OB Exam 1 Flashcards
Long Acting Reversible Contraception
- IUDs
- Sterilization
- Implant
Induced Abortion
Purposeful interruption of pregnancy before 20 weeks of gestation
Therapeutic Abortion
Abortion for medical reasons
Aspiration
Most common abortion procedure in first trimester
Medical Abortion
- Mexotrexate and misoprostol
- Mifepristone and misoprostol
Dilation and Evacuation
- 2nd trimester abortion
- Can be performed at any point up to 20 weeks gestation (13-16 weeks is most common)
Meiosis
- Each oogonium produces a single haploid ovum once some cytoplasm moves into the polar bodies
- Polar bodies will degenerate
- Born with oogonia that can develop into eggs
- FSH causes follicular cells to proliferate -> form the Zona pellucida and Atrum -> use cholesterol to form estrogen (or testosterone in men)
- Estrogen surge leads to negative feedback which causes LH surge and follicle opens up to release oocyte
- Each spermatogonium produces four haploid spermatozoa
Cleavage
Rapid mitosis
Cellular Multiplication Progression
Blastomeres->Morula->Blastula->Blastocyst
Cellular Differentiation
- Begins in the blastocyst
- Inner cell mass becomes embryonic tissues and amnion
- Trophoblast becomes placenta
- All tissues develop from the primary germ layers
- Ectoderm (skin, peripheral nerves)
- Mesoderm (muscles, CV system, organs)
- Endoderm (inner lining of organs)
- Amnion (amniotic sac)
- Yolk Sac (not important in humans)
- Allantois (umbilical cord)
- Chorion (surrounds entire amnion, develops chorionic villi which is the fetal portion of the placenta)
Implantation
Occurs around the time the blastocyst is developed
Corpus Luteum
- Endocrine gland within the ovary
- LH stimulates the release of progesterone (hormone of pregnancy)
Ectopic Pregnancy
- Egg is fertilized and remains in the fallopian tube
- Causes severe abdominal pain
Amniotic Fluid
- Slightly alkaline
- Lungs are last to develop and need amniotic fluid
- Functions = cushions against injury, maintains temperature, permits symmetric growth and muscle development, extension of fetal extracellular space, stops fetus from adhering to amnion and prevents cord compression)
- Oligo = not enough fluid
- Polygo = too much fluid
Betamethasone
- Given x2 for people at risk for premature delivery
- Corticosteroid
- Promotes growth by increasing metabolism
Water breaking
- 39-40 weeks not worried
- 20 weeks very worried
- Worry about infection
Umbilical Cord
- Fuses with the embryonic portion of the placenta
- Delivers oxygenated blood and nutrients to the fetus
- Returns deoxygenated blood and waste to the placenta
- Provides circulatory pathway from chorionic villi to embryo (1 vein, two arteries)
Placenta
- Metabolic and nutrient exchange
- Maternal portion = from decidua basalis, cotyledons
- Fetal portion = chorionic villi, covered in amnion (shiny, gray)
- Placenta and embryo are homografts (exempt from immunologic reaction by host; progesterone and hCG suppress cellular immunity during pregnancy)
Fetal Circulation
- Complete 17 days after conception
- Umbilical Circulation = arteries bring oxygen poor fetal blood to placenta, vein carries oxygen rich blood back to fetus
Functions of the Placenta
- Produce glycogen, cholesterol and fatty acids
- Enzyme production
- Stores glycogen and iron
- Breaks down substances like histamine and epinephrine
- Produces hormones (hCG, progesterone, estrogen, hPL, relaxin, inhibin)
Ductus venosus
- bypasses liver to IVC
- connects umbilical vein to vena cava
Foramen ovale
- bypasses right ventricle
- takes up to 6 months to close
- most blood “skips” the lungs
Ductus ateriosus
- bypasses lungs by connecting pulmonary artery to descending aorta
- takes 3 days to close
- helps blood that would have come to lungs out of the system and into the aorta
Embryonic Stage
-day 15 to week 8
-tissues differentiate into essential organs
3 weeks = heart is most advanced
4-5 weeks = somites develop, heart beats and circulates blood, eyes and nose begin to form, arm and leg buds present
6 weeks = head is more developed, jaws and palate start to form, liver is producing blood cells, trunk straightens, digits develop, tail begins receding
7 weeks = head is rounded, GI and GU are separate tracts
8 weeks = embryo is 3cm, resembles a human, facial features continue to develop
Fetal Stage
-9 weeks until birth
-every organ and structure is present, structures grow, refine, and perfect function
9-12 weeks = eyelids are closed, tooth buds appear, genitals well differentiated, urine is produced, fetal heart can be heart, spontaneous movement
13-16 weeks = lanugo begin to develop, blood vessels clearly developed, active movements present, makes sucking motions, swallows amniotic fluid, produces meconium
20 weeks = subcutaneous brown fat appears, quickening felt by mother, 8 inches long
24 weeks = eyes structurally complete, vernix caseosa covers skin, alveoli beginning to form, viable outside the womb
25-28 weeks = testes begin to descend, lungs structurally mature (functionally still developing), rapid brain development
29-32 weeks = rhythmic breathing movements, ability to partially control temperature, bones fully developed but soft and flexible
35-36 weeks = increase in subcutaneous fat, skin is plump and less wrinkled, lanugo begins to disappear
38-40 weeks = skin appears polished, maternal antibody transfer (TDAP vaccine!), lanugo disappears except in upper arms and shoulders, fetus is flexed
Factors Influencing Fetal Development
- Quality of sperm and ovum
- Genetic code
- Adequacy of intrauterine environment
- Maternal nutrition - folic acid
- Teratogen exposure
Subjective (Presumptive) Signs of Pregnancy
- Amenorrhea
- Nausea, vomiting (morning sickness)
- Excessive fatigue
- Urinary frequency
- Breast changes
- Quickening
Objective Signs
- Enlargement of the abdomen/palpable fundus
- Changes to pelvic organs and uterus on exam
- Braxton Hicks contractions
- Abdominal striae
- Changes in skin pigmentation
- Uterine souffle
- Pregnancy tests of blood and urine
Diagnostic Signs
- Auscultation of fetal heartbeat by doppler device
- Fetal movement - palpable about 20 weeks’ gestation
- Visualization of the fetus by ultrasound
Uterus
- Enlargement due to hypertrophy
- Thickening of walls (initially through estrogen and progesterone, then pressure from uterine contents)
- Increased vasculature and lymphatics
Cervix
- Estrogen stimulates increase in glandular tissue
- Develops mucus plug (seals cervix and prevents bacteria from ascending the reproductive tract)
- Increase in regular cervical mucus
- Increased vasculature
Ovaries
- Cease ovum production
- Follicles develop and produce some hormones
- Human chorionic gonadotropin (hCG) maintains corpus luteum
- Corpus luteum secretes progesterone until placental production is sufficient
Vagina
- Estrogen causes hypertrophy, hyperplasia, and increased vascularization
- Connective tissue loosens
- Increase in acidic secretions
- Increased blood flow
Breasts
- Estrogen and progesterone cause glandular hyperplasia and hypertrophy
- Areolas darken
- Nipples become more erect
- Striae may develop
- Colostrum at 16-22 weeks
Respiratory System During Pregnancy
- Tidal volume and oxygen consumption increase
- Breathing changes from abdominal to thoracic
- Vascular congestion of nasal mucosa
- Worry about respiratory viruses
Cardiovascular System During Pregnancy
- Heart moves forward, up, and to the left
- 40-50% increase in blood volume
- Increased cardiac output
- Decreased systemic and pulmonary vascular resistance
- Slightly decreased blood pressure
- Increased pulse
- Femoral venous pressure slowly rises (lower extremity swelling)
- Supine hypotension
Hematologic Changes During Pregnancy
- Physiologic anemia due to increased plasma in bloodstream, not loss of RBCs
- Plasma increases 50%
- RBC increases 25%
- Increased WBC
- Increased platelets
- Plasma fibrinogen increases = hyper-coagulation, higher risk of PE and DVT
GI During Pregnancy
- Slows down to absorb everything (caused by hormonal changes and uterine pressure)
- GERD, n/v, differences in taste/smell, ptyalism (overproduction of saliva), gingival hypermia (soft, bleeding gums), slowed gallbladder emptying, bloating, constipation, hemorrhoids
Urinary Tract During Pregnancy
- Pressure on bladder causes frequency, decreases capacity
- Dilation of kidneys and ureters (Kidneys/glomerulus have to accommodate increased fluid)
- Increased GFR and renal plasma flow
Skin and Hair During Pregnancy
- Hyperpigmentation
- Facial chloasma = dark spots on face
- Linea nigra = darkening along the line of abdomen
- Striae = stretch marks
- Decreased hair growth
- Vascular spider nevi
- Hyperactive sweat and sebaceous glands
- Melasma = t-shaped rash
Musculoskeletal System During Pregnancy
- Pelvic joints relax
- Waddling gait
- Pubic symphysis separates
- Center of gravity changes
- Spinal curve accentuates
- Separation of rectus abdominis muscles
CNS During Pregnancy
- Decreased attention, concentration, memory
- Sleep problems
- Restless legs
Thyroid Gland During Pregnancy
- Palpable changes
- T4 increase
- BMR increase
- TSH decreases
- Slows down so resources go to baby
Parathyroid Gland During Pregnancy
- Concentration of PTH increases
- Parallels fetal calcium requirements
Pituitary Gland During Pregnancy
- Anterior = FSH, LH, TSH and ACTH alter maternal metabolism to support pregnancy, prolactin responsible for lactation
- Posterior = oxytocin and vasopressin are secreted
Adrenal Glands During Pregnancy
Increased aldosterone
Pancreas During Pregnancy
- Increased insulin needs
- Insulin resistance keeps more glucose in the body and crosses into the placenta (insulin is too big to cross placenta but glucose can)
Psychological Response to Pregnancy
- Stress and anxiety
- Introversion
- Mood swings
- Changes in body image
Couvade
- Sympathetic pregnancy
- Men experience pregnancy-related symptoms (physical or emotional)
Spontaneous Abortion
Miscarrage
Therapeutic Abortion
Abortion through medical or surgical intervention
Stillbirth
fetus born deceased after 20 weeks gestation
Term
37 0/7 weeks or greater
Preterm Labor
labor after 20 weeks but before completion of 37 weeks
Post Term Labor
- Labor after 42 weeks gestation
- Bad because placenta degrades after 42 weeks
Gravida
- a pregnant woman
- any pregnancy, including present pregnancy
Nulligravida
woman who has never been pregnant
Primigravida
woman pregnant for the first time
Multigravida
woman pregnant in second or subsequent pregnancy
Para
a woman who has given birth after 20 weeks gestation, whether infant born alive or deceased
G T P A L
Gravida Term Preterm Abortion Living Children
Schedule of Prenatal Visits
First visit during first trimester (8-10 weeks)
Every 4 weeks until 28 weeks - check for gestational diabetes
Every 2 weeks until 36 weeks - GBS swab
Every week after 36 weeks
First Prenatal Visit
Initial patient history, past medical history, family medical history, partner’s history, prenatal risk factor screening, patient health profile, establish pregnancy dating, physical assessment, PE/pelvic exam, depression screens
Pelvic Exam
cervical cancer screening, STI screening, pelvimetry
Fetal Heatbeat
Audible by doppler at 10-12 weeks
Ultrasound
Gestational sac visible at 4-5 weeks
Subsequent Prenatal Visits
- Urinalysis for protein/glucose
- BP
- Weight
- Fundal height
- Leopold maneuvers
- Fetal heart tones
Danger Signs in Pregnancy
- Sudden gush of fluid from vagina
- Vaginal bleeding - want to quantify (how much/how many pads)
- Abdominal pain - rupture, gallbladder/stones, pancreatitis,
- Temperature over 101/chills
- Dizziness, blurring of vision, double vision or spots (signs of HTN and eventually preeclampsia)
- Persistent nausea and vomiting
- Severe headache
- Edema of hands or face
- Seizures or convulsions
- Epigastric pain
- Dysuria - urinary frequency, -UTI’s (present differently in pregnancy, doesn’t have to have be burning) can cause membranes to get infected and water will break prematurely
- Absent or decreased fetal movement (esp after 20 weeks)
Teaching Topics in 1st Trimester
Explanation of labs, danger signs, orientation to health record, environmental hazards, genetic counseling/testing, nutrition, normal changes of pregnancy
Teaching Topics 2nd Trimester
Fetal movement, signs of preterm labor, emotional/family adjustments, prenatal classes
Teaching Topics 3rd Trimester
Fetal movements, signs of preterm labor, signs of labor/when to come in, circumcision, birth plan, pain relief options, labor complication, cesarean, postpartum prep
Pregnancy Tests
- Measure beta hCG (human chorionic gonadotropin)
- Urine or blood
- Home or laboratory
- Quantitative beta hCG testing
First Trimester Screening
- Pap smear (if not up to date with routine care)
- Urine culture and urinalysis
- Complete blood count (CBC)
- Rubella titer
- ABO and Rh typing
- HIV screening
- Hepatitis B - the most fatal virus
- STI screening
Screening Throughout Pregnancy
- Gestational diabetes screening test (28 weeks)
- H&H (physiologic anemia - blood volume increases throughout pregnancy so H&H can go down)
- Group B strep (GBS) testing
- Hemoglobin electrophoresis - measures the different types of hemoglobin in the blood, looks for anemias
- CF testing - if mom is negative it won’t pass onto baby
- Varicella immunity
- PPD for TB
Genetic Testing
-Fetal aneuploidy
-Neural tube defects
First Trimester screen at 11-13 weeks (blood work, ultrasound for nuchal translucency, CAN’T detect NTDs)
Quadruple Screen (15-25 weeks) alpha-fetoprotein, hCG, unconjugated estriol, inhibin A, down syndrome, trisomy 18, spina bifida, abdominal wall defects
Cell-free DNA (cfDNA) Testing
NIPS (noninvasive prenatal screening)
Can detect aneuploidies
Only a screening, not diagnostic
Amniocentesis
- Invasive
- Ultrasound guided aspiration of amniotic fluid
- Can also assess lung maturity
- Side Effects = Transient vaginal spotting/bleeding, amniotic fluid leakage, chorioamnionitis, early amniocentesis – higher rate of loss, preterm labor
Chorionic Villus Sampling
- 13 weeks
- Needle aspiration of chorionic villi from placenta
- Diagnose genetic, metabolic, and DNA abnormalities
- Cannot detect neural tube defects
- Normal does not ensure a healthy infant
- Risks = spotting, fluid loss, infection, spontaneous abortion, fetal limb reduction defects, maternal tissue contamination, oromandibular defects, Rh isoimmunization
- Benefits = early diagnosis, provides fetal karyotype, sex determination, detects hemoglobinulipathies, PJU, down syndrome, duchenne MD, factor IX deficiency
Non-stress test
- After 3 weeks
- Assess fetal wellbeing
- Accelerations imply intact CNS
- Accelerations = 15 bpm above baseline for 15 seconds
Contraction Stress Test
Start Ptocin until we get contractions and see how baby tolerates them
Biophysical Profile
fetal breathing movements gross body movements fetal tone reaction heart rate/non-stress test amniotic fluid volume
Fetal Movement Assessment
- Kick counts, fetal movement count
- Vigorous movement = well fetus
- Decreased movement = possible oxygen compromise, further testing required
- Goal is 10 movements in 2 hours
- Can’t be used before 28 weeks
Amniotic Fluid Index
- Measures amount of fluid around the fetus by US
- AFI of 5 or less requires further evaluation
Ultrasound
- Noninvasive
- Transabdominal or transvaginal
- Limited
- Standard
- Specialized
Fetal Fibronectin (fFN)
- Indicator for preterm labor
- Swab of vaginal secretions
- Glycoprotein found in trophoblast and fetal tissues
Indicators of Fetal Lung Maturity
- Lechitin Sphingomyelin Ratio
- Lamellar Body Counts
- Phosphatidylglycerol
Metabolic Changes During Pregnancy
- Increased protein retention
- Fats more completely absorbed
- Fat deposits increase
- Body switches from glucose to lipid metabolism
- Demand for carbs, iron, and calcium increases
- Increased water retention (supports extra blood volume, fetus, and growing structures)
Weight Gain Recommendations
Normal Pre-preg Weight = 25-35lb
Overweight Pre-preg = 15-25lb
Obese Pre-preg = 11-20lb
Underweight Pre-preg = 28-40lb
Nutrition Requirements
- Caloric needs = 1st trimester no change, 2nd and 3rd at 3 cal/day
- Carb needs increase
- Protein increase
- Fat increase
- Calcium increase
- Zinc essential for DNA/RNA synthesis
- Iron necessary to support fetus, placenta, and increased maternal blood volume
- Folic acid
Foods to Avoid
- lunch meat (unless heated)
- Raw milk, fish, meat, eggs
- Soft cheeses
- Unpasteurized foods
- Refrigerated smoked meats and plates
Eating Disorders
Higher risk of miscarriage, preterm birth, low birth weight, and perinatal mortality/birth defects
Pregnancy Induced Pica
- Persistent craving for and eating of non-foods
- Soaps, laundry detergent, soil, ice, pain, wood
- Iron deficiency anemia is a frequent cause
Postpartum Nutrition
- 10-12 lb immediate weight loss
- Pre-pregancy weight by 6 months
- Breastfeeding = 500 extra calories/day
- Continue prenatal vitamin
Relief of Nausea/Vomiting
- Small frequent meals
- Cracker before getting out of bed
- Avoid triggering smells
- Accupressure
- Medications (doxylamine, onsdansetron, prochlorperazine, promethazine)
Relief of Hyperemesis Gravidarum
- Control vomiting
- Correct dehydration and electrolyte imbalance
- TPN if no response
Relief of Urinary Frequency
- Frequent bladder emptying
- Maintain adequate fluid intake
Relief of Fatigue
- Schedule that allows nap/early bedtime
- Will improve in second trimester
Relief of Breast Tenderness
Well-fitting supportive bra
Relief of Nasal Stuffiness and Epistaxis
- Cool air vaporizer
- Saline nose drops
- Avoid nasal sprays
Ptyalism
- Mouth washes
- Chewing gum
- Hard candy
Relief of Increased Vaginal Discharge
- Daily bathing
- Never douche
Relief of Heartburn (Pyrosis)
- Avoid overeating, fatty/fried foods, and laying down after eating
- Low sodium antacids and H2 blocker if persistant
Relief of Varicose Veins
- Elevation of legs
- Supportive hose, elastic stockings
- Avoid crossing legs
Relief of Constipation
- Increased fluid intake and fiber
- Exercise
Relief of Backaches
- Pelvic tilt
- Support belts
- Proper body mechanics
Restless Leg Syndrome
Might be associated with iron deficiency
Relief of Round Ligament Pain
- Heating pad
- Reassurance
Fetal Activity Monitoring (Kick Counts)
- Begin at 28 weeks
- Get comfortable, eat something
Employment
- Can work until labor starts
- Be aware of environmental hazards, overfatigue, excessive physical strain, proper posture/body mechanics
Travel
- Frequent breaks with car travel
- Fly safe until 36 weeks
- Wear support hose
- Drink plenty of fluids
Sexual Activity
-Sex is safe during healthy pregnancy
Dental Care
- Continue with regular dental cleanings
- Avoid screening x-rays if possible
- Soft toothbrush for hyperemic gums
Immunizations
- Catch up prior to pregnancy
- No live attenuated virus vaccines
- Tdap recommended during 3rd trimester of every pregnancy
- Flu vaccine recommended
Herbs to avoid
- Abortifacient herbs
- Nervous system stimulants
- Stimulant laxatives
Teratogens
- any substance that adversely affects normal growth and development of the fetus
- Includes medications, work/chemical exposures, radiation, infections, tobacco, caffeine, alcohol
Caffeine use
Linked to birth defects, spontaneous abortions, preterm birth
Childbirth Educators
- Certified experts
- Teach families, individuals, or groups
Types of Childbirth/Prenatal Education Classes
- Natural (unmedicated) childbirth
- Cesarean birth education/VBAC (Vaginal Birth After Cesarean) classes
- Breastfeeding programs
- Parenting classes
- Sibling and pet classes
- CPR/safety
5-1-1 Rule
contractions every 5 minutes lasting a minute for an hour
Tips for False Labor
- Drink water
- Rest if moving
- Get up if you have been sitting for awhile
Delay of Pushing
First baby mom pushes for 2-3 hours so don’t want to start too soon or mom will get tired and will potentially end in c-section
Comfort Measures During Labor
- Relaxation, meditation and breathing
- Position changes, walking, rocking
- Massage
- Hydrotherapy
- Aromatherapy
- Music
- Use of hot/cold
Newborn Issues
- Medications at birth (erythromycin in eyes, vitamin k)
- Circumcision
- Choosing a pediatrician
Breastfed Baby
- Baby will lose weight initially
- 2 weeks to get back to birth weight
Exercises to Prepare for Childbirth
-Pelvic tilt = reduces back pain, hands and knees or standing position
-Abdominal exercises = tighten abdominal muscles with each breath, partial sit-ups
-Perineal exercises (Kegel) =
strengthen the pelvic floor
-Inner thigh exercise = sit cross-legged whenever possible, stretches muscles to prepare for positioning in childbirth
Birth Plan
- Birth setting
- Healthcare provider
- Support during labor – partner, family, doula
- Other children present
- Comfort measures
- Pharmacologic pain relief
- Medical procedures
- Newborn care
Doulas
- Trained support person during labor or the postpartum period
- Advocate for the patient
Adolescent Pregnancy Contributing Factors
Cultural factors, education, psychosocial (family disfunction, poor self esteem, abuse, mental illness)
Adolescent Pregnancy Risks to Mother
- Likely to receive late prenatal care
- Higher rates of STIs
- Psychological risk
- Social and economic disadvantages
- Less likely to complete schooler
- Longer dependence on parents
- Dating violence, consent issues
Adolescent Pregnancy Risks to Child
- Generally developmentally disadvantaged
- Preterm delivery
- higher rates of abuse/neglect
- More likely to become adolescent parents themselves
Advantages of Delaying Parenthood
- Tend to be well educated and financially secure
- More aware of realities of having a child
- Feel secure about taking on added responsibility of child
- May be ready to stay home with new baby
- Can afford good childcare
- Children have improved health and developmental outcomes
Medical Risks of Delayed Parenthood
- More likely to have chronic medical conditions
- Increased rate of miscarriage
- Increased rate of difficult labor and Cesarean delivery
- Increased risk of having an infant with Down Syndrome and other chromosomal abnormalities
- Possibly increased risk of autism
- Increased risk of twin pregnancy - body releases more than one egg, fertility treatments
- Gestational diabetes mellitus
- Hypertension and preeclampsia
- Placenta previa
- Increased incidence of low-birth-weight and preterm infants
- Increased stillbirths
LGBTQIA+ Pregnancy
- Creating an inclusive healthcare setting
- History taking
- Concerns about confidentiality and disclosure
Transgender Male Pregnancy
- Need to stop testosterone
- Ask how they refer to their body parts
Perinatal Loss
death of a fetus or infant from the time of conception through the end of the newborn period
Intrauterine Fetal Demise (IUFD)
- loss of a fetus after 20 weeks gestation
- Risk factors = history of IUFD, diabetes, obesity, non-hispanic black women, substance use, HTN, infection, late prenatal care, antiphospholipid syndrome
- May choose to go into labor naturally or induce labor
Ectopic Pregnancy
- implantation of fertilized ovum in a site other than uterine lining (ampulla of uterine tube is most common)
- Risk Factors = tubal damage/abnormalities, endometriosis, high progesterone, smoking, advanced maternal age
- embryo outgrows space and ruptures, bleeding into abdomen
- Treatment with mexotrexate or laparoscopic surgery
Recurrent Pregnancy Loss
three or more consecutive failed clinical pregnancies
Infertility
- failure to achieve pregnancy after 12 months of unprotected intercourse or therapeutic donor insemination
- After 6 months for age 35+
- Initial Care = ovulation/cycle tracking, reducing stress, improving nutrition, reduce risk factors for decreased sperm motility
- Semen analysis
- Causes in Women = ovulatory tissues, inhospitable cervical mucus, structural abnormalities of uterus/fallopian tubes
- Causes in Men = structural abnormalities, obstructions
Spontaneous Abortion
- Loss of pregnancy without outside intervention before 20 weeks gestation (miscarriage, SAB)
- Early = chromosomal issue
- Later = maternal cause
- Risk Factors = increasing maternal age, prior pregnancy loss, infection, diabetes, obesity, thyroid disease, stress, inherited thrombophilia, teratogen exposures
Threatened Abortion
unexplained bleeding, cramping without cervical dilation. May resolve or result in abortion
Imminent Abortion
bleeding and cramping with cervical dilation
Septic Abortion
abortion due to infectious causes
Missed Abortion
- fetal death without expulsion
- may require procedure to remove
Gestational Trophoblastic Disease
- Signs = vaginal bleeding (dark brown), anemia, uterine enlargement, hyperemesis gravidarum, preeclampsia
- Suction evacuation and curettage of uterus
- Careful followup
Post-Birth Evaluation After Loss
- Physical examination of fetus and umbilical cord
- Placenta to pathology
- May consider chromosomal studies
- May do maternal CBC, hba1c, thyroid studies
Neonatal Death
- Loss of newborn within first 28 days of life
- Comfort measures vs life sustaining measures
Management of Infertility
- Ovulation inducing meds (clomid)
- Hormones (gonadotropins, GnRH)
- Intrauterine insemination = insertion of sperm into reproductive tract
- In vitro fertilization = implantation of fertilized egg into the uterus
Helpful Actions with Loss
- Listen
- Talk about baby by name
- Facilitate holding the baby
- Do or make or give something in memory of the baby
Maternal Death
Death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes
Amenorrhea
- Absence of menstrual flow
- The absence of both menarche and secondary sexual characteristics by age 14
- Primary Amenorrhea = the absence of menses by age 16, regardless of presence of normal growth and development
- Secondary Amenorrhea = a 6-month or more absence of menses after a period of menstruation
Hypogonadotropic Amenorrhea
- Problem in central hypothalamic-pituitary access
- Results from hypothalamic suppression due to stress, weight loss/strenuous exercise, eating disorders, mental illness
- Pituitary then cannot release FSH or LH
Premenstrual Syndrome (PMS)
- Cyclic symptoms occurring in luteal phase of menstrual cycle
- Clusters of physical, psychologic, and behavioral symptoms
- Management with diet, exercise, ibuprofen, herbal therapies
Premenstrual Dysphoric Disorder (PMDD)
- Severe variant of PMS
- Specific criteria for diagnosis
Endometriosis
- Presence and growth of endometrial tissue outside of the uterus
- Symptoms = dysmenorrhea (severe menstrual cramps and pain), deep pelvic dyspareunia (painful intercourse)
- Management with drug therapy, surgical intervention
Menopause
- Complete cessation of menses
- Anovulation occurs more frequently
- Menstrual cycles increase in length
- Ovarian follicles become less sensitive to hormonal stimulation from FSH and LH
- Ovulation occurs with less frequency
- Progesterone is not produced by the corpus luteum
- FSH values are elevated
Dypareunia
- Pain during intercourse
- Causes = hormonal fluctuations, medications, vaginismus, psychological problems, stress
Management of Menopause
- Sexual counseling
- Nutrition
- Exercise
- Medications for osteoporosis
- Midlife support groups
Candidiasis
- Yeast infection
- Predisposing Factors = antibiotics, diabetes, pregnancy, obesity, diets high in refined sugars, use of corticosteroids and hormones, immunosuppressed states
Vulvovaginitis
Inflammation of vulva and vagina
Bacterial Vaginosis (BV)
- Risk Factors = multiple sex partners, douching, lack of condom use, lack of vaginal lactobacilli
- Fishy odor
- Treatment with metronidazole orally
- Treat with metrogel vaginally
Trichomoniasis
- Caused by trichomonas vaginalis
- Almost always sexually trasnmitted
- Common cause of vaginal infection
- Inflammation of the vagina/vulva
- NAAT test recommended
- Speculum examination with wet mount
- Treatment with metronidazole or tinidazole in single dose
Group B Streptococci
- Associated with poor pregnancy outcomes
- Screening at 36-37 weeks gestation
- Intrapartum intravenous prophylaxis (usually penicillin)
Chlamydia
- Infections often silent and highly destructive
- Difficult to diagnose
- Management with doxycycline or azythromycin
Gonorrhea
- Women often asymptomatic
- CDC recommends screening all women at risk
- All pregnant women should be screened
- Antibiotic therapy (ceftriaxone and azythromycin dual therapy)
Syphilis
- Caused by treponema pallidum
- Can lead to systemic problems and even death
- Primary = 5-90 days after exposure
- Secondary = 6 weeks - 6 months
- Tertiary = develops in one third of women affected
Herpes
- Herpes 1 - transmitted non-sexually
- Herpes 2 - transmitted sexually
- Initial infection = multiple painful lesions, fever, chills, malaise, severe dysuria
HPV
- Genital warts
- Primary cause of cervical neoplasia
Hepatitis A
- Source = feces
- Route of transmission = fecal-oral
- Chronic infection? no
- Prevention = pre/post exposure immunization
Hepatitis B
- Most threatening to the fetus and neonate
- Often a silent infection
- At at risk and pregnant women should be screened
- No specific treatment
- Source = blood/blood derived bodily fluids
- Route of transmission = percutaneous permucosal
- Chronic infection? yes
- Prevention = pre/post exposure immunization
Hepatitis C
- Risks = STIs (HBV and HIV), multiple sexual partners, history of IV drug use or blood transfusions
- No vaccine available
- Source = blood/blood derived bodily fluids
- Route of transmission = percutaneous permucosal
- Chronic infection? yes
- Prevention = blood donor screening, risk behavior modification
HIV/AIDS
-Through exchange of bodily fluids
-Severe depression of the cellular immune system associated with HIV infection characterizes AIDS
Symptoms = fever, headache, night sweats, malaise, generalized lymphadenopathy, myalgia, nausea, diarrhea, weight loss, sore throat, rash
Coitus interruptus
Withdrawal (pulling out)
Fertility Awareness Based Methods (FABs)
- Natural family planning
- Rely on avoidance of intercourse during fertile periods
- Combine charting menstrual cycle with abstinence or other contraceptive methods
- Calendar Based Methods
- Symptoms-Based Methods (2 day method, cervical mucus ovulation detection method, basal body temperature method, symptothermal method)
- Biological Marker Methods (home ovulation predictor kids)
- Apps
Spermicides
-Nonoxynol-9 (N-9) reduces sperm motility
Barrier Methods
- Condoms
- Diaphragm (4 types)
- Cervical caps
- Contraceptive Sponge
- **TSS risks are present with diaphragms, cervical caps and sponges
Hormonal Methods
- Combined Estrogen-Progestin oral contraceptives
- Injection
- Transdermal
- Vaginal ring
- Progestin-only contraception (must be taken same time every day)
- Injectable Progestins (return to fertility may be delayed)
- Implantable Progestins (nexplanon)
Warning Signs for Methods of Contraception
A: Abdominal pain may indicate a problem with the liver or gallbladder.
C: Chest pain or shortness of breath may indicate possible clot problem within the lungs or heart.
H: Headaches (sudden or persistent) may be caused by cardiovascular accident or hypertension.
E: Eye problems may indicate vascular accident or hypertension.
S: Severe leg pain may indicate a thromboembolic process
Side Effects of Contraception
- Irregular bleeding
- Increased appetite
- Headaches
- Prolonged use of shot may result in loss of bone mineral density (very important to get adequate calcium and vitamin D)
Emergency Contraception
- Oral should be taken as soon as possible but within 5 days of unprotected intercourse or birth control mishap
- Levonorgestrel (Plan B)
- Ullipristal Acetate (Ella) available by prescription
- Copper IUD insertion
IUDs
- ParaGard Copper T 380A (effective for up to 10 years)
- Mirena (releases levonorgestrel; effective for up to 5 years)
- Liletta (releases levonorgestrel; effective for up to 3 years)
- Skyla (releases levonorgestrel; effective for up to 3 years)
Female Permanent Sterilization
- Tubal occlusion
- Transcervical sterilization
- Irreversible
Vasectomy
- 2 methods available
- Low risk
- Reversible but there can be complications
Breastfeeding as Contraception (Lactation Amenorrhea Method)
More popular in underdeveloped and traditional societies
Mons Pubis
- Subcutaneous fatty tissue at lowest portion of anterior abdominal wall
- Covers anterior pubic symphysis
- Covered with pubic hair
- Provides protection during intercourse
Labia Majora
- Either side of the vulvar cleft
- Chief function to protect structures between
- Stratified squamous epithelium
Labia Minora
- Skin within the labia majora that converge near the anus
- Form the fourchette
Clitoris
- Located between labia minora
- Erectile tissue with prepuce or clitoral hood
- Primary erogenous organ of women
Urethral Meatus
- 1-2.5cm beneath clitoris
- Difficult to visualize
Paraurethral (Skene) Glands
Provide lubrication
Vaginal Vestibule
Introitus
Hymen
Vulvovaginal (Bartholin) glands
Perineal Body
- Wedge-shaped mass of fibromuscular tissue between anus and vagina
- Perineum is superficial area
- Site of episiotomy or lacerations during childbirth
Vagina
- Muscular and membranous tube
- Upper portion or vaginal vault contains fornix
- Other structures can be palpated through vaginal vault
- Allows for the pooling of sperm after intercourse
- Walls covered in rugae
- Acidic pH during reproductive years
- Lactobacillus
- Functions = protect against infection/trauma, passage for sperm, baby and menstrual flow
Uterus
Hollow, thick-walled organ
Centered in pelvic cavity between the bladder and rectum
Mature size is 6-8cm long
Two major parts = corpus and cervix
Corpus
- Fundus, cornua, isthmus
- 3 layers (perimetrium, myometrium, endometrium)
Cervix
-Functions = lubricates vagina, bacteriostatic agent, provides alkaline environment
Fallopian Tubes
- Isthmus, ampulla, fimbria
- Functions = transport the ovum to the uterus, site for fertilization, nourishing environment for ovum/zygote
Ovaries
- Layers = tunica albuginea, cortex, medulla
- Functions = store and develop follicles, secrete estrogen and progesterone
Bony Pelvis
- Function = support and protect pelvic contents, form the axis of the birth passage
- Structure = innominate (illium, ischium, pubis), sacrum, coccyx
- False Pelvis = above pelvic brim, supports the weight of the fetus and enlarged uterus
- True Pelvis = bony limits of birth canal, pelvic inlet, pelvic outlet
Breasts
- Provide nourishment and protective maternal antibodies to infants through the lactation process
- Source of pleasurable sexual sensation
Penis
- Shaft = corpus cavernosa, corpus spongiosum
- Glans = urethral meatus, prepuce or foreskin
- Functions = erection/ejaculation, voiding urine
Scrotum
- Skin and dartos muscle
- Two compartments, each with testis
- Function = protects testes/sperm, maintain temperature lower than body temperature
Testes
- Seminiferous Tubules = spermatogensis
- Interstitial (Leydig) Cells = produce testosterone
Epididymis
-Reservoir/duct for spermatozoa
Vas deferens/ejaculatory ducts
-Passageway for semen and seminal fluid
Urethra
- Passageway for urine, semen
- 3 sections = prostatic, membranous, penile
Accessory Glands
Seminal vesicles
Prostate gland
Bulbourethral (cowper) glands
Urethral glands
Semen
- Contents = spermatozoa, secretions of accessory glands
- Function = deliver viable and motile sperm to reproductive tract
Spermatozoa
- Head
- Tail (flagellum)
Female Reproductive Cycle (FRC)
- Ovarian and menstrual cycles take place simultaneously
- Menstruation = orderly process with neurohormonal control (LH and FSH)
FRC Axis
Hypothalamus secretes gonadotropin releasing hormone (GnRH)
GbRG acts on anterior pituitary to secrete FSH and LH
FSH = maturation of the follicle, maturing follicle secretes estrogen
LH = increases production of progesterone, release of mature follicle
Estrogens
- Amount greatest during proliferative phase of menstrual cycle
- Controls development of female secondary sex characteristics (maturation of ovarian follicles, increase uterine size and weight, effects on many other hormones and carrier proteins)
Progesterone
- Secreted by corpus luteum (highest during luteal phase)
- “Hormone of pregnancy”
- Allows pregnancy to be maintained
- Proliferation of vaginal epithelium
- Cervix creates thick mucus
- Breast tissue increases and prepare for lactation
Prostoglandins
- Oxygenated fatty acids produced by the cells of the endometrium
- Group E = relaxes smooth muscle and vasodilates
- Group F = increases contractility of muscles and arteries, vasoconstricts
- PGs increase during folicular maturation and play a role in follicular rupture
Ovarian Cycle
-Follicular Phase (days 1-14) =
follicle matures as a result of FSH, graafian follicle appears by day 14 (under control of FSH and LH, large, produces estrogen), ends with ovulation (Mittelschmerz, increased body temp)
-Luteal Phase (days 15-28) = Corpus luteum develops from the empty follicle, under control of LH
If ovum is fertilized → Corpus luteum maintained by hCG secreted by fertilized ovum
If ovum is not fertilized → Corpus luteum degenerates to corpus albicans when fertilization doesn’t occur
Menstrual (Uterine) Cycle
Menstrual Phase =
- Cyclic bleeding in response to cyclic hormonal changes (14 days after ovulation)
- Estrogen levels are low
- Some endometrial areas shed
- Average blood loss – 25-60ml
- Cycle lengths vary (range 2-8 days)
Proliferative Phase =
- Increasing amounts of estrogen enlarge endometrial glands with peak before ovulation
- Endometrium thickens
- Cervical mucus is thin, watery, clear
- More elastic
- Alkaline (sperm motility!)
Secretory Phase =
- Follows ovulation
- Increased vascularity of uterus in preparation for fertilized ovum
Ischemic Phase (no fertilization) =
- Estrogen and progesterone levels fall
- Corpus luteum begins to degenerate
- Small blood vessels rupture and spiral arteries constrict
- Blood escapes into stromal cells
- Menstrual flow begins
