OB Flashcards
Estrogen
- Effects secondary sex characterists
- Follicle Maturation
- Proliferation of endometrial Mucosa
Progesterone
- Decreases uterine motility and contractillity
- Build up the endometrium
- Proliferation of the endometrium
- Secretion of thick viscous mucus by the cervix.
Phases of Female Reproductive Cycle
A. Hypothalamus secretes
gonadotropin-releasing hormone (GnR)
What causes the anterior pituitary to relase FSH and LH?
GnRH
FSH-Follicle Stimulationg Hormone causes what?
Maturation of follicle.
(LH) Lutenizizing Hormone does what?
Increases production of progesterone, relase of mature follicle from the ovary.
OVARIAN CYCLE Follicle phase (days 1-14)
- Graafian follicle appears by day 14 under dual control of FSH and LH
Ovulation
What is Mittleschmerz
Discomfort of pain during ovulation
Does body temperature increase after ovulation.
Yes it increase 0.4 degrees as a reult of progresterone causing blood to come to the area.
Luteal phase
(days 15-28)
Begins when the ovum leaves follicle.
What are the phases of the endonmetrial cycle.
- Menstrual phase
- Proliferative phase
- Secretary phase
- Ischemic phase
- Menstrual phase again
Menstrual phase
Menstruation occurs in response to low levels of estrogen and prgesterone
Proliferative phase
The endometrial glands enlarge in response to increasing estrogen levels
Secretary phase
The endomtrium undergoes slight cellular growth due to estrogen, and progesterone cause marked swelling and growth.
Ischemic phase
Begins if fertiliaztion does not occur.
Fertilization
- Women usually ovulate 14 days before their menstrual period.
- After ovulation the ovum may remain viable for approximately 24 hours
- Sperm may remain ferlile for 72 hours (even up to 5 days)
- Fertilty
The caluclation of ferlie period based on the cycle calendar can be quite inaccurate, especially in the case of women with irregular cycles.
- Fertility
Monitoring of bilogical femal body changes helps to predict fertile and infertile periodss.
- Fertility
Changes in Cervical Mucus
- Fertility
During most of the cycle is scant, thick and sticky
- Fertility
Just before ovulation it becomes thin clear and elastic to promost the passage of sperm into the uterus and fallopian tubes.
- Fertility
Women may assess the elasticyt of their cervical mucus either to avoid or to promote conception. (Spinnbarkeit)
- Infertility
“Infertility is a disease defined by the failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse.
- Infertility
Is complex and often frustrating experience for the patient, as well as the clinician.
- Infertility
The reasons for infertility are varied and can sometimes be idiopathic in orgin.
4 Infertility
There are medical, ethical, as well as psychological components associated with it.
5 Infertility
Nurses need to be comfortable with own sexualty.
Sterility
Inability to achieve pregnancy
Primary Infertility
Those who have never conceived
Secondary Infertility
Those who have conceived in the past
Fecundity
The state of being ferfile; capable of producing offspring.
Etiology
- Ovulatory dysfunction (20-40%)
- Tubal and peritoneal pathology (30-40%)
- Male factors (30-40%)
- Uterine pathology is relatively uncommon
- The remainder is unexplained.
Ovulatory dysfuntion
-increases with age:aging on female fertility is clear; the fertility peak is between the ages of 20 and 24 years, decreases slighlty by age 32, and then declines progessively and more rapidly after age 40.
Spontanioius miscarrage increases from
10 percent in younger women, to 40% at age 40, even with assisted reprodductive technology.
This increase is due to progressive follicular depletion and a high incidence of abnormalities in aging oocytes.
Polycystic ovarian syndrome (PCOS) is another cause of ovarian dysfunction.
- PCOS is one of the most prevalent endocrine disorder inwoen, affecting 6% to 10% of women of childbearing age and accounting for 70% of anovulatory subfertily.
- PCOS requires work up for proper diagnosis.
- One of the most common causes is obesity, but PCOS is also found in normal weight women. Its diagnosis is importan not longer-term considerations, such as metabolic or insulin resistance syndrome and its associated consequences.
Hypothyroidism and Hyperprolactinemia
Can result in ovulatory dysfuction.
Tubal and Pelivic Problems include:
Endometriosis occurs when cells from the lining of the uterus grow in other areas of the body. This can lead to pain, irregular bleeding, and infertilty.
Tubal Scaring
From PID-Gonorrhea and Chlamydia
Asherman’s syndrome
Utererine currette (D & C)
Other causes are
endometritis and uterine surgery.
Smoking and drug use:
exposure to passive smoke have almost the same effect on infertilty-accelerated follicular depletion, abnormal menstrual cycles, and mutagenesis of the gamate or embryo.
Marijuana
inhibits secretion of GnRH and can suppress reproductive function of men and women.
Cocaine
can impair spermatogenesis in men and is associated with tubal disease in women.
Heavy alcohol consumption in men
can decrease semen quality and cause impotence it may decrease fertilty.
Environment factors
repeated exposure to chemicals, radiation, and heavy metals can cause repeated miscarriages and infertility in men and women.
Obesity
In women and men have a profound efect on infertity.- Men obesity is associated with abnormal semen parameters, such as motility and numbers.
Women obesity can cause repeated miscarriage, obulatory dysfuntion, neonatal and obsteric complications.
- Male factors
Abnormalities in the number, shape, swimming motion, and viscosity of sperm.
- Endocrine disorders
such as hypothalamic dysfunction, pituitary failure (surgery, tumor, radiation), hyperprolactinmia (tumor, drug); Thyroid disorders
- Adrenal hyperplasia
-excessive or deficient production of sex steroids
- Sexual Dysfunction
Retrograde ejactulation, Impotence, decreased libido.
Anotomic Disorders
Congential absence of vas deferens, obstruction of vas deferens, congenital abnormalites of ejaculatory system.
INFERTLITY STATS
Women age 15-44 with imparied fecunity is 6.7 million.
Percent of women ages 15-44 that have imparied fecudity is 10.8%
Number of married women 1.5 million.
Percent of married women 6%.
Number of women who have ever used fertility services 7.4 million.
Polycystic ovarian syndrome is treated with
the birth control pill
If Polycystic PCOS is not treated
women has a higher chance of getting type 2 diabetes down the line.
ABORTION -If D & C not complete
Dilation of Cervix- they go up and manual scrape the conceptions.
it can influence fertility later on in life.
Most common uterin currette
IS D & C
Oncofertility-Cancer treatment
Affects Fertility so they may seek out saving sperm and eggs before they undergo treatment.
Assisted Reproduction Technologies
Outcome of Pregnancies
15%-Miscariage
82%- percent live Births
(28% multiple, 54% single)
Meisosis of gametogenis
Production of new organsm
- Two cell state cell reduction
First Division
-Chromosomes replicate, pair and exchange information.
-Chromome pairs seperate, and cell divivides.
Second PART-
-Chromatids separate and move to opposite poles.
Cells divide, forming four daughter cells.
-Haploid cells (23 chromosomes: 22 autosome +1 sex chromosome
-Mutations (trisomy)
Gametes (sperm and ovum) unite to form a zygote (back to 46 chromosomes)
Fertilization
Occurs when one spermatozoon enters the ovum and two nuclei containing the parents chromsome merge Actual fertization takes place in the ampulla (outer third) of the fallopian tube.
GERMINAL STAGE
First 14 days of human development
Morula
(formed 12-16 cells)
Blastocyst
(100 cells)
Blastocyst is TWO PARTS
The INNER CELL MASS Develops into FETUS.
TROPHOBLAST (the OUTER LAYER OF CELLS that SURROUNDS the BLASTOCYST) Develops into placenta and fetal membranes.
Implantation of Conceptus-
- Must be in the right place at the right time.
- Site is important (fundal)
- Critical to have continuing supply of hormones (maintains the decidua-the endometrium, in the secretory phase)
- Occurs between the 6th and 10th day.
- The zygote secretes hCG (human chorionic gonadotropin)-> the corupus luteum continues to secrete Estrogen and Progestin.
- While hCG is a reliable marker of pregnancy, it cannot be detected untill after implanation: this results in fals negatives if the test is performed duriinng the very early stages of pregnacy.
FUNDAL AREA
Nuetral lining is best in that area and after baby is born uterus contract in that are less chance of getting post partum hemorage.
Because of HCG -Corpus Luteum
We continue to get progesterone and luteum.
- monozygote twins
A single Ovum and sperm which later divides into two identical infants.
- Monozygote twins
Same gentic makeup and gender
- Monozygote twins
uusually have two amnions, one chorion, one placenta
Dzygotic Twins
Two ova, fertilized by two differnt sperms
- May or may not be same gender, not identical (Fraternal)
- Two amnions, two chorions, two placentas.
Why do they occur.
A gentic factor that results in elvated serum gonadotropin levels can cause double ovulation.
-The chance of dyzygotic twins increases with maternal age up to about 35 years and then decreases abrupty.
Dizygotic Twinning occurs more often in black women than white women.
Where as the incidence of monyozygotic twins is approximatly the same in all populations.
Survial rate of twins
about 10% lower than that of dizygotic twins.
Embryonic State- 3rd to 8th week.
More likely time for any fetal damage due to teratogens.
-Tissue differentiate into essential organs.
TWINS
- Higher chance of ANEMIA.
- Babies are generally small
- Most likely preterm - amount of aminoitic fluid lower, blood transfusion from one baby to another.
Embryone state….Week 3
mestrual period is missed, embryonic disk- 3 germ layers form, early heart development starts.
Week 4
Folds at head and tail (forming C), neural tube closes, beginning of internal ear and ey, upper extermities bud, lungs and GI tract start development.
Week 5
Rapid brain grwth, heart is developing 4 chambers, lower extremities bud. The placenta works its way into the endometrium and it’s blood vessels. Nourishment is absorbed from the mother’s blood and the embryo rids itself of wast products from its metabolic system. The embryo is about 4 inches long. The head is very large due to rapid brain growth.
Progesterone
Has variance in the beginning of the pregnancy. Must be checked in the blood to make sure it is corilating with HCG levels. So both are elevated.
HCG level in first four weeks
see a lot of difference and fluctuations
1st trimsemster PROGESTERONE
12-20mg 5 to weeks of pregnancy.
Levels of HCG should be increasing at least
60% every 2-3 days.
Need other signs of symtoms can’t just depend on HCG
Because other diseases can immitate its production.
Week 6
Heart reaches final 4 chanber form, facial and ear development, midline gap closes, tail begins to recde, digists develop; a yolk sac can be seen inside the gestational sac. The yok sca insdie of the gestational sac, will be the earliest source of nutrietns for the developing fetus.
Week 7
Eyelids and internal organs form (liver, intestines, kidneys)
Week 8
Every system is formed, external genitalia still differntiating, eyelids are formed and fuse. Except external genitalia
External genetalia boy or girl
12 weeks of gestations.
Teratogens
If women is exposed early on more serious than later.
1.Toxoplasmosis-
-Teach patients to wash vegitable and fruit.
-Risk for eating raw or undercooked meat, uncooked eggs, unpasterurized mlk.
CLEAING CAT LITTER BOX.
- Toxoplasmosis
Miscarriage, mental retardation, micorcphaly, hydrocephalus, anemia, jaundice, deafness, and seizures.
Fortunatly, the later in pregnancy, the congenital infection occurs, the less severe the conswequences are to the fetus.
Syphilis
One small lesion can form on the body then when it accumuliates then it is too late.
Syphilis 1a
High risk of still birth or death shortly after birth.
Sometimes no symptoms.
Rubella
The most important consequences are miscarriages, still births, fegal anomalies, and therapeutic abortion.
Education of Rubella
Tell mother not to get pregnant after first month of getting immunization.
Rebella 2A
Most common malformations associated with CRS are Cataracts, cardiac defects, and deafness.
CMV- Herpes
It affects 50-85 % of adults in the USA by age 40.
Usually asymptomatic
-No treatment of CMV infection is a women who hasve become infected for the first time during (1-4)%
The fetus is at risk
(30%-40% will become infected in utero, and 15% of them will be sytomatic at birth)
Even though most of the affected infants survive, 90% of them have complications, such as hearing loss, vision impairment, seizures, developmental delay, and varying degrees of mental retardation.
Fetal Stage: (weeks 9-40)
Longest period of prenatal development
- All major systems are present in their basic forms, only growth and refinement during this phase.
- Teratogens less likely to damage already formed structures, however, can continue to damage CNS throughout pregnacy.
9-40 weeks fetal stage 1A
Body proportions change, eyes close and do not reopen until week 26, blood formation, urine production, by end of the 12th week fetal gender easily determined and fetal heart tones can be heard by a doppler.
Weeks 13-16
“Quickening” occuring for most women (for some not until up to 20 weeks)
Weeks 17-20
Vernix covers fetus, lanugo grows on body, brown fat starts to develop, eyebrows and head hair appear.
20 weeks
Myelination of nerves begins and continues throughout the first year, heart beat detectable with regular fetoscorpe.
Weeks 21-24
Skin translucent, lungs begin surfactant formation, immature gut and alveoli capilary exchange poor, poor survival chance.
Weeks 29-32
Skin thickens, nail present, good survival chance if born now.
Weeks 33-40
Mainly gaining weight, lungs mature, lanugo and vernix disappear by term, breast tissue palpable, tests are descending.
- HSV
While Herpes infection in adult rarely causes serious health, infection in infants can be lethal due to infants underdeveloped immune system.
- HSV
Requiring intimate personal contact, like intercourse kissing, or birth.
- If left untreated survival rate of infancts is 50%.
- Health problems that develop include: blindness, learning disabilities, spasticity, psychomotor retardation.
HIV
An infant born to an HIV+ mother has 25-45% risk of developming the disease.
An infected may be asymtomatic at birth, but soon menigntis, persistent thruh, chronic bacterial infections and the liver and spleen become enlarged.
HIV-2
Abstain from breastfeeding.
-Antiretrovirals (AZT or ZDV) during pregnacy (after 14th week)
Short corse for baby after birth for 6 weeks.
If all interventions are used only 2 percent chanc of getting infection.
QUICKENING
13-16 weeks- baby kicking.
GBS-GROUP B STREPTOCOCCUS
A leading of lifethretening perinatal infection
10-30 % percent of pregant women are colonized with GBS.
- An infant can get pneumonia, meningitis or overwelming sepsis.
- GBS-
Vascular compromise can result from GBS sepsis. Apnea, shock, disseminated intravascular coagulopathy (DIC), and peripheral gangrene may cause high mortality rates (5-20)% percent.
GBS treatment
Prenatally with PCN/Ampicillin will preven this cross infection from occuring.
OVER COUNTER OR PRESCRIBED DRUGS
FDA has developed a classification system for medications administered during pregancy.
Category A
No fetal risk
Category B
Animal studies show no risk, but no human trials done.
Category C
No adequate animal or human studies are avaialbe, or animal studies show teratogenic effect, but no human studies
Category D
Evidence of human risk exist, but the benefits outweigh the risks.
Category X
Severe fetal risk (benefits never outweighs the risks.
Street Drugs
Marijana, Cocaine, Heroin/Methadone, Amphetamine Oxycotin & Hydrocone.
INFANT EXPOSURE TO STREET DRUGS
1 in 10, there is a high risk population because of poor prenatal care and other infections (TB, STD’S, HIV.
Drug Test
Tox screen.
Tobacco
-Active ingredients: Nicotine, tar, carbon monoxide, cyanide.
Indicence: 10% of pregnant women smoke.
Neonatuatl consequences: fetal hypoxia
- 20% of all LBW
Increase risk for miscarriage, premature birth, and still births.
-Increase risk for SIDS
-Neuroligic and intellectual developmental problems that show up later in school.
Alchohol
No safe level for use in pregnancy
10% of pregnant women drink alcohol.
2 % engage in high risk behaviors-drinking two or more drinks per day or five or more drinks per occasion.
1 in 30 women report binge drinking. Women who binge heavily greatly increase the ris of alschol-related damage to their babies.
Alcohol incidence
0.5-1.5 chidlren per 1000 live births or 6,000 per year in the U.S.
Fetal Alcohol Syndrome (FAS)
FAS is the one of the most common causes of mental retardation.
- Syndrome charcterized by 3 clinical features.
1. Prenatatl and postat natal growth restrictions.
2. CNS imparimenent, microencephaly, low IQ -lower than 70, high activity level, short attention span. - recongizable facial features- short palpebral fissures, flast midface, indistint philtrum, thin upper lip, small chin.
Pollutants chemicals
Metals: Lead paint and water pipes, Cadmiumwelding, ceramics, paiting, Mercury- Large fish and dental offices.
- Solvents: semiconductor plants, photography
- Lacquers & paints: silk-screening, artists
- pesticides: arsenic-food & drinking water
- Cleaning products.
Radiation
X-rays especially in early pregnancy can camage the fragile developing fetus- including stunted grwoth, deformities, adnormal brain function, or cancer than may develop sometime later in life.
-Pregnant women should avoid x rays, or be shielded with a lead apron if needed.
Diabetitis Militis.
Most common disrder associated with pregnancy. 2 to 5% of all preganancies.
-complication pregnanies.
-Birth defects 5 to 10%.
Spontaneous Abortions- 15-20 percent. Increase risk for trauma to baby.
DIABETIS
-Congential cardia disease, anecephaly, macrosomia.
Heart Disease
-Heart disease- stresses cardiovascul system, congenical cardiac disease.
Phenylketonuria
microcephaly, cardiac disease.
Genetic linked diseases
Sickle cell, thalassemia.
Patient teaching. (M PARTUM)
A women with a special disorder should seek medical care before attempting pregnacy and should be in as stable condition as possible. Genetic couseling is also advisable prior to pregancy for women with know gentic problems in their family.
+ preganant women should never discontinue or begin taking meds without consulting MD.
Early Pregnancy
- Spontaneous Abortion
- Etopic Pregancy
- Hydatidiform Mole (Molar pregnancy)
- Hypermesis Gravidarum.
Spontaneous Abortion
20% of all preganancies end in spontaneous abortion.
Etiology of SA
Most are related to chrmosomal abnormalities, others are related to teratogens, faulty implanation, materal infections, materanl hormonal defiencies.
S x S of Spontaenous Abortion
cramping, backache, bleeding
Treatment- of SA
Bed rest, abstinence from sex, D and C if incomplete Abortion or hemorrhage.
POST SA TEACHING
Support for family this time of grieving.
-Vaginal bleeding can be significant and life threating: emergency IV fluids and medication may be needed.
Ectopic Pregancy
Implantation of ferized ovum in an area outside the uterine cavity.
-98 percent are flopian tube.
ETOPIC PREGNACY S x S
- Missed Menstraul Period
- Abdominal Pain- (one sided)
- Vaginal Spotting
- HYPOVOLEMIC SHOCK SYMTOMS- If TUBE rupters-pt may have shoulder or neck pain with minimal or no external bleeding.
Metabolic Changes during Pregnancy
- Normal Preganancy
1. Hyperinsumia
2. Insulin resistance.
1st Trisemsemster
Increase in estrogen and pregesteron, increase in insulin production in 2nd and 3rd trisemester.
- INCREASE in HPL and HGH
- -Decrease in Gluclose
- Increase in resistance
- Decrease in heapatic gycogen stores
- Increase in hepatic production of gluclose.
1st trisemester
hypoglycemia.
2nd and 3rd trisemester
hyperglycemia.
RISK of ETOPIC PREGNANCY
Hx of STD's Hx of Pelivic Inflamatory Disease Hx of previous ectopic preganices Failed Tubal Ligation Use of an IUD -Multiple induced Abortions -Materal age > 35
Etopic Pregnacies
- therapeutic Management depends on whther the tube is intact or ruptured.
- If tube intact: and embryo is < 3.5 cm-Methotrexate (inhibits cell division in the embryo causes SAB) or surgical removal (Salpingotomy)
- If Tube ruptured: goal is to control bleeding and prevent shock. Salipingetomy (removal of the tube) is performed. Emergency IV fluids and medication maybe needed.
Hydatidiform Mole (Gestational Trophoblastic Disease)
A hydratidiform mole is a relatively rare condition in which tissue around a fertilzed egg (that normally would have developed into the plancenta (Trophoblasts cells) develops into an abnormal cluster of grapelike cells.
Two types:
-Complete- empty egg fertized by normal sperm, associated with cancer.
Partial- too many chromosomes.
Hydatidiforms Mole.
Occurs in about 1 out of 1,000 pregancies in the United States. In some parts of Asia, however, the incidence mayb be as high as 1 in 200.
Prognosis: HM
If not removed, about 15% of molse can become cancerous. They burrow into the wall of the uterus and cause serious bleeding. Another 5% will develop into fast growing cancers called choricarcionmas.
Signs/symptoms. HM
Elevated levels of hCG, brownish vaginal bleeding “pune juice”, uterous laRGER THAN GESTATIONAL AGE, no fetal heart tones, excessive N & V labboratory evaluation to r/o chorliocarcinoma. follow up for malignancies for one year: DXR, MRI, CBC, Serum hCG levels every 1-2 weeks.
-no pregnancy for 1 year.
Psychosocial conderns.
Hyperemesis Gravidarum
A persistent, uncontrollable vomitting
- Can continue throut pregnacy
- Can lead to weight loss, dehydration, ketosis and electrolyte imbalance (particularly potassium loss)
Risk factors for Hyperemeis Gravidarum
-Young age
-first pregnancy
Problems with n/v in previous pregnacy
-Hx of intolerance to oral contraceptives
-Previous gallbladder disease.
Therapuetic Management of Hyperemis Gravidarium.
Drug therapy (Phenergan, Benadryl, Reglan, Zofran)
- IV fludids with Potassium (possibly TPN)
- Offer small, frequenct, portions of food, with no strong odors or tastes, high in Potassium and Magnesium. Simple carbohydrates may be tolerated best.
- Emotional support.
CBS GROUP B
Women must get treatment ONE TO TWO DOSES at about 4 hours prior to delievery. - We want to prevent real serious infections.
TYLONAL
Category B.
Folic Acids and Prenatal Vtamins are
Category A
Sinfloid and Sinclair , gluborite
Category C
