AHN 548 Unit 4 Quizlet Combined
What is the Characteristics of Terminal Complement deficiency?
Rarely lupus or glomerulonephritis
How is anemia of chronic renal failure treated?
Recombinant human erythropoietin (epoetin alpha) and iron
What are the common infections associated with Terminal Complement deficiency?
Recurrent Neisseria Infections, Meningococcal Gonococcal infections.
What are the most common infections associated with IgA deficiency?
Recurrent Respiratory or GI tracts infections
What are the common infections associated with Job's syndrome
Recurrent Staph. Aureus infections and abcess
3 or more consecutive spontaneous abortions before 20 weeks of gestation
Recurrent abortion
Triple/Quad Screen
(Maternal serum alpha feto protein, hCG, estriol, inhibin-A) Triple/Quad: 16-18 weeks MSAFP 15-22 weeks indication: combined with maternal age, weight, race, and gestation, the quad screen computed the risk the fetus has certain defects Nursing: maternal blood sample is needed. This is OLNY screening test that is not diagnostic of anything
Hyperactive reflexes
(clonus) best assessed at the ankel joint.
A unique form of coagulopathy DIC)
(not occurs with HELLP syndrome. The platelet count is low, but coagulation factor assays, prothrombin time (PT), partial thromboplastin time (PTT), and bleeding time remain normal. In some instances hemolysis does not occur and the condition is called ELLP. NOT a separate illness!!!
Labs that reflect an anion gap metabolic acidosis include...
(pH <7.3), serum HCO3 <15, hyperglycemia & elevated serum ketones
Acute phase of Kawasaki Syndrome
(up to 11 days) Fever, irritability, conjunctivitis, oropharyngeal edema, rash, LAP, distal exremity erythema and edema
Juvenile Idiopathic Arthritis (JIA) characterized by?
* Characterized by chronic synovitis and associated extra-articular manifestations
Henoch-Schonlein Purpura follows?
* Follows viral infections, esp. URI
Location of ectopic timeframes for rupture
* Isthmic tend to rupture earliest at 6-8 weeks because small diameter of portion of the tube * Ampullary rupture later (8-12 weeks) * Intestinal pregnancies are last to rupture at 12-16 weeks as the myometrium allows more room for ectopic growth
Henoch-Schonlein Purpura usually?
* Usually self-limiting (Majority recover in 4 weeks). Steroids are not generally recommended.
Dermatomyositis (DM)
*5% of all collagen vascular d. in children *5-14 years, female: male 2:1
*Antidote for mg toxcity*
*ANTIDOTES--Calcium Gluconate* or calcium chloride (antidotes for magnesium sulfate can be given ----IV may be ordered *(10 ml of a 10% solution, or 1 g) OR ----slow IV push (usually by the physician) over at least a 3 minute period* to avoid undesirable reactions such as arrhythmias, bradycardia, and ventricular fibrillation ( Cunningham, 2010).
Dermatomyositis (DM) hallmarks
*Hallmarks are various skin manifestations coupled with nonsuppurative muscle inflammation
Kawasaki Syndrome - Treatment
*IVIG (intravenous gamma globulin) 2 g/kg *salicylates in high doses 100 mg/kg/day in febrile phase, later 5 mg /kg/ day is used for antiplatelet effects
Dermatomyositis (DM) no association with
*No association of malignancy in pediatric DM, but higher calcinosis (nodular calcium deposits) in nonmuscle tissues
Dermatomyositis (DM) Treatment
*Steroids are mainstay of treatment 1 - 2 mg/kg/day of Prednisone IVIG, methotrexate
Kawasaki Syndrome - Prognosis
*Very good if no cardiac involvement *1-2% die with cardiac involvement
4. (MP@H) Gentle exercise (e.g., range of motion
, stretching, Kegel exercises, pelvic tilts) is important in maintaining muscle tone, blood flow, regularity of bowel function, and a sense of well-being. Relaxation techniques can help reduce the stress associated with a high risk pregnancy and prepare the woman for labor and birth.
Medical and psychosocial management of pt with fetal demise
- offer options of immediate induction vs expectant management - rare complications with expectant management: intrauterine infection and maternal coagulopathy -evacuation of uterus: D&E or induction - bereavement: offer opportunity to hold infant and keep mementos including photos or footprints; psychological counseling, visits with clergy and support groups
Oligohydramnios and IUGR
- oligo is frequently found in IUGR: due to reduced fetal blood volume, renal blood flow and UO; chronic hypoxia will also divert blood flow from kidney to more critical organs
Cervical incompetence and insufficiency
- painless cervical dilation that can lead to pelvic pressure - bulging membranes - fetal loss - cervical cone biopsy can lead to this
Causes of SGA or IUGR
- poor maternal environment - intrinsic fetal abnormalities - congenital infections - fetal malnutrition
Methods to screen and diagnose fetal growth disorders
- review of mom's medical and OB history - uterine size by fundal ht measurement (only a screening tool) - US: gold standard: biparietal diameter, head circumference, femur length, abdominal circ - Umbilical artery doppler: abnormal dopplers can hlep predct fetuses at increased risk of poor outcome
Managment of IGUR
- serial US assessments every few weeks - if pregnancy is remote from term, periodic BPP, mBPP, or NST indicated - timing of delivery should be based on antenatal testing, fetal growth pattern, dopplers, and GA
Uncontrolled DM during organogenesis: organs affected the most
- spine and heart problems - increased growth - polyuria: polyhydramnios
Why are random samples of GH no value in diagnosis of GHD?
- wide range of normal and abnormal values - growth hormone secretion is pulsatile
What is the characteristics IgA deficiency?
--> Most common Immunodeficiency 1. IgA levels only 2. Usually asymptomatic
Uterine Rupture
-50% occur prior to onset of labor Incisional pain -Abrupt onset pain Tx: H/O > plan a C/S at 37-38 weeks Risk of C-hyster
Breech Dx
-Leopold's maneuvers -Pelvic exam > feel fetal head or butt, face, limbs -Ultrasound: gold standard ---big round thing under pubic symphosis
CI to VBAC
-Prior classical C/S or myomectomy ---Up to 7% risk of rupture > bad for mama and baby ->1 prior LTCS (some say >2) -History of uterine rupture > if you ruptured before you will ruptured again -Physician not willing!
Compound Presentation
-Prolapse of fetal extremity (hand/foot) alongside presenting part ---Usually hand up by the head ---Sometimes possible to push the hand back -increased risk of cord prolapse -Increased Risk of maternal traumatic vaginal delivery
What are the normal variants for short stature?
1. Familial genetic variant -normal linear growth velocity & a short target height 2. Constitutional delay: bone age consistent with height age -slow growth rate for the 1st 2-3 years, then a low- normal growth velocity -family history of short stature & delayed puberty are often present
What is the cause/incidence of juvenile acquired hypothyroidism?
1. Hashimoto's thyroiditis 2. pituitary deficiency of TSH 3. Hypothalamic deficiency of TRH 4. Iodide deficiency 5. Damage to the gland
What is short stature?
1. Height falling > 2 SD's below mean, or a marked deviation from previously established growth curve. 2. Failure o grow more than 4cm per year 3. 5% of the population
What are the most common infections associated with CVID?
1. Increased pyogenic upper and Lower Respiratory Infection. 2. Is associated with Lymphoma and autoimmune disease.
What are the five phases of ALL treatment?
1. Induction 2. Consolidation 3. Maintenance therapy 4. Bone marrow transplantation 5. Tyrosine kinase inhibitors/immunotoxins
What do the PI calculation mean in relation to IUGR?
1. Infants with asymmetric IUGR have low PI (they are long, lightweight infants below the 10th percentile) 2. Infants that are constitutionally small will have a normal PI.
Tests useful in helping diagnose short stature issues
1. Radiograph of left bone or wrist for bone age 2. CBC 3. ESR 4. UA, BUN, creatinine 5. Electrolytes, calcium, and phosphorus 6. Stool examination for fat 7. Karyotype (girls) and/or Noonan's testing 8. T4 and TSH 9. IGF-1 (IGFBP-3 <4 y/o)
What is the Characteristics of Leukocyte Adhesion deficiency?
1. Recurring skin infections 2. Mucosal infections 3. Pulmonary infections. 4. Omphalitis in newborn period 5. Delayed separation of the umbilical cords
Management of hypothyroidism?
1. Refer to a pediatric endocrinologist 2. Hormone replacement therapy with synthroid-brand specific, rather than generic levothyroxine, is preferred for maintaining thyroid level consistency
When should pregnant women with Rh negative blood receive RhoGam
1. Rh negative women with significant bleeding anytime during pregnancy (including ectopic) 2. After an amniocentesis or major procedure is performed 3. After any major abdominal trauma during pregnancy 3. 28 weeks- always 4. Within 72 hours of delivery if infant has Rh+ blood
What are the laboratory/diagnostics for Type II diabetes mellitus
1. Serum fasting blood sugar>/= 126 mg/dl on 2 separate occasions is diagnostic 2. random blood sugar >/= 200 mg/dl & polydipsia, polyuria, & wt loss indicate need to confirm diagnosis by fasting studies 3. Glucosuria 4. Serum BUN and creatinine may be elevated 5. Elevated Hgb A1c (normal in children 5.5-7%) 6. Impaired glucose tolerance: FBS >/= 100& </=125
Shoulder Dystocia: Management
Anticipation > call for help -expect with babies > 4,000 g McRoberts' maneuver Suprapubic pressure > push in direction of whichever way the face is facing Woods Corkscrew Maneuver: anterior shoulder = counterclockwise; posterior = clockwise Delivery of Posterior Arm Fracture of Clavicle
What two types of medications have been associated with folate deficiency?
Anticonvulsants (phenytoin and phenobarbital) Cytotoxic drugs (methotrexate)
Treatment for McCune-Albright syndrome
Antiestrogens (tamoxifen) or Agents blocking estrogen synthesis (ketoconazole) or Aromatase inhibitors (letrozole)
Shoulder Dystocia complications
Fracture of Long Bones / Clavicle > 18-25% Erb's palsy - Brachial Plexus Paralysis > 80% will resolve by 18 months Asphyxia (uncommon) -can't expand lungs to breathe, umbilical cord compressed in birth canal Maternal Laceration > episiotomy or something to try to dislodge the baby Neonatal Death (rare)
Shoulder Dystocia RFs
GDM (or even elevated 1hour GTT) > independent and risk for bigger baby H/O >what was weight of baby? mother's anatomy? Prolonged 2nd Stage > not descending Macrosomia > EFW (estimated fetal weight) Postterm pregnancy
Side effects of gold salts
GI upset, bone marrow suppression, hepatotoxicity
Lymphatic vessels
General term used to designate the structures that collect and transport lymph. Transports back to the blood any fluids that have escaped from the blood vascular system. An elaborate system of drainage vessels that collect the excess protein-containing interstitial fluid and return it to the bloodstream.
vaso-occlusive
Ischemia and pain caused by sickle-shaped red blood cells that obstruct blood flow to a portion of the body. Most common.
Why should any girl with short stature have a chromosomal evaluation?
It can be the only obvious manifestation of Turner syndrome
What are symptoms of ALL?
Decreased bone marrow production of red blood cells, white blood cells, or platelets and leukemic infiltration of extramedullary sites. Intermittent fevers are also common, hepatomegaly, splenomegaly, lymphadenopathy, pallor, petechiae, and purpura
How is Growth Hormone Deficiency characterized?
Decreased growth velocity and delayed skeletal maturation in the absence of other explanations
When should pregnant women undergo antibody screening?
First prenatal visit
physiological signs of pain
Flushed skin, diaphoresis, hypertension, tachycardia oxygen desaturation, restlessness, dilated pupil
Preclampsia Pathophysiology
Main pathogenic factor: disruptions in placenta perfusion and endothelial cell dysfunction. Arteriolar vasospasm diminishes diameter of blood vessels, which impedes blood flow to all organs and increases BP Function are depressed in organs (placenta, kidneys, liver, brain).
C-hyster prevention
Reduce chance of large bleeding: -had C/S before, optimize hemoglobin -anemic > get on iron supplement -ferritin below a certain level > infusion of IV prep of iron
3. Change(s)* of the peripheral extremities, such as:
Peripheral edema Peripheral erythema Desquamation Periungual desquamation
_______ must be monitored when prescribing isoniazid
TOXICITY
Thalassemia minor
Thalassemia disease that occurs when only one defetive gene is inherited. May even by asymptomatic.
How are FSH and LH affected in central precocious puberty?
The FSH and LH may still be at prepubertal ranges. You must determine the maturity of the hypothalamus-pituitary axis by measuring the pubertal LH response after administration of a GnRH agonist.
What factors are more important than pregnancy in determining the course and prognosis of TB?
The anatomic extent of the disease, the radiographic pattern, and the susceptibility of the patient
hyperpigmentation: more pronounced in dark-skinned women
The areolae, axillae, (and genitals) are most commonly affected, although scars and nevi also may darken
EFW (estimated fetal weight)
US calculating Head Circumference, BPD, Abdominal Circumference, Femur Length less accurate closer to term Most accurate indicator of fetal size and weight is maternal perception!!!
Cesarean Hysterectomy indications
Uncontrollable bleeding at C/S Placenta Accreta > can't get to separate Number prior sections > higher risk for accreta Placental location > anterior wall NEED blood available!! Worry about DIC
What does Acute Lymphoblastic Leukemia result from?
Uncontrolled proliferation of immature lymphocytes
Symptoms of psychosocial short stature
Unusual eating or drinking habits Bowel and bladder incontinence Social withdrawal Delayed speech
*NURSE ALERT* *Abruptio*
Uterine tenderness in the presence of increasing tone may be the earliest finding of an abruption. Idiopathic preterm contractions also may be an early sign. abdomen will be HARD. *IMMERGENT C-SECTION* Intense PAIN, do not wait on LABs. REPORT IMMEDIATELY!
FHR: Category THREE Bradycardia SINUSOIDAL PATTERN
Variability ALWAYS ABSENT, Late/Variable decels: RECURRENT
Proper Presentation
Vertex presentation -LOA - left occiput anterior (mom's left and anterior direction) -ROA - right occiput anterior -LOP - left occiput posterior -ROP - right occiput posterior -"Sunnyside up" - OP -OT is occiput transverse
When is growth hormone therapy contraindicated in patients with Prader-Willi syndrome?
Very obese children Children with respiratory impairments Sleep apnea Unidentified respiratory infections
Pemphigoid Gestationis..."Herpes Gestationes" not caused by herpes virus, it's autoimmune
rare, 2nd/3rd trimesters, vesicles to bullae, start on trunk, spare face, palms and soles
What is idiopathic Type 1 DM?
rare- not assoc with autoimmunity, pts suffer from episodic attacks of ketoacidosis, they may have absolute insulin def only during attack
what happens with the bladder in the recipient and donor
recipient: large donor: small/absent (echogenic bowel sign of hypoxia in donor)
Sensory pain
recognizing the sensation as painful
Most common: Plaque psoriasis looks like...
red and white scaley patches...then silvery-white appearance (elbows/knees, anywhere)
Thalassemia intermedia
what type of thalassemia has increased serum bilirubin, may develop bone problems, subject to infections and gall stones, delayed puberty, splenomegaly and has moderate to severe anemia.
good pregnancy outcomes
when proteinuria develops it moves them into preeclampsia. ( this occurs in those women who are diagnosed with gestational hypertension prior to the 35 week of pregnancy.
What would peripheral blood smears show in ALL?
Abnormalities in RBC such as teardrops
What do you see on chest x-ray on DiGeorge Syndrome patients?
Absent thymic shadow
When should glucose monitioring be done?
fasting, 1-2h after meals, night time
Define iron deficiency anemia
Hemoglobin more than 2 standard deviations below normal for age and gender
HELLP Syndrome includes
Hemolysis, increased Liver enzymes, decreased Platelets
What is the most common cause of lower gastrointestinal bleeding during pregnancy?
Hemorrhoids.
Warfarin is usually switched to ______ during pregnancy
Heparin
systematic onset JIA lab results
Hepatosplenomegaly, LAP, serositis, pleuritis, pericarditis, hyperbilirubinemia, leukocytosis, anemia may be seen 25% progress to chronic joint symptoms
What are typical features of fulminant hepatic failure because of herpes simplex occurring during the third trimester of pregnancy?
Herpes simplex hepatitis can result in fulminant hepatic failure with a 40% mortality rate, with half the reported adult cases occurring during pregnancy. The clinical and biochemical features are usually indistinguishable from other causes of acute liver failure; however, jaundice is characteristically absent. Typical skin lesions are evident in less than half of patients, and diagnosis may ultimately rest on liver biopsy, cultures and serology.
Will estradiol levels be high or low with peripheral precocious puberty ovarian involvement?
High
Treatment plan for septic abortion
Hospitalization & IV ABX therapy. Selection of ABX agents should provide for both anaerobic and aerobic coverage. If retained products of conception are diagnosed, a D&C is indicated.
effects of diabetes in pregnancy: spontaneous abortion, gestational hypertension, pretem labor, ________(excessive amniotic fluid)
Hydramnios
What is treatment for CML?
Hydroxyurea, busulfan, TKIs
Define hyperthyroidism
Hyper function of the thyroid which results from excess circulating levels of T3 and/or T4
Severe and persistant vomiting that leads to weight loss, dehydration and fluid and electrolyte imbalance...this is called
Hyperemesis Gravidarum
List the cholestatic disorders of pregnancy.
Hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, preeclampsia and HELLP (hemolysis, elevated liver tests, low platelets) syndrome.
What is tumor lysis syndrome?
Hyperkalemia, hyperuricemia, ,hyperphosphatemia usually occurs when treatment is started
Chronic hypertension
Hypertension present before pregnancy or diagnosed before week 20 of gestation Chronic hypertension with superimposed preeclampsia Women with chronic hypertension may acquire preeclampsia or eclampsia
Hypertensive Disorders in Pregnancy Chapter 27 OB EXAM #4
Hypertensive Disorders in Pregnancy Chapter 27 OB EXAM #4
What is Grave's disease
Hyperthyroidism: most common in children and associated with: -diffuse enlargement of thyroid -hyperactivity of the gland -presence of antibodies against different fractions of the thyroid gland
Infants with growth hormone deficiency often present with what signs and symptoms?
Hypoglycemia Micropenis
From which gland is the gonadotropin releasing hormone released?
Hypothalamus
Describe the diagnositic process of evaluating a DVT.
If a DVT is suspected, begin with bilateral compression ultrasound. If positive, treat. If negative, then complete a d-dimer study. If low, then DVT is ruled out. If high, must proceed to venogram to confirm or deny. D-dimer may be high due to pregnancy alone, so venogram is essential
chronic pain
PNS response, continues after healing, long duration, depressed/withdrawn, doesn't report pain, body adapts
TTTS differentials
PPROM preterm premature rupture of membranes Anomalous twin
What are the two types of causes of Central precocious puberty?
Idiopathic Central nervous system abnormalities
Most common cause of central precocious Puberty?
Idiopathic (spontaneous & unknown)
What is the most common type of Growth Hormone Deficiency?
Idiopathic with an incidence of 1:4000
Complications reported with HELLP syndrome
include renal failure, pulmonary edema, ruptured liver hematoma, DIC<, ARSDS, VARIANT OF DIC, placental abruption, and preterm birth.
Blood -
increased ESR & CRP, Anemia. Leukemoid reaction, increased platelets, RF, ANA
Intrahepatic cholestasis...
increased bile acids in serum lead to bile salt deposition in skin...severe pruritis, mostly palms and soles, worse at night
The Koebner phenomenon
increased psorietic appearance where there was skin trauma
Is the function of the diaphragm and chest wall impaired or unimpaired?
unimpaired because the tidal breathing is larger so the excursions are increased
Systemic Lupus Erythematosus (SLE) etiology
unknown (a) Immune disorder (b) Exposure to drugs e.g., anticonvulsants, hydralazine, sulfonamides, procainamides
A ______ birth is preferred because it carries less risk for infection or respiratory complications in women with HD
vaginal
Granuloma gravidarum (pyogenic granuloma): red/purple nodule
vascular tumar which occurs between 2nd and 5th month of gestation
pregnancy is a state of hypercoaguability. what are some of the causes?
venous stasis, increased levels of clotting factors, and decreased fibrinolytic activity
What are treatments for AML?
Administration of anthracylines, cytarabine, and etoposide to induce remission. Once remission is obtained patients who have an appropriate match undergo allogenic HSCT while those without appropriate donors are treated with additional cycles of chemotherapy
Where is human growth hormone produced?
Anterior pituitary gland
placental _______ occur in almost all MC twins
anastomoses
After delivery the uterus make take longer to contract
and the patient may need HEAMABATE. ( some question about the use of methergine with these patients)
Shoulder Dystocia
anterior shoulder gets stuck behind the mother's pubic symphysis DM (#1 cause), macrosomia, shoulder dislocation
Antilymphocyte globulin (ALG)
antithymocyte globulin (ATG) is the principal drug treatment.
Maternal factors for spontaneous abortion:
* Systemic Disease: * Uterine and Cervical Factors * Toxic Factors: * Trauma
*Rash
- waist down distribution, petechiae to purpura
Reasons for classical c/s
-Previa - Location of placenta prevents access to baby with low transverse incision -prematurity: lower uterine segment hasn't thinned out yet -transverse lie > can't get baby to turn -start with low transverse but can't get baby out, then "T-up" -STAT C/S or Very urgent C/S
What is the management for hyperthyroidism?
1. Refer to pediatric endocrinology
Signs and symptoms of short stature?
1. assess for chronic disease, neglect, endocrine deficiencies 2. investigate underlying causes based upon proportion
fatigue's effect on pain
increases perception of pain
If normoglycemia cannot be achieved with diet and exercise, start with....
insulin (glucose crosses the placenta, insulin does not), Glyburide and metformin are used.
FHR tachycardia
>160 bpm
Kawasaki Syndrome etiology
? Microbe
Interleukin-10 may...
improve psoriasis during pregnancy
___ disparity in 1st trimester may predict discordant birthweight ____________ CO = 13X increase in discordant birth weight Doppler can distinguish between healthy, constitutionally small twin from similar-sized IUGR twin Cord Doppler High SD, absent to reversed diastolic flow Pulsatile UV = impending heart failure MCA SD Ratio head sparing DV
CRL Velamentous
Drugs of choice for women with HTN include: methyldopa (Aldomet), Alpha adrenergic and beta-blockers (labetalol) and Nfedipine a _______
Ca Channel blocker
What electrolyte is used to prevent preeclampisia?
Calcium; a least 1g daily
Leopold's Maneuvers
28 wks and beyond determine the position of the baby > position is usually confirmed with ultrasound Cephalic prominence - if baby is breech mom can feel the head pushing up on the ribs 1st maneuver = Fundal > butt 2nd maneuver = Sides > Location of small parts - hands and feet may be palpable or smooth back 3rd maneuver = Presenting part above the pubic symphysis > the head (hard mass - movable if not engaged) $th maneuver = anterior
peak severity of asthma
29-36weeks
when monochorionic twins divide: - Di- Di:__days - Mono- Di:__-__days Mono-Mono: ___-___ days -Conjoined: ___day
3 4-8 8-13 13 and on
Metformin (buguanide that suppresses hepatic glucose production & increases insulin sensitivity),
Category B- does cross the placenta; AVOID in the FIRST TRIMESTER
Growth hormone resistance syndrome
Caused by mutations in the growth hormone receptor or other parts of the signaling pathway - similar to GHD but no response to GH therapy
RF assoc with fetal demise
- non-hispanic black race - nulliparity - AMA - obesity - smoking - multiple gestation - poor nutrition status - hx of fetal demise, PTD, IUGR, pre-e in prior preg
What causes of pancreatitis may be exacerbated during pregnancy?
The incidence of gallstones is increased during pregnancy although pancreatitis is rare. Pregnancy may worsen underlying hypertriglyceridemia and precipitate pancreatitis. Hyperparathyroidism may first become manifest during pregnancy and cause pancreatitis.
Dermatomyositis (DM) Clinical Features
Fatigue, symmetric proximal muscle weakness (hips, legs) * Tender, swollen muscles, gait abnormalities 75% have characteristic rash Guttron patches: red, scaly patches on elbows, knees and knuckles
What affects the secretion of human growth hormone GH?
Growth hormone releasing hormone GhRh: stimulates secretion Somatostatin: inhibits secretion
Name the pregnancy complications experienced by obese women.
Class I (BMI 30-34.9) and class II (BMI 35-39.9) obesity is associated with increased risk for gestational hypertension, preeclampsia, gestational diabetes, and fetal macrosomia, as well as a progressively increased rate of cesarean delivery. Women in this group who undergo cesarean delivery are more likely to have wound dehiscence and infections. The risk of stillbirth and neonatal death is doubled in this group as well.
Medical management of 1st trimester abortion include:
Combined mifepristone/misoprostol. Can also use Methotrexate
What can sometimes be the first sign of IUGR?
Discrepancy in fundal height measurements
Hyperhemolytic
Accelerated rate of RBC destruction characterized by anemia, jaundice, and reticulocytes. this complication suggests other coexisting conditions, like a viral illness or a transfusion reaction.
FHR: Category ONE FHR:110-160
Accelerations/Early eceleration: present/absent, Variability: moderate, Late/Variable/Prolonged decelerations: absent
maternal ABG value for PCO2
31mmHg
Most common Childhood Malignancy and is associated with trisomy 21?
ALL
What CBC findings occur with CML?
Anemia Thrombocytosis Leukocytosis
Why do preterm infants have reduced iron stores?
Because the majority of iron stores are acquired in the 3rd trimester.
Systematic Onset JIA (Still disease) complication
Complication: Macrophage Activating Syndrome (type of DIC)
Pancytopenia
Deficiency of all blood cells
T/F: uncontrolled asthma affects organogenesis
FALSE
Are boys or girls more likely to have CNS abnormalities in central precocious puberty?
Males
gold standard TB test in pregnancy
PPD: mantoux tuberculin skin test
Toddler
Regression Clingy Refuse to let parent out of signt Show distress by biting, hitting, tear
Histerlin
Subdermal implant replaced annually for the treatment of central precocious puberty
HD class 2: ______ with increased activity
symptomatic
FHR: Category TWO: (kinda confusing) Brady without variability or Tachycardia
Accelerations: can not induce, Variability: in brady (minimal/marked), in tachy (absent without recurrent decels), Prolonged decels of 2-10 min
What medications for inflammatory bowel disease are safe in pregnancy?
(1) 5-ASA drugs: sulfasalazine, mesalamine, and balsalazide are category B. Olsalazine is category C. (2) Azathioprine and 6-mercaptopurine (both category D) have been reported safe in pregnancy; the attendant increased risk of IUGR and prematurity should be weighed with the benefits of inducing remission. (3) Corticosteroids: prednisone and prednisolone (category C) are widely used in pregnancy; budesonide (category C) is formulated to exert a local effect and is theoretically safe. (4) Cyclosporine (category C) is controversial because of its side-effect profile. (5) Infliximab (category C) is not currently being used and lacks pregnancy data. (6) Methotrexate (category X) is teratogenic and should not be used. (7) Metronidazole is category B.
What gastrointestinal motility disturbances may occur during pregnancy?
(1) Abnormal esophageal motility with increased nonpropulsive motor activity and decreased contraction wave amplitude and velocity. (2) Decreased lower esophageal sphincter pressure. (3) Decreased LES sensitivity to pharmacologic and physiologic stimulation. (4) Decreased secretion of acid and pepsin by the stomach. (5) Prolonged transit through the stomach and small bowel. (6) Prolonged intervals between interdigestive small bowel myoelectric complexes. (7) Increased villus height, gut hypertrophy, increased activity of brush border enzymes in the small intestine. (8) Slower colonic transit. (9) Enhanced colonic absorption of sodium and water. (10) Slower gallbladder emptying.
Describe the factors that lead to the decreased risk of peptic ulcer disease in pregnant women.
(1) Avoidance of NSAIDs and smoking during pregnancy. (2) Protective effect of estrogen on gastric and duodenal mucosa. (3) Immunological tolerance to H. pylori, thus decreasing the inflammatory response.
What is the differential diagnosis of nausea and vomiting in pregnancy?
(1) Gastrointestinal causes: gastroenteritis, gastroparesis, achalasia, biliary tract disease, hepatitis, small bowel obstruction, peptic ulcer disease, pancreatitis, and appendicitis. (2) Genitourinary causes: pyelonephritis, uremia, ovarian torsion, nephrolithiasis, degenerating fibroids. (3) Metabolic disease: DKA, porphyria, Addison disease/crisis, hyperthyroidism. (4) Neurologic disorders: pseudotumor cerebri, vestibular lesions, migraines, CNS tumor. (5) Pregnancy related conditions: fatty liver of pregnancy and preeclampsia. (6) Miscellaneous: drug toxicity/intolerance and psychological.
What is the differential diagnosis of hepatomegaly in pregnancy?
(1) Infiltrative disease: acute fatty liver of pregnancy (2) Inflammatory condition: hepatitis (3) Passive congestion: right-sided heart failure or Budd-Chiari syndrome (4) Malignancy (rare)
What are the abdominal causes of acute volume loss (with or without abdominal pain) during pregnancy?
(1) Ruptured ectopic pregnancy. (2) Placental abruption. (3) Ruptured liver. (4) Ruptured splenic artery aneurysm.
What is the differential diagnosis of jaundice in pregnancy?
(1) Viral hepatitis: serum transaminases increased mild-to-moderate range, positive serology, prominent inflammatory infiltrate on liver biopsy with cellular disarray. (2) Acute fatty liver of pregnancy: serum transaminases minimally increased, prominent microvesicular fat deposition on liver biopsy. (3) Toxic injury: history of exposure to tetracycline, isoniazid, erythromycin, or methyldopa. (4) Cholestasis of pregnancy: pruritus, bile salt elevation. (5) Severe preeclampsia: hypertension, proteinuria, thrombocytopenia, elevated creatinine, uric acid, and transaminases. (6) Mononucleosis: flu-like symptoms, elevated transaminases, positive heterophile antibody. (7) CMV hepatitis: elevated transaminases, positive viral culture or PCR, CMV antibodies. (8) Autoimmune hepatitis: elevated transaminases, ANA, liver-kidney microsomal antibodies.
Kawasaki Syndrome triphasic course
(1) acute course (0-11 days) (2) subacute (11 - 21 days) (3) convalescent (21-60 days)
Disorders of vasopressin include:
(1) central (neurogenic) diabetes insipidus (2) nephrogenic diabetes insipidus (3) the syndrome of inappropriate secretion of antidiuretic hormone
*Periarticular swelling where most common?
(75% cases) specially knees, ankles, usually no warmth or erythema
Additional management reccom in mutigestational pregnancy?
- more frequent prenatal visits to screen for maternal HTN - periodic US for fetal growth screening: serial cervical US has been shown to be able to predict PTD in twins to allow time for BMZ use
How is the diagnosis of chorionicity and zygosity made?
- 1st trimester US most accurate time to ID chorionicity - monozygous embryos dividing <72 hours after fertilization will be dichorionic - US diagnosis of dichorionic twins cannot determine zygosity - Monochorionic embryos dividing >72 hours after fertilization are always monozygous - diamniotic dichorionic placentation: occurs with division prior to morula state (within 3 days) - diamniotic monochorionic: division between days 4-8 - monoamniotic, monochorionic placentation: division between 8-12 - after 13th day: conjoined
What factors determine safest timing of delivery in multiple gestation
- 38 weeks has been shown to have lowest risk of perinatal mortality - maternal/fetal complications may warrent delivery at earlier GA
What are the two initial tests for precocious Puberty?
- X-ray of the left wrist and hand to determine skeletal maturity - Estradiol level to rule out ovarian cysts or tumors
Interventions for prevention of PTD in multigestational pregnancies
- adequate wt gain in first 20-24 weeks--> aids in development of placenta
How should a pt with hx of unexplained fetal demise be followed in future pregnancy
- antenatal surveillance with NST, BPP starting at 32 weeks - US to follow growth - fetal kick counts - frequent visits to document fetal ht tones and reassurance
What is accelerated with the use of heparin during pregnancy
- bone loss - heparin induced thrombocytopenia - bleeding
Uteroplacental insufficiency
- can lead to asymmetric growth restriction: normal length but weight below normal usually; head-sparing effect
Symtpoms, signs, and diagnostic methods to confirm fetal demise
- cessation of fetal movements - possible bleeding/cramping and/or labor - uterine size < dates - Dx made with US
death of a twin: first step in management
- check fibrinogen levels: if decreasing, may lead to a coagulopathy - should check weekly or biweekly depending on levels - induction should be considered but may be delayed to allow viable twin to mature
Causes and conditions assoc with fetal demise
- chromosomal, genetic, structural abnormalities - IUGR - placental abnml - maternal medical conditions - Pre-e and eclampsia - infections - cord acciden - placental abruption
Work up for fetal demise
- complete perinatal and FH - PE on fetus - autopsy of fetus and possibly radiologic studies - placental pathology - fetal karyotype - maternal medical hx - r/o infectious causes - antibody screen - fetal-maternal hemorrhage (Kleihauer-Betke) - urine tox screen
What are the causes for peripheral precocious puberty?
- congenital adrenal hyperplasia - adrenal tumors - McCune-Albright syndrome - familial male-limited gonadotropin independent precocious puberty - gonadal tumors - exogenous estrogen, both oral and topical - ovarian cysts - HCG-secreting tumors in males
Twin-twin transfusion syndrome
- death in utero of either twin is common - surviving infants: increased rates of nuerologic morbidity (increased risk of cerebral palsy) - excessive volume--> cardiomegaly, tricuspid regurg, ventricular hypertrophy and hydrops fetalis (recipient) - recipient twin is plethoric, macrosomic , hypervolemnic - donor: anemic, hypovolemic, growth retardation - either twin can develop hydrops
Definition of fetal demise
- deaths after 20 weeks
What would a plain radiograph show with ALL?
- demineralization - periosteal elevation - growth arrest lines - compression of vertebral bodies
US markers suggestive of dizygotic (non-identical twins)
- dividing membrane thickness > 2mm, twin peak sign (lamda sign), different fetal genders, two separate placentas (anterior and posterior)
Causes of short stature
- familial short stature - constitutional growth delay - endocrine disorders - intrauterine growth restriction - inborn errors of metabolism - intrinsic diseases of bone - short stature associated with chromosomal defects - chronic systemic diseases, congenital defects, and cancers - psychosocial short stature (deprivation dwarfism)
TTTS in the 2nd and third trimester will have what 3 things
- fluid difference "stuck twin"= poly/oli -growth differences -cord size difference -echogenic bowel in donor -bladder recipient: large donor: small
Constitutional growth delay growth pattern
- have a delay in skeletal maturation and a delay in the onset of puberty. - final height is appropriate for target height
What nutritional deficiencies is mom at higher risk for with twin gestation?
- increased blood volume: dilutional anemia and physiologic anemia - Ca depletion also exacerbated - normal wt women recomm to gain additional 10-15 lbs (total 35-40) * need Ca and Fe suppl
Potential consequences of IUGR
- increased perinatal morbidity and mortality (primary) Intrapartum: - increased risk of fetal HR abnormalities - C-sec deliv - low apgar scores - cord blood acedemia Neonatal: - polycythemia - hyperbilirubinemia - hypoglycemia - hypothermia - apneic episodes Longterm: - increased risk of cardiovascular disorders, HTN - Chronic obstructive lung disease - DM
What would an abdominal US show in ALL?
- kidney enlargement from leukemic infiltration or uric acid nephropathy - intra-abdominal adenopathy
What would a chest radiograph show in ALL?
- mediastinal widening - anterior mediastinal mass - tracheal compression secondary to lymphadenopathy or thymic infiltration
Spinal anesthesia side effects
-Vasodilation > precipitous drop in BP > nauseated and can affect babies HR ---Pre-load women with 1-2L of IV fluid before -Rare > complete sympathetic blockade > bradycardic and then asystolic ---Can reverse this with a shot of Epi -anesthesia usually goes up to mid thoracic area (T4) > feel like they can't breathe ---reassure numbness or tingling in hands -1% get spinal headache -watch for infection at site
External Cephalic Version
-change the position of the baby through maternal abdominal wall -may cause placental injury or baby may not tolerate > constant monitoring during with U/S, EFM -who? Singleton breech or 2nd twin breech; > 36 weeks gestation (want the baby to be full term) -Terbutaline > relaxes the myometrium -Epidural - for pain from the pressure of pushing -induce labor right then when successful > or baby will go back (unstable lie)
INSULIN- FIRST LINE for many OBs-
0.7 units/kg first trimester; 1unit/kg later in gestation, ^ with obesity
1. Location of most ectopic pregnancies? 2. Incidence? 3. Mortality facts
1. Fallopian tube 95% (tubal) All others are classified as other (i.e. ceervical, ovarian, abdominal, etc) 2. 19.7 per 1000 3. leading cause of death in 1st trimester and accounts for 4-10% of all pregnancy deaths
When can amniocentesis be performed?
15-20 weeks
VBAC
1% risk of rupture NO induction > higher risk of rupture
*S/S of Preeclampsia* *NTK*
1+proteinura systloci BP >30 Diastoloic BP >15 of baseline WT gain in one week at least 2 lbs *Edema* (is not being used a primarly DX of preeclampsia)
1. CV sampling is performed when? 2. What is CV not able to diagnose?
1. 9-13 weeks 2. NTD
Preferred TB regiem in the pregnant ptx
1. 9months of INH and RIF
1. What is a heterotopic pregnancy? 2. Incidence? 3. Predispositioning factors for heterotopic pregnancies?
1. A pregnancy that occurs in combination with a intrauterine pregnancy 2. less than 1 in 30,000 3. Risk factors include: past smoking, PID, and presence of IUD
Other physical findings associated with hyperthyroidism?
1. Afib 2. Tachycardia 3. Thyroid goiter (often without bruit) 4. Grave's ophthalmopathy may be present 5. Hyperactive deep tendon reflexes
Causes of congenital hypothyroidism
1. Aphasia, hypoplasia, or maldescent of thyroid 2. Inborn errors of thyroid hormone synthesis, secretion, or recycling 3. Maternal antibody-mediated 4. TSH receptor deficit 5. Thyroid hormone receptor deficit 6. In-Utero exposure 7. Iodine deficiency
What malignancies are associated with Wiskott-Aldrich Syndrome?
1. Atopic disorders 2. Lymphoma 3. Leukemia
Causes of acquired hypothyroidism
1. Autoimmune thyroiditis 2. Thyroidectomy or radio iodine therapy 3. Irradiation of the thyroid 4. Thyrotropin deficiency 5. TRH deficiency due to hypothalamic injury or disease 6. Medications 7. Large hemangiomas 8. Idiopathic
What is the Characteristics of C1 esterase deficiency?
1. Autosomal dominant disorder with recurrent episodes of Angioedema lasting 2-72 hrs. 2. Provoked by stress or trauma 3. Can lead to life-threatening airway edema
what circulatory values will decrease during pregnancy
1. BP 2. systemic vascular resistance 3. pulmonary vascular resistance
Presence of four of the following five conditions:
1. Bilateral conjunctival infection 2. Change(s)* in the mucous membranes of the URT 3. Change(s)* of the peripheral extremities 4. Rash, primarily truncal; polymorphic but nonvesicular 5. Cervical lymphadenopathy
Laboratory/diagnostics for short stature?
1. CBC, LFTS, Electrolytes, ESR 2. bone age (consider skeletal survey for disproportionate features 3. UA 4. Thyroid function test 5. Anti-endomysial and antigliadin antibodies for celiac disease 6. Stool for ova & parasites (O&P) 7. Growth hormone level 8. Sweat test if recurrent bronchitis (r/o CF)
what circulatory values will increase during pregnancy
1. CO 2. HR 3. SV
What is the characteristics of Common Variable Immunodeficiency (CVID)?
1. Combined B-cell and T-cell defects 2. All Ig levels are low 3. Normal B-cell numbers --> low number of plasma cell
Management of short stature
1. Depends upon cause 2. Refer to appropriate sub specialist 3. Family support
Disporportionate stature
1. Dwarfism 2. Rickets
Treatment for SCA
1. Educate early 2. DailyPCN from 2mo- 5 years 3. All routine vaccinations plus stressed importance for Flu annually and Pneumococcal 23 at ages 2 and 5, PCV 13 between 6-18, and Meningococcal if recommended by provider. 4. Fever 38.5 or higher- immediate medical eval and blood cx/ antibiotics. 5. Treat pain, oxygen status, and hydration aggressively. 6. Blood transfusions only for acute issues like increasing oxygen-carrying capacity 7. Can give daily oral hydroxyurea
what respiratory values will decrease during pregnancy
1. FRC 2. airway resistance
Systemic Lupus Erythematosus (SLE)
Accounts for 10% of collagen vascular disease, affects 1:20000 children, females affects 8 times more
What are the signs/symptoms of Type II Diabetes Mellitus (DM2)?
1. Insidious onset of hyperglycemia may be asymptomatic 2. Generalized pruritus 3. Recurrent vaginitis is often the first symptom in women 4. Peripheral neuropathies & recurrent blurred vision are more common than in DM1 5. Chronic skin infections 6. Acanthosis nigracans 7. Polydipsia, polyphagia, polyuria may be present but less common symptoms for DM 2 8. In early disease, physical findings are unremarkable
What is proportional short stature?
1. Intrauterine growth retardation IUGR 2. maternal/fetal infection 3. Chromosomal abnormalities 4. Failure to thrive 5. Variety of endocrine diseases -hypopituitarism -growth hormone deficiency -diabetes -hypothyroidism
What follow up is recommended if IUGR is suspected?
1. Kick counts, BPP and UA Doppler are recommended 1-2/wk for suspected IUGR. 2. US to assess fetal growth performed every 3-4 weeks.
What is the cause/incidence of congenital hypothyroidism?
1. May affect fetus in 1st trimester 2. absence or underdevelopment of the thyroid gland 3. inherent dysfunction in transport/assimilation of iodine 4. hypothalamic or pituitary disorder 5. Occurs in 1:4,000 live births
Why is hypothyroidism due to?
1. May be due o disease of thyroid gland itself, or to a deficiency of pituitary thyroid-stimulating hormone (TSH) or hypothalamic thyrotropin-releasing hormone (TRH) 2. Most often due to autoimmune thyroiditis; other causes include iodine deficiency, deficient pituitary, and destruction of the gland by sugary, external radiation or trauma.
What is the dietary teach for management of Type I diabetes Mellitus?
1. May consult dietician 2. Total carb intake 50-60% of total caloric intake 3. Fats 25-30 of total calories 4. Fiber 25g/1,000 calories 5. Protein, 10-20% of total calories 6. Total caloric intake to achieve ideal body weight
What is the incidence of hyperthyroidism?
1. More common in females 8:1 2. Onset between 12 and 14 yrs old
Fun facts about oxytocin:
1. Most active during parturition and breast feeding 2. Stimulates contractions during labor 3. Stimulates more of it's own release
What malignancies are associated with Ataxia-Telangiectasia?
1. NHL 2. Leukemia 3. Gastric Carcinoma
What are signs/symptoms of hyperthyroidism?
1. Nervousness/restlessness 2. Heat intolerance, increased sweating, warm moist skin 3. Muscle cramps 4. frequent basilar migraine 5. weight changes-usually a loss 6. Palpitations, chest pain 7. menstrual irregularities 8. fine hair
What are the laboratory/diagnostics with hypothyroidism?
1. Newborn screening is mandatory 2. Elevated TSH 3. The following will be decreased -T4 and free T4 4. increased serum cholesterol and liver enzymes 5. hyponatremia, hypoglycemia 6. anemia
what are the signs/symptoms of hypothyroidism in neonates/infants?
1. No obvious symptoms in the 1st month of life 2. lethargy, poor feeding, prolonged bilirubin elevation 3. Growth deceleration 4. Large fontanels 5. Bradycardia 6. Hypotonia
When should screening be considered for Type II Diabetes Mellitus?
1. Obesity & gas 2 of the following risk factors: -family hx of Type II DM -race/ethnicity of African American, Native American, Hispanic, or Asian/Pacific islander -Signs associated with insulin resistance *Acanthosis nigricans *Hypertension *Dyslipidemia *Polycystic ovarian disease
What are the signs/symptoms of advanced disease with Type I diabetes mellitus?
1. Ophthalmic exam may reveal micro aneurysms or cotton wool spots 2. Evidence of peripheral vascular insufficiency 3. Diminished deep tendon reflexes (DTR's)
Factors increasing risk for tubal pregnancy?
1. PID and other STD's 2. Previous ectopic 3. Previous tubal ligations or sterilizations 4. endometriosis and uterine leiomyomas 5. Developmental abnormalities 6. Use of ART 7. IUD 8. Smoking
What are the signs/symptoms of Type I diabetes mellitus
1. Polyuria, polydipsia, & polyphagia are class symptoms 2. Nocturnal enuresis 3. Weight loss with increased hunger 4. Fatigue, weakness, parasthesia 5. LOC changes ranging from irritability to coma 6. Loss of subcu fat and muscle wasting suggestive of insidious onset 7. Dysfunction of peripheral sensory nerves 8. May show evidence of dehydration
How to calculate the Ponderal Index
1. Ponderal index (PI) can be calculated to indicate if small size is related to IUGR or simply constitutional in origin. PI = [weight (in g) x 100] / [length (in cm)]3
What is Type I Diabetes Mellitus (DMI)?
1. Previously known as insulin dependent or juvenile diabetes 2. Certain human leukocyte antigens (HLA-DR3 or HLA-DR4) are strongly associated with the development of DMI 3. At symptom presentation, most of the pancreatic islet cells have been destroyed and islet cell antibodies are detected (autoimmune process) 4. Believed to be the result of an infectious or toxic environmental insult to pancreatic B cells of genetically predisposed persons
What is Type 2 Diabetes Mellitus (DM2)?
1. Previously referred to as non insulin dependent diabetes mellitus (Non-IDDM or adult onset DM) 2. not linked to human leukocyte antigen system (HLA) 3. No islet cell antibodies identified 4. Presence of obesity or family history increases risk
What is the characteristics of Ataxia-Telangiectasia?
1. Progressive cerebellar ataxia 2. Oculocutaneous Telangiectasias 3. DNA repair defect
What medications are used to treat hyperthyroidism?
1. Propranolol for symptomatic relief: begin dosing with 10mg may go to 80 mg 4x's day 2. Thiourea drugs (PTU and Tapazole) for pts with mild cases, small goiters or fear of isotopes
What are the treatments for hyperthyroidism?
1. Radioactive iodine 131-I 2. Thyroid surgery (must be euthyroid preoperatively- normally functioning) 3. 2-3 drops of Lugol's solution every day for 10 days can reduce the vascularity of the gland
What are the laboratory/diagnostics for Type I diabetes mellitus
1. Serum fasting blood sugar>/= 126 mg/dl on 2 separate occasions is diagnostic 2. random blood sugar >/= 200 mg/dl & polydipsia, polyuria, & wt loss indicate need to confirm diagnosis by fasting studies 3. Glucosuria & ketonuria 4. Plasma ketones 5. Serum BUN and creatinine may be elevated 6. Elevated Hgb A1c (normal in children 5.5-7%) 7. Impaired glucose tolerance: FBS >/= 100& </=125
Two types of preterm deliveries:
1. Spontaneous- may have history of previous preterm birth, genital tract infections, nonwhite race, multiple gestation, bleeding in second trimester, and low pre-pregnancy weight. 2. Indicated- deliveries caused by medical or obstetric disorders that place the mother and/or fetus at risk
What is the laboratory/diagnostics for Hyperthyroidism?
1. TSH is the most sensitive test and will be decreased 2. T4-free thyroxin index & T3 Triiotothyronine will be elevated 3. Serum antinuclear bodies (ANA) usually elevated without evidence of lupus
What are the 4 types of diabetes?
1. Type 1 2. Type 2 3. Gestational 4. Other
TREATMENT OF THROMBOEMBOLISM
1. UNFRACTIONED HEPARIN/LMWH
What is the management for physical condition and pharmaceuticals for Type II Diabetes Mellitus?
1. Weight management 2. Oral antidiabetics 3. Insulin therapy in addition to oral therapy for severe hyperglycemia and ketoacidosis
What is the characteristics of Bruton's Congenital Agammaglobulinemia?
1. X-linked Recessive B-cell deficiency (boys) 2. Symptoms begin > 6 month old 3. Absent tonsils and other lymphoid tissue
treatment for a positive PPD but normal CxR
1. begin isoniazid after delivery if a repeat chest radiograph is normal 2. begin isoniazid after first trimester if there has been recent conversion
______ and ______ are the two pneumonias that increase mortality
1. coccidioidomycosis 2. H1N1
what meds are avoided in pregnancy
1. decongestants 2. antibiotics 3. warfarin 4. iodides 5. live vaccines 6. alpha AR 7. immunotherapy
What baseline studies need to be established in the management of Type I diabetes mellitus?
1. family history, age of onset, presence of obesity 2. is insulin required 3. presence of cardiac risk factors 4. diagnostic markers such as ketones & antibodies 5. Baseline fasting triglycerides, cholesterol, renal studies, ECG
What is the management for Type II Diabetes Mellitus regarding obtaining baseline data?
1. family history, age of onset, presence of obesity 2. is insulin required 3. presence of cardiac risk factors 4. diagnostic markers such as ketones & antibodies 5. Baseline fasting triglycerides, cholesterol, renal studies, ECG
Pneumonia in pregnancy can be very serious. _____ can occur, due to loss of normal ventilatory reserve in the patient, or fetal intolerance. _______ alkalosis can result. Immunologic changes can also result, such as decreased ____ _______ ______ and ____.
1. hypoxemia 2. respiratory alkalosis 3. cell mediated immunity 4. CD4
treatment of a positive PPD and abnormal CXR
1. if lesion is calcified or fibrotic, then give isonazid after delivery 2. if it is active TB, do 3 sputum smears and cultures. begin isoniazid, rifampin and ethambutol immediately
What are older women that become pregnant at an increased risk of:
1. increased risk of c-section 2. stillbirth 3. placenta accreta 4. genetic anomalies
Stage I Stage II Stage III Stage IV Stage V
1. poly/oil 2. addition of absent bladder in donor 3. abnormal dopplers 4. hydrops 5. death of one or both twins
What are adolescent pregnancies at an increased risk for:
1. preeclampsia 2. eclampsia 3. growth restriction 4. maternal malnutrition
Two most common causes of septic abortion
1. retained products of conception 2. bacteria that have been introduced into the uterus via ascending infection.
what antibiotics are teratogenic
1. tetracycline 2. aminoglycosides 3. sulfonamides 4. quinolones
Leading causes of maternal death in pregnancy
1. thromboembolic disease 2. hypertensive disease 3. hemorrhage, infection 4. ectopic pregnancy
What are signs/symptoms of hypothyroidism in older children?
1. weakness, muscle fatigue 2. arthralgias, cramps 3. Cold intolerance 4. constipation 5. weight gain 6. mental/physical sluggishness, poor motor coordination 7. Delayed bone age, poor growth 8. Dry skin, thinning hair, brittle nails 9. puffy eyes and thick tongue 10. edema of the hands & face, ascites 11. slowed deep tendon reflexes (DTR's) 12. Diminished heart sounds
1/3 rule in asthma
1/3 will get better 1/3 will get worse 1/3 will stay the same
Chronic Villus Sampling (CVS)
10-12 weeks indication: detection of genetic disorders interpretation: dependent on the particular type of chromosomes testing Nursing: increased risk of miscarriage, U/S is needed for visualization, advantage of CVS over amniocentesis is that it can be done earlier, Rhogam as indicated
Fetal Nuchal Translucency
10-14 weeks indication: where there is a h/o of downs syndrome or the patient is at high risk interpretation: >2.5 mm is abnormal, > or equal to is indicative of downs Nursing: patient teaching relating to the test
PUBS (Direct Coombs Titer)
10-22 weeks indication: documented fetal hemolytic disease (anemia) interpretation: extent of anemia of fetus Nursing: increased risk of miscarriage, U/S guidance, team effort to assure that specimens are transported safely, Rhogam is indicated
Fetal Heart Rate: FHR normal
110-160 bpm
HTN must return to normal in ___wks postpardum in order for it to be Gestational
12
At what age should iron levels be screened?
12 mos
RF for GDM: maternal obesity, large infant, materl age > 25yrs, hx of GDM, fasting glucose is over ____mg/dL
126mg/dL
Amniocentesis
14 weeks until term indication: assessment of chromosomes, fetal lung maturity, infection, meconium, etc. interpretation: depends on what is being tested Nursing: education on Rhogam for Rh- moms post procedure, fetal monitoring for those 24 weeks or greater, fetal kick counts, labor precautions, etc.
When to reassess IV/IM
15 minutes
Discordant CRLs Asymmetric NT's: one normal, one enlarged Abnormal DV flow
1st trimester TTTS
Number of yolk sacs __YS = Mono/Di ___YS Mono/Di *or*
2 1
glyburide (sulfonylurea), minimally crosses the placenta;
2.5-5mg/d initially to max of 20mg/d; Category B or C
GH cause is unknown and usually develops after the ____ wk of gestation
20
How many sporadic and genetic skeletal dysplasias are there that can cause disproportionate short stature?
200
Fetal Fibrinectin
24-34 weeks gestation indication: used to predict the likelihood of POL Interpretation: NEGATIVE means that the patient is unlikely to of into preterm labor. Predictive value is 95%. POSITIVE result means that patient will go into labor, predictive value 25-40% Nursing: this test may predict who will not go into preterm labor but NOT who will go into preterm labor
When should a pregnant woman receive RhoGAM?
28 weeks gestation
S/Sx: of severe preeclampsia: 110/60+ proteinuria is _-_+, upper body periorbital edema
3-4+
______% of pregnant women are abused
30%
Physical Exam:
Accurate B/P essential Dependent edema Pitting edema ( 27-3) Deep tendon reflexes (DTRs) ( table 27-4) Urinalysis for protein S/S severe preeclampsia
Drugs for mild pain
Acetaminophen (tylenol) NSAIDS
Polyarticular Onset JIA
35% of JIA > 5 joints involved in the absence of systemic signs and symptoms onset > 8 years, females > males
Group B Strep (GBS)
36-37 weeks indication: test performed to detect status of mom interpretation: +GBS requires that the mother will have IV antibiotics administered during labor. -GBS means that mother will not need antibiotics Nursing: is GBS status is unknown, membranes are ruptured >18hrs, POL is determined, and multiple fetuses then the mom is treated. If patient is GBS+, has not been in labor, and is scheduled for c-section then antibiotics are NOT needed
when does asthma typically improve
36-40weeks
Probability of delivering 2 live infants if normal US at 6 weeks: MC ___ DC ____
39% 76%
What are the common infections associated with Chronic Granulomatous Disease?
Chronic skin, Lymph node, Pulmonary, GI, and urinary tract infections, osteomyelitis, and hepatitis
RF for Gestational HTN include: First pregnancy, Obesity, Family Hx, Age over ____ or under 19, chronic HTN/renal disease, DM
40
Maximum % of fat, carbs, and protein for disease modification are...
40%fat & carb, 20%protein/3 meals
When to reassess rectal
45-60minutes
HTN complicates
5 to 10% of all pregnancy. CHTN higher in women over 40 and older is nearly 10 times higher than for those younger than age 20. Morbidly 10 to 20% of maternal death world wide. Preeclampsia is the 2nd leading cause of mortality in the U.S.
What % of pts with GDM, will go on to have Type 2 DM later in life?
50%
Pauciarticular Onset JIA 50% children have?
50% children have iridocyclitis. First clinical sign is cellular exudate in anterior chamber, synechiae lead to irregular pupil and later band keratopathy, cataract and glaucoma develops
__to __% surviving twins delivered preterm
50-80%
What is the characteristics Severe Combined Immunodeficiency (SCID)?
=> defect in the stem cell maturation. => decreased adenosine deaminase
a twin has a ___ greater chance of perinatal death than a singleton
5x
Growth hormone therapy can improve final height by an average of how many centimeters in girls with Turner syndrome?
6 cm
What is the recommended oral dose of iron for supplementation?
6 mg/kg/d in 3 divided doses
How long should individuals with malabsorption issues wait to become pregnant?
6 months
Kawasaki Syndrome peak age?
6 months - 2 years
the CDC recommneds routine immunixation with HepB vax for all newborns at birth and at ages 1-2 mos, and ___-___ months
6-18
when to reassess oral
60 minutes
When should a medical abortion patient follow up with their care provider?
7-14 days after starting medical abortion
GA at which Risk of developing mental retardation with sufficient doses of radiation
8-15 weeks
Why are CBCs so useful in patients with ALL?
95% of all patients with ALL have at least one type of cytopenia
Chronic Myelogenous Leukemia is caused by the translocation of these two chromosomes
9; 22
Definition of low birth wt in singleton
< 2500g
Pauciarticular Onset JIA
< 5 joints large joints, symmetric involvement
FHR bradycardia
<110 bpm
A GTT consists of ....
A baseline glucose, then 100g of glucose. Testing at 1 hour, 2 hours and 3 hours after. Considered positive if 2 of the 4 levels are elevated.
What is hypothyroidism?
A condition resulting in lack of circulating thyroid hormone
What is the mechanism of Leukocyte Adhesion deficiency?
A defect in the chemotaxis of leukocytes
What is the Characteristics of Job's syndrome
A defect in the neutrophil chemotaxis FATED F = Coarse Facies A = Abscesses T = Retain primary teeth E = Hyper-IgE (eosinophilia) D = Dermatologic (server eczema)
When does screening for newborn hypothyroidism occur?
A few days after birth
Leukemia
A malignant disease of the blood-forming organs of the body that results in an uncontrolled growth of immature white blood cells (blasts or stem cells).
What are the causes of central precocious puberty involving CNS abnormalities?
Acquired: abscess, chemo, radiation, surgical trauma Congenital: arachnoid cysts, hydrocephalus, hypothalamic hematoma, septo-optic dysplasia, supresellar cyst Tumors: astrocytoma, craniopharyngioma, glioma
Factor 8
A or classic 80-85% of all cases. needed for forming thromboplastin.
What is imatinib mesylate (Gleevec)?
A tyrosine kinase inhibitor that has had dramatic success in the treatment of CML.
What physical findings suggest that nausea and vomiting in a pregnant woman may be because of an independent disease process?
Abdominal pain or tenderness that is worse than the mild epigastric discomfort that occurs after retching, fever, headache, goiter, or an abnormal neurologic examination. A caveat: severe nausea and vomiting may rarely cause a neurologic abnormality, such as thiamine-deficiency encephalopathy or central pontine myelinolysis.
Dermatomyositis (DM) Lab data
Abnormal EMG, muscle biopsy, increased creatine kinase (CK), SGOT, Aldose, ESR, positive ANA T2 weighted MRI of thigh shows inflammatory changes
What lab tests should be measured for girls showing signs of adrenarche and advanced bone age?
Androgens: testosterone, androstenedione, dehydroepiandrosterone-sulfate Adrenal intermediate metabolites: 17-hydroxyprogesterone
3 types of CNS abnormalities in central precocious puberty
ACQUIRED, CONGENITAL AND TUMORS
antibodies in SLE
ANA is positive in most pts. Other antibodies include ds-DNA ab, Anti-La, Anti-Ro, anti sm and anti RNP
what diameters of the chest are increased due to the enlarging uterus
AP and transverse
Increased perinatal mortality risk, multifetal gestation, congenital anomalies, and low birth weight are all concerns with usage of what?
ART
Treatment of JIA
ASA (aspirin) 100 mg/kg/day (Blood levels 20-30 mg/dl) to maximum of 2.4 - 3.6 gm/ day. NSAID - Ibuprofen, Naproxen, Tolmetin,
Most sensitive measure for evaluating fetal growth restriction
Abdominal circumference measurement is the single most sensitive measurement for evaluating fetal growth restriction.
What is the most frequent cause of an acute abdomen in pregnancy?
Acute appendicitis, which approximates 1 in 1500 deliveries, can occur at any time, with a slight predominance during the second trimester. Maternal mortality is rare, but the rate of fetal loss is 10% to 20%, because of preterm labor or IUFD. Preterm labor usually occurs within 5 days of surgery, and could either be because of the disease or the inflammatory response to surgery. The differential diagnosis includes pyelonephritis, cholecystitis, renal or ureteral calculi, adnexal torsion, degenerating myoma, extrauterine pregnancy, and placental abruption.
What is the most common malignancy in childhood?
Acute lymphoblastic Leukemia
ALL
Acute lymphoblastic Leukemia; most common malignancy of childhood. Unknown cause, occurs from the presence of more than 25% malignant hematopoietic cells in bone marrow aspirate.
Henoch-Schonlein Purpura-Clinical Features
Acute onset of skin rash, arthritis, abdominal pain *Rash *Subcutaneous edema (nonpitting, es. Hands, feet) *85% abdominal pain *Periarticular swelling
What type of anemia is usually normocytic or macrocytic but not megaloblastic?
Anemia of hypothyroidism
What are clinical manifestations of AML?
Anemia, thrombocytopenia, neutropenia, hyperleukocytosis,, venous stasis
What ancestries are more likely to develop alpha thalassemia?
African Mediterranean Middle eastern Chinese Southeast Asian
What are 5 tyrosine kinase inhibitors?
Imatinib mesylate Dasatinib Erlotinib Nilotinib Ponatinib
Risk factors for Preeclampsia
Age <20 Age > 35 Nulliparity Multiple gestation DM Thyroid disease Renal disease Family hx Hydatidiform mole Collagen vascular disease Antiphospholipid syndrome
What are the normal changes in liver function tests that occur in pregnancy?
Albumin may decrease by 1 g/dL, while bilirubin and the transaminases may be normal or decreased. These changes are because of hemodilution caused by the increased plasma volume between the 6th and 32nd weeks of gestation. Alkaline phosphatase (ALP) is increased because of both increased bone turnover and the leakage of placental ALP into the maternal circulation. Fibrinogen, transferrin, ceruloplasmin, and cholesterol are all increased.
What happens when you give transfusion to IgA deficiency patients?
Anaphylactic Transfusion reaction due to anti-IgA antibodies.
Women with DM Type 2 often have a body in the shape of what fruit?
Apple :)
What measurements help determine if short stature is disproportionate?
Arm span Upper-to-lower body segment ratio
SEVERE PRECLAMPSIA INTERVENTIONS 4.
Assessments of fetal well-being (e.g., NST, BPP) are ordered because of the potential for hypoxia related to uteroplacental insufficiency. Electronic fetal monitoring is carried out at least once a day. Vaginal examination may be done to check for cervical changes. Abdominal palpation establishes uterine tonicity and fetal size, activity, and position. The woman with severe preeclampsia is maintained on bed rest, and seizure precautions are initiated. Noise and external stimuli should be minimized. ( box 27-2)
Chronic Hypertension
Associated with increased incidence of: Placenta abruption Superimposed preeclampsia Increased perinatal mortality Fetal growth restriction PTL Diets sodium limited to 2. 4 g sodium. Tx- Aldomet ( Methyldopa) Labetalol and Nifedipine ( 27-5)
When should screening for Type II Diabetes Mellitus begin if done?
At age 10 or onset of puberty-whichever occurs 1st and repeat every 2 years
Treatment for Fanconi anemia
Attentive and prompt support of symptoms - neutropenic patients with fever parenteral broad spectrum antibiotics - transfusions used judiciously - oxymetholone - definitive treatment: reduced intensity hematopoietic stem cell transplant
What is Type 1 diabetes, formerly IDDM or juvenile -onset.....
Autoimmune destruction of the beta cells in the islets of the pancreas = absolute insulin deficiency. usual onset is young, can appear for the first time at pregnancy. If both parents are affected , 33% risk for infant.
Define Grave's Disease
Autoimmune disorder marked by increased production of thyroid hormone
What is the genetic inheritance for constitutional aplastic anemia?
Autosomal recessive
What is the Characteristics of Chediak-Higashi syndrome?
Autosomal recessive disorder that leads to a defect in the neutrophil chemotaxis/ microtubule polymerization. The syndrome includes: 1. Partial Oculocutaneous albinism 2. Peripheral neuropathy 3. Neutropenia
What is oral hydroxyurea used for
In the SCA patient, oral hydroxyurea can increase level of fetal hemoglobin, decrease hemolysis, and reduce pain and dactylics in younger children
Factror 9
B or Christmas disease
Medication Treatments for hyperthyroidism
B-adrenergic blocking agents Anti thyroid agents Iodide
What are the most common infections associated with DiGeorge Syndrome?
Increased risk of viral, fungal and PCP
When is precocious puberty in males
Before age 9
What presentations of gallstone disease are common during pregnancy? Which are rare?
Biliary colic and acute cholecystitis are common; jaundice and acute pancreatitis are rare.
Most accurate test for dating a pregnancy in the 2nd trimester?
Biparietal diameter and head circumference
Define small for gestational age infants
Birth weight below 10th percentile for the population's birth weight-gestational age relationship
First sign of threatened abortion
Bleeding with or without cramping within 1st 20 weeks of
How is the diagnosis of ALL made?
Bone marrow aspiration, which shows a homogenous infiltration of leukemic blasts replacing normal marrow elements.
How is ALL diagnosed?
Bone marrow examination
What are the signs and symptoms of CML?
Bone pain Fever Night sweats Fatigue Dyspnea Priapism Fever Pallor Ecchymosis Hepatosplenomegaly
What are some signs of chronic myelogenous leukemia?
Bone pain, fever, night sweats, fatigue, leukostatsis, anemia, and thrombocytosis
What are the signs and symptoms of female precocious puberty?
Breast development Pubic hair Menarche Axillary hair Acne Body odor
Clinical findings of ALL
Bruising, pallor, bone pain (hip or legs), splenomegaly, superior vena cava syndrome
What immunodeficiencies are associated with Compliment disorders?
C1 esterase deficiency Terminal Complement deficiency
What is the characteristics Thymic aplasia (DiGeorge Syndrome)?
CATCH-22 C = Cleft palate A = Abnormal Facies T = Thymic aplasia -> T-cell deficiency C = Cardiac Defect H = Hypocalcemia -> parathyroid dysfunction 22 = microdeletion at chromosome 22q11
What are the recommended tests for iron deficiency anemia?
CBC Ferritin CRP Reticulocyte hemoglobin
ALL diagnostic
CBC (neutropenia, thrombocytopenia, anemia) blasts on peripheral blood smears, elevated lactate dehydrogenase
What is the most useful initial test for ALL?
CBC with differential that might show neutropenia, thromboycytopenia, or anemia
mainstay of asthma treatment
CORTICOSTERIODS! BUDESONIDE is the DOC then give bronchodilators
What are the two main types of precocious puberty?
Central, which is gonadotropin releasing hormone dependent Peripheral, which is gonadotropin releasing hormone independent
What is myeloproliferative disease?
Characterized by ineffective hematopoiesis that result in excessive peripheral blood counts
What is transient myeloproliferative disorder?
Characterized by proliferation of blasts usually megakaryocytic origin
women with _____ preeclampsia: can be treated at home, monitor BP and Wt rest, non stress tests ____ diet
NAS
Hematopoesis
Childhood= marrow of long bones. Adolescence= bones of torso and skull. Regulated by erythropoietin which is produced in liver of fetus and kidneys after birth.
What chromosome does beta thalassemia effect?
Chromosome 11
What chromosome does alpha thalassemia effect?
Chromosome 16
What immunodeficiencies are associated with Phagocytic disorders?
Chronic Granulomatous Disease Leukocyte Adhesion deficiency Chediak-Higashi syndrome Job's syndrome
Juvenile Idiopathic Arthritis (JIA) pathology
Chronic nonsuppurative inflammation of the synovium Synovial edema, hyperemia with lymphocytosis and plasma cell infiltration - Joint effusions - Pannus formation - Articular surface destruction - Deformity, subluxation, ankylosis, tenosynovitis, and myositis - Fibrinous serositis (pericardium, pleura and peritoneum) - Vasculitis - rash
Laboratory Tests Table -( 27-3)
Complete blood count (CBC) (including a platelet count) Clotting studies (including bleeding time, PT, PTT, and fibrinogen) Liver enzymes (lactate dehydrogenase [LDH], AST, ALT) Chemistry panel (BUN, creatinine, glucose, uric acid) Type and screen, possible cross match LDH values differ according to the test/assays being done
Lymphatic system
Composed of red bone marrow, thymus, spleen, lymph nodes, lymphatic vessels; picks up fluid leaked from blood vessels and returns it to the blood; Involved with immunity; Without the system, the body would swell and fluid becomes trapped in your tissues
Two types of hypothyroidism
Congenital Acquired
Types of Growth Hormone Deficiency
Congenital Genetic Acquired Idiopathic
What is the number one inherited bone marrow failure syndrome?
Constitutional aplastic anemia (fanconi anemia)
Eclampsia Key NTK interventions
Convulsions Aspiration Immediate Care
What type of anemia appears in the first year of life, is transfusion dependent, and no treatment can lead to facial deformities, massive hepatosplenomegaly, poor growth, and pathologic fractures?
Cooley anemia (beta thalassemia major)
Why must we be careful when watching hcg levels in a ectopic pregnancy that is not evident on US
Could be elevated based on multiple pregnancies
Most accurate test for dating a pregnancy in the first trimester?
Crown rump length
School age
Crying, withdrawn Deny sadness by hiding tears Decreased concentration Psychosomatic complaints Angry outburst, disruptive Comfort patient by taking over tasks Fear of death of loved ones
Surgical abortion after 14 weeks from LMP
D&C
GDM is common and resolves quickly after birth; however some women can develop ______ later in life
DM
General treatments for hyperthyroidism
Decreased strenuous activity Medications Radiation therapy Surgical removal of part or all of the thyroid
What is the principle mechanism of anemia of chronic renal failure?
Deficiency in erythropoietin, a hormone produced in the kidney
What is the mechanism of immunodeficiency in Chronic Granulomatous Disease?
Deficient Superoxide production by the PMN and Macrophages.
How is diagnosis confirmed with constitutional aplastic anemia?
Demonstration of an increased number of chromosome breaks and rearrangements in peripheral blood lymphocytes
Adolescent
Depression Mood swing Withdrawal angry, guilty Acting out, risk taking, delinquency Suicide attempts Philosophical reasoning sleeping and eating disorders
What are treatment options for brain tumors?
Dexamethasone, keppra to prevent seizures, systemic chemotherapy
What immunodeficiencies are associated with T-cells disorders?
DiGeorge Syndrome Ataxia-Telangiectasia Severe Combined Immunodeficiency Wiskott-Aldrich Syndrome
What conditions are associated with AML?
Diamond Blackan anemia, neurofibromatosis, down syndrome, wiskott Aldrich kostmann, and li-fraumeni syndrome
McRoberts' maneuver
Done immediately Lay mom down flat, hyperflex her hips and knees, get them all the way back as far as you can to open up pelvis and exert suprapubic pressure
What is the ceiling effect
Doses higher than recommended do not produce greater pain relief
Who is at an increased risk for acquired autoimmune hypothyroidism?
Down syndrome Turner syndrome Celiac disease Vitiligo Alopecia Type 1 diabetes
What syndrome has a 14-fold increase in the overall rate of leukemia?
Down's Syndrome
Splenic Sequestration
Due to ____ (pooling of sickled cells) and repeated infarction, over time the spleen becomes fibrotic and shrinks (autosplenectomy), typically before the end of childhood.
At what stage of pregnancy is pancreatitis most likely to occur?
During the third trimester and the postpartum period.
What are differential diagnosis for ALL?
EBV, CMV, aplastic anemia, juvenile rheumatoid arthritis
Decelerations: early, late, variable
Early decelerations- mimics contractions, often represents head compression. Late decelerations- falls in the FHR after contraction has started and ending after contraction has ended. Associated with fetal hypoxemia and a potential for perinatal morbidity and mortality
Eclampsia- Defined
Eclampsia is usually preceded by various premonitory symptoms and signs, including persistent headache, blurred visions, severe epigastric pain, and altered mental status. However, convulsions can appear suddenly and without warning in a seemingly stable woman with only minimum blood pressure elevations (Sibai, 2007). The convulsions that occur in eclampsia are frightening to observe.
Von Willebrand
Effects females and males; a bleeding disorder results from a deficit of von Willebrand factor (promotes platelets to come together and stick).
Definition of IUGR?
Estimated fetal weight (EFW) at or below the 10th percentile for gestational age.
What is the benefit of exercise for obese pregnant women?
Exercise is beneficial for the primary prevention of gestational diabetes, especially in women with a BMI ≥33. It is also useful in maintaining euglycemia in gestational diabetes patients who fail diet control alone. The following relative contraindications to aerobic exercise should be kept in mind: extreme morbid obesity, poorly controlled type 1 diabetes, history of extremely sedentary lifestyle, and orthopedic limitations.
What are the genes for Constitutional aplastic anemia?
FANCA FANCB FANCC
S/S severe preeclampsia
FRONTAL HEADACHE HEARTBURN C/O RUQ pain w hard rock ab *abruptio* visual disturbances Seizures (call for help and provide safety for pain)
FLACC
Face, Legs, Activity, Cry, consolable
Systematic Onset JIA (Still disease) signs
Fever, (typically has 1-2 spikes per day with daily normal) rash, irritability, arthritis and visceral involvement dominate the presentation Hectic fevers with chills (typically late afternoon spikes) Maculopapular rash, 2-6 mm, red, irregular borders, often with central clearing, on trunk and proximal extremities.
True or false: growth hormone therapy is beneficial in psychosocial short stature?
False
T/F: A history of Budd-Chiari syndrome precludes a subsequent normal pregnancy.
False.
T/F Breastfeeding is contraindicated in chronic hepatitis B carriers.
False. After neonatal hepatitis B vaccination and immunoprophylaxis, chronic hepatitis B carriers have a less than 4% risk of HBV transmission. This risk is approximately equivalent to the vertical transmission rate in chronic hepatitis B carriers who do not breast feed. Women with high viral loads or who are HBeAg positive could be at higher risk for transmission, although the exact risk is unknown.
T/F: Cesarean section should be performed in all pregnant women with chronic hepatitis B.
False. Appropriate immunoprophylaxis of the infant after delivery is sufficient.
T/F: Pregnancy is contraindicated in patients with chronic cholestatic liver diseases.
False. Cholestasis may worsen but can be managed and usually returns to baseline after delivery in primary biliary cirrhosis, Dubin-Johnson syndrome, and the familial intrahepatic cholestatic syndromes such as Alagille syndrome.
T/F: Treatment for Wilson disease should be discontinued during pregnancy.
False. Discontinuing penicillamine treatment for Wilson disease increases the risk of maternal hepatic and neurologic failure and hemolysis, and has been associated with fatal relapses. The drug itself is usually well tolerated by both the mother and her fetus. Trientene seems to be safe as well, although a few data are available. Zinc therapy is also effective in preventing relapse in pregnancy.
T/F Helicobacter pylori infection is responsible for symptomatic dyspepsia in pregnancy.
False. In a study of 416 pregnant patients, although 42% were found to be seropositive for H. pylori, they were no more likely to experience dyspepsia than seronegative controls.
T/F: Hepatomegaly is normal during pregnancy.
False. Pregnancy has little effect on liver size and architecture; therefore, a finding of hepatomegaly should prompt a search for an underlying pathology.
T/F Liver transplant is a contraindication to pregnancy.
False. Pregnancy planned at least two years after liver transplant with stable allograft function can have excellent maternal and neonatal outcomes although the risks are significant. Transplant recipients considering pregnancy should be counseled that pregnancy complications include preterm delivery (19%-20%), fetal growth restriction (10%), congenital malformations (4%-16%), spontaneous abortions (11%), graft rejection (10%), HELLP syndrome (8%), hypertension (up to 20%), preeclampsia (4%-20%), cesarean delivery (45%), maternal deaths (up to 3%). These numbers are higher than in the general population but lower than the corresponding outcomes quoted before 1998.
T/F: An ileostomy precludes a vaginal delivery.
False. The rate of cesarean section is not affected by the diagnosis of inflammatory bowel disease, and the decision should generally be based on obstetric indications. One exception is women with active or inactive perirectal, perianal, or rectovaginal fistulas who may have poor wound healing at the episiotomy site.
T/F Spider angiomata and palmar erythema are signs of liver disease in pregnancy.
False. These are normal findings in up to 60% of pregnant women, and disappear rapidly after delivery. Their etiology is thought to be related to the hyperestrogenemia of pregnancy.
T or F: Palliative care's primary goal if to manage pain for people with end stage disease.
False: Management of pain in any stage of chronic illness
When can fetal cord testing be performed?
Fetal cord sampling can be done in second and third trimester and gets fast results and access can allow treatment of certain conditions in utero.
What fetal condition is linked with a 4-gene deletion?
Fetal hydrops and fetal demise/neonatal death
Kawasaki Syndrome: Diagnostic Criteria of Center for Disease Control
Fever of 5 or more days Presence of four of the following five conditions: (next slide) Illness that cannot be explained by other known disease process
What are the most common GI symptoms associated with pregnancy?
Gingivitis 40% to 100%, Reflux 30% to 50%, Constipation 11%, Hemorrhoids 30% to 40%, Nausea and vomiting 70% to 85%. The following GI symptoms are also significantly more common among pregnant women: xerostomia, heartburn, eructation, improved appetite, early satiety, epigastric pain, nocturnal pain, and black stools
How do you treat central precocious puberty?
Give GnRH analogues that down regulate pituitary GnRH receptors and thus decrease gonadotropin secretion. 1. Leuprolide: monthly IM injections 2. Histrelin: subdermal implant replaced annually.
What are the two categories brain tumors can be divided in?
Glial tumors or nonglial tumors
OTHER TREATMENTS
Gold Salts (oral or IM), antimalarials, D-penicillanine, methotrexate, IVIG, sulfasalazine. Methotrexate 10-15 mg/m2/wk po or IM Systemic corticosteroids Tumor Necrosis Factor eg. Infliximab, etanercept, adalimumab PT / OT
What is the most common cause of hyperthyroidism?
Grave's Disease
Signs and symptoms of hypothyroidism
Growth retardation Decreased physical activity Weight gain Constipation Dry skin Cold intolerance Delayed puberty
What is psychosocial short stature?
Growth retardation associated with emotional deprivation
What antisecretory medications are safe for use during pregnancy?
H2 receptor antagonists are pregnancy category B. Proton pump inhibitors have documented safety and are category B, except for omeprazole (category C). Regarding other drugs, metoclopramide and sucralfate are both category B.
Is every RH positive baby carried by a Rh negative mother at risk for HDFN?
HDFN usually does not affect the mother's first baby, but once she has produced Rh antibodies, all future Rh-positive babies are at risk for HDFN. This is why administering Rhogam is so important to Rh negative mothers.
What syndrome is a variant of preeclampsia?
HELLP
What is gestational diabetes (GDM).....
Hallmark of GDM is insulin resistance, etiologically similar to Type 2 (unmasked by the metabolic changes of pregnancy)
NURSE ALERT for Mg
IF Mg toxicity is suspected, prompt actins are needed to prevent respiratory or cardiac arrest. The magnesium infusion should be *discontinued immediately*.
effects of rubella on the embryo/fetus: microcephaly, mental retardation, congenital cataracts, deafness, cardiac defects and _____
IUCG (intrauterine growth restriction)
If women stop smoking by 16 weeks gestation, what risk is the same as a non-smoker?
IUGR
What is the most common cause of central precocious puberty?
Idiopathic
The immediate goal of care during a convulsion
Immediate Care. is to ensure a patent airway (see Emergency box). When convulsions occur, turn the woman onto her side to prevent aspiration of vomitus and supine hypotension syndrome. Note the time and the duration of the convulsion. After the convulsion ceases, suction food and fluids from the glottis, and administer 10 L of oxygen by a facemask, insert an 18 gauge if one not in place, then start magnesium. ( may give valium or other meds if convulsions continue) Some facilities may continue the Magnesium for 12 to 24 hours after delivery for seizure prophylaxis.
Rash of systematic onset JIA
Important differential diagnosis of FUI erythematous, macular, and often evanescent. It can be more prominent during periods of fever.
In regards to iron levels, why are iron deficiency anemias different from anemia of chronic inflammation?
In both cases, iron levels are low, but anemia of chronic inflammation is not associated with elevated iron-binding capacity. It is associated with elevated serum ferritin levels.
What are causes for folic acid deficiency?
Inadequate dietary intake Malabsorption Increased folate requirements
What are the common infections associated with Chediak-Higashi syndrome?
Increase incidence of overwhelming pyogenic infections with: 1. Streptococcus pyogenes 2. Staph. Aureus 3. Pseudomonas
What are the CBC laboratory findings that will be abnormal with megaloblastic anemia?
Increased MCV and MCH
Female secondary sex characteristics
Increased breast size Increased uterine size More scalp hair
What are the most common presenting signs in male precocious puberty?
Increased linear growth rate Growth of pubic hair
What are the risks to the pregnancy when Crohn disease is active at the time of conception?
Increased rates of spontaneous abortion, premature delivery, low birth weight, and neonatal vitamin K deficiency. A case report published in 2001 linked a fetal subdural hematoma diagnosed at 22 weeks to maternal vitamin K deficiency secondary to Crohn disease.
Treatment of ALL
Induction, Consolidation, Intensification, maintenance, intrathecal chemo, bone marrow transplant, tyrosine kinase inhibitors (imatinib or dasatinib)
What are the fetal complications of hyperemesis gravidarum?
Infants born of women who had been admitted for hyperemesis gravidarum are more likely to be low birth weight, small for gestational age, born prematurely, and have a 5-minute APGAR less than 7. These effects are largely attributable to poor maternal weight gain, defined as less than 7 kg.
What is a common underlying cause for B12 deficiency (cobalamin) in infants?
Infants who were breast fed by mothers who are strict vegetarians
2. Change(s)* in the mucous membranes of the URT such as:
Infected pharynx Infected lips Dry, fissured lips "Strawberry" tongue
Juvenile Idiopathic Arthritis (JIA) etiology
Infectious Autoimmune
What are the common infectious agents associated with Chronic Granulomatous Disease?
Infectious organisms are catalase (+ve): Staph. Aureus E. Coli Candida Klebsiella Pseudomonas Aspergillus
What is thought to cause anemia of chronic inflammation?
Inflammatory cytokines that inhibit erythropoiesis, and shunting of iron into, and impaired iron release from, reticuloendothelial cells
What is the role of interferon alpha therapy for hepatitis during pregnancy?
Interferon alfa has been shown to produce clinical improvement in 28% to 46% of patients with hepatitis C, and has also been shown to alter the natural history of hepatitis B and D infection. However, it has abortifacient properties and should be avoided in pregnancy.
Signs and symptoms of ALL
Intermittent fevers Bruising Pallor Bone pain Petechiae Purpura Hepatomegaly Splenomegaly Lymphadenopathy Enlarged testes Superior vena cava syndrome Edematous periorbital area Leukemic infiltration Anemia
What is the usual cause for cobalamin deficiency in children?
Intestinal malabsorption
Where is folic acid absorbed?
Jejunum
Selective mapping and treatment of vessels lends to better outcomes than nonselective (coagulating all vessels crossing twin membranes) Selective: coagulates Direct A-A, V-V, and intertwin A-V connections
LCPV laser coagulation of placental vessels
Polyarticular Onset JIA: what is normally spared?
LS spine is usually spared
adrenergic blocker and a nonselective- adrenergic blocker used doing pregnancy
Labetolol
When is cholecystectomy safe during pregnancy?
Laparoscopic cholecystectomy is the most common laparoscopic procedure in pregnancy. Several studies have shown no increased risk of preterm delivery or adverse outcome after first trimester laparoscopic cholecystectomy. The laparoscopic approach is also feasible in the third trimester. Nonoperative management of symptomatic cholelithiasis is associated with higher recurrence of symptoms necessitating hospitalization, increased risk of gallstone pancreatitis (associated with a 10%-20% rate of fetal loss,) increased risk of miscarriage, preterm labor and preterm delivery compared to those undergoing laparoscopic cholecystectomy. Furthermore, such non-surgical approaches like bile acid therapy, lithotripsy, and dissolution with methyl terbutyl ether are not recommended during pregnancy because of the lack of safety data.
Spleen
Largest organ in lymphatic system, brings blood into contact with lymphocytes, enlarges during infection, hemolytic anemias and liver malfunction.
(LCPV) More aggressive treatment 66% survival 70% recipient 60% donor Neurologic handicap 13%
Laser Coagulation of Placental Vessels
Pauciarticular Onset JIA late onset?
Late onset - > 8 years, hips, ankles, knees and foot joints are involved, may progress to lumbar and sacral joint involvement
Tolerance
Level of pain person is willing to accept
Treatment of hypothyroidism?
Levothyroxine 75-100 mcg/m2/d
Stadol
Light IV narcotic with short half life used to take edge off or if needs to sleep a little bit Would not give if you think she will deliver imminently > narcotic > may have depressive effect on the baby
Why is acute appendicitis more hazardous to the mother during pregnancy than in the nonpregnant state?
Local perforation may be contained by the uterine wall on one side and may result in premature delivery with free perforation and generalized peritonitis after the uterus empties and pulls away from the appendiceal abscess.
__ twins= worry about TTTS
MC
___ twining with placental shunt from donor artery to recipient twin
MC
Aneuploidy risk: ____= same as singleton ____ = 2x singleton risk that one of them as aneuploidy abnormality Maternal serum screening less reliable with multiples
MC DC
what is the best diagnostic clue for TTTS
MC twins with asymmetric fluid
Chemotherapy
MOPP ABVD
What is the preferred imaging for brain tumors?
MRI is preferred CT with contrast can also be used
What imaging is necessary after a diagnosis of precocious puberty is made?
MRI: evaluate for CNS lesions US: ovaries and adrenal glands
Labor Suppressants: Terbutaline, Ritodrine, Nifedipidine, and not the first drug of choice ______ ____
Magnesium Sulfate
SEVERE PRECLAMPSIA INTERVENTIONS 4.
Magnesium Sulfate. ( Box 27-3) One of the important goals of care for the woman with severe preeclampsia is prevention or control of convulsions. Magnesium sulfate is administered as a secondary infusion (piggyback) to the main intravenous (IV) line by volumetric infusion pump. An initial loading dose of 4 to 6 g of magnesium sulfate, per protocol or physician's order, is infused over 15 to 20 minutes. This dose is followed by a maintenance dose of magnesium sulfate that is diluted in an IV solution per physician's order (e.g., 40 g of magnesium sulfate in 1000 ml of lactated Ringer's solution 1g= 25ml) and administered by infusion pump at 2 g/hour. This dose should maintain a therapeutic serum magnesium level of 4 to 7 mEq/L. Blood levels of magnesium sulfate are checked periodically. After the loading dose, there may be a transient lowering of the arterial blood pressure secon-dary to relaxation of smooth muscle by the magnesium sulfate
What do fanconi anemia patients have an increased risk for?
Malignancy
What is the most common cause of upper gastrointestinal hemorrhage during pregnancy?
Mallory-Weiss tear, followed by erosive esophagitis.
C/S indications
Malpresentation Previa Macrosomia Hx of dystocia/4th degree laceration Previous Uterine Scar Active Genital HSV: If known hx put on suppressive rx at 36 weeks Fetal Malformation > Any reason you think fetus will not tolerate labor (conjoined twins, spina bifida Cephalopelvic disproportion (CPD) Failure to progress: Started dilating and stopped; Baby not descending with pushing Placental Abruption Cord prolapse Fetal distress (NRFHT): Non reassuring fetal heart tones > Lack of variability and decelerations Maternal conditions: Severe pre-eclampsia, eclampsia, Cardiac condition (AS), Neuromuscular disease
What are some common treatments for hyperemesis gravidarum?
Management for hyperemesis gravidarum is supportive, with intravenous fluid resuscitation. No antiemetic has been approved for treatment, although they have been widely used. Antihistamines, phenothiazines, and combination doxylamine + pyridoxine have all been shown to effectively reduce nausea and vomiting. Pyridoxine alone has no effect on vomiting but reduces the severity of nausea. Ginger capsules reduce both nausea and vomiting. Multivitamin supplements taken during the time of conception may decrease the severity of nausea and vomiting. Oral methylprednisolone reduces hospital readmission rates. Acupuncture and acupressure have no significant treatment effect. Thyroid function should also be assessed because high serum beta hCG may stimulate the thyroid and therefore cause clinical hyperthyroidism. However, treatment for hyperthyroidism should not be started unless there is evidence of intrinsic thyroid disease, even if TSH levels are suppressed.
RF if IUGR
Maternal Factors: - medical conditions: HTN, renal disease, DM, vascular/autoimmunne disease - Substance use/abue: tobacco, alcohol, cocaine - Infections: viral, protozoal - teratogen exposure Fetal Factors: - small constitutional size - genetic and structural abnormalities - multifetal gestation Placental Factors: - primary placental disease: chorioangioma, mosaicism - abnormal placentation: previa, abruption, hematoma
What kind of workup may be considered in the setting of severe placental thrombosis or infarction, significant fetal growth restriction, or in the pt with a history of thrombosis
Maternal thrombophilia workup
Increased maternal and fetal risks with multifetal gestation
Maternal: - increased risk of gestational DM, HTN, anemia, ante and postpartum hemorrhage - increased risk of thrombosis compounded by increased risks of obeisty, maternal age, bed rest, C-sec in multiple gestations Fetal Risks - increase chance of miscarriage, fetal growth restriction, PTD, prenatal asphyxia, stillbirth (all more common in monochorionic gestations) - increased risk of fetal anomalies: but each dichorionic twin set has same risk as a singleton; risk is double for monochorionic gestation - risk for development of Cerebral palsy: 5-6 times more - risk of infant death rate 5x higher
Mild Preeclampsia & Home Care (MP)
May be managed at home Stable, urine protein < 500mg (300-500) in a 24 hour collection Activity Restriction ( pg 663) Teaching ( Box pg 662) Diet
What might imaging show for ALL?
Mediastinal widening or anterior mediastinal mass and tracheal compression secondary to lymphadenopathy. Abdominal ultrasound may show kidney enlargement from leukemic infiltration of uric acid
What type of anemia is characterized by a deficiency of vitamin B12, folic acid, or both?
Megoblastic anemia
What is metformin?
Metformin (glucophage) is currently FDA approved for use in children 1. 850 mg 2x's daily or 500 mg 3x's daily 2. Doesn't stimulate insulin action but reduces gluconeogenesis 3. Should not be given in hepatic or renal failure or those prone to hypoxia 4. Significan GI upset-howerver typically transient 5. Little or no hypoglycemia 6. Needs to be discontinued 48 hours prior to a procedure
1st line antihypertensive in pregnancy
Methylodopa
What is the severity of anemia with most chronic inflammation?
Mild to moderate with hgb levels of 8-12 g/dL
Most common aneuploidy in spontaneously aborted pregnancies
Monosomy X or Turner Syndrome. Trisomies account for more than half of aneuploid losses with Trisomy 16 being most common.
Leuprolide
Monthly intramuscular injection used in treatment of central precocious puberty
What are common characteristics of brain tumors?
Morning headache, vomiting, papilledema, school failure, personality changes
Iron Deficiency Anemia
Most prevalent nutritional disorder and mineral disturbance. Children 12 to 36 months are at highest risk because of cow's milk low iron and lactose intolerance. Premature infants are at risk because of reduced fetal iron supply. Adolescents are at risk because of rapid growth and poor eating habits.
What are the benefits of multiple-micronutrient supplementation during pregnancy?
Multiple-micronutrient supplementation is associated with a significant decrease in the number of low-birth-weight and small-for-gestational-age babies, as well as of maternal anemia, when compared to supplementation with two or less micronutrients. There were, however, no additional benefits obtained when compared with the WHOrecommended iron-folate supplementation.
S/S of HYPERGLYCEMIA & DKA include...
N/V, dehydration, abdominal pain, confusion
What CBC abnormalities can occur with ALL?
Neutropenia thrombocytopenia Anemia
The medication used for tocolysis and tx of HTN during pregnancy
Nifedipine: Ca+ channel blocker
is immunization for HepB contraindicated during pregnancy?
No
is Warfarin (Cumadin) given during pregnancy for women with HD?
No, may cause birth defects and are not given during pregnancy
Henoch-Schonlein Purpura
Nonthrombocytopenic purpura, arthritis / arthralgia, GI and renal symptoms Small vessel vasculitis * 75% are < 10 yrs (av. age 5 yrs.)
First trimester testing includes:
Nuchal translucency can indicate abnormality and lead to further testing like chorionic villus
Severe Preeclampsia KEY Interventions
Nutrition Magnesium sulfate Control of blood pressure *NEVER abbreviate MGSO4 any where in a medical record -safe med.*
What are the benefits of bariatric surgery for obese women contemplating pregnancy?
Obese women who have undergone bariatric surgery are less likely to have gestational diabetes, hypertension, macrosomia, or cesarean delivery. Bariatric surgery itself is not associated with adverse perinatal outcomes, despite earlier reports of increased rates of GI bleeding, anemia, IUGR, and neural tube defects. It is advisable to wait 12 to 18 months after surgery before attempting to conceive as well as to supplement with vitamin B12, folate, iron, and calcium.
Risk factors for GDM include....
Obesity: BMI >30, family Hx, minority ethnicity (AA, Hispanic), older age >35-40, , Hx of unexplained stillbirth, PCOS (polycystic ovaries).
Sickle Cell Disease
Occurs mainly in African Americans but also Mediterranean races. When the child inherits both HbA and HbS, they are said to have the sickle cell trait. When the child inherits predominately HbS, they have sickle cell anemia. The newborn with sickle cell is generally asymptomatic because of fetal Hgb which rapidly decreases during first year.
When should growth hormone therapy start in children with Down's syndrome?
Only if their linear growth is abnormal compared to the Down's syndrome growth chart
2 principle hormones of the posterior pituitary
Oxytocin and arginine vasopressin (which are synthesized in the ventral hypothalamus)
Signs and symptoms of megaloblastic anemia
Pallor Mild jaundice *Smooth and beefy red tongue* Irritable/poor feeders Paresthesia/weakness/unsteady gait
What are the two main signs and symptoms of iron deficiency anemia?
Pallor and fatigue
What is a glucose challenge test?
Patient ingests 50g of glucose followed by glucose level 1 hour after. If the results are >140 then a glucose tolerance test (GTT) should be done.
When is insulin started with Type I diabetes mellitus?
Patients presenting with ketones must start insulin. the rule of thumb is to begin w/0.5 u/kg/day, giving 2/3 of does in am and remaining 1/3 in pm
Which hormones influence nausea and vomiting in pregnancy?
Peak levels of human chorionic gonadotropin correlate temporally with the peak symptoms of nausea and vomiting. The extent of their emetogenic stimulus may be increased in conditions where there is an increased placental mass, such as in multiple gestation or molar pregnancy. Estrogen levels are also correlated with the frequency of nausea and vomiting. Estrogens in OCPs show a dose-response relationship for nausea and vomiting, and women thus sensitized have an increased likelihood of exhibiting nausea and vomiting in pregnancy. Cigarette smokers are less likely to have nausea and vomiting in pregnancy, which may be caused by the associated lower levels of both hCG and estradiol, compared with nonsmokers.
SubAcute phase of Kawasaki Syndrome
Peeling of hands and feet Thrombocytosis, coronary artery aneurysms (male, < 12 months, females > 2 weeks), recurrence of fever or rash, exaggerated leukocytosis and ESR are worrisome indicators of coronary artery disease.
Treatment for threatened abortion
Pelvic rest and progesterone, limit caffeine, no drugs, ETOH, or cigarettes, and restricted activity
Male secondary sex characteristics
Penis increases in length and diameter Scrotum becomes pigmented and rugose Internal genitalia begin to secrete hormones Increased hair growth everywhere Sebaceous glands increase secretion Vocal cords increase in size and length, deepening the voice
How CML is usually diagnosed?
Peripheral smear
Systemic Lupus Erythematosus (SLE)Treatment
Prednisone 1-2 mg/kg/day Immunosupressive drugs eg. Azathioprine, cyclophosphamide, mycophenolate Anticoagulants esp if anticardiolipin antibodies are positive
What are treatments for ALL?
Prednisone, dexamethasone, methotrexate, mercaptopurine, vincristine, chemotherapy, Bone marrow transplant, Tyrosine kinase inhibitors
With CML, what would be seen with a peripheral smear?
Predominance of myeloid cells in all stages of maturation, increased basophils, and relatively few blasts
What are the excess energy requirements during pregnancy (kcal/day)?
Pregnancy increases energy requirements by 300 kcal/day during the second and the third trimesters. Lactation increases energy requirements by 500 kcal/day.
Preeclampsia
Pregnancy-specific syndrome in which hypertension develops after 20 weeks of gestation in a previously normotensive woman
What are some risk factors for iron deficiency anemia?
Premature infant Low birth weight infant Perinatal blood loss Neonatal anemia Exclusive breastfeeding beyond 4 months without supplementation Whole milk
What features are associated with a higher risk of nausea and vomiting of early pregnancy?
Primigravid status, younger age, nonsmokers, obesity, less than 12 years of education, previous nausea with oral contraceptive use, and corpus luteum primarily on the right ovary.
What can be given weekly beginning the 2nd trimester to decrease risk of preterm delivery of patients with history of spontaneous preterm delivery
Progesterone in the form of 17alpha-hydroxyprogesterone injections 250mg
What test can identify an abnormal pregnancy?
Progesterone test- less than 5ng/ml has 100% specificity for abnormal pregnancy. Normal intrauterine pregnancies usually have progesterone levels of greater than 20ng/ml
Skin in pregnancy: PUPP
Pruritic urticarial papules and plaques of pregnancy, "halo", mostly on abdomin....but anywhere,
Define Precocious Puberty
Pubertal development that occurs before the age limit set for normal onset (8yrs for Caucasian girls; 7yrs for African American girls; rare in boys)
leading cause of maternal death in pregnancy. when is the risk greatest?
Pulmonary embolism; greater risk postpartum!
precocious puberty results from premature activation of the normal hypothalamic-pituitary-gonadal axis.
Pulsatile hypothalamic secretion of gonadotropin-releasing hormone (GnRH) stimulates pituitary secretion of luteinizing hormone (LH) and folliclestimulating hormone (FSH).
Anemia
Reduction in the number of RBCs; and/or hemoglobin is below normal. Most common hematologic disorder of infancy and childhood not a disease but an indication or manifestation. Effects can be profound may lead to cardiac failure.
Beta-Thalassemia
Refers to inherited blood disorders characterized by deficiencies in the rate of production of specific globin chains in Hgb. Occurs most often in persons living near the Mediterranean sea.
Preschooler
Regression Fear going of sleep Nightmares Afraid of the dark Fascinated with death Ask many questions Complains of abdominal pain
Why should a normal appendix found at laparotomy during pregnancy not be removed?
Removal of a normal appendix has been associated with a tripling of the risk of fetal loss.
*30-50% have ?
Renal involvement - hematuria, proteinuria; occasionally nephrotic syndrome, nephritis + 5% have ESRD
Fetal well-being- (stress of labor) is assessed by...
Scalp stimulation or fetal O2 sats. Expeditious delivery if shoulder dystocia or Erb's palsy evident.
Systematic Onset JIA (Still disease)
Represents about 20% of all JIA
Infant
Resists cuddling eat less cries excessively Clingy Sleeps more than usual
Side affect for opioids
Respiratory Depression
What happens in Acute Lymphoblastic Leukemia (ALL)?
Results in uncontrolled proliferation of immature lymphocytes
What is the Somogyi effect?
Results when nocturnal hypoglycemia stimulates a surge of counter regulatory hormones that raise blood sugar. This pt is hypoglycemia at 3am and rebounds with an elevated blood sugar at 7am. Treatment: reduce or eliminate HS dose of insulin
What is the Dawn phenomenon
Results when tissue becomes desensitized to insulin nocturnally. Blood sugar gets progressively higher throughout the night & is elevated at 7am. This desensitization is felt to be due to presence of growth hormone, which spikes at night. Treatment: add or increase HS dose of insulin.
Important obstetric history to look further into regarding previous stillborn or neonatal deaths?
Review records including autopsy, placental pathology, and karyotype
What is the most common symptom of appendicitis in pregnancy?
Right lower quadrant pain is the most common presentation in all three trimesters. The dictum that appendicitis presents as right upper quadrant pain during the third trimester has not been validated by studies.
Preeclampsia Risk Factors- *NTK*
Risk factors are Primigravidity or ( moms over 40 or under 19) Multifetal pregnancy or hydatidiform mole Obesity IUGR, placenta abruption, fetal death Chronic Renal disease & chronic HTN Collagen disease Diabetes ( type 1) RH Incompatibility Periodontal disease (See Box 27-1)
What is the cause of acute granulomatous peritonitis in pregnancy or the puerperium?
Rupture of fetal contents into the peritoneum or meconium spillage during cesarean delivery.
acute pain
SNS response, resolves with healing, short duration, restless/anxious, reports pain
Breech tx
SVD: usually only if preterm or 2nd twin (reach in and turn) ---Anoxia (cause brain injury); Birth Injury; Cephalohematoma (head becoming stuck); Brachial plexus injury; Fracture (clavicle or long bones) External Cephalic Version C/S > preferred and probably safest for baby
Second trimester testing includes:
Second trimester- triple test with MSAFP, beta HCG and estriol or add inhibin for quad test, for neural tube defects or trisomy 21.
What are the most common infections associated with SCID?
Server and frequent: 1. Bacterial infections 2. Fungal infections 3 Opportunistic infections
What is the rate of maternal-fetal transmission of hepatitis B?
Several factors modify the perinatal transmission rate of hepatitis B. In the absence of immunoprophylaxis, 10% to 20% of women who are seropositive for HBsAg alone will transmit the virus to their fetus. This rate increases to 90% in women who are seropositive for both HBsAg and HbeAg. The age of gestation when the illness occurs also affects transmission rates for acute hepatitis B. It is 10% during the first trimester, and increased to 80% to 90% during the third trimester. Intrapartum transmission of the infant via exposure to contaminated blood and genital secretions accounts for 85% to 95% of cases of perinatal transmission; the rest comes about from hematogenous dissemination, breastfeeding, and close physical contact between the mother and her neonate.
Causes of Iron Deficiency
Severe hemorrhage, inability to absorb iron, excessive growth requirements, inadequate diet, and GI bleeding r/t lactose intolerance.
What cells are affected in SCID?
Severe lack of B-cell and T-Cell
What type of anemia occurs in most forms of renal disease that have progressed to renal insufficiency?
Severe normocytic anemia
What are primary sex characteristics?
Sexual characteristics present at birth that comprise the external and internal genitalia
What are the adverse effects of severe nausea and vomiting on the mother and her fetus?
Significant morbidity to the mother might include Wernicke encephalopathy, splenic avulsion, esophageal rupture, pneumothorax, and acute tubular necrosis. A higher incidence of low birth weight (LBW) is associated with hyperemesis gravidarum, but not with mild to moderate vomiting. Both maternal and fetal deaths are very rare.
What 2 conditions result in early morning hyperglycemia?
Somogyi effect and dawn phenomenon
Most common complication of pregnancy
Spontaneous abortion defined as the passing of pregnancy at < 20 weeks gestation; fetus <500g
Postpartum diabetes management includes...
Start back on ADA diet, glucose 140-150mg/dL to assist in healing, insulin sensitivity increases- Closely monitor glucose.
What are the most common infections associated with Wiskott-Aldrich Syndrome?
Strep Pneumoniae Staph. Aureus H. Influenza type b Other encapsulated organism
What is the recommended treatment schedule for growth hormone deficiency?
Subcutaneous recombinant growth hormone given 7 days a week for a weekly total dose of 0.15-0.3 mg/kg
What is the primary manifestation of idiopathic or acquired GHD?
Subnormal growth velocity
Juvenile Idiopathic Arthritis (JIA) clinical features
Swelling of joints, loss of anatomical landmarks, tenderness, decreased joint mobility, warmth, erythema and maybe joint deformity Morning stiffness, gel phenomenon, weather exacerbations *Arthralgia maybe the only initial complaint
What is the Characteristics of Wiskott-Aldrich Syndrome?
Symptoms are presented at birth Patient has high IgE/IgA ratio and decreased IgM and thrombocytopenia WIPE W = Wiskott-Aldrich Syndrome I = Infections P = Purpura (thrombocytopenia) E = Eczema
Thalassemia major
Symptoms of ___ Pallor, poor appetite, jaundice, chronic hypoxia, enlarged liver, enlarged spleen, possible CHF. Bone marrow spaces enlarge (in order to make more blood cells in response to the hematopoietic defects)—this weakens bones so they fracture more readily, also causes changes in the contours of the face.
what are the three main risks for monozygotic twins
TTTS: twin to twin transfusion syndrome TRAP: twin reversed arterial perfusion Twin Embolization syndrome
Laboratory findings. ( 27-3)
Table 27-3
What is CALLA?
The common ALL antigen found on the cell surface of leukemia blasts
Term infants have enough iron prevent iron deficiency for how long?
The first 4 months of life
What features distinguish hyperemesis gravidarum from the more common nausea and vomiting that occurs during early pregnancy?
The following criteria are often used to diagnose hyperemesis gravidarum: persistent vomiting not related to other causes, acute starvation with large ketonuria, loss of at least 5% the prepregnancy weight, and electrolyte abnormalities. Hyperemesis is also associated with abnormal liver function tests. Serum bilirubin can be increased up to five times the upper normal limit. Transaminases and alkaline phosphatase can show mild to moderate increases. Serum amylase may be increased; however, the origin of this is mainly the salivary glands.
How are FSH and LH affected in peripheral precocious puberty?
The initial FSH and LH are low. LH response is suppressed by GnRH stimulation
What is the severity of alpha thalassemia dependent on?
The number of gene deletions on chromosome 16. The more gene deletions, the more severe the disease
What is the rate of maternal-fetal transmission of hepatitis C?
The rate of perinatal transmission of hepatitis C is proportional to the maternal viral titers. The overall risk of vertical transmission is 7% to 8%, and is higher in women who are also infected with HIV. Furthermore, the presence of antibodies is not protective against transmission. The transmission rate by breastfeeding is 2% to 3%.
Which malformations are associated with immunosuppressive therapy after liver transplantation?
The occurrence of meningocele, urogenital defects, cleft palate, hypospadias, multicystic dysplastic kidneys, and membranous ventricular septal defect have been associated with immunosuppression after a liver transplant. No consistent pattern has, however, been identified in these patients.
Define Acute Lymphoblastic Leukemia
The presence of more than 25% malignant hematopoietic cells (blasts) in bone marrow aspirate
What is Leukemia defined by?
The presence of more than 25% malignant hematopoietic cells (blasts) in the bone marrow aspirate
Where can defects occur that cause hypothyroidism?
Thyroid gland Hypothalamus Pituitary Gland
What happens with the translocations of chromosomes 9 and 22?
The resulting protein fusion is a constitutively active tyrosine kinase that interacts with a variety of effector proteins and allows for deregulated cellular proliferation, decreased adherence of cells to the bone marrow extra cellular matrix, and resistance to apoptosis.
What are the risk factors for hyperemesis gravidarum?
The risk factors associated with hyperemesis gravidarum are obesity, multiple gestation, molar pregnancy, and a family history or history of hyperemesis gravidarum in a previous pregnancy. A population-based study from Canada identified several other factors associated with hyperemesis gravidarum severe enough to warrant hospitalization: hyperthyroid disorders, psychiatric illness, previous molar pregnancy, preexisting diabetes, gastrointestinal disorders, and asthma. Most of these factors are medical and fetal factors that are not modifiable.
What is the risk of relapse of ulcerative colitis in a patient with inactive disease during pregnancy and the puerperium?
The same as it is in the nonpregnant state. The most likely time for relapse of inflammatory bowel disease during pregnancy is the first trimester. The postpartum period is not necessarily a high-risk time for relapse; the degree of postpartum disease activity correlates with activity at term.
Preeclampsia *NTK*
The ultimate cause remains unknown. is seen more frequently in primigravidas. Younger than 20 years and older than 40 years having the highest rates of occurrence.
NURSE ALERT
The woman is at risk for a boggy uterus and a large lochia flow as a result of the magnesium sulfate therapy. Uterine tone and lochia flow should be assessed frequently. *The preeclamptic woman is unable to tolerate excessive postpartum blood loss because of hemoconcentration. Oxytocin or prostaglandin products are used to control bleeding. Ergot products (e.g., Ergotrate and Methergine) are contraindicated, because they increase blood pressure.
Does cesarean section decrease the risk of perinatal transmission of hepatitis C?
There are no randomized control trials regarding the preferred mode of delivery of pregnant women with hepatitis C. One observational study reported a decreased perinatal transmission rate with cesarean delivery, but this has not been confirmed by other studies.
What are the signs and symptoms for constitutional aplastic anemia?
They depend on the degree of abnormality Thrombocytopenia: purpura, petechiae, bleeding Neutropenia: severe or recurrent infections Anemia: weakness, fatigue, pallor
Chronic hypertension Defined
This disorder is associated with severe maternal and fetal complications. Chronic hypertension with superimposed preeclampsia is defined with the following findings: *1*. In women with hypertension before 20 weeks of gestation, with new-onset proteinuria *2*. In women with both hypertension and proteinuria before 20 weeks of gestation *3*. Sudden increase in proteinuria *4*. A sudden increase in BP in a woman whose hypertension has previously been well controlled *5*. Thrombocytopenia *6*. Elevated liver enzymes
Lab findings with constitutional aplastic anemia?
Thrombocytopenia or leukopenia occur first, followed by anemia then severe aplastic anemia Macrocytosis associated with anisocytosis and increased fetal hgb levels
Laboratory findings in hypothyroidism
Total T3 decreased Total T4 decreased T3 resin uptake decreased TSH elevated (primary) or low/normal (central)
What are other causes of hyperthyroidism?
Toxic adenoma subacute thyroiditis thyroid-stimulating hormone secreting pituitary tumor high dose of amiodarone
What is the treatment for megaloblastic anemia?
Treat the cause. Oral or parenteral doses of vitamin b12 for cobalamin deficiency. Oral doses of folic acid for folic acid deficiency.
How do you treat anemia of chronic inflammation?
Treat the underlying disorder
How do you treat peripheral precocious puberty?
Treatment depends on the underlying cause. Ovarian cysts: monitor only by US Congenital adrenal hyperplasia: glucocorticoids Surgical resectiony is rare
True or false: SGA and IUGR infants have skeletal maturation that corresponds to chronological age or is only mildly delayed
True
True or false: growth hormone therapy is FDA approved for SGA/IUGR infants
True
T/F: Immunoprophylaxis of hepatitis B is necessary for the infants of HbeAg-negative, HBsAg-positive mothers.
True. While on average the risk of transmission is lower in this group, it is still significant. Therefore, infants of HBsAg-positive mothers, regardless of HbeAg status, should receive both hepatitis B immune globulin and hepatitis B vaccine within 12 hours after birth, followed by two injections of hepatitis B vaccine during the first 6 months of life.
Patients using Methotrexate should be concerned for:
Tubal rupture during MTX administration and worsening pain 2-3 day after administration (Both prompt immediate evaluation)
What are some syndromes associated with short stature?
Turner Down Noon an Prader-Willi
Thalassemia trait
Two of the alpha genes are affected - the affected genes can be on the same or different chromosone. The RBCs produced are slightly small and with some slight anemia. But the health of the patient is rarely compromised.
What are the most common infections associated with Bruton's Congenital Agammaglobulinemia?
Types of infectious agents: 1. Pseudomonas 2. Strep. Pneumoniae 3. Haemophilus
How long after a medical abortion should you wait to check a urine hCG?
Urine hCG testing should not be checked at least 3 weeks
Spinal anesthesia
Usually used in C/S > pressure but no pain
Epidural block
Usually used in SVD
Most common cause of IUGR is:
Viral infection (CMV most common viral infection)
SEVERE PRECLAMPSIA INTERVENTIONS 3.
Weight is measured on admission and usually at the same time every day thereafter. Breath sounds are auscultated for crackles or diminished breath sounds, which may indicate pulmonary edema. An indwelling urinary catheter may be inserted to measure urinary output
Erythrocytes, leukocytes and thrombocytes
What are the three formed elements of blood?
Frank breech
buttocks first and feet by head, upward leg position resolves after birth
Check for proteinuria
by dipstick testing- or 24 urine. ( reuslts proteinuria is at least 30mg/dl or greater in at least 2 random urine specimens collected 6 hours apart. If 24 urine than reaults will be greater than 300mg/24hrs.
Seizure
call for help calmly provide safety roll to side pad side rails
psychogenic pain
can't identify anything physiologically from cascade of emotions
SEVERE PRECLAMPSIA INTERVENTIONS 2.
With a gestational age of 34 weeks or greater, labor induction usually is performed. Vaginal birth is considered safer than cesarean birth and should be attempted. In pregnancies of less than 34 weeks, the plan includes pharmacology to prevent seizures and control BP and continue maternal fetal surveillance for indicators of worsening conditions. Corticosteroids may be given to promote fetal lung maturation. If the birth can be delayed for 48 hours, steroids such as betamethasone (12.5 mg intramuscularly [IM] 24 hours apart) may be given to the woman (Benefits begin 24 after the first dose is administered)
What effect does inflammatory bowel disease have on fertility?
Women with ulcerative colitis have a similar fertility rate compared to the general population. An exception is women who have undergone proctocolectomy with ileoanal anastomosis and J-pouch. This group has a longer time to pregnancy, probably stemming from surgery-related pelvic adhesions. Women with Crohn disease may have a lower fertility compared to the general population. Fertility is highest in those in remission or following surgical resection of active disease.
Signs and symptoms of hyperthyroidism
Worsening school performance Poor concentration Fatigue Hyperactivity Emotional lability Nervousness Insomnia Weight loss Palpitations Heat intolerance Exophthalmos
What is the characteristics of Chronic Granulomatous Disease?
X-linked (2/3) or autosomal recessive (1/3) 1. Anemia 2. Lymphadenopathy 3. Hypergammaglobulinemia 4. Have granulomas of the skin and GI/GU tracts
What are the genetic association with Wiskott-Aldrich Syndrome?
X-linked recessive disorder (male only disorder)
Aplastic Anemia
a bone marrow failure condition in which the formed elements of blood are simultaneously depressed.
Hemophilia
a disorder where the blood does not clot normally due to a clotting factor deficiency and even the slightest injury can cause severe bleeding. give clotting factors, corticosteroids, exercise, and nsaids (with caution).
Hodgkin's Disease
a malignancy of the lymph system. May metastasize to spleen, liver, bone marrow or lungs. Characteristic Reed-Sternberg cells (giant multinucleated).
for a positive dx of TB, what components are necessary
a positive PPD CXR
* Preeclampsia*
a pregnancy-specific syndrome in which hypertension develops *after 20 weeks of gestation* in a previously normotensive woman, is characterized by the presence of hypertension and proteinuria.
Symmetrical IUGR consists of:
a. All organs are proportionately decreased in size. b. Most likely cause is a genetic disorder, infection or other problem. (Could be an early, severe nutritional deprivation, but most likely the others causes.) c. Brain is small because of an overall decrease in number of cells.
Causes if IUGR include:
a. Congenital abnormalities. (growth impairment d/t chromosomal abnormalities occurs earlier in gestation than placental abnormalities) b. Trisomy 21 (Down syndrome) - most common; Trisomy 18 (Edward's syndrome) - 2nd most common; Trisomy 13 c. Sex chromosome abnormalities (ie: Turner's syndrome) d. Achondroplasia (if either parent is affected) e. Osteogenesis imperfecta f. Abdominal wall defects/gastroschisis g. Others: Smith-Lemli-Opitz syndrome, Meckel's syndrome, Robert's syndrome, Donohue syndrome, Seckel's syndrome, Potter's syndrome, duodenal atresia, pancreatic agenesis
Substances or environmental factors that can have an adverse effect on the developing fetus include:
a. Drugs-alcohol, anti-seizure medications (phenytoin, valproic acid), lithium, mercury, thalidomide, diethylstilbestrol (DES), warfarin, isotretinoin b. Infectious agents-CMV, listeria, rubella, toxoplasmosis, varicella, mycoplasma c. Radiation more than 0.05 Gy (5 rad) to the fetus increase the teratogenic risks to the fetus
Maternal factors directly related to IUGR include:
a. Hypertension (most common maternal cause of IUGR) b. Malnutrition/ malabsorption c. Vascular disease & hypoxemia d. Hypoxemia e. Drug/alcohol use (legal and illegal)
Asymmetrical IUGR consists of:
a. Organs are disproportionately decreased in size. Blood flow is shunted to more vital organs such as brain and heart vs. kidneys and liver. Therefore brain and heart of less restricted in size than kidneys and liver. b. Most likely cause is intrauterine deprivation that leads to shunting of blood to more vital organs. Disproportionate growth more prominent when deprivation occurs in latter half of pregnancy. c. Brain is larger than those with symmetrical IUGR and small brain size is attributable to small size of brain cells rather than decreased number of brain cells.
mild thickening of scalp hair is caused by a prolonged
active (anagen) phase of hair growth, late gestation
A patient presents with severe and sudden dyspnea, in shock. After an hour she develops DIC. What do you suspect
amniotic fluid embolism
What heart sound is characteristic of a PE
an accentuated S2 tachycardia, tachypnea (also cyanosis and fever)
Idiopathic Thrombocytopenic Purpura
an acquired hemorrhagic disorder that occurs in childhood can be acute or chronic.
Ultrasound
any gestation indication: dating the pregnancy, fetal location, # of fetuses, location of placenta, fluid level, assist with other tests, anatomy of fetus, size of fetus interpretation: variant on what is being examined Nursing: use gel warmer for patient comfort, always wipe excess gel, in early preg. a full bladder is needed to elevate the uterus
Rubella Titer
anytime Indication: to determine mother's immunity to rubella Interpretation: > or equal to 1:9= immune status. < or equal to 1:8= non-immune or susceptible status
Indirect Coombs Titer
anytime during pregnancy or PP indication: screening test for Rh incompatibility interpretation: > or equal to 1:8 indicates the necessity for Rhogam in the postpartum period or that amniocentesis is indicated anterpartally Nursing: maternal blood sample needed, education
HELLP syndrome
appears in approximately 5to 20% of women with preeclampsia. Common in Caucasian women, S/S malaise, flu like symptoms, Epigastric or right upper quadrant abdominal pain, nausea and vomiting and headache. Some may develop thrombocytopenia such as bruising or hematuria.
5. (MP@H) Diet. Diet and fluid recommendations
are much the same as for healthy pregnant women. Diets adequate protein ( 60 to 70 g), 1200 mg calcium, 400mcg of folic acid and adequate zinc and ( 2to 6 g of sodium have been suggested to prevent preeclampsia; however, the efficacy of these diets has not been proven. Adequate fluid intake helps maintain optimum fluid volume and aids in renal perfusion and bowel function. ( Gilbert 2011) *Eat foods with roughage* ( while grain, raw fruits, and vegetables), 6 to 8 glasses of water per day, and avoid ETOH and Tobacco- while limiting caffeine intake.
During seizure the most important things
are patent airway and client safety!!! ( page 667)
Cord Doppler Studies (Velocimetry Waveforms)
around 24 weeks to term indication: any suspected or documented cases of UPI and specifically IUGR interpretation: ratio normally decreases as pregnancy advcances. SYS:DIAS ratio > or equal to 3 indicates IUGR and/or UPI Nursing: eductaion, follow up dependent on results
Non-Stress Test (NST)
around 24 weeks to term indication: detection of fetal well being. CNS status interpretation: REACTIVE: noraml baseline FHR, with at least 2 accels of 15 beats over baseline lasting 15 seconds in a 20 minute frame. NON-REACTIVE: either deceased variability or maybe only one accel noted
Fetal Movement Assessment (Kick Counts)
around 24 weeks to term indication: high risk pregnancies, any decreased fetal movements, after procedures (amino, PUBS, etc.) Interpretation: no agreed upon # generally 5 movements in 60 seconds or 10 movements in 12 hours indicate that the fetus is doing well and the CNS is intact Nursing: education on how to perform the test: lie on side, decrease stimuli, mark the movements, hydrate, fetal movement doe snot decrease near term
Biophysical Profile
around 24 weeks until term gestation indication: assessment of fetal status during high risk pregnancies interpretation: 8/10 is normal, <6 indicates problems with O2 delivery and/or CNS damage, <4 is abnormal Nursing: education, follow up with the results
Contraction Stress Test (CST)
around 24 weeks- term indication: performed to determine the fetal response to contractions to estimates the fetus ability to tolerate labor interpretation: POSITIVE: abnormal and ominous finding, late decels are noted on tracing. NEGATIVE: is normal, the fetus is reactive with no decels. sporadic or occasional decals are suspicious. Nursing: can be performed via nipple stimulation or by administering IV pitocin. Prior to beginning test obtain 10 min baseline.
Mendelssohn Syndrome
aspiration pneumonia associated with delivery
cytomegalovirus infection will often be asymptomatic in the mother but the infant can have: mental retardation, seizures, blindness, deafness, dental abnormalities and _______ "blue berry muffin" rash
petechiae
HD class 1: ______ at normal activity levels
asymptomatic
GDM usually occurs _______ of pregnancy when insulin antagonists are secreted
at midpoint
At what time may the CO increase during pregnancy
beginning in the 8th week
Cognitive aspect of pain
beliefs, attitudes, memories, meaning
Cutaneous lupus..."erythematous papules or small plaques with slight scaling"
binding of autoantibodies leads to immune cascade:
name the at risk category: genetic considerations that could interfere, inherited disorders
biophysical
What is SCID aka?
bubble boy disease
Complete breech
buttocks and feet are next to each other with bent knees
the most commonly used corticosteroid is:
celestone
Types of precocious puberty
central and peripheral
Assess uterine activity,
cervical changes, and fetal status. Membranes may rupture, or fast dilatation may have occurred - delivery may be immediate. ( decelerations may occur, if delivering regional anesesthia is not recommended)
What is type 2 diabetes, formerly referred to as NIDDM or adult-onset....
characterized by insulin resistance & beta cell dysfunction, if both parents have type 2, 60-75% chance in offspring, ketoacidosis is rare
Fanconi syndrome
characterized by pancytopenia, hypoplasia of bone marrow and patchy brown discoloration of skin.
RF+ group progresses to
chronic joint destruction in 50% pt, RF neg. group has little joint destruction Any joint may be involved (wrists, knees, elbows, ankles, hands, feet)
Intrahepatic cholestasis...
pruritis and exclusively secondary skin lesions...after 30th week, most common in Araucanos Indians of Chile and Boliovia
Synovial Fluid -
cloudy, protein increased, cells increased (5,000-80,000), mostly PMN, Glu N/decreased, complement N/decreased
Tests for septic abortion
complete blood count, urinalysis, endocervical cultures, blood cultures, and abdominal x-ray to rule out uterine perforation should be obtained. Ultrasound should be performed to look for retained products of conception.
________ _______ disease more common in TTTS twins than uncomplicated MC twins
congenital heart
Preeclampsia progresses to eclampsia when _____ occur
convulsions
S/Sx of worsening preeclampsia: increased edema, H/A, epigastric pain, ___ urinary output, N/V, bleeding gums
decreased
*abruptio*
decreased placenta perfusion
Magnesium sulfate
decreases neuromuscular irritability, depressing cardiac conduction, and decreasing CNS irritability.
How do you determine treatment for peripheral puberty?
depends on underlying cause 1. Ovarian cyst: not tx indicates 2. Congenital adrenal hyperplasia: glucocorticoids & surgery 3. McCune Albright Syndrome: antiestrogens or aromatase inhibitors
Cutaneous tumors which may grow rapidly during pregnancy include...
desmoid, leiimyomas, keloids, melanocyte nevi,
First trimester Thick echogenic chorion completely surrounds each embryo sac 2nd & 3rd trimester Two placentas Thick inter-twin membrane 'Twin Peak Sign' Gender?
dichorionic twins
Spider telangiectasias (spider nevi or spider angiomas)
dilation of arterioles, central erythematous spots radiating outward, gums, tongue, upper lip and eyelids
Defined by one twin being in normal range and other twin being <10th percentile (prognosis worse in MC twins)
discordant twin growth
______ twins: fraternal - two ova -two egg - two of everything
dizygotic
McCune-Albright syndrome is seen more commonly in girls than boys and sometimes is associated with other endocrine hyperfunction, such as...
hyperthyroidism, Cushing's syndrome, hyperprolactinemia, or pituitary gigantism.
name the at risk category: smoking, caffeine alcohol
psychosocial
Aplastic
due to the short life of the sickle cell the bone marrow has a hard time keeping up with RBC productions resulting in
Pregnancy related erythema occurs when/where...
early gestation, diffuse and motteled or, focal to palmar and thenar (fleshy part of palm at base of thumb) areas
Pauciarticular Onset JIA early onset?
early onset - females > males; < 5 years, ANA + in 25% pts;
What classic symptom has been eliminated as a sign of preeclampsia?
edema
three big signs of GH: HTN, ____ and protenuria
edema
Accelerations: 32 weeks or greater
elevations above the baseline of 15 beats/min, lasts 15 seconds or longer
Acceleration: <32 weeks
elevations of 10 beats/min lasting greater than10 seconds
hirsutism on the face and breasts caused by
endocrine changes during pregnancy, 2nd and 3rd trimesters
name the at risk category: infections, radiation, exposure to chemicals
environmental
vascular changes in pregnancy are caused by...
estrogen effects: congestion, distention and proliferation of blood vessels
ATOPIC DERMATITIS
estrogen/progesterone modulation of immune/inflammatory responses/mast cell secretions: urticaria. Condition may worsen or improve during pregnancy
(Toxicity - of aspirin
hyperventilation, drowsiness, tinnitus. Side effects - gastritis, hemorrhage, complications - Reyes Syndrome)
Non-pitting edema to..
face, eyelids, and extremities pronounced in the morning
what factors are increased in women without venous thromboembolism
factors I, II, VII, VIII, X
T/F: heparin crosses the placenta
false
Normal glucose values are...
fasting 70-95, 1-hour after meal: <130-140, 2-hour after: <120
*Other symptoms -
fever, malaise, painful scrotal swelling, cerebral vasculitis, nosebleeds, seizures, parotitis, pancreatitis and cardiopulmonary disease
Lymphocytes
fight infection and are produced and mainly found in lymph tissue.
PO2 in first trimester vs. second trimester
first = 106-108mmHg third = 101-104mmHg
Variability:
fluctuations in FHR of 2 cycles per minute or greater; ranges from absent to marked
HELLP syndrome Laboratory diagnosis
for a variant of severe preeclampsia that involves hepatic dysfunction Hemolysis (H) Elevated liver enzymes (EL) Low platelets (LP) Diagnosis associated with increased risk for adverse perinatal outcomes
Since the woman with preeclampsia is at risk
for abruptio placentae, it is important to assess uterine tone and tenderness and the presence of vaginal bleeding.
Assess the edema
for distribution, degree and pitting. ( seen most in feet and ankle)
Side effects - of NSAIDs
gastritis, liver toxicity, renal toxicity, interference with platelet function
physiological pain
genetic, anatomic, physical determine in how stimuli are recognized
What are other specific types of diabetes? A variety of ....
genetic, drug, or chemical-induced diabetes
Routine screening for Gestational Diabetes consists of performing a.....
glucose challenge test between 24 and 28 weeks.
Where does gonadotropin releasing hormone, human growth hormone, FSH, LH, vasopressin, and oxytocin come from?
gonadotropin releasing hormone: hypothalamus growth hormone, FSH, and LH: anterior pituitary vasopressin and oxytocin: posterior pituitary
Many women with HELLP syndrome may not
have signs or symptoms of severe preeclampsia or may ve only slight elevations in BP. As a result, women with HELLP syndrome are often misdiagnosed as having a variety of other medical or surgical disorders (Sibai et al., 2007).
What are the normal TSH levels in children?
healthy serum levels of TSH are 0.7-6.4 mIU/L.
1. (MP@H) Maternal assessment should include:
hematocrit, platelet count, liver function tests, and 24 urine once each week.
if reflexes are lost, clue Mg levels are _____, antidone if problem occurs is: ______
high, gluconate
what are three things to ask yourself?
how many? MFM (many first membranes) who's first? How do the membranes look?
Why is hyperthyroidism?
hyperthyroidism or thyrotoxicosis denotes a series of clinical disorders associated with increased circulating levels of free thyroxine or triiodothyronine
NST Nursing
if non-reactive persists a BPP is indicated. If the infant is in a sleep cycle, acoustic stimulation may be necessary. fetus may not be reactive until around 28-30 weeks when the autonomic nervous system matures. so 10x1-x20 rule is appropriate for gestational age. The mother can push a button hooked up ti the EFM to mark when she notes movement
Contraindications of use of methotrexate in ectopic pregnancy?
ii. TABLE 13-2 p. 246 1. ABSOLUTE - a. breastfeeding b. immunodeficiency c. alcoholism, alcoholic liver disease, chronic liver disease d. blood dyscrasias (leukopenia, thrombocytopenia, etc) e. active pulm disease f. PUD g. Hepatic, renal, hematologic dysfunction 2. RELATIVE - a. Gestational sac > 3.5 cm b. embryonic cardiac motion Also unreliable patients
referred pain
in one spot but feel somewhere else
SEVERE PRECLAMPSIA INTERVENTIONS 1. HOSPITAL CARE
in severe preclampsia pt will be hospitalized.
3. (MP@H) Activity Restriction. Bed rest
in the *lateral recumbent position* is a standard therapy for preeclampsia and may improve uteroplacental blood flow. Complete bed rest has been shown to be beneficial in decreasing blood pressure and promoting diuresis. Adverse physiologic outcomes related to bed rest include cardiovascular deconditioning; diuresis with accompanying fluid, electrolyte, and weight loss; muscle atrophy; thrombophlebitis, and psychological stress. These changes begin on the first day of bed rest and continue for the duration of therapy. Thus, modified bed rest with bathroom privileges may be ordered to help decrease negative effects
Expected side effects of MAG SULFATE (loading dose only)
include a feeling of warmth, diaphoresis, burning at IV site. Symptoms of mild toxicity include: lethargy, muscle weakness, decreased or absent DTRs, double vision, an slurred speech. Increasing toxicity may be indicated by maternal hypotension, bradycardia, bradypnea, and cardiac arrest. Serum magnesium levels are obtained per hospital protocol or if any signs of toxicity are present *NTK-- drug cal for MAG SULFATE*
Preterm labor (PTL) and preterm delivery (PTD) IUFD SGA and IUGR Structural anomalies More common in multiples Monozygotic > Dizygotic Placental variants Succenturiate lobes and vasa previas Abnormal cord origins Abnormal fetal presentation increased incidents of c/s Maternal complications 2x risk for preeclampsia, post partum hemorrhage, death 3x risk for eclampsia (seizure, stroke, etc)
increased risks for twins
Postpartum, scalp hair enters a prolonged resting (telogen) phase of hair growth, causing
increased shedding (telogen effluvium), which may last for several months or more than one year after pregnancy, hair loss
McCune-Albright syndrome is characterized by the triad of It is
irregularly edged ("coast of Maine") café-au-lait spots, fibrous dysplasia of skull and long bones, and precocity due to autonomously functioning ovarian cysts.
If mom is Rh___ and Fetus is Rh ____ then incompatability occurs
mom:Rh NEGATIVE, fetus Rh POSITIVE
Preeclampsia Defined
is a condition unique to human pregnancy; signs and symptoms develop only during pregnancy and disappear quickly after birth of the fetus and placenta.
HELLP syndrome
is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction; it is characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). A woman's platelet count must be less than 100,000
Hemopatopoietic stem cell transplantation
is considered early on if compatible donor can be found.
2. (MP@H)Fetal movement
is counted daily. Non-stress test (NST), once or twice a week, and a biophysical profile (BPP) as needed.
With preeclampsia, the main pathogenic factor
is not an increase in BP but poor perfusion as a result of vasospasm and reduced plasma volume. Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and increases BP Function in organs such as the placenta, kidneys, liver, and brain. Fig. 27-1. *Plasma colloid osmotic pressure* decreases as serum albumin levels decrease. Intravascular volume is reduced as fluid moves out of the intravascular compartment, resulting in hemoconcentration, increased blood viscosity, and tissue edema. ( this increase risk for pulmonary edema) *Decreased liver perfusion* results in impaired liver function and elevated Liver enzyme.The women may complain of epigastric or right upper quadrant pain. Hemorrhagic necrosis in the liver can cause a subcapsular hematoma is a life-threatening complication and a surgical emergency
Chronic hypertension
is present before the pregnancy or diagnosed *before 20 weeks of gestation*. Most will have uncomplicated pregnancies, but there is an increased risk of poor fetal growth and fetal demise.
The only cure for preeclampsia
is the birth of the fetus
Gestational hypertension
is the onset of hypertension, without proteinuria, after 20 weeks of pregnancy, which may be transient or chronic in nature. Most commonly occurs around 37 weeks. BPs return to normal within 6 weeks after delivery. Hypertension is defined as above 140 systolic and 90 diastolic.
Eclampsia
is the onset of seizure activity or coma in the woman diagnosed with preeclampsia, with no history of preexisting pathology that can result in seizure activity (Roberts & Funai , 2009, Sibai, 2007). The initial presentation of eclampsia varies, with one third of the women developing eclampsia during the pregnancy, one third during labor, and one third within 48 hours postpartum (Roberts and Funai).
Standard method of surgically treating ectopic in stable patient
laparoscopy
Standard method of surgically treating ectopic pregnancy in unstable patients
laparotomy
Iron deficiency puts children at risk for elevations of what toxin?
lead exposure/absorption
Reduced kidney perfusion
leads to possibly oliguria. Protein, primarily albumin, is lost in the urine. Uric acid clearance is decreased; however, and serum uric acid levels increase. Sodium and water are retained
90% of DVTs are ____ sided. ________ site is more likely than _______.
left the iliofemoral site is more common than the calf
Periumbilical "white halo"...
lesions spare the periumbilical area
Med TX for central precocious puberty
leuprolide and histrelin
babies born to drug addiction will have s/sxs of withdrawls and _____ birth weight
low
Triple/Quad Screen Interpretation
low levels of MSAFP and unconjuncted estriol and increased levels of hCG in conjunction with inhibit-A (increased with Trisomy 21 and decreased with Trisomy 18) are suspicious of DS. Elevated of MSAFP level is suspicious of Neural Tube Defects
A newborn can be born with _______ will have respiratory problems along with high birth weights, caused by DM
macrosomic
Systemic Lupus Erythematosus (SLE)-Clinical Features
malar rash. Erythema, erosion, and atrophy are present. Note sparing of nasolabial folds. Mucosal ulceration of the lips as evidence of vasculitis Scarring alopecia Cutaneous vasculitis Purpuric, ulcerative, and necrotic skin lesions of active disease.
Control of Blood Pressure. Antihypertensive medications
may be ordered to lower the diastolic blood pressure. Because a degree of maternal hypertension is necessary to maintain uteroplacental perfusion, antihypertensive therapy must not decrease the arterial pressure too much or too rapidly. The target range for the diastolic pressure is therefore less than 110 mm Hg and the systolic pressure less than 160 mm Hg (ACOG, 2002; Cunningham et al., 2007) Safe drugs to give includes: hydralazine, labetalol and nifedipine ( Table 27-5)
Approximately 25% of women with chronic hypertension
may develop preeclampsia or eclampsia.
hyperpigmentation in pregnancy is caused by...
melanocyte-stimulating hormone, estrogen and progesterone
women abused during pregnancy are more likely to have _________, stillbirths, and low-birth weight babies
miscarriages
As long as twins don't get beyond stage 1, invasive treatment may be avoided Monitor fluid, Dopplers, cardiac anatomy Serial amnio reductions to avoid PTL/PTD
monitoring
What? No membrane to keep them separate Rare, but account for a significant percentage of twin pregnancies with bad outcomes 68% loss in first trimester If one twin demises, increased risk of brain/renal hypoxic injury in survivor Immediate delivery does NOT prevent hypoxic damage Delivery at 32-34 weeks assuming everything is normal Spike in perinatal loss 36-38 weeks 21.9%
mono mono
___________ twins are 3-4times more likely than DC to have a twin demise
monochorionic
1st Trimester Mono/Mono 2nd trimester Single placenta No twin peak sign Thin membrane Same gender
monochorionic twins
_______ twins: identical - one ova -one sperm - divides into two developing blastocysts
monozygotic
Familial short stature growth pattern
normal birth weight and length but growth decelerates during the first two years of life. Growth resumes and follows the normal growth curve at the low percentage. Skeletal maturation and puberty timing are consistent with chronological age
To prevent neonatal hypoglycemia...
o in labor 5% dextrose in LR @ 125ml/h = 6.25g glucose/h o Monitor glucose Q2-4h early labor, 1-2h in active labor o Continuous insulin infusion: 0.5-2.0u/h, titrated to glucose
MOB
multiple OB
What are the two atypical agents in pneumonia bacteriology
mycoplasma pneumonia and chalmydia pneumonia
During pregnancy, the upper airway undergoes certain changes such as hyperemia, hyper secretions, and mucosal edema. What consequences may occur as a result?
nasal obstruction, epistaxis, sneezing spells, changes in voice, polyposis of the nasal sinus mucosa
Non-reassuring fetal status...bradycardia...
new baseline is less than 80
does the health care provider need permission from the mother to drug screen the baby?
no
if a woman confides that she is being abused during pregnancy, should this information be reported?
no
if the mother has genital herpes (type two) and has no lesions is a Csection still necessary
no
Contraception recommended for diabetes....
no estrogen is recommended due to vascular complications in DM, progesterone only and levonorgestrel IUD
With mild preeclampsia, (Table 27-2.)
no evidence of organ dysfunction and severe cases
can the rubella vax be given during pregnancy?
no, its a live attenuated form of the virus
should you stop bronchodilators in pregnancy?
no- continue woman on the standard asthma regime
Has ceiling effect
non- Opioids
what is the effective treatment for CMV
none
when a woman of childbearing age is immunized for Rubella, she should not get pregnant for at least ____ ____ after the immunization.
one month
Affect pain
ones emotional response to pain
Systemic corticosteroids -
only suppress symptoms, no remission or joint destruction prevention
Doesn't have ceiling effect
opioids
Drugs for moderate pain
opioids, nonopioids, anestetic
Lymph nodes
organisms are destroyed and antibody production is stimulated.
______ thickness in mm same as the weeks of the pregnancy= normal
placental (abnormal 30 weeks and 40mm)
Tonic contraction of all body muscles (seen as arms flexed, hands clenched, legs inverted)
precede the tonic-clonic convulsions. Seizures may recur within minutes of the first convulsion, or the woman may never have another.
Pemphigoid Gestationis..."Herpes Gestationes" treatment...
prednisone: 20-60 mg daily, oral antihistamines, cyclosporin, and IV immunoglobulin (refractory cases)
Breastfeeding is strongly encouraged because...
protective against childhood DM
women with Gestational HTN will not have _____ in their urine
protein
Preeclampsia is when GH includes _______
proteinuria
Deep tendon reflexes (DTRs)
reflect the balance between the cerebral cortex and spinal cord. They are evaluated as a baseline and to detect any changes. The biceps and patellar reflexes and ankle clonus are assessed and the findings recorded. See Table 27-4
Three Methotrexate (MTX) regimens used in ectopic pregnancies
single dose, two-dose, fixed multidose protocol. 1. Single dose: 50 mg/m² IM injection most common. hCG levels measured at 4 and 7 days posttreatment w/ expected 15% decrease from day 4 to 7, then weekly until level equals zero. If levels do not drop appropriately a second MTX dose or surgery 2. Fixed multidose ifs most effective, esp with advanced gestation and those w/ embryonic cardiac activity.
Footling breech
single or double footling, foot is the presenting part
Common causes of perinatal morbidity in preterm infants include:
resp distress, intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, sepsis, apnea, retinopathy of prematurity, and hyperbilirubinemia
S/S during seizure include:
respirations which are halted and begin again with long deep stertorous inhalation, hypotension follows and muscular twitching disorientation and amnesia persist for awhile after the convulsion.
what trimester has the greatest incidence of DVTs
second!
_________ reduction available with ____ twins - not with ____twins
selective DC MC
Group B Strepp is very common affecting 30% of adults may be asymptomatic, usually in GI tract/vagina fetus:spontaneous abortion, ____ in newborn
sepsis
Systemic corticosteroids - indications
severe systemic disease, unresponsive to salicylates; Iridocyclitis uncontrolled by topical steroids
If the woman has mild preeclampsia (MP)
she may be managed at home with frequent maternal and fetal evaluation and bp less than 150/100. and proteinuria less than 500mg per day.
FAS facial features of an infant include short palpebral fissures, flat nasal bridge, thin upper lip, and a _______ head
small
are babies born to mom with uncontrolled asthma big or small
small! low birth weight and higher chances of prematurity
What is a classic sign of megaoblastic anemia?
smooth beefy red tongue
name the at risk category: low income, teenagers, life style issues for more mature moms...
socio-demographic
X-Ray -
soft tissue swelling, osteoporosis, periostitis, epiphyseal thickening and closure, atlantoaxial subluxation, sacroilitis.
NURSE ALERT Immediately after a seizure,
the woman may be very confused and can be combative. Pad the side rails to prevent injury, and maintain a quiet, darkened environment. It may take several hours for the woman to regain her usual level of mental functioning. The woman should not be left alone. Provide emotional support to the family and discuss with them the management and its rationale and the woman's progress.
RF+ pts have?
subcutaneous nodules (firm, nontender nodules on pressure points) usually females sym. small jt
75% have characteristic rash -
symmetrical, erythematous, with atrophic changes over knees, elbows, PIP, MCP, violaceous discoloration of eyelid, scaly red malar rash
Melasma (chloasma or mask of pregnancy)
symmetrical: occurs in the malar (cheeks), mandubular and central facial areas. Use sunscreen
HD class 3: ________ with ordinary activity
symptomatic
HD class 4: _______ at rest
symptomatic
How should diabetes be managed if patient has a scheduled C-section?
take evening insulin or oral meds preceding night, but not in a.m., glucose level is monitored and treated with IV insulin infusion to maintain at 70-120
GDM becomes apparent when...
the beta cells are unable to overcome the decreased insulin sensitivity & hyperglycemia results.
in the presence of increased CO2, what respiratory value increases
the minute ventillation
all women fhould be screened for HepB during the course of prenatal care and the screening shold be repeated during the _____ trimester
third
Successful home care requires the woman
to be well educated about preeclampsia and highly motivated to follow the plan of care. COMPLIANCE WITH PLAN.
Preeclampsia contributes significantly
to restrictions of fetal growth and incidence of placental abruption,premature birth, and early degenerative aging of the placenta. Impaired placental perfusion leads to early degenerative aging of the placenta. The rate of fetal complications is directly related to the severity of the disease
Arteriolar vasospasms and decreased blood flow
to the retina lead to visual symptoms such as scotomata (blind spots- dim vision, double visons) and blurring. Neurologic complications associated with preeclampsia include cerebral edema and hemorrhages and increased central nervous system (CNS) irritability, which manifests as headache, hyperreflexia, positive ankle clonus, and seizures
what is the most common cause of pulmonary edema in pregnancy
tocolytic induced! associatd with B-AR, especially TERBUTALINE
Nociceptive pain
treat with both opioids+nonopioids stimulation of peripheral nerve fibers caused by injury/disease OUTSIDE of nervous system dull ache/pressure somatic, visceral, cutaneous
neuropathic pain
treated with anticonvulsant/antidepressant abnormal processing of sensory input caused by damage to nerve tissue burning/stabbing peripheral, central
T/F MCV and MCH are elevated with megoblastic anemia.
true
T/F: warfarin crosses the placenta
true
-increased risk: -pre-E -vaginal bleeding -prolapsed cord -PTD (post traumatic stress)
twins
TTTS occurs when the blood exchange between the twins is __________
unbalanced
Non-reassuring fetal status...tachycardia
with a decrease in variability, repetitive late decelerations or, severe variable decelerations
Insulin resistance that occurs in normal pregnancy is associated with....
with an increase in insulin release by the beta cells of the pancreas in order to maintain glucose homeostasis.
pt can have hypertension
without preclampsia
can Hep B virus cross the placenta barrier?
yes
is asthma in pregnancy predictable?
yes! between pregnancies in the same patient
is breast feeding safe if the mother has herpes?
yes, as long as there are no lesions on the breasts
RF negative group is usually
younger with sym large joint involement
Cardiomyopathy - aka acquired congenital heart disease Results from volume overload to recipient Cardiomegaly, tricuspid regurg, impaired ventricular function, biventricular hypertrophy RVOT obstruction Pulmonary atresia/stenosis 9.6% Structural heart defects 15-23X with TTTS compared to singletons
yup
Insulin in gestational diabetes
■ basal coverage NPH ■ prandial coverage rapid acting or regular insulin