theresa maurer Flashcards
habitual abortion
spontaneous abortion that has terminated the course of 3 or more consecutive pregnancies
first trimester bleeding and pain
ectopic pregnancy should always be suspected
Threatened abortion
s/s
Rx
diagnosis
bleeding in first half pregnancy
fresh or old brown blood
may or may not having cramping and low backache
Rx: pelvic rest, bed rest, no sex, notify midwife if there is fever, a gush, increased bleed or increase low back pain.
Rx: heavy bleeding/febrile, no bleeding but ctx and abnormal ultrasound-immediate physician eval
slight bleeding and no other abnormal findings, reiterate Rx regular RTC
gentle spec exam, screen vaginitis cervicitis
gentle bimanual exam, uterine size, effacement, dilation, membrane status
febrile
signs of fever
inevitable abortion
s/s
eval
treatment
follow up
combo of bleeding ctx, ROM, dilation
assess gestational age, amount bleeding, ab pain, emotional status, previous or stat hematocrit, dilation, vital signs
choices: if bleeding is not excessive, pain not excessive and emotional status good, hematocrit 30%
1. go to physician for induced abortion D&C
2. go home await spontaneous abortion
take temp every 4 hours
call midwife if a pad is soaked in less than 1 hr
clots larger than 2.5 cm
fever of 100 +
when aborted call midwife
followup: counsel, support, sex 2-4weeks, genetic counseling.
incomplete abortion
placenta is not expelled with fetus
can cause bleeding or infection
D&C
missed abortion s/s diagnosis plan follow up
vag spotting bleeding, low ab back pain
fundal height ceases to increase, uterus decreases
regressed mammary changes
loses weight
persistent amenorrhea
no fetal heart tones
diagnosis: ultrasound
severe coagulation problems may occur from carrying non viable fetus
order coagulation serums, prothrombin,fibronogen, platelets, partial prothrombin, endocrinologic workup, uterine abnormalities screen
followup: counsel, support, sex 2-4weeks, genetic counseling.
incompetent cervix
s/s
predisposed
rare in primigravidas
evidence in 2nd trimester
painless dilation, ROM, expulsion of fetus, vag discharge free from infection s/s (itching, odor etc)
previous fetal loss, cervical surgery
cerclage
reason for
follow up
Classic shirodkar-permanent suture stays until birth, csection delivery
Modified Shirodkar- purse string suture each pregnancy removed at delivery
Mcdonalds- purse string suture each pregnancy removed at delivery
can be done if cervix is 4 cm
vaginal exam every 2 weeks
counseling
client to report any s/s of bleeding, ROM, foul odor, fever.
suspicious history of incompetent cervix- assesment
History- s/s previous loss, infections in relation, discharge etc.
gestational age, genetic abnormalities, previous suction abortios, cervical traumas
Pelvic ex- consis, length, dilation (internal, ext) membranes, position station present part
history of cervical trauma without fetal loss
plan
vaginal exam every two weeks starting at 2nd trimester until fetal viability or
history of fetal loss but no current signs of cervical incompetence
vaginal exams every 1-2 weeks starting in 2nd trimester until viability or dilation
cerclage is removed in these cases
infection, suture not intact, or laceration cervix
after ROM, impending labor or 38 weeks, labor start
all unless it is a Classic Shirodkar suture
hydadtiform mole
complete/partial
chorionic villi are clear vessels with pedicles hanging like grapes, mass of cyst clear vesicles
complete- all vesicles
partial- vesicles with non viable fetus and sac
some are benign with potential to be malignant & proceed choriocarcinoma
benign
not harmful
malignant
infectious volatile
hydadtiform mole
likelyhood
s/s
10 times higher in women over 45 years
persistent nausea and vomiting, uterine bleeding evident at 12 weeks, brown blood, intermittent, anemia, large for dates baby, shortness of breath, tender ovaries, not fht, parts or palpation.
PIH, preeclampsia, eclampsia, before 24 weeks!
very high Hcg levels
ectopic pregnancy
predisposed
types
diagnosis
pelvic infections, IUD, precious ectopic & tubal preg
types: cervical, tubal, ovarian, abdominal
order quantitative Hcg & ultrasound
cervical ectopic pregnancy
s/s
rare,not lasting after 20 wks
painless bleeding at implantation
cervical mass, distention, thinning of cervical wal, dilation of ex os, enlarged fundus
tubal ectopic pregnancy
s/s
differential diagnosis
labs
most common 95% or more cases
classic case of tubal cases knowing or unknowing suspected pregnancy but spotting has substituted menses.
s/s sharp stabbing pain, tearing, low ab pain
hypotension, shock, tenderness, painful exam, tender boggy mass to one side of uterus
pain in the neck or shoulder* especially inhaling
displaced uterus
low Hcg or neg pregnancy tests
differential: salpingitis, threatened/inc abortion, twisted ovarian cyst, ruptured corpus luteum follicular cyst
CBC with differential and quantitative beta Hcg
ultrasound
abdominal ectopic pregnancy
s/s
s/s sharp stabbing pain, tearing, low ab pain
hypotension, shock, tenderness, painful exam, tender boggy mass to one side of uterus, displaced uterus
pain in the neck or shoulder* especially inhaling
gastrointestinal upset, transverse lie, painful fetal movement, very audible heart tones, small parts outside of uterus, cervical displace, dilation no effacement.
hyperemesis gravidarum
s/s
plan
s/s: excessive nausea and vomiting, extends past 1st trimester, poor appetite and intake, weight loss, dehydration,electrolyte imbalance, extreme response to psycho social events, acidosis (starvation), alkalosis (no hydrochloric acid), hypokolemia(low potassium)
labs: BUN and electrolytes
urine dipstick for acetone and glucose
blood gases, serum pH,
spilling glucose and acetone- immediate eval, glucose to assess for diabetes
dehydration IV fluids
continues after IV fluids admit to hospital
Tuberculosis mycobacterium s/s history labs treatment
initial lesion develops on lung, exudate inflammed, necrosis of lung tissue-airborne droplets
s/s- fever, night sweats, weight loss, persistent colds and cough, chronic cough with yellow green mucous
pleurisy(chest pain, inflammation) rales
previously infected, exposure to, history, environmental, poverty, drug use, socioeconomic
Mantoux test, PPD test, not if active infection!
chest xray and sputum test
BCG vaccine can cause positive test- xrays everty 2 years. scar on arm from vaxx
treatment: INH (isoniazid chemotherapy) for women under age 35 during pregnancy with positive PPD neg xray and post PPD and post xray. If not in pregnancy then after pregnancy, treatment continued if pregnancy occurs mid treatment.
reportable disease.
A Sickle Cell screen should be offered to which group of clients?
african descent
cultures prone to certain disease african mediterranean french canadian jewish
Sickle cell anemia is found primarily in 1/375 birth of African-Americans.
Thalasemia is predominantly found in those of Mediterranean descent;
TaySachs disease is found in those of French Canadian descent
Ashkenazi Jewish descent.
hepatitis
most common in US
rare forms
inflammation of the liver via an infection hep A and hep B hep D is secondary to B -mediterranean D & E rare- Asia, south america reportable diseases
Hep A (infectious hepatitis) route of transmission
s/s
most common worldwide- impoverished pop, poor hygienic
fecal oral route is transmission - contaminated food and water
s/s- flu, fatigue, malaise, weak, nausea, low fever, upper right pain, rapid onset, 10-15 days acute to resolve 2 months
no risks to newborn,no transmission
vaccine for at risk or close contact ISG (immune serum globin)
routine screen
Hep B (serum hepatitis) route of transmission s/s transmission treatment labs
transmission through blood, blood products, needles , saliva, vag secretions, semen.
1-6 months incubation
may lead to chronic carrier, active hep, liver disease, cirrhosis.
s/s rash fever, fatigue, weak, nausea, vomit, low fever, upper right pain, tender enlarged liver, headache
vertical transmission to the baby is common, any route of delivery, postnatal close contact
infects all body fluids but breast milk!!!
breastfeeding contraindicated if cracked sore nipples
90% change of transmission, 90% become carriers, transmitted to offspring, 25% die of cirrhosis, liver carcinoma
babies receive hep b vax at birth within 1 hour 90-95% protection, hep b vax is given to mothers who havent been vaxxed prior
IgM- active antibody IgG- antigen
routine screen
Hepatitis C
40-50% of hep cases in US
low incidence of vertical
transmission to baby
blood test positive for hepc antibody
rubella (German measles)
risks to newborn
s/s
labs
treatment
1st trimester infection- 20% chance of congenital malformations
1st month- 50% malformations
glaucoma, cardiac defects, deafness, brain and deafness, SA, eyes, heart, brain CNS
s/s low fever, drowsy, sore throat, rash, spreads rapid, swollen glands, lasts 3-5 days
routine screen- rubella titres
1:10 or above immunity
below 1:10- lack of immunity offer vaxx POSTPARTUM
1:64 or higher ACTIVE infection- consult -series of titers consult
live vaxx not in pregnancy!
1st trimester- option to abort
avoid pregnancy 3 months after vax
cytomegalovirus
s/s
transmission
common viral infection-various strains
most asymptomatic:
fever sore throat, swollen glands, fatigue
transmission is effective in fetal period (10-40 weeks)
not seen until birth
risks: microcephaly, hydrocephaly, small eyes, seizures, blindness, encephalitis. IUGR, oligiohydraminos
no vaxx and no treatment
test babies saliva, urine, blood high concentrations
toxoplasmosis
s/s
transmission
testing
parasitic protozoa, infected meats, raw or undercooked, cat feces, soil. raw milk
s/s fatigue, malaise, muscle pain, swollen lymph
death, preterm, CNS, anecephalus, hyrdocephalus, eye and brain defects. hydrops
the earlier the infection the more severe disease. 1st and 2nd trimester most transmission.
3rd transmission always congenital anomalies
preconception, skin test 48-72 hrs
ELISA lab, high titers recent infection, rising titers current infection, low titers immunity
IgG antibodies from previous infection protects baby
consult with virologist, routine screen
Spiraymicin
cordocentesis can check baby for infection
varicella (herpes zoster=shingles)
s/s
risks
treatment
highly contagious viral infection form of HSV
25-40% of babies have congenital varicella syndrome
infection in 1st 20 weeks of pregnancy greatest risk
incubation 10-21 days
contagious 2 days before lesions and 7-10 days after lesions are crusted
fever chills, malaise, lesions head neck to trunk, pneumonia, chest pain, cough, fever
risks: cataracts, chorioretinitis, limb hypoplasia, dydronepherosis, micorcephaly,
maternal pneumonia 40% maternal death
varicella contracted at the very end of pregnancy , no antibodies, 5% babies die
treatment VZIG- exposed first 20 weeks and 6 days before delivery 2 days after delivery
routine testing serological for antibodies, vax prior to pregnancy no conception atleast 3 months!
why are pregnant women more susceptible to UTI
normal hydronephrosis may cause urine stasis
preventing UTI
drink 8 glasses of water, empty bladder, cranberry, good hygeine
presence of bacteria significant in clean catch
50,000 bacteria of same species per mililitre
100,000 of nonpatho, or 100,000 mixed
contaminated specimen
bacteria reported in urinalysis
coliforms, e coli, enterococci, klebsiella.
s/s of UTI
risks
treatment
urinary frequency, dysuria, pain, suprapubic pain
preterm labor and birth, low birth weight, pyelonephritis, inflamed kidneys
amoxicillin, ampicillin repeat culture 2 weeks, if doesn’t work 2nd round of diff antibiotics, suppressive therapy if doesn’t work
recurring UTI factors
diabetes, sickle cell trait, history of UTI
cystitis
s/s
labs
inflammation of the bladder, bacterial infection
s/s urgency, frequency, dysuria, low ab pain, hematuria
culture- nitrates, high WBC, high bact, rbc in urine, blood in urine
treatment same
acute pyelonephritis cause s/s risks treatment
inflammation of both kidneys, bacterial
2% freq in pregnant women
compression of ureters by uterus
dilation and decreased tone of ureters from progesterone
urine stasis- decreased bladder tone, urine stasis
s/s fever, chills, hematuria,nause vomit, hx of UTI, frequency CVA tenderness (right side kidney), low abpain
risks- septic shock, respiratory distress, anemai, pretern labor/delivery
treatment: refer to physician IV therapy, electrolytes, IV antibiotics.suppression therapy
why is hemoglobin lowered in pregnancy
hemodilution results in blood expansion and increase in plasma but not rbc’s, ration of rbc’s to plasma is disproportionate.
why does a women need increased iron in pregnancy
because of the increase in rbc’s
factors that effect hemoglobin
race, sex, elevation, smoking meds,
Africans have a hemoglobin 1 gdl higher
women who smoke or live higher altitudes have a higher low
anemia levels and definition
decrease in # of rbc or decrease in the concentration
less than 12 in nonpregnant
less than 10 in pregnant
s/s of anemia
fatigue, dizzy, malaise, headache, sore tongue, skin pallor, hx of heavy menses, close pregnancies, pale nails, hx anemia, nause vomit no appetite, PICA
initial lab test of rbc size
microcytic-decreased rbc size, iron deficient, thallasemia, lead disease
normocytic- blood loss, sicke cell, G6PD, med side effects
macrocytic-vitamin B 12 deficient, folic acid deficient
high iron foods
green leafy veggies, liver, egg yolk, raisins, fortified
treatment anemia
true anemia= hypochromic*
start on iron, folic acid and vita C supplements
