Pathophysiology 3 Flashcards
Preconception Counseling
- name obesity as a health condition (use classification system)
- counsel on risk: high risk conditions associated with obesity
- Encourage lifestyle changes: point the patient to resources, follow up
- Refer to specialist when needed
Identify Obesity
- Screening: ACOG recommends annual weight-BMI calculation
- Definitions: use BMI to identify weight class
Obesity and Conception
- obese women have lower rates of fertility
1. anovulation(PCOS)
2. leptin impairs ovarian functioning
3. low fertilization potential of ova
4. risk of spon abortion
5. success rates of ART impacted negatively
6. infrequent intercourse - reversible if loose weight*
Lifetime/Pregnancy risks of obesity
- diabetes, HTN, cancer (endometrial), arthritis, cholesterol, stroke, heart disease
- gestational HTN, preeclamsia, gestational diabetes, macrosomia, cesarean section, birth defects, still birth
Counsel of Lifestyle Changes
Motivational Interviewing
- feedback-identify behaviors and results
- responsibility-stress who will suffer
- advice-teach, give ideas
- menu-identify difficult situations
- empathy-understand & involved
- self-efficacy-learn from mistakes
Ability for Obesity Counseling
- track calories
- encourage to join support groups (weight watchers)
- exercise (start w/minimal goals, taking stairs)
- track weight loss
Candidates for Bariatric Surgery
- well informed, motivated
- BMI >40
- acceptable surgical risk
- failed nonsurgical management
- BMI >35 with complications of obesity (sleep apnea, diabetes, joint disease)
Pregnancy & Bariatric Surgery
- not during pregnancy but after
1. Restrictive: gastric banding
2. Combination restrictive/malabsorption
Effects of Gastric Bypass of Pregnancy
Lowers risk: -preeclampsia -gestational diabetes -macrosomia -congential anomalies -average weight gain in pregnancy Higher risk: -cesarean section -PPROM
Obesity & Cesarean Section
-higher rates in obesity & bariatric surgery
Obesity & Blood Clots
Give anticoagulation? not if BMI only
- may be necessary if unable to use extremity compression techniques
- compression devices acceptable
- unfractionated/LMWH acceptable (weigh risk of bleeding. dosing)
Obesity Risk during Pregnancy
- Screen for nutritional deficiencies: Fe, B12, Vitamin D, Ca
- (bariatric surgeon, met w/nutritionalist)
- surgical complications: anastomotic leaks, bowel obstruction, hernia, band migration, involve bariatric surgeon
Obesity: Dumping Syndrome
- rapid transit of high glycemic carbohydrates
- do not use glucola
- screen with fasting & postprandial blood sugars for 1 week
- avoid extended release medicine
Pathophys of Thromboembolic Disorders
- physiologic changes of pregnancy contribute to Virchow’s triad
- venous stasis in lower extremities from compression of IVC and pelvic veins by enlarging uterus
- increased hormone-mediated deep vein capacitance secondary to increased circulating levels of estrogen & production locally of prostacyclin & nitric oxide
- Progesterone: inc. decidual & hemostatic systems
- doubling of fibrinogen levels
- increases factors: 7,8,9,10,12 1000%
- vWF inc 400%
- 40% dec in free protein S conc. = resistance to activated protein C
- returns to baseline 6 weeks postpartum
Risk Factors for Thromboembolic Disorders
- age >35
- obseity
- trauma
- immobility
- infection
- smoking
- nephrotic syndrome
- hyperviscosity syndromes
- cancer
- surgery
- history of DVT/PE
Risk Factors for Thromboembolic Disorders
Pregnancy Specific
- increased parity
- postpartum endomyometrisis
- operative delivery
- cesarean delivery (9x increased over vaginal)
Antiphospholipid Antibody Syndrome
-14% of thromboembolic disease in pregnancy
DIAGNOSIS: 1.presence of prior VTE/characteristic obstetric complications 2. anticardiolipid antibodies or lupus
-associated with venous (DVT/PE) and aterial stroke events
Inherited Thrombophilias
- Factor V Leiden homozygous
- Antithrombin III deficency
- Prothrombin Gene G2021A
Diagnosis of Deep Venous Thrombosis
- Venous USG
- D-Dimer
- Contrast Venography (allergy)
- MRI
Diagnosis of Pulmonary Embolism
- EKG Changes
- Chest X-ray
- Spiral CT Scan**gold standard
- Pulmonary arteriography
- VQ scan
- MRA
- D-Dimer Assays
Treatment of Thromboembolic Disorders
- Unfractionated Heparin: reverse with protamine sulfate
- Low Molecular Weight Heparin
- Warfarin/Coumadin: takes 72hrs to start working
- Fondaparinux: doesn’t cross placenta
- IVC filters: doesn’t prevent clot
- Preoperative prevention
Menorrhagia
prolonged (>7days) or excessive (>80mL) uterine bleeding occuring at regular intervals
Metrorrhagia
-uterine bleeding occurring at irregular but frequent intervals
Menometrorrhagia
-prolonged uterine bleeding occurring at irregular intervals
Hypermenorrhea
-synonymous with Menorrhagia
Polymenorrhea
-uterine bleeding occurring at regular intervals of less than 21 days
Intermenstrual Bleeding
-bleeding of variable amounts occurring between regular menstrual periods
Causes of Abnormal Uterine Bleeding: Pregnancy
- Implantation Bleeding
- Abortion
- Molar Trophoblastic
- Ectopic
Causes of Abnormal Uterine Bleeding: Neoplasia/Anatomy
- vulva & vagina
- cervix: squamous cell carcinoma
- Uterine Corpus: uterine fibroids, endometrial cancer
- ovary
- endometriosis
Causes of Abnormal Uterine Bleeding?
- trauma
- systemic disease: coagulopathies, blood dyscrasias, endocrinopathy
- drug effects
Pregnancy on Asthma
- Dyspnea 60-70% all pregnant women
- pregnancy has unpredictable effect on underlying asthma
Asthma Effects on Infant
- increased risk IUGR
- increased neonatal hypoxia
- increased low birth rate
- increased neonatal mortality
Best Measure of Pulmonary Function
-FEV1
Choice for Rescue inhaler in Pregnancy?
SABA- albuterol
Choice for Controller in Pregnancy?
ICS - Budesonide
Choice for ADD On in Pregnancy?
LABA - Salmeterol
What may cause bronchospasms and should be avoided in pregnancy?
Hemabate (PGF2)
Birth Control Pill Benefits
- dec. risk of ovarian & endometrial cancer
- decreased dysfunctional uterine bleeding
- menstrual regularity (inc. hemoglobin)
- inc. SHBG so dec. androgens: less hirsuitism & acne
- can be used “off label” for poly cystic ovary syndrome
Side effects of Oral Contraceptives
Estrogen: nausea, breast tenderness/enlargement
- low does, increased breakthrough bleeding
- unexpected bleeding common with low dose
- older formulations with >50mcg of ethinyl estradiol caused more MI and stroke
- venous thromboembolism: with combination pills especially in smokers
Progesterone-Only
“mini pill”
- daily & continuously, no placebo
- take at same time each day
- best for women breast-feeding
- women > 35 years old who smoke
Transdermal Patch
- mixe
- new patch 3 weeks off for 1 week
- less effective in women >90kg adipose tissue
- breakthrough for 2 cycles
- skin irritation
Prevalence of Urinary Incontinent
10-35% of adults
- women>men
- patients under-reporting
Classifying Urinary Incontinence
- stress
- urge
- mixed
- overflow
- functional
- unconscious or reflex
- fistula
Management Urinary Incontinence
- assess
- understand risk factors & reversible causes
- treat reversible conditions
- educate
- treat to improve quality of life
- agree on management plan
Risk Factors of Urinary Incontinence
F>M
menopause, childbirth, immobility, environmental barriers, altered cognition, meds, smoking, collagen disorders,
Increased risk of Urinary Incontinence with past medical history?
- parity
- any repairs or other birth trauma (forceps/vacuum)
Drugs to prevent voiding?
- anti-cholinergic
- alpha-adrenergic
Drugs to promote voiding?
- cholinergic-bladder irritability
- alpha-blocking-decrease sphincter tone
Diet and Urinary Incontinence?
caffeine
spicy foods
alcohol
citrus food & drinks
Q-Tip Test
-assesses bladder neck mobility
-sterile technique
-anesthetic gel
+30> hypermobility
-stress urinary incontinence (SUI) often has hypermobility, but if have it not necessarily SUI
Laboratory Testing Urinary Incontinence
Urinalysis & Culture
- bacterial mucosal irritation
- endotoxin inhibition of alpha-adrenergic receptors in urethra
To hold the urine??
-urethral pressure must be greater than bladder, abdominal, volume pressure
Treatment of Urinary Incontinence
- treat reversible conditions first
- behavioral therapy
- medications
- devices
- surgery
Reversible Causes of Urinary Incontinence
- UTI
- atrophic urethritis/vaginitis
- dietary
- meds
- excess fluid intake/caffeine
- delirium
- phychological
- restricted mobility
Nonsurgical Treatment of Stress incontinence
- Kegel exercises (stop peeing mid stream, then start again)
- Pessaries: requires regular care, managed by patient
- Fem-Soft (helps prevent leaking)
Surgical Treatment of Stress Incontinence
- Burch Retropubic Urethropexy
- Sling (mesh: have erosion/problems)
- Urethral Bulking: inject substance to close urethra up some (if to much can’t pee)
Symptoms of Prolapse
- pressure
- bulge “down there”
- vaginal irritation/Ulvers
pain is not presenting symptom
Symptoms of Anterior Prolapse
- stress urinary incontinence
- incomplete bladder emptying
- possible increased frequency of UTIs
Symptoms of Posterior Prolapse
- incomplete stool evacuation
- splinting to assist defecation
Risk Factors of Prolapse
- childbirth
- increased intra-abdominal pressure (chronic cough/lifting/obesity/constipation/straining)
- Neurologic Injury
- Genetic Predisposition (connective tissue abnormalities)
- Estrogen Deficiency
