havens and/or treatment. Because many victims of domestic abuse have contact with the health care system only for care related to pregnancy and childbirth, consistent, ongoing, and appropriate screening for domestic violence is an especially important aspect of prenatal care. Secondary intervention strategies also include providing nonjudgmental support to women once situations of domestic violence have been identified, discussing issues of domestic violence with men, encouraging intervention programs for abusive men, and volunteering for services that serve families affected by domestic violence. Lastly, nonjudgmental support is important.

Question 40

Tertiary intervention of DV

Answer 40

o Tertiary intervention (leaving the abuser)- The process of leaving an abusive relationship is recognized as being complex and challenging for women. It has been described as a four-phase social psychological process of reclaiming self, with the four phases being counteracting abuse, breaking free, not going back, and moving on. Intervention at this level requires that clinicians be educated about domestic violence patterns, as well as the resources available in the community and available to the affected woman specifically. Women who have been identified as victims of domestic violence should be specifically questioned about escalating violence that may put her at risk for serious injury. The priority at this level is to ensure the immediate and long-term safety of the woman and her fetus, as well as any other children the woman may have. Clinicians caring for women who have revealed the presence of domestic violence should maintain consistent and descriptive documentation in the health care record of the violent behavior that is reported by the client.

Question 41

o Abuse Assessment Screen (AAS)

Answer 41

• One of the most widely used tools for detection of DV
• Consists of 4 questions asked during a routine health hx
• Have you ever been emotionally or physically abused by your partner or someone important to you?
• Within the last year, have you ever been hit, slapped, kicked or otherwise physically hurt by someone?
• Since you’ve been pregnant, have you been slapped, kicked or otherwise physically hurt by someone?
• Within the last year, has anyone forced you to have sexual activities?
• Does not have instructions for scoring or a cutting score (which indicates a problem).
• Serves as a tool to elicit information and open dialogue between clients and providers.
• When using the screen during a health history, providers should ask the questions in such a way that fosters open communication and give plenty of time to answer each question.
• She may not disclose the first time you ask so it is important to ask at each subsequent visit.

Question 42

o Barriers to diagnosis- DV

Answer 42

providers feel powerless with loss of control, and have a fear of offending the woman, Time constraints in scheduled office visits. Lack of information and training about violence so they are uncomfortable asking if she is a victim of violence. Belief that this is a “private” or family matter rather than a societal problem and health concern; The effects of the provider’s own traumatic experience(s) witnessing or experiencing violence, either past and/or present; Concerns about the legal ramifications of knowing this information; Discomfort with patients expressing emotion and concern about setting time boundaries; Concern about how listening to these experiences will affect them; and feeling helpless to intervene.

Question 43

BArrier to Disclosing DV

Answer 43

• Fear of increased violence if partner discovers she has disclosed the DV, Fear r/t threats that he will kill her or her children in she leaves, feelings of guilt, embarrassment, self-blame, and fear of not being believed; of being judged and blamed; of not being understood or helped; and of the threat and/or reality of revictimization or retaliation by the perpetrator if they were to seek help.

Question 44

o Strategies for care

Answer 44

Effective care for women experiencing domestic violence requires collaboration with the woman, social workers, and community resources to develop a safety plan. The woman will need a plan of action, including money, clothes, child care, and a place to go should she decide to leave. Perhaps a neighbor or family member can be identified and incorporated into the safety plan. Extra clinic visits can be scheduled to assist the woman in planning, and in some communities, arrangements can be made for the woman to meet with local shelter personnel at the clinic during a scheduled “prenatal visit.” The health care provider can show the woman where in the telephone directory to find numbers for local shelters and services so that specific written information, which the abuser might find, need not be given. As discussed above, it is important that the clinician not try to “fix” a situation by telling an abused woman what to do. It is the clinician’s role to assist the woman in making her own informed decisions. The health care provider can provide support, information, and appropriate referrals. Providing education about domestic violence can help dispel beliefs that the woman may cling to, such as that the abuser may change or that the abuse will end after the baby is born.

Question 45

o Physical signs : DV

Answer 45

Mixture of old and new injuries, injuries of the soft tissues and areas usually covered by clothes, trauma to the breasts and abd, characteristically abusive injuries resulting from fingernail scratches, rope burns, or cigarette burns,

Question 46

o Psychological signs/symptoms/hallmarks- DV

Answer 46

Depression, anxiety, substance abuse, lack of social support (if they did have social support the support tends to NOT be familial),

Question 47

o Behavior : DV

Answer 47

• Pregnant women in abusive relationships may start prenatal care late in pregnancy due to the controlling behavior of their partners. Less likely to be married, more likely to participate in WIC, more likely to have unintended pregnancies. More likely to seek elective abortion without partner being aware of supportive (often prohibited from using contraception by partner). More likely to abuse multiple substances and continue them throughout pregnancy. More likely to be involved with partners who use marijuana, cocaine, or ETOH

Question 48

• Know the physical and psychological signs, symptoms, hallmarks and varying behaviors of women who have been victims of CSA, and how to screen for this during prenatal visits.

Answer 48

o it is important for nurses to be aware that there is no typical profile of a CSA survivor, and an almost infinite range of signs and symptoms can be presented by this population.

Question 49

physical signs : CSA

Answer 49

asthma and respiratory disorders; dizziness and fainting; cardiovascular conditions; irritable bowel syndrome; auto-immune illnesses; chronic pain and fatigue; morbid obesity; sleep disturbances; musculoskeletal disorders; pseudoneurological symptoms; gastrointestinal disorders; and migraine headaches, particularly cluster migraines, sexual dysfunction, breast disease, nausea, chronic menstrual problems, menorrhagia, chronic urinary tract infections, premenstrual syndrome, hyperemesis, prolonged labors, shorter labors, longer pregnancies, and increased rates of postpartum depression, increased rates of abortions, increased rates of complications of pregnancy, more ultrasounds than usual during the pregnancy, and higher birth weights of infants.

Question 50

o Psychological signs/symptoms/hallmarks- CSA

Answer 50

most often present as a range of posttraumatic responses on a continuum, from a brief stress reaction following a single traumatic event to posttraumatic stress disorder (PTSD), inability to trust, feelings of isolation, affective numbness, low self esteem, anger, eating d/o, compulsive d/o, suicidal ideation/attempts, psych hospitalizations.

Question 51

Behavior of CSA

Answer 51

younger age at first intercourse, younger age at first pregnancy, multiple sexual partners, negative reaction to or denial of the pregnancy, pseudocyesi, more complaints of stress during pregnancy, difficulty relating in group settings, fear, anxiety or panic attacks, self-injurious behaviors, substance abuse, employment problems, increased potential for revictimization in adulthood, homelessness, survival prostitution.

Question 52

• Understand potential reactions to prenatal care visits (physical exams) & childbirth in women who are victims of CSA, and midwifery strategies to best help them.

Answer 52

o Pregnancy can be a trigger for a return to the feeling of terror and shame for many women due to the changes in the pregnant body, the feelings of vulnerability that pregnancy naturally brings, and office procedures like vaginal exams. This can take the form of flashbacks of previously repressed memories, nightmares, increased anxiety, and behavior changes. Women who have survived CSA have an increase in pregnancy nausea & vomiting and preterm labor

Question 53

Two issues essential to caring for women who have survived CSA are 
#1

Answer 53

• Trust: women need to trust their provider, however this can be a difficult task for CSA survivors. “A provider can say some things a survivor client may need to hear. For example, “I know it may take some time to feel that I am trustworthy. So here are some things about me you can count on. I will keep your confidentiality. I’ll try to remember to ask permission to touch you, and I will keep you informed of your condition” (Sperlich & Seng, pg 68). For women who have not disclosed prior abuse, they may not disclose until they have been asked numerous times or until they can judge that the provider ‘gets it’ and is competent at addressing these issues (Sperlich & Seng, 2008).

Question 54

Two issues essential to caring for women who have survived CSA are #2

Answer 54

• Control: Almost half of CSA women experience memories of prior abuse when undergoing a medical vaginal exam (Leerners, 2007). Survivors need to be in control of when the exams are done, and when they can be stopped for any reason, without penalty. For those women who have disclosed CSA and even if a client has not disclosed prior abuse, but is showing distress during a pelvic exam, it would be appropriate to say, “I see this is stressful for you - I’m going to stop now. Are you OK? Let me know if I may continue. “ Having control is important to reduce re-traumatization of women during pregnancy care.

Question 55

o Nurses may assist women during the perinatal period to regain confidence in their bodies, develop knowledge and skills that will increase their abilities for a positive childbirth experience, and contribute to the healing process.

Answer 55

• Knock before entering the room
• Provide private, well lighted exam room
• encourage questions and dialogue
• Reiterate that she is always free to talk about feelings that she thinks may be related to the abuse, or memories that may resurface, even if she doesn’t quite understand or has difficulty articulating them.
• Consider having a female assistant in the exam room for both patient comfort and risk management.
• Relinquish control. Recognize that the woman has the right to control her birth experience to the extent that it is possible.
• Are there fears or triggers he is concerned about?
• Explore with the woman how she has dealt with stressful, difficult, or physically demanding experiences in the past.

Question 56

incidence of Depression during pregnancy

Answer 56

12-30%

Question 57

risk factors for depression during pregnancy

Answer 57

family history (genetics may affect up to 37% of an individual developing depression),excessive stress, decreased seratonin- which helps to inhibit the stress response and increased noradrenergic responsiveness to stress- norepinephrine and dopamine. Increased levels of estrogen during pregnancy may decrease seratonin levels, and thyroid dysfunction may predispose mood disorders.

Question 58

s/sx recognition depression during pregnancy

Answer 58

insomnia or hypersomnia, feeling overwhelmed, fatigue, anxiety, change in sleep or appetite habits, isolation, feeling of hoplessness agitation

Question 59

maternal outcome of depression during pregnancy

Answer 59

increased risk for preeclampsia, increased substance abuse or risk of suicide, decreased self care and late to seek medical treatment, dysregulation of hypothalmic-adrenal-pituitary axis may lead to disruption of placental blood flow, mental illness during pregnancy is the strongest predictor of mental illness postpartum, preeclampsia

Question 60

fetal outcomes depression during pregnancy

Answer 60

IUGR, PTB, increased admission to the NICU after birth, bonding is affected, increased risk of miscarriage early on

Question 61

o Treatment options: depression during pregnancy

Answer 61

: screen for depression and talk about it,- managment either includes lifestyle changes or medication
Psychotherapy considered 1st line, not appropriate are monotherapy for moderate to severe depression but should be used as adjutant in these cases
Social support
Exercise
Diet

Question 62

• Know appropriate data gathering/evaluation in pregnant women with depression when deciding treatment strategies.

Answer 62

Need to determine the severity of the depression, any family history of depression,
Medications are not appropriate for MILD depression or for those without a diagnosis of depression

Question 63

• Know the risks of SSRI use in pregnancy.

Answer 63

Paxil has been associated with cardiac defects and should not be used
SSRIs (zoloft) have show an increase in persistent pulmonary HTN of the newborn which is characterized by neonatal jitteriness, hypertonia, feeding difficulties, tachypnea, and rarely seizures and resp. distress, and the rate of this is only 1-2 per 1000 births.

Question 64

antidepressants

Answer 64

Medications:
TCAs- not used usually because of side effect profile. have not been associated with congenital anomalies, but have been associated with neonatal abstinence effects
Bupropion- not well studied yet but so far has not shown an increase in congenital anomalies
SSRIs-1st line option. Zoloft is often considered 1st (low serum levels, almost undetectable in breast milk). Paxil is avoided d/t increased risk of cardiac defects

Question 65

• Know alternative treatment therapies for pregnant women with mild depression.

Answer 65

Assess the woman’s social support systems, look for ways to improve diet- especially with omega 3 in the diet because of its role in seratonin function, encourage exercise and sleep, accupuncture and light therapy may be effective.

Question 66

• Know appropriate medication management for pregnant women with depression: those who are currently taking medications and those who are starting while pregnant

Answer 66

For women already taking medication for depression before pregnancy and if the medication is successfully controlling her depression, usually the medication is not changed because the risk of adverse effects overall in pregnancy is pretty low and changing medications may lead to relapse. If a woman needs to start antidepressants during pregnancy than waiting until after the first trimester is idea. Zoloft is first line but can lead to increased risk of cardiac septal defects (0.2%) but its advantages are that it has lower maternal serum levels than other SSRIs and can be used in breastfeeding.

Question 67

o Rh sensitization

Answer 67

An individual who lacks a specific red cell antigen can produce antibodies when exposed to that antigen. These antibodies can prove harmful if she receives a blood transfusion or they may be harmful to a fetus during pregnancy. Rh sensitization occurs when an Rh positive baby is born to an Rh negative mother and fetal blood mixes with maternal blood. There are several pathways for this mixing to occur such as during the third stage of labor when the placenta separates. When this occurs antibodies are produced by mom which will affect subsequent Rh positive pregnancies. This can lead to hemolytic disease of the newborn.

Question 68

o ABO incompatibilities

Answer 68

ABO incompatibility can occur when an infant with A or B blood type is born to a mother with O type blood, or an infant with B or AB blood is born to a mother with type A blood, or an infant with A or AB blood is born to a mother with type B blood. This can lead to ABO incompatibility which is usually treated with phototherapy.

Question 69

differences between ABO incompatibility & Rh isoimmunization

Answer 69

ABO - effects 1st pregnancy, milder, treat with phototherapy, is considered more of a pediatric concern rather than OB concern, no need to screen during pregnancy for ABO incompatibilities due to only causing mild anemia. Most antibodies of ABO incompatibilities do not cause a problem during preganncy because they are IgM immunoglobulin and do not readily cross the placenta. In addition fetal RBC have less immunogenic properties. It can affect subsequest pregnancies but is NOT PROGRESSIVE

Question 70

differences between ABO incompatibility & Rh isoimmunization

Answer 70

Rh - effects later pregnancies (after Rh sensitization occurs), fatal, affects subsequent pregnancies and deleterious effects are progressive, we screen for this in pregnancy and it is considered and OB problem. Antibodies readily cross placenta-cause fetal hydrops, anemia, CHF, and death

Question 71

o Criteria for RhoGAM

Answer 71

RhoGAM is administered after threatened of spontaneous miscarriage later than 12 weeks gestation 50-300mg IM, after procedures or trauma 300mg IM, for prophylaxis at 28-36 weeks 300 mg IM with negative antibody screen. And 300 mg IM or IV Postpartum usually within 72 hours.

Question 72

• Know the causes of fetomaternal hemorrhage that can induce isoimmunization.

Answer 72

Ectopic pregnancy, SAB, MVA, trauma, termination of pregnancy, amniocentesis, Chorionic villus sampling, external version, placenta previa, abruption, fetal death

Question 73

• Understand how maternal Kell sensitization can occur

Answer 73

o How it occurs Anti-Kell sensitization can occur after blood transfusion with Kell positive blood; also related to maternal fetal incompatibility. Donated blood in U.S. is NOT routinely screened for kell antibodies (9% of population have Kell antibodies)

Question 74

how it is detected,

Answer 74

through antibody testing. Use cordocentesis for fetal detection (if Kell antibodies are + in mom and FOB’s status can not be certain), amniocentesis often underestimates Kell isoimmunization/fetal anemia.

Question 75

potential problems

Answer 75

rapid and severe Fetal anemia.

Question 76

midwifery actions

Answer 76

ask about hx of blood transfusion and antibody testing done at first visit. If antibody screen is positive for anti-Kell, consult→ Need to determine fetal status (if fetus doesn’t have Kell antibodies it will be no problem)

Question 77

• PUPPP syndrome

Answer 77

o Definition: benign dermatosis that usually arises late in the third trimester of a first pregnancy, more often occurring in women with multiples or a lot of weight gain during pregnancy, more common in primigravida women giving birth to males infants, or those with maternal hypertension. Seldom reoccurs in future pregnancies; has no adverse affects on the fetus

Question 78

o S/SX: PUPP

Answer 78

Small vesicles surrounded by a narrow pale halo that appears in the straie of the abdomen but not around the periumbilicus, face, palms, or soles, and in a few days, the eruption spreads to the buttocks and proximal thighs and may generalize. Patients present for a diagnosis of their unusual skin eruption and seek relief from the intense itching. Small vesicles often are noted, but larger bullae, though documented in one case, typically do not occur and would suggest the possibility of herpes gestationis. Less commonly, target lesions and annular and polycyclic wheals may be present. Usually does not affect the face, palms, or soles.

Question 79

PUPP appropriate data gathering

Answer 79

gravida and para, where is the rash, when did it start, and has she tried any treatments on it

Question 80

PUPP labs

Answer 80

No blood or urine laboratory tests are diagnostic of pruritic urticarial papules and plaques of pregnancy (PUPPP). However, one large series of cases showed a significant reduction of serum cortisol levels in patients with PUPPP compared with normal pregnant controls. If appropriate consider R/O cholestasis with LFTs/Bile salts, Infection with titers and/or skin biopsy/culture

Question 81

treatment for PUPP

Answer 81

corticosteroids and antihistamines

usually resolves in 4-6 weeks independent of delivery

Question 82

symptom alleviation PUPP

Answer 82

may require high-potency topical (class I or II) steroids, such as fluocinonide, or even systemic steroids Prednison

Question 83

caution with high potency corticosteroids because

Answer 83

could cause systemic absorption if used for greater than 2 weeks time or with open skin, and risk is higher with ointments than with creams or lotions. Use cautiously in those that have DM or HTN

Question 84

Oral antihistamines

Answer 84

Diphenhydramine, an antihistamine, has a sedative effect that may help patients to sleep better; it is also an effective agent against pruritus resulting from histamine release during inflammatory reactions. Vistaril can also be used and may help

Question 85

General treatment measures PUPP

Answer 85

include the use of cool, soothing baths; emollients; wet soaks; and light cotton clothing.

Question 86

• Herpes gestationis AKA: pemphigoid gestationalis

Answer 86

o Definition: pregnancy-associated autoimmune disease most common in caucasians and does not necessarily occur in the first pregnancy. A greater prevalence of premature and small-for-gestational-age (SGA) babies is associated with early onset and the formation of blisters. More common in whites and has a higher relative prevalence in people with other autoimmune diseases, including Hashimoto thyroiditis, Graves disease, and pernicious anemia, which are also associated with HLA-DR3 and DR-4 haplotypes. Can increase maternal long term incidence of Graves Disease.

Question 87

S/sx herpes gestationis aka pemphigoid gestationalis

Answer 87

: Prodromal symptoms include malaise, fever, nausea, headache, then a papular rash.Typically manifests during late pregnancy, with an abrupt onset of extremely pruritic urticarial papules that turn into blisters on the abdomen and trunk. The initial clinical manifestations are erythematous urticarial patches and plaques, which are typically periumbilical. These lesions progress to tense vesicles and blisters. Some patients may present with urticarial plaques and may never develop blisters. These hivelike plaques differ from true urticaria because of their relatively fixed nature. The rash spreads peripherally, often sparing the face, palms, and soles. Mucosal lesions occur in less than 20% of cases. Patients may have secondary infections at blister sites.

Question 88

appropriate data gathering

Answer 88

any history of autoimmune disease

Question 89

labs • Herpes gestationis AKA: pemphigoid gestationalis

Answer 89

Routine laboratory studies are not helpful. The results with most hematologic studies are within normal limits, although peripheral eosinophilia is not uncommon and may correlate with disease severity. Laboratory values that may be elevated include immunoglobulin levels, erythrocyte sedimentation rates, acute phase reactant levels, and antithyroid antibodies. The criteria for the diagnosis of pemphigoid gestationis include an appropriate clinical presentation, histologic findings of a subepidermal blistering process (as described below), and skin biopsy and direct immunofluorescence (DIF) results that show a linear band of C3 deposition with or without immunoglobulin G

Question 90

treatment options for Herpes gestationis AKA: pemphigoid gestationalis

Answer 90

collaboration with an immunodermatologist. Tepid baths, compresses, and emollients may help alleviate pruritus. Patients with mild disease can be treated with antihistamines and midpotency topical or intralesional steroids, such as triamcinolone. However, these are usually ineffective in more severe cases, and systemic steroids remain the mainstay of therapy. Prednisone at 0.5 mg/kg/d - then taper dose down as it gets better

Question 91

• Prurigo gestationis

Answer 91

group of skin disorders related to atopic eczema

Question 92

s/sx • Prurigo gestationis

Answer 92

small pruritic rapidly excoriated lesions on the forearms and trunk that look like scabies or other insect bites, usually appear at 25-30 weeks and may persist up to 3 months after delivery

Question 93

treatment Prurigo gestationis

Answer 93

oral antihistamines or topical corticosteroids

Question 94

• Intrahepatic cholestasis of pregnancy AKA pruritis gravidarum

Answer 94

o Definition: due to slowed emptying of bile from the gallbladder/incomplete clearance of bile acids causing them to accumulate in the plasma. may have some genetic factors, is more common in multiparas, multifeta, older maternal age, and may also be associated with high levels of estrogen during pregnancy. Can cause increased risk of PTB and MSAF, as well as increased stillbirth after 36 weeks gestation

Question 95

• S/SX Intrahepatic cholestasis of pregnancy AKA pruritis gravidarum

Answer 95

: pruritis that begins in the late second or third trimester usually and on the soles of the feet or palms of hands that gets worse at night, but can be generalized, but there is NO RASH! May also have icterus, steatorrhea, diarrhea, and fat malabsorption causing vitamin K deficiency may occur.

Question 96

appropriate data gathering • Intrahepatic cholestasis of pregnancy AKA pruritis gravidarum

Answer 96

any family history of hepatic disease, personal history of hepatitis C, gravida and parity

Question 97

labs for • Intrahepatic cholestasis of pregnancy AKA pruritis gravidarum

Answer 97

dyslipidemia, hyperlipidemia, elevated alkaline phosphatase and serum transaminase levels, bile salt levels over 40 are associated intrauterine fetal demise, stillbirth, preterm birth, and nonreassuring fetal heart rates in labor. Upon diagnosis during pregnancy BPP and doppler studies should be done and referral. Remember that itching may proceed lab changes by up to 3 weeks. LDH will commonly be the first lab to change (elevation

Question 98

Treatment options • Intrahepatic cholestasis of pregnancy AKA pruritis gravidarum

Answer 98

antihistamines and topical emollients, ursodeoxycholic acid (first line), vistaril, or dexamethasone

Question 99

• Discuss the following as related to asthma in pregnancy:

o Scope of the problem

Answer 99

• Asthma complicates approx. 4-8% of pregnancies (ACOG bulletin)
• Normal physiologic changes of pregnancy may exacerbate asthma symptoms in as many as 30% of women. (varney, p. 779).
• Asthma affects 7.2% of the adult population and accounts for 13.6million office visits, and 1.8million ER visits annually. Asthma affects proportionally more children than adults and is more common in African Americans and among low income population. (pharm for WH)
• With mild disease, 13 percent of women had an exacerbation in pregnancy and 2.3 percent required admission; with moderate disease, these numbers were 26 and 7 percent; and for severe asthma, 52 and 27 percent. Women with severe disease are more likely to have an exacerbation during pregnancy. Approximately 20 percent of women with mild or moderate asthma have been reported to have an intrapartum exacerbation. (cunningham)

Question 100

o Potential perinatal problems & effects on pregnancy- ASTHMA

Answer 100

• Increased risk for depression & miscarriage.
• Life-threatening complications from status asthmaticus include muscle fatigue with respiratory arrest, pneumothorax, pneumomediastinum, acute cor pulmonale, and cardiac arrhythmias.
• Maternal and perinatal mortality rates are substantively increased when mechanical ventilation is required.
• Studies vary, but some show slight increase in risk for preeclampsia, placental abruption, FGR, preterm ROM, PTL, LBW, CS delivery, and perinatal and maternal mortality.
• Fetal hypoxemia develops well before maternal oxygenation is compromised leading to decreased umbilical blood flow, increased systemic and pulmonary vascular resistance, and decreased cardiac output.
• Incidence of FGR increases with asthma severity so aggressive management is important.
• With reasonable control of asthma, perinatal outcomes are generally good.

Question 101

o Midwifery management including labs & referral ASTHMA

Answer 101

• In addition to evaluation and medication, midwifery counseling includes avoidance of triggers, the importance of correct medication use, and warning signs of worsening disease. (varney)

Question 102

o Midwifery management : behavior & lifestyle changes ASTHMA

Answer 102

• Behavior and lifestyle changes are particularly important for women with asthma who have not had their asthma well controlled prior to becoming pregnant. These women can need extensive health education and preventative health strategies such as how to avoid triggers, how to take their medication, the importance of influenza vaccine, and how to do fetal movement counts. (varney)

Question 103

Asthma medication in pregnancy

Answer 103

• Recommendations for medications during pregnancy include albuterol as a short-acting drug, inhaled corticosteroids (e.g., budesonide [Pulmicort]) for long-term control, and intranasal corticosteroids for relief of comorbid symptoms such as allergic rhinitis. Antihistamines such as loratadine (Claritin) and cetirizine (Zyrtec) may also be used. However, when a woman is well controlled on other medications, she should remain on her current regimen through pregnancy.

Question 104

pulmonary function test

Answer 104

• Pulmonary function testing should be routine in the management of chronic and acute asthma. (cunningham).

Question 105

• Diagnostics: asthma

Answer 105

• peak flow, spirometry, possibly CXR to r/o other disease as well as a CBC.

Question 106

• Education: asthma

Answer 106

• She will need to stay on the medications throughout the pregnancy.
• asthma action plan: medication regimens, dosage and frequency, when to contact provider or go to ER.

Question 107

asthma: environmental control

Answer 107

: pets/allergens, air conditioning, mask or respirator when outside or doing yard work, avoid exposure to cold air.
• Limitations: decreased activity, pre-exercise warm-up, administration of short-acting beta agonist (SABA) 15min before exercise.

Question 108

• Referral

Answer 108

• worsening of frequency and severity of asthma symptoms
• respiratory distress
• any patient on step 4 or higher on the stepwise approach to managing asthma chart needs consult with asthma specialist. (pharm for WH)

Question 109

o Normal thyroid physiology

Answer 109

During pregnancy, physiologic changes in thyroid metabolism result in lower levels of thyroid-stimulating hormone (TSH) and alterations in the levels of free T4 and T3. Later in pregnancy, TSH values return to the normal nonpregnant range.

Question 110

Thyroid function tests change during pregnancy

Answer 110

due to the influence of two main hormones: human chorionic gonadotropin (hCG), the hormone that is measured in the pregnancy test and estrogen, the main female hormone.

Question 111

hCG

Answer 111

o HCG can weakly turn on the thyroid and the high circulating hCG levels in the first trimester may result in a slightly low TSH (called subclinical hyperthyroidism). When this occurs, the TSH will be slightly decreased in the first trimester and then return to normal throughout the duration of pregnancy

Question 112

estrogen

Answer 112

o Estrogen increases the amount of thyroid hormone binding proteins in the serum which increases the total thyroid hormone levels in the blood since >99% of the thyroid hormones in the blood are bound to these proteins. However, measurements of “Free” hormone (that not bound to protein, representing the active form of the hormone) usually remain normal. The thyroid is functioning normally if the TSH, Free T4 and Free T3 are all normal throughout pregnancy.

Question 113

10-12 weeks of pregnancy & thyroid hormone

Answer 113

o For the first 10-12 weeks of pregnancy, the baby is completely dependent on the mother for the production of thyroid hormone. By the end of the first trimester, the baby’s thyroid begins to produce thyroid hormone on its own. The baby, however, remains dependent on the mother for ingestion of adequate amounts of iodine, which is essential to make the thyroid hormones. The World Health Organization recommends iodine intake of 200 micrograms/day during pregnancy to maintain adequate thyroid hormone production. The normal diet in the United States contains sufficient iodine so additional iodine supplementation is rarely necessary.

Question 114

Concentration of thyroid binding globulin (TBG)

Answer 114

increases in pregnancy because of reduced hepatic clearance and estrogenic stimulation of TBG synthesis
• The test results that change significantly in pregnancy are those that are influenced by serum TBG concentration.
o These tests include total thyoxine (TT4), total triiodothyronine (TT3), and resin triiodothyronine uptake (RT3U).
o Although there may be a transient increase in free thyroxine (FT4) and free thyroxine index (FTI) in the first trimester (possibly related to human chorionic gonadotropin [hCG] stimulation), this increase does not result in elevations beyond the normal nonpregnant range

Question 115

• Plasma iodide levels

Answer 115

decrease during pregnancy because of fetal use of iodide and increased maternal renal clearance of iodide.
o This alteration is associated with a noticeable increase in thyroid gland size in approximately 15% of women

Question 116

• Fetal thyroid begins concentrating iodine

Answer 116

at 10–12 weeks of gestation and is controlled by pituitary TSH by approximately 20 weeks of gestation.
o Fetal serum levels of TSH, TBG, FT4, and free triiodothyronine (FT3) increase throughout gestation, reaching mean adult levels at approximately 36 weeks of gestation.
o Thyroid- stimulating hormone DOES NOT cross the placenta, and only small amounts of thyroxine (T4) and triiodothyronine (T3) cross the placenta.
o Thyrotropin-releasing hormone (TRH), iodine, and TSH receptor immunoglobulins do cross the placenta, as do the thioamides propylthiouracil (PTU) and methimazole.

Question 117

o Clinical signs, diagnosis and perinatal complications of hyperthyroidism

Answer 117

• Hyperthyroidism S/S: nervousness, tremors, tachycardia, frequent stools, excessive sweating, heat intolerance, weight loss, goiter, insomnia, palpitations, and hypertension.

Question 118

o Graves’ disease:

Answer 118

ophthalmopathy (signs including lid lag and lid retraction) and dermopathy (signs include localized or pretibial myxedema).

Question 119

diagnosing hyperthyroidism

Answer 119

Elevated levels of FT4 or an elevated FTI, with suppressed TSH in the absence of a nodular goiter or thyroid mass. (Varney’s Midwifery, p. 782). Low TSH level (lower than the trimester-specific reference range for normal in pregnancy or less than 0.01 mU/ L) and elevated free T4
o Most common cause of hyperthyroidism is Graves’ disease.
• Graves’ disease often improves during the third trimester of pregnancy and may worsen during the postpartum period.

Question 120

thyrotoxicosis:

Answer 120

excess production of TSH, gestational trophoblastic neoplasia, hyperfunctioning thyroid adenoma, toxic multinodular goiter, subacute thyroiditis, extrathyroid source of thyroid hormone, very high levels of hCG, seen in severe forms of morning sickness (hyperemesis gravidarum), may cause transient hyperthyroidism.

Question 121

• Perinatal Complications: hyperthyroidism

Answer 121

Inadequately treated maternal thyrotoxicosis → greater risk of preterm delivery, severe preeclampsia, heart failure, increase in medically indicated preterm deliveries, low birth weight, spontaneous abortion, gestational diabetes, (rarely) thyroid storm.
o Fetal and neonatal risks associated with Graves’ disease are related either to the disease itself or to thioamide treatment of the disease.
o (American Thyroid Association, p. 1) Uncontrolled maternal hyperthyroidism → fetal tachycardia, small for gestational age babies, prematurity, stillbirths, possibly congenital malformations, fetal goiter, fetal hyperthyroidism, cardiac decompensation, hydrops
o Thyroid stimulating immunoglobulins (TSI) do cross the placenta and can interact with the baby’s thyroid. Although uncommon (2-5% of cases of Graves’ disease in pregnancy), high levels of maternal TSI’s → fetal or neonatal hyperthyroidism

Question 122

o Clinical signs, diagnosis and perinatal complications in hypothyroidism

Answer 122

• Hypothyroidism S&S: fatigue, constipation, intolerance to cold, muscle cramps, hair loss, dry skin, prolonged relaxation phase of deep tendon reflexes, and carpal tunnel syndrome. May progress to weight gain, intellectual slowness, voice changes, and insomnia.

Question 123

hypothyroidsm • Diagnosis

Answer 123

elevated TSH with normal FTI in an asymptomatic patient. (Varney’s Midwifery, p. 782). Elevated TSH (higher than the trimester-specific reference range for normal in pregnancy) and low free T4. Subclinical hypothyroidism: elevated TSH level with normal T4 function.

Question 124

Hashimoto’s disease

Answer 124

o Results from a primary thyroid abnormality or hypothalamic dysfunction. Most common etiologies: Hashimoto’s disease (chronic thyroiditis or chronic autoimmune thyroiditis), subacute thyroiditis, thyroidectomy, radioactive iodine treatment, and iodine deficiency

Question 125

hypothyroidism causes

Answer 125

o (American Thyroid Association, p. 2) Hypothyroidism can occur during pregnancy due to the initial presentation of Hashimoto’s thyroiditis, inadequate treatment of a woman already known to have hypothyroidism from a variety of causes, or over-treatment of a hyperthyroid woman with antithyroid medications.
o In developed countries, Hashimoto’s disease is the most common etiology; characterized by the production of antithyroid antibodies, including thyroid antimicrosomal and antithyroglobulin antibodies.
• Both Hashimoto’s disease and iodine deficiency are associated with goiter (a sign of compensatory TSH production); Subacute thyroiditis is NOT associated with goiter

Question 126

• Perinatal Complications: hyPOthyroidism

Answer 126

left untreated → myxedema and myxedema coma; preeclampsia, high incidence of LBW due to medically indicated preterm delivery (i.e., abruption, preeclampsia); miscarriage, anemia, gestational hypertension, placental abruption, and postpartum hemorrhage.

Question 127

o Iodine-deficient hypothyroidism

Answer 127

babies with congenital cretinism (growth failure, mental retardation, and other neuropsychologic deficits).

Question 128

• Treatment with iodine

Answer 128

in the first and second trimesters of pregnancy significantly reduces the incidence of the neurologic abnormalities of cretinism

Question 129

o Untreated congenital hypothyroidism

Answer 129

cretinism.

Question 130

• If identified and treated within the first few weeks of life

Answer 130

near-normal growth and intelligence can be expected

Question 131

Untreated, or inadequately treated hypothyroidism

Answer 131

maternal anemia (low red blood cell count), myopathy (muscle pain, weakness), congestive heart failure, pre-eclampsia, placental abnormalities, low birth weight infants, and postpartum hemorrhage; more likely to occur in women with severe hypothyroidism. Mild hypothyroidism may have no symptoms or attribute symptoms they may have as due to the pregnancy.

Question 132

o Thyroid hormone is critical for brain development

Answer 132

Children born with congenital hypothyroidism (no thyroid function at birth) can have severe cognitive, neurological and developmental abnormalities.

Question 133

the incidence in pregnancy : hyperthyroidism

Answer 133

• Hyperthyroidism occurs in 0.2% of pregnancies
o Graves’ disease accounts for 95% of these cases
o (American Thyroid Association, p. 1) Graves’ disease occurs in 1 in 1500 pregnant patients.
o (Varney’s Midwifery, p. 783). Hyperthyroidism occurs in 0.5% of pregnancies

Question 134

the incidence in pregnancy: • Hypothyroidism

Answer 134

5–8% incidence in patients with type 1 (insulin-dependent) diabetes
o (Varney’s Midwifery, p. 782). Prevalence of overt hypothyroidism in the United States, where iodine deficiency is rare, is approximately 0.3%.
o Congenital hypothyroidism: 1 per 4,000 newborns, and only 5% of neonates are identified by clinical symptoms at birth
o (American Thyroid Association, p. 2) Approximately, 2.5% of women will have a slightly elevated TSH of greater than 6 and 0.4% will have a TSH greater than 10 during pregnancy.

Question 135

mitral valve prolapse

Answer 135

• signs/symptoms Most are asymptomatic. If symptomatic they may have tachycardia, atypical chest pain, arrhythmias, syncope. You may hear systolic click on auscultation

Question 136

• Management of mitral valve prolapse

Answer 136

New guidelines issued by the American Heart Association in 2007 DO NOT advise routine antibiotic prophylaxsis for women with MVP anymore. The exception to this are those women who have symptomatic mitral regurgitation. Also, prophylaxsis is recommended for women who are at high risk, such as pregnant women with a valve repair with prosthetic material, or those who were born with a cardiac defect that required repair, such as tetralogy of Fallot. These high risk situation are most likely found in women who will not be under your care. So basically, there is no need to do antibiotic prophylaxsis anymore on women with MVP who are healthy.

Question 137

• Know the benign causes of abdominal pain in pregnancy

Answer 137

round ligament pain, constipation, heartburn

Question 138

• Know the pathologic causes of abdominal pain in pregnancy

Answer 138

appendicitis, cholecystitis may mimic normal pregnancy discomforts
• Differential Diagnoses: abdominal pain, acute cholecystitis, cholecystitis: unspecified, cholelithiasis, appendicitis, peptic ulcer, acute cystitis, spontaneous abortion, ectopic pregnancy

Question 139

• Know how to assess abdominal pain in pregnancy

Answer 139

Timing of abdominal pain in relation to gestational age provides key info to diagnose trimester specific conditions such as ectopic pregnancy
• Client History and Chart Review:
o Review prior ultrasound findings
o Location: lower, upper abdomen, radiating to upper back: Cholecystitis
o Onset/duration.
o Diet history: timing of pain in relation to meals; consider cholecystitis if pain occurs after fatty meals
o Characteristics: sharp, dull, constant, colicky, severe, mild
o Associated Symptoms: nausea, vomiting, constipation, diarrhea, syncope, vaginal bleeding, visual changes, dysuria, urinary urgency, abdominal itching, dark urine, light-colored stools, fatigue
o History of Pica
o Bowel Activity
o Relieving and Exacerbating factors
o Recent trauma

Question 140

o Murphy’s Sign:

Answer 140

Palpation of costal margin; RUQ pain with inhalation; grasp or breath “catching” indicative of gallbladder disease
o Abdominal Exam: presence of rigidity, pain location, assess rebound tenderness and muscle guarding, bowel sounds

Question 141

o McBurney’s Point

Answer 141

: Appendix moves progressively closer to gallbladder as gestation progresses
o Pelvic exam: speculum exam; look for products of conception in 1st trimester
o Suprapubic tenderness

Question 142

• Diagnostic Testing

Answer 142

o	Ultrasound: uterus, abdomen, gallbladder
o	Quantitative HCG
o	Urinalysis and Culture
o	24 hr urine collection if suspecting HELLP
o	CBC: WBC elevation
o	Liver enzyme panel
o	Serum amylase and lipase
o	NST
o	Possible endoscopy or laparoscopy

Question 143

Mild Cholelithiasis

Answer 143

: low-fat diet; fiber rich foods; cleanse the gallbladder - oatmeal, pears, beets, artichoke, dandelion greens, flax seed; milk thistle herb capsules; olive oil and lemon juice flush
• Reassurance of normalcy if physiologically normal diagnoses
• Supportive presence if surgical intervention is needed
o Surgery may be delayed until after pregnancy in Mild Cholelithiasis
o Surgery may be done regardless of pregnancy in Appendicitis
• Medical Consult for significantly elevated WBC, suspected problem requiring surgical intervention, emergent situation, diagnostic uncertainty

Question 144

assessment for gastric bypass surgery

Answer 144

Discuss with client prior to her becoming pregnant:
• What kind of bariatric surgery she had
• How much weight she has lost and how stable her weight is now
• Any problems since surgery
• Adequacy of her storage of iron, calcium, and B vitamins, especially folate (folic acid)

Question 145

In pregnancy, there may be a delay in the diagnosis of bariatric-related operative complications

Answer 145

anastomotic leaks, bowel obstructions, internal hernias, ventral hernias, band erosion, and band migration

o All gastrointestinal problems such as nausea, vomiting, and abdominal pain, which occur commonly during pregnancy, should be thoroughly evaluated in patients who have had bariatric surgery

Question 146

o Dumping syndrome

Answer 146

can occur after gastric bypass procedures; related to the ingestion of refined sugars or high glycemic carbohydrates that the stomach rapidly empties into the small intestine. Fluid shifts from the intravascular compartment into the bowel lumen result in small-bowel distention.
• Symptoms include gas pain, abdominal cramps, bloating, nausea, vomiting, and diarrhea.
• Hyperinsulinemia and consequent hypoglycemia can occur later, resulting in tachycardia, palpitations, anxiety, and diaphoresis.
• If patient has history of malabsorption surgery (e.g. Roux-en-Y) do not use 50g GTT GDM screen (will most likely cause dumping syndrome). Monitor BG X1 at home

Question 147

Symptoms of possible problems during pregnancy that are related to your surgery

Answer 147

include feeling sick, throwing up, stomach pain, heartburn, or cramping.
• If you have these symptoms, be sure to tell your provider and remind him/her that you have had bariatric surgery.

Question 148

Rising HCG levels in the first trimester

Answer 148

(doubling every 48–72 hours) can cause nausea and vomiting. Hypermesis gravidarum (HG), commonly referred to as “morning sickness,” can prevent adequate intake of fluids; therefore hydration is important.

Question 149

• Symptoms

Answer 149

nausea and vomiting, gastroesophageal reflux disease (GERD), intolerance to solid foods, abdominal pain, and pain at port site. 
•	As hCG levels stabilize, the nausea often also subsides, but it may be necessary to prescribe antiemetic class B medications, such as metoclopramide, ondansetron, hydrochloride, or promethazine.

Question 150

• HG can be overlooked

Answer 150

when indeed a gastric prolapse or gastric slip has occurred. HG can put the gastric band patient at risk for band slippage or gastric prolapse.

Question 151

• Unfilling fluid from the gastric band may be necessary

Answer 151

for some due to discomfort, food intolerance, nausea and vomiting, or from the higher levels of progesterone found in pregnancy.
• The patient should not receive fills during the first trimester. Band fluid may need to be reduced if HG or concerns for maternal health and dietary needs are reduced.
• If needed, a fill may be performed by the patient’s treating bariatric physician after 14 weeks gestation.

Question 152

o A pregnant gastric band patient may experience discomfort

Answer 152

at port site due to her growing abdomen. With both rapid weight loss and pregnancy, the incidence of gallstones and kidney stones is increased. Incidence of gout is also increased in these patients

Question 153

o HG can put the gastric bypass patient at risk for ulcerations

Answer 153

of the gastric pouch.

Question 154

symptoms of gastric ulceration

Answer 154

• Symptoms may include N/V, intolerance to foods, and GERD.
• Gastric or duodenal ulcers may be perceived as heartburn typically experienced during the second and third trimester.
• An obstetrician not familiar with bariatric surgery may attribute symptoms, such as HG, GERD, and food intolerance, to normal pregnancy symptoms instead of the previous bariatric surgery, thus delaying treatment.
• For instance, an internal hernia may be overlooked as initial abdominal discomfort until it becomes an evident emergent situation.
• Abdominal pain can be a sign of intestinal hernia or other surgical etiology and consult with a bariatric surgeon is advised.
• In all bariatric patients, increased gallstones, kidney stones, and gout are slightly increased due to rapid weight loss and pregnancy

Question 155

• Evaluate:

Answer 155

Early involvement of the bariatric surgeon in evaluating abdominal pain is critical because the underlying pathology may relate to the weight loss surgery.
o (ACNM, p. 1) The portions of the stomach and intestine that are no longer used after bariatric surgery are where calcium, iron, folic acid, and vitamins B and D are absorbed into the body. You will need to take daily multivitamin supplements of these important nutrients to stay healthy.

Question 156

multivitamins

Answer 156

multivitamins containing vitamins A, D, and E (i.e., fat-soluble vitamins). Dosage of these vitamins should not be greater than two times the daily recommended intake

Question 157

broad evaluation for micronutrient deficiencies (most common nutritional deficiencies after Roux- en-Y gastric bypass surgery are of protein, iron, vitamin B12, folate, vitamin D, and calcium) at the beginning of pregnancy for women who have had bariatric surgery should be considered.

Answer 157

• With an absence of a deficiency, monitoring the blood count, iron, ferritin, calcium, and vitamin D levels every trimester may be considered.
• daily recommendation for protein intake of 60 g is the same regardless of bariatric surgery status; (Delmont) Seventy-five percent of each meal should contain lean protein, and 65 to 90g per day is recommended. Protein supplements, including protein shakes, especially during the first and second trimesters, are sufficient in fulfilling this requiremen

Question 158

Carbohydrates

Answer 158

A minimum of 25 percent, approximately 100 to 150g/day, should come from complex carbohydrates, such as fruits, vegetables, and 100-percent whole grains.

Question 159

• Fats.

Answer 159

Mono- and polyunsaturated fats help develop nerve sheaths in the growing fetus and are a source of energy for the pregnant patient. It is recommended that the patient consumes 25 to 35g of mono- and polyunsaturated fats/day.

Question 160

• Meal size and frequency

Answer 160

Each meal should equal between 6 to 8oz of food. and the patient should eat approximately 5 to 6 meals per day. It is recommended that 75 percent of the day’s total meals consist of protein and 25 percent of carbohydrates to allow a continuous fueling of nutrition to both mother and fetus, and to stabilize blood sugar levels.

Question 161

• Water.

Answer 161

The suggested daily intake of water for the pregnant patient after bariatric surgery is 64oz.

Question 162

Vitamin K

Answer 162

• DO NOT exceed 5,000IU of Vitamin K intake daily.

Question 163

vitamin B12

Answer 163

• Patients who have undergone gastric bypass, gastric sleeve, or duodenal switch should take 1,000mcg vitamin B12 sublingually daily, intranasally one time per week, or subcutaneously (SQ) or intramuscularly (IM) one time per month.

Question 164

• Vitamin B-1 (thiamine)

Answer 164

recommendations are 1 to 2mg/day and calcium (my bariatric program prefers patients take calcium citrate 1,500 to 1,800mg/day. Vitamin D intake recommendation is 2,000IU/day and 25 to 35gms per day of fiber.

Question 165

• Omega 3 fatty acids

Answer 165

are recommended at 1,000 to 2,000mg/day and iron (ferrous fumarate) 30 to 60mg/day.

Question 166

vitamin A

Answer 166

excess of vitamin A consumption during pregnancy is associated with birth defects, so supplemental dosages of vitamin A should be limited to 5,000 international units per day during pregnancy.

Question 167

Before you become pregnant, and a few times during your pregnancy, the following may occur:

Answer 167

• Blood work to check your iron, folate, calcium, and vitamin status.
• Monitor your weight gain and might ask you to keep a food journal.
• Offered additional ultrasound scans to make sure that your baby is developing and growing well.

Question 168

Contraceptive counseling

Answer 168

is especially important for adolescents because pregnancy rates after bariatric surgery are double the rate in the general adolescent population
• increased risk of oral contraception failure after bariatric surgery with a significant malabsorption component, nonoral administration of hormonal contraception should be considered in these patients

Question 169

what is the recommended time to wait to conceive after bariatric surgery

Answer 169

o Recommended waiting 12–24 months (12-18 months per ACNM) after bariatric surgery before conceiving so that the fetus is not exposed to a rapid maternal weight loss environment and so that the patient can achieve full weight loss goals; (Delamont) Pregnancy should be avoided during the first 1 to 2 years following bariatric surgery, as it is a time where the patient is still experiencing change; this waiting period postoperatively can also help decrease risk factors, such as hormonal instability in the mother, that may strain a developing fetus
• Should pregnancy occur before this recommended time frame, closer surveillance of maternal weight and nutritional status may be beneficial. Use of ultrasound for serial monitoring of fetal growth also may be useful and should be considered.
o No consensus on the management of patients during pregnancy who have had an adjustable gastric banding procedure, but early consultation with a bariatric surgeon is recommended.

Question 170

Alternative testing for DM

Answer 170

Alternative testing for gestational diabetes should be considered for those patients with a malabsorptive- type surgery.
• Patients with dumping syndrome may not tolerate the 50-g glucose solution commonly administered at 24–28 weeks of gestation to screen for gestational diabetes.
• One proposed alternative is home glucose monitoring (fasting and 2-hour postprandial blood sugar) for approximately 1 week during the 24–28 weeks of gestation
• (Delmont) Conduct screening for diabetes during the first or early second trimester and again in the third trimester when HPL levels can influence glucose metabolism.
• Diabetes screening is necessary in pregnant patients who have undergone Roux-en-Y gastric bypass (RYGB) or duodenal switch (DS) operations as malabsorption of increased glucose loads can precipitate dumping to offer a fasting blood sugar.
• Patients who have undergone sleeve gastrectomy (SG) or adjustable gastric banding can tolerate the 50gm glucose load so diabetes screening can be offered to them without concern for glucose intolerance.
• If it is confirmed that a patient has gestational diabetes, the patient or clinician should schedule an appointment with a dietitian who is familiar with bariatric surgery.

Question 171

o Consultation with a nutritionist

Answer 171

after conception may help the patient adhere to dietary regimens and cope with the physiologic changes of pregnancy
• (ACNM, p. 1) Teach client to chew her food thoroughly and to eat very slowly, because her stomach cannot hold large amounts of food. Eating too much too quickly may cause nausea and vomiting. Encourage drinking fluids often to prevent dehydration.

Question 172

After operations such as the Roux-en-Y gastric bypass

Answer 172

absorptive surface of the intestine is decreased → decreased time for absorption.

Question 173

Roux en Y

Answer 173

• Extended-release preparations are NOT RECOMMENDED in these patients; instead oral solutions or rapid release formulations are preferred
• Gastric pouch is smaller and bariatric surgeons have cautioned against using nonsteroidal anti- inflammatory drugs postpartum to avoid gastric ulceration
• In using medications in which a therapeutic drug level is critical, testing drug levels may be necessary to ensure a therapeutic effect.
• (Delmont) tablet or suspension is advised for medications. Due to possible poor absorption and limited gastric secretions, the patient SHOULD NOT take extended-release or gelatin capsules. Antiemetics may be advisable due to their improved effects on gastric emptying and during postpartum if breast milk supply is suspected to be inadequate.

Question 174

Bariatric surgery should not alter the course of labor and delivery, and as such does not significantly affect its management.

Answer 174

• May be admitted earlier in labor, need labor induction, require more oxytocin, and have longer labor
• Cesarean delivery rates are higher after bariatric surgery even after controlling for confounders (previous cesarean delivery, obesity, and fetal macrosomia)
• Bariatric surgery SHOULD NOT be considered an indication for cesarean delivery.
• (Delmont) Patients who have experienced massive weight loss prior to pregnancy are at risk of soft tissue shoulder dystocia loss occurring during vaginal births. Soft tissue shoulder dystocia can occur from the added weight of maternal soft tissue in the lower abdomen that can compress against the uterus and add an increased risk of shoulder dystocia.

Question 175

o Factor V Leiden-

Answer 175

The most prevalent of the known thrombophilic syndromes, this condition is characterized by resistance of plasma to the anticoagulant effects of activated protein C. The unimpeded abnormal factor V protein retains its procoagulant activity and predisposes to thrombosis. Heterozygous inheritance for factor V Leiden is the most common heritable thrombophilia. Moreover, factor V Leiden mutation is found in up to half of nonpregnant individuals with thromboembolic disease. Homozygous inheritance of two aberrant copies is rare and increases the risk of thrombosis during pregnancy by more than tenfold

Question 176

o Prothrombin G20210A mutation

Answer 176

This missense mutation in the prothrombin gene leads to excessive accumulation of prothrombin, which then may be converted to thrombin. Found in approximately 2 percent of the white population, it is extremely uncommon in nonwhites. Case-control studies suggest that the relative risk of thromboembolism is increased 3- to 15-fold during pregnancy

Question 177

o Antiphospholipid antibodies

Answer 177

These autoantibodies are detected in about 2 percent of patients who have nontraumatic venous thrombosis. The antibodies are directed against cardiolipin(s) or against phospholipid-binding proteins. They are commonly found in patients with systemic lupus erythematosus. Women with moderate-to-high levels of these antibodies may have antiphospholipid syndrome, which is defined by a number of clinical features such as thromboembolism or certain obstetrical complications that include.
• at least one otherwise unexplained fetal death at or beyond 10 weeks;
• at least one preterm birth before 34 weeks; or
• at least three consecutive spontaneous abortions before 10 weeks.

Question 178

thromboembolism

Answer 178

either venous or arterial—most commonly involves the lower extremities. Importantly, the syndrome also should be considered in women with thromboses in unusual sites, such as the portal, mesenteric, splenic, subclavian, and cerebral veins. Antiphospholipid antibodies are also a predisposing factor for arterial thromboses. In fact, they account for up to 5 percent of arterial strokes in otherwise healthy young women. Thromboses may occur in relatively unusual locations, such as the retinal, subclavian, brachial, or digital arteries.

Question 179

• Know the physiology of VTE

Answer 179

the conditions that predispose to the development of venous thrombosis: (1) stasis, (2) local trauma to the vessel wall, and (3) hypercoagulability. The risk for each increases during normal pregnancy. For example, compression of the pelvic veins and inferior vena cava by the enlarging uterus renders the venous system of the lower extremities particularly vulnerable to stasis. This stasis is the most constant predisposing risk factor for venous thrombosis. Venous stasis and delivery may also contribute to endothelial cell injury. Lastly, marked increases in the synthesis of most clotting factors during pregnancy favor coagulation.
• Venous stasis is the most constant risk factor

Question 180

• Understand the factors associated with the increase risk for VTE

Answer 180

o Obstetrical: CS, DM, hemorrhage and anemia, Trauma, vascular injury, obesity; multifetal gestation; multiparity; puerperal infection severe preeclampsia; hyperemesis; inactivity and venous stasis;
o General: prior history of thrombosis; antiphospholipid syndrome; and thrombophilias such as factor V Leiden; age >35, obesity, smoking.
o The most constant predisposing factor is increased venous stasis

Question 181

• Know clinical presentation of DVT.-

Answer 181

o Common symptoms of a lower extremity DVT include: abrupt onset swelling, localized redness, pain or discomfort. DVT begins in veins of the calf and thigh in pregnancy, as it does in nonpregnant women, with a clear preference for involvement of the left leg. DVT occurs with equal frequency in each trimester and postpartum (PE is more common in PP period).
o Any woman reporting leg pain, unilateral swelling, redness and or pain should be evaluated
o Occasionally, reflex arterial spasm causes a pale, cool extremity with diminished pulses
o Conversely, there may be appreciable clot, yet little pain, heat, or swelling. Importantly, calf pain, either spontaneous or in response to squeezing or to stretching the Achilles tendon—Homans sign— may be caused by a strained muscle or a contusion.

Question 182

o Venous compression ultrasonography (venous doppler) is

Answer 182

a noninvasive technique that is currently the most-used first-line test to detect deep-venous thrombosis. The diagnosis is based on the noncompressibility and typical echoarchitecture of a thrombosed vein. In pregnant women, the important caveat is that normal findings with venous ultrasonography results do not always exclude a pulmonary embolism. This is because the thrombosis may have already embolized or because it arose from deep pelvic veins inaccessible to ultrasound evaluation. In pregnant women, thrombosis associated with pulmonary embolism frequently originates in the iliac veins. Moreover, the natural history of calf deep-venous thrombosis during pregnancy is unknown.

Question 183

o Invasive contrast venography

Answer 183

remains the standard to exclude lower extremity deep-venous thrombosis. It has a negative-predictive value of 98 percent, and fetal radiation exposure without shielding is only about 300 mrad. But venography is associated with significant complications, including thrombosis, and it is time consuming and cumbersome. Thus, noninvasive methods are usually used to confirm the clinical diagnosis.

Question 184

o Impedance Plethysmography

Answer 184

is an extremely accurate test to assess thromboses in the lower iliac, femoral, and popliteal veins. However, it is only 50-percent sensitive for detection of clots in the small calf veins . Moreover, because of decreased venous return of the lower extremities, it is associated with increased false-positive results during pregnancy. Given these limitations as well as the wide availability of ultrasonography, it is seldom used today

Question 185

o Spiral computed tomography (CT)

Answer 185

scanning is widely available and very useful for detecting lower extremity deep-venous thrombosis as well as those within the vena cava and iliac and pelvic venous systems. Although radiation and contrast agents are required, the benefits of CT outweigh any theoretical risks if lead shielding is used. Fetal radiation exposure is negligible unless the pelvic veins are imaged.

Question 186

o MRI

Answer 186

allows excellent delineation of anatomical detail above the inguinal ligament. Thus, in many cases, MRI is immensely useful for diagnosis of iliofemoral and pelvic vein thrombosis. MRI imaging is 100-percent sensitive and 90-percent specific for detection of venographically proven deep-venous thrombosis. (but very expensive)

Question 187

o Serum testing for D-Dimer

Answer 187

is useful in diagnosis DVT in non-pregnant women, however this has limited use in pregnancy. D-dimer values increase progressively throughout pregnancy, and the ranges for normal values by gestational week are not yet universally established. A low d-dimer can rule out DVT, and a high d-dimer result is common in pregnancy, thus confounding diagnosis.

Question 188

• Know the potential problems of DVT

Answer 188

PE- In women presenting with DVT, almost half will have a silent PE. Without treatment ¼ women will have PE (treatment reduces risk to <5%)

Question 189

• Be familiar with treatment measures for DVT

Answer 189

Anticoagulation and limited activity: Anticoagulation is initiated with either unfractionated or LMW heparin (most common). Over several days, leg pain dissipates. After symptoms have abated, graded ambulation should be started. Elastic stockings (TED Hose), are fitted and anticoagulation is continued. Recovery to this stage usually takes 7-10d.

Question 190

• Understand the role of the midwife in a woman who is experiencing symptoms of VTE

Answer 190

The role of the midwife is to know risk factors that place pregnant women at risk for VTE, know the signs and symptoms, be able to make an accurate physical assessment, and refer quickly, as this can quickly become an emergency situation. (Lets talk)

Question 191

o Complications

• Less than 18 years old

Answer 191

STI’s, especially Chlamydia, increased risk for DM2 later in life if they have > 2 pregnancies during adolescent

Question 192

complication • Over 35

Answer 192

Increasing numbers of married women in the US are delaying childbearing. ‘the last egg in the basket’, that time is running out, and that each pregnancy is more valuable.
• Fear of pregnancy loss; believe that they have little time to conceive another child.
• Being treated as a member of an ‘at-risk’ group may heighten anxiety unnecessarily.
• Categorizing all women 35 years or over as ‘at risk’ may result in a self fulfilling prophecy → more likely to suffer reduced emotional well-being → predicts that they will be at greater risk for obstetric complications.
• Anxiety related to testing for genetic abnormality
• Carefully plan their pregnancies with the assistance of reproductive technology. Worry about not having a perfect or normal baby.
• Many women are ready to set aside career paths and take on the new role of mothering, while others find career and mothering roles to cause conflict and produce anxiety

Question 193

o Pregnancy outcomes

• Less than 18

Answer 193

Late to Prenatal Care; Preterm labor; Preeclampsia; Anemia; LBW, in adequate maternal weight gain

Question 194

neonatal outcome for maternal age less than 18 year old

Answer 194

) 2 X’s rate of LBW and SGA

• 3 X’s infant mortality

Question 195

neonatal outcome for maternal age more than 35 year old

Answer 195

increase in low birth weight and prematurity
• (Lets’ Talk) not associated with an increase in adverse neonatal outcomes, although the rate of medical complications such as hypertension and diabetes are more common, and the incidence of cesarean section is increased

Question 196

maternal age >35 associated with

Answer 196

chronic HTN
preeclampsia
increase C/S birth Higher frequency of cesarean section delivery in older mothers has been partly attributed to the over cautious attitude of the medical profession’s perception of late pregnancy as a last chance to have a child

Question 197

Factors Associated With Teen Pregnancy:

Answer 197

Lack of a father in the home due to an increased need for male attention and love; having older siblings, especially if an older sister has experienced an adolescent pregnancy; sexual abuse in childhood; living in neighborhoods that are characterized by high residential turnover, poverty, and crime rates; high parental psychological control; increasing number of single parent families with decreased home supervision; an increase in time teens spend not in communication with adults but with videos, TV, and computers; and the profusion of sexual media that portray sex with no consequences; adolescent bodies mature before cognitive development and emotional maturity are fully developed - attracts male attention before ability to understand how to deal with it (Jordan PDF) Limited education; persistence of poverty; unstable family structure; poor parenting; repeated pregnancy; parents work full time (minimal supervision); her mother was a teen parent; cultural contraindication on sexuality leads to teens hiding sexual behavior; no access to birth control

Question 198

• Midwifery Actions

Answer 198

parent-child closeness is associated with reduced teen pregnancy risk by teens remaining sexually abstinent, having fewer sexual partners, and using contraception more consistently. Evidence also shows that parental supervision and monitoring of children is another important factor related to adolescents at lower pregnancy risk. (Jordan PDF) Continuity of care important to teens to establish relationship; Centering Pregnancy: growth & empowerment

Question 199

Adolescence

Answer 199

is a period of exploration and discovery. Self-reliance, self-control, and the capacity for independent decision making all increase over the adolescent years.
• Adolescence is a time of choices. It involves gaining autonomy, assuming responsibility, and making choices about health, family, career, peers, and schooling. Choices regarding sexual intercourse or use of substances can have serious implications

Question 200

Level of Cognitive Development

Answer 200

The ability to comprehend health risks, weigh options, reflect on one’s own behavior, and consider the long-term consequences of one’s actions develops during adolescence. This ability greatly varies depending on the level of cognitive development as noted below.

Question 201

• Early adolescence: 14 and under

Answer 201

o Very egocentric; concrete thinker; minimal ability to see herself in the future and to connect current actions with future events and consequences.
o Locus of control as external; that is, her destiny is controlled by others (parents and school authorities).
o Not uncommon for girls in this very young age group to be impregnated by adult males over age 18

Question 202

• Middle Adolescents: 15 to 17 Years

Answer 202

o Seeks independence from family and turns increasingly to her peer group for identification.
o Experimenting with drugs or alcohol and sex are common avenues for rebellion. Believes that she is invincible and will not suffer negative consequences for risk taking behavior.
o Wants to be treated as an adult, however fear of adult responsibility will cause fluctuation in behavior.
o Very challenging time for parents and families; at times she seems like a child at other times she acts very mature.
o Beginning to move from concrete thinking to formal operational thought but still is not able to anticipate long-term consequences of her present actions. (E.g.) Not using birth control during sex. No conscious decision is made about being sexually active, and the initial experience of sex often is not planned. Even after regular intercourse is established, the thinking that, “it won’t happen to me” is common

Question 203

• Late Adolescence: 18 and 19 Years

Answer 203

o Developed the ability to think abstractly and anticipate consequences; capable of formal operational thought, and can problem solve, conceptualize, and more easily make decisions.
o For this reason, many experts in adolescent pregnancy consider age 18- 19 to be in the category of an adult.
o Locus of control orientation changes from external to internal. Teens with future goals such as college or a job tend to use birth control methods more consistently. If they do become pregnant, they’re more likely to have an abortion as compared with pregnant teens lacking future goals.
o Additionally, teens with a higher sense of self-esteem will often have a stronger internal locus of control. They are more able to withstand sexual pressures of peer behavior and boyfriends, and to use birth control methods, resulting in a lower pregnancy rate.

Question 204

advantage of having a baby after 35

Answer 204

More likely to be well educated, higher socioeconomic status, low parity, healthy, and exercise prudent health choices
• (Let’s Talk) greater satisfaction with the motherhood role, greater sensitivity to the needs of the child, and greater commitment to the parenting experience
• (Let’s Talk) more likely to be financially and emotionally stable; involved in a stable marriage
• (Let’s Talk) benefits from the varied adult life experiences. Have already accomplished their professional goals and are ready to realize the personal goal of parenthood

Question 205

disadvantage having a baby before 18

Answer 205

More likely to be of lower socioeconomic status and of high parity
• (Let’s Talk) Higher risk for preterm birth, for low birth weight infants, for increase neonatal morbidity, SGA, and low Apgar scores
• (Let’s Talk) lower educational attainment and a greater risk of welfare dependence and poverty than women who postpone childbearing past their teen years. Younger teen mothers were most likely to have a second teen birth within 24 months than teens who were not mothers
• (Let’s Talk) likely to keep the fact of pregnancy to themselves for some time due to fear of parental anger, disappointment and disapproval → delay in seeking prenatal care

Question 206

disadvantage of having a baby after age 35

Answer 206

Increased rates of fetal/neonatal mortality and, to a lesser extent, morbidity
• negative effect on birth weight at <10th percentile (IUGR, LBW)
• Increased incidence of Preterm Birth
• maternal medical conditions, such as hypertension and diabetes, are more often present
• Higher rates of c-section and intervention in labor, especially in nulliparous women
• (Let’s Talk) grandparents of the older mother are more likely to be absent or less able to help with the practical demands of child rearing.
• She may also be providing care for an elderly parent in addition to the new responsibilities of caring for her own child.
• women in a long term marriage relationship may find a significant role strain with the addition of a new family member that takes away time that was previously given to the spouse.

Question 207

• Identify major nutritional concerns related to pregnant adolescents

Answer 207

• (Let’s Talk) Adolescence is notoriously a time of erratic and often poor quality dietary habits. Needs of pregnancy compound an already compromised nutritional status for many pregnant adolescents.
• Young women have caloric intakes during pregnancy well below the RDA for gravid women → many pregnant teens gain less than 20 pounds during pregnancy → low birth weight and other perinatal complications.
• Early childbearing can set a young woman up for life-long obesity; competition for nutrients between the growing pregnant adolescent and her fetus; pregnant teens gain and keep more weight than their non-pregnant counterparts; if a teen has 2 pregnancies, she gains less height than other teens

Question 208

Therapeutic strategies for pregnant teens

Answer 208

o reducing adult height and increasing overweight → obesity and the incidence of chronic diseases from adolescence to adulthood.
• (Jordan PDF) Poor diet - Often deficient in calcium, iron, regular meals
• Weight gain - Body image issues Adolescent obesity

Question 209

• Understand the incidence and impact of physical abuse in pregnant adolescents.

Answer 209

More common in pregnant adolescents than in older pregnant women; Linked with a higher rate of dropping out of high school, second trimester bleeding, and substance use

Question 210

• Direct effects of physical abuse during pregnancy

Answer 210

abdominal trauma → placental abruption, premature rupture of membranes, and premature labor.

Question 211

• Indirect effects of physical abuse during pregnancy

Answer 211

probably more pervasive and ultimately may be more damaging to the women - depression, anxiety, isolation, decreased social support, low self-esteem, and the use of unhealthy coping behavior such as smoking and use of alcohol and drugs

Question 212

screening adolescent

Answer 212

• Adolescents must never be screened for abuse with a third person present.
o Screening for physical abuse at least every trimester instead of just at the first prenatal visit allows for a teen to establish a trusting relationship before deciding to disclose abuse
o Midwives also need to know other state’s reporting laws and act accordingly because states vary in how they interpret the status of pregnant adolescents.

Question 213

• Very young pregnant teens (younger than age 15) have special considerations. Higher incidence of impregnation by adult males (18 or older) than older adolescent girls

Answer 213

o This fact brings issues of statutory rape and legal ramifications into the picture. The 1996 federal welfare reform law calls for the reduction of adolescent pregnancy rates through aggressive enforcement of statutory rape laws at the local and state level
o At this young age, girls are not considered to have the cognition to be able to give adult consent to sexual activity with an adult male. State laws specify whether an age difference between sex partners is necessary for statutory rape to have occurred.

Question 214

• Understand how the Centering model of prenatal care benefits pregnant adolescents.

Answer 214

• Centering Pregnancy: model of group prenatal care that provides for the assessment, education, and support of pregnant women and may be particularly useful in adolescent populations.

Question 215

Programs that help young women

Answer 215

discover their inner strength
create environment for empowerment 
build community 
empowerment 
learn from each other 
problem solve 
increase sense of self worth 
gain self confidence 
equalize the power differential present in traditional care 
ownership of health behaviors and shares responsibilities 
discover their voice. 
exploration of the joys fears and concerns