Women's Health Lecture 1 Flashcards
abdominal pain in primary care- you should always assume is what?
pregnancy until proven otherwise
At what age do you refer a young female who has not had a period?
16 years old. Refer to endo or gyno
Early onset of menses (7 or 8yo) is associated with what? What is important for these patients?
Early menses associated with increased body fat because increased body fat induces menses in women. Anticipatory guidance in relation to this is very important for parent and child.
in regards to reproduction, what hormone does the hypothalamus release? where does it go?
hypothalamus releases GnRH “I want to get pregnant” hormone- gets sent to pituitary
pituitary then secretes what, which does what?
FSH, which “gets the eggs ready” so stimulates egg growth within follicles in the ovaries
meanwhile, estrogen is building up. What is its job? When it gets to ___ picograms, what happens?
Its job is to “get the nest ready” When it gets to 200 picograms, LH level surges which stimulates one egg/ follicle to leave the ovary and go to the uterus AKA ovulation
After ovulation what happens?
Surge in progesterone signaling that the body is “ready to support pregnancy until placenta is ready.” If sperm = pregnancy. If no sperm progesterone level falls and the whole process starts all over again
how many days is a normal menstrual cycle?
28 days +/- 7 is normal
What is the first phase of the cycle called and what is the predominant hormone of this phase?
1st phase is called the follicular phase-predominant hormone is estrogen (estrodial mostly)
What is the second phase of the cycle called and what is the predominant hormone of this phase?
2nd phase is called luteal phase- progesterone dominates in this phase- its roll is to support fertilized egg/ support the pregnancy until the uterus can take over.
what hormone level remains high throughout pregnancy?
progesterone
which phase of the menstrual cycle varies?
follicular phase
What is the importance of a prenatal vitamin?
Need 400mcg of folic acid, ideally 3-6 months prior to conceiving to prevent neural tube defects.
Once pregnancy is confirmed, what is needed in the PNV?
DHA
Which vaccines are recommended DURING pregnancy?
flu and pertussis (Tdap) Tdap booster recommended during EACH pregnancy (CDC)
Which vaccine is important to have BEFORE becoming pregnant?
MMR
Explain getting your basal body temperature.
Should take your temp. first thing in the morning, before even moving (have it at your bedside). Need to be consistent, need to look at retrospective data of past several months. We are looking for a rise of 0.5 degrees F
The ovulation predictor kits that are sold OTC are monitoring what?
they detect a surge in LH (signals ovulation)
What does gravida mean?
number of times pt has been pregnant
What does para mean?
number of time pt has given birth past 22 weeks
What is the thick egg- white mucous substance called that is expelled from the vagina? What does it signify?
“mittelschmerz” signifies that ovulation is imminent- occurs just before ovulation (temp lowers slightly, then spikes when ovulation occurs)
What is the difference between a qualitative and quantitative hCG test?
Qualitative- gives you yes or no answer- simple urine dip that is sold OTC.
Quantitative- measures the serum level of hCG (level needs at least 50 to be read); used to test viability of pregnancy. (Hcg should double or triple in 48- 72hrs if pregnancy is viable)
these are equally as accurate
presumptive/ probable/ positive signs of pregnancy
see cards on Chapter 19
When does hCG peak?
60- 90 days post fertilization
How does Plan B work?
Makes conditions unfavorable for implantation. 85% effective
What are the “M&M” abortion drugs?
Mifepristone- “antiprogestin” blocks endometrial growth, detaches
Methotrexate- prevents placental villi proliferation
Misoprostol (cytotec)- causes uterine contractions (used for ripening in labor)
Uterine sizing- non- pregnant
lemon; it is firm, non- tender
Uterine sizing- 8 weeks
tennis ball/ orange- Hegar, Goodell, CHadwick all +
Uterine sizing- 10 weeks
baseball- ***first FHT 10- 12 weeks
Uterine sizing- 12 weeks
softball- above symphysis pubis
Uterine sizing- 16 weeks
halfway to navel- ***quickening felt
Uterine sizing- 20- 36 weeks
20 weeks at umbilicus, then add 1 cm/ week gestation- concordant with gestational age + or - 1 (shouldn’t be off by more than 3cm)
Uterine sizing- Term
head engaged “ballottement”- vertex position 95% by 36 weeks
What is the best predictor of gestational age?
crown- rump length. (length of head to tail on US)
What are reasons for needing an early referral in patients who are trying to conceive?
advanced age (30+) h/o miscarriage h/o medical conditions or Fhx obese/ overweight the "needy"
What is it called when pt is vomiting a lot during pregnancy? How can you treat it/ nausea in pregnancy?
hyperemesis gravidarum. If being triggered by PNV, prescribe less offensive ones or children “gummies” could prescribe ginger (500mg daily), could use peppermint, crackers, could prescribe Zofran if really bad (category C), IV hydration in the hospital if very severe
Interventions for constipation in pregnant women?
water, fiber, milk of magnesia, colace
How do you manage asthmatic patients who are pregnant?
“mama don’t breath, baby don’t breath” ***Need pt to do peak flow every morning (1st thing in the morning) should continue baseline regimen, and if they notice peak flow decreasing, step it up that day. Ex. inhaled steroid daily, but pt notices bad peak flow numbers- use higher dose of inhaled steroid (still better than it getting out of control and having to go on PO steroids)
Which is safe to use in pregnancy- Tylenol or Ibuprofen?
Tylenol. Can’t use NSAIDS
What is OK to prescribe if pt is complaining of nasal congestion/ runny nose? What is the patho behind this common symptom?
Low dose claritin (5 or 10mg) is OK, saline nasal sprays are ok- antihistamines conservatively are OK but no sudafed (decongestant) esp during first trimester. Also benadryl is OK
patho- hormones increase fluid of mucous membranes ie. cervix but also nose to protect from invading bacteria to prevent infection
Milestones throughout pregnancy include?
weeks 4- 12 baselines
weeks 12- 16 genetic screening/ testing
weeks 16- 20 US to look at anatomy/ find out sex
weeks 20- 24 age of vitality, begin leopolds
weeks 24- 28 prepare for OGTT and RhoGAM if need
weeks 28- 32 repeat HgB, STI testing
weeks 32- 36 Kickcounts, group beta- strep, manage TOBP
What does effacement mean?
thinning of the cervix
What is considered preterm labor?
cervical effacement/ dilation between 20-37 weeks
What is the #1 risk factor for preterm labor?
A h/o preterm labor, premature birth or repeated pregnancy loss
What is the name of the procedure that sews up the cervix so it is reinforced and can carry the baby?
Cerclage
Pregnancy category A
controlled studies show no risk to fetus. ex- synthroid
Pregnancy category B
no evidence of risk in human; either animal findings show risk or if no adequate human studies have been done and animal findings are negative
Pregnancy category C
Risk cannot be ruled out: human studies are lacking, and animal studies are either positive fetal risk or lacking as well. However, potential benefits may justify the potential risks
Pregnancy category D
positive evidence of risk: investigational or post marketing data show risk to fetus. Nevertheless, potential benefits may outweigh risks
Pregnancy category X
Contraindicated in pregnancy; studies on animals and/or post market reports on humans have shown fetal risk that clearly outweigh any possible benefits
As a PCP, which categories would you prescribe?
A,B, maybe C if experienced. (Flonase category C)
New FDA pregnancy and lactation labeling rule (PLLR) says what, and when did it take effect?
Effective June 30, 2015. Replaced by 3 narrative subsections: 1. pregnancy 2. lactation 3. females and males of reproductive age. Each has to contain the following: registries, risk summary, clinical considerations, and data
Weight gain in pregnancy for underweight, normal, overweight and obese patients?
underweight (BMI < 18.5)- 28-40lbs
normal weight (BMI 18.5- 24.9)- 25- 35lbs
overweight- (BMI 25- 25.9)- 15- 25lbs
obese (BMI 30+)- 11- 20lbs
Recommended initial therapy for gestational diabetes? (other than lifestyle modifications)
Sulfonylureas (glipizide, glimepiride). You can give a glucometer- if you do make sure to give instructions with it. If sulfonylureas not working add long acting insulin then lastly short acting with meals
How do Sulfonylureas work?
By stimulating beta cells in the pancreas
Why is A1c not reliable in pregnancy?
Changes in RBC production, anemias, etc.
Glucose tolerance test interpretations
need to fail 2/3 fasting >95 1 hour > 180 2 hours > 155 3 hours > 140
What is pregnancy induced hypertension (PIH)?
elevated BP WITHOUT proteinuria: >30mmHg systolic or >15mmHg diastolic when compared to before 20 weeks gestation, or 140/90 if no baseline available. BP returns to normal usually 12 weeks post- partum
management of PIH includes what?
monitor BP, labs (CBC, LFTs, 24 hr urine, CrCL, Hgb/Hct) US to monitor fetal growth,* non- stress test after 32 weeks, rest (left lateral)
What should you always do when a pregnant patient comes to your office- no matter the complaint or what you are treating her for?
Urine dip. Check for proteinuria. Even if BP is normal always dip their urine.
HELLP syndrome***
Hemolysis Elevated Liver enzymes Low Platelets
pre- eclampsia s/s and treatment
sudden weight gain .2lbs/wk, digital/ facial edema (puffy face and hands), HTN (trace protein on UA), reflexes WNL progress to 3-4+ (hyper reflexia).
Tx: bedrest, surveillance, steroids to help mature fetal lungs, hospitalization
what is eclampsia? s/s?
PIH + preeclampsia + seizure = eclampsia. Prodromal s/s (headaches, visual disturbances, RUQ or epigastric pain), BP over 160/100 consistently, tonic/ clonic seizures, oliguria, elevated creatinine, proteinuria of 5g or more in 24 hours, fetal distress in utero
What is placenta abruption? s/s
separation of placenta from uterine wall.
80% will have obvious bleeding, bright red, frank and 20% bleeding will be concealed- will have “rigid” abdomen, not always painful. Have about 10 mins to get to OR to save baby if this happen
Fetal well- being: kick counts- what does it do, how do we tell the patient to do it?
It monitors the fetal status, decreased activity= increased risk for fetal death. Tell mom to monitor kicks for 1 hour every day, should feel at least 10 movements, if not try again, if still not 10- call OB. They start 28- 32 weeks.
Fetal well being: NST- when should you do it? what should it show?
Not accurate before 28 weeks so don’t do it before then. It should show 2 accelerations of the fetal heart rate 15bpm above and 15 seconds beyond baseline in 20 minutes of testing. Tells us that the placenta is delivering enough oxygen to baby.
Fetal well- being: biophysical profile- what are the 5 variables and how are they scored?
This evaluates fetus in real- time US 1. fetal breathing 2. gross body movements 3. fetal tone 4. amniotic fluid volume 5.NST If the variable is normal= 2 points; abnormal= 0 points Total of 10 possible points. 8-10 is normal, 6-8 repeat in 24 hours, <4 thinking about delivering baby
Hypothyroid considerations in pregnancy
20-40% increase in demand by week 4 gestation. Want to keep TSH less than 2.5, so need to increase dose of synthroid. test q4-6 weeks until 20 weeks gestation or med stable. Post partum- test 3 mos, 6 mos, keep in mind for differentials up until 1 year after pt gave birth
most common causative organism in mastitis? tx with?
Staph- tx with amoxil. Need to pump and dump after taking abx.
most common complication that we will treat in primary care post partum?
mastitis
PCP needs to screen for what in post partum patients?
depression! Use PHQ2-9. ensure proper psych referral if needed. If treating, Zoloft is good- monitor for suicide/ homicidal ideation
